Global Prevention of HIV Infection for Neglected Populations: Men Who Have Sex with Men

Chris Beyrer

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

The global epidemiology of human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) suggests both reemergent spread among men in resource‐sufficient countries since 2000 and emerging epidemics among MSM in resource‐limited countries. Both epidemic contexts are evidence of the current limits of prevention of HIV infection in MSM.

A range of evidence‐based preventive interventions exist, but few new interventions have shown efficacy among MSM. Circumcision has not been investigated for MSM. New interventions are needed. Trials of preexposure prophylaxis are pending and may markedly alter the prevention landscape. For MSM in developing countries, basic services for prevention of HIV infection have yet to reach the large majority of men. Homophobia and discrimination limit access of MSM to prevention services and markedly increase vulnerability, as does criminalization of same‐sex behavior. Decriminalization of same‐sex behavior is a structural intervention for prevention of HIV infection and has recently been embraced by a nonbinding statement from the United Nations.

Reprints or correspondence: Dr Chris Beyrer, Center for Public Health and Human Rights, Johns Hopkins BSPH, 615 N Wolfe St, E 7152, Baltimore, MD 21205 (cbeyrer@jhpsh.edu).

In the third decade of the human immunodeficiency virus (HIV) and AIDS pandemic, we face a painful reality—although men who have sex with men (MSM) were among the first affected populations and, in well‐resourced countries, communities of MSM were pioneers in prevention of HIV infection and behavior change, there is now evidence of multiple reemerging epidemics of HIV infection among these men [1, 2]. A recent analysis of data from 8 industrialized countries, including the United States, United Kingdom, the Netherlands, France, Germany, Spain, Australia, and Canada, found that, although the prevalence of diagnosis of HIV infection generally decreased from 1996 through 2000, diagnoses of HIV infection among MSM have increased by 3% per year from 2000 through 2005 [2]. Marked increases in the rate of diagnosis of syphilis among MSM in 5 of these 8 countries over the same period suggest that at least some of the increase in the prevalence of HIV infection was attributable to increases in sexual risk–taking behavior [2]. Among US MSM, a particular concern is the disproportionate burden of HIV infection among MSM of color, especially among African American MSM, who are at strikingly higher risk of HIV infection, even after controlling for individual‐level sexual risk behaviors [3, 4]. Rates of undiagnosed HIV infection among black MSM are also strikingly higher than those among MSM of other race and ethnicity groups, suggesting that HIV testing, counseling services, and messages are failing to reach these men, even as rates of HIV infection increase.

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