‘Critically low’ awareness of HIV status among gay men in Africa

The analysis, which reviewed 75 studies from 28 African countries involving just under 45,000 men who have sex with men, also found a link between countries with severe anti-LGBT legislation and lower levels of testing and status awareness among this population group.

The study assessed the extent by which African-based men who have sex with men have engaged with the HIV treatment cascade over time, and the effect of anti-LGBT legislation on testing, treatment and viral suppression.

HIV testing among men who have sex with men was found to have increased over time. After 2011, 67% of men who have sex with men had tested for HIV at least once, and half (50%) had tested in the past 12 months. Before this, around half (52%) had tested at least once and around a third (32%) had tested in the past 12 months.

But despite the rise in testing, only 19% of HIV-positive men who have sex with men were aware of their status, only a quarter (24%) were on treatment, and a quarter (25%) were virally suppressed. This means that, although African-based men who have sex with men are more likely than other African men to test for HIV, they are far less likely to be on effective treatment. These outcomes are also far worse than those reported among men who have sex with men in European and Asian countries.

Researchers reviewed studies involving at least ten men who have sex with men published between 1980 and 2018 from each region in Africa. Most of the studies included in the final analysis were carried out in eastern, western and southern Africa and used varied definitions of men who have sex with men, the majority of which included transgender women. More than half of the studies analysed were carried out after 2011.

Despite a substantial increase over the past few years in the number of studies examining the HIV treatment cascade among African-based men who have sex with men, data remains scarce for most outcomes along the cascade apart from HIV testing.

After 2011, the proportion of men who have sex with men who had ever taken an HIV test was highest in southern Africa (80%), and lowest in northern Africa (34%), with the greatest increase seen in western Africa (from 42% to 71%). The proportion of men who have sex with men who had taken an HIV test in the past 12 months was highest in southern Africa (67%) and lowest in eastern Africa (40%).

However, the proportion of HIV-positive men who have sex with men who were aware of their status did not increase over time, standing at 17.6% before 2011 and 18.5% afterwards. No significant increases in status awareness were seen when analysing by region, although an increase was seen over time in South Africa.

An association was found between low testing levels among men who have sex with men and the severity of a country’s anti-LGBT legislation. In countries with the most severe anti-LGBT legislation, around 58% of men who have sex with men had ever tested for HIV, compared to 72% in countries with the least repressive laws.

Around 35% of men who have sex with men facing severely anti-LGBT laws had tested in the last 12 months, compared to 49% in the least repressive countries. Only 7% of HIV-positive men who have sex with men living in countries with severely repressive laws were aware of their status, compared to 22% in the least hostile environments.

Little data exists about later stages of the treatment cascade, but the findings reveal that just 60% of HIV-positive men who have sex with men who are aware of their status are on treatment, of whom 76% are virally suppressed.

But because levels of diagnosis and treatment-access remain low, overall this equates to only a quarter of HIV positive men who have sex with men on treatment and virally suppressed. These critically low levels mean HIV transmission among African-based men who have sex with men is set to continue.

Further studies are urgently needed to provide more accurate estimates of levels of status awareness, engagement in care, treatment coverage and viral suppression among African-based men who have sex with men to improve access to these vital and lifesaving services.

Jim Pickett, rectal-micro studies