Are Low- and Middle-Income Countries Repeating Mistakes Made by High-Income Countries in the Control of HIV for Men who have Sex with Men?

Abstract

Men who have sex with men (MSM) have been represented disproportionately in the HIV epidemic in high income countries since the first HIV/AIDS cases were reported in MSM in 1981. Among all vulnerable HIV populations, MSM account for the preponderance of prevalent AIDS cases in Western Europe [1,2]. Similarly, the largest numbers of persons with newly diagnosed HIV infections (range 45%–65%) are MSM in the United States, Canada, Australia, and New Zealand [3–7]. In contrast, in many low- and middle-income country (LMICs) HIV epidemics were driven by injection drug use (IDU), heterosexual sex, and/or contaminated blood collection and transfusion [8,9]. In recent years, rapid increases in the HIV epidemic among MSM have been observed LMICs in Asia [10], Africa [11], South America [12] and Eastern Europe and Central Asia [13]. For example, MSM account for nearly one third of prevalent AIDS cases in Thailand [14] and Brazil [15], and 30% –75% of estimated new HIV infections in various parts of Laos and China [16,17]. A small number of epidemiologic studies have also shown high incidence (6.8/100 person-years) among MSM in Kenya and South Africa [18] and high HIV prevalence (4–23%) in Ukraine [19], though MSM comprise a small proportion of the total HIV cases in Africa, Eastern Europe and Central Asia, perhaps due, in part, to stigmatization and underreporting. As the HIV/AIDS epidemic enters its 4th decade post-recognition, many LMICs are repeating the mistakes made by high income countries in HIV control targeting MSM. A series of questions arise continually: Are MSM epidemics in LMICs driven by imported cases from high income countries? Have LMICs missed the window of opportunity to control the HIV epidemic among MSM? What experiences from the prevention and care for HIV among MSM populations have been learned from high income countries that could be applicable to the burgeoning MSM epidemic in LMICs?