Out of the Closet and Into Public Health Focus: HIV and STDs in Men Who Have Sex With Men in Middle Income and Resource-Limited Countries

From the earliest days of the human immunodeficiency virus (HIV) epidemic, it has been recognized that diverse patterns of human behavior have been most highly associated with HIV transmission in different parts of the world. Early epidemiologic studies suggested that the epidemic in the developed world was partially potentiated by sex in men who have sex with men (MSM), as well as injecting drug use, but to a lesser extent by heterosexual intercourse. On the other hand, HIV spread in Africa and Asia seemed to be primarily associated with heterosexual HIV transmission.1 However, scholarly work in recent years has well-documented that along side of the global heterosexual epidemic, most developing countries have significant MSM epidemics.2 These data are still fragmentary, because many of the populations are relatively or almost fully hidden due to social stigma and governmental sanctions e.g.,1,3–5 and prevalence rates are often based on convenience samples, yielding biased estimates. Nevertheless, these emerging data are concerning. For example, in Senegal, 2 independent studies revealed HIV prevalence rates of over 20% among MSM6; and HIV prevalence in a Kenyan MSM sample was 24.6% in 2005.7 Data emerging from Asia are also concerning, with HIV prevalence increasing by 200% between 2002 and 2007 among MSM in Hong Kong.8 In cross-sectional studies from Southeast Asia, HIV prevalence rates have ranged widely, with the highest, 30.8%, being found in Thailand.9 In Japan, 67.4% of individuals newly diagnosed with HIV during 2007 were MSM.10 The importance of concentrated HIV/sexually transmitted disease (STD) epidemics among MSM in middle and low income countries in Asia and Africa11 is further enhanced by the publication by Yang et al in this journal.12 The data represent one of the first prospective studies of MSM conducted in China, identifying a cohort of 397 men in Nanjing through respondent-driven sampling. The investigators found an impressive annualized HIV incidence rate of 5.1%. MSM who were most likely to become HIV infected included those who had been having sex with other men for more than 10 years, those who met partners at saunas, those who had an initial diagnosis of syphilis at the start of the study, and those with multiple sexual partners and/or engaged in unprotected anal sex in the past 6 months. These data underscore a concerning trend, that an increasing wave of new HIV and STD infections are occurring in Chinese MSM. There are many factors that potentiate the spread of HIV in MSM around the world. Certainly this Chinese study, as many others, has demonstrated high coprevalence of HIV and STDs e.g.13–15 Of note, in the current study, was a syphilis prevalence of 12.7% among the men at entry into the study. These data suggest that comprehensive STD and HIV screening programs are warranted for this population, given the morbidity and mortality that untreated infections may pose, as well as their potential role in enhancing HIV acquisition and transmission. Biologic cofactors, such as concurrent STDs are not the only facilitator of the global HIV and STD epidemics among MSM. These populations are often stigmatized and there are psychosocial stresses that may increase their propensity for risk-taking behavior.16 A recent study of MSM in Chennai, India found that the predictors of engaging in unprotected intercourse included being less educated, having clinically significant depressive symptoms, and lower condom use self-efficacy. MSM testing positive for HIV infection in this sample tended to be less educated and not living with parents, which may be a marker for disenfranchisement in a traditional society. In addition to needing to address mental health concerns, another recent study from Chennai, India, found that only one-quarter of the MSM queried reported engaging in an HIV prevention intervention or program in the prior year.17 Men who were older, more educated, or “out” about having sex with other men were more likely to have reported participating in an HIV prevention intervention or program. The invisibility of many subsets of MSM in non-Western societies makes them less likely to benefit from HIV and STD prevention messages. This decreased engagement in prevention services is most dramatically demonstrated by the fact that among male clients attending an HIV and STD voluntary counseling site in Mumbai, India, MSM who were married to women (presumably more covert about their homosexual behavior), were significantly more likely to be HIV infected.18 Because married MSM may not perceive themselves as risky, particularly if they are usually the insertive partner, they may receive less HIV prevention counseling. Yet, they may serve as a “bridge” population, unaware of their infection and continuing to engage in unprotected sex with their wives, resulting in further HIV transmission to female partners and, potentially, to offspring. To prevent a further widening of the global HIV and STD epidemic among MSM, multilevel interventions are needed. Several Asian and African governments (most recently, Uganda) have contemplated or enacted punitive laws that could serve to potentiate covert HIV risk-taking behavior by discouraging high-risk individuals from seeking access to preventive services, as well as HIV/STD diagnostic testing. e.g.19,20 It was the recognition that antiquated penal codes from the Victorian era, that led a coalition of Indian intellectuals and civil rights and public health activists to successfully convince the Delhi High Court to repeal Code 377, the sodomy law. Unfortunately, local health care providers may exacerbate institutional homophobia because of mirroring social rejection of homosexuality, in addition to being ignorant about appropriate diagnostic screening practices, as well as culturally appropriate counseling. In recent years, there has been an increase in the availability of educational materials to assist health care professionals in providing culturally competent care.21 Because of the psychosocial context of being an MSM in many countries, concerns such as internalized homophobia derived from familial and societal rejection, may be associated with engaging in high-risk behavior. Additionally, societal rejection of homosexuality can lead to psychosocial problems such as depression and/or use disinhibiting substances on a regular basis, both of which, in turn, lead to increased HIV risk behavior. HIV risk behavior in MSM seems to vary with co-occurring psychosocial problems, which may vary in type in different geographic or cultural settings, as seen in the United States22,23 and India.16–18 Such problems may be directly related to sexual risk taking, and may also moderate the effectiveness of public health interventions to reduce sexual risk taking. For example, one recent study of HIV-infected MSM in the United States suggested that one theoretical model of sexual risk taking, social cognitive theory, did not apply to HIV-infected MSM with comorbid depression, but did for HIV-infected MSM who did not have comorbid depression.24 Thus, to gain traction in decreasing the spread of HIV and STDs among MSM, public health officials and clinicians need to develop comprehensive programs that will incorporate HIV and STD screening with counseling, as well as promulgation of culturally tailored services to deal with substance use and addiction, as well as mental health concerns. In an era where there is increased optimism that wider use of antiretrovirals may decrease HIV transmission,25 it would be unfortunate if human rights violations and societal biases could exacerbate the global HIV and STD epidemics among highly vulnerable populations throughout the world. Public health policy will need to be abetted by nuanced and sensitive responses that encourage sexual and gender minority populations to come out of the closet in order to access clinical services.