Transcript ANAL INTERCOURSE AND HIV AMONG MSM EPIDEMIOLOGICAL REALITIES AND WAYS FORWARD Stefan Baral MD MPH CCFP FRCPC Johns Hopkins School of Public Health, USA.

ANAL INTERCOURSE AND HIV
AMONG MSM
EPIDEMIOLOGICAL REALITIES AND WAYS FORWARD
Stefan Baral MD MPH CCFP FRCPC
Johns Hopkins School of Public Health, USA
Overview

Epidemiology of HIV among MSM
Epidemic Scenarios of HIV among MSM
 Assessment of Data Quality
 Molecular Epidemiology
 Ecological Model of Risk Factors for HIV among MSM


Anal Intercourse as a Risk factor for HIV

Moving Forward
 Human

Rights-Affirming HIV Prevention Strategies
Conclusions
Introduction

Epidemiology




Ongoing epidemics among MSM in multiple LMIC
Newly identified epidemics in previously unstudied areas
Resurgent epidemics among MSM in high income countries (HIC)
Responses


Inadequate coverage and access for prevention, treatment, and care
Inadequate “toolkit” of prevention services for MSM
Epidemic Scenarios Algorithm
HIV prevalence in any high-risk
subgroup >5%
Unavailable Data
HIV prevalence ratio (MSM/gen pop)
Ratio ≥ 10
Ratio < 10
HIV prevalence ratio (IDU/gen pop)
HIV prevalence ratio (IDU/gen pop)
Ratio ≥ 10
Ratio < 10
Ratio ≥ 10
Ratio < 10
% population IDU
SCENARIO 3
≥ 1%
< 1%
% population MSM
< 10%
SCENARIO 1
SCENARIO 4
Source: Beyrer et al, Epidemiological Reviews, 2010
SCENARIO 2
Epidemic Scenarios for MSM
Evidence suggested four epidemic scenarios for LMIC MSM epidemics
-Scenario 5 will come from MENA region: now largely “unavailable data”
Beyrer C, et al, Epidemiology Reviews, 2010.
Scenario 1 - MSM risks are the predominant exposure
mode for HIV infection in the population
40.00%
H
I
V
P
r
e
v
a
l
e
n
c
e
30.00%
20.00%
Aggregate MSM
Prevalence
10.00%
0.00%
General
Population
Prevalence
SCENARIO1
MSM are the predominant exposure group for HIV
Beyrer C, et al, Epidemiology Reviews, 2010.
Scenario 2- MSM risks occur within established HIV
epidemics driven by injecting drug use (IDU)
50.00%
H
I
V
P
r
e
v
a
l
e
n
c
e
40.00%
30.00%
Aggregate IDU
Prevalence
Aggregate MSM
Prevalence
20.00%
General Population
Prevalence
10.00%
0.00%
Poland
Serbia
Armenia
Georgia
Moldova
Russia
East Timor
Ukraine
SCENARIO 2: Same sex practices are evaluated in the context
of established HIV epidemics among IDU
Beyrer C, et al, Epidemiology Reviews, 2010.
Scenario 3 - MSM risks occur in the context of mature
and widespread HIV epidemics among heterosexuals
30.00%
H
I
V 20.00%
P
r
e
v
a
l
e
n 10.00%
c
e
Aggregate MSM HIV Prevalence
General Population Prevalence
HIV Prevalence among Men (15+)
0.00%
Namibia
Botswana South Africa
Kenya
Tanzania
Malawi
Nigeria
Sudan
Uganda
SCENARIO 3: Same sex practices are evaluated in the context of high
prevalence and mature HIV epidemics among heterosexuals
Beyrer C, et al, Epidemiology Reviews, 2010.
HIV Prevalence among MSM in Africa
4.9%
(1,778)
4.4%
(90)
Morocco
Tunisia
5.7%
(259)
6.2%
(267)
5.9%
(262)
Egypt
21.5% 21.8%
(463) (501)
25.0%
(N/A)
Senegal
13.3%
(215)
The Gambia
9.3% 7.3%
(713) (406)
17.2%
13.4% (1,291)
(1,125)
Sudan
Nigeria
24.6%
19.0%
(285)
(563)
13.2%
(306)
Ghana
Uganda
Legend
Kenya
Tanzania
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
21.4%
(201)
12.4%
(218)
Malawi
19.7%
(117)
Namibia
Botswana
25.0%
(200)
10.6%
(538)
12.3%
(509)
40.7%
(285)
28.9%
(249)
Soweto
Cape Town (Township)
Cape Town
Modified From : van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009
SCENARIO 4: MSM, heterosexual, and IDU
transmission all contribute significantly to the HIV epidemic
30%
H
I
V
P
r
e
v
a
l
e
n
c
e
20%
Aggregate MSM
Prevalence
10%
General
Population
Prevalence
0%
SCENARIO 4: MSM, heterosexual, and IDU
transmission all contribute significantly to the HIV epidemic
Beyrer C, et al, Epidemiology Reviews, 2010.
EPIDEMIC SCENARIOS: Unavailable Data
• Kyrgyzstan
• Lebanon

Algeria
Azerbaijan
Djibouti
Iran
Iraq
Jordan
Kazakhstan

94 other Countries






• Libya
• Syria
• West Bank and Gaza
Assessment of Data Quality

Disease burden among MSM in LMIC

Data is predominantly Prevalence Data from Convenience Samples
 May not be generalizable to general population of MSM


Samples are among young MSM—so likely very conservative estimates of
disease burden
HIV Incidence has been characterized in


Cohort studies in Kenya, Peru, Brazil, Thailand
RCT in South Africa
HIV-1 incidence in MSM cohort, Kilifi, Kenya
40
50
2006-2011, 479 MSM in follow-up; 733.8 person years
0
10
20
30
9.1 per 100 person-years (95% CI; 7.2 – 11.6)
2006
2007
2008
2009
Calendar Year
Provided by Sanders, E. Kenyan Medical Research Institute, 2011
2010
2011
HIV among MSM in High Income Countries
Source: Sullivan, et al, 2009. Reemergence of the HIV Epidemic Among Men Who Have Sex With Men in North
America, Western Europe, and Australia, 1996–2005
Number of newly diagnosed HIV infections among men who have sex
with men, Hong Kong, Singapore, Taiwan and Japan, 2002 - 2007
Hong Kong
Taiwan
Singapore
180
Japan
1200
160
1000
120
800
100
600
80
60
400
Number of cases
Number of cases
140
40
200
20
0
HK
SG
TW
JP
0
2002
2003
56
38
305
50
54
336
340
2004
67
94
503
449
2005
Year 96
101
584
514
2006
2007
118
108
743
571
168
145
1075
690
Source: van Griensven, Baral, et al. 2009. The Global Epidemic of HIV Infection among Men who have Sex with Men. Current Opinion in HIV/AIDS
Phylogenetic Analysis of HIV among MSM
Region
Country
Reported HIV-1
subtypes
MSM (n)
HIV-1 subtypes in MSM
Reference
Africa
South Africa
C, AC
147
C (87%), B (11%), BF (2%)
Senegal
CRF02_AG, C, B
70
C (40%), AG (24%), B (18.6%), cpx (4.3%)
Middelkoop,
2011
Ndiaye, 2009
Kenya
A, AC
13
A, AC, AD, ACD
China, National sample CRF07_BC, CRF08_BC,
B, CRF01_AE
China, Beijing
CRF07_BC, CRF08_BC,
B, CRF01_AE
Singapore
CRF01_AE, B, G,
CRF33_01B,
CRF34_01B
Taiwan
B, CRF01_A/E,
CRF_07BC, CRF08_BC
Thailand
CRF01_AE, B, CRF01/B,
BC
Mongolia
B, CRF02_A/G
44
B (41%), CRF01_AE (30.2%), CRF07_BC
(2.3%)
B (71.1%), CRF01_AE (24.4%), CRF07_BC
(4.4%)
CRF01_AE, B, CRF34_01/B*
41
B (98%), CRF01_AE (1.3%), CRF07_B/C
(0.7%)
CRF01_AE (74.7%), B (7%), BC (3%),
CRF01/B (15.2%)
B (78%), CRF02_AG (9.8%)
Brazil
Argentina
399
124
B (80.1%), F (13%), B/F (11.4%)**
B 57.9% overall, predominant in MSM
Asia
Americas
B, F, B/F
B, BF, C, F
54
44
301
99
Source: Beyrer, et al 2012. The Epidemiology of HIV among MSM. Lancet. 2012.
Tovanabutra,
2010
Wang, 2008
Zhang, 2007
Lee, 2009
Kao, 2011
Arroyo, 2010
Jaqdagsuren,
2011
De Castro, 2010
Pando, 2011
Changing Patterns of MSM Subtype in Cape Town
(Note: cohorts not matched)
Heterosexual
MSM
1990s
C
B
B
2010
C
C
Source: Middelkoop, Williamson, .., Bekker, HIV Subtypes in MSM in Cape Town: evidence of bridging between epidemics, MOPE034 IAS 2011
HIV Clade by Race among MSM in Cape Town
SA Black
SA Coloured
SA White
Source: Middelkoop, Williamson, .., Bekker, HIV Subtypes in MSM in Cape Town: evidence of bridging between epidemics, MOPE034 IAS 2011
Ecological Model for HIV Risk in MSM
Level of Risks
Stage of Epidemic
Public Policy
Community
Network
Individual
Source: Baral and Beyrer, 2006
Anal Intercourse

Highest Risk form of Sexual Transmission
 1.4%
Per Sexual Act Probability of Transmission
 No
significant difference between heterosexual and samesex risk of anal intercourse
 Approximately 14 times higher than penile-vaginal per-act
probability
Source: Baggaley, et al. HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV
prevention. Int Journal of Epidemiology, 2010
Anal Intercourse is not limited to MSM

In Cape Town, South Africa:

Anonymous surveys of 2593 men and 1818 women:
 Anal intercourse (past 3 months): Men = 14%; Women = 10%
 Condom use during anal intercourse: Men = 67%; Women = 50%
Kalichman et al (2009)

In KwaZulu-Natal, South Africa:

42% of truck drivers (n=320) reported anal sex with female sex workers
Ramjee et al (2002)

In Kenya:

Survey among FSW (n=147):
 40.8% reported ever practising anal intercourse, 30% reported never or rarely using
condoms during anal intercourse
 consistent condom use lower in anal sex than peno-vaginal intercourse
Schwandt et al (2006)

In Nigeria:

anal sex practiced by 12% of public secondary schools students (N= 521)
Bamidele et al (2009)
Modified from: Salim Karim, Does Africa need a rectal microbicide?, 2011
Anal Intercourse – Per Partner
Source: Baggaley, et al. HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV
prevention. Int Journal of Epidemiology, 2010
Anal Intercourse

Biological Drivers of HIV Risk Among MSM
 Anal
Intercourse is far higher per-act and per-partner
risk of HIV transmission
 Reasons:


HIV is a gut-tropic virus
Increased trauma during intercourse
 Sexual
 In
Positioning
penile-vaginal intercourse, sexual positioning is
biologically determined
 In penile-anal intercourse among men, sexual positioning is
versatile
Rights-Affirming HIV Prevention Programs

Combination HIV Prevention Interventions (CHPI)

Behavioural Interventions

Increasing condom and lubricant use during sex


Biomedical Interventions

Biomedical interventions aim to decrease transmission and acquisition
risk of sex


Eg. Peer Education, Risk Reduction Counselling, Adherence Counselling
Eg. Oral or topical antiviral chemoprophylaxis, Treatment as Prevention
Structural Interventions

Rarely been appropriately evaluated because of complexity in study
design to characterize efficacy and effectiveness of these
interventions

Eg. Decriminalization, Government-sponsored anti-stigma policy, Mass media
engagement, Gender engagement programs, Community systems strengthening, Health
Sector Interventions
Prerequisites for Effective HIV Prevention
Programs

Identification

Must be able to Identify MSM


Risk Assessment

Must be able to appropriately stratify MSM according to
risk


Willing to Self-Disclose
Asked about risks in a competent and sensitive manner
Follow Up

Must be able to follow up participants to assess adherence
and efficacy of intervention
Safe Environment
 Client trust in health care facility

Research Priorities for Structural Interventions
Research Priorities for Structural Interventions
HIV Research Priorities among MSM in Africa
Interventions
Prioritized Components of
Experimental Arm
Other Identified Research Priorities
Structural
1.
2.
3.
Healthcare worker training
Social Capital
Community Capacity
Building
Linkages to care, HCT, Bridging between heterosexual and MSM
services and individuals, Criminalization research – country/context
based, Advocacy, Decriminalization, Cultural key role player training –
community leaders and police, Awareness and education around
PEP/PrEP, Policy/Access to PEP, Linkages to care – good referrals,
Mass media, Building competency in all services, Safe access, Safe
spaces, Skilled health care professionals, Electronic media, Tools for
(guidelines, screening, and adherence), Economic education -- income
generation
Behavioral
1.
2.
3.
Adherence Counseling
Risk Reduction counseling
Mental health counseling
Education, Choices – condoms/interventions, HIV Prevention counseling
for positive individuals, Male Couples counseling, Alcohol and drug
awareness and preparation, Psychosocial support counseling
Biomedical
1.
2.
3.
Rectal Microbicide
PrEP
Condoms/CondomCompatible Lubricants
Vaccines (Hep A/B, HPV), Anal Health (Pap smear, exam), TB
screening, ART>350 and for sero-discordant male couples
Prevention Expenditures for MARPS

Concentrated Epidemics
 MSM
and SW predominant risk groups
 3.3%
of non-treatment expenditures supporting MSM
 2% of non-treatment expenditures support FSW

Generalized Epidemics
 Emerging
evidence of risk among MSM and SW
<
0.1% of non-treatment expenditures supporting MSM and
SW

With few exceptions, most African States have invested 0% of
national expenditures for prevention needs for MSM and SW
Source: Global HIV Prevention Working Group: Global HIV Prevention: The Access, Funding, and Leadership Gaps. 2009
Conclusions

HIV continues to disproportionately affect MSM in high and low
income settings
 The exclusion of MSM from national responses has not been a
decision based in evidence
 In every setting where MSM have been studied, they have been
found to carry disproportionate burden of HIV compared to other
age-matched general population men

Data quality is sub-optimal with limited:




HIV incidence data
Population-based prevalence data
HIV risk factors include individual level and structural drivers
of risk including stigma, criminalization, and human rights
violations
Molecular epidemiology demonstrates that these epidemics
are not separated from prevalent strains in each country
Moving Forward

Epidemiology

Filling in the map



We have studies in several countries including Swaziland,
Malawi, The Gambia, Cameroon, Togo, and Burkina Faso
Characterizing Incidence Data, Phylogenetic Analysis
Prevention

Combination HIV Prevention Research

Biomedical, Behavioral, and Structural Approaches