Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people.
Recommendations for a public health approach. 2011
SUMMARY
Since the beginning of the epidemic in the early 1980s, men who have sex with men (MSM) and transgender people have been disproportionately affected by the human immunodeficiency virus (HIV). The risk for infection remains high among them; and there has been a resurgence of HIV infection among MSM, particularly in industrialized countries. Data are emerging of new or newly identified HIV epidemics among MSM in Africa, Asia, the Caribbean and Latin America.
A meta-analysis of surveillance data in low- and middle-income countries found that MSM are 19.3 times more likely to be HIV-infected than the general population. Reported HIV prevalence among MSM ranges from 0% to 32.9%, with rates surpassing 20% in countries as diverse as Bolivia, Jamaica, Mexico, Myanmar, Thailand, Trinidad and Zambia. HIV incidence among MSM ranges from 1.2 to 14.4 per 100 person-years. Recent studies from sub-Saharan
Africa reported that HIV prevalence among MSM ranges from 6% to 31%. In Asia, the odds of MSM being infected with HIV are 18.7 times higher than in the general population; and the HIV prevalence ranges from 0% to 40%. In Latin America, it is estimated that half of all HIV infections in the region have resulted from unprotected anal intercourse between men. The few existing epidemiological studies among transgender people have shown disproportionately
high HIV prevalence ranging from 8% to 68%, and HIV incidence from 3.4 to 7.8 per 100 person-years. It is important to note that underlying correlates of HIV and STI risk as well as the specific sexual health needs of transgender people may be distinct from those of MSM. Although the same basic HIV and STI prevention interventions may be indicated for the two groups, public health professionals should avoid conflating the two groups and work towards a more nuanced understanding of each group’s needs.
Criminalization, and legal and policy barriers play a key role in the vulnerability of MSM and transgender people to HIV. More than 75 countries currently criminalize same-gender sexual activity. And transgender people lack legal recognition in most countries. These legal conditions force MSM and transgender people to risk criminal sanctions if they want to discuss their level of sexual risk with a service provider. They also give police the authority to harass organizations that provide services to these populations. Long-standing evidence indicates that MSM and transgender people experience significant barriers to quality health care due to widespread stigma against homosexuality and ignorance about gender variance in mainstream society and within health systems. Social discrimination against MSM and transgender people has also been described as a key driver of poor physical and mental health outcomes in these populations across diverse settings. In addition to being disproportionately burdened by STI and HIV, MSM and transgender people experience higher rates of depression, anxiety, smoking, alcohol abuse, substance use and suicide as a result of chronic stress, social isolation and disconnection from a range of health and support services.
From a health systems’ perspective, MSM and transgender people may delay or avoid seeking health, STI or HIV-related information, care and services as a result of perceived homophobia, transphobia, ignorance and insensitivity. MSM and transgender people may be less inclined to disclose their sexual orientation and other health-related behaviours in health settings that may otherwise encourage discussions between the provider and patient to inform subsequent clinical decision-making. Providers are likely to feel biased when their own cultural, moral or religious leanings are incongruent with a patient’s reported sexual orientation, behaviours or gender identity. Additionally, enquiry into the level of knowledge among physicians, nurses and other health care providers on MSM and transgender-related health issues has shown that the clinical curriculum, particularly in low- and middle-income countries, do not
address these knowledge gaps. Despite the strong impact of the HIV epidemic on MSM and transgender people, to date, no technical recommendations have been made to guide health systems’ response to the epidemic among them. In September 2008, the World Health Organization (WHO) held a global consultation on “Prevention and treatment of HIV and other sexually transmitted infections (STI) for men who have sex with men and transgender populations”, in Geneva, Switzerland.
Recommendations from that global consultation, as well as from WHO regional consultations, called for the need to develop guidance for delivering an evidence-based, package of interventions for implementation by the health sector to prevent and treat HIV and other STIs among MSM and transgender people. The guideline is designed for use by national public health officials and managers of HIV/AIDS and STI programmes, nongovernment organizations (NGOs) including community and civil society organizations, and health workers. It may also be of interest to international funding agencies, the scientific media, health policy-makers and advocates. This guideline will provide recommendations for regional and country partners on appropriate interventions designed to address needs of MSM and transgender people. It also provides an opportunity to highlight and emphasize the correlation between prevention and treatment in the response to the HIV epidemic among MSM and transgender people, particularly in light of increasing evidence about the preventive benefit of antiretroviral therapy (ART). This may lead to a substantial reduction in transmission at the population level. The development of this document followed the standard procedures currently in place at the World Health Organization for the production of evidence-based recommendations, which utilize the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. These recommendations are proposed as a standard of prevention and care attainable in resource-limited settings. WHO recommends that this guidance be available for MSM and transgender people in high-income countries as well. For the development of these guidelines, the overarching principle is respect for and protection of human rights.
Recommendations on human rights and non-discrimination in health-care settings
1. Legislators and other government authorities should establish antidiscrimination and protective laws, derived from international human rights standards, in order to eliminate discrimination and violence faced by MSM and transgender people, and reduce their vulnerability to infection with HIV, and the impacts of HIV and AIDS.
2. Health services should be made inclusive of MSM and transgender people, based on the principles of medical ethics and the right to health.
Recommendations on HIV prevention, care and treatment
Prevention of sexual transmission
1. Using condoms consistently during anal intercourse is strongly recommended for MSM and transgender people over not using condoms. Strong recommendation, moderate quality of evidence
2. Using condoms consistently is strongly recommended over serosorting for HIV-negative MSM and transgender people. Strong recommendation, very low quality of evidence Serosorting is suggested over not using condoms by HIV-negative MSM and transgender people under specific circumstances as a harm reduction strategy. Conditional recommendation, very low quality of evidence
3. Not offering adult male circumcision to MSM and transgender people for the prevention of HIV and STI is suggested over offering it. Conditional recommendation, very low quality of evidence
HIV testing and counselling
4. Offering HIV testing and counselling to MSM and transgender people is strongly recommended over not offering this intervention. Strong recommendation, low quality of evidence
5. Offering community-based HIV testing and counselling linked to care and treatment to MSM and transgender people is suggested over not offering such programmes. Strong recommendation, very low quality of evidence
Behavioural interventions, information, education, communication
6. Implementing individual-level behavioural interventions for the prevention of HIV and STIs among MSM and transgender people is suggested over not implementing such interventions. Conditional recommendation, moderate quality of evidence
7. Implementing community-level behavioural interventions for the prevention of HIV and STIs among MSM and transgender people is suggested over not implementing such interventions. Conditional recommendation, low quality of evidence
8. Offering targeted internet-based information to decrease risky sexual behaviours and increase uptake of HIV testing and counselling among MSM and transgender people is suggested over not offering such information. Conditional recommendation, very low quality of evidence
9. Using social marketing strategies to increase the uptake of HIV/STI testing and counselling and HIV services among MSM and transgender people is suggested over not using such strategies. Conditional recommendation, very low quality of evidence
10. Implementing sex venue-based outreach strategies to decrease risky sexual behaviour and increase uptake of HIV testing and counselling among MSM and transgender people is suggested over not implementing such strategies. Conditional recommendation, very low quality of evidence
Substance use and prevention of bloodborne infections
11. MSM and transgender people with harmful alcohol or other substance use should have access to evidence-based brief psychosocial interventions involving assessment, specific feedback and advice. In line with existing WHO guidance
12. MSM and transgender people who inject drugs should have access to needle and syringe programmes and opioid substitution therapy. In line with existing WHO guidance
13. Transgender people who inject substances for gender enhancement should use sterile injecting equipment and practise safe injecting behaviours to reduce the risk of infection with bloodborne pathogens such as HIV, hepatitis B and hepatitis C. In line with existing WHO guidance
HIV care and treatment
14. MSM and transgender people living with HIV should have the same access to ART as other populations. ART should be initiated at CD4 counts of ≤350 cells/mm3 (and for those in WHO clinical stage 3 or 4 if CD4 testing is not available). Access should also include management of opportunistic infections, co-morbidities and treatment failure. In line with existing WHO guidance
15. MSM and transgender people living with HIV should have access to essential interventions to prevent illness and HIV transmission including, but not limited to, care and support and antiretroviral therapy. In line with existing WHO guidance
Recommendations on prevention and care of other sexually transmitted infections
1. MSM and transgender people with symptomatic STIs should seek and be offered syndromic management and treatment. In line with existing WHO guidance
2. Offering periodic testing for asymptomatic urethral and rectal N. gonorrhoeae and C. trachomatis infections using NAAT is suggested over not offering such testing for MSM and transgender people. Conditional recommendation, low quality of evidence Not offering periodic testing for asymptomatic urethral and rectal N. gonorrhoeae infections using culture is suggested over offering such testing for MSM and transgender people. Conditional recommendation, low quality of evidence
3. Offering periodic serological testing for asymptomatic syphilis infection to MSM and transgender people is strongly recommended over not offering such screening. Strong recommendation, moderate quality of evidence
4. MSM and transgender people should be included in catch-up HBV immunization strategies in settings where infant immunization has not reached full coverage. In line with existing WHO guidance
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La OMS recomienda elaborar leyes contra la discriminación como forma de luchar contra el VIH en homosexuales y personas transexuales
La Organización Mundial de la Salud (OMS) ha dado a conocer una serie de recomendaciones generales y de salud pública con el objetivo de ampliar el acceso a los servicios de tratamiento y prevención de las infecciones de transmisión sexual, y muy en especial de la infección por el VIH, de los hombres que tienen relaciones homosexuales y de las personas transexuales. Se trata de la primera vez que dicha organización elabora un documento específico sobre este colectivo. Entre las recomenaciones, una especialmente significativa: poner fin a la discriminación de este colectivo.
Según expresa la OMS en un comunicado, en los países industrializados se ha detectado un resurgimiento de la infección por el VIH en los hombres que tienen relaciones homosexuales. También se han identificado epidemias en dicho grupo en África, Asia, el Caribe y América Latina. En términos generales, estos hombres tienen casi 20 veces más probabilidades de contraer la infección por el VIH que la población general. Por lo que se refiere a las personas transexuales, las tasas de infección oscilan entre un 8% y un 68%, según el país o región.
Uno de los motivos que la OMS ha detectado es el estigma que recae en muchos hombres que tienen relaciones homosexuales y en las personas transexuales, que en muchos países siguen sometidos a criminalización, condenados a la clandestinidad y al margen de los servicios de prevención y tratamiento.
La OMS recomienda la implementación de prácticas más incluyentes para combatir esta situación. Algunas de ellas son:
- Elaborar leyes contra la discriminación e idear medidas para proteger los derechos humanos, así como establecer servicios más incluyentes para los hombres que tienen relaciones homosexuales y las personas transexuales.
- Ofrecer pruebas y orientación sobre la infección por el VIH, seguidas de tratamiento de los pacientes con un número de linfocitos CD4 de 350 o menos, como se recomienda en las directrices de tratamiento de la infección por el VIH publicadas por la OMS en 2010.
- Ampliar las intervenciones comportamentales para la prevención de las infecciones de transmisión sexual, en particular la producida por el VIH, en los hombres que tienen relaciones homosexuales y los transexuales.
- Usar siempre condón en vez de escoger a la pareja sobre la base de su estado serológico con respecto a la infección por el VIH.
