How Are Anti-LGBT Laws Affecting Progress Towards UNAIDS HIV Targets in Africa?

HIV testing rates have improved among high risk populations including men who have sex with men (MSM) in Africa, but new research indicates that the developments are not enough to meet the UNAID’s 90-90-90 targets. The shortcomings may be linked to existing anti-LGBT legislation in some nations.

These results were determined from a meta-analysis of HIV testing and treatment among MSM in Africa that also examined the effects of criminalization of same-sex relationships and stigma. The results of the research were published in The Lancet HIV.

The study team, led by investigators from Imperial College London, extracted data on HIV testing and engagement with HIV care among African MSM from research published between January 1, 1980, through October 10, 2018.

The investigators identified 75 studies that provided data on 44,993 African MSM across at least 1 testing and treatment outcome. The team used inverse-variance random-effects models to derive pooled estimates and subgroup and meta-regression analysis to evaluate associations between HIV testing and awareness outcomes with study and participant characteristics, which included the severity of national anti-LGBT legislation.

Analysis found that HIV testing increased significantly over time. With the pooled proportions of MSM ever tested for HIV at 67.3% (95% confidence intervals [CI]: 62.1-72.3; 44 estimates) the proportion of MSM tested within the past 12 months was 50.1% (42.4-57.8; 31 estimates) after 2011, which marked 14.8 percentage points and 17.9 percentage points higher than before 2011, respectively.

After the year 2011, the number of MSM ever tested was highest in southern Africa (80.0%) and lowest in northern Africa (34.4%), with the greatest increase observed in western Africa (from 42.4% to 70.9%).

Additionally, the team found that testing and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation when compared with countries with least severe legislation (57.4% vs 71.6%, p = 0.0056; 35.5% vs 49.3%, p = 0·010; 6.7% vs 22.0%, p = 0.0050).

"Globally, MSM are about 28 times more likely to be living with HIV than men in the general population,” James Stannah, MPH, from the Medical Research Council Centre for Global Infectious Disease Analysis, at Imperial, said in a press release. “This inequality is particularly apparent in sub-Saharan Africa where almost two-thirds of countries still criminalize same-sex relations between men, many with long prison sentences and some with the death penalty.”

Data further suggest that only 18.5% of MSM with HIV were aware of their status, and 23% of individuals who were aware of their status were taking antiretroviral therapy (ART). Moreover, pooled levels of viral suppression among MSM on ART were 75.6%, but only 24.7% among all MSM living with HIV.

"These results are important because MSM in Africa have not received sufficient national and global attention, yet are disproportionately affected by HIV,” Marie-Claude Boily, PhD, lead author from Imperial's School of Public Health, said in the statement. “This study, the first large-scale analysis of HIV testing and treatment among MSM in Africa, suggests 3 in 4 MSM living with HIV in Africa may not be on ART, meaning a large fraction will unnecessarily die of AIDS - and can pass on the virus to their partners. To reduce the burden of HIV among the MSM community and globally, we need to reach those groups of people who are most likely to acquire and transmit the virus."

According to the authors, further studies are needed to determine accurate estimates of status awareness, participation in HIV care, and viral suppression among MSM in Africa in order to provide direction to prevention efforts aimed at improving access to HIV services. Additionally, the link between anti-LGBT legislation and lower HIV testing rates and status awareness should be explored.