HIV testing and the HIV care continuum among sub-Saharan African men who have sex with men and transgender women screened for participation in HPTN 075

Abstract

Throughout the world, men who have sex with men (MSM) are at increased risk for HIV infection compared to heterosexual men. Little is known about awareness of HIV infection and other gaps in the HIV care continuum for MSM, especially in sub-Saharan Africa (SSA). This information is urgently needed to address the HIV epidemic in this population. This study assessed gaps in the HIV care continuum among persons screened for participation in a multi-country prospective study that evaluated the feasibility of recruiting and retaining MSM for HIV prevention studies in SSA (HIV Prevention Trials Network (HPTN) 075, conducted in four cities in Kenya, Malawi, and South Africa). Participants were recruited using site-specific strategies, that included outreach and informal networks. Transgender women (TW) were eligible to participate. During screening, 601 MSM and TW were tested for HIV infection and asked about prior HIV testing, HIV status, engagement in care, and HIV treatment. Viral load testing and retrospective antiretroviral (ARV) drug testing were performed for HIV-infected participants. Most participants (92.2%) had a prior HIV test; 42.1% were last tested >6 months earlier. HIV prevalence was 30.4%. HIV infection was associated with older age and identifying as female or transgender; 43.7% of the HIV-infected participants were newly diagnosed, especially younger persons and persons with a less recent HIV test. Almost a third of previously-diagnosed participants were not linked to care. Most participants (88.7%) in care were on ARV treatment (ART). Only about one-quarter of all HIV-infected participants were virally suppressed. These findings demonstrate substantial prevalence of undiagnosed HIV infection and sub-optimal HIV care engagement among MSM and TW in SSA. Increased HIV testing frequency and better linkage to care represent critical steps in preventing further HIV transmission in this population. Once in care, gaps in the HIV care continuum appear less critical.

HIV infection and engagement in HIV care cascade among men who have sex with men and transgender women in Kigali, Rwanda: a cross‐sectional study

“…The high proportion of viral suppression among MSM who reported not knowing their status or using ART, suggests that more MSM participants knew their HIV status and were on ART than those who self‐reported. This misreporting of HIV status and engagement in care has been described previously (10). Although, there is a possibility that some are elite controllers, this proportion is much higher than what would be expected based on several studies of elite controllers in Africa (39‐41).…”

“…Furthermore, structural determinants increase HIV risk by limiting the uptake and provision of HIV prevention and treatment services for MSM (9). Consequently, MSM generally have lower engagement in HIV prevention and treatment services and poorer outcomes compared to other adults in SSA (10,11).…”

HIV incidence in a multinational cohort of men and transgender women who have sex with men in sub-Saharan Africa: Findings from HPTN 075

“…Participants in Cape Town were also more likely to be diagnosed with an STI (rectal GC and/or CT, or syphilis) at enrollment. The difference in HIV prevalence between Cape Town and Blantyre observed at screening (31.7% and 22.1%, respectively) [ 16 ] might also have contributed to the difference in HIV incidence. This difference is consistent with the higher estimated overall HIV prevalence reported among MSM in South Africa and Malawi (26.8% and 17.3%) [ 36 ] and among 15- to 49-year-old men in South Africa and Malawi (18.9% and 9.2%, respectively) [ 40 ].…”

“…The study was conducted at four sites: Kisumu, Kenya; Blantyre, Malawi; Cape Town and Soweto, South Africa. At these sites, the observed HIV prevalence among those screened for study participation was 16.6%, 22.1%, 31.7%, and 49.1%, respectively [ 16 ]. Prior HIV incidence estimates for MSM in Kenya and South Africa ranged from 5.1/100 PY (95% CI: 2.6, 9.8) to 12.5 PY (95% CI: 8.1, 19.2) [ 6 , 11 – 13 ].…”

From general to specific: moving past the general population in the HIV response across sub‐Saharan Africa

“…Past epidemiological studies among men who have sex with men in Botswana, Namibia, Malawi, South Africa, Kenya, Senegal and Nigeria suggest that sex with women is relatively common among men who have sex with men. The reported proportion who recently had sex with women has ranged from 20% to 75% [43‐46].…”