HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: a systematic review and meta-analysis, by James Stannah, Elizabeth Dale, Jocelyn Elmes, Roisin Staunton, Chris Beyrer, Kate M Mitchell, Marie-Claude Boily was published in the journal The Lancet HIV:www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30239-5/fulltext
HIV disproportionately affects gay, bisexual, and other men who have sex with men (MSM) in Africa, where many countries criminalise same-sex behaviour. We assessed changes in the engagement of African MSM with HIV testing and treatment cascade stages over time, and the effect of anti-LGBT legislation and stigma.
We systematically searched Embase, Global Health, MEDLINE, Scopus, and Web of Science for peer-reviewed cross-sectional or longitudinal studies recruiting at least ten MSM, published from Jan 1, 1980, to Oct 10, 2018. We extracted or derived estimates of HIV testing, engagement with the HIV treatment cascade, or both among African MSM from published reports. We derived pooled estimates using inverse-variance random-effects models. We used subgroup and meta-regression analysis to assess associations between testing and status awareness outcomes and study and participant characteristics, including the severity of country-level anti-LGBT legislation.
Our searches identified 75 independent eligible studies that provided estimates for 44 993 MSM across one or more of five testing and treatment cascade outcomes. HIV testing increased significantly over time overall, with pooled proportions of MSM ever tested for HIV of 67·3% (95% CI 62·1–72·3; 44 estimates) and tested in the past 12 months of 50·1% (42·4–57·8, 31 estimates) after 2011, which were 14·8 percentage points and 17·9 percentage points higher than before 2011, respectively. After 2011, ever testing was highest in southern Africa (80·0%), and lowest in northern Africa (34·4%), with the greatest increase in western Africa (from 42·4% to 70·9%). Levels of testing ever, in the past 12 months, and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation compared with countries with the 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). Few estimates were available for later stages of the treatment cascade. Available data after 2011 suggest that the pooled proportion of MSM HIV-positive aware has remained low (18·5%, 12·5–25·3; 28 estimates), whereas proportions of current antiretroviral therapy (ART) use were 23·7% (15·5–33·0; 13 estimates) among all MSM living with HIV and 60·1% (48·6–71·1; five estimates) among MSM HIV-positive aware of their status. Pooled levels of viral suppression among MSM currently on ART were 75·6% (64·4–85·5; four estimates), but only 24·7% (18·8–31·2; four estimates) among all MSM living with HIV.
Despite improvements in HIV testing among MSM in Africa, HIV status awareness, ART coverage, and viral suppression remain much lower than required to achieve UNAIDS 90–90–90 targets. Further studies are urgently needed to provide more accurate estimates of levels of status awareness, engagement in care, ART coverage, and viral suppression among MSM to inform prevention efforts aimed at improving access to HIV services for MSM. Severe anti-LGBT legislation might be associated with lower HIV testing and status awareness; therefore, further research is needed to assess the effect of such legislation on HIV testing and engagement with the HIV treatment cascade among MSM.
Research in context
Evidence before this study
Gay, bisexual, and other men who have sex with men (MSM) are disproportionately burdened with HIV globally, with particularly high prevalence in Africa. Engagement in all stages of the HIV treatment cascade (including testing, status awareness, engagement in care, and antiretroviral therapy use) might be particularly challenging in many African countries where existing legislation criminalises same-sex relations. We searched Embase, Global Health, MEDLINE, Scopus, and Web of Science, for studies published between Jan 1, 1980, and Oct 10, 2018, reporting on HIV testing and the HIV treatment cascade among MSM in Africa. Abstracts of non-English articles were translated, when possible, and full texts received and translated, if potentially relevant. We included peer-reviewed cross-sectional or longitudinal studies recruiting at least ten MSM and excluded mathematical modelling studies, qualitative studies, conference abstracts and reviews, and studies reporting cascade outcomes using self-reported HIV status to derive the number of MSM living with HIV in the denominator. We did not make exclusions based on language. Although several studies have reported negative effects of specific anti-LGBT legislation on HIV treatment and care in countries including Uganda and Nigeria, no study has systematically reviewed the evidence on the influence of legislation on HIV testing and the treatment cascade across Africa. Additionally, the HIV treatment cascade has never been comprehensively reviewed and summarised for MSM in Africa. The most recent literature review of the treatment cascade among key populations (done in 2015) reported on MSM, sex workers, and people who inject drugs globally, but only three studies on MSM in Africa were included.
Added value of this study
To our knowledge, this is the first systematic review and meta-analysis of the engagement of MSM in Africa with HIV testing and all stages of the HIV treatment cascade, which also assesses progress over time and the relationship between HIV testing and treatment and the severity of anti-LGBT legislation. We included data from 75 independent studies from 28 countries and estimated pooled proportions of HIV testing, status awareness, engagement in care, antiretroviral therapy use, and viral suppression for 44 993 MSM. Our analysis of available HIV testing data over time suggests that after 2011, pooled estimates of levels of testing ever (67%) and in the past 12 months (50%) were significantly higher than before 2011, with the greatest increases in western Africa. Despite this increase, pooled estimates of status awareness after 2011 suggest that it is still low (19%). Our pooled estimates after 2011 also suggested that MSM on antiretroviral therapy can achieve relatively high viral suppression (76%). However, among all MSM living with HIV, current antiretroviral therapy use (24%) and viral suppression (25%) remain extremely low. We found that more severe anti-LGBT legislation was statistically significantly associated with lower levels of testing and status awareness. We also showed that despite a substantial increase in the number of studies on the HIV treatment cascade among MSM in Africa over the past few years, data remain scarce for all outcomes except HIV testing, especially from central and northern Africa.
Implications of all the available evidence
Despite improvements in HIV testing among MSM in Africa, particularly since 2011, and levels of testing among MSM exceeding those among all men in all regions, HIV status awareness, antiretroviral therapy coverage, and overall viral suppression have remained very low, with HIV status awareness and antiretroviral therapy coverage among MSM much lower than among all men, despite higher testing. Additional efforts are urgently needed to reach the UNAIDS 90-90-90 targets among MSM across Africa. Furthermore, our findings support previous evidence suggesting an association between anti-LGBT legislation and access to testing and treatment. Further research is needed to assess the effect of repealing such legislation on access to HIV services for MSM. Additionally, in spite of an increase over time in the number of studies, more data are still needed on the engagement of MSM in all stages of the HIV treatment cascade, particularly status awareness, engagement in care, antiretroviral therapy use, and viral suppression, and more research needs to be done in northern and central Africa, where few data were available.