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

2. 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

3. 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

4. Epidemic Scenarios Algorithm HIV prevalence in any high-risk subgroup >5% HIV prevalence ratio (MSM/gen pop) Unavailable Data HIV prevalence ratio (IDU/gen pop) Ratio < 10 HIV prevalence ratio (IDU/gen pop) Ratio < 10Ratio ≥ 10Ratio < 10Ratio ≥ 10 % population IDU ≥ 1%< 1% % population MSM SCENARIO 3 SCENARIO 2 < 10% SCENARIO 1 SCENARIO 4 Ratio ≥ 10 Source: Beyrer et al, Epidemiological Reviews, 2010

5. 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.

6. Scenario 1 - MSM risks are the predominant exposure mode for HIV infection in the population

7. SCENARIO1 MSM are the predominant exposure group for HIV Beyrer C, et al, Epidemiology Reviews, 2010.

8. Scenario 2- MSM risks occur within established HIV epidemics driven by injecting drug use (IDU)

9. SCENARIO 2: Same sex practices are evaluated in the context of established HIV epidemics among IDU Beyrer C, et al, Epidemiology Reviews, 2010.

10. Scenario 3 - MSM risks occur in the context of mature and widespread HIV epidemics among heterosexuals

11. SCENARIO 3: S ame sex practices are evaluated in the context of high prevalence and mature HIV epidemics among heterosexuals Beyrer C, et al, Epidemiology Reviews, 2010.

12. Legend 2002 2003 2004 2005 2006 2007 2008 Senegal 21.5% (463) 21.8% (501) Ghana 25.0% (N/A) Nigeria 13.4% (1,125) Sudan 9.3% (713) 7.3% (406) Kenya 24.6% (285) Tanzania 12.3% (509) Malawi 21.4% (201) Soweto 28.9% (249) Botswana 19.7% (117) 25.0% (200) Cape Town (Township) Cape Town 10.6% (538) Namibia 12.4% (218) Egypt 6.2% (267) HIV Prevalence among MSM in Africa 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 2009 2010 2011 17.2% (1,291) The Gambia 13.3% (215) 4.9% ( 1,778 ) Tunisia 4.4% ( 90 ) Morocco 5.7% (259) 13.2% ( 306 ) Uganda 5.9% (262) 40.7 % ( 285 ) 19.0% (563)

13. SCENARIO 4: MSM, heterosexual, and IDU transmission all contribute significantly to the HIV epidemic

14. Beyrer C, et al, Epidemiology Reviews, 2010.

15. EPIDEMIC SCENARIOS: Unavailable Data  Algeria  Azerbaijan  Djibouti  Iran  Iraq  Jordan  Kazakhstan  94 other Countries Kyrgyzstan Lebanon Libya Syria West Bank and Gaza

16. 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

17. HIV-1 incidence in MSM cohort, Kilifi, Kenya 9.1 per 100 person-years (95% CI; 7.2 – 11.6) 2006-2011, 479 MSM in follow-up; 733.8 person years Provided by Sanders, E. Kenyan Medical Research Institute, 2011

18. 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

19. Hong Kong Singapore Taiwan Japan HK 56 50 67 96118 168 SG385494101108145 TW -3365035847431075 JP305340449514571690 Number of newly diagnosed HIV infections among men who have sex with men, Hong Kong, Singapore, Taiwan and Japan, 2002 - 2007 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

20. Phylogenetic Analysis of HIV among MSM Region Country Reported HIV-1 subtypes MSM (n)HIV-1 subtypes in MSMReference Africa South AfricaC, AC147C (87%), B (11%), BF (2%) Middelkoop, 2011 SenegalCRF02_AG, C, B70C (40%), AG (24%), B (18.6%), cpx (4.3%) Ndiaye, 2009 KenyaA, AC13A, AC, AD, ACD Tovanabutra, 2010 Asia China, National sample CRF07_BC, CRF08_BC, B, CRF01_AE 44 B (41%), CRF01_AE (30.2%), CRF07_BC (2.3%) Wang, 2008 China, Beijing CRF07_BC, CRF08_BC, B, CRF01_AE 54 B (71.1%), CRF01_AE (24.4%), CRF07_BC (4.4%) Zhang, 2007 Singapore CRF01_AE, B, G, CRF33_01B, CRF34_01B 44CRF01_AE, B, CRF34_01/B* Lee, 2009 Taiwan B, CRF01_A/E, CRF_07BC, CRF08_BC 301 B (98%), CRF01_AE (1.3%), CRF07_B/C (0.7%) Kao, 2011 Thailand CRF01_AE, B, CRF01/B, BC 99 CRF01_AE (74.7%), B (7%), BC (3%), CRF01/B (15.2%) Arroyo, 2010 MongoliaB, CRF02_A/G41B (78%), CRF02_AG (9.8%) Jaqdagsuren, 2011 Americas BrazilB, F, B/F399B (80.1%), F (13%), B/F (11.4%)** De Castro, 2010 ArgentinaB, BF, C, F124B 57.9% overall, predominant in MSM Pando, 2011 Source: Beyrer, et al 2012. The Epidemiology of HIV among MSM. Lancet. 2012.

21. Changing Patterns of MSM Subtype in Cape Town (Note: cohorts not matched) Heterosexual MSM 1990s 2010 B C C C B Source: Middelkoop, Williamson,.., Bekker, HIV Subtypes in MSM in Cape Town: evidence of bridging between epidemics, MOPE034 IAS 2011

22. HIV Clade by Race among MSM in Cape Town SA BlackSA Coloured SA White Source: Middelkoop, Williamson,.., Bekker, HIV Subtypes in MSM in Cape Town: evidence of bridging between epidemics, MOPE034 IAS 2011

23. Ecological Model for HIV Risk in MSM Stage of Epidemic Individual Community Public Policy Network Level of Risks Source: Baral and Beyrer, 2006

24. Anal Intercourse  Highest Risk form of Sexual Transmission  1.4% Per Sexual Act Probability of Transmission No significant difference between heterosexual and same- sex 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

25. 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

26. 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

27. 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 Positioning In penile-vaginal intercourse, sexual positioning is biologically determined In penile-anal intercourse among men, sexual positioning is versatile

28. Rights-Affirming HIV Prevention Programs  Combination HIV Prevention Interventions (CHPI)  Behavioural Interventions Increasing condom and lubricant use during sex Eg. Peer Education, Risk Reduction Counselling, Adherence Counselling  Biomedical Interventions Biomedical interventions aim to decrease transmission and acquisition risk of sex 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

29. Prerequisites for Effective HIV Prevention Programs  Identification  Must be able to Identify MSM Willing to Self-Disclose  Risk Assessment  Must be able to appropriately stratify MSM according to risk 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

30. Research Priorities for Structural Interventions

32. HIV Research Priorities among MSM in Africa Interventions Prioritized Components of Experimental Arm Other Identified Research Priorities Structural 1.Healthcare worker training 2.Social Capital 3.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.Adherence Counseling 2.Risk Reduction counseling 3.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.Rectal Microbicide 2.PrEP 3.Condoms/Condom- Compatible Lubricants Vaccines (Hep A/B, HPV), Anal Health (Pap smear, exam), TB screening, ART>350 and for sero-discordant male couples

33. 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

34. 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

35. 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