1. HIV Prevention among Men Who Have Sex With Men Greg Millett CDC IAC Sympsoium July 22, 2012

2. (Cairns, 2012) Scientific Advances: Biological Interventions

3. Global HIV prevalence of HIV in MSM compared with regional adult prevalence in 2011 Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012

4. Challenges

5. Greater HIV transmission efficiency among MSM compared with heterosexuals Greater background prevalence in concentrated epidemics Greater likelihood of infection during anal sex – 18x greater – Equal vaginal & anal per contact risk probabilities= 80% reduction in incidence Transmission chain interruption W M, but not M M Graphic from: E. White “…even substantial behavior change, such as reductions in extra-primary partnerships, would not reduce transmission frequency enough to control epidemics of HIV among MSM.” (Beyrer, 2012)

6. Circumcision Heterosexual MenCircumcision MSM Weiss, AIDS, 2000 Millett, JAMA, 2008 Sexual role versatility and protective effect of circumcision among MSM vs. heterosexuals

7. In population with high cART coverage (70%), per- act anal intercourse transmission probability estimates for URAI ‘remarkably similar’ to those estimates made preceding HAART Possible reasons – STIs – Risk compensation – cART adherence – Viral load (infectivity) Per-act-risk of transmission for UAI among MSM (cART vs pre cART era) Jin, 2010

8. Continued Potential for HIV Transmission among Virally Suppressed Determine the prevalence of seminal HIV shedding among HIV+ MSM on stable cART. Of total 101 MSM – 30% detectable HIV DNA and/or RNA in semen – 18% detectable HIV in blood plasma Of 83 MSM w/ undetectable blood plasma – 25% had detectable HIV in their semen – 11x greater odds of having an STI – 5.5X greater odds of UIAI serosorting (Politch, 2012)

9. TasP not associated with reductions in HIV incidence among MSM in UK 40 000 HIV+ UK MSM – 26% undiagnosed – 80% of diagnosed MSM on ART (84% with CD4<350) Access to & retention in care >95% from 2001-2010 HIV incidence still climbing because – Risk behavior and increasing STIs – Low annual testing (15 - 25% of all MSM aged 15-59) – Undiagnosed  60%-80% transmissions 62% of undiagnosed infective (VL >1500 copies/ml ) 34-60% transmissions primary HIV infection (first few months) (Delpech, IAPAC, 2012)

10. Co-Occurring Conditions and Amplification of HIV Risk among MSM “AIDS prevention among MSM has overwhelmingly focused on sexual risk alone. Other health problems among MSM not only are important in their own right, but also may interact to increase HIV risk. HIV prevention might become more effective by addressing the broader health concerns of MSM while also focusing on sexual risks.” (Stall, AJPH, 2003) 0%0% 1%1% 2%2% 3%3% High risk sex7.111.215.822.5 HIV prevalence13.020.927.222.4 P<.001 Psychosocial health problems Poly drug use Depression Childhood sexual abuse history Partner violence Implications for PrEP or ART adherence among PWAS

11. Mean Community Viral Load among White and Black MSM Living with HIV/AIDS in DC, 2008 N=762N=3,395 (West, 2011)

12. Diagnosed HIV+ OR, 3.00 (2.06-4.40) Undiagnosed HIV OR, 6.38 (4.33-9.39) >200 CD4 cells/mm 3 before ART initiation OR, 0.40 (0.26-0.62) ART adherence OR, 0.50 (0.33-0.76) HIV suppression OR, 0.51 (0.31-0.83) ART utilization/ access OR, 0.56 (0.41-0.76) HIV Detection Viral Suppression (Millett, 2012) Disparities persist between black and white MSM throughout treatment cascade

13. Diagnosed HIV+ OR, 3.00 (2.06-4.40) Undiagnosed HIV OR, 6.38 (4.33-9.39) Health insurance coverage OR,0.47 (0.29-0.77) >200 CD4 cells/mm 3 before ART initiation OR, 0.40 (0.26-0.62) ART adherence OR, 0.50 (0.33-0.76) HIV suppression OR, 0.51 (0.31-0.83) ART utilization/ access OR, 0.56 (0.41-0.76) HIV Detection Viral Suppression Healthcare visits OR, 0.61 (0.42-0.90) Lower income (<$20k) OR, 3.42 (1.94-6.01) (Millett, 2012)

14. Criminalization of Homosexuality & HIV Prevalence Disparities by Region (Millett, 2012)

15. Funding Challenges: MSM not targeted proportionate to HIV burden Countries that criminalize same-sex – spend less on MSM services – less likely to have HIV surveillance for MSM (amFAR, 2011) Underfunding for MSM programs via PEPFAR or Global Fund (Health affairs, 2012; amFAR, 2011) Under PA 04012, CDC awards $300M to 59 HDs each year In 2009, health departments allocated – 38% of HE/RR funds to high- risk heterosexuals and 27% to MSM – 44% of CTR funds to high-risk heterosexuals and 10% to MSM. (CDC, 2011) International examplesNational exmple

16. Global HIV prevalence among MSM, 2007-2011 Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012

17. Opportunities

18. Zeroing on HIV effective prevention interventions

19. HIV Prevention Costs (Monetary and Otherwise) Modeling cost of various prevention modalities to decrease HIV incidence among MSM over 10 years – Oral PrEP global scale  $26B – Early ART for dx positives  $26B – Provision of latex condoms and water-based lubricant  $134M (Beyrer, 2012) MSM-GF survey of 5000 MSM – ¾ low & middle income countries – 39% easy access to free condoms – 25% easy access to free water- based lubricant Barriers: knowledge & stigma – Kenyan sex workers (29% no lube & 36% oil-based lube) w condoms (Geibel, 2008) – Jamaican MSM– stigma accessing condoms/ lube (Willis, 2011) “…seeking health care and disclosing same-sex partners is not safe for MSM in many parts of the world, and a comprehensive approach to HIV prevention requires that we take steps to change this.” (Sullivan, 2012)

20. ART coverage and reductions in HIV incidence among MSM in Denmark Denmark HIV epidemic is driven by MSM In most Western countries, HIV incidence among MSM is increasing In Denmark, overall HIV incidence is decreasing – Most HIV+ MSM in care and virally suppressed on ART – No increase in incidence taking place despite increasing risk behavior Biomedical interventions reversing trends among MSM

21. Combination prevention for MSM & attaining the National HIV/AIDS Goals (Sorenson & Sansom, CROI, 2011) InterventionsAnnual # of new infections (-25%) HIV transmission rate (-30%) % MSM with HIV aware of status (90%) % Newly dx linked to care in 1 yr (85%) % Dx w/ undetected viral load (20%) Current practice18907.2%60.1%78.1%64.2% Testing from 15%-28% 1550 (-18%) 6.1% (-16%) 74.5%91.8%60.1% (-6%) Increase HIV awareness from 80%-90% 1868 (-1%) 7.1% (-1%) 60.9%78.7%63.9% (0%) Increase linkage to care from 70%-85% 1876 (-1%) 7.1% (-1%) 60.4%81.4%650% (1%) Increase viral load suppressed from 80%-90% 1675 (-11%) 6.6% (-8%) 61.6%78.9%72.7% (13%) Tx at diagnosis1759 (-7%) 6.7% (-7%) 61.7%78.6%72.8% (14%) Combination of all above 1054 (-44%) 4.3% (-40%) 79.1%98.4%83.6% (30%)

22. Population attributable risk and cost analyses in intervention planning Interventions targeting low prevalence activities among MSM may be the most important and cost effective in reducing new infections Prevalence: 5% reported UAI with HIV+ partner Impact: Population attributable risk 34% Cost: $AUD 102M

23. Evaluating Harm Reduction Activities among MSM Data from prospective studies of HIV- negative MSM from US, Canada, Peru, Ecuador, Australia (Vallabhaneni, 2012) Examined respondents who only reported engaging in one of the following risk reduction activities – No UAI (47% of the group) – Monogamy: UAI, but only within a monogamous, seroconcordant relationship (11%) – Insertive UAI only (10%) – Serosorting: UAI HIV negative partners (8%) – Seropositioning: Insertive UAI with HIV+ or unknown status partners (3%) – Risky sex: UAI with no risk reduction strategy (21%). Assessed hierarchy or protective effect by activity Results: – HIV annual incidence in MSM with no safer-sex strategy was 2.95%. – Serosorters, incidence = 1.44% (a 51% reduction) – 100% condom use/no anal sex= 0.76% a year (74% reduction) – Seropositioning= 0.73% (75% reduction). – ‘top only’ =0.4% (86% reduction). – Monogamy= 0.25%, a 91.5% reduction in HIV risk. However, most men do not engage in only one of these strategies in their lifetime MSM who reported consistent strategy only represented 23% of sample

24. Risk reduction strategies are complex and vary by context Safe Sex/ Partner reduction Negotiated safety No sex or no UAI Serosorting/ Strategic Positioning Viral load

25. Thank You Gregorio A. Millett GMillett@CDC.gov