James Stannah, MPH, on HIV Testing Rates Among MSM in Africa
The UNAIDS 90-90-90 targets are ambitious treatment goals to help end the HIV/AIDS epidemic around the world. Findings from a new study indicate that crucial gaps in this target are still not being bridged in Africa.
The study was led by James Stannah, MPH, whilst working as a researcher in the Department of Infectious Disease Epidemiology at the Medical Research Council Centre for Global Infectious Disease Analysis at Imperial College London in the United Kingdom. He is currently a doctoral student at McGill University in Montreal, Canada.
For their study, Stannah and colleagues performed a systematic review of peer-reviewed cross-sectional and longitudinal studies that included men who have sex with men (MSM) in Africa. After analyzing the data, Stannah and colleagues found that while overall HIV testing had increased over time, HIV status awareness, antiretroviral therapy (ART) coverage, and viral suppression among MSM in Africa were much lower than needed to achieve the UNAIDS 90-90-90 targets.
Infectious Diseases Consultant reached out to Stannah to learn more about these findings and how the UNAIDS 90-90-90 may be met in the future.
ID CON: When you compared rates of HIV testing among MSM from before 2011 with those recorded after 2011, you found that rates increased 14.8 percentage points for ever-testing and 17.9 percentage points for being tested in the past 12 months. What interventions or events may have influenced this significant increase?
James Stannah: Our research cannot answer this question, as we did not look into why testing has increased over time, but generally speaking, HIV treatment guidelines and eligibility criteria have changed over time to allow a larger fraction of people living with HIV to be treated. This may have influenced HIV testing. Similarly, these improvements may also reflect the expansion of national HIV testing campaigns and community-based testing services.
ID CON: Further analysis showed that ever-testing was highest in southern Africa and lowest in northern Africa, and that rates of ever-testing were statistically significantly lower in countries with the most severe anti-LGBT legislation. What do the effects of anti-LGBT legislation mean for HIV testing and the treatment cascade? How can these challenges be overcome?
JS: Our results only suggest that there is an association between HIV testing and status awareness and the severity of anti-LGBT legislation among MSM in Africa. This does not necessarily suggest a causal relationship, and our study was not designed to determine this. Nonetheless, interventions can be implemented to minimize the negative effects of anti-LGBT legislation and stigma among African MSM and to increase the uptake of HIV testing services, including home-based testing, training of health care workers, and the implementation of community-based stigma-reduction program.
ID CON: Although you found that testing rates had increased over time, the proportion of African MSM who knew their HIV status remained low. In your opinion, what can be done to increase HIV-positive awareness and increase patients’ access to ART?
JS: To increase the levels of MSM living with HIV aware of their status in Africa, we need to increase testing. This can be achieved with further expansion of community-led services and access to rapid and home-based testing. In the presence of anti-LGBT legislation, increased support or counseling from LGBT-friendly organizations is also essential to engage more MSM with testing to increase status awareness and subsequent linkage to care and treatment initiation. Additionally, further research into the effects of anti-LGBT legislation is necessary to determine whether repealing such legislation will influence HIV testing and engagement with the HIV treatment cascade for MSM in Africa.
ID CON: How will these findings together impact clinical practice and how HIV is managed?
JS: Ideally, these findings will impact clinical practice and HIV management through suggesting that good levels of viral suppression can be achieved by MSM once on treatment. Therefore, more MSM in Africa need to be tested, aware of their status, and then linked to care, since once linked to care and on ART, levels of viral suppression are good. If we do not improve access for MSM in Africa to HIV testing and the HIV treatment cascade, HIV will continue to spread in this population, and MSM will continue to die from HIV-related conditions. Targeting increased testing, status awareness, treatment, and viral suppression is therefore imperative for saving the lives of MSM living with HIV in Africa and to prevent further HIV transmissions.
Reference:
Stannah J, Dale E, Elmes J, et al. HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: a systematic review and meta-analysis. Lancet HIV. 2019;6(11):PE769-E787. https://doi.org/10.1016/S2352-3018(19)30239-5.