http://pag.aids2012.org/session.aspx?s=51

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

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

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

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

7. Per-act-risk of transmission for UAI
among MSM (cART vs pre cART era)
• 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
Jin, 2010
– Viral load (infectivity)

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
0 1 2 3
focused on sexual risk alone. % % % %
Other health problems among High risk sex 7.1 11.2 15.8 22.5
MSM not only are important
HIV prevalence 13.0 20.9 27.2 22.4
in their own right, but also
P<.001
may interact to increase HIV
risk. HIV prevention might Psychosocial health problems
become more effective by • Poly drug use
addressing the broader health • Depression
concerns of MSM while also • Childhood sexual abuse history
• Partner violence
focusing on sexual risks.”
(Stall, AJPH, 2003)
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
50,000
Mean Community Viral Load (copies/mL)
45,000
40,000 39,173
35,000
30,000
25,000
20,000
18,283
15,000
10,000
5,000
0
White Black
N=762 N=3,395 (West, 2011)

12. Disparities persist between black and white
Undiagnosed HIV
MSM throughout treatment cascade
OR, 6.38 (4.33-9.39)
HIV Diagnosed HIV+
Detection OR, 3.00 (2.06-4.40)
ART utilization/ access
OR, 0.56 (0.41-0.76)
>200 CD4
cells/mm3 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)
Viral Suppression
(Millett, 2012)

13. Undiagnosed HIV
OR, 6.38 (4.33-9.39)
HIV Diagnosed HIV+
Detection OR, 3.00 (2.06-4.40)
Health insurance
coverage
OR,0.47 (0.29-0.77)
ART utilization/ access
OR, 0.56 (0.41-0.76)
>200 CD4
cells/mm3 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)
Viral Suppression
(Millett, 2012)

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

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

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

20. ART coverage and reductions in HIV incidence
among MSM in Denmark
Biomedical interventions reversing trends • Denmark HIV epidemic is
among MSM 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

21. Combination prevention for MSM & attaining
the National HIV/AIDS Goals (Sorenson & Sansom, CROI, 2011)
Interventions Annual # of new HIV % MSM with % Newly dx % Dx w/
infections transmission HIV aware of linked to care undetected
(-25%) rate (-30%) status (90%) in 1 yr (85%) viral load (20%)
Current practice 1890 7.2% 60.1% 78.1% 64.2%
Testing from 1550 6.1% 74.5% 91.8% 60.1%
15%-28% (-18%) (-16%) (-6%)
Increase HIV 1868 7.1% 60.9% 78.7% 63.9%
awareness from (-1%) (-1%) (0%)
80%-90%
Increase linkage 1876 7.1% 60.4% 81.4% 650%
to care from (-1%) (-1%) (1%)
70%-85%
Increase viral 1675 6.6% 61.6% 78.9% 72.7%
load suppressed (-11%) (-8%) (13%)
from 80%-90%
Tx at diagnosis 1759 6.7% 61.7% 78.6% 72.8%
(-7%) (-7%) (14%)
Combination of 1054 4.3% 79.1% 98.4% 83.6%
all above (-44%) (-40%) (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- • Results:
negative MSM from – HIV annual incidence in MSM with no
US, Canada, Peru, Ecuador, Australia safer-sex strategy was 2.95%.
(Vallabhaneni, 2012) – Serosorters, incidence = 1.44% (a 51%
reduction)
– 100% condom use/no anal sex= 0.76% a
• Examined respondents who only year (74% reduction)
reported engaging in one of the following – Seropositioning= 0.73% (75%
risk reduction activities reduction).
– No UAI (47% of the group) – ‘top only’ =0.4% (86% reduction).
– Monogamy: UAI, but only within a – Monogamy= 0.25%, a 91.5% reduction
monogamous, seroconcordant relationship in HIV risk.
(11%)
– Insertive UAI only (10%)
– Serosorting: UAI HIV negative partners (8%) • However, most men do not engage in
– Seropositioning: Insertive UAI with HIV+ or only one of these strategies in their
unknown status partners (3%) lifetime
– Risky sex: UAI with no risk reduction strategy
(21%).
• MSM who reported consistent
strategy only represented 23% of
• Assessed hierarchy or protective effect by sample
activity

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

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