Across low- and middle-income countries, MSM have nearly 20 times higher odds of HIV infection than the general population of reproductive-age adults.8 Community norms and values that stigmatize same-sex sexual behavior present significant barriers to accessing HIV prevention services.5–7,9,50 Health workers may not have relevant clinical skills and experience serving MSM, or they may be overtly discriminatory. Reduced utilization of health and HIV services by MSM, due to actual or perceived discrimination, may limit knowledge of the risks of unprotected anal intercourse and access to prevention methods. This is evident in the literature because sexual stigma has been associated with sexual risk behavior among MSM.40,51–53
Moreover, stigma and discrimination, such as (1) exposure to homophobic abuse, homophobia, or homonegativity, (2) a lack of social support, (3) shame, blame, and social isolation, and (4) victimization at school or work, have all been associated with negative HIV-related outcomes.27,40–42,46–48 Research indicates that due to social exclusion, expulsion from schools and higher education, and limited opportunities for other employment, sexual and gender minorities are more likely to be homeless or to engage in survival or commercial sex work.54,55
Health care related stigma has been reported among MSM in several studies, including studies in Southern Africa, Uganda,18 Malawi, Botswana, and Namibia, where there was a strong association between experiencing discrimination on the basis of sexuality and fear of health care services.56 Even where homosexuality is legal, such as South Africa, MSM continue reporting challenges in access to health care services that are heteronormative and lack health components designed specifically for MSM.57 Outside the health sector, broader community-level determinants have been observed in studies among MSM in Lesotho and Swaziland. Study participants commonly report violent physical assaults because of their sexuality—76.2% abuses in Lesotho, for example. However, tailored community-based programs led by MSM have yielded greater feelings of connection, social support, and self-esteem among community members.58 In Cameroon, men who were living with HIV were more likely to have obtained health services, thanks mainly to a dynamic community-based organization in the study city that provides HIV prevention, care, and treatment specifically for the lesbian, gay, bisexual, and transgender population (adjusted odds ratio, 4.9; 95% confidence interval, 1.6 to 14.6).59,60 In Senegal, a pilot community-driven MSM cohort study demonstrated the value, in terms of retention and psychosocial community support, of interventions conducted jointly by the community and research team.30
One of the most extreme manifestations of community-level stigma affecting MSM is criminalization of same-sex practices. Such laws are critical barriers to HIV reduction and have been associated with reduced health awareness, increased fear of health care, perpetuated discrimination and stigma, violence, limited health care treatment options, reduced effectiveness of health care delivery, and higher HIV incidence and prevalence. Currently, in sub-Saharan Africa, there are 38 countries, and in the Caribbean, there are 10 countries that criminalize same-sex practices.61 Criminalization not only encourages stigma but also feeds cultures of violence, which in turn worsen health conditions for MSM and entire communities. Law enforcement officials often choose to ignore antigay violence; some countries have reported that, instead, police themselves engage in violence against MSM. A recent review estimated that the odds of HIV infection in MSM populations relative to general populations are nearly twice as high in African and Caribbean countries that criminalize same-sex practices than in those countries where such practices are legal.62
The denial of care and government-sponsored brutality limit the provision and uptake of HIV prevention, treatment, and care services for transgender women.82 The organization Transrespect versus Transphobia Worldwide (TvT) has cataloged the murder of nearly 1400 transgender people across the world since 2008. More than 200 murders were reported in the past year. Given the difficulty of collecting these data, this is a very conservative estimate.83
There were fewer studies meeting inclusion and exclusion criteria examining quantitative community-level associations with HIV risk among PWID than studies conducted among other key populations. However, a community network providing emotional support helped to decrease the odds of HIV infection among males who inject drugs in India,28 and greater social support was associated with a decrease in inconsistent condom use among FSWs who inject drugs in China.34 Supportive social environments can decrease HIV risk behaviors and encourage better access to HIV prevention services for PWID, as well as for MSM and FSW.100 Strathdee et al,100 using data from population-based studies in Ukraine, used mathematical models to demonstrate that reductions in beatings by the police could reduce HIV incidence—principally by reducing needle sharing among communities of PWID afraid to use needle and syringe exchanges for the fear of police abuses. Community responses involving harm reduction and providing safe injection facilities have reduced the most common form of non-AIDS mortality in opioid injectors—overdose.101
The data presented here highlight the importance of the continued measurement of community-level determinants of HIV risks and the innovation of tools addressing these risks as components of the next generation of the HIV response. Although this review demonstrated the great heterogeneity in the studies evaluating the benefits and harms of community-level determinants for key populations, the evidence collectively suggests that these responses are urgently needed if the calls to “end the AIDS epidemic” are to be anything more than mere rhetoric. The studies presented here seem to suggest that if HIV services are offered to key populations in ways consistent with human dignity, safety, and good clinical and public health practices, uptake improves, and HIV spread can be markedly reduced. Unfortunately, even in recent epidemiologic research and surveillance studies, evaluating risks among key populations commonly do not collect community-level data but instead focus almost exclusively on individual-level determinants such as levels of HIV-related knowledge, condom usage, and numbers of sexual partners. The lack of evidence on determinants at the community level impedes the development and scale-up of evidence-based and human rights–affirming HIV prevention, treatment, and care programs.
With advances in ART-based prevention and treatment strategies, the “what” of the tools needed to end the HIV pandemic has been defined. However, the “how” remains an open question—especially for key populations, given the limited population-level information on the effectiveness of HIV prevention, treatment, and care programs. Thus, the next generation of effective HIV prevention science research must improve our understanding of the multiple levels of HIV risk factors, while programming for key populations must address each of these risk levels. Failure to do so will cost lives, harm communities, and undermine the gains of the HIV response to date.
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