Time for a more holistic approach to HIV prevention for men who have sex with men?
Authors: Sunil S Solomon, Alok Saxena
Journal: The Lancet Global Health (2021)

After the identification of HIV in India in 1986,1Simoes EA Babu PG John TJ et al.Evidence for HTLV-III infection in prostitutes in Tamil Nadu (India).Indian J Med Res. 1987; 85: 335-338PubMed Google Scholar there was a rapid increase in incidence, with more than 5 million estimated infections by the early 2000s.2National AIDS Control OrganisationNational consultation on HIV estimates/surveillance. India 2004. Policy and program implications. HIV estimates—2004.http://nacoonline.org/facts_hivestimates04.htmDate accessed: April 25, 2008Google Scholar The National AIDS Control Programme (NACP) rapidly responded with widespread implementation of HIV prevention and testing programmes and the rollout of free antiretroviral therapy (ART), which resulted in a dramatic decline in HIV burden, with an estimated 2·35 million infections in 2019.3National AIDS Control Organisation and ICMR-National Institute of Medical StatisticsIndia HIV estimates 2019 report.http://naco.gov.in/sites/default/files/INDIA%20HIV%20ESTIMATES.pdfDate: 2020Date accessed: February 20, 2021Google Scholar However, the decline was not uniform across all populations; declines were primarily observed in heterosexual populations who account for the majority of HIV infections in India. Men who have sex with men (MSM) still bear a disproportionately high HIV burden compared with the general population in India, with a nearly 15 times higher burden.3National AIDS Control Organisation and ICMR-National Institute of Medical StatisticsIndia HIV estimates 2019 report.http://naco.gov.in/sites/default/files/INDIA%20HIV%20ESTIMATES.pdfDate: 2020Date accessed: February 20, 2021Google Scholar In response to this high burden, the focus of the NACP during the past decade has been on improving service access among vulnerable populations such as MSM, to achieve HIV and AIDS epidemic control. Over the past few years, substantial progress has been made. The 150-year-old law that criminalised homosexuality between consenting adults under Section 377 of the India Penal Code was deemed “unconstitutional” by the Supreme Court of India and was repealed in 2018. The NACP shifted its focus to increasing coverage of MSM with its targeted interventions programme—the primary prevention strategy of the NACP for key populations. The targeted interventions programme, delivered primarily via community-based organisations, provides access to essential HIV prevention and testing services and uses a peer-navigation approach to ART linkage and retention. Consequently, although there remains a high HIV burden among MSM in India, there have been substantial improvements in the HIV continuum of care.4Lucas GM, Solomon SS, McFall AM, et al. HIV care continuum changes among PWID and MSM in India: a tale of two key populations. Conference on retroviruses and opportunistic infections 2019; Seattle, WA; March 4–7, 2019 (abstr 1038).Google Scholar, 5National AIDS Control Organisation and All India Institute of Medical SciencesBehavioural Surveillance Survey-lite 2020: top line findings.http://www.naco.gov.in/sites/default/files/BSS%20Lite%20Report.pdfDate: 2020Date accessed: February 20, 2021Google Scholar In the Behavioural Surveillance Survey from 2020, approximately 90% of MSM who were aware of their HIV status self-reported being on ART.5National AIDS Control Organisation and All India Institute of Medical SciencesBehavioural Surveillance Survey-lite 2020: top line findings.http://www.naco.gov.in/sites/default/files/BSS%20Lite%20Report.pdfDate: 2020Date accessed: February 20, 2021Google Scholar However, new challenges continue to emerge. Despite the success of the targeted interventions programme, there are still many MSM who do not self-identify as MSM. These individuals generally marry women to satisfy the heteronormative cultural norm that prevails in India. They often prefer to keep their MSM identity hidden and hence, do not engage with the targeted interventions programme. Furthermore, the penetration of internet access across India and access to dating mobile applications such as Grindr and Planet Romeo have resulted in a virtual population of MSM who are seldom reached by current strategies. Many of these individuals struggle with issues of gender identity and depression and face barriers with respect to self-esteem and stress as a result of the secret lives they live.6Sivasubramanian M Mimiaga MJ Mayer KH et al.Suicidality, clinical depression, and anxiety disorders are highly prevalent in men who have sex with men in Mumbai, India: findings from a community-recruited sample.Psychol Health Med. 2011; 16: 450-462Crossref PubMed Scopus (68) Google Scholar They often turn to substance use, including alcohol, as a coping mechanism, which can negatively affect HIV outcomes.7Kumar P Aridoss S Mathiyazhakan M et al.Substance use and risk of HIV infection among men who have sex with men in India: analysis of national IBBS data, India.Medicine (Baltimore). 2020; 99e21360Crossref PubMed Scopus (1) Google Scholar, 8Prabhu S McFall AM Mehta SH et al.Psychosocial barriers to viral suppression in a community-based sample of human immunodeficiency virus-infected men who have sex with men and people who inject drugs in India.Clin Infect Dis. 2020; 70: 304-313Crossref PubMed Scopus (4) Google Scholar The advent of the COVID-19 pandemic is likely to only further aggravate this depression, substance use, and stress. In this issue of The Lancet Global Health, Steven Safren and colleagues9Safren SA Thomas B Biello KB et al.Strengthening resilience to reduce HIV risk in Indian MSM: a multicity, randomised, clinical efficacy trial.Lancet Glob Health. 2021; 9: e446-e459Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar present results from a trial of a culturally adapted resilience-based psychosocial intervention for MSM in India consisting of group and individual counselling sessions. The trial was done across two reputable organisations (the National Institute for Research in Tuberculosis [Chennai, India] and the Humsafar Trust [Mumbai, India]) that have been at the forefront of HIV research among MSM in India. The intervention was associated with a 72% (95% CI 53–83) larger reduction in condomless anal sex acts from baseline to 12 months of follow-up than in the standard-of-care control group, which was mediated through improvements in self-esteem and depressive symptoms. It is important to note that there were significant declines in condomless anal sex acts over time even among participants in the control group, which brings into question the social desirability bias of the self-reported responses and the degree to which it varied between the two study groups, as the authors have noted. It is worrying that, despite these declines in self-reported condomless anal sex acts, there was no effect on HIV and sexually transmitted infection incidence, and the HIV incidence in this sample was higher than what has previously been observed among MSM across India10Solomon SS Mehta SH Srikrishnan AK et al.High HIV prevalence and incidence among MSM across 12 cities in India.AIDS. 2015; 29: 723-731Crossref PubMed Scopus (57) Google Scholar and what is observed among MSM enrolled in the NACP targeted interventions programme.3National AIDS Control Organisation and ICMR-National Institute of Medical StatisticsIndia HIV estimates 2019 report.http://naco.gov.in/sites/default/files/INDIA%20HIV%20ESTIMATES.pdfDate: 2020Date accessed: February 20, 2021Google Scholar Regardless, this trial shows the positive impact of a psychosocial intervention on self-esteem and depression, and lays the foundation for other such interventions. To ensure broad applicability, it is crucial to identify strategies to scale this intervention to be delivered by staff with minimal training, such as peer navigators and outreach workers who are part of the targeted interventions programme. Also, due to the COVID-19 pandemic, there has been a rapid transition to telemedicine and virtual service delivery approaches within the NACP. Developing such an intervention to be delivered electronically (eg, via smartphones) could improve access as well as attendance; attendance at the counselling sessions was suboptimal in the trial,9Safren SA Thomas B Biello KB et al.Strengthening resilience to reduce HIV risk in Indian MSM: a multicity, randomised, clinical efficacy trial.Lancet Glob Health. 2021; 9: e446-e459Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar which could possibly explain the absence of an effect on biological outcomes. Programmes tend to be designed in a disease-specific manner, but we need to re-think interventions to be person-centric, incorporating strategies to address issues such as mental health, substance use, social support, and ageing, as well as traditional HIV programming. There is a correlation across these issues that impacts HIV outcomes, highlighting the need for a comprehensive programme to ensure physical, mental, and social wellbeing of MSM. Such an approach will require an immense amount of political commitment and interprogramme and interministerial coordination, but this approach is greatly needed. SSS reports grants from Gilead Sciences and Abbott Diagnostics, outside of the submitted work. AS declares no competing interests.The views presented here reflect the opinion of the authors and do not necessarily reflect the views of the Johns Hopkins University School of Medicine, USA or the National AIDS Control Organisation, India. Strengthening resilience to reduce HIV risk in Indian MSM: a multicity, randomised, clinical efficacy trialA resilience-based psychosocial intervention for MSM at risk of HIV acquisition or transmission in India was efficacious in reducing condomless anal sex acts, with evidence for mediation effects in two key target resilience variables. HIV prevention programmes for MSM in India should address mental health resilience to augment reductions in the risk of sexually transmitted HIV. Full-Text PDF Open Access