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Stepping up the Pace for MSM and Transgender Women

20 th International AIDS Conference Melbourne, Australia. Stepping up the Pace for MSM and Transgender Women. Beatriz Grinsztejn , MD, PhD Oswaldo Cruz Foundation, Brasil. Overview. Global HIV epidemics among MSM Why? What can be done? What are the unmet needs?.

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Stepping up the Pace for MSM and Transgender Women

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  1. 20th International AIDS Conference Melbourne, Australia Stepping up the Pace for MSM and Transgender Women Beatriz Grinsztejn, MD, PhD Oswaldo Cruz Foundation, Brasil

  2. Overview • Global HIV epidemics among MSM • Why? • What can be done? • What are the unmet needs?

  3. Who are we talking about ? • MSM • All men who engage in consensual male-to-male sex • TGW • Individuals who were assigned as male a birth but who identify as women Photos: UNAIDS and CDC

  4. Global HIV Epidemics Among MSM

  5. Global HIV Prevalence Among MSM 2007-2011 Beyrer et al. The Lancet. 2012

  6. HIV PrevalenceAmong MSM Countries withgeneralized HIV epidemics Data adaptedfromBaralet al. Curr.Opinionon HIV/AIDS.2014; Geospatial data http://thematicmapping.org Lastavailableyear. Mostsamples are notprobabilistic

  7. HIV Incidence Among MSM, 1995-2013 Beyrer, et al, AIDS 2013

  8. HIV Incidence in a Cohort of MSM Bangkok Sixty months cumulative Kaplan Meier HIV incidence in a cohort of MSM from Bangkok, Thailand, 2006 - 2012 23.9 (21.1, 27.0) All Source: van Griensven et al, AIDS. 2013

  9. AIDS cases amongyoungmen in Brazil MS/SVS/Departamento de DST, Aids e Hepatites Virais. Note:AIDS cases until 30/06/2013

  10. TransgenderWomen HIV Prevalenceamong TGW and OR comparedtothe general population (15-49 years) Adaptedfrom: Baral et al. The Lancet InfectiousDisease. 2013

  11. Why?

  12. Modified Ecological Model for HIV Risk in MSM Baral et al. BMC Public Health 2013, 13:482

  13. Individual Level Risks Estimating per-act HIV transmission risk: a systematic review • Estimated from Leynaert et al. Am J Epidemiol 1998; Jinet al. AIDS 2010; Vittinghoffetal. Am J Epidemiol1999; DeGruttolaet al. J ClinEpidemiol 1989 Source: Patelet al. AIDS.2014

  14. Sexually Transmitted DiseasesHigh rates of STIs associated with HIV HPTN 061 N= 1553 black MSM enrolled at 6 US cities Mayer etal.PLOS One.2014

  15. Network Level Risks • 14,560 B clade MSM infected in the UK • 52% had at least 1 link • Network Structure • Small world • Transmission dynamics • in the large clusters: • median time of onward transmission: 17 months • 20% of new HIV infections occurred within 6 months of index acquisition Infectiousness of recent infection accelerates HIV transmission within MSM networks. Leigh Brown et al. JID.2011

  16. Acute InfectionThe Bangkok Cohort Unprotected Intercourse and Sexual Partners over preceding 4 months Enrollment into Bangkok Acute Cohort 3 days 2 days Mainprotocol All wk 24 and wk 48 changes from baseline p<0.05 Changes from wk 24 to wk 48 NS Updated from Ananworanich J, PLoS ONE 2012 www.clinicaltrials.gov 00796146

  17. The Role of Main Partnerships in HIV Epidemics among MSM • Important proportion of new cases arise from main partners • Because with main partners, men1: • Have sex more often • Are more likely to have anal sex • Are less likely to use condoms • Yet: • men’s knowledge of their male partners’ status is no more accurate than their knowledge of casual partners’ status1 • Men in main partnerships perceive themselves to be at lower risk for HIV infection2 • Men in main partnerships are less likely to have been recently tested for HIV2 Sources: 1 Sullivan et al,AIDS 2009; 2 ; Goodreau et al, PLoSONE 2012; Davidovich et al, AIDS 2001

  18. Syndemics Halkitiset al. A Holistic Approach to Addressing HIV Infection Disparities in Gay, Bisexual, and Other Men Who HaveSexWithMen. AmericanPsychologist.2013

  19. Resilience Despite the stressors MSM experience, the majority are not depressed and are not using substances Resilience is self evident in gay men’s life histories

  20. StructuralRisks Homophobia • Opinion Survey by the Pew Research Center • 39 countries • 37,653 respondents • March -May, 2013 • acceptance of homosexuality is widespread in countries where: • religion is less central • richest countries in the world • younger respondents and women are more tolerant Availableat: http://www.pewglobal.org/2013/06/04/global-acceptance-of-homosexuality/

  21. StructuralRisksCriminalization http://www.theguardian.com/news/datablog/2013/oct/15/state-sponsored-homophobia-gay-rightshttp://www.ilga.org

  22. Stigma, DiscriminationandViolence http://76crimes.com/2014/04/10/researcher-in-raid-uganda-police-were-clueless/

  23. Structural Stigma and all-cause Mortality Fig. 2. Survival time by type of residential area, General Social Survey/National DeathIndex, 1988 - 2002 Hatzenbuehleret al. Social Science & Medicine . 2014

  24. Survivalamong HIV infectedindividuals in careat Fiocruz, Rio de Janeiro, Brazil Luz et al under review

  25. Disparities Between Black and White MSM in the US Throughout the Treatment Cascade Undiagnosed HIV OR, 6.38 (4.33-9.39) HIV Detection Diagnosed HIV+ OR, 2.59 (1.82-3.69) 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 Adapted from Millett, The Lancet, 2012

  26. Undiagnosed HIV OR, 6.38 (4.33-9.39) Lower income (<$20k) OR, 3.42 (1.94-6.01) HIV Detection Diagnosed HIV+ OR, 2.59 (1.82-3.69) Health insurance coverage OR,0.47 (0.29-0.77) Healthcare visits OR, 0.61 (0.42-0.90) 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, The Lancet, 2012

  27. Moscow MSM: HIV Diagnosis and Treatment HIV prevalence RDS adj: 12.4% (95%CI: 9.3 – 16.1) Beyrer, et al (NIMH R01 MH085574-01A2) “High Risk Men: Identity, Health Risks, HIV and Stigma” funded from 2009 - 2014.) Unpublished data

  28. HIV Care Cascade Among 1,146 HIV Positive MSM From 12 sites In India Prevalence • Engagement in care was better in sites with established epidemics where there have been more government-led targeted interventions. • Awarenessof status was better among individuals who had received other services (e.g., TB treatment and STI treatment • Solomon SS et al IAS 2014 MOPE150O • Mehta SH et al CROI 2014

  29. TransgenderWomenBarriers in theContinuum HIV CareandTreatment • Barriersto health careaccessandengagement • Harassmentandviolence • Fearofdisclosureoftransgenderidentity • Lackofgenderaffirming envinonments in health careservices • Competingpriorities in life • Intersectingstigma • Lackofcompetent medical providers • Lackofinclusion in HIV awarenessandpreventioncampaigns • Lowlevelsof HIV testing • Canada 46% Bauer et al 2012 • Bangkok 50% Nemoto et al 2012 • Treatmentoutcomes: FewstudiesevaluatedcARToutcomesamongTGW • LesslikelytohavereceivedcARTMelendez et al 2006 • Worseadherence; more difficultiesintegrating HIV treatment in theirlivesSevelius et al 2010 • Higher HIV relatedmortality Das et al 2010 • Similar rates of virologic suppresion and retention in carein research settings Yehia 2013 • PrEP access and outcomes • Lack of preventive effect among the TGW in the iPrEX study Grant et al 2010 • Few TGW assessed for participation in na US Demo Project Cohen et al CROI 2014

  30. What can be done?

  31. HPTN 052EarlyTreatment 96% reduction in transmission p < 0.001 Cohen et al. NEJM 2011 Grinsztejn et al. Lancet ID 2014

  32. Treatment as Prevention • PARTNER Study • observational study in 75 European sites • HIV serodifferent couples in which the positive partner is on ART • risk of within-couple HIV transmission during periods where condoms are not used consistently and the HIV positive partner is on suppressive ART Rodger et al. HIV transmission risk through condomless sex if the HIV positive partner is on suppressive ART: PARTNER study . CROI 2014

  33. Treatment as Prevention Opposites Attract: Currently recruiting in Sydney, Melbourne, Brisbane, Rio de Janeiro and Bangkok

  34. Challenges of TasP in MSM Epidemics • Higher proportion of infections in MSM networks due to acute/recent infections • Higher HIV Incidence in youngest age strata in several settings • least likely to be in care • Late HIV diagnosis • for most men globally, treatment initiation in 2013 was still below 300 CD4s • Risk compensation? • increases in other STI (USA, UK, France, Australia) • No data available for the trans population

  35. Pre-Exposure Prophylaxis (PrEP)

  36. Strategies to Improve PrEP Delivery and Adherence Novel adherence strategies New PrEP drugs and dosing strategies Alternative delivery systems and formulations Injectables: Rilpivirine-LA GSK744 Rectal Microbicides:MTN-017 (TFV rectal gel)

  37. Creating Demand for HIV Testing

  38. What are theUnMETneeds?

  39. Estimated Resource Needs and Reported Spending, 2012 • 21 countries reported spending for MSM • The spending amount reported by countries, when non-zero, was compared against estimated resource need for MSM from UNAIDS investment framework 2011. Source: UNAIDS Investment Framework 2011, GARPR 2013

  40. Drivers of HIV Transmission among MSM and Targets for Prevention Source: Patrick Sullivan , et al. The Lancet, 2012

  41. Moving ForwardResearch Priorities for MSM & TGW • Evaluation of combination prevention packages tailored to MSM and TGW is a top priority • Evaluation of adherence interventions to support TasP and PrEP • Evaluate interventions to increase resilience • Studies designed to address issues relevant to TGW are urgently needed • Structural interventions • Formative research • Implementation Science

  42. Final Remarks • MSM and TGW remain under high risk for HIV acquisition worldwide • Sinergy between Tasp & PrEP • Homophobia/Transphobia/Criminalization

  43. “The barriers to access to HIV services, including education and support, stand before us like mountains - mountains of fear, mountains of prejudice, mountains of ignorance. These barriers, including those that come from within us, need to be overcome” Paul Semugoma, IAS Blog May 2014

  44. Acknowledgments • Chris Beyrer • Luiz Loures • Stephan Baral • Andrea Wirtz • Shruti Mehta • Frits Van Griesven • Jintanant Ananworanich • Eugene Kroone • Joseph Amon • Albert Liu • Paul Semugoma • Gleb Latnik • Kenneth Mayer • Patrick Sullivan • Andrew Grulich • Andrew Philips • Mariangela Simão • Valdilea G. Veloso • Paula Mendes Luz • Raquel De Boni • Veriano Terto • Jorge Beloqui • Carolyn Yanavich

  45. Obrigada!

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