Promising results from a combination HIV prevention strategy for MSM in Central America

Effectiveness of a combination prevention strategy for HIV risk reduction with men who have sex with men in Central America: a mid-term evaluation.

Firestone R, Rivas J, Lungo S, Cabrera A, Ruether S, Wheeler J, Vu L. BMC Public Health. 2014 Dec 4;14:1244. doi: 10.1186/1471-2458-14-1244.

Background: Despite over a decade of research and programming, little evidence is available on effective strategies to reduce HIV risks among Central American men who have sex with men (MSM). The Pan-American Social Marketing Organization (PASMO) and partners are implementing a HIV Combination Prevention Program to provide key populations with an essential package of prevention interventions and services: 1) behavioral, including interpersonal communications, and online outreach; 2) biomedical services including HIV testing and counseling and screening for STIs; and 3) complementary support, including legal support and treatment for substance abuse. Two years into implementation, we evaluated this program's effectiveness for MSM by testing whether exposure to any or a combination of program components could reduce HIV risks.

Methods: PASMO surveyed MSM in 10 cities across Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama in 2012 using respondent-driven sampling. We used coarsened exact matching to create statistically equivalent groups of men exposed and non-exposed to the program, matching on education, measures of social interaction, and exposure to other HIV prevention programs. We estimated average treatment effects of each component and all combined to assess HIV testing and condom use outcomes, using multivariable logistic regression. We also linked survey data to routine service data to assess program coverage.

Results: Exposure to any program component was 32% in the study area (n = 3531). Only 2.8% of men received all components. Men exposed to both behavioral and biomedical components were more likely to use condoms and lubricant at last sex (AOR 3.05, 95% CI 1.08, 8.64), and those exposed to behavioral interventions were more likely to have tested for HIV in the past year (AOR 1.76, 95% CI 1.01, 3.10).

Conclusions: PASMO's strategies to reach MSM with HIV prevention programming are still achieving low levels of population coverage, and few men are receiving the complete essential package. However, those reached are able to practice HIV prevention. Combination prevention is a promising approach in Central America, requiring expansion in coverage and intensity.

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Editor’s notes: In countries where same-sex behaviour is criminalised and/or highly stigmatised, men who have sex with men (MSM) often find it very difficult to obtain appropriate sexual health services.  Such difficulties contribute to the continued high prevalence of HIV among MSM in some settings.  Strategies to prevent HIV transmission, increasingly favour a combination of activities which aim to reflect specific social conditions. It is important that these complex prevention programmes are systematically evaluated. This paper discusses one of the first evaluations of a combined HIV prevention strategy including behavioural, biomedical and psychosocial components. The strategy is aimed specifically at MSM in Central America, among whom the authors note that HIV prevalence ranges from 7.5% to 11.1%. About one-third of MSM participants in respondent-driven samples, reported exposure to at least one component of the programme during the two years of implementation. But few, three percent, received all three components, reflecting the hard-to-reach nature of the population as well as programmatic issues. Despite the modest coverage, there was some evidence that the programme was associated with reported risk reduction and HIV testing uptake. The study provides promising results, but highlights the need to tackle stigmatisation and social exclusion of MSM in this region, to enable prevention strategies to be effective at scale.

Latin America
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