HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: a systematic review and meta-analysis

Abstract

Background: HIV disproportionately affects gay, bisexual, and other men who have sex with men (MSM) in Africa, where many countries criminalise same-sex behaviour. We assessed changes in the engagement of African MSM with HIV testing and treatment cascade stages over time, and the effect of anti-LGBT legislation and stigma.

Methods: We systematically searched Embase, Global Health, MEDLINE, Scopus, and Web of Science for peer-reviewed cross-sectional or longitudinal studies recruiting at least ten MSM, published from Jan 1, 1980, to Oct 10, 2018. We extracted or derived estimates of HIV testing, engagement with the HIV treatment cascade, or both among African MSM from published reports. We derived pooled estimates using inverse-variance random-effects models. We used subgroup and meta-regression analysis to assess associations between testing and status awareness outcomes and study and participant characteristics, including the severity of country-level anti-LGBT legislation.

Findings: Our searches identified 75 independent eligible studies that provided estimates for 44 993 MSM across one or more of five testing and treatment cascade outcomes. HIV testing increased significantly over time overall, with pooled proportions of MSM ever tested for HIV of 67·3% (95% CI 62·1-72·3; 44 estimates) and tested in the past 12 months of 50·1% (42·4-57·8, 31 estimates) after 2011, which were 14·8 percentage points and 17·9 percentage points higher than before 2011, respectively. After 2011, ever testing was highest in southern Africa (80·0%), and lowest in northern Africa (34·4%), with the greatest increase in western Africa (from 42·4% to 70·9%). Levels of testing ever, in the past 12 months, and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation compared with countries with the least severe legislation (57·4% vs 71·6%, p=0·0056; 35·5% vs 49·3%, p=0·010; 6·7% vs 22·0%, p=0·0050). Few estimates were available for later stages of the treatment cascade. Available data after 2011 suggest that the pooled proportion of MSM HIV-positive aware has remained low (18·5%, 12·5-25·3; 28 estimates), whereas proportions of current antiretroviral therapy (ART) use were 23·7% (15·5-33·0; 13 estimates) among all MSM living with HIV and 60·1% (48·6-71·1; five estimates) among MSM HIV-positive aware of their status. Pooled levels of viral suppression among MSM currently on ART were 75·6% (64·4-85·5; four estimates), but only 24·7% (18·8-31·2; four estimates) among all MSM living with HIV.

Interpretation: Despite improvements in HIV testing among MSM in Africa, HIV status awareness, ART coverage, and viral suppression remain much lower than required to achieve UNAIDS 90-90-90 targets. Further studies are urgently needed to provide more accurate estimates of levels of status awareness, engagement in care, ART coverage, and viral suppression among MSM to inform prevention efforts aimed at improving access to HIV services for MSM. Severe anti-LGBT legislation might be associated with lower HIV testing and status awareness; therefore, further research is needed to assess the effect of such legislation on HIV testing and engagement with the HIV treatment cascade among MSM.

Funding: US National Institutes of Health, UK Medical Research Council.

Figure 1:. Study selection

MSM=men who have sex with men. ART=antiretroviral therapy.

Figure 2:. Forest plot of the proportions of African men who have sex with men who ever tested for HIV

Weighted (blank squares) and unweighted (filled squares) study estimates and their 95% CIs, and pooled estimates (diamonds) and their 95% Cls are shown for proportions of men who have sex with men in Africa who ever tested for HIV (self-reported), overall and stratified by region of Africa. Numerators and denominators of weighted study estimates were derived from the effective sample size (appendix pp 3, 4). *Self-calculated estimates.

Figure 3:. Forest plot of the proportions of African men who have sex with men tested in the past 12, 6, and 3 months

Weighted (blank squares) and unweighted (filled squares) study estimates and their 95% CIs and pooled estimates (diamonds), and their 95% CIs are shown for proportions of men who have sex with men in Africa tested for HIV (self-reported) in the past 12 months, 6 months, and 3 months, overall and stratified by region of Africa. Numerators and denominators of weighted study estimates were derived from the effective sample size (appendix pp 3, 4). *Self-calculated estimates.

Figure 4:. Forest plot of the proportions of African men who have sex with men (MSM) with HIV who are aware of their status

Weighted (blank squares) and unweighted (filled squares) study estimates and their 95% CIs, and pooled estimates (diamonds) and their 95% CIs are shown for proportions of men who have sex with men in Africa who are HIV-positive aware of their status, overall and stratified by region of Africa. Men who have sex with men who are HIV-positive aware of their status are those who reported living with HIV before testing positive during the study. Numerators and denominators of weighted study estimates were derived from the effective sample size (appendix pp 3, 4). *Self-calculated estimates.

Figure 5:. Forest plot of the proportions of African men who have sex with men living with HIV ever or currently engaged in care, or linked to care within 30 days of diagnosis

Study estimates and their 95% CIs and pooled estimates (diamonds) and their 95% CIs are shown for proportions of men who have sex with men in Africa living with HIV ever or currently engaged in care (self-reported), or linked to care within 30 days of diagnosis, overall and stratified by region of Africa. All study estimates were unweighted. Men who have sex with men living with HIV are those who tested positive during the study. Numerators and denominators of weighted study estimates are rounded to the nearest whole number. ^*Self-calculated estimates.

Figure 6:. Forest plot of the proportions of African men who have sex with men (MSM) living with HIV ever or currently on antiretroviral therapy (ART)

Weighted (blank squares) and unweighted (filled squares) study estimates and their 95% CIs, and pooled estimates (diamonds) and their 95% CIs are shown for proportions of men who have sex with men in Africa living with HIV ever or currently on antiretroviral therapy (self-reported ), overall and stratified by region of Africa. Men who have sex with men living with HIV are those who tested positive during the study. Numerators and denominators of weighted study estimates were derived from the effective sample size (appendix pp 3, 4). NR=not reported. *Self-calculated estimates.

Figure 7:. Forest plot of the proportions of African men who have sex with men (MSM), HIV-positive aware of their status, ever or currently on antiretroviral therapy

Weighted (blank squares) and unweighted (filled squares) study estimates and their 95% CIs, and pooled estimates (diamonds) and their 95% CIs are shown for proportions of MSM HIV-positive aware of their status ever or currently on antiretroviral therapy (self-reported), overall and stratified by region of Africa. MSM HIV-positive aware of their status are those who reported living with HIV before testing positive during the study. Numerators and denominators of weighted study estimates were derived from the effective sample size (appendix pp 3, 4). ART=antiretroviral therapy. *Self-calculated estimates.

Figure 8:. Forest plot of the proportions of African men who have sex with men (MSM) living with HIV, HIV-positive aware of their status, and currently on antiretroviral therapy (ART) who were virally suppressed

Weighted (blank squares) and unweighted (filled squares) study estimates and their 95% CIs, and pooled estimates (diamonds) and their 95% CIs are shown for proportions of MSM in Africa living with HIV, HIV-positive aware of their status, and currently on ART (self-reported) who were virally suppressed, overall and stratified by region of Africa. MSM HIV-positive aware of their status are those who reported living with HIV before testing positive during the study. Numerators and denominators of weighted study estimates were derived from the effective sample size (appendix pp 3, 4). Viral suppression was measured within studies with viral load testing using thresholds defined by the study authors. *Self-calculated estimates.