Epidemiological overview: MSM and transgender women in Asia and the Pacificadmin
Epidemiological overview: MSM and transgender women in Asia and the Pacific
HIV Australia | Vol. 11 No. 4 | November 2013
By Chris Beyrer
In the third decade of HIV in Asia and the Pacific, the epidemiology of HIV continues to change and to challenge our best efforts to respond.
The predicted generalised epidemics among reproductive-age adults, which some models had predicted could reach the levels now seen in Sub-Saharan Africa, did not occur in most of Asia, and appear increasingly unlikely.
This vast and diverse region, however, does continue to have many concentrated, or ‘hot spot’, epidemics that require research and program efforts, community action, and government and donor support.
HIV burdens continue to be seen among various groups in many states, including people who inject drugs in Vietnam, China, Malaysia, Burma/Myanmar and Northeast India, among others, and sex workers and heterosexual young adults in India, Thailand, Cambodia, Papua New Guinea and Myanmar.1
But arguably the most striking feature of HIV in the region in 2013 is the high HIV incidence and prevalence among men who have sex with men (MSM) and transgender women in virtually every Asia-Pacific state where surveillance has been done.2, 3, 4
This is particularly disturbing for MSM and transgender women in countries such as Thailand, India, Burma/Myanmar and Laos, where HIV rates in other populations are in marked decline, as in Thailand, or have remained consistently low, as in Laos.5
This pattern can perhaps be described as ‘de-linked’ spread; that is, HIV appears to be moving rapidly within MSM and transgender networks and driving unacceptably high HIV burdens among these persons, but spread continues to slow in general populations.
In East Asia, including the developed and relatively low HIV burden states of Taiwan, Singapore, Hong Kong, Japan and South Korea, we see a similar picture in which HIV outbreaks, albeit at lower levels than in much of the region, are under way primarily in gay, bisexual and other MSM groups.
A large body of recent work has documented the expanding epidemic of HIV among gay, bisexual and other MSM in multiple cities in China, particularly the densely populated cities along China’s eastern seaboard and in the long-affected south-western region.9, 10, 11
The recent report by Wu, et al., was a very large investigation of HIV and syphilis among MSM in 61 Chinese cities.12 They found an overall HIV prevalence of 4.9% (2314/47,231; 95% Confidence Interval (CI), 4.7%–5.1%) and a national syphilis rate among MSM of 11.8% (5552/47,231; 95% CI, 11.5%–12.0%).
While there was considerable geographic variation across the country, as we might expect, HIV was found among MSM across all sites, suggesting a major public health challenge ahead for China.
In South Asia, including India, Pakistan and Nepal, HIV rates have been high among MSM, among male sex workers, and among the large traditional communities of transgender women, including those among the Hijra population of Pakistan and India.13, 14
The best data, and some of the only prospective cohort data on MSM in the region, has come from Bangkok, Thailand. Reports from 2006 onwards show that the next wave of HIV spread in Thailand was among MSM, a group that was among the earliest affected in the late 1980s.15 But the current epidemic is quite different.
It is marked by very high incidence rates among the youngest age groups, and sustained rates of new infection despite a national HIV testing program and universal access to an antiretroviral program.16
HIV acquisition rates among the youngest men in the Bangkok cohort reached over 30% of all men after five years of follow-up, despite regular HIV testing and counselling, free sexually transmitted infection care, and condom and lubricant distribution.17
The epidemic among Thai MSM illustrates the severity of the epidemic among MSM in the region, and also challenges our thinking about responses.
While stigma and some negative social attitudes towards open expression of same-sex relationships do prevail in Thai culture and society, homosexuality is not illegal as it is in many neighbouring countries and there are no explicit legal barriers to accessing HIV services. Yet HIV spread among young Thai MSM is severe and ongoing.
One clear challenge suggested by the current epidemiology is that HIV is not simply driven by individual-level risk behaviours; it is also driven by network-level factors.18 Indeed, in the large networks of very high transmission and acquisition dynamics that characterise these outbreaks, quite modest individual-level risks can translate into very high lifetime probabilities of HIV infection.
Network-level factors that may be important in MSM HIV outbreaks include the size of these networks, the efficiency of HIV transmission in unprotected receptive anal sex, the sex role versatility of MSM, and the high proportion of new infections due to onward transmission of recent and acute infections.
All of these factors are likely affected by the proportion of untested and untreated men living with HIV infection in the region. They require us to rethink individual-based approaches and to grapple with network- and community-level interventions.
The role of non-injecting drug use – particularly the use of amphetamine-type substances – in HIV risks is emerging as a related challenge in some networks of MSM in the region.19
Transgender women and HIV in the Asia-Pacific
The epidemiology of HIV among transgender women (male-to-female transgender persons) is just emerging in the region and poses challenges to HIV responses. A recent review of the global burden of HIV among transgender women found data from only 15 countries worldwide.20
However, among the 11,066 transgender women included in this data the pooled HIV prevalence was 19.1% (95% CI, 17.4–20.7) and transgender women were some 48 times more likely to have HIV than other reproductive-age adults in the same population.21Data were available for transgender women from six Asia-Pacific countries: Australia, India, Indonesia, Pakistan, Thailand and Vietnam.
HIV rates were highest among transgender women in India (43.7%) (95% CI, 31–56.4) but were also high in Indonesia (26.1%) (95% CI, 21.6–30.6) and in Thailand (12.5%) (95% CI, 5.1–19.9).
The epidemiology among these communities is often confounded by the fact that transgender sex workers, a subset of transgender women, are often over-sampled or exclusively sampled from these communities, a bias that may drive HIV estimates among this population.
Nevertheless, these are highly burdened communities and they require much greater attention, engagement and inclusion in tailored HIV programming across the Asia-Pacific.
Given these high burdens of HIV, high rates of acquisition among young MSM, and evidence of ongoing spread despite available prevention services, the challenge facing the Asia-Pacific region is how to better respond to these epidemics.
As in the past, and in other settings where vigorous responses are under way, this will only happen with the strong leadership, engagement and support of the affected community.22
Fortunately, the Asia-Pacific region does have strong and growing community engagement around HIV and the health and rights of lesbian, gay, bisexual and transgender people more broadly. But greater community involvement and donor support with current prevention and treatment approaches may not be enough.
New and more potent prevention technologies and approaches, including innovations in testing and tailoring of pre-exposure prophylaxis and of enhanced antiretroviral treatment approaches for MSM already living with HIV, are likely to be key.23
To make these services available, and to adapt them to this very large and diverse region, a new coalition may be necessary. Communities and scientists, implementers and policy leaders are going to have to work together around a new mobilisation to bring innovation, greater engagement with young men in need, and new approaches to this next wave of HIV spread.
This is critical work in the HIV response in the Asia-Pacific region: it must and can be done.
Chris Beyrer MD, MPH, is a professor of Epidemiology, International Health, and Health, Behavior, and Society at the Johns Hopkins University Bloomberg School of Public Health.
In 2012, he became President-elect of the International AIDS Society, and will serve as President of the IAS, the world’s largest body of HIV professionals, from 2014–16.
1 UNAIDS, (2012). Report on the global AIDS epidemic 2012. UNAIDS, Geneva.
2 Beyrer, C., Sullivan, P., Millett, G., Sanchez, J., Baral, S., Collins. C, et al. (2013, July 9). The global HIV epidemics in men who have sex with men. AIDS. [Epub ahead of print] PMID: 23842129 [PubMed – as supplied by publisher].
3 Kanter, J., Koh, C., Razali, K., Tai, R., Izenberg, J., Rajan, L., et al. (2010, September). Risk behaviour and HIV prevalence among men who have sex with men in a multiethnic society: a venue-based study in Kuala Lumpur, Malaysia. AIDS, 24(suppl 3), S30–40.
4 Baral, S., Sifakis, F., Cleghorn, F., Beyrer, C. (2007, December). Elevated risk for HIV infection among men who have sex with men in low and middle income countries 2000–2006: results of a metaanalysis. PloS Med, 4(12), e339.
5 Beyrer, C., Baral, S., van Griensven, F., Goodreau, S., Chariyalertsak, S., Wirtz, A., et al. (2012, July 28). Global epidemiology of HIV infection in men who have sex with men. Lancet, 380(9839), 367–77.
6 Kao, C., Chang, S., Hsia, K., Chang, F., Yang, C., Liu, H., et al. (2011). Surveillance of HIV Type 1 recent infection and molecular epidemiology among different risk behaviors between 2007 and 2009 after the HIV Type 1 CRF07_BC outbreak in Taiwan. AIDS Res Hum Retroviruses, 27(7), 745–49.
7 van Griensven, F., de Lind van Wijngaarden, J. (2010). A review of the epidemiology of HIV infection and prevention responses among MSM in Asia. AIDS, 24(suppl 3), S30–40.
9 Lin, H., He, N., Zhou, S., Ding, Y., Qiu, D., Zhang, T., et al. (2013). Behavioral and molecular tracing of risky sexual contacts in a sample of Chinese HIV-infected men who have sex with men. American Journal of Epidemiology, 177, 343–50.
10 Fan, S., Lu, H., Ma, X., Sun, Y., He, X., Li, C., et al. (2012). Behavioral and serologic survey of men who have sex with men in Beijing, China: implication for HIV intervention. AIDS Patient Care STDS, 26, 148–55.
11 Wu, Z., Xu, J., Liu, E., Mao, Y., Xiao, Y., Sun, X., et al. (2013, July). National MSM Survey Group. HIV and syphilis prevalence among men who have sex with men: a cross-sectional survey of 61 cities in China. Clin Infect Dis, 57(2), 298–309.
13 Altaf, A. (2009). Explosive expansion of HIV and associated risk factors among male and hijra sex workers in Sindh, Pakistan. J Acquir Immune Defic Syndr, 51, 158.
14 Sahastrabuddhe, S., Gupta, A., Stuart, E., et al. (2012). Sexually transmitted infections and risk behaviors among transgender persons (hijras) of Pune, India. J Acquir Immune Defic Syndr, 59, 72–78.
15 Centers for Disease Control and Prevention (2006). HIV prevalence among populations of men who have sex with men – Thailand, 2003 and 2005. Morb Mortal Wkly Rep, 55, 844–48.
16 van Griensven, F., Thienkrua, W., McNicholl, J., Wimonsate, W., Chaikummao, S., Chonwattana, W., et al. (2013, March 2013). Evidence of an explosive epidemic of HIV infection in a cohort of men who have sex with men in Thailand. AIDS, 27(5), 825–32.
18 Beyrer, C., Baral, S., van Griensven, F., Goodreau, S., Chariyalertsak, S., Wirtz, A., et al. (2012, July 28). Global epidemiology of HIV infection in men who have sex with men. Lancet, 380(9839), 367–77.
19 Colfax, G., Santos, G., Chu, P., Vittinghoff, E., Pluddemann, A., Kumar, S., et al. (2010). Amphetamine-group substances and HIV. Lancet, 376, 458–74.
20 Baral, S., Poteat, T., Strömdahl, S., Wirtz, A., Guadamuz, T., Beyrer, C. (2012, December 21). Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet, 13(3), 214–222.
22 Trapence, G., Collins, C., Avrett, S., Carr, R., Sanchez, H., Ayala, G., et al. (2012). From personal survival to public health: community leadership by men who have sex with men in the response to HIV. Lancet, 380, 400–10.
23 Sullivan, P., Carballo-Diéguez, A., Coates, T., Goodreau, S., McGowan, I., Sanders, E., et al. (2012). Successes and challenges of HIV prevention in men who have sex with men. Lancet, 380(9839), 388–99.