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 influence of anti-LGBT legislation and stigma.
Methods
We systematically searched the peer-reviewed literature to October 10th , 2018 for studies and extracted or derived estimates of HIV testing and/or engagement with the HIV treatment cascade 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 overall proportions of MSM ever tested of 67·3% (95%Confidence interval 62·1-72·3%,N=44) and tested in the past 12 months of 50·1% (42·4-57·8%,N=31) post-2011 – 14% and 18% points higher than pre-2011, respectively. Post-2011, ever testing was highest in Southern(80·0%) and lowest in Northern(34·4%) and Central(56·1%) Africa, with the greatest increase in Western Africa(from 42·4 to 70·9%). Levels of both testing outcomes and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation.
Few estimates were available for later stages of the treatment cascade. Available data post61 2011 suggest that the pooled proportion of MSM HIV-positive aware has remained low (18·5%, 12·5-25·3%,N=28) whereas proportions of current ART use were 23·7% (15·5- 33·0%,N=14) among all MSM living with HIV and 53·4% (36·9-69·5%,N=6) among MSM HIV-positive aware. Levels of viral suppression among MSM currently on ART were good (pooled: 75·6%, 64·4-85·5%,N=4), but low among all MSM living with HIV (pooled: 24·7%, 18·8-31·2%,N=4).
Interpretation
Available data suggests that levels of HIV status awareness among MSM living with HIV in Africa remain low, despite recent improvements in HIV testing; limited data is available on levels of engagement in care, ART use and viral suppression. We found that severe anti LGBT legislation was associated with lower HIV testing and status awareness. Achieving UNAIDS 90-90-90 targets will require substantial improvements.