Abstract

Men who have sex with men (MSM) are at disproportionate risk for HIV infection globally. The past 5 years have seen considerable advances in biomedical interventions to reduce the risk of HIV infection. To be impactful in reducing HIV incidence requires the rapid and expansive scale-up of prevention. One mechanism for achieving this is technology-based tools to improve knowledge, acceptability, and coverage of interventions and services. This review provides a summary of the current gap in coverage of primary prevention services, how technology-based interventions and services can address gaps in coverage, and the current trends in the development and availability of technology-based primary prevention tools for use by MSM. Results from agent-based models of HIV epidemics of MSM suggest that 40–50 % coverage of multiple primary HIV prevention interventions and services, including biomedical interventions like preexposure prophylaxis, will be needed to reduce HIV incidence among MSM. In the USA, current levels of coverage for all interventions, except HIV testing and condom distribution, fall well short of this target. Recent findings illustrate how technology-based HIV prevention tools can be used to provide certain kinds of services at much larger scale, with marginal incremental costs. A review of mobile apps for primary HIV prevention revealed that most are designed by nonacademic, nonpublic health developers, and only a small proportion of available mobile apps specifically address MSM populations. We are unlikely to reach the required scale of HIV prevention intervention coverage for MSM unless we can leverage technologies to bring key services to broad coverage for MSM. Despite an exciting pipeline of technology-based prevention tools, there are broader challenges with funding structures and sustainability that need to be addressed to realize the full potential of this emerging public health field.

Keywords

Men who have sex with men Technology HIV prevention 

This article is part of the Topical Collection on HIV and Technology

Electronic supplementary material

The online version of this article (doi: 10.1007/s11904-015-0293-5) contains supplementary material, which is available to authorized users.

Introduction

Men who have sex with men (MSM) represent less than 2 % of the US population [1] but account for about two thirds of new HIV diagnoses annually [2]. Primary HIV prevention for MSM is challenging because of the high biological risk of HIV transmission through anal intercourse not protected by condoms [3, 4], stigma, and discrimination [5, 6, 7] which can result in decreased willingness to access prevention services, imperfect knowledge of HIV serostatus by MSM living with HIV [8], and a prominent role of transmission “bursts,” in which infections arising from acutely and recently infected men play a key role [9]. Because of these challenges to HIV prevention, there is growing consensus that a comprehensive package of prevention services will be required to meaningfully reduce HIV incidence among MSM [10]. A comprehensive primary prevention package will include access to basic prevention services, such as HIV and STI testing, prevention counseling when needed; availability of prevention commodities, such as condoms, condom compatible lubricants, and perhaps home HIV testing kits; meaningful availability of new biomedical prevention modalities, including preexposure prophylaxis (PrEP) and nonoccupational postexposure prophylaxis (nPEP); referrals to culturally competent services for substance use, alcohol abuse, intimate partner violence, and mental health needs; and culturally competent, safe spaces in which to access services without fear of discrimination [10].

Historically, MSM have accessed prevention services in a number of settings. Although most HIV tests in the USA are reported to occur in physician’s offices, among MSM only about one in four HIV tests is reported to occur in a private doctor’s office, with nearly half occurring in HIV counseling and testing sites, public clinics, STD clinics, and outreach testing programs [11]. Health departments, community-based organizations, and AIDS service organizations provide HIV testing and condom distribution services. Evolving technologies, such as internet-based services, short messaging service capabilities, and mobile apps running on smartphones or tablets, offer new opportunities to directly provide or refer men to certain types of prevention services [12].

Here, we will review the scale of primary prevention services required to meaningfully reduce HIV incidence in MSM in the USA and summarize current levels of coverage. We will then describe the ways in which technologies can support improving scale of primary prevention for MSM and give recent examples of how technology is being used to improve primary HIV prevention.

How Much Coverage of Prevention Interventions Is Needed to Reduce HIV Incidence?

Several recent modeling studies provide evidence of the levels of coverage of HIV prevention services that will likely be required to reduce HIV incidence among MSM. Agent-based simulation models allow researchers to test counterfactual scenarios and estimate the impact on HIV incidence of implementing different combinations of prevention tools at varying levels of coverage. In a model of the US epidemic based on the PUMA transmission model of Goodreau et al. [13], researchers determined that providing PrEP to 40 % of behaviorally eligible MSM would result in a roughly 25 % reduction in new HIV infections [10]. Brookmeyer et al. found similar results in a model of HIV transmission among South African MSM, noting that a package of 50 % coverage of preexposure prophylaxis among high-risk MSM, 50 % reduction in “never tested” MSM, and a 50 % increase in ART coverage of MSM living with HIV would be required to achieve a one third reduction in new HIV infections [14]. Khanna et al. reported that simply increasing HIV testing frequency among MSM, even to every 3 or 6 months, was insufficient to reduce new HIV infections, but that personalized testing recommendations for HIV testing frequency were predicted to reduce incidence [15•]. The modeling results highlight two important points: HIV testing alone is unlikely to have a meaningful impact on HIV incidence, and 40–50 % coverage of multiple primary preventions will be required to make meaningful reductions in HIV incidence among MSM.

How Are We Doing with Coverage Levels of HIV Prevention Among MSM in the USA?

Figure 1 depicts the estimated coverage of primary HIV prevention interventions for MSM in the USA, according to three data sources that represent large numbers of diverse MSM or a probability sample of MSM: the National HIV Behavioral Surveillance System for MSM [16, 17], the American Men’s Internet Survey [18], and a 2014 Kaiser Family Foundation population-based sample of MSM [19]. The results show that for most primary prevention modalities, coverage is substantially less than the 40–50 % target coverage that is estimated to be needed to result in meaningful reductions in HIV incidence among MSM. Only self-reported HIV testing in the past 12 months and receipt of free condoms reach the 40 % threshold. A web supplement with interactive charts that depict coverage of specific interventions among MSM by age, race, income, education, identity, sexual identity, and rural/urban residence is available (https://jebjones.shinyapps.io/intervention_coverage).

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