WHAT DOES CISGENDER MEAN?
Cisgender is a term that is used to describe people whose gender identity matches the sex they were assigned at birth. For example, someone who was assigned male at birth (AMAB) and identifies as a man is a cisgender man. On the other hand, an AMAB person who identifies as a woman is a transgender woman. Similarly, an AMAB person who does not identify as either a man or woman often identifies as non-binary/genderqueer.
For the remainder of this fact sheet, man/men will be used to describe cisgender men. Many of the statistics and information below may apply to AMAB transgender people, such as transgender women, but cisgender men and transgender women are different populations with different behaviors, risk profiles, and HIV burdens. Read more about HIV among transgender people.
HOW SERIOUS IS HIV FOR MEN WHO HAVE SEX WITH MEN?
Globally, gay men and other men who have sex with men (MSM) are 27 times more likely to acquire HIV than the general population. New diagnoses among this group are increasing in many areas around the world.
In 2017, MSM accounted for 57% of new HIV infections in Western Europe and North America, 41% in Latin America and the Caribbean, 25% in Asia and the Pacific, 20% in Eastern Europe, Central Asia, the Middle East, and North Africa, and 12% in Western and Central Africa.
In the U.S., MSM accounted for 69% (26,198) of the 37,968 new HIV diagnoses in 2018. Racial and ethnic minorities are disproportionately affected. In 2018, rates of new HIV diagnoses among MSM were:
- Black/African American MSM: 37%
- Hispanic/Latino MSM: 30%
- White MSM: 27%
Young MSM are particularly at risk, with 25% of new HIV diagnoses occurring among youth 13-24 years of age and 39% occurring among MSM 25-34 years of age. Read more about HIV in adolescents and young people.
WHY ARE MSM PARTICULARLY AT RISK FOR HIV?
Because HIV prevalence among MSM is so high in many countries, members of this group have an increased chance of being exposed to the virus. The following factors contribute to the global burden of HIV among MSM:
Legal factors: Some countries have progressive attitudes and policies regarding the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community. In Latin America, North America, Western Europe, and Central Europe, many countries have made significant progress in recognizing the rights of LGBTQ people and allow marriage or civil unions between people of the same sex. However, most of Africa, Asia, and Russia continue to ignore and abuse the human rights of LGBTQ people. Punitive laws that criminalize same-sex activity in 71 countries around the world drive this population underground, elevating their risk of HIV and preventing them from accessing essential healthcare services. Thirteen countries, including 6 countries that are members of the United Nations, impose the death penalty. Another 5 make such punishment technically possible, even though it is rarely enforced. In 26 other countries, the maximum penalty is prison with terms varying anywhere from a few years to life imprisonment. Around 41 countries have laws that restrict non-governmental organizations (NGOs) from working on LGBTQ issues.
Even in countries where same-sex activity is legal, other laws discriminate against LGBTQ people and stigma and discrimination stop MSM from accessing HIV services and can lead to risk-behaviors that drive transmission.
Social and cultural factors: Many MSM have experienced homophobic stigma, discrimination, and violence. This drives MSM to hide their identity and sexual orientation. Many fear a negative reaction from healthcare workers and as a result, MSM are less likely than heterosexual people to access HIV services.
MSM are more likely to experience depression due to social isolation and being disconnected from health systems. This can make it harder to cope with aspects of HIV such as adherence to medication.
Biological factors: One of the main reasons for high vulnerability to HIV among this group is that unprotected anal sex carries a higher risk of transmission than vaginal sex. The lining of the rectum is very thin and can be damaged very easily during sexual activity. This makes it easier for HIV to enter the body. Receptive anal intercourse carries the highest risk of acquiring HIV while insertive anal sex carries the highest risk for transmitting HIV to others.
Having a sexually transmitted infection (STI) also makes a person more susceptible to HIV infection. STI rates among MSM are high and have been rising for many years. Various studies in different countries have found that MSM are fearful of experiencing discrimination, judgment, mistreatment, and confidentiality breaches in healthcare settings. As a result, many MSM live with undiagnosed STIs which puts them at higher risk for HIV.
Behavioral factors: Having multiple sexual partners is common among MSM, yet many MSM do not use condoms or take medicines to prevent or treat HIV consistently. These medicines include pre-exposure prophylaxis (PrEP) to prevent HIV transmission and antiretroviral therapy (ART) to treat HIV infection. In 33 countries, less than 60% of MSM reported using a condom at last anal sex and only 15 countries had rates higher than 80%.
Statistics vary around the world, but HIV testing is also low among MSM. People who do not know they have HIV can’t take advantage of HIV care and treatment and may unknowingly pass HIV to others.
Alcohol and drugs are a common part of socializing in some communities of MSM. Being under the influence of drugs or alcohol can make it more likely that people will have unprotected sex and a higher number of sexual partners, both of which increase the risk of HIV transmission.
PREVENTING HIV INFECTION AMONG MSM
It is evident that prevention strategies are failing to reach this group due to high HIV prevalence in communities around the world. When MSM are targeted by HIV prevention campaigns they can be extremely effective. It is important that a combination of prevention programs are available.
Encouraging condom use
One of the most important prevention responses is to make condoms and water-based lubricants available and accessible to MSM. Condoms are highly effective in preventing a person from getting or transmitting HIV infection if used the right way every time during sex. Read more about how to use condoms the right way: external condoms and internal condoms.
Unprotected receptive anal sex (bottoming) is the riskiest type of sex for getting HIV. Unprotected insertive anal sex (topping) is less risky for getting HIV but very risk for passing HIV to others. In general, there is little to no risk of getting or transmitting HIV from oral sex. Read more about safer sex guidelines.
In many settings, providing condoms and lubricants in gay-friendly places is much more effective than requiring MSM to purchase them from pharmacies or healthcare settings that they may be fearful of visiting.
HIV counseling and testing
Effective ways to encourage HIV testing among MSM are to provide home-based testing and community-based testing. Community-based testing is carried out at local pop-up clinics or mobile vans in areas where MSM feel comfortable. This removes the need to test in clinics where MSM may experience discrimination and mistreatment. Home-based testing has the benefit of the person being able to avoid identification by healthcare workers. The privacy of conducting an HIV test alone at home makes this an appealing option for many MSM.
HIV self-testing should be made more widely available to help increase testing and earlier diagnosis. MSM should be educated about the use of self-testing kits to heighten their confidence in using them as an alternative to testing at regular healthcare settings.
The CDC recommends that all sexually active MSM get tested for HIV at least once a year. Some sexually active MSM (including those who have more than one partner or those who have casual sex with people they don’t know) may benefit from getting tested more often, such as every 3-6 months. Find an HIV testing site near you.
Pre-exposure prophylaxis (PrEP)
PrEP is the daily use of antiretroviral medications (ARVs) to reduce the risk of HIV infection among HIV-negative people. Research has shown that PrEP reduces HIV transmission among MSM by 92%. The World Health Organization (WHO) estimates that if PrEP use is scaled up, 20-25% of new HIV infections among MSM could be prevented. PrEP can be combined with other prevention methods, such as condoms, to reduce the risk of HIV even further.
In the U.S., PrEP use among MSM remains low, especially among Black/African American and Hispanic/Latino MSM. In 2017, only 19% of Black/African American and 21% of Hispanic/Latino MSM took PrEP compared to 31% of White MSM.
Post-exposure prophylaxis (PEP)
PEP is the use of ARVs to prevent HIV infection as soon as possible after potential exposure to HIV. It must be taken within 72 hours of possible exposure. WHO recommends offering PEP to MSM as part of a package of prevention options. It must also be coupled with counseling about the importance of finishing the treatment course. PEP is not the right choice for people who may be exposed to HIV frequently. If a person is at ongoing risk for HIV, such as through repeated exposures to HIV, they should talk to a healthcare provider about taking PrEP.
HOW CAN MSM WITH HIV PROTECT THEIR PARTNERS WHO DON’T HAVE HIV?
The best way to prevent transmission to HIV-negative partners is to take HIV medicines every day. ART is recommended for everyone who has HIV. ART can’t cure HIV infection, but it can reduce the amount of HIV in the body (called viral load).
One of the main goals of ART is to reduce a person’s viral load to an undetectable level. An undetectable viral load means that the level of HIV in the blood is too low to be detected by a viral load test. People with HIV who have an undetectable viral load have effectively no risk of transmitting HIV to an HIV-negative partner through sex. Maintaining an undetectable viral load is also the best way to stay healthy, live longer, and prevent HIV-related illnesses, called opportunistic infections (OIs).
Other steps MSM with HIV can take to protect their HIV-negative partners include using condoms during sex and talking to their partners about taking PrEP.
ANTIRETROVIRAL THERAPY (ART) AMONG MSM
Worldwide, only 40% of MSM with HIV are estimated to be accessing ART. Those living in low- and middle-income countries generally report the lowest access to ART, with especially low rates in countries which criminalize same-sex identities and behaviors. Reasons cited for such low access include homophobia, stigma, discrimination, and harassment from healthcare workers. These can cause MSM to delay, interrupt, or avoid treatment altogether.
In the U.S., MSM have about the same viral suppression rates compared to all people with HIV.
|Received some care||Retained in care||Achieved viral suppression|
|Women with HIV||65%||49%||57%|
|All people with HIV||65%||50%||56%|
Taking HIV medicine every day can make the viral load undetectable. People who get and keep an undetectable viral load (or remain virally suppressed) can stay healthy for many years and have effectively no risk of transmitting HIV to their sex partners.
WHO has produced comprehensive guidance on HIV services for MSM and recommends that adherence can be increased significantly by addressing HIV stigma and discrimination.
THE BOTTOM LINE
In the U.S. and around the world, men who have sex with men (MSM) are disproportionately affected by HIV. This is due to a range of biological, cultural, social, legal, and behavioral factors.
MSM should get tested for HIV at least once a year, and in some cases more frequently. This is especially true for MSM who have multiple sex partners or who inject drugs. If they test positive for HIV, they can take steps to reduce the risk of infecting their partners and ensure their own health.
The best way to prevent infection is by using condoms, taking PrEP if HIV-negative, and taking strong ART if HIV-positive.
With early testing and treatment, MSM can live long and healthy lives and prevent HIV transmission to their sexual partners.
Reviewed May 2021Print PDF