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Epidemics in MSM are re-emerging in many high-income countries and gaining greater recognition in many low-income and middle-income countries. Better HIV prevention strategies are urgently needed. At the beginning of the epidemic, stand-alone behavioural interventions mostly aimed to reduce unprotected anal intercourse, which, although somewhat efficacious, did not reduce HIV transmission. Biomedical prevention strategies reduce the incidence of HIV infection.

Delivery of barrier and biomedical interventions with coordinated behavioural and structural strategies could optimise the effectiveness of prevention. Modelling suggests that, with sufficient coverage, available interventions are sufficient to avert at least a quarter of new HIV infections in MSM in diverse countries. The World Bank used the highest attainable standard of evidence HASTE system which also includes data for implementation science in its review Alex dose need lube to take allan santos of published work, whereas WHO used the grading of recommendations assessment, development and evaluation GRADE system.

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Early HIV prevention efforts focused on behaviour change and yielded many successes, but did not provide sufficient strategies to curb the epidemic. More recently, approaches have been inclusive of biomedical strategies. Treatment and behavioural and biomedical approaches are not at odds with one another, but rather have complementary roles in a broad, coordinated, and science-based approach to HIV prevention in MSM.

Indeed, the strengths and opportunities associated with each strategy suggest that the intelligent combination of approaches is better than any single approach. Even Alex dose need lube to take allan santos MSM were represented in studies, they were often not the focus of the investigation.

Behavioural inter ventions have the strongest evidence but have only slight effects on self-reported behaviours, and no evidence shows a reduction in the incidence of HIV infection. Barrier and biomedical interventions have higher estimated efficacy including for reduction of the incidence of HIV infection than do behavioural interventions, but this efficacy might not be supported by evidence from randomised trials eg, condoms or have been tested in many MSM—eg, treatment as prevention.

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Other approaches—such as testing for and treatment of HIV and other sexually transmitted infections STIs —have strong biological plausibility and collateral prevention benefits but do not effectively lessen the incidence of HIV infection. Effect size is expressed as a risk ratio when possible, but in some cases represents an odds ratio or prevalence ratio.

Outcome Alex dose need lube to take allan santos unprotected anal intercourse in 54 cases, HIV or other sexually transmitted infection in five, and number of sex partners in one. Red halos show significance. The red dotted line signifies a null effect ie, no increase or decrease in the targeted outcome.

The appendix contains further information and references for included interventions. Efficacy is generally slight, fidelity is of concern, and few resources are available to bring individual or multisession ie, those in which more than one contact is necessary approaches to scale. Furthermore, most randomised studies have been done in North America or Europe appendixwhere most substantial investment has been made in the scale-up of behavioural interventions.

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However, even in these areas, biomedical approaches are increasingly emphasised. Investigators reported significant falls in the frequency of unprotected receptive anal intercourse in the intensive counselling group.

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However, the incidence of HIV infection in the intensive counselling group was not significantly lower than that in the control group. Results of post-hoc analysis of data from intermediate timepoints suggested significant but transient reductions in the incidence of HIV infection, and emphasised the need for long-term assessments of behavioural interventions.

Retention was lower in the intervention than in the control group, suggesting that intensive, multisession interventions might not be universally accept able.

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Additionally, self-reported falls in the frequency of risky behaviours are an insufficient standard for measuring the efficacy of interventions to prevent HIV acquisition.

Few rigorous assessments of theory-based behavioural interventions are available in developing countries appendix. Behavioural interventions might be more effective in settings that have little experience of specific prevention interventions and programmes for MSM than in those which have a lot of experience of such strategies.

Research is needed to assess the acceptability and cultural relevance of such approaches in these settings. If interventions have little cultural relevance, then adaptation or full re-evaluation might be necessary. If behaviour change is achieved to an adequate scale, transmission of HIV can be reduced. The responses of gay communities in the USA, Canada, and Australia 10 — 13 to the AIDS epidemic in the s show that community-initiated strategies can have an important role in shaping of epidemics.

After the discovery of the viral cause of AIDS and the development of an antibody test, MSM in several countries 10 — 13 reduced their numbers of sex partners and used condoms more often than before, and the incidence Alex dose need lube to take allan santos HIV infection fell sharply in some settings.

Researchers have assessed the efficacy of interventions to increase adherence to antiretroviral therapy. Proven interventions to increase adherence to antiretrovirals 16 could serve as a basis for development of adherence strategies targeted at HIV-negative men prescribed Alex dose need lube to take allan santos pre-exposure prophylaxis.

Much evidence shows that alcohol and use of non-injection drugs are important drivers of HIV infections in MSM communities worldwide. Biomedical and barrier approaches destroy HIV in the rectal or vaginal compartment, create a hostile environment which can be pharmacological or immunological that prevents local viral replication, or provide a barrier between the virus and susceptible cells. Evidence shows that condoms and pre-exposure treat ment with antiretrovirals reduce the risk of HIV infection.

The efficacy of other approaches—eg, postexposure treatment with antiretrovirals, HIV vaccines, use of antiretrovirals for prevention—is supported by evidence in non-MSM populations. Strategies such as treatment of drug addiction and STIs are probably important but empirical evidence is weaker for them than for other interventions. Additionally, injection-drug-using MSM should have access to proven bio medical prevention strategies such as needle exchange and opioid-substitution treatment, especially in regions of the world where injection drug use is a major driver of the HIV epidemic.

Condoms are highly efficacious in HIV prevention.

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Despite these findings, condom use by MSM is problematic. Issues include difficulty in negotiating condom use with sexual partners, 24 condom slippage or breakage, 25 and availability in developing countries.

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However, participants reported condom slippage, pain, and rectal bleeding. Condom-compatible lubricants probably provide additional prevention benefits when used with condoms because they reduce condom breakage and rectal trauma.

Antiretroviral therapy can be given to HIV-negative people after a high-risk HIV exposure so-called postexposure prophylaxis; appendix or before potential high-risk activity pre-exposure prophylaxis. The pre-exposure prophylaxis initiative iPrEx was a study 31 designed to assess the safety and efficacy of pre-exposure prophylaxis with daily tenofovir and emtricitabine Truvada in MSM and transgender women. The regimen was fairly well tolerated, but researchers noted a transient but significant increase in nausea and unintentional weight loss in the tenofovir and emtricitabine group.

Adherence was low in some sites outside the USA. These guidelines recommend daily tenofovir and emtricitabine and HIV antibody tests every 2—3 months. However, its findings also raise issues that have to be resolved before oral pre-exposure prophylaxis can be fully integrated into HIV prevention strategies.

The potential for long-term toxic effects should be established, as should acceptability, Alex dose need lube to take allan santos training procedures for prescribers, methods to avoid failing to diagnose occult infections during the window period, how to monitor adverse events, whether viral resistance will be problematic, and whether intermittent dosing regimens will be as efficacious as daily dosing.

Additional research should focus on which subgroups of MSM should receive oral pre-exposure prophylaxis and for how long, and how to fund this intervention. Very few same-sex couples were included in the study, and a separate analysis of efficacy in MSM was not possible. Observational studies suggesting that treatment of HIV-positive people is effective for HIV prevention have been reported in heterosexual populations, 35 but a systematic review identified no studies focusing on MSM.

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