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Men who have sex with Men (MSM) are currently at marked risk for HIV infection in Low- and Middle-Income Countries (LMICs) in Asia, Africa, Latin America and the Caribbean, and in Eastern Europe and Central Asia. Estimates of HIV prevalence rates have been consistently higher among MSM than for the general population of reproductive-age men virtually wherever MSM have been well studied. Although scarce, HIV incidence data support findings of high acquisition and transmission risks among MSM in multiple contexts, cultural settings, and economic levels. Research among MSM in LMICs has been limited by the criminalization and social stigmatization of these behaviors, the safety considerations for study participants, the hidden nature of these populations, and a lack of targeted funding. Available evidence from these countries suggests that structural risks social, economic, political, or legal factors in addition to individual-level risk factors are likely to play important roles in shaping HIV risks and treatment and care options for these men. Services and resources for populations of MSM remain markedly low in many settings. They have limited coverage and access to HIV/AIDS prevention, treatment, and care services with some estimates suggesting that fewer than one in ten MSM worldwide have access to the most basic package of preventive interventions.

Despite a fair amount of progress on understanding human immunodeficiency virus (HIV) epidemiology globally, the Middle East and North Africa (MENA) region is the only region where knowledge of the epidemic continues to be very limited, and subject to much controversy. It has been more than 25 years since the discovery of HIV, but no scientific study has provided a comprehensive data-driven synthesis of HIV/AIDS (acquired immunodeficiency syndrome) infectious spread in this region. The current report provides the first comprehensive scientific assessment and data-driven epidemiological synthesis of HIV spread in MENA since the beginning of the epidemic. It is based on a literature review and analysis of thousands of widely unrecognized publications, reports, and data sources extracted from scientific literature or collected from sources at the local, national, and regional levels. The recommendations provided here focus on key strategies related to the scope of this report and its emphasis on understanding HIV epidemiology in MENA as a whole. The recommendations are based on identifying the status of the HIV epidemic in MENA, through this synthesis, as a low HIV prevalence setting with rising concentrated epidemics among priority populations. General directions for prevention interventions as warranted by the outcome of this synthesis are also discussed briefly, but are not delineated because they are beyond the scope of this report. This report was not intended to provide intervention recommendations for each MENA country.

Since the beginning of the epidemic sex workers have experienced a heightened burden of HIV across settings, despite their higher levels of HIV protective behaviors (UNAIDS, 2009). Unfairly, sex workers have often been framed as 'vectors of disease' and 'core transmitters' rather than workers and human beings with rights in terms of HIV prevention and beyond. By gaining a deeper understanding of the epidemiologic and broader policy and social context within which sex work is set one begins to quickly gain a sense of the complex backdrop for increased risk to HIV among sex workers. This backdrop includes the critical role of stigma, discrimination and violence faced by sex workers, as well as, the importance of community empowerment and mobilization among sex workers to address these regressive forces. The eight country case studies work to highlight the experiences of diverse populations of and contexts for sex work across settings. Given the limited epidemiologic and intervention evaluation data available among male and transgender sex workers, however, our collaborative team (Johns Hopkins University, or JHU, World Bank, United Nations Population Fund (UNFPA), and Global Network of Sex Work Projects, or NSWP) determined that the systematic review, mathematical modeling and cost-effective analyses would focus on female sex workers. Throughout the process of this analysis as a whole, the participation of sex worker perspectives and sex worker organizations such as NSWP and their regional partners has been critical by providing documents and resources, input and consultation throughout the analytical process.

Recent evidence suggests that the prevalence of HIV/AIDS is increasing in the Middle East, North Africa, and Eastern Mediterranean (MENA/EM) region, and that the total number of AIDS-related deaths has risen almost sixfold since the early 1990s. Although this figure is low compared with those for Africa, South Asia, and the Caribbean, low prevalence does not equal low risk. The situation can change rapidly, and even conservative estimates indicate that AIDS poses a real threat to the region’s long-term growth.This book reviews the current knowledge available on the prevalence of HIV/AIDS in the MENA/EM region with the goal of stimulating discussion among policy- and decisionmakers. In other regions, early investments in good surveillance and effective prevention programs have proved to be relative bargains, compared with the costs of a full-blown epidemic. As the authors argue, the time to act is now, while prevalence levels are still low. To that end, they make specific recommendations and offer best practices and case studies from around the world.This volume is the product of the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (Eastern Mediterranean Regional Office), and the World Bank. It will be of particular interest to those in the fields of public health, social policy, and economic development, as well as to students and scholars of the region.

The HIV/AIDS epidemic has the potential to impede and even reverse development if not addressed early enough. Poverty and income inequality have been shown to facilitate the diffusion of HIV epidemics. While abject poverty in the Middle East and North Africa region remains low, a significant proportion of the population (23.2%) live under 2 per day and are extremely vulnerable in their ability to cope with shocks.In order to preserve the benefits of national and regional development investments put in place by governments, and donor agencies, greater investments to improve HIV/AIDS advocacy, information and prevention strategies are needed now to maintain the current low prevalence levels. This title outlines the role of the Bank in confronting the HIV/AIDS epidemic in the region based on a review of needs and gaps at the regional and country level.

How should the corporate sector engage in fighting the global burden of the AIDS epidemic? India's relatively low HIV prevalence rate often raises the question of whether it is in corporate sector interest to allocate resources to combat HIV and AIDS. The five case studies in this report feature a selection of Indian companies that felt compelled to engage in this fight and id allocate resources in order to do so. The challenges these companies encountered and innovative methods they used to surmount these challenges serve as useful lessons for those interested in launching similar intiatives.

The Centers for Disease Control and Prevention (CDC) have identified Atlanta, Georgia as a high-risk environment for STI/HIV infection. Condoms are an inexpensive and effective method for preventing STI/HIV infection. The majority of individuals acquire their condoms through purchase, rather than through free condom distribution programs. However, individuals purchasing condoms in stores encounter numerous barriers. This study assessed the environmental and physical barriers surrounding condom purchases in stores in downtown Atlanta. The findings revealed a combination of high environmental and physical barriers, low visibility of condoms in stores and limited selection of safer sex supplies. In the most densely populated area of the city, stores which sold condoms were few (n = 25), equating to 1 store per ~7000 people. In 80% of stores, personnel were required in order to access the condoms. In 28% of stores, condoms were hidden underneath the counter. The majority of stores offered only one brand of male condoms with a limited selection of lubricants and no dental dams or internal condoms. Barriers and discomfort surrounding purchasing condoms can contribute to embarrassment, which has a negative impact on condom acquisition and ultimately on condom use. Efforts must be made to lower barriers in Atlanta and make condoms more readily available to high-risk populations. Community advocacy has been effective in removing barriers to condoms. Access can furthermore be improved by: installing condom vending machines in public locations, offering self-check-out in stores that do not have physical barriers and encouraging individuals to order condoms online.

This report the findings and outcomes of the three joint UNESCO/World Bank missions to Guyana, Jamaica, and St. Lucia, and elaborates on next steps identified for action at both national and regional levels. The report also sets these findings and next steps within the broader context of the Caribbean plan for action and presents in its appendixes sample resources to guide the development of a comprehensive response to Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV&AIDS) by the education sector. The priority placed on the education sector's response is based on evidence that education contributes towards the knowledge and personal skills essential for the prevention of HIV, and protects individuals, families, communities, institutions, and nations from the impact of AIDS. Education helps to overcome the conditions that facilitate the spread of HIV and can create the understanding and tolerance that contribute to reduced stigma and discrimination against vulnerable and marginalized communities and people living with HIV. The CARICOM regional body in the Caribbean, as well as leadership at the national level, has demonstrated commitment to accelerating the education sector response to HIV&AIDS. To fully maximize efforts at the national and regional levels, including (i) information and research; (ii) capacity building for planning, decision- making and coordination; (iii) strengthening teacher education and learning materials; and (iv) stigma, discrimination and human rights, including attention to cultural differences, will be addressed more systematically.

Background Correct and consistent condom use is the most effective method to reduce transmission of sexually transmitted infections (STIs). Objective To compare the HIS-UK intervention to usual condom information and distribution care for effect on chlamydia test positivity. Methods Trial design A 3-parallel arm randomised controlled trial (1:1:1 allocation, two intervention arms vs. control). Randomisation using permuted blocks of varying lengths, with stratification by site, ethnicity and sexual-partnering risk. Repeated measures design with monthly follow-up to six months post-randomisation. Setting Sexual health services in seven NHS Trusts and one university medical centre. Telephone and video consultations, online and in participants’ homes in England, UK. Participants Target sample of 2231 men and people with penises, aged 16-25, at risk of STIs. Intervention HIS-UK delivered (1) face-to-face by health professionals (proHIS) or (2) digitally (eHIS). Two-weeks self-practice and experimentation using the HIS-UK condom kit. Primary health outcome Chlamydia test positivity by six-months. Secondary outcomes Frequency of unprotected sexual intercourse, reported condom use errors and problems, attitudes and use experience. Analyses Chlamydia test positivity by six months analysed by logistic regression. Secondary outcomes analysed using linear mixed effects models with fixed effects and a random effect for the repeated measures, and generalised estimating equations with a logit link, adjusting for fixed effects and specifying an autoregressive-1 correlation structure. Results Seven hundred twenty-five participants (proHIS:241, eHIS:243, control:241) randomised. 575 participants completed all baseline activities, 189 (32.9%) reached six-months post-randomisation. The absolute difference in chlamydia test positivity between arms was -4.9 percentage points at six months (7.9% HIS-UK, 12.8% control). The odds of chlamydia test positivity during follow-up were 55% lower for HIS-UK participants ( p =.261). HIS-UK showed a positive impact on recent condom use over time ( p <.001). Significant reductions in condom errors and problems among HIS-UK participants were observed ( p =.035). Lubricant use increased among HIS-UK participants, with evidence of an intervention-by-time interaction ( p =.051), and a decline in poor condom fit and feel reports, but without intervention effect. Conclusions This study provides valuable insights into the potential of HIS-UK to enhance sexual health practices among at-risk populations at-risk of STI transmission. Trial registration ISRCTN registration: 11400820 (23/10/2019).

Globally, HIV disproportionately affects men who have sex with men (MSM). This study explored associations between access to HIV services and (1) individual-level perceived sexual stigma; (2) country-level criminalization of homosexuality; and (3) country-level investment in HIV services for MSM. 3,340 MSM completed an online survey assessing access to HIV services. MSM from over 115 countries were categorized according to criminalization of homosexuality policy and investment in HIV services targeting MSM. Lower access to condoms, lubricants, and HIV testing were each associated with greater perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in HIV services. Lower access to HIV treatment was associated with greater perceived sexual stigma and criminalization. Criminalization of homosexuality and low investment in HIV services were both associated with greater perceived sexual stigma. Efforts to prevent and treat HIV among MSM should be coupled with structural interventions to reduce stigma, overturn homosexuality criminalization policies, and increase investment in MSM-specific HIV services.