Baral Stefan, Sifakis Frangiscos, Cleghorn Farley, Beyrer Chris
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
PLoS Med. 2007 Dec;4(12):e339. doi: 10.1371/journal.pmed.0040339.
Recent reports of high HIV infection rates among men who have sex with men (MSM) from Asia, Africa, Latin America, and the former Soviet Union (FSU) suggest high levels of HIV transmission among MSM in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, we conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data.
A comprehensive review of the literature was conducted using systematic methodology. Data regarding HIV prevalence and total sample size was sequestered from each of the studies that met inclusion criteria and aggregate values for each country were calculated. Pooled odds ratio (OR) estimates were stratified by factors including HIV prevalence of the country, Joint United Nations Programme on HIV/AIDS (UNAIDS)-classified level of HIV epidemic, geographic region, and whether or not injection drug users (IDUs) played a significant role in given epidemic. Pooled ORs were stratified by prevalence level; very low-prevalence countries had an overall MSM OR of 58.4 (95% CI 56.3-60.6); low-prevalence countries, 14.4 (95% CI 13.8-14.9); and medium- to high-prevalence countries, 9.6 (95% CI 9.0-10.2). Significant differences in ORs for HIV infection among MSM in were seen when comparing low- and middle-income countries; low-income countries had an OR of 7.8 (95% CI 7.2-8.4), whereas middle-income countries had an OR of 23.4 (95% CI 22.8-24.0). Stratifying the pooled ORs by whether the country had a substantial component of IDU spread resulted in an OR of 12.8 (95% CI 12.3-13.4) in countries where IDU transmission was prevalent, and 24.4 (95% CI 23.7-25.2) where it was not. By region, the OR for MSM in the Americas was 33.3 (95% CI 32.3-34.2); 18.7 (95% CI 17.7-19.7) for Asia; 3.8 (95% CI 3.3-4.3) for Africa; and 1.3 (95% CI 1.1-1.6) for the low- and middle-income countries of Europe.
MSM have a markedly greater risk of being infected with HIV compared with general population samples from low- and middle-income countries in the Americas, Asia, and Africa. ORs for HIV infection in MSM are elevated across prevalence levels by country and decrease as general population prevalence increases, but remain 9-fold higher in medium-high prevalence settings. MSM from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved.
近期来自亚洲、非洲、拉丁美洲及前苏联（FSU）的男男性行为者（MSM）中高HIV感染率的报告表明，在低收入和中等收入国家的MSM中存在高水平的HIV传播。为了调查全球MSM中的HIV流行情况以及MSM疫情暴发与普通人群的关系，我们对低收入和中等收入国家中MSM的HIV研究进行了全面综述，并对报告的MSM及育龄期成人HIV流行率数据进行了荟萃分析。
采用系统方法对文献进行全面综述。从每项符合纳入标准的研究中获取HIV流行率及总样本量数据，并计算每个国家的汇总值。合并比值比（OR）估计值按以下因素分层：国家的HIV流行率、联合国艾滋病规划署（UNAIDS）分类的HIV疫情水平、地理区域以及注射吸毒者（IDU）在特定疫情中是否起重要作用。合并ORs按流行率水平分层；极低流行率国家MSM的总体OR为58.4（95%CI 56.3 - 60.6）；低流行率国家为14.4（95%CI 13.8 - 14.9）；中等至高流行率国家为9.6（95%CI 9.0 - 10.2）。比较低收入和中等收入国家时，MSM中HIV感染的ORs存在显著差异；低收入国家的OR为7.8（95%CI 7.2 - 8.4），而中等收入国家为23.4（95%CI 22.8 - 24.0）。按IDU传播是否占主要部分对合并ORs进行分层，在IDU传播普遍的国家，OR为12.8（95%CI 12.3 - 13.4），在IDU传播不普遍的国家为24.4（95%CI 23.7 - 25.2）。按地区划分，美洲MSM的OR为33.3（95%CI 32.3 - 34.2）；亚洲为18.7（95%CI 17.7 - 19.7）；非洲为3.8（95%CI 3.3 - 4.3）；欧洲低收入和中等收入国家为1.3（95%CI 1.1 - 1.6）。
与美洲、亚洲和非洲低收入和中等收入国家的普通人群样本相比，MSM感染HIV的风险明显更高。MSM中HIV感染的ORs在不同国家的流行率水平上均有所升高，并随着普通人群流行率的增加而降低，但在中等至高流行率环境中仍高出9倍。低收入和中等收入国家的MSM迫切需要预防和护理，而且似乎研究不足且服务欠缺。
