Challenges and emerging opportunities for the HIV prevention, treatment and care cascade in men who have sex with men in Asia Pacific

The number of newly reported HIV infections among MSM in the region has been increasing, with the majority of transmissions occurring in this population. The HIV prevalence and incidence among MSM in metropolitan areas, such as Bangkok and Manila, are among the highest reported globally. In Bangkok, the HIV prevalence among MSM has consistently been around 30% throughout the past decade, while in Manila, 80% of newly reported HIV cases are currently in MSM and residents of the capital. The rising epidemic predominance of MSM is particularly present in metropolitan areas, characterized by high population density and a large MSM community. These areas attract and harbor large MSM communities, served by a growing number of physical and virtual businesses catering to their social, sexual, and other needs. The HIV epidemic in MSM is continuing without any signs of decline or reversal, despite the overall epidemic development associated with the focus on treatment for prevention (TFP) appearing to be positive. The TFP strategy has been promoted as the pathway to the effective control of the HIV epidemic and creation of an AIDS-free generation. However, the apparent lack of impact of TFP in MSM raises doubt about whether this blanket approach across all risk groups is the right method to stop the HIV epidemic in this population. A critical review of this strategy and its results is justified, and possibly, the TFP strategy may need to be reconsidered or supplemented by other approaches to exercise more preventive effect. The HIV care cascade in MSM shows a sobering picture of TFP in engaging and retaining MSM along the continuum. Widening the cascade with a preventive extension, including pre-exposure prophylaxis (PrEP), the first proven efficacious and only biomedical HIV prevention strategy in MSM, will be instrumental in achieving HIV epidemic control in this group. PrEP has been shown to be highly effective in preventing HIV infection in MSM, with efficacy rates ranging from 44% to 96% in various studies. The International Pre-Exposure Prophylaxis (IPrEX) study, evaluating daily oral dual ARV pre-exposure prophylaxis (PrEP) in MSM, was the first to show preventive efficacy. Subsequent studies have demonstrated the efficacy of PrEP in high-risk heterosexual men and women and persons who inject drugs. More recent clinical and pharmacological studies have demonstrated close to 90% protection of less than daily intake of dual oral PrEP in MSM. The HIV epidemic in MSM in the Asia Pacific region is a complex issue, and a multifaceted approach is needed to address it. The TFP strategy may need to be reconsidered or supplemented by other approaches, such as PrEP, to exercise more preventive effect. A critical review of the TFP strategy and its results is justified, and further research is needed to develop effective HIV prevention strategies for MSM in the region.