Men who have sex with men are disproportionately affected by human immunodeficiency virus (HIV) compared to the general population in nearly all countries collecting reliable surveillance data. In low- and middle-income countries they have 19.3-fold greater odds of being infected with HIV compared with the general population. HIV prevalence among men who have sex with men across North, South and Central America, South and Southeast Asia and sub-Saharan Africa ranges from 14% to 18%. Even as HIV incidence is in decline worldwide, the rate of new HIV infections among men who have sex with men remains unchanged and is increasing in some high-income countries like the United States. In 2011 the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Development Programme (UNDP) and The Global Forum on MSM & HIV (MSMGF) developed a guidance document on Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people. The document sets out technical recommendations on interventions for the prevention and treatment of HIV and other sexually transmitted infections (STIs) among men who have sex with men. In 2014, WHO released the Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. These bring together all existing guidance related to key populations, including men who have sex with men, with updates on selected guidance and recommendations. The recommendations of these two publications are summarized in Table 1 at the end of this Introduction. Following the dissemination of the 2011 Recommendations and the 2014 Key Populations Consolidated Guidelines describing effective, evidence-based interventions (the what), a need was expressed for guidance focused on implementation (the how). This publication responds to that need by offering practical advice on implementing HIV and STI programmes for men who have sex with men, aligned with the 2011 Recommendations and the 2014 Key Populations Consolidated Guidelines. It contains examples of good practice from around the world that may support efforts in planning programmes and services, and describes issues that should be considered and how to overcome challenges. The health and prevention benefits of antiretroviral therapy (ART) in the management of HIV are now strongly supported by research. Behavioural prevention programmes including use of condoms and lubricant, early diagnosis, prompt linkage to sustained care and ART, and viral suppression constitute points along a comprehensive continuum of HIV-related services. When services are easily accessible, implemented effectively and delivered in close partnership with their intended beneficiaries, this comprehensive continuum of health services reduces morbidity, mortality and onward transmission of HIV. However, current service delivery models are not as effective as they should be in linking and retaining men who have sex with men to the services they need, resulting in a failure to fully realize the health and prevention benefits of all interventions currently at our disposal. The findings revealed a drop-off in service retention at every point along the continuum.

Annotation. Business as usual is no longer a viable response to the HIV-related risks of men who have sex with men and transgender people. Where data exist on HIV in these populations, they show that our collective responses are failing far more often than they are reaching scale or succeeding. Just as disconcerting, in many parts of the world, is the fact that few reliable data exist at all.

In all countries of the European Union and European Economic Area, men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmitted infections including gonorrhoea, syphilis, chlamydia and hepatitis B and C. In several countries in the region, the incidence of these infections has increased among MSM, in some cases markedly, over the last decade. There is evidence that services to prevent, diagnose and treat infections are not being delivered at the appropriate scale to impact on transmission patterns. Based on a systematic review of the literature and expert opinion, the European Centre for Disease Prevention and Control suggests that there is good evidence to ensure that the following key components are considered for inclusion in national and sub-national public health programmes in countries in Europe.^The evidence indicates that these services and interventions can effectively prevent and reduce HIV and STI transmission among MSM, address the needs of MSM who are living with HIV, as well as promote sexual health among all MSM. 1. Vaccinations: Promote and deliver vaccination to protect against hepatitis A and B. Consider vaccination for human papilloma virus (HPV). 2. Condoms: Provide easily accessible condoms and condom-compatible lubricants and promote their effective use. 3. HIV and STI testing: Provide voluntary and confidential HIV and STI counselling and testing via a variety of modalities that are easy to access for the target group. Voluntary partner referral can support the early diagnosis and treatment of contacts. 4. Treatment: Timely provision of treatment for HIV, viral hepatitis and STI should be ensured. Preventive benefits of treatment are significant. 5.^Health promotion: Provide accurate and accessible information that enables men to understand and assess sexual health-related risks and prevention efficacy, and that promotes awareness of one's own HIV and STI status. 6. MSM-competent health services: MSM-competent points of care offering a comprehensive sexual health programme including health promotion, counselling, peer support, prevention, adequate diagnostics and treatment will increase service uptake. Ensure target group involvement and training for providers on how to offer comprehensive care for MSM. 7. Targeted care for MSM living with HIV: Provide antiretroviral treatment for HIV and vaccination; regular STI screening using adequate diagnostics; treatment for STIs; individual counselling, sexual health promotion and peer-support groups for men living with HIV.^Prevention services for MSM should be targeted following the analysis of relevant and reliable epidemiological data, so that services are directed at the appropriate scale to those geographical and risk populations most at risk of HIV and STI infection. Combinations of the suggested key interventions should be offered to MSM in order to achieve synergy and the highest levels of effectiveness. Prevention needs and preferences of MSM vary across and within country settings, by individual and over time. Offering and implementing prevention packages in collaboration with the target group, or where appropriate, by the target group, is crucial to the success of national and sub-national prevention programmes. As many countries in Europe experience constrained public health budgets, it is more important than ever to implement targeted and evidence-based measures that address the groups most affected by the HIV epidemic as well as those most at-risk for disease acquisition and transmission.^The promotion of sexual health using positive messages framed in an empowering environment in relation to individual needs, will ensure greater effectiveness of the prevention efforts resulting in increased sexual health and reduced new infections of HIV and other STI in Europe.

The term "men who have sex with men" - frequently shortened to MSM - describes a behaviour rather than a specific group of people. It includes self-identified gay, bisexual, transgendered or heterosexual men. Many men who have sex with men do not consider themselves gay or bisexual. They are often married, particularly where discriminatory laws or social stigma of male sexual relations exist. Largely because of the taboo, the female partners of men who have sex with men are often unaware of their partner's other liaisons, and the threat posed to themselves. Forced sex among men is not uncommon, especially in men-only environments such as prisons. Men who have sex with men are found in all societies, yet are largely invisible in many places. In terms of HIV, sex between men is significant because it can involve anal sex, which when unprotected carries a very high risk. Sex between men is thought to account for between 5 and 10% of global HIV infections, although the proportion of cases attributed to this mode of transmission varies considerably between countries. It is the predominant mode in much of the developed world. Globally less than one in twenty men who have sex with men have access to the HIV prevention and care services they need. Many factors contribute to this situation including denial by society and communities, stigma and discrimination, and human rights abuse. Vulnerability to HIV infection is increased where sex between men is criminalised, as men are either excluded from, or exclude themselves from, sexual health and welfare agencies out of fear. A range of interventions to reduce risk behaviours among men who have sex with men have proven successful, including: condom promotion, safer-sex campaigns and skills training; peer education with outreach programmes; and programmes tailored to subpopulations such as male sex workers and men in prisons. Specific policy measures are crucial for making prevention, care and support available to men who have sex with men. First and foremost, they must be included in national HIV programming and funding priorities. The governments must support organisations of men who have sex with men, enabling them to promote HIV prevention and care programmes and to participate in HIV planning and policymaking. Legislation should be changed, decriminalizing same-sex acts and providing protective laws against discrimination based on sexual orientation.