Approach to HIV Prevention in Cuba for Men Who Have Sex with Other Men

: This paper describes the main interventions for the prevention of human immunodeficiency virus infection, aimed at men who have sex with men, who constitute a risk group for acquiring the disease. For its preparation, the scientific literature published in national and international sources and documents considered relevant to the subject was selected. The analysis and recommendations focused on the health sector and the group of men who have sexual relations with other men. The approaches to the human immunodeficiency virus in Cuba are considered among the high-impact prevention programs, prepared both by civil society, through subsidies from the World Fund to Fight AIDS, Tuberculosis and Malaria, as well as by technicians from the National Program for Prevention and Control of STIs-HIV/AIDS. They include personalized service packages, which contain structural, biomedical and behavioral elements for key population groups in the social contexts where they are most needed. As is well known, the risk for each individual depends on their practices and not on the group to which they belong. These offer a common base for the development and promotion of effective programs for prevention, which allow organizing efforts directed at key populations, especially men who have sex with other men, and in this way reduce the number of new infections each year.


Introduction
Men, who have sex with men (MSM), represent a disproportionate burden of disease in terms of the human immunodeficiency virus (HIV) epidemic in all regions of the world. Their behavior and situational awareness need to be monitored using case surveillance data. [1][2][3][4] It is argued that the availability of reliable data on HIV behavior and the paucity of sensitively implemented social science research focused on men who have sex with men, they constitute great challenges, especially in repressive countries that penalize and stigmatize homosexual relations, cross-dressing, and the sex trade. [2][3] In Cuba, as in other regions of the world, MSM have been profoundly affected by HIV. A recent review concluded that they are six times more likely to contract the virus than heterosexual men, and represent 87.4% of diagnosed cases among males. Therefore, it is essential to promote prevention programs and effective policies in the health sector for the provision of prevention services in this population group. [5][6][7][8][9][10][11][12] It is also known that when designing preventive interventions aimed not at individuals, but at population groups -such as MSM-, there is a risk of stigmatizing them. For this reason, the participation of MSM, as a group of technicians, is essential in the design and development of programs according to their needs, while addressing their rights more broadly. [5][6][7][8][9][10][11][12] There is now a consensus among researchers that to guide responses to HIV, combination approaches to prevention should be adopted that are sustained over time, effective, and evidence-based. These should include easy access to condoms, lubricants, screening tests, and pre-and post-exposure prophylaxis, in addition to efforts to reduce vulnerability and address structural problems. [6][7][8][9][10][11][12] It is in this context that HIV prevention must continue to innovate and act resolutely-by addressing the different aspects of the response to the virus from a public health perspective-and offer information for a critical analysis of prevention interventions adopted by the health sector, specifically focused on MSM.
The main HIV infection prevention interventions aimed at men who have sex with men are described below, which represent promising potential with important limitations in Cuba. [2]

Materials and Methods
A literature and documentary review was conducted to identify information on the main HIV infection prevention interventions aimed at MSM. The following steps were followed: Definition of the task: in this step the information problem was identified in Cuba HIV prevention directed at MSM and the international recommendations directed to the health sector to respond to the infection, with emphasis on this group of population.
Definition of search strategies based on the terms: HIV prevention, men who have sex with men, public health.
Location of results in national and international scientific literature, and selection of those considered relevant to the subject of study, between the years 2010 and 2020.
Synthesis of what was contributed by the subject: once the collected information was organized, the search results were presented, which are identified with their respective credit and included in the bibliographic references and citations that stand out as such.
Evaluation of inform obtained, and realization of reflections on the elements to be incorporated into the work.
At all times, the ethical criteria for the handling and confidentiality of the information provided were respected.

Discussions
The application of the combined prevention approach is presented as the best strategy to respond to HIV directed at MSM. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), this comprises a set of biomedical interventions, promoting healthy and structural behaviors, based on evidence and human rights, focused on meeting the needs of individuals and communities. [12,14] In line with the UNAIDS definition, since 2016 the World Health Organization (WHO) has recommended a set of essential health sector interventions to respond to HIV (based on the conceptual framework of combination prevention), aimed at key population groups, such as men who have sexual relations with men. [12] Recommended interventions include comprehensive condom and lubricant distribution programs; interventions to reduce harm resulting from the use of psychoactive substances; interventions on individual and group behavior; HIV testing and counseling, treatment, and care for HIV infection; prevention and treatment of co infections and other co morbidities, such as viral hepatitis, tuberculosis, and mental health problems, and interventions related to sexual and reproductive health. [12,16] Likewise, it is proposed that these should be accompanied by other interventions to achieve a favorable environment, through the approach of stigmatization, discrimination and violence against people from key population groups. This requires the promotion of favorable legislation, political commitment and financial, and the empowerment of the community. [12,16] Other examples of comprehensive programs for MSM, not necessarily standardized to the WHO proposal, combine behavioral interventions (Skills building focused on proper condom use and ne go tilting safer sex). Regarding HIV treatment, ensure that every one with HIV has access to treatment services and receives necessary support and care; also address barriers to access (programs desensitization aimed at medical care providers). [2] The provision of the set of interventions for the prevention of infection described above are among the international recommendations addressed to the health sector to respond to the HIV epidemic, reduce the number of new infections and advance towards the targets set for 2020 and end the AIDS epidemic by the year 2030. [12] In Cuba, the health system is supported by the political will of the State and constitutes a national priority. Likewise, the response to the HIV epidemic has been characterized by the constant evaluation of control strategies and the updating of their approaches. [7,17] In this sense, the update of the National Strategic Plan for the Prevention and Control of STIs, HIV and Hepatitis 2019-2023, took into account technical guides and international commitments, such as the Sustainable Development Goals, the World Health Organization's Global Health Sector Strategy HIV (2016-2021), UNAIDS' Fast-track Action to End the AIDS Epidemic (2016-2021), and the Organization's HIV/STI Action Plan Pan American Health (2016-2021). [5,13,[18][19][20] Thus, the HIV approach strategies for the period 2019-2023 use a set of specific interventions, which include personalized service packages, which contain structural, biomedical and behavioral elements for MSM in the social contexts where they are most needed. As is known, the risk for each individual depends on their practices and not on the group to which they belong. [5][6]10] The figure 1 describes the main areas of focus for HIV prevention efforts, targeting MSM. These show how the combined prevention approach has been incorporated into the work of national institutions and civil society. Likewise, the complete set of interventions for prevention described is considered among those with proven efficacy, in accordance with global and regional plans and strategies. The above interventions involve a variety of activities needed to reduce the number of new HIV infections in key population groups, such as MSM. In this sense, using scientifically proven programs in a coordinated manner, adjusted to the needs of people and places of greatest risk, will contribute to improving the impact of prevention, with the aim of achieving the sustainability of the results and ending the AIDS epidemic by 2030. [12, 16, 20 -22] Combining behavioral interventions, such as HIV testing connected to treatment and medical care, have been shown to work best to get more people to participate in and stay in care. It is considered that if only services are undertaken in an isolated and fragmented manner, and do not take advantage of the broader range of available interventions, overall successes and results cannot be expected. [12] Although progress has been made in Cuba in the application of the combined prevention approach, adapted to the national reality, to the characteristics of the epidemic and to vulnerable populations, it is important to facilitate support programs so that more individuals know their serological status and urge them to remain HIV-negative, and encourage viral load suppression and interest in staying healthy in those who are positive. [5][6]10] The offer of the infection detection test has improved, from the incorporation of rapid tests and the training of MSM as peer counselors for the performance of the test in community activities, therefore more people with HIV in Cuba know their diagnosis (87%). However, according to the results of the behavioral studies carried out in the country, the numbers of MSM have had an HIV test in the last twelve months. [6,10,[22][23][24][25][26] In this sense, the offer of HIV testing and counseling services specifically for MSM in the contexts where it is most necessary constitutes a prevention strategy that works by mobilizing these groups to know their serological status. As is known, if someone is known to be HIV positive, they can get medical attention early and suppress the virus through the use of antiretroviral treatment. [5, In Cuba, the coverage of people with HIV with antiretroviral therapy, both in the general population and in key groups, exceeds 80% of those diagnosed. However, there is no correspondence between the number of people recruited and those who have managed to suppress the viral load (71.6%), to achieve epidemic control. [5][6]10] People living with HIV with suppressed or undetectable viral loads have a minimal chance of transmitting the virus to others. The added benefit of this strategy is that people involved in their medical care and as healthy individuals, they also have a great opportunity to be active participants in their communities. [14][15] The levels of adherence to treatment to suppress the community viral load and have a sustained impact on the incidence of new infections and on mortality from AIDS are insufficient. A preliminary study carried out on a sample of 300 deaths from AIDS in 2018, obtained from the HIV/AIDS database of the Cuban Ministry of Public Health, found that in 63% of the subjects the cause of death was associated with poor adherence to treatment. [6,10,27] Although poor adherence to treatment prevails among the causes of mortality for the sample studied, these results are neither definitive not generalized, and they do not have to coincide with the causes of morbidity in HIV-positive people under antiretroviral treatment, or in the reduction of community viral load levels for the national context. [27] However, it is necessary to strengthen the strategies of the national response to the HIV epidemic, related to the consolidation of skills related to antiretroviral treatment, adherence to medications and self-care, through individual and group behavioral interventions conducted by peer educators, with support from health service providers.
On the other hand, interventions such as pre-and post-exposure prophylaxis (PrEP and PEP) have been integrated into comprehensive HIV infection prevention programs in Cuba, as an additional prevention option for people at substantial risk of HIV infection. The effectiveness of these is greater when combined with the use of condoms and other forms of prevention. [5,12,15] These interventions favor the link with health services, for periodic screening and more timely treatment of other sexually transmitted infections. All of this constitutes an opportunity to support adequately and more firmly the groups of MSM, in order to speed up the expansion of the offer of preventive services aimed at this group in particular. [15] Likewise, providing PEP in cases of risk episodes due to unprotected consensual sexual intercourse (for example, condom breakage), constitutes an opportunity to prevent infection after sexual exposure and a criteria for offering pre-exposure prophylaxis according to WHO recommendations. [12] Guaranteeing the supply of pre-and post-exposure prophylaxis involves, among other challenges, facilitating access to delivery points, dealing with discrimination and moralistic attitudes in health providers that limit the acceptance of the service, as well as the planning to specifically address disclosure in key population groups -such as MSM-, to increase the demand for these prevention alternatives.
Access to other prevention actions such as condoms and lubricants is crucial to apply a comprehensive, effective and sustainable approach to HIV prevention, so their promotion should continue to be prioritized. In Cuba, the latest data available on the use of condoms in MSM during their last anal intercourse with a male partner indicate 63.9 %. [5-6, 9, 25] Although increases can be observed compared to 2015 (56.9%), attention must be paid to the supply of condoms in the pharmacy network and in non-traditional points of sale, through a targeted distribution that supports their systematic and correct use. Attention should also be paid to the availability in the primary care system (as an input for sexual and reproductive health programs), and the assurance of free delivery through civil society to key population groups during educational activities. [26] Likewise, subjective reasons have been identified for not protecting themselves in the different types of couples (stable or occasional) among MSM. Arguments such as "they don't like to use condoms" (34.1%), "not having a condom at the moment" (27.1%) or "trust in the partner" (13.7%), stand out among the main reasons to not protect oneself. These arguments should not be ignored, especially since they could be modifiable, and even complement other measures for HIV prevention, such as the use of pre-exposure prophylaxis. [25] Although biomedical strategies have focused the interest of this research, they are unlikely to generate long-term results in preventing infection by themselves. The response to the epidemic must consider the cultural and social context that affects the risk of infection by the virus and the access to prevention services, fueled by stigma, discrimination and violence, based on sexual orientation and gender identity or expression. [2,12] As part of national efforts to mitigate the structural factors that limit adequate access to HIV infection prevention services, it is necessary to implement mechanisms to document and monitor violence (observatories), train key population groups on the resolutions and norms to prevent and punish discrimination, and create oversight mechanisms for human rights, with special emphasis on this sector of the population. [5,10]

Conclusion
The prevention interventions adopted by the health sector offer a common foundation for the development and promotion of programs with proven effectiveness for the prevention of HIV infection. The analysis carried out provides information that favors decision-making and allows reorganizing efforts to have a greater impact in order to reduce the number of new infections in men who have sex with men.