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Background UNAIDS has established new program targets for 2025 to achieve the goal of eliminating AIDS as a public health threat by 2030. This study reports on efforts to use mathematical models to estimate the impact of achieving those targets. Methods and findings We simulated the impact of achieving the targets at country level using the Goals model, a mathematical simulation model of HIV epidemic dynamics that includes the impact of prevention and treatment interventions. For 77 high-burden countries, we fit the model to surveillance and survey data for 1970 to 2020 and then projected the impact of achieving the targets for the period 2019 to 2030. Results from these 77 countries were extrapolated to produce estimates for 96 others. Goals model results were checked by comparing against projections done with the Optima HIV model and the AIDS Epidemic Model (AEM) for selected countries. We included estimates of the impact of societal enablers (access to justice and law reform, stigma and discrimination elimination, and gender equality) and the impact of Coronavirus Disease 2019 (COVID-19). Results show that achieving the 2025 targets would reduce new annual infections by 83% (71% to 86% across regions) and AIDS-related deaths by 78% (67% to 81% across regions) by 2025 compared to 2010. Lack of progress on societal enablers could endanger these achievements and result in as many as 2.6 million (44%) cumulative additional new HIV infections and 440,000 (54%) more AIDS-related deaths between 2020 and 2030 compared to full achievement of all targets. COVID-19–related disruptions could increase new HIV infections and AIDS-related deaths by 10% in the next 2 years, but targets could still be achieved by 2025. Study limitations include the reliance on self-reports for most data on behaviors, the use of intervention effect sizes from published studies that may overstate intervention impacts outside of controlled study settings, and the use of proxy countries to estimate the impact in countries with fewer than 4,000 annual HIV infections. Conclusions The new targets for 2025 build on the progress made since 2010 and represent ambitious short-term goals. Achieving these targets would bring us close to the goals of reducing new HIV infections and AIDS-related deaths by 90% between 2010 and 2030. By 2025, global new infections and AIDS deaths would drop to 4.4 and 3.9 per 100,000 population, and the number of people living with HIV (PLHIV) would be declining. There would be 32 million people on treatment, and they would need continuing support for their lifetime. Incidence for the total global population would be below 0.15% everywhere. The number of PLHIV would start declining by 2023., John Stover and co-workers assess the potential health impacts of UNAIDS’ HIV/AIDS targets., Author summary Why was this study done? The previous UNAIDS strategic plan expired in 2020, creating a need for a new plan to guide efforts for the next 5 years. Modeling contributed to the development of the new plan by assessing the epidemiological impact of proposed intervention coverage targets and estimating the financial resources needed to achieve them. What did the researchers do and find? We applied mathematical simulation models to 77 high HIV burden countries to examine the effects of the proposed intervention coverage targets on trends in new HIV infections and AIDS-related deaths. The results were extended to a total of 173 countries to provide a comprehensive global analysis. Results show that achieving the 2025 targets would reduce new annual infections by 83% (71% to 86% across regions) and AIDS-related deaths by 78% (67% to 81% across regions) by 2025 compared to 2010. Progress on societal enablers (access to justice, prevention of stigma and discrimination, and prevention of gender-based violence [GBV]) is essential to achieve these targets. Coronavirus Disease 2019 (COVID-19)–related disruptions could increase new HIV infections and AIDS-related deaths in the short term, but targets could still be achieved by 2025. What do these findings mean? Although global efforts have failed to achieve the ambitious 2020 targets, it is still possible to achieve the 2030 goal of eliminating AIDS as a public health threat. Many of the 2025 intervention coverage targets have already been achieved in some settings. Additional effort is required to accelerate progress in all countries and in all populations.

Introduction In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track. Methods We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS’ definition of ‘community-led’ and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research. Findings Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices. Conclusions and recommendations Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.

Paul De Lay and co-authors introduce a Collection on the design of targets for ending the AIDS epidemic.

Objectives To describe levels of national HIV spending and examine programmatic allocations according to the type of epidemic and country income. Methods Cross-sectional analysis of HIV expenditures from 50 low-income and middle-income countries. Sources of information included country reports of domestic spending by programmatic activity and HIV services. These HIV spending categories were cross tabulated by source of financing, stratified by type of HIV epidemic and income level of the country and reported in international dollars (I$). Results Fifty low-income and middle-income countries spent US $ 2.6 billion (I$ 5.8 billion) on HIV in 2006; 87% of the funding among the 17 low-income countries came from international donors. Average per capita spending was I$ 2.1 and positively correlated with Gross National Income. Per capita spending was I$ 1.5 in 9 countries with low-level HIV epidemics, I$ 1.6 in 27 countries with concentrated HIV epidemics and I$ 9.5 in 14 countries with generalized HIV epidemics. On average, spending on care and treatment represented 50% of AIDS spending across all countries. The treatment-to-prevention spending ratio was 1.5:1, 3:1, and 2:1 in countries with low-level, concentrated and generalized epidemics, respectively. Spending on prevention represented 21% of total AIDS spending. However, expenditures addressing most-at-risk populations represented less than 1% in countries with generalized epidemics and 7% in those with low-level or concentrated epidemics. Conclusions The most striking finding is the mismatch between the types of HIV epidemics and the allocation of resources. The current global economic recession will force countries to rethink national strategies, especially in low-income countries with high aid dependency. Mapping HIV expenditures provides crucial guidance for reallocation of resources and supports evidence-based decisions. Now more than ever, countries need to know and act on their epidemics and give priority to the most effective programmatic services.

Mexico serves as a major producer of heroin, marijuana and methamphetamine and a trans-shipment route for cocaine destined for U.S markets, which has profound effects on the health of its people. Since 2007, over 20,000 drug-related fatalities occurred nation-wide in association with warring drug trafficking organizations. Social, political and economic forces coupled with wide economic disparities between Mexico and the U.S have created major corridors for drug trafficking and migration through northern border states, such as Baja California and Chihuahua, which now face twin epidemics of HIV and drug addiction.1 Baja California has the second highest cumulative AIDS incidence among Mexico’s 32 states.2 In Tijuana, a city of 1.5 million people adjacent to San Diego, CA, up to 1 in 116 persons aged 15–49 was HIV-infected in 2006.3 Among female drug injectors, HIV prevalence is 12%.4 Compared to Mexico overall where 0.2% injected any drug in 2008, 4.8% injected drugs in Baja California, and rates of methamphetamine use were highest in the country.5 Methamphetamine use was independently associated with HIV infection among the city’s female sex workers and their clients, among whom HIV prevalence is nearly identical (5–6%).6 Until recently, Mexico’s response to its drug problem mirrored that of the U.S., emphasizing supply reduction and interdiction. Harm reduction was initially limited to grassroots efforts of local non-governmental organizations (NGOs) in Ciudad Juarez and Tijuana. There was only one publicly funded methadone program in the country, in Ciudad Juarez. However, with growing recognition that rising HIV rates were linked to drug abuse in these cities and others, harm reduction became officially embraced, both in Baja California7 and nation-wide.8 In scaling up its response to HIV prevention, Mexico’s Federal Ministry of Health mobilized the Centro Nacional para la Prevencion y el Control del VIH/SIDA and state health officials to implement mobile clinics (‘condonetas’), delivering condoms, rapid HIV testing, educational materials and syringe exchange to high risk neighborhoods in border cities like Tijuana and other Mexican cities.9 By 2010, syringe exchanges were operating in nine Mexican states. Mexico has also embarked upon drug policy reform. On August 24, 2009, Mexican President Felipe Calderon approved an unprecedented law that deregulates possession of small, specified amounts of cocaine, heroin, methamphetamine and marijuana for personal use.10 The law specifies that police apprehending persons possessing these drugs in equal or lesser amounts will receive no penal action until a third apprehension, whereupon they will be required to enter drug treatment or jail. This law, to be enacted in August 2010, is intended to re-direct law enforcement to drug dealers and traffickers, while moving towards a harm reduction approach for drug dependence. A nation-wide expansion to expand opioid substitution treatment programs is underway under the direction of the Consejo Nacional contras las Adicciones, placing appropriate emphasis on demand reduction. These bold steps to addressing Mexico’s drug problem reflect a shift away from the ‘war on drugs’ philosophy that many deem to have failed,11 towards a more balanced approach. Other countries in Latin America (e.g., Ecuador, Argentina, Brazil) and elsewhere (e.g., Portugal) have also embarked upon drug policy reforms that involve some degree of decriminalizing drug possession.11 Mexican health officials, NGOs and researchers from Mexico and the U.S. are working in partnership to implement and evaluate the health and societal outcomes of these initiatives, and a new police education program focused on demand reduction, harm reduction and human rights being introduced in Baja California and Chihuahua. These initiatives will help ensure that Mexico’s health and drug policies are grounded in empirical evidence and the right to health for all people.

The prevalence of male same-gender sexual behavior in Mexico City in relation to HIV transmission was studied. A household probability survey of 8,068 adult men was conducted in 1992-93 using the Mexican National Health Survey sampling frame. The response rate was 59%. Differences between respondents and nonrespondents indicated no evidence for significant bias. A random subsample of 1,116 individuals provided serum or saliva for HIV testing. An estimated 2.5% of men practiced same-gender sex in their lifetime: 2.1% (95% CI: 1.7 - 2.4%) reported bisexual behavior and 0.4% (95% CI: 0.3 - 0.6%) reported exclusively homosexual behavior Among bisexuals, 70% reported sex only with women in the previous year, 7% reported sex only with men, 13% reported sex with both, and 10% were sexually inactive. A condom was used by 46% in their last homosexual encounter An estimated 0.1% of married men were homosexually active in the previous year The HIV prevalence estimate was 0.2% in the sample. The rate was 4% among homosexual/bisexual men and 0.09% in heterosexual men (p < 0.0001). Estimates of homosexual behavior and HIV infection from this population-based sample are lower than results from nonprobability studies. The low prevalence of condom use anticipates future growth of the epidemic in the homosexual population. Bisexual behavior appeared to be infrequent and transitory, particularly among married men. For more than a decade the impact of the human immunodeficiency virus (HIV) infection has been felt in many countries. Mexico is not an exception, and AIDS is among the leading causes of death in the young adult population. The fact that HIV is mainly transmitted by sexual activity makes it imperative that we have a better understanding of sexual behavior, in order to be able to favorably influence the trend of the epidemic. Case reports suggest that the epidemiological pattern of AIDS in Latin America is different from that observed in other parts of the world. Within this region, Mexico seems to have unique characteristics (Mann, Tarantola, & Netter, 1992; Valdespino, Izazola, & Rico, 1988); 95% of the cases to date among men and 45% among women are due to sexual transmission. Among men with sexually acquired AIDS, 60% were classified as homosexuals, 25% as bisexuals, and 15% as heterosexuals. HIV transmission due to injection drug use is negligible in Mexico (< 1% of reported cases). As of December 31, 1994, 20,796 AIDS cases had been reported in Mexico, most of which have occurred in men (85%), and in Mexico City (56%) (Instituto Nacional de Diagnostico y Referencia Epidemiologicos [INDRE], 1995).

In Mexico, public health services have provided universal access to antiretroviral therapy (ART) since 2004. For individuals receiving HIV care in public healthcare facilities, the data are limited regarding CD4 T-lymphocyte counts (CD4e) at the time of entry into care. Relevant population-based estimates of CD4e are needed to inform strategies to maximize the impact of Mexico's national ART program, and may be applicable to other countries implementing universal HIV treatment programs. For this study, we retrospectively analyzed the CD4e of persons living with HIV and receiving care at state public health facilities from 2007 to 2014, comparing CD4e by demographic characteristics and the marginalization index of the state where treatment was provided, and assessing trends in CD4e over time. Our sample included 66,947 individuals who entered into HIV care between 2007 and 2014, of whom 79% were male. During the study period, the male-to-female ratio increased from 3.0 to 4.3, reflecting the country's HIV epidemic; the median age at entry decreased from 34 years to 32 years. Overall, 48.6% of individuals entered care with a CD4≤200 cells/μl, ranging from 42.2% in states with a very low marginalization index to 52.8% in states with a high marginalization index, and from 38.9% among individuals aged 18-29 to 56.5% among those older than 50. The adjusted geometric mean (95% confidence interval) CD4e increased among males from 135 (131,142) cells/μl in 2007 to 148 (143,155) cells/μl in 2014 (p-value

Donor nations and philanthropic organizations increasingly require that funds provided for a specific health priority such as HIV should supplement domestic spending on that priority—a concept known as “additionality.” We investigated the “additionality” concept using data from Honduras, Rwanda, and Thailand, and we found that the three countries increased funding for HIV in response to increased donor funding. In contrast, the study revealed that donors, faced with increased Global Fund resources for HIV in certain countries, tended to decrease their funding for HIV or shift funds for use in non-HIV health areas. More broadly, we found many problems in the measurement and interpretation of additionality. These findings suggest that it would be preferable for donors and countries to agree on how best to use available domestic and external funds to improve population health, and to develop better means of tracking outcomes, than to try to develop more sophisticated methods to track additionality.

This document aims to give an epidemiological overview of HIV and AIDS in Mexico, to highlight some aspects of both the governmental and nongovernmental response, and to emphasize important challenges in the fight against the epidemic. The HIV and AIDS epidemic in Mexico is confined to specific groups such as men who have sex with men and intravenous drug users. It has low prevalence among general population, a percentage we aim to maintain. Universal access to retroviral treatment in Mexico is an achievement that is sustainable only if a constant reduction of new cases is accomplished. This can only be obtained by preventive measures that are based on evidence. It is necessary to strengthen nongovernmental associations that are working on prevention. In 2009, the number of nongovernmental associations that received official financing was relatively low. It is necessary to improve the epidemic vigilance and evaluation systems. This would allow better follow-up of the activities that confront the epidemic, and to obtain better feedback for the procedures.

BACKGROUND: An estimated 1.86 million people are living with HIV in Latin America and the Caribbean (LAC). The region is comprised of mainly middle-income countries with steady economic growth while simultaneously there are enormous social inequalities and several concentrated AIDS epidemics. This paper describes HIV spending patterns in LAC countries including analysis of the levels and patterns of domestic HIV spending from both public and international sources. METHODS AND FINDINGS: We conducted an extensive analysis of the most recently available data from LAC countries using the National AIDS Spending Assessment tool. The LAC countries spent a total of US$ 1.59 billion on HIV programs and services during the latest reported year. Countries providing detailed information on spending showed that high percentages are allocated to treatment and care (75.1%) and prevention (15.0%). Domestic sources accounted for 93.6 percent of overall spending and 79 percent of domestic funds were directed to treatment and care. International funds represented 5.4 percent of total HIV funding in the region, but they supplied the majority of the effort to reach most-at-risk-populations (MARPs). However, prevalence rates among men who have sex with men (MSM) still reached over 25 percent in some countries. CONCLUSIONS: Although countries in the region have increasingly sustained their response from domestic sources, still there are future challenges: 1) The growing number of new HIV infections and more people-living-with-HIV (PLWH) eligible to receive antiretroviral treatment (ART); 2) Increasing ART coverage along with high prices of antiretroviral drugs; and 3) The funding for prevention activities among MARPs rely almost exclusively on external donors. These threats call for strengthened actions by civil society and governments to protect and advance gains against HIV in LAC.

The purpose of this paper is to: (1) collect relevant data and estimate Japanese international financial assistance for HIV/AIDS control; (2) discuss the difficulties in collecting relevant data and the limitations of the collected data; and (3) conduct a comparative analysis on the estimated data with OECD and Kaiser Family Foundation aggregate data. The point is that we have comprehensively collected and estimated the data on Japanese international expenditures for HIV/AIDS control while there is no reliable data that is totally managed and published. In addition, we discuss the difficulties and limitations of data collection: unpublished data; insufficient data; inseparable data; problems of exchange rates; gaps between disbursement and commitment; and difference in year period among calendar, fiscal and organization-specific years. Furthermore, we show the risk of underestimating the Japanese international contribution to HIV/AIDS control on the basis of OECD and Kaiser data. In this respect, it is significant to comprehensively collect and estimate the data on Japanese international assistance for HIV/AIDS control. Finally, we derive the implication that it is crucial for a relevant international organization and/or individual countries to comprehensively collect and administer data for international cooperation in the development of health policies for HIV/AIDS.

Objective. To estimate the prevalence of risk factors for HIV infection among Mexican migrants and immigrants (MMIs) in different geographic contexts, including the sending communities in Mexico, the receiving communities in the United States (US), and the Mexican North border region. Material and Methods. We conducted a probability survey among MMIs traveling through key border crossing sites in the Tijuana (Baja California, Mexico)-San Diego (California, US) border region (N=1 429). Results. The survey revealed substantial rates of reported sexually transmitted infections, needle-sharing and sexual risk practices in all migration contexts. Conclusions. The estimated levels of HIV risk call for further binational research and preventive interventions in all key geographic contexts of the migration experience to identify and tackle the different personal, environmental, and structural determinants of HIV risk in each of these contexts.

The HIV/AIDS epidemic is apublic health problem that has had an impact on all health systems around the world. Mexico is no exception. Although it has been acknowledged that we have a concentrated epidemic, the problem continues to grow.The objective of this study was to evaluate if the medical school curricula in Mexico included the topic of HIV/AIDS and to assess the level of knowledge medical students have about this disease.Descriptive study of eight medical schools interviewing pre-graduate medical students.Only 15% of the curricula of private medical schools and 21.7% of public schools included the subject of HIV/AIDS. Although it is difficult to standardize this finding, an average of 8.8 hours was assigned to the study of HIV/AIDS. 90% of the professors involved in teaching the topic of HIV/AlDS hadno clinical experience in thefieldHIV/AIDS is a low priority subject in our medical school curricula. Efforts must be placed to standardize and reinforce this highly important topic.

Oral fluid samples collected using the OraSure HIV-1 oral specimen collection device were recently approved by the US Food and Drug Administration for HIV testing. To validate the performance of such samples obtained with the OraSure device the authors sampled both serum and saliva obtained by laboratory personnel from 134 known HIV-1-positive persons using the Abbott recombinant anti-HIV-1 second generation ELISA to test for potential detection of false-negative results. All were positive for both serum and oral fluid and confirmed by Western blot. In a 1992-93 population study among sexually active men aged 15-60 years in Mexico City 369 paired samples and 1215 unmatched oral fluid samples were obtained for HIV-1 testing for a total of 1584 persons. On the basis of 503 paired samples 134 from the known HIV-positive persons and 369 from the population survey the sensitivity and specificity of HIV-1 testing in oral fluid using the Abbott recombinant test were calculated to be 98.5% and 100% respectively. There were two HIV-positive results among the 1215 unmatched oral fluid specimens but only one was confirmed by Western blot. One man was confirmed HIV-positive among the 369 paired samples. Therefore two of 1584 persons tested were found to be infected with HIV-1 an estimated prevalence of 0.126% among sexually active men aged 15-60 in Mexico City during 1992-93. A 1987 probability survey estimated a prevalence of 0.04% among sexually active men in Mexico City. HIV-1 seroprevalence among blood donors in Mexico is 0.09%. The authors believe oral fluid samples are ideal for use in field surveys to determine the prevalence of HIV infection.

To compare patterns of sexual behavior among bisexual, heterosexual and homosexual men.A household probability survey was carried out in Mexico City in 1992-1993 using the national health surveys sampling frame. Information from 8,068 men was obtained; however, the main analysis of this paper refers only to men sexually active in the previous 5 years.Bisexuals reported more prevalent anal intercourse with women (16% vs. 3%, p = 0.01), and more sexual encounters with female sex workers than exclusive heterosexuals (10% vs. 4%; p = 0.04). Bisexuals used condoms more often with sex workers than did heterosexuals (p = 0.01). Most of the bisexuals (79%) did not engage in anal receptive or insertive intercourse with males in the previous year, practicing instead oral insertive sex or only masturbation; 35% of homosexuals did not report practicing anal sex. Bisexuals who engaged in anal intercourse had less anal receptive behavior than homosexuals (13% vs. 60%, p0.01); of these, due to condom use, only 7% of bisexuals and 18% of homosexuals had unprotected anal receptive sex in the last intercourse with a male.Bisexuals practice less risky sexual behavior with males than exclusive homosexuals. This finding may imply that bisexual men in Mexico are an ineffective epidemiological bridge for HIV transmission. The English version of this paper is available too at:http://www.insp.mx/salud/index.html.

To assess non-participation bias in a survey of male sexual behavior.A household survey was carried out in 1992-1993 using a probability sampling frame in Mexico City. Demographic variables were available for all eligible men. The extent of non-participation bias was estimated using a version of the Heckman method, which utilizes two equations, one to predict participation and the other to predict reports of same-gender sexual behavior.A total of 8,068 of the 13,713 eligible men completed a face-to-face questionnaire (response rate 59%); 173 men (2.1%) reported bisexual behavior in their lifetime, and 37 (0.4%) reported only male partners. Survey participation was predicted using demographic variables: 67% of the observations were correctly predicted by a probit regression model: 82% of participants and 53% of non-participants (pseudo-r2 = 0.13). Same-gender sexual behavior was predicted by variables indicating attachment to gay/bisexual social networks, history of sexually transmitted diseases, positive attitudes towards gay and bisexual males, and lack of support from male relatives. Ninety-seven per cent of the cases was correctly predicted by the probit model (pseudo-r2 = 0.14). The correlation between these two equations was not statistically significant.These results indicate that prevalence estimates of same-gender sexual behavior among Mexico City men were not biased by selective survey participation. Careful selection and training of household interviewers may have assisted in minimizing potential bias.

Gay, bisexual, and other men who have sex with men (MSM) have been among the most affected populations by HIV since the AIDS pandemic was first identified in the 1980s. Evidence from a wide range of studies show that these men remain at the highest risk for HIV acquisition in both developed and developing countries, and that despite three decades of evidence of their vulnerability to HIV, they remain under-served and under-studied. Prevention strategies targeted to MSM are markedly under-funded in most countries, leading to limited access to health services including prevention, treatment, and care. We explore the global epidemic among MSM in 2008, the limited funding available globally to respond to these epidemics, and the human rights contexts and factors which drive HIV spread and limit HIV responses for these men. What do we mean by the term MSM? MSM is a construct from the 1990s that tries to capture behavior and not identity. It was crafted to avoid stigmatizing and culturally laden terms such as gay or bisexual, which do not capture the wide diversity of orientations, sexual practices, cultures, and contextual settings in which male same-sex behaviors occur, and where HIV transmission and acquisition risks are centered. MSM includes both gay and non-gay identified men, bisexual men, and MSM who identify themselves as heterosexuals. It also includes men engaging in "situational" sex between men, such as can occur in prisons, schools, militaries or other environments; and it includes male sex workers who may be of any orientation but are often at very high risk for HIV. MSM may include some biologically male transgender persons, though some do not identify as male. And MSM includes a wide array of traditional and local terms worldwide–with enormous cultural diversity in Asia, Africa, Latin America and elsewhere. We use the term MSM here at its most inclusive.