Understanding differences in knowledge and behaviors among men who have sex with men (MSM), men who have sex with women (MSW), and women, is critical to tailor HIV treatment. We investigated these differences among an international sample of people living with HIV (PLHIV) in 25 countries.

Data came from the 2019 Positive Perspectives Study, an online convenience sample of PLHIV in 25 middleand high-income countries. Participants were categorized as MSM (n=1018), MSW (n=479), or women (n=696), based on self-classified gender and sexual orientation. Descriptive and multivariable analyses were performed (p<0.05).

Mean age was 43.4 years among MSM, 36.6 among MSW, and 41.0 among women. Overall, 24.2% [116/479] of MSW reported suboptimal health on all four domains assessed (sexual/mental/physical/overall), significantly higher than MSM (18.0% [183/1018], p=0.005), but similar to women (22.8% [159/696], p=0.585). Overall, the median number of reasons reported for missing HIV medication ≥1 time in the past month was 7, 2, and 1 for MSW, women, and MSM, respectively. The percentage reporting viral suppression among MSW (57.0% [273/479]) was significantly lower compared to both MSM (89.2% [908/1018], p<0.001), and women (62.8% [437/696], p=0.046). Yet, MSW were the least comfortable discussing with providers concerns about transmitting disease (MSW=42.8% [205/479]) vs MSM (70.3% [716/1018], p <0.001), or women (58.0% [404/696], p<0.001). The percentage of all MSW who considered having children a priority at time of starting treatment (30.5% [146/479]) was 1.4 times higher compared with women (22.6% [157/696], p=0.002) but about 6 times higher than MSM (5.4% [55/1018], p<0.001). Within multivariable analyses, being told of ‘Undetectable = Untransmittable’ by healthcare providers was positively associated with optimal sexual health among MSM in high-income countries (AOR=1.52; 95% CI: 1.01–2.32), MSM in middle-income countries (AOR=2.89; 95% CI: 1.57–5.32) and women in middleincome countries (AOR=1.29; 95% CI: 1.04–1.60), but not among MSW in either middle- or high-income countries.

Compared with MSM, women and especially MSW had greater unmet need – a previously unrecognized gap. Relatively low rates of viral suppression among MSW have implications for HIV transmission to women via heterosexual contact. Acknowledging these differences when planning and administering care can help address disparities.

Data analysis and medical writing was supported by Zatum LLC.
The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. E. Castellanos and B. Allan report personal fees from ViiV Healthcare during the conduct of the study, and personal fees from ViiV Healthcare outside the submitted work. N. Van de Velde reports grants from ViiV Healthcare and GlaxoSmithKline outside the submitted work. G. M. Corbelli reports personal fees from ViiV Healthcare during the conduct of the study, and personal fees from ViiV Healthcare and HIV Vaccine Trials Network outside the submitted work. W.D. Hardy reports personal fees from ViiV Healthcare, during the conduct of the study; and personal fees from ViiV Healthcare, Advisory Boards, Merck, and from Gilead Sciences, outside the submitted work. P. de los Rios and B. Young report grants from ViiV Healthcare during the conduct of the study, as well as outside the submitted work. A. Eremin and C. Okoli report personal fees from ViiV Healthcare, during the conduct of the study. P. de los Rios, C. Okoli, B. Young, M. Muchenje and N. Van de Velde are employees of ViiV Healthcare.
This work was sponsored by ViiV Healthcare.
CO, PD, BY and NV conceptualized the study. All authors contributed to the study design, analyses, drafting of the manuscript, and substantial revisions. All authors gave final approval for the manuscript to be submitted for publication.
Not commissioned; externally peer reviewed.
Stutterheim SE, Pryor JB, Bos AER, Hoogendijk R, Muris P, Schaalma HP. HIV-related stigma and psychological distress: The harmful effects of specific stigma manifestations in various social settings. AIDS. 2009;23(17):2353-2357. doi:10.1097/QAD.0b013e3283320dce
Marongiu A, Hope VD, Parry JV, Ncube F. Male IDUs who have sex with men in England, Wales and Northern Ireland: are they at greater risk of bloodborne virus infection and harm than those who only have sex with women?. Sex Transm Infect. 2012;88(6):456-461. doi:10.1136/sextrans-2011-050450
Misachi J. Countries Where Homosexuality Is Illegal. The World Atlas. Published November 20, 2018. Accessed January 8, 2020.
Orza L, Bewley S, Logie CH, et al. How does living with HIV impact on women's mental health? Voices from a global survey. J Int AIDS Soc. 2015;18(Suppl 5):20289. doi:10.7448/IAS.18.6.20289
Nachega JB, Uthman OA, Anderson J, et al. Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis. AIDS. 2012;26(16):2039-2052. doi:10.1097/QAD.0b013e328359590f
Turan B, Budhwani H, Fazeli PL, et al. How does stigma affect people living with HIV? The mediating roles of internalized and anticipated HIV stigma in the effects of perceived community stigma on health and psychosocial outcomes. AIDS Behav. 2017;21(1):283-291. doi:10.1007/s10461-016-1451-5
Campbell JC, Baty ML, Ghandour RM, Stockman JK, Francisco L, Wagman J. The intersection of intimate partner violence against women and HIV/AIDS: a review. Int J Inj Contr Saf Promot. 2008;15(4):221‐231. doi:10.1080/17457300802423224
Risher K, Mayer KH, Beyrer C. HIV treatment cascade in MSM, people who inject drugs, and sex workers. Curr Opin HIV AIDS. 2015;10(6):420‐429. doi:10.1097/COH.0000000000000200
Okoli C, de Los Rios P, Eremin A, et al. Relationship Between Polypharmacy and Quality of Life Among People in 24 Countries Living With HIV. Prev Chronic Dis. 2020;17:E22. doi:10.5888/pcd17.190359
de Los Rios P, Okoli C, Punekar Y, et al. Prevalence, determinants, and impact of suboptimal adherence to HIV medication in 25 countries. Prev Med. 2020;139:106182. doi:10.1016/j.ypmed.2020.106182
Okoli C, Brough G, Allan B, et al. Shared Decision Making Between Patients and Healthcare Providers and its Association with Favorable Health Outcomes Among People Living with HIV. AIDS Behav. 2020;1-12. doi:10.1007/s10461-020-02973-4
Okoli C, Van de Velde N, Richman B, et al. Undetectable Equals Untransmittable (U = U): Awareness and associations with health outcomes among people living with HIV in 25 countries. Sex Transm Infect. 2020. doi:10.1136/sextrans-2020-054551
de Los Rios P, Okoli C, Young B, et al. Treatment aspirations and attitudes towards innovative medications among people living with HIV in 25 countries. Popul Med. 2020;2(July):23. doi:10.18332/popmed/124781
World Bank Country and Lending Groups. The World Bank. https://datahelpdesk.worldbank.... Accessed November 2, 2020.
Mascolini M, Zuniga JM. Perceptions of health, HIV disease, and HIV treatment by patients in 6 regions: analysis of the 2555-person AIDS treatment for life international survey. J Int Assoc Physicians AIDS Care (Chic). 2008;7(4):160-177. doi:10.1177/1545109708322728
Nachega JB, Morroni C, Zuniga JM, et al. HIV treatment adherence, patient health literacy, and health care provider-patient communication: results from the 2010 AIDS Treatment for Life International Survey. J Int Assoc Physicians AIDS Care (Chic). 2012;11(2):128-133. doi:10.1177/1545109712437244
Nachega JB, Morroni C, Zuniga JM, et al. HIV-related stigma, isolation, discrimination, and serostatus disclosure: a global survey of 2035 HIV-infected adults. J Int Assoc Physicians AIDS Care (Chic). 2012;11(3):172-178. doi:10.1177/1545109712436723
Maman S, Abler L, Parker L, et al. A comparison of HIV stigma and discrimination in five international sites: the influence of care and treatment resources in high prevalence settings. Soc Sci Med. 2009;68(12):2271-2278. doi:10.1016/j.socscimed.2009.04.002
Genberg BL, Hlavka Z, Konda KA, et al. A comparison of HIV/AIDS-related stigma in four countries: negative attitudes and perceived acts of discrimination towards people living with HIV/AIDS. Soc Sci Med. 2009;68(12):2279-2287. doi:10.1016/j.socscimed.2009.04.005
Langebeek N, Gisolf EH, Reiss P, et al. Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis. BMC Med. 2014;12:142. doi:10.1186/PREACCEPT-1453408941291432
Increase HIV Testing and Prevent HIV Risk. Accessed January 8, 2020.
Zule WA, Bobashev GV, Wechsberg WM, Costenbader EC, Coomes CM. Behaviorally bisexual men and their risk behaviors with men and women. J Urban Health. 2009;86(Suppl 1):48-62. doi:10.1007/s11524-009-9366-3
Golin C, Marks G, Wright J, et al. Psychosocial characteristics and sexual behaviors of people in care for HIV infection: an examination of men who have sex with men, heterosexual men and women. AIDS Behav. 2009;13(6):1129-1142. doi:10.1007/s10461-009-9613-3
European Centre for Disease Prevention and Control, World Health Organization Regional Office for Europe. HIV/AIDS surveillance in Europe 2018 - 2017 data. Copenhagen, DK: WHO Regional Office for Europe; 2018. Accessed November 2, 2020.
Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Preliminary); vol. 30. Published November 2019. Accessed November 2, 2020.
26. Kumar S, Gruskin S, Khosla R, Narasimhan M. Human rights and the sexual and reproductive health of women living with HIV - a literature review. J Int AIDS Soc. 2015;18(Suppl 5):20290. doi:10.7448/IAS.18.6.20290
Carlsson-Lalloo E, Berg M, Mellgren Å, Rusner M. Sexuality and childbearing as it is experienced by women living with HIV in Sweden: a lifeworld phenomenological study. Int J Qual Stud Health Well-being. 2018;13(1):1487760. doi:10.1080/17482631.2018.1487760
Craft SM, Delaney RO, Bautista DT, Serovich JM. Pregnancy decisions among women with HIV. AIDS Behav. 2007;11(6):927-935. doi:10.1007/s10461-007-9219-6
Kass NE. Policy, ethics, and reproductive choice: Pregnancy and childbearing among HIV-infected women. Acta Paediatr Suppl. 1994;400:95-98. doi:10.1111/j.1651-2227.1994.tb13344.x
UNAIDS. Fact sheet - Latest global and regional statistics on the status of the AIDS epidemic. Published July 6, 2020. Accessed November 2, 2020.
Lazarus JV, Safreed-Harmon K, Barton SE, et al. Beyond viral suppression of HIV - the new quality of life frontier. BMC Med. 2016;14(1):94. doi:10.1186/s12916-016-0640-4
Global HIV targets. Avert website. Updated October 1, 2019. Accessed January 8, 2020.
Schick V, Herbenick D, Reece M, et al. Sexual behaviors, condom use, and sexual health of Americans over 50: implications for sexual health promotion for older adults. J Sex Med. 2010;7(Suppl 5):315-329. doi:10.1111/j.1743-6109.2010.02013.x