Differences in HIV Treatment Experiences, Perceptions, and Behaviors by Gender and Sexual Orientation in 25 Middle-Income and High-Income Countries: Findings from the 2019 Positive Perspectives Survey

Introduction 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. Methods 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). Results 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. Conclusions 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.