Reply to Kojima and Klausner

To the Editor—We have noted and agree with the insight provided by Kojima and Klausner that more successful human immunodeficiency virus type 1 (HIV-1) testing of men and engagement in care of those who are HIV-positive are critical to controlling the epidemic, especially in high-burden low- and middle-income countries (LMICs) [1]. Our recent review focused on viral suppression, that is, achieving the last “90” in the World Health Organization goal of 90-90-90 in LMICs, and was not intended to specifically address the challenges of testing or linkage to care [2]. We did describe strategies for improving testing and linkage to care for populations at especially high risk for nonsuppression due to social vulnerability or lack of attention. Testing and treatment initiation are critical steps toward achieving epidemic control, but sustained viral suppression is a lifelong challenge with many barriers. Accordingly, we focused on the most pressing gaps in viral suppression among vulnerable subpopulations, including adult males.

In addition to men who have sex with men (MSM) and prisoners, we included the general population category in our paper (in which heterosexual, nonincarcerated men are included) [2]. Certainly, the recommendations made by Kojima and Klausner to improve testing among men in LMICs will help achieve the “expanded and consistent access to HIV testing” we recommended for the general population in Table 1 of our review [2]. Unfortunately, population-based, gender-disaggregated reports on 90-90-90 outcomes are not currently widely available in LMICs, but efforts are being made to address this gap. As more data emerge, we expect detailed intra- and cross-country comparisons of 90-90-90 outcomes for men (MSM and heterosexual), women (pregnant/breastfeeding and nonpregnant), and other key subpopulations.

Notes

Financial support. J. B. N. receives research grant support from the US National Institutes of Health (NIH)/National Institutes of Allergy and Infectious Disease, the AIDS Clinical Trial Group/Stellenbosch University Clinical Trial Unit (2UM1AI069521-08); and the Pittsburgh-Stellenbosch University AIDS-comorbidities Training Research Program (Pitt-SU AICoTRP; NIH/FIC 1D43TW010340-01).

Potential conflicts of interest. J. W. M. is a consultant to Gilead Sciences and owns share options in Co-Crystal Pharmaceuticals, Inc. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.