Population Size Estimation of Men Who Have Sex With Men in Low- and Middle-Income Countries: Google Trends Analysis.

Background: Population size estimation (PSE) for key populations is needed to inform HIV programming and policy. Objective: This study aimed to examine the utility of applying a recently proposed method using Google Trend (GT) internet search data to generate PSE (Google Trends Population Size Estimate [GTPSE]) for men who have sex with men (MSM) in 54 countries in Africa, Asia, the Americas, and Europe. Methods: We examined GT relative search volumes (representing the relative internet search frequency of specific search terms) for "porn" and, as a comparator term, "gay porn" for the year 2020. We assumed "porn" represents "men" (denominator) while "gay porn" represents a subset of "MSM" (numerator) in each county, resulting in a proportional size estimate for MSM. We multiplied the proportional GTPSE values with the countries' male adult population (15-49 years) to obtain absolute size estimates. Separately, we produced subnational MSM PSE limited to countries' (commercial) capitals. Using linear regression analysis, we examined the effect of countries' levels of urbanization, internet penetration, criminalization of homosexuality, and stigma on national GTPSE results. We conducted a sensitivity analysis in a subset of countries (n=14) examining the effect of alternative English search terms, different language search terms (Spanish, French, and Swahili), and alternative search years (2019 and 2021). Results: One country was excluded from our analysis as no GT data could be obtained. Of the remaining 53 countries, all national GTPSE values exceeded the World Health Organization's recommended minimum PSE threshold of 1% (range 1.2%-7.5%). For 44 out of 49 (89.8%) of the countries, GTPSE results were higher than Joint United Nations Programme on HIV/AIDS (UNAIDS) Key Population Atlas values but largely consistent with the regional UNAIDS Global AIDS Monitoring results. Substantial heterogeneity across same-region countries was evident in GTPSE although smaller than those based on Key Population Atlas data. Subnational GTPSE values were obtained in 51 out of 53 (96%) countries; all subnational GTPSE values exceeded 1% but often did not match or exceed the corresponding countries' national estimates. None of the covariates examined had a substantial effect on the GTPSE values (R2 values 0.01-0.28). Alternative (English) search terms in 12 out of 14 (85%) countries produced GTPSE>1%. Using non-English language terms often produced markedly lower same-country GTPSE values compared with English with 10 out of 14 (71%) countries showing national GTPSE exceeding 1%. GTPSE used search data from 2019 and 2021, yielding results similar to those of the reference year 2020. Due to a lack of absolute search volume data, credibility intervals could not be computed. The validity of key assumptions, especially who (males and females) searches for porn and gay porn, could not be assessed. Conclusions: GTPSE for MSM provides a simple, fast, essentially cost-free method. Limitations that impact the certainty of our estimates include a lack of validation of key assumptions and an inability to assign credibility intervals. GTPSE for MSM may provide an additional data source, especially for estimating national-level PSE.