Executive Summary

More than 20 years have elapsed since gay communities around the world began the fight for HIV treatment and prevention programs specifically for gay men and other men who have sex with men (MSM).¹ In far too many countries today, however, MSM continue to have little or no access to HIV services of any kind and as a result are plagued by high rates of infection. In an unfolding tragedy of epic proportions, the numbers tell the story. HIV prevalence among MSM in Mexico is 26%. In Thailand, it is 25%. In Bolivia, 22%. Globally, MSM are 19 times more likely to be infected with HIV than the general population.²

As this Special Report makes clear, this story is one of abject failure on the part of the institutions that have been charged with leading the response to HIV/AIDS at local, national, and international levels. For the first time, this report contrasts the most recent epidemiological data on HIV among MSM -- data that show alarmingly high rates of infection -- with reports from 128 countries that speak to an epidemic of denial, indifference, and inaction. Importantly, the report also outlines the crucial steps that must be taken to adequately address the HIV/AIDS epidemic among MSM. These evidence-based interventions have been proven effective in numerous settings, but lack of political will has impeded their adoption in regions where they are needed most.

At the first UN General Assembly Special Session (UNGASS) on HIV/AIDS in 2001, UN member states unanimously adopted a Declaration of Commitment on HIV/AIDS. This was followed in 2006 by an agreement to achieve universal access to HIV/AIDS programs by 2010. Now, two years from the target date, the question arises: on the road to universal access, how far have we come and how distant is that goal? This is especially relevant for MSM -- one of the most marginalized and neglected populations in the context of HIV/AIDS.

The Current Crisis

It is well documented that MSM face a significantly higher risk of HIV infection than the general population in every region of the world. A 2007 analysis of data from 38 low- and middle-income countries found an overall HIV prevalence among MSM of 12.8%. At the furthest end of the spectrum, MSM in Bolivia are 179 times more likely to be infected with HIV than the general population.

In spite of the evidence that the HIV epidemic continues to grow among MSM populations, few countries have taken proactive steps to reverse this crisis. MSM-targeted HIV programs comprise less than 1% of total HIV spending in Latin America, despite the reality that a quarter of the people in Latin America living with HIV are MSM and sex between men is the most prominent mode of HIV transmission.

Stigma, Criminalization and Violence

In many countries, institutionalized homophobia and criminalization of homosexual activity facilitate the spread of HIV, severely hindering efforts to provide treatment and prevention for MSM. In 86 countries, consensual same-sex sexual activity is a criminal offence. In 21 countries, male-male sex is punishable by prison sentences of 10 years or more; in seven countries, it is punishable by death. Just this year in Egypt, police used laws against homosexual activity to arrest and persecute men who were thought to be HIV positive. As one of the most highly vulnerable populations to HIV, MSM need focused attention and strategies to receive adequate prevention and treatment. And yet, in many countries throughout the world, stigma and criminalization prevent these populations from getting even a fraction of the services they need.

Even in countries without legal prohibitions against samesex sexual behavior, widespread stigma and discrimination often lead to low testing rates, limited knowledge about HIV prevention, and increased likelihood of transmission. In many cases -- particularly in countries where political leaders deny the existence of same sex sexuality -- these essential HIV services for MSM are absent altogether. Perhaps most shocking is the extent to which violence against MSM in developing countries is linked to rising rates of HIV among those same populations. Over the past year, violence against men due to their gender identification and sexual orientation has raised international alarm. Gambian president Yahya Jammeh said he would "cut off the head" of any homosexual caught in his country. Police in Senegal conducted mass arrests of men thought to be gay, and in Jamaica, a mob broke into a private residence and severely beat a group of gay men having a dinner party. Violence against MSM is a human rights violation that should not be tolerated and that must be addressed as part of national efforts to expand access to HIV prevention, treatment, and care programs.

Lack of Data, Lack of Action

As part of the 2001 UNGASS Declaration of Commitment, member countries are required to measure their progress periodically against a series of specific indicators. Twentythree UNGASS indicators were identified for the 2008 and 2010 reports, five of which were relevant to MSM. These indicators pertained to prevalence of HIV infection, rates of HIV testing, HIV knowledge, condom use, and access to prevention programming.

Almost half of the 128 countries reviewed failed to report any data whatsoever on HIV/AIDS among MSM. Fewer than one-third reported on more than three of the five UNGASS indicators. Seventy-nine countries (62%) did not report on HIV seroprevalence among MSM. In other words, almost two-thirds of the countries surveyed appear to have no information on the extent of HIV/AIDS among their MSM residents.

At the regional level, the dearth of information on efforts to combat HIV among MSM is most apparent in Africa, the epicenter of the global epidemic. Of the 52 countries reviewed, two-thirds did not report on any of the five indicators related to MSM. Asia and the Middle East fared marginally better. Of 33 countries reviewed in these regions, 12 did not report on any of the five indicators. Though little is known about HIV rates among MSM populations throughout the world, a pattern has emerged indicating that when countries adequately measure MSM populations, they find greater than anticipated epidemics. Since MSM populations are highly vulnerable to HIV infection, many countries that do not report any data on MSM may be unaware of an epidemic in their midst.

Lack of data means lack of action. Without data on the HIV epidemic among MSM populations, governments cannot assess the need for prevention and treatment programs targeting these populations. Too many governments interpret the lack of information about HIV among MSM to mean a lack of need for MSM-specific HIV programs. Lack of data then becomes a justification for little or no funding for HIV services for MSM.

But it is not only national governments that are guilty of ignoring MSM. International HIV/AIDS funding and policies have largely ignored the growing crisis of HIV infections among MSM. Because donor countries and other organizations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria primarily fund HIV/AIDS efforts through national governments, MSM programs rarely receive adequate resources, while governments without any MSM programs continue to be awarded substantial AIDS funding. Often MSM are grouped with other "vulnerable populations" such as injection drug users, sex workers, and orphans, despite the substantial differences among these most at-risk populations.

In a hopeful development, several donor countries have begun to take a stand against discrimination in the countries whose HIV programs they support. The Netherlands, for example, recently adopted a policy making it a priority to end criminalization of homosexuality in the developing countries receiving Dutch funding. It is imperative that other nations strongly encourage recipient countries to value the health and human rights of all of their citizens, regardless of sexual orientation.

A Call to Action

These findings bear out conclusively that, more than 25 years into the HIV/AIDS epidemic, the AIDS crisis persists among MSM worldwide and continues to be fueled by homophobia and official indifference. International neglect of these populations will serve only to undermine the global effort to fight HIV/AIDS in any context and among all populations.

This Special Report closes with detailed recommendations and conclusions, which are summarized as follows:

amfAR urges all countries to:

• Develop evidence-based plans and programs to scale up access to specific, culturally appropriate HIV prevention, treatment, care, and support services for MSM.

• Develop indicators for reporting progress in HIV treatment, care, and support programs for MSM.

• Identify best practice models and approaches to ensuring universal access to HIV/AIDS prevention, care, treatment, and support programs with MSM.

• Conduct baseline and ongoing surveys to gather data and to monitor and evaluate the state of the HIV epidemic among MSM.

• Decriminalize same-sex sexual behavior and take the legislative steps necessary to eliminate stigma and discrimination against MSM.

amfAR calls on the international HIV/AIDS funding community to:

• Fund HIV/AIDS programs for MSM and allocate adequate human and financial resources to assist countries in their efforts to ensure universal access to HIV treatment, care, and support programs for MSM.

• Organize regional consultations on pathways to scaling up access for MSM to HIV/AIDS prevention, care, treatment, and support programs.

• Encourage recipient countries to review and reform legislation with the aim of decriminalizing MSM so that all populations have equal access to HIV services.

1. The term men who have sex with men (MSM) is used to encompass all who engage in male-male sexual behavior. It includes gay men, bisexual men, MSM who do not identify as gay or bisexual, male sex workers, transgendered people, and a range of culture- and country-specific populations of MSM.

2. Baral S, Sifakis F, Cleghorn F, et al. "Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000-2006: A systematic review." PLoS Med. 2007 December 1;4(12):e339.