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Asia, the Pacific and the Middle East

Part of MSM, HIV and the Road to Universal Access: How Far Have We Come?

From amfAR, The Foundation for AIDS Research

August 2008

There were more than 5 million people living with HIV/AIDS in Asia, the Pacific, and the Middle East in 2007. In many countries in these regions, injection drug use and unprotected sex (especially commercial sex) are largely responsible for the spread of HIV. Asia is home to some of the most populous countries in the world, resulting in large numbers of people living with HIV/AIDS, even when national HIV prevalence is relatively low. For example, in India 0.36% of those aged 15-49 were living with the virus in 2007, for a total of approximately 2.5 million people. China's epidemic is largely fueled by injection drug use, but MSM account for a growing number of infections.

Indonesia harbors the fastest-growing epidemic in Southeast Asia, due to injection drug use, commercial sex, and sex between men. Thailand has registered some success in slowing the spread of HIV, but 30-50% of injection drug users are believed to be HIV positive, and HIV prevalence among MSM is rising rapidly.


Review of Country Progress Reports

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Asian, the Pacific, and Middle Eastern countries reviewed: Armenia, Azerbaijan, Bangladesh, Cambodia, China, Fiji, Georgia, India, Indonesia, Japan, Jordan, Kazakhstan, Kyrgyzstan, Lao People's Democratic Republic, Lebanon, Malaysia, Marshall Islands, Mongolia, Nepal, Pakistan, Palau, Papua New Guinea, Philippines, Qatar, Republic of Korea, Seychelles, Singapore, Sri Lanka, Tajikistan, Thailand, Turkey, Tuvalu, Vietnam.


1. Country Reporting: How Many Countries Reported on MSM?

Country reporting of five UNGASS indicators relevant to MSM

Summary: Out of the 33 countries reviewed, 12 (Azerbaijan, Fiji, Japan, Jordan, Marshall Islands, Palau, Qatar, Republic of Korea, Seychelles, Singapore, Tajikstan, and Tuvalu) did not report on any of the five indicators. Nine countries (Armenia, Cambodia, China, Georgia, Kazakhstan, Malaysia, Pakistan, Sri Lanka, and Turkey) reported on 1-3 indicators. Twelve countries (Bangladesh, India, Indonesia, Kyrgyzstan, Lao People's Democratic Republic, Lebanon, Mongolia, Nepal, Papua New Guinea, Philippines, Thailand, and Vietnam) reported on 4-5 indicators.


2. Seroprevalence: What percentage of MSM Are Living With HIV?

UNGASS Indicator: Percentage of MSM who are living with HIV

Summary: Twenty countries (Azerbaijan, China, Fiji, Japan, Jordan, Kazakhstan, Kyrgyzstan, Lebanon, Marshall Islands, Mongolia, Pakistan, Palau, Papua New Guinea, and Qatar, Republic of Korea, Seychelles, Singapore, Sri Lanka, Tajikistan, and Tuvalu) did not report on HIV seroprevalence among MSM. Of the countries that reported on HIV seroprevalence among MSM, nine (Armenia, Bangladesh, Cambodia, Georgia, Indonesia, Lao People's Democratic Republic, Nepal, Philippines, and Turkey) reported prevalence of 0-5%. Three countries (India, Malaysia, and Vietnam) reported HIV seroprevalence among MSM of 6-10%. One country (Thailand) reported HIV seroprevalence among MSM of more than 15%.


3. Testing: What Percentage of MSM Have Taken an HIV Test in the Last Year?

UNGASS Indicator: Percentage of MSM who received an HIV test in the last 12 months and who know their result

Summary: Sixteen countries in the regions (Armenia, Azerbaijan, China, Fiji, Japan, Jordan, Marshall Islands, Pakistan, Palau, Qatar, Republic of Korea, Seychelles, Singapore, Tajikistan, Turkey, and Tuvalu) did not report on HIV testing among MSM. Twelve countries (Bangladesh, Georgia, India, Indonesia, Kazakhstan, Lao People's Democratic Republic, Lebanon, Nepal, Philippines, Sri Lanka, Thailand, and Vietnam) reported HIV testing rates among MSM of below 40%. Two countries (Cambodia and Papua New Guinea) reported rates of 40-59% and three countries (Kyrgyzstan, Malaysia, and Mongolia) reported HIV testing rates among MSM of 60% or higher.


4. Knowledge: What Percentage of MSM Know How to Prevent HIV?

UNGASS Indicator: Percentage of MSM who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission

Summary: Seventeen countries in the region (Azerbaijan, Cambodia, China, Fiji, Georgia, Japan, Jordan, Malaysia, Marshall Islands, Pakistan, Palau, Qatar, Republic of Korea, Seychelles, Singapore, Tajikistan, and Tuvalu) did not report on the level of understanding among MSM about HIV prevention. Six countries (Bangladesh, Lao People's Democratic Republic, Mongolia, Philippines, Sri Lanka, and Thailand) reported that 0-39% of MSM demonstrate accurate knowledge of HIV transmission. Four countries (India, Indonesia, Nepal, and Vietnam) reported that 40-59% of MSM know how HIV is transmitted. Six countries (Armenia, Kazakhstan, Kyrgyzstan, Lebanon, Papua New Guinea, and Turkey) reported rates of 60% or more.


5. Behavior: What Percentage of MSM Used a Condom the Last Time They Had Sex?

UNGASS Indicator: Percentage of men reporting the use of a condom the last time they had anal sex with a male partner

Summary: Fourteen countries in Asia, the Pacific, and the Middle East did not report on condom use among MSM (Azerbaijan, Fiji, Georgia, Japan, Jordan, Malaysia, Marshall Islands, Palau, Qatar, Republic of Korea, Seychelles, Singapore, Tajikistan, and Tuvalu). Eight countries (Bangladesh, China, Indonesia, Lao People's Democratic Republic, Lebanon, Pakistan, Philippines, and Turkey) reported condom use rates of 20-39% among MSM. One country (India) reported a condom use rate of 40-59%. Five countries (Kazakhstan, Mongolia, Nepal, Sri Lanka and Vietnam) reported condom use rates of 60-79%. Five countries (Armenia, Cambodia, Kyrgyzstan, Papua New Guinea, and Thailand) reported condom use rates among MSM of 80% or higher.


6. Coverage: What Percentage of MSM Are Being Reached by HIV Prevention Programs?

UNGASS Indicator: Percentage of MSM reached with HIV-prevention programs

Summary: Twenty-one countries in the regions (Armenia, Azerbaijan, Cambodia, Fiji, Japan, Jordan, Kazakhstan, Lao People's Democratic Republic, Malaysia, Marshall Islands, Pakistan, Palau, Qatar, Republic of Korea, Seychelles, Singapore, Sri Lanka, Tajikistan, Thailand, Turkey, and Tuvalu) did not know how many MSM are being reached by HIV prevention programs. Five countries (Bangladesh, China, Lebanon, Papua New Guinea, and Philippines) reported reaching less than 20% of MSM. One country (Vietnam) reported reaching 20-39% of MSM. Three countries (India, Indonesia, and Nepal) reported reaching 40-59% of MSM. Three countries (Georgia, Kyrgyzstan, and Mongolia) reported reaching 60% of MSM or more.


Case Study: India

In India, 0.36% of those aged 15 to 49 are estimated to be living with HIV, representing a total of approximately 2.5 million people. About 6.4% of the country's estimated two million MSM are believed to be infected with the virus.1 These numbers are disputed, however, among people who work with MSM populations because of the difficulty of identifying and counting MSM in India.

Although the Indian government in its UNGASS progress report acknowledges the need to focus on MSM, many civil society leaders claim that current efforts to slow the spread of HIV among MSM are inadequate and inappropriate. One difficulty cited is the view among some that HIV/AIDS among MSM is a problem to solve quickly rather than a community issue to address. For example, one respondent interviewed for this case study maintained that the government funds religious groups that try to "solve" the problem by "converting" homosexual men into heterosexuals.

While respondents noted that the social and legal environment in India has changed considerably and that testing and prevention services are more widely available now than in the past, all respondents noted that current HIV testing, prevention, and treatment efforts are still highly inadequate. Reaching non-feminized MSM -- men who often do not consider themselves homosexual -- presents another difficulty in providing health services to MSM. Targeted interventions often miss these MSM groups because they are not visibly identifiable, often do not consider their actions as homosexual, are more often married, and consider feminized MSM as social inferiors with whom they don't wish to be categorized. MSM in India face considerable discrimination from medical service providers and this serves as a barrier for treatment access. Respondents noted the need for awareness of MSM issues among healthcare providers, sensitivity training for the medical community, and MSMspecific care. Including MSM-specific information in HIV education programs for the general public would be an effective means of reaching MSM without forcing them to reveal their sexual behavior and face continued discrimination.

Although the Indian government has made progress in addressing the HIV-prevention and care needs of MSM, section 377 of the country's penal code prohibits homosexual relations and abetting such relations. Repealing the law might not make much difference in terms of decreasing the social stigma that MSM currently face, but it could serve to provide immunity to MSM community workers and allow communities to challenge police extortion and harassment.


India 2008 Country Progress Report: UNGASS Indicators Relevant to MSM

India 2008 Country Progress Report: UNGASS Indicators Relevant to MSM


Case Study: Nepal

The Nepal UNGASS report estimates that about 0.48% of the adult population is living with HIV, a total of about 70,000 people. Among MSM, HIV prevalence is estimated at 3.3%.2

Homophobia is deep-seated in Nepal, particularly toward meti (feminized men). The Nepali civil code forbids "unnatural sex" but does not define the act. In July 2004, a lawyer filed a case in the Supreme Court of Nepal accusing the government of failing to control the openly homosexual activities of the Blue Diamond Society, a Nepali NGO that works on issues of sexual health and advocacy for LGBT populations. The lawsuit also demanded that the Blue Diamond Society be dissolved.3 In August of the same year, 39 members of the Blue Diamond Society were jailed for 13 days without any charges, before eventually being charged with public nuisance. As the right of the Blue Diamond Society to exist was debated at the Supreme Court and the Home Ministry, community mobilization began to occur, and when a more progressive government came to power, the Society decided to take its own case to the Supreme Court in 2007. On December 21 of that year, the Nepali Supreme Court ruled that the government must recognize LGBT as "natural" people and protect their rights. The conservative nation's recognition of MSM represents a major step forward in the battle against discrimination and HIV/AIDS.

Nepal's victory is by no means the final step in the inclusion of MSM and transgender people in mainstream society; according to a Human Rights Watch advocate, "Things are [still] pretty horrific for a lot of people in Nepal."4 The new protective rulings, however, provide ammunition for advocates who can now demand that MSM be included in the national HIV/AIDS plan. In the opinion of the director of the Blue Diamond Society, who was also recently elected as Nepal's first openly gay member of Parliament, "People are talking more openly and becoming more friendly, but we also need to work for the next few years." Although he acknowledges that reducing stigma towards MSM, particularly meti, and increasing resources for HIV/AIDS prevention and treatment of MSM is "a huge, huge task," the country's new laws provide a platform from which Nepali advocates can begin to reshape their society.


Nepal 2008 Country Progress Report: UNGASS Indicators Relevant to MSM

Nepal 2008 Country Progress Report: UNGASS Indicators Relevant to MSM


References

  1. India National AIDS Control Organisation: India 2008 UNGASS Country Progress Report (2008).

  2. Nepal Ministry of Health and Education: Nepal 2008 UNGASS Country Progress Report (2008).

  3. Sunil Pant: "MSM and HIV/AIDS in Nepal."

  4. Schleifer.



  
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This article was provided by amfAR, The Foundation for AIDS Research.
 
 

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