Recent data make clear that men who have sex with men (MSM)1 are seriously affected by HIV around the world. In low and middle-income countries, MSM are on average 19 times more likely to be infected with HIV than the general population.2
HIV prevalence rates among MSM have been reported as high as 30% in Jamaica and 25% in Thailand. In Sub-Saharan Africa, the primary target of the Presidents Emergency Plan for AIDS Relief (PEPFAR), the U.S. global strategy to combat AIDS, HIV prevalence rates among MSM have been recorded at 43% in coastal Kenya, 25% in Ghana, 21% in Malawi, 20% in Botswana, and 12% in Namibia.3
Homophobia, stigma and discrimination fuel HIV transmission, driving MSM underground, where shame and secrecy exacerbate HIV risk. Fear of rejection,4 public humiliation,5 ridicule by health-care workers,6 pressure to have children,7 and blackmail8 are but a few reasons why MSM may conceal their behavior. As but one example, in April 2009, Uganda's tabloid newspaper Red Pepper published a full page article listing the names and descriptions of 50 suspected homosexuals, including photos of four individuals. Gender-based violence against men perceived to be gay has been reported at extreme levels in the Caribbean,9 Iraq10 and elsewhere, ranging from verbal harassment to physical violence, including torture and murder. Homosexuality is illegal in 80 countries around the world, and is actually punishable by death in five of those nations, as well as in parts of two other countries.11
Those men who are willing and able to come forward and access HIV services are, on average, out of luck. A 2007 meeting of the Global HIV Prevention Working Group estimated that only 9% of MSM are reached with HIV prevention services.12 More recent global data is telling in its own way -- analysis of the 2008 UNGASS country reports from Latin America, the Caribbean, Eastern Europe, the Middle East, Asia, and Africa found that 71% of countries did not even report on the number of MSM receiving HIV prevention services.13
Disturbingly, many men may not even realize they are at risk. Misconceptions that sex between men carries no risk of HIV transmission have been widely reported in Africa and in the Caribbean in both anecdotal reports and published research literature.14,15 Prevention messaging and imagery that focuses exclusively on heterosexual transmission may suggest that HIV risk is only a factor between partners of the opposite sex -- especially given that the word "sex" in certain contexts can indicate reproduction.16 Where men do know the risk of HIV transmission between men, access to the necessary prevention products can be a big issue. Oil-based products like Vaseline and body creams are more commonly used in some contexts because they are less expensive and more widely available than water-based lubricants,17 though they have the distinct disadvantage of breaking down latex condoms and rendering them ineffective.
While delivering the Jonathan Mann memorial lecture in health and human rights at the 2008 International AIDS Conference, Jorge Savedraa pointedly noted that "we have failed to bring down the incidence among MSM because, with some exceptions, we have not tried."18 Public denouncements against MSM in recent years by political and religious leaders continue to be a significant hurdle to addressing HIV among MSM as a priority issue.19 Ugandan President Yoweri Museveni asserted in 1999 that "we don't have homosexuals in Uganda."20 In 2008, Gambian President Yahya Jammeh vowed "stricter laws than Iran" on homosexuality, pronouncing that he would "cut off the head" of any gay person found in Gambia.21
The lack of research and data on HIV among MSM makes their plight less obvious or even unknown to regional and national AIDS control organizing bodies. Without reliable information on the number and percentages of MSM living with HIV, it is harder to justify allocating resources towards reaching them with HIV services. MSM must be integrated into routine HIV surveillance practices to ensure that planners have the most up to date information on the state of their local epidemic. Scaling up efforts is also hindered by a lack of funding, which globally is not proportional to the scale of the epidemic among MSM: merely 1.2% of prevention funding goes towards combating HIV among MSM.
More voices are needed to bring these issues to light, but significant social, structural and policy barriers exist. Aside from laws criminalizing homosexuality and general hostility toward MSM, restrictive regulations and laws can get in the way of effective advocacy. In some countries, organizations that seek equal rights and empowerment for MSM are ineligible to gain official non-governmental or non-profit organizational status, which often precludes them from receiving donor funding. Harassment of HIV outreach workers who seek to educate and serve MSM is likewise detrimental.
Success in treating MSM infected and affected by HIV around the world will require extremely broad social and political changes as much as localized clinical services. There are encouraging signs for the road ahead. The 2008 reauthorization of PEPFAR includes a new directive for HIV prevention education specifically targeting MSM.22 The 2009 HIV Implementers' Meeting -- a gathering largely comprised of PEPFAR grantees and other frontline HIV service organizations -- included, for the first time, a workshop solely dedicated to reaching MSM, and several other presentations on MSM. Among the innovative projects discussed was making use of cell phones -- ubiquitous in many African contexts -- to deliver HIV prevention information, coupled with MSM-trained counselors just a phone call away. The program was a resounding success in Ghana.
Both the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNAIDS have recently released new strategic documents on reaching MSM and other sexual minorities. A worldwide coalition of MSM activists, the Global Forum on MSM and HIV, is linking allies from all world regions together to educate and advocate for the health and human rights of MSM. U.S. Global AIDS Ambassador Dr. Eric Goosby and UNAIDS Executive Director Michel Sidibé spoke at a September 2009 Congressional Briefing on MSM and the global HIV epidemic -- unprecedented public support for reaching MSM through PEPFAR.
So what, exactly, is needed to address HIV among MSM? The 2009 World AIDS Day theme, "Universal Access and Human Rights," could not be a more fitting directive.
Krista Lauer, MSc., is Manager of International Policy at AIDS Project Los Angeles, and Policy Associate at the Global Forum on MSM and HIV. She currently serves as Chair of the HIV Policy Working Group on MSM and Other Sexual Minorities.