Men Who Have Sex with Men and HIV/AIDS

I care . . . Do you? "I care . . . Do you?" is the slogan for the second year of a two-year campaign intended to create a sustained focus on the role of men in the AIDS epidemic.

Key Messages

Effective responses include a combination of the following:

• breaking down social and cultural barriers against the discussion of male-to-male sex;

• educating health staff, including those in sexually transmitted infection (STI) clinics, to overcome ignorance and prejudices about men who have sex with men (MSM);

• ensuring the commitments of national AIDS programs and donor agencies to include the issue of MSM in their programs and funding priorities;

• scaling up peer education among MSM;
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• promoting high-quality condoms and water-based lubricants, and ensuring their continuing availability; and

• reviewing and formulating laws that protect the rights of MSM.

Facts

At least 5-10% of HIV cases worldwide are due to sexual transmission between men, though this figure varies considerably from country to country, and region to region. In Australia, New Zealand, North America and most of Western Europe, UNAIDS believes the figures are closer to 70%.

Sex between men exists in all societies. It frequently involves anal sex which, when unprotected, carries a high risk of HIV transmission, especially for the receptive partner. Sex between men is the main route of HIV transmission in some parts of the world. In other places, other forms of transmission are more common. Nearly everywhere, however, sex between men is a significant and interconnected part of the epidemic. It cannot be ignored.

Many men who have sex with other men, whether occasionally or frequently, do not regard themselves as "homosexual" or "bisexual." They are very often married. Even if they are not, they may have sex with women as well. This applies particularly to those societies wherein marriage is strongly promoted by society and the family. This contributes to the fact that much of the sex between men is covert.

Most same-sex behavior is conducted by choice. There are also, however, instances of institutions in which men are obliged to spend long periods in all-male company, such as in the military, prisons and male-only educational establishments, and in which male-to-male sex can be common. Male prisons, for example, have been shown to make a significant contribution to some countries' epidemics, both through drug injecting and male-to-male sex.

Issues

Denial

Hostility towards, and misconceptions about, sex between men have resulted in inadequate HIV prevention measures in many countries. Government, policy-makers and program managers sometimes deny that male-to-male sex occurs in their part of the world. And some governments refuse to support prevention programs for men who have sex with men. As a result, these men and their partners are at increased risk of HIV infection. Denial is an enormous obstacle to AIDS prevention efforts and care among MSM.

Inadequate Epidemiological Data

A lack of, or unreliable, epidemiological data are an obstacle to HIV prevention work. In some places, surveys do not include a category for MSM, and data pertaining to this group are therefore often not available.

Lack of Knowledge or Awareness

In countries where HIV education emphasizes only heterosexual transmission, men may be ignorant of the risks of male-to-male sex, or consider that the risks do not apply to them. They may therefore be less likely to protect themselves.

Lack of Appropriate Programs

Many countries lack AIDS programs for MSM. At the same time, existing programs may be inappropriate. Educational material that is suitable for people in a self-identified gay bar may be too explicit -- and thus counterproductive -- for those men who do not self-identify as "gay," but who nevertheless have sex with other men.

Difficulty in Reaching Many of the Men Who Have Sex with Men

Many MSM engage in casual, fleeting and anonymous sexual encounters. They may also not identify themselves as "gay" or think that they belong to the group of men who have sex with men. The combination of these factors makes them difficult to reach for prevention work. Male sex workers can be particularly difficult to access, especially where the work is clandestine and the workers are not organized by an establishment.

Difficulty in Sustaining "Safer Sex" Practices

Despite the initial successes in many prevention campaigns, in some places -- particularly industrialized countries -- MSM have been found in recent years to practice safer sex (including condom use) less regularly than before. Among the reasons for this are: information fatigue; a lack of innovative outreach work; decreased funding for prevention efforts; and uncertainty among HIV-infected men who are receiving antiretroviral treatment about the continued risks (to themselves or their partners) of unsafe or unprotected sex.

Inadequate, Inaccessible or Inappropriate Health Facilities

MSM seeking attention for sexual or medical matters, or tests for HIV or other STIs, may find such facilities to be lacking. Alternatively, the facilities may exist, but the men may find access to them difficult, due to negative attitudes on the part of health staff towards same-sex behavior, lack of discretion or anonymity for clients, inconvenient location/opening hours, or cost.

Stigmatization and Criminalization

Societies can be hostile towards men who engage in same-sex behavior, stigmatizing it and treating it as sinful or criminal -- with severe penalties, in some places. Men will then often choose not to be honest about the fact that they have had sex with other men. Afraid of being questioned, they will be reluctant to report symptoms of STIs, including HIV. Because of this, HIV and safer sex education, the provision of condoms, and appropriate STI and other medical care are made extremely difficult. Hostility on the part of society also hinders effective HIV prevention efforts aimed at adolescents and young men who have sex with other men.

Ideas for Action

• Personal questioning:
  • What are your own reactions towards someone who has sex with men?

  • Do you discriminate? How would you react if your son or close friend disclosed to you that he was having sex with other men?

  • Is sex between men a criminal act in your country?

  • Should sex between men be a criminal act?

  • If it is, what should you do?

• Help parents better understand the development and psychology of their children and young people.

• Teach parents how to adjust to the development of their child's sexuality.

• Train peer educators to talk to men who have sex with men about HIV prevention in bars and other places where they meet socially or for sex.

• Debate and advocate the availability of condoms and lubricants in your school, workplace or social setting.

• Discuss the links between drug and alcohol use and sex between men.

• Urge male celebrities to speak openly about men who have sex with men and the need for men to change their behavior. Also provide these celebrities with simple messages on these topics to be used in public forums or media interviews.

• Encourage open discussions about sex between men in the community as well as in male-only institutions, including discussions on the possibility of HIV transmission between men within and outside these environments.

• Encourage networking and information exchange between MSM organizations in different countries.

• Train doctors and other health workers to talk with, and listen to, their male patients about sexual behavior, sexuality and safer sex.

• Invite representatives of groups of men who have sex with men to talk to AIDS service organizations and to other forums where HIV prevention is discussed.

• Include a component on men who have sex with men in the planning and implementation of AIDS prevention and care programs.