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Men who have sex with men and HIV policies in developing countries

Malawi | A man with HIV lies on a bed waiting to be moved in the Zomba General Hospital. There is little research about men who have sex with men in Malawi, which one of the reports highlighted here attributes to homophobia / Patrick Brown - Panos PicsMalawi | A man with HIV lies on a bed waiting to be moved in the Zomba General Hospital. There is little research about men who have sex with men in Malawi, which one of the reports highlighted here attributes to homophobia / Patrick Brown - Panos Pics

Leaders from around the world will meet in Vienna to attend the XVIII International AIDS conference this month. The overarching theme of the conference, cited on the website, is the “emphasis on the importance of protecting and promoting human rights as a prerequisite to a successful response to HIV”. The conference is particularly focused on the rights of people most vulnerable to HIV such as women, children, drug users, migrants, prisoners, sex workers, transgender and men who have sex with men (MSM). This topic guide aims to shed light on one of these marginalised and highly vulnerable groups, men who have sex with men (MSM), and to explain how HIV policies employed by some countries in the developing world are addressing their needs.

Research has found that MSM around the world often face relatively high levels of HIV infection. In Thailand, HIV prevalence is 1.6 per cent but, considering the MSM population alone, HIV prevalence  rises to 24.6 per cent. This is not just an issue for developing countries: the rate of HIV among MSM in the United States is 44 times higher than that among other men, according to the Centers for Disease Control and Prevention. Despite MSM being highly vulnerable to  HIV, they are distinctly neglected in the global debate about HIV prevention and treatment. This topic guide features four countries:  Brazil, Bangladesh, South Africa and Malawi. Out of these Brazil is the only country that has a government action plan to specifically address MSM and transgender people in HIV rhetoric.

Nearly 80 nations around the world criminalise same-sex acts between consenting adults with penalties ranging from fines, imprisonment and, in seven countries, death. Some states are now stepping up or legislating for new criminal penalties on same-sex acts. Since 2009 the Ugandan parliament has been mulling over a proposal to include life imprisonment and even the death penalty as punishments for people convicted of  performing certain categories of same-sex sexual acts.

Criminalisation pushes up HIV rates

UNAIDS and other international agencies dealing with HIV and AIDS research have found that criminalising same-sex acts can in fact lead to greater HIV prevalence. The report “Social discrimination against MSM: Implication for HIV policy and programs” cites statistics from a 2008 UNAIDS study on HIV prevalence among MSM in the Caribbean. According to the report, countries that did not criminalise homosexuality such as Cuba (HIV prevalence rate of two per cent in the MSM population) had a far lower prevalence rate than countries that did criminalise it, such as Jamaica (25 per cent HIV prevalence in the MSM population).

Punitive laws coupled with stigma from families and society can force MSM to engage in risky sexual behaviour, increasing their vulnerability to HIV. The report “HIV prevalence, risks for HIV infection and human rights among MSM in Malawi, Namibia and Botswana” said that over a fifth of the men who participated in the study had experienced blackmail or extortion on account of their sexual orientation. According to the report, there was a strong link between MSM having been blackmailed and not taking a HIV test in the previous six months, which suggests that stigma was preventing men from going for HIV tests. Moreover, all the studies featured in this topic guide reported that healthcare workers did not have adequate training to respond to MSM health needs. The report, “Breaking the silence: South African HIV policies and the needs of men who have sex with men”  found that healthcare workers were ill-equipped to deal with the psychological and physical needs of MSM seeking healthcare.

While undertaking research for this topic guide it became evident that there is a lack of consistent information and studies regarding MSM. The publications cited here all called for more research into this topic. MSM are one subset of the populationmost vulnerable to HIV. However, reducing HIV incidence in this population will only be possible if HIV programmes become explicitly targeted at MSM.

The key issues section of this topic guide looks at recent research papers about effective HIV policies regarding MSM in four countries: Bangladesh, Brazil, Malawi and South Africa. Studies mentioned can be found at the links section, while the resources section provides questions on the issue for journalists to use.

South African HIV policy and MSM

The report “Breaking the silence: South African HIV policies and the needs of men who have sex with men” assesses the effectiveness of current HIV policies in the country and how they fulfil the needs of the local MSM population. South Africa is the only country on the continent that legally recognises same-sex relationships and outlaws discrimination on the basis of sexual orientation. However, experience has shown that this legal framework has been insufficient to ensure MSM to have access to HIV prevention resources and services. The report finds that people in same-sex relationships face discrimination by the healthcare system in South Africa.

  • South African HIV/AIDS and STI National Strategic Plan 2007-2011 acknowledges that there is little information about the HIV epidemic among MSM as there was little information available about this group
  • To date, the United Nations General Assembly Special Session (UNGASS) indicators relating to MSM have not been included in South African country reports submitted to UNAIDS
  • There is a lack of training for health workers to respond to the psychological and physical needs of people with same-sex partners. The report recommends that the government should provide training and reference materials for health workers about this population
  • The report suggests numerous policy recommendations such as:
    1. a country-wide HIV surveillance amongst MSM population to discover the extent of the prevalence
    2. inclusion of MSM in deciding programme and funding priorities
    3. inclusion of the  Lesbian, Gay, Bisexual and Transgender (LGBT) network to overcome stigma and homophobia

Latin America

The HIV prevalence rate among MSM in Brazil is 4.6 per cent but only 0.6 per cent among the overall population. Moreover, there has been no significant reduction of HIV prevalence among MSM since the 1990s. In the early 2000s, Brazil’s Ministry of Health partnered with LGBT civil society organisations as part of the “Brazil without homophobia” campaign that has incorporated the HIV prevention message. This led to the drafting of the “National Plan to combat the AIDS and STD epidemic among gay men, MSM and transvestites”. This five-year plan (2007-2011establishes a policy of prevention and integral health care with the intention that it will reduce this population’s vulnerability to HIV and STDs. Some of the policies are outlined below.

  • A minimum investment of 10 per cent of the government STD/AIDS prevention fund for transgender and MSM by 2009, increasing to 15 per cent by 2011
  • Raising awareness of the citizenship rights of homosexuals through media channels
  • Publicising violations of rights associated with vulnerability to STD/AIDS
  • Highlighting  the vulnerability of gay men and other MSM to STDs, including HIV andAIDS in schools.
  • Expanding HIV surveillance with respect to MSM to increase research knowledge in the area
  • Increasing the purchase of lubricant gels from 4 million to 10 million units, meet demand for harm reduction kits and condoms for MSM by 2011
  • Providing training courses and reference materials for health care workers to eliminate discrimination of gay men and other MSM

Bangladesh HIV policy and MSM:

The report “HIV and sexual risk behaviour amongst recognised high-risk groups in Bangladesh” studies a number of groups  living in Bangladesh who are vulnerable to HIV. Intravenous drug users; MSM; female, transgender (hijra) and male sex workers; and transitioning populations  were studied for the report. Male to male sex is an offence under section 377 of the Bangladesh penal code. Although  the incidence ofHIV and AIDS is relatively low among the general population, it could potentially become an epidemic especially if high-risk groups are not included in prevention and treatment programmes. Even if HIV prevalence rises to only one per cent of Bangladesh’s population, this would mean that one million people would be affected by HIV, putting a considerable strain on the already stretched health care system.

  • Bangladesh’s Armed Forces have started an HIV and AIDS education and life-skills programme for the troops. As a result, the study reported that only three Bangladeshi peace keepers contracted HIV out of 55,000 deployed to missions in countries with very high HIV prevalence.
  • The Imam (religious leaders) Training Academy introduced HIV and AIDS awareness and prevention, primary healthcare, STIs and reproductive health to its curriculum in 1998. Imams are respected and credible members of their communities and so their role in HIV prevention is crucial. Furthermore, imams address either male-only or female-only congregations. This helps to overcome the social taboo of discussing HIV and AIDS in Bangladesh. However, one imam told the researchers that the issue of using condoms in sexual relations outside marriage is a difficult subject to address. The report calls for religious scholars to discuss these issues to find a potential way forward.
  • There are more than 380 NGOs implementing, on behalf of the government, HIV prevention activities throughout the country. However, the fact that NGOs are dependent on international funding can make programme sustainability uncertain.
  • The report found that some NGOs claimed to reach high numbers of MSM, in  terms of HIV and AIDS education as well as health care support, but as sexual activity between men is illegal and highly taboo in Bangladeshi culture, prevention activities are difficult.
  • The report calls for targeted and cultural behavioural change communication to address the stigma facing MSM, more voluntary HIV counselling and testing centers (VCTs) and supportive care for people with HIV as well as public health-orientated services for sex workers.

Southern Africa (Malawi, Botswana and Namibia)

The report “HIV prevalence, Risks for HIV Infection, and Human Rights among MSM in Malawi, Namibia and Botswana” studies 537 MSM over the three countries to find out more about HIV prevalence and behaviour. The researchers recruited MSM through in-country community-based organisations with experience of working with gay, bisexual and MSM. The qualitative report found that MSM over the three countries were a high-risk group for HIV and human rights abuses. There is little research on MSM in these countries, a fact the report attributed to homophobia and discrimination that prevented men from coming forward. Same-sex acts are illegal in Malawi and Botswana but legal status is ‘unclear’ in Namibia. One of the study’s authors, Professor Beral, estimates that Malawi has a 21.4 per cent HIV prevalence rate among MSM compared to 11 per cent in the general population. Malawi has outlined in its 2003 HIV/AIDS strategy that there should be no discrimination against same-sex couples to access healthcare, but the report shows that this is not the case on the ground.

  • Disclosure of sexual orientation was more common in Botswana and Namibia than in Malawi. Less than 10 per cent of respondents from Malawi disclosed their sexual orientation during any interaction with healthcare workers
  • Almost half of the respondents reported human rights abuses as a result of their sexual orientation. This included blackmail, denial of housing and healthcare. Those exposed to blackmail were less likely to have tested for HIV in the past six months. According to the research, these structural barriers to available healthcare will result in ineffective interventions for HIV transmission among MSM.
  • A quarter of MSM interviewed in Botswana were afraid to seek healthcare because of their sexual orientation. In Malawi this accounted for 17.6 per cent and in Namibia 18.6 per cent.
  • To date there has been no government expenditure to fund evidence-based and targeted HIV prevention programmes for MSM in these countries.
  • The report calls for MSM to be included and targeted by HIV prevention and treatment programmes as it is a vital component for any HIV strategy to be effective:
    1. Prevention programs are needed that are rights-affirming and evidence-based
    2. Structural interventions to decrease stigma and increase access to care such as coordinated media strategies
    3. Decreased enforcement of criminalisation laws

Questions for policy makers:

  1. What is your government doing to include MSM in HIV policies?
  2. Does the government think it is necessary to have explicit policies targeting MSM in your country?
  3. What is the HIV prevalence among MSM in your country?
  4. How much finding is earmarked for HIV prevention programmes targeted for MSM?

Questions for healthcare workers:

  1. Do you feel that you have adequate training to deal with MSM patients in your country?
  2. What training or resources do you need to treat MSM patients?
  3. What are the main problems, if any, have you found when treating MSM patients?

Questions for MSM:

  1. What problems, if any, have you faced in accessing information on HIV and HIV treatment?
  2. What do you want the government to do to tackle HIV prevalence among MSM in your country?
  3. Have you faced discrimination on account of your sexual orientation in your country?
  4. Do you have problems accessing healthcare because of disclosing your sexual orientation in your country?

Questions for civil society and NGOs:

  1. What do you want the government to do to deal with HIV prevalence in the MSM community?
  2. How is your organisation targeting MSM for HIV prevention and treatment programmes?
  3. Why is it necessary for there to be specific HIV policies to target MSM?

Glossary:

Men who have sex with men (MSM) men who engage in sexual activity with members of the same sex, regardless of how they identify themselves; many men choose not to accept social identities of gay or bisexual.

LGBT is an  acronym referring collectively to lesbian, gay, bisexual, and transgender people.

STD/STI is an initialism referring to sexually transmitted diseases/infections,  illnesses that have a significant probability in being transmitted through human intercourse.

Research cited

Baral, S., et al (2009), HIV Prevalence, risks for HIV infection, and human rights among Men who have sex with men (MSM in Malawi, Namibia, and Botswana
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657212/

Islam, M., and Connigrave K., (2008), HIV and sexual risk behaviours among recognised high-risk groups in Bangladesh: need for comprehensive prevention programme
http://www.ijidonline.com/article/S1201-9712(08)00003-9/fulltext

The Global Forum on MSM and HIV (2010), Social discrimination against men who have sex with men (MSM): Implications for HIv policy and programs
http://bit.ly/d91rQR

Ministry of Health, Brazil (2008), National plan to combat the AIDS and STD epidemic among gay men, MSM and transvestites
http://bit.ly/9MizFN

Rispel, L., and Metcalfe, C., (2009), Breaking the silence: South African HIV policies and the needs of men who have sex with men
http://www.ncbi.nlm.nih.gov/pubmed/19523590

Further information

Caceres., C., (2009), Key Challenges in programming priorities for the HIV response concerning sexually diverse populations in Latin America
http://www.bvsde.paho.org/texcom/sct/045632.pdf

Malawi government HIV policy 2003 final draft – http://bit.ly/9YKPgG

Public policy and government programme for young MSM: Case studies from Brazil and Mexico, presentation by Advocates for Youth
http://info.k4health.org/youthwg/iywg/Ackerman_MAR_pres.pdf

UNAIDS (2009), LGBT Communication Manual
http://data.unaids.org/pub/Manual/2010/lgb0_communication_manual_20100301_en.pdf

Sex, drugs and HIV, a talk by Elizabeth Pisani
http://www.ted.com/talks/elizabeth_pisani_sex_drugs_and_hiv_let_s_get_rational_1.html

Useful organisations

AVERT

An international HIV and AIDS charity, based in the UK, working to avert HIV and AIDS worldwide, through education, treatment and care – http://www.avert.org/

Directory of HIV and AIDS charities in the world

http://www.cellscience.com/HIVCharities.html

International HIV/AIDS Alliance

An NGO working to “prevent HIV infection; improve access to HIV treatment, care and support; and lessen the impact of HIV and AIDS worldwide, particularly among the most vulnerable and marginalised”
http://www.aidsalliance.org/homepagedetails.aspx?id=1

National AIDS/STD Programme (NASP), Bangladesh

The Bangladesh government HIV and AIDS wing of the Department of Health that co-ordinates all HIV and AIDS programmes in the country
http://www.bdnasp.net/

UNAIDS

A joint UN programme on HIV/AIDS, “bringing together the efforts and resources of ten UN system organizations in the AIDS response to help the world prevent new HIV infections, care for people living with HIV, and mitigate the impact of the epidemic”
http://www.unaids.org/en/default.asp

UNGASS Declaration of commitment on HIV/AIDS

http://www.ecpp.co.uk/ungass.htm

World Health Organisation

The directing and coordinating authority for health within the United Nations system
http://www.who.int/topics/hiv_aids/en/

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