“In countries without laws to protect sex workers, drug users and men who have sex with men, only a fraction of the population has access to prevention. Conversely, in countries with legal protection and the protection of human rights for these people, many more have access to services. As a result, there are fewer infections, less demand for antiretroviral treatment and fewer deaths. Not only is it unethical not to protect these groups; it makes no sense from a health perspective. It hurts all of us.”
Ban Ki-moon, Secretary-General of the United Nations, World AIDS Conference, Mexico City, 2008
Hidden or ignored HIV epidemics among men who have sex with men (MSM) and transgender people are spreading rapidly in many low and middle income countries, according to a growing number of studies (detailed below) including some conducted in parts of the world where such data previously did not exist, including sub-Saharan Africa, Asia, and the Middle East and North Africa (MENA) region.
“These epidemics are ubiquitous and severe,” said Dr Carlos Fernandez Cáceres, Director of Research at the Peruvian Network for Education, Sexual Health and Development of Young People at the opening plenary at this year’s Conference on Retroviruses and Opportunistic Infections (CROI). Dr Cáceres has authored several studies on calculating the number of men who have sex with men in low and middle-income countries — and his talk at CROI provides much of the material for this article. “Furthermore, there is a growing consciousness that social exclusion of MSM limits access to prevention and care… At present UNAIDS and the WHO estimate that less than 10% of MSM in low and middle income countries have access to HIV prevention and care,” he said.
Sex between men has been an important mode of HIV transmission since the infection was first observed over 25 years ago, and the HIV epidemics in many industrialised countries are predominately or significantly located in men who have sex with men.
But many countries, where sexual activity between men or with a transgender person remains illegal or taboo, have long denied the existence of MSM among their populations or describe same-sexual activity as an imported ‘Western vice’. MSM and transgender people are so reviled in some cultures and their environment so oppressive, that many prefer to remain hidden even when gravely ill, given the risks of rejection, violence or blackmail by healthcare workers, friends, neighbours and family, and, in some settings, the fear of being incarcerated or even put to death. This makes it much more difficult to come by reliable data on the size of this marginalised population and their burden of HIV.
Consequently —and also because of wilful neglect— “the commitment and resources allocated to HIV services for men who have sex with men (MSM) and transgender people fall far short of what is required to achieve universal access to appropriate HIV prevention, treatment, care and support services across the world,” according to the recently published UNAIDS Action Framework: Universal Access for Men who have Sex with Men and Transgender People.1
Failure to acknowledge the epidemic of MSM and transgender people has allowed the disease to spread among this population and is beginning to increase the pressure on health services for treatment.
“We have failed to bring down the incidence among MSM because, with some exceptions, we have not tried” said Jorge Saavedra, from Mexico’s Centro Nacional para la Prevencion y Control del VIH/SIDA (CENSIDA said at the World AIDS Conference.
The UNAIDS Framework (which will help direct UN agency action on this issue) states that “addressing the HIV epidemic among marginalized groups is not just important in and of itself; it is often one of the most effective strategies to reduce heterosexual spousal transmission and avert larger heterosexual epidemics.” In other words, many MSM are in bisexual relationships — and without effective prevention services, there is the potential for an unmanaged epidemic among MSM that could lead to more transmission to the general population. Likewise, where MSM and injection drug-using overlap, failure to address HIV in one concentrated epidemic affects the other.
Importantly, however, the UNAID document stresses that regardless of one’s personal belief or bias, everyone “including men who have sex with men and transgender people, have the right to the highest attainable standard of health, non-discrimination and equality before the law, and freedom of expression and association, among others.”
As the UNAIDS Framework demonstrates, there is a growing emphasis on addressing the HIV-related needs of MSM and transgender people among international technical agencies, and multilateral, bilateral and private donors (including notably the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). International and local advocacy is also increasingly challenging laws, attitudes and behaviour that limit access of MSM and transgender people to essential health services. And potentially, in a climate where donor funding for HIV services is not guaranteed, it may be harder to justify supporting national programmes that do not to provide equitable access to health services to all its citizens.
But programmes and healthcare providers that want to provide non-judgmental access to care and services may still face a number of challenges, including identifying of the local MSM and transgender population, assessing its healthcare needs, earning its trust, and designing and delivering appropriate services and interventions. However, a growing number of implementers and organisations are beginning to share experiences on this front.