Don’t Forget MSM

Few populations are more threatened by the global HIV epidemic than men who have sex with men (MSM). In many regions, they are up to nine times more vulnerable to HIV than the general population. This vulnerability is due, in part, to unsafe sexual behaviors, but also to the social stigmatization, marginalization, and violence that drive MSM underground.

Homophobia is too often embedded in a country’s laws as well as its culture. In some 80 countries around the world, consensual homosexual sex is a crime that carries the penalty of imprisonment – and worse. Just last year, legislation was introduced to the Ugandan Parliament that would increase punishment for same-sex acts to life in prison and even the death penalty. Unfortunately, Uganda is not alone among African nations in considering such regressive legal persecution of sexual minorities.

On the streets, other trends are equally troubling. This month, the Asia Pacific Coalition on Male Health (APCOM) released its documentation of evidence that violence by police and other authorities against MSM and transgender people is on the rise throughout the region, a “campaign of hate and discrimination directed at the most vulnerable of citizens,” according to APCOM Chairperson Sivananda Khan.

Both discriminatory cultural norms and punitive laws prevent MSM from accessing HIV and other health services because they fear exposure of their sexuality could lead to mistreatment, incarceration, and violence. This creates a vicious cycle: Where the demand for the few existing services for MSM is stifled, even fewer MSM-targeted services are created. This is confirmed by data showing that only one in 10 MSM around the world has access to HIV prevention services.

Where human rights suffer, so does public health. In 2008, a UNAIDS report found higher levels of HIV prevalence among MSM in countries that criminalize homosexuality. For example, Guyana, where homosexuality is illegal, has HIV prevalence of more than 20 percent among MSM. In neighboring Suriname, where homosexual sex is not a crime, HIV prevalence among MSM is below 8 percent. Similar patterns are found worldwide.

But even in very difficult settings, prevention, testing and counseling, and care services are helping MSM deal with HIV. In Ghana, as in most of Africa, homosexuality is illegal and highly stigmatized. Yet a handful of small programs quietly and courageously provide hidden MSM populations with critical HIV services. The Center for Popular Education and Human Rights (CEPEHRG) in Accra and the Maritime Life Precious Foundation in Takoradi, both supported by PEPFAR, offer peer education, drop-in clinics, and an innovative, cell phone-based information, referral and counseling service. While both programs must operate with great sensitivity to prevailing public attitudes, their successes are noticed by Ghanaian officials, and collaborative efforts – such as MSM-friendly training for nurses and counselors in the public health sector – are increasing. Over time, Ghana may develop into a regional pioneer in programming for MSM and a model to other African nations.

In India, which repealed its legal ban on homosexual sex in India in 2009, the Humsafar Trust of Mumbai has spent years advocating for the rights of MSM and for an end to stigma and discrimination against sexual minorities. As the threat of HIV grew, Humsafar’s leaders realized they needed to create the kind of HIV programs for MSM that government health agencies were simply not providing. Humsafar has since built a wide array of prevention, treatment, care and support services, a true continuum of care for Mumbai’s complex and diverse MSM populations, despite discrimination against MSM in the larger society. Now, Humsafar and similar MSM organizations advise the Indian government on policy matters and help the Ministry of Health design national HIV programs that respond to the needs of MSM.

These pioneering programs represent promising approaches that address the needs of MSM in challenging settings. With increased emphasis on reducing overall HIV prevalence by focusing on this most-at-risk population, program planners and implementers on the ground need ready access to research, tools and successful interventions targeting MSM. The AIDSTAR-One Knowledge Base topic on hard-to-reach MSM gathers and synthesizes these resources to help support the design and implementation of evidence-informed programs.

As the evidence increasingly confirms that HIV prevention programming targeting MSM is effective at slowing HIV transmission, governments, public health practitioners, and the general population must engage in honest dialogue about how best to meet the needs of this vulnerable population.


This post was originally published by The Global Health Magazine Blog on December 14, 2010

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