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PEPFAR II promotes HIV prevention for men who have sex with men (MSM) and increased epidemiological research
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The reauthorization the President's Emergency Plan for AIDS Relief (PEPFAR), passed and signed into law in July 2008, calls for HIV prevention designed for men who have sex with men (MSM) as well as research to better understand HIV among MSM in the global epidemic. This is especially important in Africa and the Caribbean, where homosexuality is largely underground and little epidemiological research exists. International and local experts agree: understanding and addressing the needs of men who have sex with men are keys to ending the AIDS crisis. Specifically, PEPFAR II contains the following language:
TITLE III—BILATERAL EFFORTS
Subtitle A—General Assistance and Programs
SEC. 301. Assistance to Combat HIV/AIDS
H.R. 5501 -31
(iv)Assistance for appropriate HIV/AIDS education programs and training targeted to prevent the transmission of HIV among men who have sex with men;
H.R. 5501 - 32
(i) gather epidemiological and social science data on HIV; and
(ii) evaluate the effectiveness of prevention efforts among men who have sex with men, with due consideration to stigma and risks associated with disclosure;
African leaders support more HIV prevention targeted toward MSM and research on the extent of the epidemic among MSM. At the United Nations High-level Meeting on AIDS in June 2008, African political and public health leaders released a report calling for prevention among MSM and "good surveillance data and better monitoring" so that resources are "spent where they will do the most good."1 The report, Securing Our Future: Report of the Commission on HIV/AIDS and Governance in Africa, was co-chaired by Kenneth Kaunda, former President of Zambia and Pascoal Mocumbi, former Prime Minister of Mozambique (both PEPFAR recipient countries). It cites studies indicating that sex between men "could be an important factor in several of the epidemics in this region, despite the widely-held assumption that sex between men is ‘alien' to African societies." 2
The Commission report describes how stigma and discrimination help perpetuate the epidemic, then calls for protecting human rights, "promoting safer sexual behaviour among these groups and their partners," and "implementing policies and legal frameworks that do not criminalize and discriminate against the target groups."3 It concludes:
There is a clear need for further research on this aspect of the HIV epidemics in sub-Saharan Africa, and for prevention efforts that focus on averting HIV transmission among men who have sex with men and their female partners.4
In its 2008 World Disasters Report, the International Federation of Red Cross and Red Crescent Societies reports that HIV/AIDS is a disaster not only for the countries hardest hit but also for men who have sex with men wherever they live. A recent review of evidence from 39 low- and middle-income countries found that, on average, the HIV prevalence rate among MSM is 12.8 times the rate among the whole adult population, and prevention services for MSM currently reach only 9 percent of that group.5 Markku Niskala, Secretary General for the Federation, writes that these men "have the same human rights as everyone else, the same right to healthcare and protection from disease."
Thank you for including language in PEPFAR II calling for prevention programs for MSM and research on HIV among MSM in the epidemic. Now we must move to implement these provisions and channel funding toward groups working to prevent HIV among MSM around the world.
HIV transmission between men who have sex with men (MSM) is cause for concern the world over: According to UNAIDS, 5-10 percent of all HIV infections worldwide are due to sexual transmission between men. Men having sex with other men represent the primary mode of HIV transmission in Latin America and account for approximately one third of HIV transmission in Asia. In countries with relatively low prevalence, the difference in rates between MSM and the general population is often extreme. For example, in Mexico, the HIV/AIDS rate among MSM is 109 times that among all adults.6 In Africa, HIV transmission occurs overwhelmingly through heterosexual contact, though a recent study of MSM in low- and middle-income countries found that African men who have sex with men are 3.8 times more likely to be HIV-positive than the general population, suggesting a concentrated epidemic among MSM. However, relatively little data exists to substantiate the role of male-to-male sex in the epidemic in Africa, in part because only two of the 15 PEPFAR countries track this behavior as a mode of infection.
Dual discrimination against MSM and HIV exacerbates transmission: Anti-gay bias is widespread in the former Soviet Union, Asia, and Latin America, and homosexuality remains stigmatized and often criminalized in Africa. Two thirds of African countries ban homosexual sex or, at least, male-to-male sex. Punishments range from imprisonment (five years in Cameroon, Senegal, and Ghana; life in Uganda) to death (in Mauritania, Sudan, and parts of Nigeria). Such state oppression not only violates basic human rights but also drives behaviors which are already stigmatized and may transmit disease further underground, fueling the HIV epidemic. Stigma and discrimination generate economic, political, legal, and social factors that increase both risk and barriers to access prevention, treatment, care, and support for MSM.9 UNAIDS estimates that only one in 20 MSM have access to HIV prevention and treatment services they need.
Current HIV prevention efforts are not effective in reaching MSM, to the detriment of both men and women: Limited research efforts in Kenya and Ghana have shown that men who have sex with men do not consider themselves at risk of contracting HIV, because all of the prevention messages thus far have focused on heterosexual couples. 10,11 Many MSM also have sex with women, thus contributing to the risk women face. 12,13
Social and epidemiological research on MSM infected and affected by HIV in Africa is necessary to move forward in combating the epidemic: There is a dearth of research on HIV and same-sex behavior in African nations. Many researchers, whether publicly or privately funded, do not inquire about same-sex practices for many reasons ranging from personal bias to fear about safety where persecution of perceived homosexuals is state-sanctioned.14 U.S. support via PEPFAR for research on this issue will not only delineate the needs and health concerns of this vulnerable segment of the population, but also encourage African governments to confront the HIV challenge from all fronts. 15,16
For more information please contact:
Sean Cahill, Ph.D.
Managing Director, Public Policy, Research and Community Health
Gay Men's Health Crisis
212.367.1275
seanc@gmhc.org
www.gmhc.org |
Krista Lauer, Manager,
International Policy Government Affairs
AIDS Project Los Angeles
The David Geffen Center
213.201.1317
klauer@apla.org
www.apla.org
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1Securing Our Future: Report of the Commission on HIV/AIDS and Governance in Africa (Addis Ababa, Ethiopia: United Nations Economic Commission for Africa, 2008)., p. 86.
2Ibid, p. 192.
3Ibid, p. 87.
4Ibid, p. 192.
5World Disasters Report: Focus on HIV and AIDS 2008, (Geneva, Switzerland: International Federation of Red Cross and Red Crescent Societies, 2008), available online at http://www.ifrc.org/publicat/wdr2008/index.asp, p. 31.
6World Disasters Report, 2008, p. 56.
7Baral S, S. F. (2007). Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000-2006: A Systematic Review. Public Library of Science (PLoS) Medicine, 4(12): e339. doi:10.1371/journal.pmed.0040339.
8Johnson, C. A., Off The Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa. (New York: International Gay and Lesbian Human Rights Commission (IGLHRC), 2007).
9World Disasters Report, 2008, p. 51.
10Focused discussion groups conducted by the International Gay and Lesbian Human Rights Commission (IGLHRC), Accra, Ghana, September 20, 2006 and Mombasa, Kenya, June 9, 2006; as cited in Johnson, C. A., "Off The Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa" (IGLHRC, 2007).
11International HIV/AIDS Alliance (United Kingdom), "Meeting the Sexual Health Needs of Men Who Have Sex with Men in North Africa and Lebanon (MSM/MALE Project)":1; 2006; as cited in Off The Map (IGLHRC, 2007).
12UN Human Rights Committee, Communication No. 488/1992: Australia. 04/04/94. CCPR/C/50/D/488/1992. (Toonen v. Australia, date of communication: Dec. 25 1991); as cited in Off The Map (IGLHRC, 2007).
13Horizons Program, Kenya, 18; Horizon Program, Senegal, 11; as cited in Off The Map (IGLHRC, 2007).
14Johnson, Off The Map (IGLHRC 2007), p. 32-33.
15Carlos F Caceres, Kelika Konda, and Mario Pecheny, "Review of the Epidemiology of Male Same-Sex Behavior in Low- and Middle-Income Countries: Review of HIV Prevalence and the Epidemiology of Preventive and Bridging Behavior among MSM in Low- and Middle-Income Countries" (Geneva: UNAIDS, March 2005): 6.
16Johnson, Off The Map (IGLHRC 2007), p. 81.
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