Appropriate prevention and care services for men who have sex with men and transgender people in resource-limited settings

“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.

Difficulties studying HIV in MSM and transgender people

“We have more information [about MSM and HIV] but remain far from knowing what we need to know especially in Africa, Eastern Europe and the MENA region,” said Dr Caceres. “And the existing information is far from being of ideal quality.”

As already noted, criminalisation and prejudice make it difficult to study this population. Not only are MSM not included in the routine national HIV surveillance, governments often try to discourage independent research. For instance, government officials in Togo told a research team in Togo not to bother with looking for MSM in that country because they did not exist.² However, a small study went on to identify at least 122 MSM in one locality, about 47% of whom are married and also have sex with women or girls — so clearly there is a need for appropriate prevention services.

Dr Cáceres also noted that research is often limited because culture and behavioural categories of MSM and transgenders are often poorly understood when a study begins. “Survey research has to be direct, and hence, fails to be nuanced enough. For example, something as simple as asking about sex between men, fails to recognize that [in many cultures], having sex is something that men can only do with women. Sexual activity with other men is called something different.”

For instance, a 2005 study in AIDS in described how traditional Western ideas of what constitutes sex between men do not often correlate with the Asian experience.³ The study reported that in Thai culture there are three genders: male, female and Katoey: the latter are males who adopt female names, roles, and identities, and are perceived as a second category of women. Men who have sex with transgender persons known as Katoey, do not perceive themselves —and are not perceived by others in Thailand — to be engaging in sex between men, and consequently require culturally appropriate targeted prevention.

This raises another issue — that the term MSM itself is somewhat problematic. It was coined in an attempt to encompass non-gay-identified men who have sex with men and to describe their HIV risk — although increasingly, studies show that the risks of HIV infection vary with sexual role (receptive or insertive) and whether the man identifies himself as gay or homosexual.  Some surveys categorise transgender people (who were assigned a male identity at birth, but who now identify as female or exhibit predominantly female characteristics) as MSM. But according to Dr Caceres, “it is increasingly inappropriate to include male-to-female transgenders in the MSM category since they are evolving as a separate group identity and do not accept to be conflated with MSM.”

Notably, studies suggest that transgender people are even more vulnerable to HIV than gay-identified men. (Chris Green, a treatment advocate working with the Spiritia Foundation in Jakarta describes some of the challenges — as well as some progress — providing HIV services to the transgender population in Indonesia in a case study later in this article).

In addition, surveys use different methodologies to recruit participants — some of which gather more representative samples than others. Some studies send workers out in the community to places or venues known to be frequented by MSM — but this may only capture the most visible members of MSM. Another method to reach invisible and stigmatised population is ‘snowball sampling’ in which individual members of the NGOs or men known to them invite friends to answer the research questionnaire, who then invited other friends until they reached a desired sample-size. But this sampling method does not usually produce a representative sample of the entire population as it is essentially reliant on networks of friends and therefore all residents may come from a particular stratum of society. A variation of snowball sampling called respondent-driven sampling (RDS), uses a more structured approach that can be corrected for bias and is increasingly being used by studies.

Finally, Dr Cáceres noted there has been a lot of variation in behavioural questions, timeframes evaluated, etc, that makes it difficult to compare results from one survey to another directly.

Men have sex with men in every country and culture – though the extent and public acknowledgement of it vary

Nevertheless, according to a global review Dr Cáceres conducted with UNAIDS published last year, the limited available data show that between 3% of men in Africa and almost 20% of men in Asia report having sex with other men.⁴ The review included 14 studies from Africa, 62 from Asia, one from the Caribbean, five from Eastern Europe/Central Asia, 24 from Latin America and one from the MENA region. Whether the differences in reported same-sex activity reflects actual differences in behaviour or is due to a greater reluctance on the part of African men to be identified as an MSM is difficult to say.

MSM and transgender people often have multiple risk factors for HIV — such as injecting drug use, or sex work, which is especially common in contexts where they are rejected by the families and living on the streets. A study in Mombasa, Kenya, estimated that at least 700 MSM were selling sex to men in and around the city.⁵ Notably the sex was being sold to other Kenyans — not foreigners. This points to a much larger MSM population of MSM in Kenya overall, according to an accompanying editorial, as “most MSM do not sell sex.” ⁶

Similarly, there may be around 40,000-50,000 male sex workers (malishias) and transgender sex workers (hijra) having sex with men in Pakistan, according to a recent report on IRIN PlusNews. The article states that “although many MSWs are gay, poverty, lack of job opportunities and broken homes appear to be the driving force behind this activity.” As Pakistan is a conservative Islamic country, this population is ignored if not denied — but failing to address its needs risks putting Pakistan at risk of a larger HIV epidemic.

Shivananda Khan, founder of Naz Foundation International told HATIP “one issue that constantly crops up in South Asia is class and economic status, along with religious affiliation, particularly Islam, which has an enormous impact on risks and vulnerabilities.”

The majority of clients of male sex workers are often married men. Dr Cáceres review found that a substantial proportion of MSM are likely also report being married or having heterosexual sex.

Frequent Heterosexual Behavior among MSM ⁷

A couple of other studies presented at CROI also reported significant proportions of men who have sex with men have concurrent partnerships with both males and females. One, presented by Dr Chris Beyrer of the Center for Public Health and Human Rights at the Johns Hopkins School of Medicine in Baltimore, described findings from Malawi, Namibia and Botswana.⁸ In terms of self-identity, two-thirds of men in Botswana identified as ‘gay’, 48% in Namibia and 40% in Malawi. In Malawi, 53% identified as ‘bisexual’ and 29% in the other two countries. Meanwhile, one in six (one in four in Malawi) was ‘bisexually concurrent’ with ongoing relationships with at least one partner of either sex.

Beyrer stressed that these men reported a high rate of condom use with their female partners and that he was encouraged by the high knowledge of HIV infection and prevention.  But the sample may not really be representative of all MSM in those settings because the snowball sampling used in these particular surveys may have oversampled urban well-educated professionals who were unusually well-informed about HIV.

In contrast, in a study of largely rural or semi-urban and poor MSM in Tamil Nadu, India, 85% of MSM reported having also had sex with a woman, 60% defined themselves as bisexual and a third (34%) were married — but notably the married men were the most likely to be HIV infected and to have other sexually transmitted infections.⁹ This group, according to the presenter Sunil Suhas Solomon, also of Johns Hopkins, could potentially spread HIV to their wives and needed further study in order to design appropriate prevention services.

Evidence suggests there are MSM and transgender HIV epidemics virtually everywhere

 In 2007, a meta-analysis by Stefan Baral also of Johns Hopkins pulled data from existing studies in countries in Latin America, Asia and in Africa on the risk of being HIV-positive as compared to men from the general population, in all of those regions.¹⁰

“Overall, the odds of having HIV infection are markedly higher among men who have sex with men than among the general population of adults of reproductive age across Asia, Africa, the Americas and the countries of the former Soviet Union,” the investigators commented.

How much of an increased risk depended upon the setting and background prevalence of HIV. For instance, in Latin America, MSM had an odds ratio (OR) for HIV infection of 33.3 (95% CI 32.3–34.2), in Asia the OR was 18.7 (95% CI 17.7–19.7), while it was 3.8 (95% CI 3.3–4.3) for Africa. But in some individual countries, including Bolivia, Mexico and Egypt, MSM were more than 100 times more likely to be HIV-infected than the men in the general population. The overall HIV prevalence in MSM was around 16.1% in Latin America, 11.4% in Asia and 13.0% in Africa.

At a WHO technical consultation last September, Ed Saunders reviewed data from 2000 to 2008 on the HIV prevalence among MSM from Africa.¹¹ 

HIV prevalence among MSM cohorts in Africa

Subsequent aggressive studies have documented a much higher rate of HIV among MSM in South Africa.

The data from one of the studies listed above comes from a vaccine preparedness study in Mombasa, Kenya.¹² Although the overall HIV prevalence for MSM at enrolment was 24.5% (95% CI, 19.7–30.7%), the HIV prevalence was 43.0% (95% confidence interval (CI), 34–52%) among men who had sex exclusively with other men and 12.3% (95% CI, 7–17%) for MSM who also had sex with women. Of MSM who reported anal intercourse in the last three months, 37% reported that all episodes had been without condoms. Over three-quarters of MSM (82%), reported at least one episode of unprotected anal intercourse with any partner in the last thee months.

In Latin America, Dr Cáceres presented an analysis of data from the UNAIDS Global Report 2008 showing that the relative burden of HIV is 10 to 15 times higher in MSM than in female sex workers. “However this pattern, according to UNAIDS, is not reflected in the prevention strategies,” said Dr Cáceres.

In India, surveillance data suggest that the HIV prevalence among sex workers and the general population is going down. But Dr Cáceres cited WHO data from 2007 from 17 Indian states that paint a different picture among MSM. In only six states is the prevalence below 5%, while in four states, the prevalence is above 10%.

HIV prevalence among MSM in the capital cities of Thailand, Cambodia, Vietnam and China ¹³

Recently, there has been clear evidence showing that the risk of HIV infection is increasing in some countries.

For instance, annual surveys carried out in China show an increase in sexual risk taking and HIV transmission rates among MSM between 2004 and 2006.¹⁴ In 2004 just 0.4% of the men were HIV-positive in 2004 but this shot up to 4.6% in 2005 and 5.8% in 2006. Hepatitis C infection rates also rose sharply from 0.4% in 2004 to 5.2% in 2006. These rises are being fuelled by a low rate of condom use and an increasingly number of sexual partners, according to the researchers.

Likewise, Thailand, which has been praised for its response to HIV among other populations, only recently began to gather sentinel data on HIV prevalence amongst men who have sex with men due to stigma and discrimination.¹⁵  When they did finally look, they found a 17% prevalence. However, subsequently, it has increased to 31%, and a study presented at the World AIDS Conference last year reported that 5% of men who have sex with men in Thailand acquire HIV each year.¹⁶ Prevalence of STIs was also high: 44% of men had hepatitis B, 20% had genital herpes (HSV-2), 4% had syphilis, 9% had chlamydia, and 6% had gonorrhoea.

In all of these studies, the methods used to identify MSM were not perfect, and the cohorts sampled may not have been completely representative of the overall MSM and transgender populations in each country, and the reported prevalence cannot be considered to be exact. Nevertheless, these studies provide ample evidence of previously invisible subcultures in many settings where the legal framework and social prejudice have prevented the development of an open gay community — and made these individuals more vulnerable to HIV. And where epidemiological data are poor, data on access to prevention and care services is even worse.

How to respond to the HIV epidemics among MSM in lower and middle-income countries

Strengthen the evidence base

One of the first steps required to respond to the epidemic in MSM and transgender persons is to improve the quality of the data used to inform and develop policy.

“First we need to understand and reach MSM better,” said Dr Cáceres, “by improving epidemiological, service access and sociocultural information.”

For instance, MSM need to be included in regular HIV/AIDS surveillance; MSM-related questions should be included in population-based surveys, and the access of MSM and transgenders to prevention and care should be monitored.

“We should identify new ways of reaching hard-to-reach MSM — for instance isolated, not just gay identified, married men — with tailored/adequate programmes and prioritize special vulnerability contexts such as prisons, clients and sexual partners of male and transgender sex workers — and here new information technologies are becoming an excellent option [such as mobile phones and the internet]. But as this must be done, we have to remember that we should avoid exposing subjects to State violence. And we should remember that very clearly.”

Prioritise human rights environment

The UNAIDS action framework emphasises that improving “the human rights situation for men who have sex with men and transgender people [is] the cornerstone to an effective response to HIV.”

Dr Cáceres concurred, saying that repression and criminalisation were absurd from a public health point of view, and should be eliminated and replaced by measures that protect human rights.

The UNAIDS framework goes into much more detail and lists a series of actions needed for a conducive legal, policy and social environment — including that “men who have sex with men and transgender people are appropriately addressed in national and local AIDS plans, that sufficient funding is budgeted for work, and that this work is planned and undertaken by suitably qualified and appropriate staff…” that these populations are empowered and engaged “in the planning, implementation and review of HIV-related responses, including the support of nongovernmental and community-based organizations, including organizations of people living with HIV” as well as training and sensitizing health-care providers to avoid discriminating against, and ensure the provision of appropriate HIV-related services for, men who have sex with men and transgender people,” and so on.

An example of the training/sensitization is provided by the Get Hip initiative in Ghana, funded by USAID, described at the HIV Implementer’s Meeting in Kigali by Dr Lydia Clemmons. HIP is the High Impact Package of tools and interventions specifically targeting most at risk populations (MARPs) including female sex workers and MSM.

“We developed special tools and interventions specifically for MARPs. An example is a health worker who has never done a case history of MSM, needs some tools and some guidance. They need training, they need stigma reduction and they also need just a simple list of questions i.e. What do you even ask someone who’s actually MSM when you’ve never even encountered that population before?” said Dr Clemmons.

The programme was developed after considerable dialogue with the target communities (with over 2 220 MARPs). She noted that the health services were the last place that MARPs in Ghana wanted to go to, because of the fear of stigma. But they hired peer educators, and also had MSM and other MARPs work with the health facility staff as trainers. Dialogue was ongoing, and the community provided feedback on the quality of services delivered.

“We did identify a number of ‘trouble-makers’ at the facility level. These were nurses, especially who had extremely negative attitudes towards people who were HIV-positive or towards MSM or sex workers. Names were named. Like this person, this is what she does to us. So those people who were identified were either re-trained or they were transferred out. Again, this type of action was immediate and it bought feedback to the communities,” she said

Ensure access to effective prevention, treatment and comprehensive care 

The UNAIDS framework recommends that “All interventions should be evidence-informed, developed with, and protect, the rights of, men who have sex with men and transgender people and should include safe access to:

• Information and education about HIV and other sexually transmitted infections, and support for safer sex and safer drug use, through appropriate services (including peer-led, managed and provided services);
• Condoms and water-based lubricants (repeatedly in study after study in Africa, MSM complain of having little access to appropriate lubricants which don’t break condoms);
• Confidential, voluntary HIV counselling and testing;
• Detection and management of sexually transmitted infections through the provision of clinical services (by staff members trained to deal with sexually transmitted infections as they affect men who have sex with men and transgender people);
• Referral systems for legal, welfare and health services, and access to appropriate services;
• Safer drug-use commodities and services;
• Appropriate antiretroviral and related treatments, where necessary, together with HIV care and support;
• Prevention and treatment of viral hepatitis;
• Referrals between prevention, care and treatment services; and
• Services that address the HIV-related risks and needs of the female sexual partners of men who have sex with men and transgender people.

Dr Cáceres suggested that novel prevention technologies must be explored in MSM through coherent and reasonably-sized studies. He also stressed the need to provide comprehensive care that goes beyond directly treating HIV/AIDS to address issues such as sexual health care including sexual dysfunction, mental health including violence, substance abuse, and so-called sex addiction. More progressive and better-resourced countries such as Brazil are even assisting transgenders seeking gender reassignment.

It is extremely difficult to imagine low-income countries in Africa or MENA going for something like that. It would seem sensible to set the sights a bit lower and start out by trying to change hearts and minds for a modicum of tolerance in these countries. As the authors of the World AIDS Conference 2008 Impact Report wrote “Perhaps additional advocacy efforts targeting political leaders and government officials are required to turn the language former Botswana President Festus Mogae used in his Opening Session speech regarding “people who engage in unusual sexual practices” into an explicit acknowledgment of MSM in Africa – and other regions – and their importance in the HIV surveillance systems that have not served them well to date.”

Indeed, the fact that former President Mogae is one of the most forward-thinking leaders in Africa (but from a country where homosexuality is criminalised), illustrates what an uphill battle it will be to get those who know less about HIV/AIDS to acknowledge the need to respond to this stigmatised segment of society.

Developments in advocacy

Dr Cáceres believes, however, that “criminalization is becoming politically unsustainable in Africa. But even in countries with restrictive legal systems, MSM will work with public health authorities to improve their situation and society at large, if their confidentiality and privacy are protected, they are treated in a non-judgmental way and with respect and their legal and social situation is addressed simultaneously.”

The last few years have seen numerous developments in advocacy to address this issue. As this article has demonstrated, there has been a dramatic increase in information describing these previously invisible populations. The issue was highlighted at the World AIDS Conference, where there was the first-ever March against Homophobia at a World AIDS Conference, and subsequently at ICASA. A forum devoted to the issue was held before the South African AIDS Conference (an executive summary and the pdfs from the meeting can be found here.)

Increasingly, countries are beginning to politically recognise and include MSM in national HIV surveillance and national plans for HIV.  MSM friendly clinics for HIV VCT and STI services are being initiated in several countries.

Communities of MSM in a few countries of Africa are now more actively demanding that their health care and HIV prevention needs be addressed. There is a growing chorus of gay bloggers in Africa (for links to some of the blogs see a useful overview here).

The legal framework has changed in several countries, including thoughout the Latin American region (though not the Caribbean). And on 18 December 2008, a joint statement was read in the UN General Assembly urging all nations to “promote and protect human rights of all persons, regardless of sexual orientation and gender identity,” with 66 signatory nations. Of course, that means that over 120 countries did not support the statement— including the United States.

The United States has been more than somewhat schizophrenic on the issue. On the one hand, USAID/PEPFAR has supported some very progressive and inclusive programmes such as Get HIP in Ghana and the Health4Men services in Cape Town (see accompanying article). But at the same time, PEPFAR-funding has strengthened the hand of some most intolerant faith-based organisations in sub-Saharan Africa. It is unclear where President Barack Obama really stands on the issue, despite paying lip service to equality on the campaign trail.

Nevertheless, we would hope that the US government sends a very clear signal, at the upcoming HIV Implementer’s Meeting in Windhoek, that there should be no events like those at last year’s Implementers’ Meeting in Kampala, Uganda, when three gay and lesbian rights activists were arrested, or what happened later in the year in Senegal, where several peer educators working with MSM were arrested and imprisoned after participating in the ICASA meeting.

Negative press and political pressure ultimately resulted in charges being dropped in both of these cases — but it should never have happened in the first place, and these cases illustrate the very real risks that gay activists take to organise any sort of community response to HIV in countries where homosexuality is still criminalised.

The United Nations Development Programme (UNDP) will lead the interagency work on MSM for the UN, with the founding Executive Director of the International HIV/AIDS Alliance, Jeff O’Malley, chosen to direct the effort.

A growing number of funders, including the Elton John AIDS Foundation, the Bill and Melinda Gates Foundation and the Foundation for AIDS Research (AmFAR) have been supporting a variety of projects working with MSM and transgender communities. In particular the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) has announced a new emphasis on gender, including attention to sexual minorities, in its funding guidelines for Round 8 onwards, and is taking steps to make certain that its country-led priority setting process better addresses the needs of sexual minorities.

Resources

The Global Forum on MSM & HIV

http://www.msmandhiv.org

Amfar’s MSM Initiative

http://www.amfar.org/msm/

Men who have sex with men: Key operational guidelines of the UNAIDS Programme

UNAIDS article describing HIV epidemic in countries of the former Soviet Union

WHO Rapid Assessment and Response Guide: adaptation guide on HIV and men who have sex with men

The International HIV/AIDS Alliance’s Frontiers Prevention Project

At AIDS 2008, the Frontiers Prevention Project reported on a model programme and successful HIV prevention campaign for sex workers and men who have sex with men in Andhra Pradesh, India.

Naz Foundation International

Provides technical assistance and support to MSM groups and organisations in Asia

http://www.nfi.net/index.asp

Africagay

A coalition of 18 organisations in 10 countries of Francophone Africa: du Burkina-Faso, du Burundi, du Cameroun, du Mali, du Maroc, du Niger, de la Cote d´Ivoire, de la République Démocratique du Congo, du Sénégal, de la Tunisie et de la France.

http://www.africagay.org