MSM, HIV, Health and the Social Environment in LAC

1. MSM, HIV, Health and the Social Environment in LAC Carlos F. Cáceres, MD, PhD Professor and Director Institute of Studies in Health, Sexuality and Human Development, Cayetano Heredia University, Lima, Peru

2. Outline • Background • Epidemiological Evidence • Social Drivers • Legal and Human Rights Environments • Access to Prevention and Care • Key Challenges for Programmatic Priorities • Some hope on the horizon

3. Background • Re-emergence of global interest in MSM and HIV • Re-emergent epidemics (High income countries) • New information from other areas(Africa, Asia) • Consciousness about ubiquity and severity of MSM epidemics • Growing consciousness about the role of social exclusion and limited access to prevention and care • New settings for discussion: • New publications • Global and regional forums and networks • Strengthened salience of this topic in the UN System • New initiatives among funders

4. Background • HIV is recognized as being concentrated mostly on gay men, other men who have sex with men and M-F transgenders in LAC • Around 50% of all infections are assumed to result from sex between men • Higher in Mexico, Ecuador, Peru • Lower in Central America (but data problems in some cases?) • High proportion of MSM also have sex w/ women and/or are united to women. • Male:female ratio remains approx. at 2 to 3 male cases per female case.

5. Social organization of same-sex sexuality in LatinAmerica • Four broad contexts • Low-income urban settings: • Gender-based pattern: ‘MSM’ are feminine and/or transgender. Some are sex workers. Anally receptive • Heterosexually-identified bisexual men. Insertive • Middle-class urban settings: • ‘Modern’ gay culture: Role versatility • Closeted bisexual men: Usually insertive/versatile

6. Epidemiological Evidence

7. Methodological and data availability limitations • Still too little information • esp. Africa, Eastern Europe and MENA • Existing information reflects: • Poor understanding of the reality of these populations • Behavioral categories are inadequate • Timeframes are inconsistent • Limitations of the category ‘MSM’ • ‘MSM’: inclusive or exclusive of gay-identified? • Male-female transgenders a different category • Unfavorable legal framework

8. High Prevalence of Sex with Men amongMen in the General Population Source: Cáceres et al, Epidemiology of male same-sex behaviors and associated sexual health indicators in LMIC: 2003-2007 Indicators. Sexually Transmitted Infections 2008.

9. Frequent Heterosexual Behavior among MSM Source: Cáceres et al, Epidemiology of male same-sex behaviors and associated sexual health indicators in LMIC: 2003-2007 Indicators. Sexually Transmitted Infections 2008.

10. Population Characteristics of African MSM Beyrer, Baral, et al. Sexual concurrency and bisexual practices among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. Abstract W-149, CROI 2009 (adapted)

11. Prevalence of HIV among MSM in Low and Middle Income Countries (2007) • MSM are at high risk for being HIV infected across the lower and middle income countries of Latin America, Asia, and Africa • Even in generalized epidemics of Africa, MSM are still at significantly increased risk of HIV infection Baral, S. et al. Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000–2006: A Systematic Review, PLoS Medicine, 2007

12. HIV Prevalence among African MSM Beyrer, Baral, et al. Sexual concurrency and bisexual practices among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. Abstract W-149, CROI 2009

13. HIV Prevalence among MSM in Africa, 2000 - 2008 Egypt, 2006: 1% Egypt, 2008: 6.2% Mauritania, 2007: 19% Sudan, 2005: 9.3% Sudan, 2008: 7.8% Senegal, 2005: 22% Senegal, 2007: 22% Kenya, 2006: 11% Mombasa, 2007: 25% Nairobi, 2008: 37% Zanzibar, 2007: 12.3% Cote d’Ivoire, 2006: 19% Uganda, 2008: ~15% Nigeria, 2006: 13.4% Nigeria, 2007: 13.5% Zambia, 2006: 33% Namibia, 2008: 12% Malawi, 2008: 21% Botswana, 2008: 20% South Africa, 2008: 10% Source: Sanders E. HIV epidemic among MSM in Africa. Technical consultation on MSM, WHO, Geneva, September 15 -17, 2008

14. Ecuador Paraguay Peru Uruguay HIV Prevalence among MSM and female sex workers in selected Latin American countries* Argentina Quito Buenos Aires Provinces (7 cities) Guayaquil Bolivia La Paz Other city ports (4) Asunción + 4 cities Santa Cruz Border cities with Argentina Lima Colombia Bogotá Provinces 0 5 10 15 20 25 30 Montevideo Border cities with Brazil % HIV prevalence 0 5 10 15 20 25 30 % HIV prevalence Female sex workers MSM * Montano et al, 2005 (Source: van Griensven, 2008, adapted from UNAIDS 2008 and Beyrer 2008)

15. HIV prevalence among men who have sex with men, by state—India, 2007 HIV prevalence among MSM was ≥5% in 19 of the 37 valid sentinel sites. Source: WHO

16. HIV Prevalence in MSM and Adults in Selected Asian Countries Prevalence (%) In Asia, the odds of MSM having HIV infection is 18.7 times that of someone in the general population; In China the odds was 45.1 times MSM Adults MSM Adults (Source: van Griensven 2008, adapted from BaralS, Sifakis F, Cleghorn F, Beyrer C. PLOS 2007;4:e339)

17. Cumulative HIV incidence in Thai MSM Cohort Kaplan-Meier method (71 cases, April 2006 – December 2008) Percent survival 87.8% After 960 days of study, cumulative HIV incidence 12.2%;87.8% HIV free Days (4months = 120 days) Source: van Griensven et al – Poster 1037b at CROI 2009.

18. Shifting transmission routes show a dynamic, evolving epidemic—Thailand, 1988–2010

19. Drivers of HIV Vulnerability among MSM

20. HIV Vulnerability • HIV vulnerability depends on 3 groups of related influences: • Membership in groups or subcultures with higher HIV prevalence • Higher-level social/environmental influences which configure a hostile environment • Lower quality and coverage (in total numbers and in terms of population groups covered) of services and programs

21. Enabling Environment? • Legal Frameworks, Human Rights, Stigma and Discrimination • Persistence of unjust and irrational laws • State and private violence resulting in abuses of human rights • Presence of cultural barriers to law enforcement, resulting in discrimination • Low access to prevention and care • Low solving capacity, unfriendliness

22. Legal Frameworks regarding Same-Sex Sexual Practices in LMIC Source: Cáceres C et al. (2008). Legal Frameworks and Human Rights in relation to Sexual Diversity in LMIC. Geneva: UNAIDS.

23. LAC: Legal Status and ProgrammaticEffects • In most countries of Latin America homosexuality is legal, but still a basis for discrimination and abuse of human rights. • In most countries there is a recognition of the need to direct actions to MSM communities, but achievements are uneven • Conversely, in the Caribbean sodomy laws persist in many countries. • Disturbing reports of the impossibility of starting work on HIV prevention among MSM in some countries. • In general, however, resources allocated by countries to prevention among MSM do not match the level of need, particularly as compared to other population groups.

24. The Situation of Human Rights of Sexually Diverse Populations in LMIC • Situation of HR not determined by legal framework • States that are signatories of HR instruments must ‘respect, promote and fulfill the rights of all’. • Respect: Refrain from violating • Promote: Intervene when violations occur • Fulfill: Act in anticipation of violations to reduce their likelihood • Still significant changes must occur • SS Africa, MENA and Caribbean: Still broad violations of HR • South, East and SE Asia: Coexistence of respect and violations • Latin America & Eastern Europe: Increasing respect (w/problems)

25. The Sad Crisis in Senegal… SENEGAL: Jailing of gay activists sets back AIDS fight 19 Jan 2009 15:38:58 GMT Source: IRIN Reuters and AlertNet are not responsible for the content of this article or for any external internet sites. The views expressed are the author's alone. DAKAR, 19 January 2009 (IRIN) - International AIDS organisations have condemned the imprisonment of nine Senegalese AIDS activists for their sexual orientation, saying it threatens to reverse gains made in Senegal's fight against HIV. The men, who were involved in providing HIV prevention, care and treatment services to Senegal's lesbian, gay, bisexual and transgender (LGBT) community, have been sentenced to eight years in prison.

26. Access to Prevention and Care • Limited information on MSM worldwide • UNGASS Report Indicators: 5 out of 25 • % of MARPs who received an HIV test in the last 12 months and who know their results • % of MARPs reached with HIV prevention programmes • % of MARPs who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions • % of men reporting the use of a condom the last time they had anal sex with a male partner • % of MARPs who are HIV infected

27. 2005 2005 2007 2007 (n=31) (n=31) (n=83) (n=83) Countries reporting on MSM Countries reporting on MS But… very limited reporting • Countries reporting are those where there is a response to the MSM epidemic • Low comparability; methodological issues

28. 1 0 0 8 0 6 0 4 0 2 0 0 India China Nepal Bhutan Vietnam Pakistan Thailand Malaysia Myanmar Sri Lanka Indonesia Laos PDR Cambodia Philippines Bangladesh 2 0 0 3 2 0 0 5 Prevention Coverage among MSM in Asia • And coverage must reach 80% to reverse the epidemic in South East Asia! • (source: Report of the Commission on AIDS in Asia, based on UNGASS indicators)

29. Key Challenges to Respond to the HIV Epidemic among MSM

30. 1. Understand and Reach MSM Better • Improve epidemiologic, service access and sociocultural information • Include MSM in regular HIV/AIDS surveillance • Include MSM-related questions in pop-based surveys • Monitor access to prevention and care • Identify new ways of reaching hard-to-reach MSM with adequate programs • Prioritize special vulnerability contexts • Consider potential use of new technologies • Avoid exposing subjects to State violence

31. 2. Repeal Sodomy Laws and protect Human Rights • Eliminate repression and criminalization • Promote protective frameworks and recognition measures • Introduce enforcement of protective laws • Confront the deficiencies of the education system • Promote leadership of key international actors • Work with MSM to develop community and leadership and increase rights consciousness

32. 3. Ensure Effective Prevention • Improve delivery strategies & address special issues • Evaluate effectiveness of ongoing preventive programs. • Evaluate the role of HAART on preventive behavior, and improve prevention. • Incorporate new preventive technologies through coherent and reasonably-sized plans • Study and address the impact of new entertainment cultures an technologies • Study new meanings associated with sexuality and risk.

33. 4. Ensure Treatment and Comprehensive Care • Work closely with communities • Go beyond HIV/AIDS to consider: • Sexual health care • Mental health • Transgender concerns • Monitor programs in the public and private sectors: • Coverage, quality, effectiveness, adequacy, equity • Conduct operations research • Evaluate pilot programs to reduce inequity

34. Some Hope on the Horizon

35. Positive Developments: Asia • Historic elimination of Indian Code 337 (2 July 09)!! • MSM politically recognized and/or included in HIV Plans • Inclusion of MSM in surveillance • MSM friendly clinics for HIV VCT and STI services • Regional network (Purple Sky) for MSM preventive interventions • Peer driven and internet based MSM sexual health interventions

36. Positive Developments: Latin America • Elimination of prohibitive legal frameworks • HTCG assumed an open anti-homophobic stance • Manual against homo/lesbo/trans-phobia • Strategic Plan against homophobia • Guidelines for MSM-oriented services • MSM and TG networks are part of the SC of the HTCG • Anti-homophobic campaigns (4 countries) • Brazil: 1st LGBT Conference (called by State) • XVII IAS Conference: Ministerial Declaration; March

37. Positive Developments: Africa • Significant increase in information • Increasing recognition in many countries of the existence of MSM and the need to offer them care • Even in countries with restrictive legal systems, MSM will work with public health authorities if: • Their confidentiality and privacy are protected • They are treated in a non-judgmental way and w/ respect • Their legal and social situation is addressed simultaneously

38. The International Community takes the Challenge • Increasingly official stands from UN System • Active stand of SG and UN Assembly • UNAIDS & WHO – long term commitment • UNDP will lead interagency work • WHO defining role of health sector • Increasing interest of other funders • New forums: Global and Regional • New research efforts on MSM

39. Conclusion • Global importance of MSM epidemic and its drivers • Often bisexual and married – part of ‘general population’ • Sodomy laws and human rights violations • Low/inadequate access to prevention & care • Need to: • Improve surveillance, M&E, epi/social research • Increase access to adequate prevention • Provide comprehensive care (HIV and beyond) • Repeal sodomy laws and protect human rights • Mobilize key players internationally and in each country • Increase resources… but use them wisely • Develop and strengthen communities

40. Acknowledgements • Paul Jansen and FransMom, HIVOS • Frits van Griensven, US CDC, Thailand • GottfriedHirnschall , Rafael Mazin, PAHO • Ying-Ru Lo, TxemaCalleja, Keith Sabin, WHO • Peter Ghys, Rob Lyerla, Brazey de Zalduondo, Cate Hankins, UNAIDS • StefBaral, Chris Beyrer, JHUSPH • Jeff O’Malley, UNDP • Jan van Wijngarten, RapeepunJommaroeng, UNESCO • Judy Auerbach, SFAF • Fernando Olivos, IESSDEH/UPCH Gracias!