AIDS Alert International
International HIV/AIDS groups need to focus more on MSM, amFAR says
Prevention focus often overlooks group
HIV-infected men who have sex with men (MSM) in resource-limited countries, often are overlooked, underserved, and discriminated against, international HIV/AIDS advocates say.
"It's fair to say that for too long the important institutions that were mobilizing to fight AIDS overlooked the epidemic among men who have sex with men," says Kevin Frost, chief executive officer, amFAR of New York, NY.
"When people talk about HIV/AIDS in Africa, they are talking about a generalized epidemic," Frost says. "That generalized epidemic masked these concentrated parts of the epidemic, particularly among MSM in this case."
Without attention and support from the international world, HIV-infected MSM in resource-limited countries are subjected to local homophobia and stigma, Frost says.
"It's impossible to get around the fact that there's an extraordinary amount of institutionalized homophobia in African countries," Frost says. "Even countries with success stories like Uganda have the most institutionalized homophobia with the government."
As a result, MSM may avoid being tested, or band together as HIV/AIDS advocates, which further marginalizes their status and places them at risk.
This is why amFAR has begun to provide grants to community organizations that address the HIV prevention and services needs of MSM.
"Male-to-male sexual behavior exists in every culture and society around the world, and we know it puts men at risk for HIV," says Sam Avrett, MPH, consultant with the MSM Initiative of amFAR.
"Here we are 25 years into the epidemic and not enough is being done to address HIV among MSM," Avrett says. "HIV-positive MSM are not getting access to treatment and care."
While this is especially true in resource-limited countries, it's also true in affluent nations, Avrett says.
"Look at the infection rates among black gay men in the United States," he says. "It's a major problem, and certainly the HIV epidemics among black gay men in the United States are not new — they're a product of more than 20 years of neglect, and they need to be addressed."
Recent studies now suggest that HIV infection among MSM in the 33 states that have named-based HIV reporting increased by 13 percent from 2001 to 2005.1
"On a personal note, I came into the fight against AIDS, in New York City, as a gay man in the early years of epidemic," Frost says. "And my perception of the epidemic was shaped by that perspective."
Many of Frost's friends were infected with HIV, and all of them were affected by the epidemic, he says.
"You couldn't live in New York and be an innocent bystander," Frost adds.
"Interestingly though, as the disease and our work in the epidemic became more international and our perspective on the disease became more international, it became less about being gay," Frost explains. "I think that is because the size and the scope of the international epidemic in the developing world looks so heterosexual that whatever issues there are about men who have sex with men becomes lost in that."
Internationally, the little amount of information that is available about MSM and HIV paints a stark picture.
"In the places where we do have data on levels of HIV infection among MSM, the numbers are staggering," Frost says.
"In Bangkok, for instance, the sero-prevalence is 32 percent among MSM," he says. "So how in the world are these populations overlooked by [international] institutions? It's an enormous failure on part of our global response to the epidemic."
According to data collected by amFAR, fewer than 5 percent of men who have sex with men have access to HIV prevention, treatment, and care. In some places, such as the Asia-Pacific region, only 2 percent of MSM receive HIV prevention services.
"Male-to-male sexual activity is illegal in 85 countries around the world," Frost says. "The same stigma that allowed the epidemic to spin out of control in the United States is contributing to the epidemic in the developing world."
A recent study HIV risk and MSM in low and middle-income countries found that MSM are at greater risk of being infected with HIV when compared with the general population.2
In medium-high prevalence areas, the HIV risk for MSM is nine times higher than for the general population, suggesting an urgent need for prevention and care.2
It's in this environment of an underground MSM population that often is at high risk of HIV infection that amFAR began last year to offer small grants to community organizations that would provide MSM groups HIV education, prevention, outreach, and advocacy.
The MSM Initiative also is pushing for better data on MSM, their social and sexual networks, and their HIV-related needs, Avrett says.
The third part of the initiative is to help advocates hold their governments accountable to meeting the needs of at-risk MSM, he adds.
"That's one of the amazing things about all of this: there are men who have sex with men who are willing to stand up and speak out in most countries of the world, and they're doing amazing work in all of these countries," Avrett says.
So far, amFAR has funded 17 organizations with a total of $350,000 in grants. A second round of grants was recently announced for Latin America and Asia, and that will be about the same size, he says.
"We're trying to raise more money and are continuing to reach out to those foundations and individuals who have always supported amFAR," Avrett says. "AmFAR has a long history of responding to the epidemic in ways that try to reach the leading edge and push responses to the epidemic in ways that reflect the most current needs."
Fundraising for international efforts involving MSM populations has been a bit of a challenge, Frost notes.
"It's been a struggle to get people in the gay community to feel connected with MSM in the developing world," he says. "It's something we continue to work on."
The most surprising reaction to the amFAR grant announcements has been the large number of applications submitted, Avrett and Frost say.
"When we did a request for proposals for funding work related to MSM and HIV, we received 84 proposals from 25 countries — all in Africa," Avrett says. "It was more than $2 million in funding requests."
Seven of the 84 applicants are being funded, and amFAR is trying to raise money to fund an additional 10, he adds.
"And we did a similar process in the Caribbean where we're funding five organizations that are working in more than five countries," he says.
Although amFAR has been working on MSM issues domestically and internationally for some tie, even the organization's leaders were surprised at the level of response to their grants announcement, Frost says.
"There is an outpouring of support for this initiative that was surprising to us," he says. "This does speak to this overwhelming sense of need."
The other piece of good news is that the HIV prevention and care needs of MSM around the globe finally is starting to hit the radar of various nations and AIDS organizations, Avrett says.
"AmFAR is not the only organization working on this," Avrett says. "We're working in partnerships with other groups who see the same situation and are trying to recalibrate the global AIDS effort."
The attention has helped change some governmental policies, as well.
"China has changed where MSM are now part of their national HIV efforts," Avrett says.
Likewise, more attention is being paid to MSM and HIV in Eastern Europe and Central Asia. And the International AIDS Society's XVII International AIDS Conference, which will be held Aug. 3-8, 2008, in Mexico City, Mexico, will feature plenary speakers, including Jorge Saavedra, MD, of Centro Nacional para la Prevención y el Control del VIH/SIDA (CENSIDA) of Mexico City discussing MSM and HIV.
"So the international AIDS conference will have a great deal of content and energy about this topic, and it's certainly a major issue across all of the Latin American countries," Avrett says. "There will world attention focused on this issue in August."
Reference:
- Jaffe HW, et al. The reemerging HIV/AIDS epidemic in men who have sex with men. JAMA. 2007;298(20):2412-2414.
- 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 Med. 2007;4(12):e339.
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