The HIV pandemic has historically been thought of as either concentrated in specific populations—such as gay men, injection drug–users, sex workers—or generalized across the entire population in sub-Saharan Africa and the Caribbean. But as more and better epidemiological data has become available, the evidence is clear: men who have sex with men (MSM), regardless of whether or not they identify as gay, also are at the core of those generalized epidemics.
MSM in developing countries are 19 times more likely to be infected with HIV than the general population, according to a 2007 literature review.
Even in Africa, at the heart of the pandemic, in Malawi, 21 percent of MSM are infected with the virus compared with 11 percent of the general population, whereas Zambia's rates are 33 percent versus 15 percent, respectively, says Chris Beyrer, director of the Johns Hopkins Center of Public Health and Human Rights.
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"The argument that gay and bisexual men are a trivial sideshow in the global fight against AIDS is wrong," he told the Global Forum on MSM and HIV, an advocacy network that met this summer prior to the International AIDS Conference in Vienna, Austria.
That epidemiologic evidence has largely have been ignored by most nations' plans for HIV prevention and care. Cultural values—machismo, homophobia and religion have overridden the data and dominated policy decisions in many places; most recently in the news are Uganda and Malawi.
Some 85 countries still criminalize sexual activity between adults, and eight, including Nigeria and several Islamic countries, impose the death penalty for homosexual acts. Uganda has been embroiled much of the past year in a debate about whether or not to write such a death penalty into their statutes, with evangelical Christians, both local and in the U.S., fanning the flames.
A recent survey of 303 MSM in Kampala, Uganda, found that 37 percent had been physically abused at some point in their lives, 37 percent had been blackmailed and 26 percent had been forced to have sex, according to Joseph Barker, a researcher with the U.S. Centers for Diseases Control and Prevention (CDC).*
Even more troubling, members of this group were five times more likely to be infected with HIV. The overall HIV prevalence was 4.5 percent in adult males in Kampala, 13.7 percent among those participating in the survey and 22.4 percent among those who had experienced violence.
"We have a situation where laws and their arbitrary, inappropriate enforcement are increasing risk and vulnerability—thereby imposing barriers to effective HIV responses for those most vulnerable and the general population," says Jeffrey O'Malley, director of the United Nations Development Programme (UNDP) HIV Group.
Joint United Nations Programme on HIV/AIDS (UNAIDS) Executive Director Michel Sidibe says discrimination against MSM is a human rights issue and unacceptable. But his message seems to be compartmentalized, reserved for preaching to the choir of those working with MSM; his speech to the Global Forum is absent from the UNAIDS Web site.
The recent International AIDS Conference reinforced the trend: Just 2 percent of presentations focused on gay and bisexual men, according to George Ayala, executive officer of the Global Forum.
This trend toward scientific omission has reinforced local social stigma and violence directed against this minority. The results are an amplification of new infections that might otherwise have been reined in, and a continued expansion of the pandemic.
The epidemic in Peru is concentrated among MSM, and the government there is one of the few that has used this information to direct its prevention funding toward that population. It also changed other policies such as stopping the harassment tactic of police raids on gay clubs to help to build trust between the government and community as well as allow for a better delivery of HIV prevention messages.
Peru has demonstrated what can be done, says Steve Morin, director of the Center for AIDS Prevention Studies at the University of California, San Francisco. "There was a need to develop a gay community identity and a human rights movement in order to organize an HIV response," he says.
Robert Carr, director of the International Council of AIDS Services Organizations in Toronto thinks that only a comprehensive HIV program that focuses on human rights will overcome the cultural biases that are inhibiting development of effective programs to reach MSM.
He says HIV programs for MSM must concentrate on key institutions such as the media and government policymakers; confront religious leaders and their claims that homosexuality is both a sin and a legacy of Western colonialism; independently fund agencies serving MSM; and bring the force of U.N. agencies to bear in support of human rights and good governance.
*Correction (11/15/10): This sentence was edited after posting to correct the spelling of Joseph Barker's name.