Focused AIDS programmes in Asia and the Pacific
21 March 2007
It’s an unfortunate reality that all too often, the people most at risk and most in need of HIV prevention, treatment and care programmes are those least likely to have access to these services. According to latest estimates, only one in ten people ‘most at risk’ has access to prevention services. In many cases, for injecting drug users, sex workers and men who have sex with men, AIDS poses a double burden—on the one hand, there are a very limited number of programmes specifically designed to reach them, and on the other hand, they are often faced with discrimination, stigma and in some cases even criminal prosecution by the societies they live in.
But evidence and experience shows that focusing AIDS programmes and services specifically on people who are most at risk leads to encouraging progress within the response and can help reduce stigma and discrimination.
This month’s review of the UNAIDS Best Practice collection looks at the issue of men who have sex with men (MSM) in the Asia and the Pacific region and the focused programmes implemented in six countries that are showing progress.
In Asia, men who have sex with men are disproportionately affected by HIV. It is estimated that HIV prevalence is as high as 14% in Phnom Penh, Cambodia; 16% in Andrha Pradesh, India; and 28% in Bangkok, Thailand.
Men who have unprotected sex with men may also have unprotected sex with women and thus serve as an epidemiological bridge for the virus to the broader population. For example, a survey of over 800 men in China who have sex with men found that 59% reported having had unprotected vaginal sex with women in the previous year.
“It is a commonly held misperception that male-male sex happens only among men who self identify as ‘gay’. Most men who have sex with men living outside the West are not identifiable as such, they live and work in their communities unremarked and are often heads of families with children,” the Best Practice outlines
“HIV transmission prevention programmes addressing men who have sex with men are therefore vitally important. However, this population is often seriously neglected because of official denial by governments, the relative invisibility of men who have sex with men, stigmatization of male-to-male sex, ignorance or lack of adequate information,” it says.
The MSM programmes, implemented in Bangladesh, India, Indonesia, the Philippines, China and New Zealand, were chosen to be part of the UNAIDS Best Practice collection due to their success in providing comprehensive interventions that engage all actors involved in the AIDS response.
Although different in their make-up, the programmes have common elements and activities that have proved to be effective in reaching and supporting men who have sex with men on AIDS issues in Asia.
Advocacy activities with governments, health services and mainstream communities are common to all programmes. In Bangladesh, successful advocacy from the Banhu Social Welfare Society, including networking and participation in governmental meetings, has ensured the inclusion of issues relating to men who have sex with men in the five-year National AIDS Strategic Plan. In Indonesia, the Aksi Stop AIDS and Family Health International programme have worked hard to engage the authorities in the AIDS response. The Indonesian Ministry of Health is now recognising the seriousness of the situation and communities of men who have sex with men have been invited to participate in consultations on AIDS-related issues.
The Best Practice publication highlights a number of interesting outreach activities that some of the programmes are implementing. For example, in Hong Kong, the ‘AIDS concern’ organization set up a programme focusing on customers of saunas. Materials promoting safer sex such as leaflets, comic books and information brochures were produced and distributed across 13 saunas and outreach workers met with owners and staff to foster relationships and assess the situation. Increasingly, condoms, and lubricant were also distributed. “Good relations between the outreach workers and the sauna owners continue and there have been increased opportunities for contact with clients as a result of testing services. As a result clients are less apprehensive,” the publication states.
The programmes highlighted in the publication underline that activities implemented by people living with HIV have been proven to be more effective and help to further break down AIDS-related stigma and discrimination.
Know your epidemic
As the Best Practice outlines, in many countries, prevention efforts are hindered by laws that criminalize male-male sex, making work with men who have sex with men difficult and hindering their contribution to the response to the epidemic. Where social, cultural and religious attitudes make the issue politically sensitive, politicians are generally reluctant to support policies and programmes that might result in public criticism from community leaders and groups .
HIV prevention programmes for men who have sex with men like those featured in the Best Practice are vitally important to stop HIV transmission. However, lack of research about men who have sex with men including their behaviours and attitudes, and criminalization and stigmatization of and legal discrimination against these men, are also significant barriers to implementing effective programmes. Research was an integral part to the success of the AIDS Concern sauna outreach activities in Hong Kong – as part of the activity a research project was undertaken to determine the prevalence of high risk behaviours among sauna clients, levels of access to free condoms and lubricant, and the nature of information materials that would be best suited to sauna clients.
Through the examples of the six MSM programmes, the publication underlines that HIV programming for men who have sex with men needs to be carefully tailored to local cultures and conditions. Rather than relying on approaches based on patterns of male-male sexual behaviour observed in Western Europe and North America, local sexual minorities should be identified and engaged in developing programmes. In New Zealand, the New Zealand AIDS Foundation promotes the use of a community’s cultural resources to make AIDS information materials relevant and attractive. Designs, images, colours, language and models are used which are instantly recognizable as belonging to either the Maori or Pacific Islander communities.
As the Best Practice underlines, UNAIDS supports a range of responses aimed at reducing the vulnerability of men who have sex with men to HIV and its impacts including the promotion of high-quality condoms and water-based lubricants, ensuring their continuing availability; safer-sex campaigns and skills training; peer education among men who have sex with men and female partners; and strengthening organizations of self-identified gay men, enabling them to promote and rapidly increase HIV prevention and care programmes for men who have sex with men.
“Twenty five years into this epidemic, the reality is that only one in ten men who have sex with men have access to HIV prevention services. This is a massive failure, and setting it right has to be among the highest priorities for the increasingly strong global AIDS response as we aim to achieve universal access to HIV prevention, treatment, care and support for all groups, including men who have sex with men and transgender people,” said Purnima Mane, UNAIDS Director of Policy, Evidence and Partnerships.
Download the Best Practice: HIV and Man who have Sex with Men in Asia and the Pacific
Read more on men who have sex with men (MSM)
Download UNAIDS Policy brief on MSM ( en | fr | es | ru | pt ) (227 Kb, pdf)
Other UNAIDS Best Practice reviews:
Learning from experience
A faith-based response to HIV in Southern Africa
Traditional Healers join the AIDS response