Sexual minorities

Homophobia and criminalization of consensual adult sexual behaviour represent major barriers to effective responses to HIV.

By signing the 2006 United Nations Political Declaration on HIV/AIDS, governments committed to removing legal barriers and passing laws to protect vulnerable populations. However, over 80 countries still criminalize consensual same sex acts among adults.

It is against this repressive context that communities worldwide celebrate the International Day Against Homophobia each 17 May, which marks the anniversary of the World Health Organization’s decision to remove homosexuality from its list of mental disorders in 1990. Therefore, 17 May is an opportunity to highlight once again the urgent need for joint efforts to reduce and end discrimination, violence and criminalization based on sexual orientation.

Homophobia and criminalization of consensual adult sexual behaviour represent major barriers to effective responses to HIV. Such responses depend on the protection of the dignity and rights of all people affected by HIV, including their right and ability to organize and educate their communities, advocate on their behalf, and access HIV prevention and treatment services.

“The decision to criminalize same sex relations is a serious setback to the AIDS response and to the rights of those affected by the law,” said Michel Sidibé, Executive Director of UNAIDS. “As these discriminatory laws can drive people underground, they will have a negative impact both on the delivery of HIV prevention programmes and on access to treatment for those living with HIV.”

Evidence shows that protection of the rights of men who have sex with men, lesbians and transgenders, both in law and practice, combined with scaled-up HIV programming to address their HIV and health needs are necessary and complementary components for a successful response to the epidemic.

UNAIDS urges all governments to take steps to eliminate stigma and discrimination faced by men who have sex with men, lesbians and transgenders and create social and legal environments that ensure respect for human rights and universal access to HIV prevention, treatment, care and support.

“There is no place for homophobia. Universal access to HIV prevention, treatment, care and support must be accessible to all people in need—including men who have sex with men,” said UNAIDS Executive Director Michel Sidibé.

Countries that have non-discrimination laws against men who have sex with men, injecting drug users and sex workers have achieved higher rates of coverage of HIV prevention efforts.

Dr. Guillermo Maza, Minister of Health of El Salvador signing the ministerial decree on 5th March 2009.

The Ministry of Public Health and Social Assistance of El Salvador approved, as part of its National Plan on HIV prevention, a set of actions to reduce homophobia and any type of discrimination based on sexual orientation in the health services.

In its 2008 country progress report El Salvador identified human rights violations as a major barrier to an effective response to the AIDS epidemic. The ministerial decree signed on 5th March 2009 by the Minister of Health Dr. Guillermo Maza, guarantees access to health services and respect of human rights to men who have sex with men, transgender, transvestites and lesbians.

The ministerial order states that all public health services such as hospitals, health clinics, etc. and their staff must facilitate, promote and support actions to eradicate discrimination based on sexual orientation. The decree also calls for all health institutions in the country to report back on the actions taken to reduce homophobia and discrimination.

“This ministerial decree reflects the fundamental principle of respect for the human rights of all those who suffer from stigma and discrimination and it reaffirms the spirit of the universal access to HIV prevention, treatment, care and support under a human rights frame,” said César Antonio Nuñez UNAIDS Director Regional Support Team for Latin America.

The decree also encourages multilateral cooperation agencies and International financing institutions to provide funds and technical support directed to effectively respond against discrimination.

According to UNAIDS, El Salvador has an HIV prevalence rate of 17.8% amongst men who have sex with men (MSM).

Aside from the individual pain homophobic attitudes inflict, the continuing stigma attached to same-sex relations is complicating the task of slowing the spread of HIV in the Latin America region in general where sex between men is a leading mode of HIV transmission according to national reports. Stigma and homophobia increase the isolation of gays, bisexuals and transgender people making them more reluctant to come forward, get advice and access HIV services such as treatment, testing and counseling.

By signing the ministerial decree, El Salvador builds on the country’s commitment to seriously expand efforts to address stigma and discrimination in health settings which will facilitate the intake of HIV services by one of the key populations at higher risk of HIV infection

UNAIDS Executive Director Michel Sidibé (right) met with Minister of Foreign Affairs, Mr Celso Amorim.
Credit: UNAIDS/M. Silva

The upcoming Group of Twenty (G20) meeting in London, the global financial crisis, and universal access were some of the main topics Mr Michel Sidibé and Brazilian Government counterparts discussed during his first official visit to Brazil as the Executive Director of UNAIDS.

UNAIDS Executive Director Michel Sidibé (left) greets Minister of Health of Brazil, Mr José Gomes Temporão.
Credit: UNAIDS/M. Silva

Mr Sidibé met with the Minister of Foreign Affairs, Mr Celso Amorim, the Minister of Health, Mr José Gomes Temporão, the Minister of Human Rights, Mr Paulo Vanucchi, and the Minister of Women’s Affairs, Ms Nilcéa Freire.

A meeting also took place between Mr Sidibé and the HIV/AIDS Parliamentarian Group, the LGBTT (lesbian, gay, bisexual, transgender and transvestite) Citizenship Group and the Human Rights Commission. The forum which took place at the National Congress in the capital Brasilia, was an opportunity for lively exchange of ideas and viewpoints on a range of issues at the heart of Brazil’s efforts to respond to the HIV epidemic and address human rights. These issues were also underlined in meetings Mr Sidibé had with the President of the Congress and the Senate President.

Civil society share challenges and barriers in responding to diverse epidemics

UNAIDS Executive Director Michel Sidibé meets representatives of group Arco-Iris.
Credit: UNAIDS/D. Ramalho

Two separate meetings with civil society groups in Rio de Janeiro provided Mr Sidibé an overview of the challenges facing several populations most affected by HIV, including sex workers, transgenders, gay adolescents and indigenous peoples in the Amazon region.

With ten national representatives of the Brazilian Interdisciplinary Association of AIDS (ABIA), Mr Sidibé was informed of the difficulties in responding to the many faces of Brazil’s epidemics.

HIV prevention was underscored by many representatives as an urgent issue to address, with a lack of resources to reach out to the groups most-at-risk from HIV seen as the biggest hurdle in preventing new infections.

With Grupo Arco-Íris (Rainbow Group), Mr Sidibé heard from several representatives of diverse lesbian, gay, bisexual, transgender and transvestite groups. They explained the concerns and challenges faced by them as LGBTT living in Brazil.

Grupo Arco-Íris is advocating for a change in the law in the federal senate that would make homophobic acts a criminal offence. So far, the group has collected more than 40,000 signatures in support of the law. The group also launched a HIV prevention campaign called “entre garotos” (between boys) that targets gay adolescents between the ages of 16 and 22 through tailored advertising and information displays at cafes, bars, dance halls, and other venues popular with young men who have sex with men.

Mr Sidibé pledged his continuing support to the LGBTT community and encouraged its members to mobilize and rally around efforts to achieve universal access to HIV services in Brazil.

The District of Columbia HIV/AIDS Epidemiology Update 2008 report.

At least 3% of residents in Washington D.C. are living with HIV according to a report published today by US health officials at the District of Columbia's HIV/AIDS Administration.

The leading mode of transmission of HIV in the district is men having sex with men. Heterosexual transmission and injecting drug use closely follow, the report says.

“Today’s findings by US health officials show that there is no room for complacency in responding to HIV,” said Paul de Lay UNAIDS Deputy Executive Director, Programme, ad interim and Director of Evidence, Monitoring and Policy.

“We must continue to learn from each other and work together - both in developing and high-income countries – to ensure universal access to HIV prevention, treatment, care and support services for citizens.”

The District of Columbia HIV/AIDS Epidemiology Update 2008 reports that HIV is found in all demographics in Washington: more than 4% of African-Americans, almost 2% of Latinos and 1.4% of Caucasians are living with HIV. However African-American men are disproportionably affected, accounting for 76% of people living with HIV.

This follows the broader pattern across the United States where racial and ethnic minorities are disproportionately affected by the HIV epidemic. Although African Americans represent about 13% of the population (US Census Bureau, 2006), in 2005 they accounted for 48% of new HIV diagnoses.

The United States of America has one of the largest HIV epidemics in the world, with an estimated 1.2 million people living with HIV in 2007 (UNAIDS, 2008).

This article first appeared in the official programme of the 23rd Teddy Award

23rd TEDDY Award, 59th Berlinale International Film Festival

Film offers invaluable insights into the lives of different cultures, groups, and people. It is a medium that has a long history in addressing controversial topics and issues. For men who have sex with men, cinema has been a powerful platform to highlight the challenges they face in society.

From the 1969 release of Midnight Cowboy through to the works of Rosa von Praunheim, social acceptance of the acknowledgement and openness about men who have sex with men has grown. Most recently, major Hollywood films such as Brokeback Mountain (2006) have brought further mainstream attention and acceptance. Undoubtedly, AIDS – and its impact on this community – has been one of the most powerful storylines used in the past two decades, especially as the men who have sex with men community continues to be one of the groups hardest hit by the epidemic. The landmark film Philadelphia (1993) has been widely used to change attitudes towards AIDS and men who have sex with men, as well as to evoke an upsurge of compassion.

Nearly three decades since AIDS was first recognized, much progress has been made globally to prevent new HIV infections and provide antiretroviral therapy to those who need it. But men who have sex with men continue to bear a substantial burden of HIV infection, with increasing numbers of new infections occurring in a number of countries worldwide.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) works closely with communities and organizations of men who have sex with men and promotes their leadership and participation in the global AIDS response. UNAIDS acts as a bridge builder, linking men who have sex with men and their organizations with governments, other civil society and international partners. UNAIDS’ role is to ensure commitment to the protection of the human rights of men who have sex with men, and support countries to put in place strategies and programmes to achieve universal access to HIV prevention, treatment, care and support.

Obstacles in responding to the sexual health needs of men who have sex with men

A significant hurdle in reaching out to men who have sex with men in a number of countries is the criminalization: few men who have sex with men come forward for fear of stigma, discrimination, and/or legal repercussions and this, in turn, impedes efforts to reach men who have sex with men, and their partners with HIV services, such as prevention, treatment, care and support. Within the diverse communities related to men who have sex with men are groups which are even more stigmatized, such as sex workers, men who are living with HIV, or transgender people, and their specific needs all require attention.

A recent report addressing HIV and men who have sex with men in a number of countries in Eastern Europe, the Caucasian Republics and Central Asia found that although most of the early cases of HIV in the region were diagnosed among men who have sex with men, this remains the least understood of the most-at-risk groups. Reasons include the reluctance of these men to be identified as such (even in a medical context), homosexual sex resulting in criminal prosecution in some countries, and, even the absence of criminal sanctions, stigmatization and physical violence.

In a survey conducted among men who have sex with men in Georgia in 2005, one quarter of those interviewed (25.7%) reported having faced social exclusion, discrimination and even violence by strangers, neighbours, family members and friends because of their sexual orientation. The survey revealed that 10% of all respondents had faced physical violence, with reports of beatings and two cases of rape, while other respondents reported social rejection and unfair dismissal from work.

The impact of violence against men who have sex with men has galvanized action in Latin America where Brazil and Mexico top the table of reported incidents. But this may be because rights groups there monitor the situation more closely than elsewhere in the continent.

UNAIDS encourages governments to “know their epidemic” and know how it affects men who have sex with men. Using this information, governments need to not only invest resources in supporting HIV prevention, treatment, care and support for men who have sex with men – tailored programmes that respond to their health needs – but also address the discrimination, violence and other barriers that stand in the way of accessing services.

Epidemic among men who have sex with men

Spanning a period of just 28 years since five gay men in the United States were the first identified with an unusual pattern of diseases later labeled AIDS, the epidemic has claimed the lives of more than 25 million people so far across the globe.

Sex between men occurs in every culture and society – though its extent and public acknowledgement vary from place to place – and is thought to account for between 5% and 10% of global HIV infections. It is the predominant mode of HIV transmission in many high-income countries and continues to be the population group most-at-risk of acquiring HIV within Western Europe. However, in countries reporting on access to HIV services by key population group, only around 40% of men who have sex with men have access to the HIV prevention and care services they need.

Regional trends

Sex between men is the most prominent mode of HIV transmission in nearly all Latin American countries, the United States, Canada and some Western European countries.

In both Canada and the United States, unprotected sex between men accounted for 40% of new HIV diagnoses in Canada in 2006 and 53% in the United States in 2005. The number of new HIV diagnoses attributed to unprotected sex between men has also increased sharply in recent years in Western Europe. In Germany, for example, the number of new HIV diagnoses among men who have sex with men rose by 96% between 2002 and 2006.

The urgency in Latin America is underlined by official reports on the state of the HIV epidemic in Colombia, Ecuador, Bolivia and Peru where sex between men is acknowledged as being the main source of new HIV infections.

In Asia, unprotected sex between men poses a significant but under-studied factor in the region’s HIV epidemics. In Bangkok, HIV prevalence among men who have sex with men went from 17% in 2003 to 28% in 2005. Male sex workers also face a particularly high risk of infection.

In Africa, several recent studies suggest that more attention is needed to better understand the role of HIV transmission among this population and that the proportion of the epidemic attributable to sex between men may be larger than hitherto thought, but there is still a great lack of information.

Looking ahead

Experience has shown that effective responses to HIV are those based on respect for human rights, and unimpeded access to HIV prevention, treatment, care and support. UNAIDS supports efforts to amend laws prohibiting sexual acts between consenting adults in private, enforce anti-discrimination legislation, provide legal aid services, and promote campaigns that address homophobia. These protections, alongside universal access to HIV prevention, treatment, care and support for men who have sex with men, will go a long way to turning the tide of the epidemic in many parts of the world.

Law, law enforcement practices, stigma and discrimination must be tackled as part of national AIDS responses as vulnerability to HIV infection is increased where men are either excluded from, or exclude themselves from, sexual health programmes and services out of fear. Gay, lesbian, bisexual and transgender communities must be – and have the right to be – empowered to participate equally in the social and political life of their communities and countries. These communities, who were the frontrunners in the early days of the AIDS response, are key partners today in the movement for universal access to HIV prevention, treatment, care and support.

There is no doubt in the minds of health experts and activists that the official figures hugely underestimate the numbers of MSM living with HIV and newly acquiring HIV infection in Ukraine and elsewhere in the Region. Credit: UNAIDS/S.Dragborg

Judging by the official statistics, cases of HIV infection amongst men who have sex with men (MSM) in Ukraine, as in much of Eastern Europe and Central Asia, are so rare as to seem scant cause for concern.

“No statistics means no problem,” says Zoryan Kis of the All-Ukrainian Network of PLHIV (People Living with HIV). “The fact that the official numbers are very low is a danger for our work because we know that the epidemic exists but it is hidden.”

But there is no doubt in the minds of health experts and activists that the official figures hugely underestimate the numbers of MSM living with HIV and newly acquiring HIV infection in Ukraine and elsewhere in the Region.

In the 20 years since the first case of HIV infection was detected in Ukraine, only 158 MSM have been officially registered as living with HIV in a country with a total population of some 46 million people.

According to the 2007 UNGASS country report Ukraine has the most severe HIV epidemic in Europe, with just over 1.6 percent of the adult population estimated to be living with HIV. In 2007, 17,687 people were reported as newly infected with HIV, up 10 percent from 2006. Among them, the official number of new cases amongst MSM was just 48.

Together with the high degree of stigma attached to MSM in Ukraine, something the country shares with other countries in Eastern Europe and central Asia, this understating of the problem has contributed to authorities’ reluctance to back campaigns of prevention among MSM, activists say.

Beyond the official statistics, there is considerable data on MSM which paints a different picture. Various organisations, including UNAIDS, WHO and the International HIV/AIDS Alliance in Ukraine estimated that in 2006 there were between 177,000 and 430,000 MSM in the Ukraine, of whom between 3 and 15 percent of live with HIV, which is several hundred times the figure reflected in the official studies.

Stigma and discrimination

Official HIV figures in Ukraine, as elsewhere in the region, are based on the results of voluntary HIV testing during which people should normally be asked why they have sought a test.

But in countries where MSM face widespread discrimination and where there is a high degree of stigma attached to male to male sex, there is understandable reluctance on the part of MSM to give the true reason.

“Most of MSM are not open. They would not go and say: ‘I have had sex with men’. They would say ‘I have had risky behaviour, I have been injecting drugs or even I have visited the dentist and I am worried,” says Kis.

And often officials do not press for answers. “I have been tested four or five times, but I have never been asked for my sexual orientation,” Kis adds.

According to the European Centre for the Epidemiological Monitoring of HIV/AIDS, only 1,828 cases of HIV infection in MSM have been officially reported between 2002 and 2006 years in the 15 former Soviet countries making up the World Health Organisation’s Eastern European health region.

Turkmenistan and Tajikistan, report none, while Azerbaijan has only 10 and Belarus 29. The highest number is reported by Russia; but its 1,245 cases over the 5 years compares with more than 38,000 in Britain and 11,000 in Germany in the same period, countries with smaller overall populations.

Prevention services for MSM have improved in the last few years, but they remain significantly inadequate to impact and sustain behavioural change and thus reduce HIV transmission among this group of men in Ukraine.
Credit: UNAIDS/P.Carrera

Ambitious goals

In 2006, Ukraine set ambitious national goals for scaling up towards universal access to HIV prevention, treatment, care and support for groups at high risk of HIV. However, HIV prevention activities in the Ukraine, as in most of the rest of the region, are carried out by NGOs with financial backing from international donors, mainly the Global Fund for AIDS, Malaria and Tuberculosis.

For example, a two-year project called “Men Who have Sex with Men: HIV/STI Prevention and Support” was implemented in Kiev by the AIDS Foundation East-West, the Gay Alliance NGO and Noah’s Ark-Red Cross Sweden, with financial support from the Elton John AIDS Foundation amongst others.

The International HIV/AIDS Alliance in Ukraine, which is co-holder of the Global Fund grants, is currently undertaking 14 projects aimed at HIV prevention among MSM. They include outreach services, provision of information and education around HIV and sexually transmitted infections (STIs), behavioural change communication, promotion of safer sex, condom and lubricants distribution, counselling and rapid-testing for HIV, testing and treatment of STI, self-help groups and anti-stigma trainings.

“The scale and scope of prevention services for MSM has improved in the last few years, but they remain significantly inadequate to impact and sustain behavioural change and thus reduce HIV transmission among this group of men in Ukraine,” says Dr. Ani Shakarishvili, UNAIDS Country Coordinator in Ukraine.

The situation is similar elsewhere in Eastern Europe and Central Asia. For example, there are no state-funded HIV prevention programmes for MSM in Russia.

“Governments everywhere are reluctant to spend money on sex workers, on drug users, but MSM comes at the top of the reluctance list. It is probably the last programmes that the governments will start,” says Roman Gailevich, UNAIDS Regional Programme adviser.

The new programme marks an encouraging change of stance by the government.
Credit: UNAIDS/S.Dragborg

For the first time

Under pressure from international donors and an increasingly vocal and better organised local MSM community, the Ukrainian Government recently agreed to include and set targets for HIV prevention and treatment for MSM as a priority in its National AIDS Programme for 2009-2013.

“This change stems from comprehensive surveys in the community which show the real role of MSM in the HIV epidemic in Ukraine,” says Anna Dovbakh, head of team: policy & programme development at the International HIV/AIDS Alliance in Ukraine.

“Since 2005, activists of the LGBT (Lesbian, Gay, Bisexual and Trans-sexual) community have become more active and professional in their HIV advocacy and response,” she adds.

Activists and health experts say that the new programme, which is currently before the Parliament, marks an encouraging change of stance by the government.

But the jury is out on what real difference it will make, not least because the money for HIV prevention will continue to come from the Global Fund and other donors.

“The lack of Governmental commitment to provide resources, support and services for MSM and to address the existing legal, financial and administrative barriers to service access for MSM indicates that the Government of Ukraine is still not fully prepared to address the HIV epidemic in MSM,” says Shakarishvili.

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China announced in 2008 plans for an extensive programme to tackle sharply rising rates of HIV amongst men who have sex with men (MSM)
Credit: UNAIDS

China announced in 2008 plans for an extensive programme to tackle sharply rising rates of HIV amongst men who have sex with men (MSM), in the latest sign that the country may be starting to face up to a crisis which long seemed taboo.

Announcing the MSM campaign, the ministry of health said that risky sexual behaviour was the biggest single factor behind the spread of HIV in mainland China, excluding Hong Kong, and that men who had sex with men were now the group most likely to become infected with the virus. In China there are around 700,000 people living with HIV, and 11.1 percent of these are MSM.

“In the past between 1 and 3 percent of MSM on the mainland had HIV; Now it is anywhere from 2.5 to 6.5 percent”, Hao Yang, deputy chief of the ministry’s disease prevention and control bureau, was quoted as saying by the China Daily.

The campaign involved targeted prevention measures for the estimated 5-10 million- Chinese MSM, including stronger promotion of condom use, expanded coverage and quality of HIV prevention activities, increased access to voluntary HIV counselling and testing services, and improved access to treatment for sexually transmitted infections.

As a starting point for its new large-scale campaign to reduce HIV among MSM, China is aiming for some 21,000 MSM to be HIV-tested in order to be able to establish a clearer statistical baseline for the infection rate. This is the largest such study undertaken anywhere in the world and the first of its kind in Asia.

Its prevention effort will involve MSM community based organizations (CBOs) and civil society at all levels. Community-based organisations are carrying out AIDS awareness campaigns, VCT referrals, peer education, safer sex promotion and condom distribution; hot-lines are being run and internet chat rooms and websites used.

UNAIDS, the joint United Nations programme on HIV/AIDS, sees the empowering of MSM and other marginalized groups to protect themselves from HIV as one of the main elements of the global AIDS response.

"The Chinese government has made addressing HIV prevention among MSM a priority and that is something which UNAIDS welcomes," said Bernhard Schwartlander, UNAIDS Country Coordinator in China.

In most Asian countries MSM remains an uncomfortable subject: in many of them, sex between men is illegal and reports of harassment are frequent.
Credit: UNAIDS

But despite progress in China, a number of shortcomings remain, with stigma and discrimination still all too prevalent amongst the general population and even within the MSM community itself.

It is estimated that by late 2007, only 8 percent of MSM had been reached by comprehensive HIV prevention interventions. Furthermore, more than half of China's MSM have more than one sexual partner but only between 10 and 20 percent of them use condoms, according to health ministry estimates.

“It is critical that the government and the many MSM working groups find ways to improve their ability to work together in open and nondiscriminatory partnerships", said Schwartlander.

Largely ignored

Developments in China come amidst indications that governments elsewhere in the Asia-Pacific region are also becoming more willing to acknowledge an epidemic that many had previously largely ignored.

In most Asian countries MSM remains an uncomfortable subject: in many of them, sex between men is illegal and reports of harassment are frequent. As a result, there has been little in the way of specific support for programmes for MSM.

“A lot of attention is being drummed up, but a lot more needs to happen,” said Paul Causey, a Bangkok-based consultant working with the Asia Pacific Coalition on Male Sexual Health (APCOM) and the United Nations on MSM-related issues.

Most Asian men who have sex with other men are not open about their sexual behaviour. Social taboos and discrimination mean that many opt to disguise their sexual preferences; for many others, their sexual practices with other men may only be a small part of social roles they play or their sexual lives. Given that many men who have sex with men also have sex with women, high HIV rates among MSM can also translate into substantial numbers of women at risk of exposure to HIV.

The combination of high numbers of partners with high-risk behaviour such as unprotected anal intercourse has been a key factor behind the accelerating HIV infection rate in many Asian cities.

It said that hardly any Asian country is devoting significant resources to MSM, despite the fact that prevention costs a lot less than treatment. According to the commission, $1 invested in effective prevention can save up to $8 in treatment expenditure for expanding epidemic countries.

Most Asian men who have sex with other men are not open about their sexual behaviour. Social taboos and discrimination mean that many opt to disguise their sexual preferences.
Credit: UNAIDS

Engaging community groups

The tipping point in awakening to the dimension of the MSM crisis was the convening of a special conference in New Delhi in September 2006 entitled “Risks and Responsibilities: Male Sexual Health and HIV in Asia and Pacific”.

The conference was truly tripartite, bringing together governments, donors and 380 members of community groups. As important as the event itself was the run-up, with 16 countries holding UNAIDS-sponsored preparatory meetings. In some cases, including that of China, it was virtually the first time that government officials and representatives from the wider MSM community groups met to assess the situation and discuss solutions.

One of the other lasting achievements of that conference was the decision to launch APCOM, which brings together civil society groups, government sector representatives, donors, technical experts and the United Nations to push for an effective response to the rising HIV incidence amongst MSM.

Its efforts complement those of a United Nations technical working group on MSM and HIV/AIDS in China launched in mid-2006. The group is led by the United Nations Development Programme (UNDP).

“The technical working group is working with government, MSM community groups and donors to improve co-ordination and communication, build government capacities to involve civil society organisations (CSOs) in policy-making and public service delivery, and develop the institutional and professional capacities of CSOs,” said Edmund Settle, HIV manager for UNDP in China.

Aside from the individual pain homophobic attitudes inflict, the continuing stigma attached to same-sex relations is complicating hugely the task of slowing the spread of HIV. Credit: L. Tanabe, National STD/AIDS Programme, Brazil

Every two or three days a person is killed in Brazil in violence connected with his or her sexuality, according to Brazil’s oldest gay rights association, Grupo Gay da Bahia (GGB). In Mexico, the reported figure is nearly two a week.

Most of the victims are men who have sex with other men (MSM) -  whether they are gays or bisexuals -  or transgender people.

But if Brazil and Mexico top the table of violence against men who have sex with men in Latin America, this may be because rights groups there monitor the situation more closely than elsewhere in Latin America. Much violence simply goes unreported elsewhere, gay activist organizations say.

“Brazil and Mexico are the only countries which have a register, which keep track of the murders. That does not mean necessarily that there is more violence there,” says Arturo Díaz Betancourt of the Mexican National Council for the Prevention of Discrimination.

It is notable that when the United Nations Special Rapporteur on Extra-Judicial Killings made an official mission to Guatemala in 2006 his attention was drawn to a series of murders of gay and transgender people, and his subsequent report to the Human Rights Council stated “There has been impunity for murders motivated by hatred towards persons identifying as gay, lesbian, transgender, and transsexual. Credible information suggests that there were at least 35 such murders between 1996 and 2006. Given the lack of official statistics and the likely reticence if not ignorance of victims’ family members, there is reason to believe that the actual numbers are significantly higher.”

Many Latin American countries boast socially advanced legislation when it comes to defending sexual freedom and orientation. With law reform in Nicaragua and Panama over the past 12 months, there are now no states in Latin America which criminalize homosexual relations, for example.

Yet perhaps influenced by a lingering “machismo”, prejudice and discrimination continue to flourish, whatever the laws say. Latin America is widely regarded as having a long way to go to successfully counter homophobia, or “fear or hatred of homosexuals.”

“There is a real contrast between reality and theory. This is the developing region of the world with the highest number of laws against discrimination based on sexual orientation,” says Dr. Ruben Mayorga, UNAIDS Country Coordinator for Argentina, Chile, Paraguay and Uruguay.

Aside from the individual pain homophobic attitudes inflict, the continuing stigma attached to same-sex relations is complicating hugely the task of slowing the spread of HIV in a region where sex between men is a leading mode of HIV transmission, health experts say.

Stigma and homophobia increase the isolation of gays, bisexuals and transgender people making them more reluctant to come forward, be identified and get advice.

“Homophobia represents a threat to public heath in Latin America,” the Pan American Health Organization affirmed in a report. “This form of stigma and discrimination based on sexual orientation does not just affect the mental and physical health of the homosexual community, but contributes to the spread of the HIV epidemic.”

UNAIDS has long campaigned against discrimination whether against those infected by the HIV virus or against a person for his or her sexual orientation.

Main source of new HIV infections

Stigma and homophobia increase the isolation of gays, bisexuals and transgender people making them more reluctant to come forward, be identified and get advice. Credit: L. Tanabe, National STD/AIDS Programme, Brazil

The urgency in Latin America is underlined by official reports on the state of the HIV epidemic in Colombia, Ecuador, Bolivia and Peru where sex between men is acknowledged as being the main source of new HIV infections. HIV prevalence is far higher than in the general population with rates of between 10% and 20% in many Latin America’s main cities.

In its 2008 report to the UN General Assembly (UNGASS) on the state of the HIV epidemic, Brazil stated that MSM are 11 times more likely to be HIV positive than the population as a whole.

In parts of Central America, where there is major political and social resistance to recognising the rights of gays, lesbians and transgender people, HIV incidence rates amongst MSM are particularly high.

And the impacts of these high rates of HIV extend beyond men who have sex with men themselves. In Peru, for example, most women who get infected by the virus get it from men who have had sex with other men, according to a Health Ministry study, thus prevention among MSM is crucial for effective prevention of HIV transmission to women.

Prevention fails to keep pace

Spending on HIV prevention amongst MSM in Latin America is well below what is called for by the extent of the epidemic within that group. On average, less than 10% of the money spent on prevention goes into campaigns aimed specifically at MSM, according to UNAIDS.

In Bolivia, it was estimated in 2005 that fewer than 3% of MSM had access to prevention services, compared with 30% coverage for sex workers.

“All these years, prevention has not been carried out where it needs to be, which is where the epidemic lies,” said Díaz. “They have not worked with gays, with trans (gender people), on the contrary there is rejection and deep discrimination,” he said, referring to the situation across the region.

The explanation lies in a mix of political, cultural and even religious factors, rights activists and health officials say.

“Politically, MSM is not something to make a lot of noise about. In most countries and by many institutions it is not sees as a political gain,” says Mayorga.

Religious groups, whether Roman Catholic or evangelical, which regard sexual relations between people of the same sex as “sinful” have often strenuously opposed attempts to pay special attention to MSM.

“Governments are highly influenced by religious sectors that mobilise against policies that benefit gays, bisexuals or trans,” says Orlando Montoya, who works in Ecuador with ASICAL, an organization promoting the health of gays, other MSM and lesbians in Latin America.

However, it is hard to generalize. Some churches have been at the forefront of outreach to men who have sex with men and many local religious organizations in Latin America have responded to HIV with tolerance and compassion, including among the most marginalized populations.

Internationally overlooked

But it is not just a question of country governments not paying due attention to MSM. Latin America has not attracted the level of international investment in stemming HIV epidemics that has been seen in other parts of the world -- in Asia and in Africa.

To some extent, the region has been victim of the three “nots” when it comes to receiving international financing for its HIV efforts, Mayorga says. It is ‘not’ very populated, it is ‘not’ very poor and it is ‘not’ a very big epidemic.

Rules covering assistance by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the principal international financing arm against the diseases, have worked against the region because they have tended to exclude middle and upper middle income countries, such as Argentina and Chile.

However, the Fund has recently agreed to study proposals for assistance for programmes in better-off countries facing concentrated epidemics with HIV prevalence rates of over 5 % in groups at risk, such as MSM, drug users, transgendered people or sex workers.

Renewing the focus

In the face of the persistent evidence of neglect, there are some positive signs in the region that MSM epidemics will be responded to with more adequate measures and policies.

In the past four or five years, Brazil and Mexico, and to a more limited extent Argentina and Colombia, have run campaigns against homophobia. These countries, together with others, have also sought to incorporate special MSM action into programmes to contain the spread of HIV.

The official programme “Brazil without Homophobia” was launched in 2004, with the aim of improving the service given to gays, other MSM and transgender people within state health institutions. It will also scale up coverage and the response to the HIV epidemic within these groups.

Peru has launched a national plan giving priority to prevention programmes for what are defined as “most-affected” groups – which include MSM, sex workers and prisoners. With financing from the Global Fund, the plan aims to extend prevention coverage to at least 25% of MSM and 50 percent of sex workers.

Similarly, Bolivia has drawn up a national plan to cut HIV infection rates by half by 2015, which includes campaigns to strengthen rights of MSM and transgender people and to combat discrimination and stigma.

Despite these promising developments, Latin America is still a long way from getting its MSM epidemics under control and homophobia and stigma remain significant stumbling blocks to achieving it.

From Cape Town to Lagos, several new studies are starting to provide a better understanding of men who have sex with men (MSM) within the context of HIV in Africa.

“Homosexuality is very much understudied in West Africa, and in Nigeria it is criminalized, making it difficult to reach MSM,” said Sylvia Adebajo, a researcher at the University of Lagos, Nigeria. “As a result, the lives of MSM are characterized by denial, violence, and stigmatization”.

Ms Adebajo was speaking at an ICASA session held yesterday on men who have sex with men and HIV infection in Africa. She said that a significant hurdle in reaching out to MSM in Africa, and in particular in West Africa, is criminalization; few MSM come forward for fear of stigma, discrimination, and legal repercussions.

At this forum researchers presented several findings, some preliminary, that shared similar conclusions: HIV prevalence for MSM is many times higher than ‘background populations’, few self-identified MSM seek medical support or identify themselves in their communities, startling numbers do not wear condoms when having sex, many engage in bisexual behaviour, and few get tested to know their HIV status.

“Many MSM when they finally had a HIV test and it was positive, had not known their status and had continued to engage in high-risk behaviour for some time,” said researcher Earl Ryan Burrell of the Desmond Tutu HIV Foundation. “HIV programmes in South Africa are heavily heterosexual and female focused… more recognition of MSM as a risk group is needed,” he added. His ongoing study in Cape Town and its surrounding townships showed that many MSM are not aware of the risks associated with certain sexual acts, despite self-identifying as MSM and having varying levels of access to HIV prevention information.

A study completed in 2006 in Nigeria revealed that little is known about the link between HIV prevalence and MSM in the country. But of those surveyed nearly all reported having multiple concurrent partnerships with both male and female sexual partners. Condom use was low and when condoms were worn, many men used saliva or soap or oil-based lubricants, such as domestic cooking oil which can damage the surface of  condom.

The researchers ended the session by encouraging African governments to invest more resources in supporting HIV prevention and, most importantly, to recognize MSM as a group that requires tailored programmes. “More is needed to be known. Each of these communities have their unique prevention and treatment needs,” said Ms Adebajo.

In 1990, the World Health Assembly approved the 10th Edition of the International Classification of Diseases (World Health Organization) on May 17, which established that sexual orientation (heterosexual, bisexual or homosexual), on its own, would no longer “be considered as a disorder”. For this reason May 17 is used to mark the International Day against Homophobia.

Of the 192 member states of the United Nations, 85 have laws that criminalize homosexual behaviour. In some of these countries, conviction can result in the death penalty.

The criminalization of homosexuality fuels discrimination and can force people to hide their sexuality for fear of prosecution. Where people cannot live openly with their sexual orientation, the risk of HIV infection and the impact of AIDS are greatly enhanced as people may be too afraid to access HIV prevention or treatment services. This is compounded where human rights violations on the basis of sexual orientation and gender identity are widespread. These violations include violence, vilification, arbitrary arrests, forced HIV tests, and discrimination.

In many cases—particularly where political or social leaders deny the existence of same sex sexuality or criminalize it—HIV services tailored to their needs are absent altogether from national responses to AIDS.

Infection rates remain disproportionately high among men who have sex with men. “To reduce HIV incidence among this group, as well as protect their human rights, we have to confront, condemn, and eradicate homophobia” said Susan Timberlake UNAIDS Senior Advisor, Human Rights and Law.

UNAIDS works with governments, civil society and the media to fight homophobia and other forms of stigma and discrimination directly and indirectly related to HIV.