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Assessing the Role of Human Rights Protections for Sexual Minorities in HIV Prevention in Asia

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Assessing the Role of Human Rights Protections for Sexual Minorities in HIV Prevention in Asia Assessing the Role of Human Rights Protections for Sexual Minorities in HIV Prevention in Asia: A Meta-Analysis by JAMES EDWARD ANDERSON, B.P.A.P.M. A thesis submitted to The Faculty of Graduate Studies and Research in partial fulfilment of the requirements for the degree of Master of Arts The Norman Paterson School of International Affairs Carleton University Ottawa, Ontario March 1,2012 © 2012, James Edward Anderson Library and Archives Bibliotheque et Canada Archives Canada Published Heritage Direction du Branch Patrimoine de I'edition 395 Wellington Street 395, rue Wellington Ottawa ON K1A0N4 Ottawa ON K1A 0N4 Canada Canada Your file Votre reference ISBN: 978-0-494-91560-8 Our file Notre reference ISBN: 978-0-494-91560-8 NOTICE: AVIS: The author has granted a non­ L'auteur a accorde une licence non exclusive exclusive license allowing Library and permettant a la Bibliotheque et Archives Archives Canada to reproduce, Canada de reproduire, publier, archiver, publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public communicate to the public by par telecommunication ou par I'lnternet, prefer, telecommunication or on the Internet, distribuer et vendre des theses partout dans le loan, distrbute and sell theses monde, a des fins commerciales ou autres, sur worldwide, for commercial or non­ support microforme, papier, electronique et/ou commercial purposes, in microform, autres formats. paper, electronic and/or any other formats. The author retains copyright L'auteur conserve la propriete du droit d'auteur ownership and moral rights in this et des droits moraux qui protege cette these. Ni thesis. Neither the thesis nor la these ni des extraits substantiels de celle-ci substantial extracts from it may be ne doivent etre imprimes ou autrement printed or otherwise reproduced reproduits sans son autorisation. without the author's permission. In compliance with the Canadian Conformement a la loi canadienne sur la Privacy Act some supporting forms protection de la vie privee, quelques may have been removed from this formulaires secondaires ont ete enleves de thesis. cette these. While these forms may be included Bien que ces formulaires aient inclus dans in the document page count, their la pagination, il n'y aura aucun contenu removal does not represent any loss manquant. of content from the thesis. Canada Abstract The notion of human rights being critical for HIV prevention is omnipresent within HIV discourse. In a world divided between States that criminalize homosexuality and those that protect sexual minorities, there is a need to better understand the relationship between human rights for sexual minorities and HIV prevention among men who have sex with men. To quantitatively measure this relationship, this study constructed an original instrument (the Sexual Orientation and Gender Identity Human Rights Index) to compare the legal environments for sexual minorities. Next, this study performed a meta-analysis on epidemiological and behavioural studies from 22 Asian countries in order to find national averages for HIV prevalence, inconsistent condom use, recent HIV testing, adequate HIV knowledge, and exposure to HIV prevention services. Although the relationships were mostly weak, the results do support the argument that greater human rights protections for sexual minorities is related to improved indicators of HIV prevention. ii Acknowledgements I would like to thank the University of Ottawa for awarding me a 2009 Summer Social Justice Fellowship, which gave me the opportunity to intern at the United Nations Educational, Scientific and Cultural Organization (UNESCO) in Bangkok, Thailand. That experience formed the inspiration and driving force behind conducting this study. I am grateful to the support provided to be me by my academic advisors, Prof. Valerie Percival (Carleton University), Prof. Penelope Simons (University of Ottawa), Prof. Edward Mills (University of Ottawa/University of British Columbia), and my supervisor, Prof. Yiagadeesen Samy (Carleton University). Also, the assistance with data analysis by Steve Kanters (Simon Fraser University, Center for Clinical Epidemiology and Evaluation) was invaluable. Lastly, I would like to thank those who helped me translate studies; my uncle James W. Anderson, who helped edit this thesis; Tanya Brunet, who has been a constant source of strength and encouragement; and my friends, family and colleagues who have supported me throughout the past four years. ~ For my mother ~ iii Contents Abstract ii Acknowledgments iii Contents iv List of Figures and Tables v Abbreviations vi Terminology vii 1 Introduction 1 1.1 Overview of the global HIV epidemic among MSM 4 2 Theoretical Framework 13 2.1 Overview of public international law and human rights 13 2.2 The human right to health 17 2.3 Human rights protection for sexual minorities 22 2.4 A human rights approach to HIV prevention among MSM 33 3 Literature Review 35 3.1 Stigma, discrimination and victimization 36 3.2 Maladaptive coping to sexual minority stress 42 3.3 Mobilizing civil society and relationship recognition 47 3.4 Facilitating sexual networking and risk-taking behaviour 51 3.5 Conclusions from the literature review 54 4 Methodology 56 4.1 Research question and hypotheses 56 4.2 Dependent variables - HIV prevention indicators 56 4.3 Independent variable - The SOGI Human Rights Index 63 4.4 Confounding variables. 67 4.5 Data collection 69 5 Data Analysis 73 5.1 Summary of findings 73 5.2 Bivariate analysis 75 5.3 Multiple-regression analysis 81 6 Conclusions and Policy Recommendations 85 6.1 General conclusions 85 6.2 Policy recommendations 88 7 Appendix 93 8 Bibliography 147 8.1 In-text references 147 8.2 Epidemiological and behavioural references 154 8.3 SOGI Human Rights references 169 iv List of Figures and Tables Figure 1: "Sexual minorities" constituting GLBT and MSM/WSW. vii Figure 2: Projected annual new HIV infections in Asia (status quo model) 3 Figure 3: Condom use among MSM 7 Figure 4: HIV testing among MSM. 7 Figure 5: HIV knowledge among MSM. 7 Figure 6: Coverage of HIV prevention for MSM 7 Figure 7: UN statement on sexual orientation, gender identity and human rights 30 Figure 8: Pathways between MSM and HIV risk, mediated by human rights 35 Figure 9: Minority stress model 43 Figure 10: Internalized homophobia and risk taking 47 Figure 11: CIRI Human Rights v. the SOGI Human Rights Index 66 Figure 12: SOGI Human Rights Index v. HIV prevalence 76 Figure 13: SOGI Human Rights Index v. inconsistent condom use 77 Figure 14: SOGI Human Rights Index v. recent HIV testing 78 Figure 15: SOGI Human Rights Index v. adequate HIV knowledge 79 Figure 16: SOGI Human Rights Index v. exposure to HIV prevention 80 Figure 17: SOGI Human Rights Index v. HIV prevention indicators (combined) 83 Figure 18: Projected annual new HIV infections in Asia (best practices model) 92 Table 1: Overview of research design 2 Table 2: Global HIV prevalence among MSM 5 Table 3: Countries reporting on the four MSN-related indicators to UNGASS 6 Table 4: Estimates of lifetime and recent MSM behaviour in LMIC 9 Table 5: Estimates of bisexual behaviour among MSM in LMIC 10 Table 6: Distribution of LMIC legal regimes with respect to sexual minorities 12 Table 7: Principle 17 - The right to the highest attainable standard of health 32 Table 8: Existing and missing data from the UNGASS biannual reports 57 Table 9: SOGI Human Rights Index template 65 Table 10: Confounding variables 68 Table 11: Summary of findings 73 Table 12: Confounding variables v. the SOGI Human Rights Index. 75 Table 13: Confounding variables v. HIV prevalence 76 Table 14: Confounding variables v. inconsistent condom use. 77 Table 15: Confounding variables v. recent HIV testing 78 Table 16: Confounding variables v. adequate HIV knowledge 79 Table 17: Confounding variables v. exposure to HIV prevention. 80 Table 18: Multiple-regression analysis of HIV prevention indicators each separately. 82 Table 19: Multiple-regression analysis of HIV prevention indicators all combined 83 Table 20: Comparison of HIV prevention indicators by legal regimes 90 Table 21: Inclusion of MSM in national strategic plans and surveillance in Asia 91 v Abbreviations AICHR ASEAN Intergovernmental Commission on Human Rights AIDS Acquired Immune Deficiency Syndrome ART Anti-Retroviral Therapy (or Treatment) ASEAN Association of Southeast Asian Nations AU African Union BSS Behavioural Sentinel Survey (or Surveillance) CAT Convention Against Torture CBO Community-Based Organization CEDAW Convention on the Elimination of All forms of Discrimination Against Women CESCR Committee on Economic, Social and Cultural Rights CRC Convention on the Rights of the Child CI Confidence Interval CIRI Cingranelli-Richards (Human Rights Dada Project) ECtHR European Court of Human Rights EU European Union GLBT Gay, Lesbian, Bisexual and Transgender HDI Human Development Index HIV Human Immunodeficiency Virus IDU Injecting Drug Users/ Injection Drug Use IACHR Inter-American Commission on Human Rights IBBS Integrated Bio-Behavioural Surveillance ICCPR International Covenant on Civil and Political Rights ICESCR International Covenant on Economic, Social and Cultural Rights IGLHRC International Gay and Lesbian Human Rights Commission ILGA International Lesbian, Gay, Bisexual, Trans and Intersex Association IQR Interquartile Range LMIC Low- and Middle-Income Country MARP Most At Risk Population MSM Men who have Sex with Men MTF Male-To-Female NCPI National Composite Policy Index NGO Non-Governmental Organization
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