AIDS and Men Who Have Sex with Men
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AIDS and men who have sex with men Joint United Nations Programme on HIV/AIDS UNICEF • UNDP • UNFPA • UNDCP UNESCO • WHO • WORLD BANK UNAIDS Technical update May 2000 UNAIDS Best Practice Collection At a Glance UNAIDS Best Practice materials The Joint United Nations Programme on HIV/AIDS (UNAIDS) publishes materials on subjects of Sex between men exists in most societies. It frequently involves relevance to HIV infection and anal sex. Unprotected penetrative anal sex carries a high risk of AIDS, the causes and consequences HIV transmission, especially for the receptive partner. of the epidemic, and best practices in AIDS prevention, care and HIV prevention programmes for men who have sex with men (MSM) are hindered by the following: support. A Best Practice Collection on any one subject typically denial that sexual behaviour between men takes place includes a short publication for journalists and community leaders stigmatization or criminalization of men who engage in sex with (Point of View); a technical summary other men of the issues, challenges and inadequate or unreliable epidemiological information on HIV solutions (Technical Update); case transmission through male-to-male sex studies from around the world (Best the difficulty of reaching many of the MSM Practice Case Studies); a set of presentation graphics; and a listing inadequate or inappropriate health facilities, including sexually transmitted disease (STD) clinics, and lack of awareness or of Key Materials (reports, articles, sensitivity among STD clinic staff about the existence of anal, books, audiovisuals, etc.) on the rectal and oral STDs subject. These documents are updated as necessary. lack of interest among donor agencies in supporting and sustaining prevention programmes among men who engage in Technical Updates and Points of same-sex behaviour, and a lack of programmes addressing male View are published in English, sex workers in particular French, Russian and Spanish. Single lack of attention in national AIDS programmes to the issue of copies of Best Practice materials are MSM. available free from UNAIDS Effective responses to these problems include a combination Information Centres. To find the of the following: closest one, visit the UNAIDS commitments by national AIDS programmes and donor agencies website (http://www.unaids.org), to include the issue of MSM in their programmes and funding contact UNAIDS by email priorities ([email protected]) or telephone (+41 22 791 4651), or write to the outreach programmes by volunteers or professional social or UNAIDS Information Centre, health workers 20 Avenue Appia, 1211Geneva 27, peer education among MSM Switzerland. the promotion of high-quality condoms and water-based lubricants, and ensuring their continuing availability safer sex campaigns and skills training, including in the use of AIDS and men who have sex with condoms, and the promotion of lower-risk sexual practices as men. UNAIDS Technical update. alternatives to penetrative sex English original, August 1997, first revision May 2000. strengthening organizations of self-identified gay men, enabling I. UNAIDS II. Series them to promote HIV prevention and care programmes 1. Acquired immunodeficiency promoting mass media campaigns, while ensuring that these are syndrome - transmission culturally appropriate 2. Homosexuality, male education among health staff, including within STD clinics, to 3. Acquired immunodeficiency overcome ignorance and prejudices about MSM syndrome - prevention and control efforts to organize health facilities to make them accessible and UNAIDS, Geneva WC 503.71 affordable breaking down social and cultural barriers against the discussion of male-to-male sex reviewing — with the aim of abolishing — laws that criminalize certain sexual acts between consenting adults in private enacting anti-discrimination and protective laws to reduce human rights violations against MSM. 2 May 2000 UNAIDS Technical Update: AIDS and men who have sex with men Background Sex between men occurs in most societies. For cultural reasons, it is often stigmatized by society. The public visibility of male-to-male sex, therefore, varies considerably from one country to another. Sex between men frequently involves anal intercourse, which carries a very high risk of HIV transmission for the receptive partner, and a significant risk, though a lesser one, for the insertive partner. HIV prevention programmes addressing men who have sex with men (MSM) are therefore vitally important. However, they are often seriously neglected – because of the relative invisibility of MSM, stigmatization of male-to-male sex, or ignorance or lack of information. Identity and behaviour self-identified gay men has also Technical Update, Prisons and grown – often through local AIDS). Sexual identity is different from initiatives – particularly in some sexual behaviour. Many men who Asian and Latin American Male-to-male sex, anal have sex with other men do not countries. Along with this self- intercourse and HIV regard themselves as identification, gay meeting places have sprung up – organized homosexual. In a number of Penetrative anal sex frequently social groups or campaigning societies, the way such men view occurs in sex between men. If groups, and gay bars, discos, their own sexual identity is HIV is present in the insertive gyms and saunas. determined by whether they are partner, and if condoms are not the insertive or the receptive used, then anal sex carries an Even in places where most MSM partner in anal sex. In these especially high risk of HIV are obliged to stay out of public societies, many men who have transmission for the receptive view, some will choose to be sex with other men self-identify partner. The risk to a receptive visible. These include transvestite as completely heterosexual, on partner in unprotected anal sex is men and transsexuals. Because the grounds that they take an several times higher than the they are often the only visible exclusively insertive role in such next most risky category, that of a ones, they frequently become activities. woman having unprotected stereotyped as typical of all MSM. vaginal intercourse with an HIV- In fact, such “transgendered” Worldwide, a large percentage of infected man. The reason for this people usually represent only a MSM are married or have sex is that the lining of the rectum is very small percentage of all MSM. with women as well. This bisexual thin and can easily tear – and behaviour is reported to be even only small lesions in the Sexual preference common in some societies, such lining are sufficient to allow the as in Latin America (see Schifter J, virus easy access. Even without et al, “Bisexual communities and Most same-sex behaviour is lesions, it has been postulated cultures in Costa Rica”, and conducted out of natural that there might be a lower Parker RG, “Bisexuality and HIV/ preference. There are also, natural immunity in the cells of AIDS in Brazil”, both in Key however, instances of institutions the rectal lining to resist HIV than Materials: Aggleton P (ed), 1996) where men are obliged to spend there is, for instance, in the lining and in North Africa (see Schmitt long periods in all-male company, of the vagina. There is also a risk A, “Different approaches to male- such as in the military, prisons, of HIV infection from unprotected male sexuality/eroticism from and male-only educational anal intercourse, though a lesser Morocco to Uzbekistan” in Key establishments, and in which one, for the insertive partner. Materials: Schmitt and Sofer male-to-male sex can be (See Detels, R, “The contributions (eds), 1992). common. While such institutional of cohort studies to under- male homosexual behaviour standing the natural history of A self-awareness among MSM represents only a small part of all HIV infection”, in Nicolosi A (ed), has developed, and now exists to male-to-male sex, it can HIV epidemiology: models and a considerable extent in nonetheless be important from methods, Raven Press, New York, industrialized countries – though the point of view of the AIDS 1994, p.239.) even in these countries there are epidemic. Male prisons, for many men who have sex with example, have been shown to The presence of other untreated other men who do not identify make a significant contribution to sexually transmitted diseases themselves as homosexual or some countries’ epidemics – both (STDs) – such as syphilis, “gay”. In some parts of the through drug injecting and male- gonorrhoea and chlamydia – can developing world the number of to-male sex (see UNAIDS further greatly increase the risk 3 AIDS and men who have sex with men: UNAIDS Technical Update May 2000 Background of HIV transmission, when HIV is countries often continued to rise, important reason for male sex present. STDs located in the anus the proportion of such cases workers not using condoms, they and rectum can often be decreased while the proportion are usually more able than asymptomatic. of cases among heterosexual female sex workers to resist men and women increased physical coercion, and can often Oral (oro-penile) sex is also correspondingly. This can hide be more selective in choosing common among MSM. While HIV the scale of the problem for MSM. clients. could be transmitted through such sex if not protected by a Major social and political condom, the risk is generally Commercial sex between men upheavals and emergency considered low. (See Samuel, situations — especially those MC, et al. “Factors associated displacing people and creating with human immunodeficiency In most countries, a certain refugees — can in certain virus seroconversion in proportion of sex between men is circumstances act as a catalyst to homosexual men in three San in some way commercial, though push significant numbers of Francisco cohort studies, 1984- this can cover a wide range of young men (as well as women) 1989”. Journal of Acquired possibilities. Much sex work is into prostitution. Immune Deficiency Syndromes highly informal, with the 1993 6(3):303-12.) expectation perhaps of a small “present” for services rendered.