AIDS and Men Who Have Sex with Men

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.

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

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. Adolescent males Some of it is full-time and The AIDS epidemic and men professional, though who have sex with men proportionally much less so than Adolescent men frequently have among female sex workers. Many sex with other males of their age male sex workers have a wife or group. They also sometimes have At least 5-10% of all HIV cases regular female partner and sex with older men — in some worldwide are due to sexual would not self-identify as cases with men considerably transmission between men, homosexual. Frequently, the older. This younger-older type of though this figure varies locally clients of male sex workers are male-to-male relationship is very considerably. In North married men or behaviourally common in certain cultures, America, Australia, New Zealand bisexual. where it is frequently within the and most of Western Europe, family (with an uncle, for UNAIDS believes the figures are Male sex workers can often find example). A ‘younger-older’ closer to 70%. themselves in a weak bargaining male relationship may be more position in their power to insist or less consensual, or it may be a In most developed countries and on condom use. However, reports violent and abusive one. In either some developing ones (such as from some countries, including case the younger man is likely to Indonesia, the Philippines and the Philippines, suggest that the be relatively vulnerable, because Mexico), the first detected cases female sex workers there face of a lack of knowledge about HIV of HIV and AIDS occurred in men more difficult conditions, and and a lack of negotiating skills — who had sex with men. Later, that the male sex workers have and also because the older although the absolute number of at least some degree of partner, simply because he has cases of male-to-male bargaining power. While probably had many more sexual transmission in several of these economic pressure is still an encounters, is more likely to be infected than a partner of the same age.

May 2000 UNAIDS Technical Update: AIDS and men who have sex with men The Challenges

Denial these factors makes them difficult Alternatively, the facilities may to reach for prevention work. exist, but the men may find Policy-makers and programme access to them difficult – for managers sometimes deny that Male sex workers can be reasons of negative attitudes on male-to-male sex occurs in their particularly difficult to access, the part of health staff towards part of the world. Denial is an especially where the work is same-sex behaviour, lack of enormous obstacle to efforts at clandestine and where the discretion or anonymity for AIDS prevention and care among workers are not organized into clients, inconvenient location or MSM. establishments. opening hours, or cost.

Inadequate epidemiological Difficulties of sustaining Stigmatization and data “safer sex” practices criminalization

Lack of, or unreliable Despite the initial successes in Societies can be hostile to men epidemiological data are an many prevention campaigns, in who engage in same-sex obstacle to HIV prevention work. some places — particularly in behaviour, stigmatizing it and In some places, risk exposure industrialized countries — MSM treating it as sinful or as criminal categories are not properly set have been found in recent years – in some places with severe up to take account of male-to- to practise safer sex (including penalties. Men will then often not male sex. condom use) less regularly than choose, or have the opportunity, before. Among the reasons for to be honest about the fact that Lack of knowledge or awareness this are: information fatigue; a they have had sex with other lack of innovative outreach work; men. Fearing to be questioned decreased funding for prevention about their sexual behaviour, In countries where HIV education efforts; and uncertainty among they will be reluctant to report emphasizes only heterosexual HIV-infected men who are symptoms of STDs, including HIV. transmission, men may be receiving antiretroviral treatment Because of this, all efforts at ignorant of the risks of male-to- about the continued risks — to education on HIV and safer sex, male sex, or consider that the themselves or their partners — of the provision of condoms, and risks don’t apply to them – and unsafe or unprotected sex. appropriate STD and other may therefore be less likely to medical care, are made protect themselves. Inadequate, inaccessible or extremely difficult. inappropriate health facilities Lack of appropriate Hostility on the part of society programmes MSM seeking attention on sexual also hinders effective HIV or medical matters, or tests for prevention efforts aimed at Many countries lack AIDS HIV or other STDs, may find such adolescents and young men who programmes for MSM. At the facilities to be lacking. have sex with other men. same time, existing programmes may be inappropriate. Educational material that is OCCUR suitable for people in a self- identified gay bar may be too The Japanese organization OCCUR is a good example of a self- explicit – and thus identified gay group working to strengthen community-type counterproductive – for those men who do not self-identify. responses on AIDS among gay men. Since 1986 OCCUR has aimed to create networks among homosexual men and women Difficulty of reaching many of in Japan, to disseminate accurate knowledge about the men who have sex with homosexuality to the general community, and to eliminate social men discrimination and prejudice. At the same time it operates safer sex campaigns on a yearly basis and publishes a newsletter for Many MSM engage in casual, people with HIV and AIDS. In December 1994, one of its leading fleeting and anonymous sexual members, a young man living with HIV, was appointed to join encounters. They may also not the official Japanese delegation to the Paris AIDS Summit. think of themselves as having sex with men. The combination of

AIDS and men who have sex with men: UNAIDS Technical Update May 2000 The Responses

Condom and lubricant Both peer education and outreach programmes directed at provision outreach programmes promote gay men have been shown to “safer sex” among MSM. have had an impact in changing One of the most important and Strategies for “safer sex” include behaviour. Airing the subject of effective responses to the switching from anal sex to other male-to-male sex in public can problem of HIV transmission in forms of sex with much lower also help reduce stigmatization. sex between men through anal risks for HIV/STD transmission, Campaigns using “small media” sex is to make high-quality male such as oral sex, intercrural sex such as pamphlets and booklets, condoms, together with water- (between the thighs – without which can be distributed based lubricants, available, penetration) and mutual discreetly, have been useful in accessible and affordable to men masturbation. An important many settings. who are likely to have sex with activity of outreach programmes other men. This can be done is providing easy access to high- effectively through the peer quality condoms and water- Gay community projects education and outreach based lubricants, and promoting programmes described below. In safer sex, knowledge of condom Another approach is to places where there is a gay use and negotiating skills. strengthen groups representing “scene”, condoms and lubricants Examples of successful projects self-identified gay men. This can be promoted in gay venues. include ALCS in Morocco (see applies not only to North This is particularly important Key Materials: Imane, 1995); America, Europe, Australia and where sex takes place on the CAN in Madras, India (see New Zealand, but also to a premises: several gay Kashyap N, “Educating Alis and growing number of large urban bathhouses, including in Hong men having sex with men: the areas in other parts of the world, Kong, Bangkok and Paris, make Chennai experience”, in AIDS including São Paulo, Mexico City, condoms and lubricants available Watch newsletter, July 1997 Bangkok, Hong Kong, Seoul, free to clients. 2(2):2-3, WHO/SEARO, New Taipei, Jakarta, Manila, Kuala Delhi); the Lentera project for Lumpur, Tel Aviv and Cape Town. Instructions on the correct use of transvestites in Yogyakarta, In Australia, the United States condoms should be supplied as Indonesia; Lambda in Chile; the and other Western countries, HIV part of the packaging of condoms Mpowerment project in Oregon, infection rates among MSM have and lubricants, or in the context USA; and Iwag Davao’s “Center dropped mainly through the of skills training. for Gay Men” on Mindanao efforts of gay men’s island in the Philippines. organizations themselves. The experience in several developing Peer education and outreach It is important that adolescents countries suggests that AIDS has programmes and young men are educated by encouraged self-identified gay their peers on HIV risks and men to move into community prevention methods. Frequently Peer education uses current organizing, sometimes with lacking access to information on minimal external support. members of the affected sex between men, they are often community. In outreach work, a ignorant of the risks and more mixture of trained professionals Parallel with this approach is the vulnerable than others, and will possibility of organizing gay bar and volunteers go out to find the tend to listen to their friends. MSM, wherever they congregate. owners in HIV prevention The face-to-face methods used in activities. This happened in Bangkok, where a gay bar these approaches afford privacy Media campaigns and confidentiality, and enable owners’ association has actively the person to ask questions. They undertaken AIDS education and also enable the educator to train Mass media campaigns on the condom promotion. the person. Both approaches – risks of unprotected sex between which have been widely used by men and promoting the use of nongovernmental AIDS service condoms and water-based Educating the health services organizations, and others – can lubricants are possible in some be effective for a large range of settings. In Australia and The public health services are casual encounters between men. Switzerland, for instance, media one of few (if any) official points campaigns together with of contact where many men who

May 2000 UNAIDS Technical Update: AIDS and men who have sex with men The Responses

have sexual encounters with men When HIV programmes aimed at Governments should review, with are likely to receive information, MSM are operating, it is vital that the aim of repealing laws that counselling, check-ups and they should be maintained. There criminalize specific sexual acts treatment. It is important that have been cases, including in between consenting adults in there should be strong developed countries, where private. (According to page 14 of educational programmes among programmes had their funds the Second International health workers to promote non- reduced, or even stopped, after Consultation on HIV/AIDS and discriminatory attitudes towards the project was declared to have Human Rights held in Geneva male-to-male sex, and to have been “successful”, or when it was in1996, “Criminal law prohibiting the appropriate counselling, thought that the risk to men sexual acts (including adultery, preventive and medical engaging in same-sex behaviour sodomy, fornication and approaches adopted. STD clinic had declined. commercial sexual encounters) staff should be sensitized to the between consenting adults existence of anally and rectally in private should be reviewed, located STDs. Anonymity is Greater understanding and with the aim of repeal. In any important in encouraging MSM to an end to denial event, they should not be use these services. allowed to impede provision of All the previous suggested HIV/AIDS prevention and care responses have a very much services”. See HIV/AIDS and A greater effort by national greater probability of success if Human Rights: International AIDS programmes and donor society adopts a non- Guidelines, available on the agencies discriminatory approach to men UNAIDS website at http:// having sex with other men – www.unaids.org/publications/ National AIDS programmes ending the stigmatization and documents/human/index.html). should address and incorporate marginalization that exist in Such action will greatly help the the particular requirements of many places. More determined provision of HIV/AIDS prevention MSM into the design of their efforts must be made to change and care services and reduce the STD/HIV prevention and AIDS public perceptions and get rid of vulnerability of MSM to HIV care programmes. While some of denial and prejudices on the infection and to the impact of them do so at present, many still subject of MSM. Serious AIDS. do not. Donor agencies should consideration should be given to be given more information on introducing anti-discrimination More research towards the situation of MSM. They and protective laws to reduce understanding same-sex should also make a higher human rights violations against behaviour, its prevalence and priority of funding the MSM, including in the context of relation to HIV risk, should also implementation and evaluation HIV/AIDS. be carried out. of projects with male-to-male sex as one of the main components.

Mass media campaign and NGO projects: the example of Brazil

In the first years of the epidemic in Brazil, from 1983 to 1987, most HIV prevention efforts were aimed at MSM. These included large-scale government-inspired mass media campaigns, and peer education and outreach programmes operated by nongovernmental AIDS service organizations. In São Paulo state – considered representative of Brazil for this purpose – the number of new AIDS cases where infection was through male-to-male sex rose steadily each year, to a maximum of 1464 in 1992. Since that year, the number of new AIDS cases has fallen each year, with 953 reported in 1995. Given the time lag between seroconversion and onset of AIDS, it is possible that HIV incidence had started to fall by 1986 or earlier. This suggests that the combination of early mass media campaigns and NGO work, both aimed specifically at MSM, was effective in Brazil.

AIDS and men who have sex with men: UNAIDS Technical Update May 2000 Selected Key Materials

Aggleton P (ed). Bisexualities and AIDS. Khan S. Sex, secrecy and Seabrook J. Love in a different climate: London: Taylor and Francis, 1996. shamefulness: developing a sexual men who have sex with men in India. Includes chapters on MSM and health response to the London: Verso, 1999. bisexual behaviour in wide range of needs of males who have sex Book based on research and countries including Brazil, China, with males in Dhaka, Bangladesh. interviews among MSM in New Delhi. Costa Rica and Mexico. London: The Naz Foundation, 1997. Explores sexual histories, lifestyles, Report based on situation analysis of attitudes and knowledge of HIV/AIDS. Aggleton P (ed). Men selling sex. MSM behaviours in Dhaka, London: Taylor and Francis, 1999. Bangladesh, incorporating findings Sullivan G, Leong LW-T (eds). Gays Describes male sex work around the from training workshops. and lesbians in Asia and the Pacific: world, with many references to HIV/ social and human services. AIDS. Chapters on Brazil, Costa Rica, Murray SO, Roscoe W (eds). Boy wives New York and London: Haworth Dominican Republic, Mexico and and female husbands: studies of Press, 1995. Peru; Bangladesh, Philippines, Sri African homosexualities. General description of homosexual Lanka and Thailand; Morocco; London: St. Martin’s Press, 1998. cultures in Asia and Pacific. Includes Canada, England, France, Collection of essays examining a three articles specifically on AIDS Netherlands, USA and Wales. range of homosexualities throughout services and strategies: in Singapore, Africa, with several historical studies. the Philippines and Australia. Altman D. Power and community. Includes chapters on Cameroon and London: Taylor & Francis, 1994. Angola in early 20th century; east Tan M. Recent HIV/AIDS trends Analyses practical dilemmas faced by African coast and Zanzibar; brothels among men who have sex with men. community-based organizations of in Dakar, Senegal; Lesotho; and Chapter in Shiokawa Y, Kitamura T MSM worldwide, highlighting tensions sexual politics in southern Africa. (eds). Global challenge of AIDS: ten between AIDS activism and service years of HIV/AIDS research. provision, and between volunteer Parker R. Beneath the equator: cultures Tokyo: Kodansha, and Basle: Karger, participation and management of desire, male homosexuality and 1995, pp. 27-34. control. emerging gay communities in Brazil. Chapter presents an overview of New York and London: Routledge, epidemiological, social and Imane L. Prévention de proximité 1999. behavioural trends among MSM with auprès des prostitués masculins au Examines how changing urban regard to HIV/AIDS in various parts of Maroc: le cas de Casablanca et de culture in Brazil over past century has world. Marrakech. Report on the programme influenced development of gay and of the Association Marocaine de Lutte other sexual identities. Describes Werasit S, Brown T, Chuanchom S. contre le SIDA (ALCS), 1993-1995. increasingly diverse gay subcultures Levels of HIV risk behaviour and AIDS Casablanca, 1995. and emerging communities. Sections knowledge in Thai men having sex Report highlights first project in Arab- on AIDS activism, and on migration of with men. In AIDS Care, 1993, Muslim world for outreach to male sex male sex workers in Brazil. 5(3):261-271. Study of MSM in workers on HIV/AIDS prevention. Northeast Thailand. Focuses on Includes aspects of attitudes and Schmitt A, Sofer J (eds). Sexuality and sexual acts, partnerships, lack of behaviour, condom distribution, STD eroticism among males in Moslem condom use, and defects in AIDS treatment, counselling and societies. New York: Harrington Park knowledge. Makes recommendations anonymous testing. Press, 1992. Range of articles for interventions. examining how MSM in Islamic societies regard their behaviour and their feelings to other men. Covers North Africa, Middle East, Central Asia and South Asia.

© Joint United Nations Programme on HIV/AIDS 2000. All rights reserved. This publication may be freely reviewed, quoted, reproduced or translated, in part or in full, provided the source is acknowledged. It may not be sold or used in conjunction with commercial purposes without prior written approval from UNAIDS (contact: UNAIDS Information Centre, Geneva–see page 2.). The views expressed in documents by named authors are solely the responsibility of those authors. The designations employed and the presentation of the material in this work do not imply the expression of any opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers and boundaries. The mention of specific companies or of certain manufacturers' products do not imply that they are endorsed or recommended by UNAIDS in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

May 2000 UNAIDS Technical Update: AIDS and men who have sex with men