Invisible Men
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UNIVERSITY OF CALIFORNIA Los Angeles Invisible Men: Constructing Men Who Have Sex with Men as a Priority at UNAIDS and Beyond A dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Philosophy in Sociology by Tara Ailinn McKay 2013 © Copyright by Tara Ailinn McKay 2013 ABSTRACT OF THE DISSERTATION Invisible Men: Constructing Men Who Have Sex with Men as a Priority at UNAIDS and Beyond by Tara Ailinn McKay Doctor of Philosophy in Sociology University of California, Los Angeles, 2013 Professor Stefan Timmermans, Chair In the last decade, gay men and other men who have sex with men (MSM) have come to the fore of policy debates about AIDS prevention. In stark contrast to global AIDS policy during the first two decades of the epidemic which excluded MSM from policy outside the West, UNAIDS now identifies MSM as “marginalized but not marginal” to the global AIDS epidemic. This dissertation provides an account of this controversial reversal of global AIDS policy and uses it as a point of departure for understanding the role of intergovernmental organizations (IGOs) like UNAIDS in the formation of global health priorities. In contrast to the emergence of other health and social policy issues, various studies observe that efforts to establish a global agenda for addressing HIV and AIDS have been highly concentrated within intergovernmental organizations. How and in whose interests do new priorities emerge within AIDS IGOs? Health policy researchers argue that IGOs have considerable influence in the formation and dissemination of health policies around the world. However, there is a particularly rich debate among sociologists and political scientists about whether and how IGOs can act autonomously and pursue policy priorities that are not supported by states. Because these organizations generally lack enforcement power and are dependent on states for financial resources and ii legitimacy, IGOs have traditionally been conceived as lacking autonomy to pursue their own policy interests independent of the interests of states. Yet, recent interventions by sociologists have shown how IGOs strategically navigate the demands of states and even attempt to reconfigure the external environment to promote alignment with the policy interests of the IGO. Nonetheless, concerns about resources continue to plague IGOs and often constrain their agency. In this dissertation I argue that a key limitation of existing studies on the autonomy and influence of IGOs is their narrow focus on the decision-making and agenda-setting stages of policy making. I extend sociological research on the influence and autonomy of IGOs by addressing how concerns about implementation shape the particular structures and strategies that AIDS IGOs adopt in order to pursue their own policy interests. Many of these strategies are not easily understood by existing theories of IGO behavior which argue that as bureaucracies, IGOs will seek to expand their autonomy and influence in a sector. In contrast, I argue that IGOs with limited power to enforce policy implementation by states are highly sensitive to an implementation-autonomy trade off and may actually give up some autonomy in decision- making in order to facilitate broader implementation by states. IGOs also face additional barriers to implementation due to decentralization of the organization at the regional- and country-level and competition from other IGOs, nongovernmental organizations, and bilateral and private donors. Using archival data from World Health Organization’s Global Programme on AIDS and its successor, the Joint United Nations Programme on HIV/AIDS (UNAIDS), two IGOs mandated by the United Nations to coordinate a global response to AIDS epidemic, I show in Chapter 1 how concerns about implementation have shaped decisions about the organizational structure of these IGOs. In addition, I show how implementation concerns have promoted the adoption of particular strategies – organizational inreach, interorganizational cooperation, iii evidence-based advocacy, and bidirectional pressure – to align policy preferences among states, other organizations, and even their own staff. The use of these strategies by AIDS IGOs has had consequences beyond the decision- making phase of policy development. Drawing on a novel dataset compiled from five waves of UN Country Progress Reports on HIV/AIDS (2003, 2006, 2008, 2010, and 2012), I show in Chapter 2 that the use of these strategies has promoted the alignment of national AIDS programs with UNAIDS policies on MSM over time. On the ground, IGO interest in HIV among MSM has also provided new technologies for seeing MSM in hostile political contexts. As I show in a country-case study presented in Chapter 3, claims for the recognition of same-sex sexualities in Malawi have had the most institutional success within the national AIDS programs which increasingly identifies MSM as a key target for public health intervention. Additionally, links between Malawian organizations and transnational research and advocacy networks have provided a context in which (male) same-sex sexualities have become statistically visible and institutionalized, providing a basis for future grassroots mobilization. At the same time, however, IGO interest in MSM has reinvigorated opposition to homosexuality among Malawian political elites and ordinary citizens. In Chapter 4 I introduce original household survey data collected in Malawi in 2012 (N=1491). Building on qualitative findings from Chapter 3, I use these data to quantitatively examine the effects of variation in aid allocations across Malawi’s administrative districts on attitudes toward homosexuality. Results show that in districts with higher levels of annual aid per capita, individuals hold more negative views of homosexuality. Thus while IGOs have had a substantial effect on state-level and donor- level adoption of policy priorities, they have had much less success in changing public views toward homosexuality on the ground. These results suggest that models of global diffusion that iv utilize policy change as an indicator for cultural change may be greatly overestimating cultural change on contentious issues like homosexuality. In sum, IGOs have become central actors in the formation, diffusion, and implementation of AIDS policy concerning same-sex sexualities. They develop new policy ideas and set priorities that may diverge substantially from the interests of member states, both rich and poor. However, IGOs also face considerable barriers to implementing their policy priorities: from reluctant states to the decentralization of staff across dozens of country offices to competition from other organizations and private donors. In this dissertation I show how barriers to implementation shape the structures and strategies of IGOs. As such, this work contends that IGOs are not simply disinterested forums in which states pursue their own interests or passive collections of rules and norms, but autonomous, influential, and self-interested actors that shape the policymaking process and the world around them, sometimes in unexpected and undesirable ways. v vi The dissertation of Tara McKay is approved. Patrick Heuveline Abigail Saguy Susan Cotts Watkins Stefan Timmermans, Committee Chair University of California, Los Angeles 2013 vii For my dad, who never finished, my mom, who made sure I did, and Vincent, who never doubted I would. viii Table of Contents Acknowledgements xiv Vita xix Introduction: (In)Visible Men 1 Chapter 1. From Marginal to Marginalized: Prioritizing Men Who Have Sex with Men in the Global Response to AIDS 29 Chapter 2. The Diffusion of Men Who Have Sex with Men to National AIDS Programs 65 Chapter 3. Between Money and Morals: Homosexuality and AIDS in Malawi, 1994-2012 106 Chapter 4. The Effects of Aid on Individual Attitudes toward Homosexuality in Malawi 145 Conclusion 172 Appendix A. Missing Country-Level Data 179 Appendix B. Malawi Household Survey Instrument 181 Appendix C. Description of Sampling Weights for Malawi Household Survey Data 196 References 199 ix List of Figures Figure 1. Total annual resources for AIDS, 1986-2007 47 Figure 2. Cumulative number of peer-reviewed articles on MSM and HIV in low- and middle-income countries, by region of study 82 Figure 3. Map of sampled districts, Malawi 150 x List of Tables Table 1. HIV/AIDS UNGASS Country Progress Report coding scheme 70 Table 2. Descriptive statistics for all country progress reports, by year 76 Table 3. Transition probability matrix for prioritization of HIV among MSM for all countries 79 Table 4. Descriptive statistics and data source for country-level characteristics, by year 85 Table 5. Probit models estimating change in prioritization of MSM, aid receiving countries only 98 Table 6. Descriptive statistics for district-level characteristics 158 Table 7. Descriptive statistics for 2012 Malawi Household Survey data (N=1491) 160 Table 8. Items measuring attitudes toward homosexuality 165 Table 9. Means and standard deviations of citizens’ priority preferences 168 Table 10. Multilevel random intercept regression coefficients and standard errors of model predicting prioritization of making laws to deal with same-sex sex 170 Table 11. Missing country-level data 179 xi List of Abbreviations amfAR American Foundation for AIDS Research CDC United States Centers for Disease Control and Prevention CEDEP Center for the Development of the People, Malawi DfID Department for International Development, United Kingdom ECOSOC United