August 2006 MSM and HIV/AIDS Risk in Asia: What Is Fueling the Epidemic Among MSM and How Can It Be Stopped? SPECIAL REPORT Table of Contents Acknowledgments ...................................................................................................................................i Executive Summary ................................................................................................................................1 Background ...............................................................................................................................................4 The Asian HIV/AIDS Epidemic HasTargetedVulnerable Communities ..............................................4 HIV/AIDS and MSM in Asia: A Smoldering Fire ...................................................................................4 What Is the Target Population? ............................................................................................................5 Diverse Populations; DiverseTerms ......................................................................................................5 MSM as a Problematic Categorization .................................................................................................5 MSM in Asia Engage in a Wide Variety of Behaviors ..........................................................................6 MSM Exist in Both Dense and Loose Networks ..................................................................................8 ,ACKOFA5NIÚED-3-#OMMUNITY ......................................................................................................8 Key Findings ........................................................................................................................................... 10 Asia Has Many MSM ............................................................................................................................ 10 Many MSM in Asia Have HIV/AIDS ..................................................................................................... 10 MSM in Asia Have a High Prevalence of Risk Behaviors .................................................................. 11 Table 1: Population and HIV Seroprevalence Data by Country ........................................................ 11 HIV Infection Among MSM Can Spread Quickly ................................................................................15 0REVENTION-ESSAGES&AILIF4HEY!RENOT3PECIÚCTO-3- .............................................................15 Interventions in Asia Have Worked .....................................................................................................16 Why Have MSM Been Neglected? .....................................................................................................17 Stigma and Violence Foster Invisibility ...............................................................................................17 MSM Are Less VisibleThan Other Vulnerable Groups .......................................................................18 Migration Further Complicates Interventions .................................................................................... 19 MSM Prevention Is Conducted Almost Exclusively by NGOs .......................................................... 19 What Is Needed? ....................................................................................................................................20 1. Recognition of the Problem and of the Urgent Need for Political Leadership ............................20 2. More Surveillance and Research to Understand Epidemics ........................................................21 3. Greater Access to Prevention andTreatment Services ..................................................................22 4. Support for Peer-Driven Initiatives ..................................................................................................23 Appendix 1: Methodology ..................................................................................................................25 Appendix 2: NGOs Leading the Way ................................................................................................27 !PPENDIX#OUNTRY0ROÚLES ............................................................................................................35 Appendix 4: Contributors ...................................................................................................................55 Appendix 5: Directory of Organizations Working With MSM in Asia .....................................56 Appendix 6: TREAT Asia and amfAR ...............................................................................................73 Appendix 7: Legality of Male-Male Sex ..........................................................................................75 Appendix 8: Bibliography/Endnotes................................................................................................. 76 Acknowledgments TREAT Asia gratefully acknowledges the invaluable contri- Among the earliest to recognize the need and commit butions of numerous organizations and individuals with- SIGNIÚCANTRESOURCESTOADDRESS()6!)$3AMONG-3-IN out whose help and support this report would not have Asia has been the U.S. Agency for International Develop- been possible. ment (USAID) and the U.S. Centers for Disease Control and Prevention (CDC). We are deeply indebted to those who have written about men who have sex with men (MSM) and HIV/AIDS in Many nongovernmental organizations (NGOs) both large Asia, and to the organizations that have supported and and small have labored to reach MSM despite widespread produced these articles and publications in order to call indifference or hostility from governments. Several of attention to the problem. Although too numerous to men- these organizations are described in Appendix 2, but two tion here, some of the excellent reports that framed this in particular deserve to be highlighted: analysis include an overview of global HIV prevention activities and gaps by the Global HIV Prevention Working • Family Health International has attacked the problem Group5 and a 2003 review of MSM networks and MSM re- on two fronts, supporting sociological and quantita- search in four Asian countries by the Australian Research tive research to document the scope of the problem Centre in Sex, Health, and Society.58 Carol Jenkins has and guiding local NGOs to implement peer-based ini- done invaluable work on the sociology of MSM and how tiatives. Its MSM initiatives started in 2000 in it affects HIV programming.85 The situation in South Asia Bangladesh, Cambodia, and India, and expanded in has been highlighted by Shivananda Khan99 (founder of 2001 to EastTimor, Indonesia, Nepal, Pakistan, Papua Naz Foundation International) and others.9 Finally, the New Guinea, the Philippines,Thailand, and Vietnam. MAP Network used its enormous collective knowledge • Naz Foundation International was described by one and experience to identify the urgent need for MSM pre- NGO staffer as a “real lighthouse in the darkness.”72 127 vention in Asia. A complete list of sources, including Along with HumsafarTrust and others in India, Naz MANYVALUABLECOUNTRY SPECIÚCREPORTS ISINCLUDEDINTHE HASHELPEDDEÚNETHE-3-LANDSCAPEIN3OUTH!SIA Bibliography/Endnotes beginning on page 76. and has worked tirelessly to publicize and reduce the plight of the South Asian MSM population. To help identify key factors fueling the spread of local epidemics in the region, our research included interviews ,AST WEWANTTOACKNOWLEDGEANDTHANKOURÚVECON- with front-line service providers, researchers, and activ- tributors. Nick Bartlett, Dr. Supriya Bezbaruah, and Paul ISTSWORKINGWITH-3-IN!SIAANDTHE0ACIÚC4HESEINDI- Causey conducted detailed interviews and provided in- viduals—more than 40 representatives in 19 countries— valuable regional context; Dr. Paul Galatowitsch designed generously gave of their time, participating in lengthy and directed the research strategy; and Dr. William Wells interviews two to three hours in duration.Their in-depth synthesized the research and wrote the main text.These knowledge of MSM issues and their insights into MSM extremely talented and dedicated individuals performed and HIV/AIDS programming needs in their countries pro- an extraordinary amount of work under enormous pres- vided vital information and added immeasurable value to sure in a remarkably short time. our work. We appreciate their time, candor, and enduring commitment to MSM and other vulnerable populations at We hope this report will serve as a catalyst for much risk for HIV and AIDS. A list of interviewees and their af- needed change, and help those working on the ground to ÚLIATIONSISINCLUDEDIN!PPENDIX make their case for the vital importance of their work. i | MSM and HIV/AIDS Risk in Asia Acknowledgments Executive Summary As the worldwide AIDS epidemic enters its second hold true.This report demonstrates that while addressing quarter-century, HIV prevalence among men who have HIV infection among MSM in Asia has been ignored for sex with men (MSM) is a growing concern, especially many reasons, it is critical to alleviating Asia’s escalating in Asia. In recent years, MSM in Asia have experienced epidemic. an extraordinary rise in HIV prevalence. Various studies report infection rates as high as 14% in Phnom Penh, Prevalence of Male-Male Sexual Activity Cambodia; 16% in Andhra Pradesh, India; and 28% in Although male-male sex is widespread in Asia, relatively