SPECIAL REPORT August 2006 Risk inAsia: MSM andHIV/AIDS How CanItBeStopped? Epidemic AmongMSMand What IsFuelingthe Table of Contents Acknowledgments....................................................................................................................................i Executive Summary.................................................................................................................................1 Background................................................................................................................................................4 The.Asian.HIV/AIDS.Epidemic.Has.Targeted.Vulnerable.Communities...............................................4 HIV/AIDS.and.MSM.in.Asia:.A.Smoldering.Fire....................................................................................4 What Is the Target Population?.............................................................................................................5 Diverse.Populations;.Diverse.Terms.......................................................................................................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 Lack of a Unified MSM Community.......................................................................................................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 Prevention Messages Fail if They Are not Specific to MSM..............................................................15 Interventions.in.Asia.Have.Worked......................................................................................................16 Why Have MSM Been Neglected?......................................................................................................17 Stigma.and.Violence.Foster.Invisibility................................................................................................17 MSM.Are.Less.Visible.Than.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.and.Treatment.Services...................................................................22 4..Support.for.Peer-Driven.Initiatives...................................................................................................23 Appendix 1: Methodology...................................................................................................................25 Appendix 2: NGOs Leading the Way.................................................................................................27 Appendix 3: Country Profiles.............................................................................................................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- significant resources to address HIV/AIDS among MSM 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.East.Timor,.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.Humsafar.Trust.and.others.in.India,.Naz. many valuable country-specific reports, is included in the has helped define the MSM landscape in South Asia 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. Last, we want to acknowledge and thank our five con- with.front-line.service.providers,.researchers,.and.activ- tributors..Nick.Bartlett,.Dr..Supriya.Bezbaruah,.and.Paul. ists working with MSM in Asia and the Pacific. These indi- 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. filiations is included in Appendix 1. make.their.case.for.the.vital.importance.of.their.work. | MSM.and.HIV/AIDS.Risk.in.Asia..Acknowledgments Executve 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,.