In every country of the world there are men who have sex with men (MSM). Some men who have sex with men label themselves as gay, others as bisexual, while a large number – particularly outside western countries – simply see themselves as ‘normal’ males who just happen to have sex with men.

In the context of the global AIDS epidemic, sex between men is significant because it involves anal sex – a practice that, when no protection is used, carries a higher risk of HIV transmission than unprotected vaginal sex. Historically, AIDS was first discovered among self-identified young gay men in the USA, and throughout the course of the global epidemic, consistently high levels of HIV infection have been found among men who have sex with men in many countries.

Organisations representing men who have sex with men have also played an active and outspoken role in the response to AIDS. In the USA and the UK for example, gay men’s organisations have raised a great deal of awareness about HIV and AIDS. These groups continue to provide many services to both prevent people becoming infected with HIV, and to help those who are HIV-positive. Another example is Brazil, where groups of gay men exerted a lot of pressure on the government to protect the rights of HIV positive people in the early years of the nation’s AIDS epidemic.

“Not only is it unethical not to protect these groups; it makes no sense from a health perspective. It hurts all of us.”

- Ban Ki-moon, UN Secretary-General

In many countries however, men who have sex with men are less visible. Sex between men is stigmatised, officially denied and criminalised in various parts of the world. This adds to the vulnerability of men who have sex with men, and makes it near impossible to carry out relevant HIV prevention campaigns in some countries. In places where homosexuality is not tolerated, men who have sex with men often hide their same-sex relations from their friends and families to avoid persecution. Many have wives, or have sex with women as well as men, and this means that they may transmit HIV to their female partners if they become infected.² The significant impact that HIV is having on men who have sex with men is therefore not an isolated problem, but one that is very much linked to countries’ wider HIV epidemics.

Addressing the lack of services for marginalised groups in the global HIV epidemic, including men who have sex with men, Ban Ki-moon, the UN Secretary-General remarked, "not only is it unethical not to protect these groups; it makes no sense from a health perspective. It hurts all of us."³

Men who have sex with men and HIV – the global picture

Worldwide, it’s estimated that sex between men accounts for between 5 and 10% of HIV infections. The situation varies between countries however, and in much of the developed world – including the USA, Canada, Australia, New Zealand and many parts of Western Europe – more people have become infected with HIV through male-male sex than through any other transmission route.⁴

Sex between men is also a prominent feature in the spread of HIV in other regions. In Latin America, sex between men is a primary route of HIV transmission. HIV prevalence in some cities in Colombia ranges from 10% to 25%.⁵ The extent to which HIV and AIDS affects men who have sex with men in Eastern Europe and Central Asia is underrepresented by official statistics. In Ukraine for example, it has been estimated that there are between 177,000 and 430,000 men who have sex with men, of whom up to 15% are living with HIV - though just 110 cases have been officially recorded since 1987.^6 7 In Asia, HIV prevalence levels among men who have sex with men have reached as high as 18% in Andhra Pradesh, India; 15% in Phnom Penh, Cambodia; and 28% in Bangkok, Thailand – figures that are many times higher than those found among these countries’ overall populations.⁸

"What we are seeing today in Asia, in every single major city that we have looked at, are epidemics of HIV in men who have sex with men that remind me of what we saw in the US, western Europe, and Australia in the 1980s" - Peter Piot, executive director of UNAIDS, speaking at the 2008 Global Forum on Men Who Have Sex with Men and HIV⁹

In Africa – a region not commonly associated with male-male HIV transmission – there is growing evidence that transmission through this route is a significant problem.¹⁰ Though data from the region is severely lacking, studies of African men who have sex with men have shown that unprotected anal sex is commonplace,¹¹ and HIV prevalence among men who have sex with men is as high as 25.3% in some west African countries.¹² In Kenya, a country where homosexuality is illegal, HIV prevalence has reached as high as 43% among some groups of men who have sex with men.¹³

Although statistics like these give an idea of the impact that AIDS is having on men who have sex with men, data is still extremely scarce in many countries. This is largely due to the fact that men who have sex with men often have no separate social identity, and are simply counted as part of the general population. It is also due to the reluctance of governments to acknowledge men who have sex with men, and to monitor this group.

Another factor blurring statistics is that it’s not always possible to tell how a man became infected. If he is having sex with women as well, he may well report that HIV was transmitted to him from a woman (or even if he is only having sex with men, he may lie because of stigma). This can distort figures.

From the information that is available, it’s clear that HIV is a significant burden to communities of men who have sex with men around the world. But why is this the case? To answer this question, we need to look at the factors that put men who have sex with men at risk.

What makes men who have sex with men vulnerable to HIV?

Biological factors

• It’s easier for HIV to be transmitted through unprotected anal sex than through unprotected vaginal sex.
• If a man has another sexually transmitted infection (STI), this can be an extra biological factor that increases his risk of becoming infected with HIV. STIs are relatively common in some communities of men who have sex with men, and because men do not always think – or are not always encouraged – to be tested for STIs that are present rectally, these infections often go undiagnosed and untreated. In many cases, fear of discrimination stops men who have sex with men from accessing testing services.

Behavioural factors

• Certain behaviours increase the risk for men who have sex with men, of becoming infected with HIV. For example, having multiple sex partners, not using condoms consistently, not learning about HIV or having a complacent or negative attitude towards safer sex.
• Alcohol and drugs are a common part of socialising in some communities of men who have sex with men. Drink and drugs can make it more likely that people will have unprotected sex and a higher number of sexual partners. In the U.S. for instance, a study in Los Angeles found that men who have sex with men using the drug crystal meth were three times more likely to be infected with HIV than non-drug using men who have sex with men.¹⁴

Social/cultural factors

• Some governments and societies are in denial about the fact that sex between men happens, and it is a taboo subject in many cultures. As a result, HIV prevention campaigns often only talk about the risks of heterosexual sex, and there is little appropriate information available to men who have sex with men, which can give them the false impression that they are not at risk.
• In countries where sex between men is criminalised, MSM are excluded from sexual health services and may find it hard to access condoms and lubricants to protect themselves from HIV.
• A certain proportion of sex between men in most countries is commercial. As with female sex workers, male or transgender sex workers may find it difficult to persuade their clients to use condoms, or may be offered more money to have unprotected sex, increasing the risk that they will become infected with HIV. In some countries there are HIV programmes aimed at female sex workers, but none targeting male sex workers.¹⁵
• In countries where antiretroviral drugs are widely available, a climate of optimism about the effectiveness of this treatment may lead some men who have sex with men to take more risks.¹⁶

Responding to HIV among men who have sex with men: the challenges

In the early years of the global AIDS epidemic, it was widely acknowledged that HIV was having a severe impact on men who have sex with men. In the US and other developed countries there were visible communities of self-identified gay, lesbian and bisexual people. This led to swift grassroots responses from gay activists, often with support from national governments, who realised that carrying out HIV prevention campaigns aimed at gay people was not only the right thing to do on humanitarian grounds, but also something that made sense as a wider public health measure. These early prevention efforts (which included condom promotion and educating men about AIDS) were very successful, and helped to reduce the number of men who have sex with men becoming infected with HIV in a number of countries.

In recent years however, the impact of these interventions has leveled off and HIV is becoming common amongst men who have sex with men in many developed countries. It has also become increasingly clear that there is a desperate need for HIV prevention initiatives aimed at men who have sex with men in regions such as Eastern Europe, Asia, Latin America and Africa. However, very few countries in these regions are making sufficient (if any) efforts to stem rising rates of HIV among men who have sex with men. It is estimated that globally, HIV prevention services reach fewer than one in ten men who have sex with men.¹⁷ Consequently, less than half of men who have sex with men in low-income and middle-income countries have correct HIV knowledge.¹⁸

"it remains an undeniable fact in all regions of the world - including here in the US - that men who have sex with men lack universal access to HIV services” - UNAIDS Executive Director Michel Sidibé, speaking at the Forum on HIV, Human Rights and Men Who Have Sex with Men in 2009¹⁹

A major reason for this shortcoming is the fact that many countries have laws banning same sex relations. A 2009 report revealed that same sex relations between consenting adults is a criminal offense in 80 countries. In five of these countries (Iran, Mauritania, Saudi Arabia, Sudan, Yemen and parts of Nigeria and Somalia), it is punishable by the death penalty.²⁰ Where such laws are in place, governments are unlikely to promote any sort of HIV interventions aimed at men who have sex with men. Groups or individuals who do try to carry out such campaigns, as much as men who have sex with men themselves, may face violence or arrest:

"The police caught me and hit me. They didn’t even give me a chance to explain... I said I was working for HIV/AIDS prevention. They asked to see my ID card but I had forgotten it that day. They took me to jail. After I promised that I would never go to cruising spots again, they let me go." HIV prevention worker working with MSM in Bangladesh ²¹

In Senegal - a country where one study recorded that 22% of men who have sex with men were living with HIV ²² - the prosecution of nine activists involved in HIV prevention, treatment and care programs caused international outrage in 2009.^23 24 Though the sentences were later repealed,²⁵ the original verdict highlights how government discrimination can limit HIV prevention among men who have sex with men.

Discrimination from authorities is sometimes also apparent when men who have sex with men who are already living with HIV, try to access testing or treatment facilities:

“Our biggest problems are the police and doctors. Many [MSM] people we work with are poor – daily wage-earners – and cannot afford expensive private doctors. When they go to a government health clinic, the doctors taunt them about their sexual preferences. Many prefer to remain untreated rather than suffer discrimination and humiliation." Christopher Jayakumar, head of the Andhra Pradesh Male Minorities Association, India²⁶

Discrimination such as this stops men who have sex with men from revealing their same-sex relations, and may force them to meet potential partners in places that are hidden from the general public. This can make it very difficult to reach them with HIV prevention campaigns.

Experts argue that governments and societies need to adopt a less discriminatory approach if HIV prevention efforts aimed at men who have sex with men are to work. This includes repealing laws that criminalise sex between men, introducing laws to reduce human rights violations, and making greater efforts to change public perceptions of men who have sex with men. India's decision in July 2009 to repeal the law criminalising homosexuality is seen as a significant step towards improving the county's provision of HIV prevention, treatment and care for men who have sex with men.²⁷ However, even in countries where the rights of men who have sex with men are legally respected, there is generally a greater need for more commitment towards tackling the problem by donors and governments, as the amount of money put towards campaigns is often disproportionate to the scale of the problem.²⁸

Crucially, more research into the impact of HIV on men who have sex with men – particularly in developing countries – would lead to a much greater understanding of the situation and make it much easier to take appropriate action.

"The frightening truth is that, in many parts of the world, we simply do not know how bad the epidemics among MSM groups may be… transmission among MSM is still not tracked in most countries, resulting in a significant research gap. More research is urgently needed to inform more effective HIV prevention efforts.” Dr. Chris Beyrer, director of the Johns Hopkins Fogarty AIDS International Training and Research Program ²⁹

HIV prevention that works

When men who have sex with men are targeted by HIV prevention campaigns, it can be extremely effective. Behavioural interventions aimed at men who have sex with men have been found to reduce the number of men having unprotected anal sex by up to 43%, and increase condom use by 81%.³⁰

One of the most important prevention responses is to make high-quality condoms, along with water-based lubricants, available and accessible to men who have sex with men (if suitably strong condoms are not used then they may break, and if oil-based lubricants are used they can damage condoms). In some countries, gay bars and other known meeting places for men who have sex with men, such as bathhouses, provide and promote condoms and lubricants. Successful prevention work has also been carried out by outreach workers and peer educators, who meet with men who have sex with men personally and provide them with condoms, lubricants, and information.

As is the case with sex workers (another marginalised group who are heavily affected by HIV), many of the most successful programmes aimed at men who have sex with men empower this group and actively involve them.

"Empowering MSM and other marginalized groups to protect themselves from HIV is one of the world's most urgent health priorities." Peter Piot, UNAIDS ³¹

Even in countries where being homosexual is not widely recognised, and where HIV services for gay men are severely lacking, groups of men who have sex with men have made a substantial difference in some areas. In India for instance, the use of peers to distribute condoms among men who have sex with men has resulted in a significant increase in condom use in the city of Mumbai, where a study found that more than two-thirds of condoms used by men who have sex with men were those handed out by peer educators.³²

In some countries it has been understood that fighting prejudice and changing public attitudes towards men who have sex with men are important prevention measures. In Mexico, the government appointed Jorge Saavedra, an openly gay, HIV-positive man, as head of its national AIDS council, and he was the driving force behind a large nationwide media campaign to reduce homophobia.³³

Another successful approach has been to introduce ‘safe spaces’ where men who have sex with men can meet, talk openly and receive sexual health services, including testing facilities and treatment. Men who have sex with men have specific STI-related needs but often feel uncomfortable going to conventional public sector health services with their problems.³⁴ Early diagnosis of HIV infection is crucial to HIV prevention among men who have sex men. A study of men who have sex with men with primary HIV infection found that most participants substantially reduced their risk of onward transmission after being diagnosed and receiving counselling.³⁵

The internet can be another effective means of reaching out to men who have sex with men, as increasing numbers of gay people are meeting online – not just in developed nations, but also in countries such as the Philippines³⁶ and Peru³⁷. Some websites used by men who have sex with men place health advisors in chatrooms, display animated characters to educate people about HIV, and encourage users to be open about their HIV-status.³⁸

The way forward

Evidence and experience shows that providing AIDS programmes and services to those who are most at risk can be hugely beneficial to a country’s fight against AIDS. Yet men who have sex with men, like other ‘key affected groups’ in the global AIDS epidemic (such as sex workers and injecting drug users) are all too often being neglected by governments and international donors. Stigma and cultural intolerance of same-sex relations are largely to blame for this situation, and until these issues are addressed it will be difficult to make headway in reducing HIV infection levels among men who have sex with men – which, in turn, will hinder the wider global fight against AIDS. Attacking stigma and discriminatory practices, whether based in law or not, will serve to empower men who have sex with men to more effectively inform themselves about HIV and facilitate access to testing, prevention, treatment, care and support.³⁹

To ensure the response to the HIV epidemic among men who have sex with men is appropriate, it should be based on a wide range of quality evidence concerning, among other things, behavioural and epidemiological trends, human and legal rights, and programme monitoring and evaluation. Furthermore, such activities should involve a wide variety of people including affected communities, governments, international organizations, NGOs and businesses.⁴⁰

"The lack of HIV-related services for MSM is a massive failure, and setting it right has to be among the highest priorities for the increasingly strong global AIDS response as we aim to achieve universal access to HIV prevention, treatment, care and support for all groups, including men who have sex with men and transgender people." Purnima Mane, UNAIDS ⁴¹

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