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Men who have sex with men (MSM) and HIV/AIDS
In every country of the world there are men who have sex with men (MSM). 1 Globally, they are a very diverse group. 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 heterosexual males who just happen to have sex with men.
"I’m not gay… I just like having sex with men." - Noun, Cambodia 2
Men may have sex with men for a variety of reasons including; attraction to other men, for pleasure or experimentation, societal or cultural norms, because of their environment (i.e. prisoners) or for financial reasons. 3
Men who have sex with men and the HIV epidemic
In the context of the global HIV and AIDS epidemic, sex between men is significant because it can involve 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.
“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
Organisations representing men who have sex with men have also played an active and outspoken role in the response to HIV and 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 assist 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 epidemic.
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 and awareness 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. 4 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. 5
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." 6
Men who have sex with men and HIV – the global picture
The situation in different regions
The situation relating to men who have sex with men in different regions is affected by many social, legal and cultural factors. Although the regions shown on the map below are broad, there are trends in the epidemic among MSM that are particular to certain regions. Hover your cursor over the coloured boxes in the image below to read more about a region:
Map showing information about: Europe, North America and Oceania; 7 8 9 10 Middle East and North Africa; 11 12 sub-Saharan Africa; 13 14 15 16 17 Eastern Europe and Central Asia; 18 19 20 21 Latin America & Caribbean; 22 23 24 25 South, East and South-east Asia; 26 27 28 29
How much is known about HIV among MSM around the world?
Although statistics like these give an idea of the impact that HIV and 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. It has been suggested that in settings where MSM are a particularly stigmatised group, collaborations between the government and NGOs are the most effective way to overcome government disregard and to reach this population. 30
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 and AIDS?
- 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 are not always encouraged to be tested for STIs that are present rectally, these infections often go undiagnosed and untreated.
- MSM are often not aware of the particularly high risk of sex with a person who has recently become infected. The viral load at this point in HIV infection is very high, and a person can be more likely to be unaware of their infection. In London, UK, a study suggested that 27 percent of infections among MSM were from a partner recently infected with HIV. 31
- Certain behaviours increase the risk of becoming infected with HIV for men who have sex with men. For example, having multiple sex partners or not using condoms consistently.
- 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. 32
- 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. 33
- 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. 34
- Dependence on one's family for emotional, economic and educational support often deters young men in particular from disclosing their status, which makes it difficult to access them with services designed for men who have sex with men. 35
- MSM are more likely to experience depression due to social isolation and disconnectedness from health systems, which can make it harder to cope with aspects of HIV such as adherence to medication. 36
Responding to HIV among men who have sex with men: the challenges
In the early years of the global HIV and 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 HIV and 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 levelled off and HIV is becoming common amongst men who have sex with men in many high-income 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 the Caribbean. It is estimated that in global cities, on average, HIV prevention services reached 55 percent of men who have sex with men in 2011. 37 However, MSM are 13 times more likely to be living with HIV than the general population, showing that prevention services need to reach more MSM in order to prevent further infections in this vulnerable group. 38
"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 2009 39
“I have no doubt that in the future, the laws that criminalise so many forms of human love and commitment will look the way the apartheid laws do to us now – so obviously wrong. Such a terrible waste of human potential.” - Archbishop Emeritus Desmond Tutu 40
A major reason for this shortcoming is the fact that many countries have laws banning same sex relations, many of which were first implemented during the colonial era and still remain. 41 As of 2012, same sex relations between consenting adults is a criminal offence in 78 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. 42 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 43
In Senegal - a country where one study recorded that 22 percent of men who have sex with men were living with HIV 44 - the prosecution of nine activists involved in HIV prevention, treatment and care programs caused international outrage in 2009. 45 46 Though the sentences were later repealed, 47 the original verdict highlights how government discrimination can limit HIV prevention among men who have sex with men.
Discrimination from authorities
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, India 48
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. 49 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 country's provision of HIV prevention, treatment and care for men who have sex with men. 50 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. 51
Lack of research
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 52
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 percent, and increase condom use by 81 percent. 53
Condoms and lubricants
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.
Empowerment and challenging prejudice
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. This makes sense from a practical, as well as ethical point of view: the resilience, and strategies that much of the population will have already built up can be utilised when developing prevention programmes. 54 Organisations staffed by MSM are often more credible and accessible to recipients. 55
"Empowering MSM and other marginalized groups to protect themselves from HIV is one of the world's most urgent health priorities." - Peter Piot, UNAIDS 56
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. 57
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. 58
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. 59 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. 60
Prevention through the internet
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 Philippines 61 and Peru. 62 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. 63
The way forward
Evidence and experience shows that providing HIV and AIDS services to those who are most at risk can be hugely beneficial to a whole country’s approach to HIV and AIDS. Governments and international donors must therefore cease to neglect the HIV epidemic among men who have sex men. This should begin with acknowledgement – at the end of 2011, only 87 countries reported on HIV prevalence among MSM. 64
"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 65
Stigma and cultural intolerance of same-sex relations are often largely to blame for rising epidemics, 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 efforts to manage HIV and 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. 66
To ensure the responses to the HIV epidemic among men who have sex with men are appropriate, they 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. 67 There should be culturally appropriate support available to men who have sex with men from across the diverse spectrum of people who belong to this group. 68
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- 2. IRIN (2007, 24th August), ‘Cambodia: focus on MSM and the spread of HIV/AIDS’
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- 33. IRIN (2006, September), ‘Pakistan: marginalised male sex workers vulnerable to HIV/AIDS’
- 34. Centers for Disease Control and Prevention (2007), ' Fact sheet: HIV/AIDS among men who have sex with men'.
- 35. 'Young People Most at Risk of HIV: A Meeting Report and Discussion Paper from the Interagency Youth Working Group, U.S. Agency for International Development, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Inter-Agency Task Team on HIV and Young People, and FHI' 2010
- 36. World Health Organisation (2011), ' Prevention and Treatment of HIV and Other Sexually Transmitted Infections Among Men Who Have Sex With Men and Transgender People'.
- 37. UNAIDS (2012) ' Global Report: UNAIDS Report on the Global AIDS Epidemic 2012'
- 38. UNAIDS (2012) ' World AIDS Day Report - Results'
- 39. Michel Sidibé (2009, 16th September),' Universal access for men who have sex with men: winds of change; signs of hope' [Speech].
- 40. Beyrer C. et al (2012, July) ‘ A call to action for comprehensive HIV services for men who have sex with men’. The Lancet, ‘HIV in men who have sex with men’
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- 43. Human Rights Watch (2003, August), 'Ravaging the vulnerable: abuses against persons at high risk of HIV infection in Bangladesh', Chapter 6: Abuses against men who have sex with men
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- 46. UNAIDS (2009, January), ' UNAIDS and broad coalition working towards the release of nine men who have sex with men in Senegal who have been convicted and imprisoned'.
- 47. BBC (2009, 20th April), ' Senegal gay convictions quashed'.
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- 49. International HIV/AIDS Alliance and Commonwealth HIV and AIDS Action Group, 2010 (2010, November) ' Enabling legal environments for effective HIV responses: A leadership challenge for the Commonwealth'
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- 51. Roehr B. (2008, 29th November), 'The invisible epidemic' BMJ 337(7681)
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- 57. MAP (2005), ' Male-male sex and HIV/AIDS in Asia'
- 58. Dominican Today (February 9th 2006), 'Anti-AIDS campaign seeks to counter machismo in Mexico'
- 59. Family Health International (2007), ‘ HIV/AIDS interventions with men who have sex with men (MSM)’
- 60. Fox J et al (2009), ' Reduction in HIV transmission risk behaviour following diagnosis of primary HIV infection: a cohort of high-risk men who have sex with men' HIV medicine 10(7).
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- 64. Beyrer C. et al (2012, July) ‘ A call to action for comprehensive HIV services for men who have sex with men’. The Lancet, ‘HIV in men who have sex with men’
- 65. UNAIDS (2007, March), ‘ Focused AIDS programmes in Asia and the Pacific’, press release
- 66. UNAIDS (2009), ‘UNAIDS Action Framework: Universal Access for Men who have Sex with Men and Transgender People’
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- 68. Millett G. A. et al (2012, July) ‘ Common roots: a contextual review of HIV epidemics in black men who have sex with men across the African diaspora’. The Lancet, ‘HIV in men who have sex with men’