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Young men who have sex with men (YMSM) and HIV/AIDS
Introduction to young men who have sex with men
Similarly, young people are at a heightened risk of HIV transmission, representing over 40 percent of new infections globally. 4 Despite the continuing impact of HIV and AIDS, evidence suggests that awareness is decreasing among young people, with sexual risk behaviours rising in some countries. 5
The same pattern of increasing prevalence and decreasing awareness exists for Sexually Transmitted Infections (STIs) in general, with many young people underestimating their exposure to STIs including HIV. In the UK, the numbers of young people with chlamydia, gonorrhea and genital herpes has risen by more than 100 percent since the 1990s. 6
Despite the obvious need for intervention, the particular needs of YMSM are often overlooked by research, policy and programs designed to help general MSM, young people and the wider population. As a result, data on this vulnerable group is limited. 7
HIV prevention challenges faced by young MSM
A lack of awareness
The Center for Disease Control and Prevention's (CDC) 2009 National Youth Risk Behaviour Survey (YRBS) found young people consume alcohol, tobacco and drugs at a higher rate than any other demographic. Being under the influence of alcohol or drugs increases the likelihood of individuals engaging in high-risk behaviours, such as unprotected sex. 10
Sexually transmitted infections (STIs)
Dependency on family for housing and income support
If a young persons family do not understand or accept their sexuality, they may withdraw their financial support. Many studies have shown that the loss of stable housing can encourage young people to engage in high-risk behaviour including unprotected sex, getting money for sex and needle sharing. 12 A shortage of income and poverty have also been associated with increases in HIV prevalence. 13 The 2012 Global Men's Health and Rights (GMHR) Survey found that 20 percent of YMSM surveyed had no income and 30 percent didn't have stable housing. 14
YMSM access to HIV prevention services is very low
The 2012, Global Men's Health and Rights (GMHR) Survey found access to HIV prevention services (including condoms, HIV testing, MSM-focused education) for MSM was low but even more so for YMSM. In fact, only 33 percent reported easy access to low-cost condoms, and even lower percentages for affordable lubricants (18 percent), affordable STI treatment (14 percent), HIV education materials for MSM (9 percent) and HIV risk reduction programmes for MSM (7 percent). 15
“There is a severe lack of general sexual health services in the Middle East and North Africa, let alone those which are equipped and sensitised to cater to the needs of young MSM, who do not have the social or financial support to consult a private care provider. YMSM need access to information and services to keep themselves healthy.” - Johnny Tohme, Lebanon 16
YMSM experience much higher levels of stigma and discrimination in the form of homophobia and violence, even compared to older MSM. Homophobia is associated with reduced access to condoms, lubricants, HIV testing, and HIV treatment. YMSM are also less likely to engage in the local community, use HIV service providers and connect with the gay community. 17
Preventing young MSM from becoming infected with HIV
The evidence on HIV infections among YMSM shows there is a need to accelerate current prevention work as well as develop new approaches. Effective management of HIV is essential in order to improve the health of people living with HIV and lower prevalence rates. HIV testing must be made widely accessible, and those who test positive for HIV must be put on the correct antiretroviral treatment (ART) regimen, and be monitored appropriately.
Treatment as prevention
The World Health Organisation (WHO), recommends that people living with HIV should commence antiretroviral treatment when a person's CD4 count is less than 500 cells/mm3. 18 Starting treatment early lowers the HIV viral load in a person’s body, reducing the risk of onwards HIV transmission. 19 Encouraging early treatment among YMSM living with HIV, is a key step to reducing HIV transmission among this vulnerable group.
Laws equalising the rights of YMSM with the general population can help normalise sexual differences. Laws can also be widened to make sure that discrimination on the basis of sexual orientation is dealt with like other forms of discrimination.
Gay men suffered particular stigmatisation when they were widely perceived to be responsible for the HIV epidemic rather than being affected by it. 20 Raising public awareness and understanding has an important part to play in challenging misconceptions like this.
In 2012, the Global Forum on MSM and HIV (MSMGF) announced a number of recommendations aimed at combating HIV among YMSM:
- addressing housing stability and economic independence
- provide comprehensive HIV prevention specific to YMSM
- improve treatment and care for YMSM living with HIV
- address barriers and facilitators that impact on access to HIV services
- support YMSM leadership and involvement. 21
Examples globally of HIV prevention for Young MSM
USA: The Mpowerment Project, based in California, works with YMSM between the age of 18-29 to initiate discussion groups and informal conversations with their peers to promote safer sex. These men provide their peers with condoms and inform them about HIV prevention. YMSM are involved in the management, design and implementation of the project, helping to ensure its relevance to other YMSM. It was the first documented HIV prevention intervention for YMSM to succeed in reducing sexually risky behaviour such as unprotected anal sex. 22 23
Costa Rica: Between 2008 and 2011, a UNAIDS supported HIV prevention programme trained 80 peer educators between the age of 18 and 24 in the cities of Limon and Puntarenas. The educators provided educational and communication materials to their counterparts through a range of means, including online games, Facebook, youth carnivals and community fairs, as well as other musical, artistic and recreational activities. 24
“It’s really great to see how at the end of a session the group knows more about HIV. We also have a better idea of how to protect ourselves and deal with our relationships more successfully. ” - José, one of the HIV peer educators in Limon, Costa Rica. 25
Senegal: An intervention in Dakar, specifically designed for MSM, and particularly effective at reaching YMSM, successfully increased HIV knowledge and use of testing services. The programme used peer educators to disseminate information and condoms. It also targetted the media to address issues facing MSM, and engaged health providers to make STI services more accessible. 26
Jamaica: From May 2012 to February 2013, the Children First Agency and UNESCO supported the Youth MSM Empowerment Project (YMEP) in Jamaica, which aimed to combat homophobia and its effects on the HIV epidemic among YMSM. The intervention provided an opportunity and the space for YMSM to express their fears and experiences in a youth-friendly setting in order to sensitise and educate key stakeholders. 27
Belgium: A Flemish HIV prevention organisation developed a project involving YMSM who had just 'come out' in working with other young men who are unsure or just finding out about their sexuality. YMSM were trained and equipped to run 'house parties' and other small events in community venues and people's homes at which young men could come together to talk about their feelings and experiences. Safer sex materials and condoms were also made available. 28
Anal sex, young MSM and HIV
Effective HIV prevention needs to take into account behaviours that put YMSM at particular risk of HIV.
Anal sex without a condom (unprotected anal sex), has the highest risk of HIV transmission during sex. Unprotected anal sex carries a high risk of HIV transmission because during anal sex it is easy to make small tears or cuts in and around the rectum. 29 The use of condoms and lubricant are important means of HIV prevention.
Why do some Young MSM have unprotected anal sex regardless of the risks?
There are a number of reasons and circumstances why YMSM decide to have unprotected anal sex, despite knowing about the risks of HIV infection. These reasons are not exclusive to YMSM, MSM in general as well as heterosexual men and women make similar decisions about whether to use condoms.
A body of research has shown how men diagnosed with HIV are more likely to have unprotected anal sex with someone who they knew were diagnosed with HIV, compared to partners who tested negative. 32 This is known as sero-sorting. A 2007 study found that 58 percent of HIV-positive men diagnosed in London clinics in the previous 12 months engaged in this type of behaviour. 33 One reason for this behaviour is greater intimacy. 34 However, many studies indicate that men having unprotected anal sex often overestimate the likelihood that a sexual partner is also HIV-positive. 35 36
Sero-sorting has the major risk of additional STI transmission or re-infection with a different strain of HIV. However, it is unclear how HIV-positive men perceive this threat, and how, if at all, they respond to it. 37
“Between the time that I became positive, and before realising that I was, I had sex with one person. It was a casual situation, but we had been chatting for several weeks before we got together. During that time I initiated my usual barrage of questions regarding status and sexual health, and told him of my presumed negative status at the time. Because I brought the conversation up in the first place, and furthermore because I was completely forthcoming and frank (and completely believed myself that I was negative) there was absolutely no reason that he doubted what I said. He was obviously completely willing and hoping to have unprotected sex - fortunately for him, I was not, and we didn't. Not only was I positive at the time, I was about two months into the progression of the disease - at one of the most virulent (and contagious) phases. It was about a month after that encounter that I got tested and my viral load was in the hundreds of thousands. ” - Darrell, New York, United States. 38
- Sex without a condom represents a romantic milestone
Others view condom-less sex as a significant milestone in a romantic or long term relationship. 39 They argue that it allows greater intimacy, enhances self-comfort, as well as comfort with a partner. It also brings stability to a relationship, which for many, is more important than the risk of HIV infection. 40
- Considered risk assessment and behaviour modification
Some HIV-positive men engaging in unprotected anal sex employ what they percieve as 'harm reduction strategies' such as avoiding the assertive role during sex and withdrawal before ejaculation. 41 42 43
- The value of risk taking
Some YMSM view risk taking as an important part of learning to make decisions for themselves. 44 Being overly worried about risks associated with anal sex can make these men feel fatalistic about the outcomes of their behaviour. 45
- Poor accessability to condoms
As already mentioned, stigma and homophobia are associated with reduced access to condoms, lubricant and other protective measures. It is recommended that special stronger condoms are used for anal sex. Some YMSM feel uncomfortable asking for these because it means potentially disclosing their sexuality when they might not want anyone to know, or feel confident about their sexual identity. 46
The role of schools in HIV prevention for Young MSM
HIV prevention initiatives are more likely to have an impact if they take into account the context in which risk behaviours occur. For YMSM, as well as other vulnerable groups, this means addressing the challenges faced at school.
A safe and supportive environment
A 2009 survey of middle and high school students across the United States found that:
- eight in ten lesbian, gay, bisexual, or transgender students had been verbally harassed at school because of their sexual orientation
- six in ten felt unsafe at school because of their sexual orientation
- almost a third skipped a day of school in the past month because they felt unsafe 47
YMSM and young people more widely, need to feel socially, emotionally and physically safe and supported. Research has shown how a positive school environment leads to declines in depression, suicidal feelings, substance abuse and truancy among gay, lesbian, bi-sexual and transgender students. 48 49
Gay-straight alliances (GSAs) are one solution, with one study showing how members of these students groups were less likely to experience violence, feel unsafe, or attempt suicide compared to students in schools without these groups. 50
Visit our 'Being Gay at School' page for YMSM's perspectives on sex education and the school environment.
Training for school staff
School health professionals, as well as teachers, can benefit from training to help them understand the needs of YMSM and shape behavioural health messages appropriately.
From 1999 to 2011, the CDC funded the American Psychological Association (APA) Healthy Lesbian, Gay, and Bisexual Students Project. The APA worked to help to build the HIV prevention capacity of schools and youth organisations. Specifically, it created a training manual and offered science-based workshops for school counsellors, nurses, psychologists, and social workers on how to effectively reach sexual minority students with HIV prevention messages and other health information. 51
School-based HIV prevention initiatives
The CDC's Division of Adolescent and School Health (DASH) helps and funds schools in the USA to implement policies and practices to reduce high risk sexual behaviour. Recognising that YMSM are a particularly vulnerable group for HIV transmission, program activities include:
- ensuring that the health education curriculum includes prevention information relevant to young people.
- providing training for school staff to help them understand the special concerns and needs of these groups.
- supporting schools in establishing GSAs or similar groups.
- linking schools to community organisations that provide health and mental health services for gay, lesbian and bisexual young people. 52
Some NGO programs contain school-based elements that typically involve training peer educators in HIV prevention which target YMSM and young people in general:
Since 2008, two NGOs in the Dominican Republic have offered comprehensive and integrated health services to meet the specific needs of vulnerable groups including young people. As well as a youth clinic, the program employs two full-time educators and a group of volunteer peer educators who visit a school for an entire week providing sex education and HIV awareness information. By May 2012, 4,300 students had accessed this service, which led to a doubling of the number of youth visiting the clinic in one year. 53
For the past decade, the Swaziland Action Group Against Abuse (SWAGAA) has been working to address the link between the HIV epidemic, gender-based violence (GBV) and human rights. Between 2009 and 2010, SWAGAA ran male engagement initiatives, school sensitisations and empowerment clubs which were attended by more than 20,000 young men and women. These education programs raised awareness about HIV and GBV prevention, human rights and human trafficking. 54
Schools and healthcare providers have a vital role to play in the provision of HIV services specific to YMSM. However, the support of families and friends provides equally valuable emotional as well as financial support. Accepting families and friends can make YMSM feel comfortable with their sexuality, build their self-confidence making them feel able to express their concerns and take action to look after their health.
Moreover, equalising the rights of YMSM with the wider population, and criminalising discrimination based on sexual orientation, reduces the stigma surrounding YMSM and paves the way for targeted prevention work encouraging YMSM to come forward and seek the help and support that they need.
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