Highlighting the Health of Men Who Have Sex With Men in the Global HIV/AIDS Response

An estimated 32.8 million individuals are living with HIV around the world,¹ of whom an estimated 10% contracted the virus through male-to-male sexual contact.² Where estimates are available, HIV prevalence among men who have sex with men (MSM) has been consistently higher than general population estimates of reproductive-age men. (Note: For the scope of this policy statement, the term “men who have sex with men” [MSM] is being used as a term that includes all males who engage in consensual male-male sex. Discussions regarding HIV risk among MSM have historically included reference to transgender individuals, on both domestic and international fronts. Given the unique HIV vulnerability of transgender people and the need for targeted research and programming, transgender individuals are not included in the “MSM” term for the scope of this policy resolution.) This is true in generalized epidemic settings as well as in Malawi and in coastal cities in Kenya, where HIV prevalence among MSM is reported to be as high as 21.4%³ and 22%,⁴ respectively. Recent studies have documented similarly high HIV prevalence rates among MSM in virtually all settings, including approximately 8.6% in Ukraine,⁵ 5% in China,⁶ and 32% in Jamaica^,7 and reported prevalence rates range from 10% to 22% in Peru.⁸ In the United States, the Center for Disease Control and Prevention (CDC) estimates that MSM account for 53% of new HIV infections, with 1 in 5 (19%) MSM infected with HIV and almost half of those (44%) unaware of their infection.⁹ All told, MSM in the United States are 44 to 86 times as likely to be diagnosed with HIV as other men.⁹ In virtually all these settings, there is considerable evidence that sexually transmitted infection (STI) rates have also increased among MSM.¹⁰

Despite the alarming incidence of HIV infection among MSM, it is estimated that only 10% of the global MSM population has access to lifesaving HIV/AIDS prevention and treatment services.^11–13 Evidence demonstrates varied reasons for this lack of access. The criminalization of same-sex sexual behavior has been shown to limit provision and uptake of HIV services for MSM.¹⁴ Globally, 76 countries worldwide criminalize same-sex behavior and MSM lifestyles, including 5 that put people to death for their sexual orientation: Iran, Mauritania, Saudi Arabia, Sudan, and Yemen.¹⁵ Social stigmatization and discrimination drive MSM underground and away from lifesaving health services.^1,16 Barriers to care and treatment programs for these men include stigma related to sexual orientation, as exemplified through a lack of comprehensive sexual health education programming that includes MSM-specific concerns and a lack of cultural competency displayed by service providers working with MSM.^17–21 

Background: The Social and Political Context Affecting Men Who Have Sex With Men

Discriminatory legislative efforts and reported homophobic violence throughout Africa and other parts of the world, including the United States, exacerbate stigma.^11,22–28 The murder of and life-threatening attacks on prominent lesbian, gay, bisexual, and transgender (LGBT) activists across the globe further remove MSM from the public eye.^29,30 These structural, governmental, and community-based factors induce fears of social isolation, public humiliation, ridicule, and lack of personal safety among MSM, thus creating systemic barriers to creating HIV prevention services targeting this population.^17,18 Childhood trauma, experienced by many MSM because of their sexual orientation, has been linked to increased sexual risk taking and polydrug use, thus further perpetuating HIV risk among MSM.³¹ And typically in societies with deep religious influences, the acknowledgment of MSM and the formation of social support structures are limited, impeding HIV prevention, care, and treatment efforts.³²

Background: HIV Prevention Successes and Calls to Action

Despite the challenges facing MSM in the global response to HIV/AIDS, there has been progress that promises improved prevention and treatment. In India, a call is being made for the decriminalization of MSM sexual behavior such that government-sponsored harassment will decrease and allow outreach workers to intervene on risky behaviors among MSM and begin curving the HIV epidemic.³³ Other organizations across the globe also recognize the importance and call for the implementation of scientifically grounded laws and policies regarding HIV/AIDS.^18,34 In American schools, gay-sensitive sexual health curricula addressing the needs of lesbian, gay, and bisexual (LGB) students have resulted in reductions in HIV risk factors, including fewer sexual partners and reduced substance use, among MSM and LGB students.³⁵ Similarly, research within schools in the United Kingdom has linked antistigma and antibullying policies to better outcomes for MSM and LGB students.²¹

Research spanning the global epidemic has prompted international HIV funders and service providers to call on governments and health care agencies to implement initiatives, aligned with the US Global Health Initiative³⁶ and the United Nations Millennium Develop Goals³⁷, to reduce HIV among MSM as a key component of all national HIV prevention strategies.¹⁸ In part, this involves holding governments accountable to internationally recognized statements of human rights, such as the United Nations’ Universal Declaration of Human Rights.38 On the basis of an analysis of global HIV rates, the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommends the allocation of HIV funding to target populations in accordance to their burden of the epidemic.³⁹ In addition, international efforts such as the Global Fund and the US President’s Emergency Plan for AIDS Relief (PEPFAR) urge governments and agencies to hold accountable recipients of HIV funding to programmatic goals and technical assistance guidelines, specifically in relation to MSM.^40,41 These goals should be established in a way to create a comprehensive package of culturally competent HIV services targeting MSM, in accordance with recommendations from UNAIDS and the World Health Organization.^42–44

Public Health Problem

A substantial rise in HIV and STI rates among MSM is being seen in countries experiencing decreases of the epidemic in the general population.^11,45 This inequity reveals that current HIV interventions targeting MSM—
1. Remain woefully inadequate at reducing the continued growth of the HIV epidemic1,⁴⁶; 
2. Reflect a lack of attention paid to MSM by governments, donors, and other stakeholders engaged in the global fight against HIV and AIDS⁴⁷; and
3. Require the support of additional and innovative behavioral, biomedical, and structural interventions,⁴⁶ despite unparalleled resource commitments through global HIV/AIDS efforts, most notably PEPFAR.³⁴

Relationship to Existing Policies of the American Public Health Association

The American Public Health Association (APHA) has previously taken a position against discriminatory behaviors and attitudes towards MSM.^48,49 Policy Statement 2004-10,⁴⁸ entitled “Proposed Resolution Condemning Actions Against Lesbian, Gay, Bisexual, and Transgender (LGBT) and HIV-Related Research and Service Delivery,” urges federal agencies not to hinder the development and delivery of HIV prevention services targeting the LGBT community; this new resolution provides the international perspective. Policy Statement 7514,⁴⁹ entitled “Homosexuality and Public Health,” urges the end of discrimination based on sexual orientation across all levels of government and service provision. It also encourages the study of challenges unique to homosexual populations regarding the access and provision of health care. The proposed action steps expand on those of Policy Statement 7514 in 2 ways: by (1) acknowledging that courses of action need to be taken both nationally and globally to reduce the growing HIV epidemic among MSM, and (2) no longer using the phrase “homosexual” and its derivatives, and instead using the more encompassing phrase “men who have sex with men” to describe populations most at risk of contracting HIV through male-male sexual contact.

APHA has previously recognized the importance of access to comprehensive sexual health education, both domestically and abroad.^50,51 Policy Statement 9207,⁵⁰ entitled “Underscoring the Continued Need for a Sustained National HIV Prevention and Public Education,” urges the development of comprehensive, well-advertised sexual health education accompanied by allocations of resources targeting HIV prevention. The proposed action steps expand upon those of Policy Statement 9207 by urging the inclusion of MSM-specific discussions within the context of a comprehensive sexual education curriculum. Policy Statement 200314,[51] entitled “Support for Sexual and Reproductive Health and Rights in the United States and Abroad,” in summary, urges continued action to maintain the United States’ leadership as a promoter of sexual and reproductive rights for all. The proposed action steps expand on those of Policy Statement 200314 by specifically calling for the inclusion of MSM-specific discussions within the context of providing comprehensive sexual health education.

Proposed Recommendations and Action Steps

In order to more fully stem the global HIV/AIDS epidemic within MSM populations, APHA urges public health professionals and international and domestic organizations to:

1. Encourage the international decriminalization of same-sex sexual behavior and the reform and repeal of laws and policies that reinforce stigma and discrimination;
2. Conduct and act upon the findings of policy analyses of HIV/AIDS-related laws to ensure that their content and enforcement reflects current, scientifically based knowledge of HIV/AIDS;
3. Create antistigma, antidiscrimination, and antibullying initiatives focused on uprooting cultural homophobia and eliminating disparities in the health status of MSM, using new media tools to enhance communication with youths and other affected populations whenever possible;
4. Expand psychosocial support and substance-abuse services to address the unique and multidimensional needs of MSM;
5. Improve and expand sexual health education to be medically accurate, age appropriate, comprehensive, and inclusive of a range of topics specific to MSM and LGBT populations, including dating violence, sexual assault, and harassment;
6. Recognize the reduction of HIV acquisition and transmission within MSM as a vital component of an evidence-based global HIV/AIDS response;
7. Recognize the reduction of HIV acquisition and transmission within MSM as a vital component of reaching global health and development goals, similar to those outlined by the US Global Health Initiative and the United Nations Millennium Development Goals;
8. Ensure the inclusion of MSM in emerging biomedical HIV interventions, such as earlier access to treatment and treatment as prevention modalities; 
9. Allocate funding for HIV research, prevention, and treatment in accordance with the representation of afflicted communities, specifically MSM, within the epidemic;
10. Develop new epidemiological tracking methodologies, or increase the effectiveness of current ones, to better understand epidemics of HIV/AIDS among MSM, including expanded sampling and recruitment techniques for hard-to-reach populations;
11. Support efforts to increase the professional and cultural competencies of health providers serving MSM and other sexual minorities; 
12. Identify and develop a comprehensive, context-specific, and culturally competent package of HIV/AIDS and STI research, prevention, and treatment services for MSM aligned with UNAIDS and World Health Organization guidelines, including supporting community-level interventions; 
13. Hold governments accountable to international human rights obligations, such as those expressed in the United Nations’ Universal Declaration of Human Rights and Declaration on Sexual Orientation and Gender Identity; and 
14. Hold accountable global funding mechanisms, such as PEPFAR and the Global Fund, to stated programmatic goals and technical guidance documents addressing MSM.

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