HIV/AIDS Interventions With Men Who Have Sex With Men (MSM)

In some parts of the world, men who have sex with men (MSM) have been disproportionately affected by the HIV epidemic. In countries where such information is gathered, HIV infection rates among MSM are often higher than in the general population. Multiple sex partners, unprotected anal sex and the hidden nature of MSM sexual relations in many communities all contribute to the prevalence of HIV among MSM.

Many countries deny the existence of MSM, resulting in an alarming lack of prevention and care services directed at men at risk. This denial and discrimination against MSM feed the secrecy in which many MSM live, increasing their risk taking and making it difficult to reach them with HIV prevention interventions. Developing and implementing interventions for this population is also difficult because of varying definitions and perceptions of gender, sexual roles, stigma, homophobia and internalized homophobia. Due to societal pressure, many MSM have both male and female partners, increasing the HIV risk for their female partners and decreasing the likelihood that MSM self-identify as MSM.

Securing the participation of members of the MSM community is essential for developing and implementing comprehensive interventions. These interventions should address not only personal factors directly related to health (such as risk practices, condom use and sexually transmitted infections) but also personal factors (enhancing self-esteem and empowerment) and structural factors (laws criminalizing homosexual sex and access to non-judgemental STI services).

Lessons Learned

Some important elements for implementing successful MSM programs include:

• Making formative assessments to determine the risks and needs of MSM.
• Involving MSM in the design and implementation of interventions.
• Using interpersonal approaches to behavior change communication, such as peer education programs and appropriate community-level interventions to reduce risk through safer sex practices.
• Creating "safe spaces" where MSM can discuss personal issues and access STI care, counseling and referral services.
• Linking interventions to condom distribution and promotion activities.
• Strengthening public and private STI services within health delivery systems used by MSM.
• Ensuring quality HIV voluntary counseling and testing (VCT) services.
• Ensuring care and support services for those affected by HIV, including quality clinical services and support groups for people living with HIV/AIDS.

To address the long-neglected impact of HIV on MSM, formative research must be conducted. This research should include a mapping exercise, an STI/HIV prevalence study (including an assessment of risk behaviors), and qualitative research aimed at better understanding the context of MSM risk-taking behavior in the developing world. Many parts of the world continue to deny the very existence of MSM. This formative research is helpful in gaining insight into who these men are and how they live their lives.

One successful approach to working with MSM has been to create or provide safe spaces where men can talk openly and receive STI care and counseling. Such centers offer a space for men to gather, and may also operate male sexual health projects with medical and psychosocial services for MSM. Another successful approach is integrating safer sex education into existing social activities.It is well accepted that peer-led interventions are most effective in reaching this target group. Peers should be brought into the decision-making process and invited to help develop interventions. These services can be provided through clinics, clubs, drop-in centers or outreach/street-based providers. Peer counselors can provide education and services to MSM and their families and can host regular support group meetings. Here, MSM can explore topics of sexuality and sexual identity, such as safer sex, gay relationships, commercial sex work, living in a homophobic society, strengthening the gay community, elating to peers, values, attitudes and conduct. In addition, long-term counseling and support services to men living with HIV or AIDS is an important service that should be provided.

Some program elements that must also be considered include:

• Ensuring the availability of lubricants. In many settings, the lack of access to water-based lubricants forces men to use oil-based lubricants for sexual activity, jeopardizing the integrity of condoms. For this reason, the myth that condoms easily break strongly persists in some countries.

• Improving access to MSM-friendly STI services. MSM have specific STI-related needs but often feel uncomfortable approaching public-sector health providers with anal and oral STIs. MSM who don't have access to MSM-friendly private-sector providers can face ridicule, violence and even prison.

• Ensuring appropriate segmentation. MSM are not a homogeneous group. In many countries, MSM communities are greatly balkanised. For example, MSM who self-identify as heterosexual do not feel they confront the same issues as those who self-identify as homosexual. Wealthy MSM often move in very different circles than poorer MSM, and MSM sex workers have another set of needs altogether. During the community assessment phase it is important to investigate these differences and to consider them when designing programs.

• Addressing human and legal rights. The marginalization and stigmatization of MSM in many settings is magnified by a lack of human and legal rights. Some countries have severe anti-sodomy laws that drive MSM sexual behavior underground and put men at risk of being imprisoned.

Resources

1. International Lesbian and Gay Association, 81 Kolenmarkt, B 1000, Brussels, Belgium. Phone +32-2-5022471. <ilga@ilga.org
2. International Gay and Lesbian Human Rights Commission, 1360 Mission St., Suite 200, San Francisco, CA 94103, USA. Phone 415-255-8680. <ilghrc@ilghrc.org http://www.iglhrc.org
3. National Latino/a Lesbian, Gay, Bisexual and Transgender Organisation — LLEGO, 1420 K St., NW, Suite 200, Washington, DC 20006. Phone 202-408-5380. http://www.llego.org
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15. Sullivan, G., Leong, LWT (eds). Gays and Lesbians in Asia and the Pacific: Social and Human Services. New York and London: Haworth Press, 1995.