I. Definition of the Prevention Area
The ability to find and target men who have sex with men (MSM) for HIV prevention research and services can depend on the visibility of various subgroups of MSM. Those who are most visible generally don’t conform to traditional standards of “masculinity” and may appear “feminine” or gender neutral. Or they may be outwardly indistinguishable from men who have sex with women only, but they remain easier to target because they identify themselves as “gay” and may frequent gay establishments.
MSM may identify themselves as gay, bisexual, “straight,” or transgendered. Up to 20 percent of MSM perceive themselves as “straight.” Such heterosexually identified or “straight” MSM are generally highly secretive about their sexual activities and often appear quite “masculine.”
II. Epidemiological Justification for the Prevention Area
MSM who self-identify as heterosexual may escape the notice or reach of researchers and programmers who seek to study and/or to provide services for MSM.
MSM are a priority for HIV prevention in all parts of the world. Globally, MSM are at significantly greater risk for HIV infection than other adults of reproductive age. Factors contributing to this risk include biological, behavioral, and structural factors, such as unprotected anal intercourse, multiple sex partners, and the social marginalization and discrimination that MSM often endure.
MSM are vulnerable regardless of national HIV prevalence levels. In medium-to-high prevalence areas, such as parts of Asia and sub-Saharan Africa, MSM are on average more than nine times more vulnerable to infection than the general population.
MSM can transmit HIV to women; this may be especially true for straight-identified MSM who, according to some studies, are more likely to be married than straight men who have sex only with women.
Surveys seldom include questions about MSM, and researchers are often discouraged from seeking data on this population due to its marginalized status. Consequently, available data likely underestimate the prevalence of MSM in a given country. The bulk of research on HIV prevention for MSM is largely derived from studies conducted in industrialized countries, where same-sex sexual behavior is typically not criminalized and where sexual minorities have often organized to protect their interests.
In developing countries, the small but growing body of research on MSM has focused mostly on men who associate their same-sex behavior with a gay identity; this focus tends to exclude MSM who are not readily identifiable or who identify as “straight.” According to a UNAIDS estimate in 2006, fewer than 5 percent of MSM around the world who need HIV services have access to them.
III. Core Programmatic Components
Research is sometimes integrated with service or intervention programs for MSM. For example, researchers conducting surveys sometimes include services for participants, such as counseling, testing, and prevention services; condom distribution; diagnosis and treatment for sexual transmitted infections; and peer education.
IV. Current Status of Implementation Experience
Although many studies demonstrate the reproducibility of research and the effectiveness of behavioral interventions for MSM in the United States, far less information is available for program outcomes in certain geographic areas, such as Africa and Asia, or among hard-to-reach subgroups of MSM.
Because of difficulties identifying or locating certain MSM subgroups, researchers and program developers may rely on long-chain or respondent-driven sampling (RDS) in order to reach MSM. Respondent-driven sampling and/or outreach relies on study participants to recruit their acquaintances to a study, who in turn recruit their acquaintances.
An obvious benefit of RDS is that MSM who are openly identified as gay can reach MSM who hide their identities and who don’t frequent gay establishments. However, some drawbacks with RDS have emerged. For example, individuals who are selected to initiate a long chain may become identified with the researchers or sponsoring organization, thus compromising their effectiveness as peers. Cronyism has been apparent in some instances. Additionally, peer-participants may misunderstand the goals of research or the offered services and expect or demand financial support.
Some programs in low-income nations have been highly successful. One particularly successful project was a media education and sensitization conference held in Senegal, which attracted media from 20 print, radio, and television media outlets. Researchers conducted a review of news articles on MSM during the 18-month period following the two-day media conference and found no “offensive or stigmatizing” articles published about MSM.
Successful programs should include behavioral surveillance plans and enhanced social science research that reflects the diversity of the sexual behavior of MSM and the varied social and political contexts affecting them. Legal protections for sexual minorities and efforts to reduce the stigma and discrimination they often face are central to the effort to ensure full access to programs for MSM.
Текст на русском языке (Russian Translation)
Read these summaries of the research providing the evidence-base that supports the prevention approach
Summary of Research Articles |
Reports and Briefs
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Moving Beyond "The Down Low": A Critical Analysis of Terminology Guiding HIV Prevention Efforts for African American Men Who Have Secretive Sex with Men
Saleh, L.D., & Operario D. Social Science & Medicine (2009), Vol. 68 No. 2, pp. 390-395.
Recent reports have described potentially high-risk behaviors of African American men who identify as heterosexual but who engage in secretive sex with other men. These men have been referred to as being "on the down low." The authors state that use of the term can both clarify and potentially increase the ambiguity of efforts to address HIV risks. They note that studies have shown “no significant differences in unprotected anal intercourse between African American MSM and other racial/ethnic groups.” They also say that using the term “on the down low” to guide public health measures can be counterproductive because it stigmatizes and increases the exoticism of secretive same-sex sexuality as a unique issue among African American men, and because it ignores the social conditions under which HIV transmission occurs. Recommendations for research and HIV prevention strategies are provided.
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Conducting a Bio-Behavioral Survey among Men Who Have Sex with Men in Tehran Using Respondent Driven Sampling: Lessons Learned
Feizzadeh, A., Gouya, M.-M., Setayeshet, H., et al.
AIDS (2008), XVII International AIDS Conference: Abstract No. MOPE0457.
Facing criminal charges and high stigma, MSM in Iran are one of the most hard-to-reach groups among the key populations most at risk of contracting HIV. This study was the first bio-behavioral survey among MSM in Iran. Respondent Driven Sampling (RDS) is a relatively new approach for sampling small, hard-to-reach populations for which no exhaustive list of group members exists. It is a variation on “snowball sampling” in which study subjects recruit future subjects from among their acquaintances. Unlike snowball sampling, RDS analyzes the data collected using mathematical models that aim to compensate for non-random data collection biases. The authors suggest that an online RDS could be a promising way to reach MSM.
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Screening for Genital and Anorectal Sexually Transmitted Infections in HIV Prevention Trials in Africa
Grijsen, M. L., Graham, S.M., Mwangome, M., et al. Sexually Transmitted Infections (2008), Vol. 84 No. 5, pp. 364-370.
The authors assert that routine screening for sexually transmitted infections (STIs) at enrollment into research programs can identify many infections that would be otherwise undetected. They studied at-risk volunteers enrolling in an HIV-1 vaccine trial and found that 67 percent of urethritis cases in men and 59 percent of cervicitis cases in women would have been missed with syndromic surveillance (relying on symptoms to screen). Receptive anal intercourse (RAI) was strongly associated with HIV-1 in men but not in women. RAI among women was associated with syphilis. The authors recommend routine STI screening and risk assessment regarding anal intercourse and condom use in African research settings where participants at high risk of HIV are recruited.
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Accessing Men Who Have Sex with Men through Long-Chain Referral Recruitment
He, Q., Wang, Y., Li, Y., et al. AIDS Behavior (2008), Vol. 12 No. 4, pp. S93-S96.
The authors compared MSM identified by two methods: convenience sampling and long-chain referral. Long-chain referral relies on study participants to recruit their acquaintances to the study, who in turn recruit their acquaintances. Long-chain referral identified more MSM who were migrants, young, from lower-income groups, and at higher risk for HIV than those identified by a convenience sample (such as all men attending a certain clinic). The authors state that long-chain referral can reach subgroups better than convenience samples. The authors report behavioral-risk outcomes associated with various subpopulations.
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Reaching African-American Men on the Down Low: Sampling Hidden Populations: Implications for HIV Prevention
Icard, L.D. Journal of Homosexuality (2008), Vol. 55 No. 3, pp. 437–449.
Studies of the impact of the HIV epidemic among African-American MSM have largely neglected men who self-identify as heterosexual but who engage in same-sex behavior. These men, commonly referred to as “men on the down low,” pose formidable challenges to researchers conducting prevention studies. The authors discuss the benefits and drawbacks of various sampling methods to identify these hard-to-reach MSM and describe a novel approach to reaching these men. Instead of relying on self-identified gay men or gay establishments, the researchers successfully used three recruiters who frequented known cruising areas (a park and the Internet) to find men who would meet the general classification of men on the down low.
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They See You as a Different Thing: The Experiences of Men Who Have Sex with Men with Healthcare Workers in South African Township Communities
Lane, T., Mogale, T., Struthers, H., et al. Sexually Transmitted Infections (2008), Vol. 84 No. 6, pp. 430-433.
This qualitative study describes interactions between MSM and health care workers (HCWs) in South Africa and found that many MSM felt their options for non-stigmatizing sexual health care services were limited by homophobic verbal harassment by HCWs. Gay-identified men sought out clinics with reputations for employing workers who respected their privacy and sexuality, and some challenged workers who mistreated them. Non-gay-identified MSM presented masculine, heterosexual identities and avoided discussing their sexuality with HCWs. The strategies MSM employ to confront or avoid homophobia from HCWs may not be conducive to health promotion. Initiatives to improve appropriate care from public sector HCWs are urgently needed.
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Sexual Risk Practices by Sexual Identity among Men Who Have Sex with Men (MSM) in Bangalore, India
Phillips, A., Boily, M. C., Lowndes, C. M., et al. Poster Discussion: AIDS 2008 – XVII International AIDS Conference: Abstract No. WEPE0717.
A cross-sectional survey of MSM in Bangalore in 2006 used face-to-face interviews to understand their self-described gender identities and sexual behavior. Four gender identities are described, including hijra (male-to-female transgender); kothi (effeminate men who remain biologically male); double-decker (more neutral-gender identity); and panthi (masculine identity but do not necessarily identify as homosexual). Men with masculine identities tend to prefer insertive anal intercourse, whereas effeminate men tend to take a receptive role. These role identities have program implications because they influence partner choice and may shape the trajectory of the HIV epidemic.
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Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000-2006: A Systematic Review
Baral, S., Sifakis, F., Cleghorn, F., et al. PLoS Medicine (2007), Vol. 4 No. 12, e-pp. 339.
MSM in low- and middle-income countries in Asia, Africa, Latin America, and the former Soviet Union experience high levels of HIV transmission. The authors examined the relationship between HIV prevalence among MSM to that of the general population in countries with low to high HIV prevalence overall. After conducting a meta-analysis of studies in low- and middle-income countries, the authors found that HIV prevalence among MSM was 58 times as high as the general population in nations with very low prevalence. In medium-high prevalence settings, HIV prevalence among MSM remained high, at nine times that of the general population. MSM from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved, due in part, say the authors, to the criminalization of sex between consenting adult men in 85 countries as of 2007.
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Prevalence of Same-Sex Sexual Behavior and Associated Characteristics among Low-Income Urban Males in Peru
Clark, J.L., Caceres, C.F., Lescano A.G., et al. PLoS ONE (2007), Vol. 2 No. 8, e-p. 778.
This study describes the lifetime prevalence of same-sex sexual contact and associated risk behaviors of men in Peru’s general population, regardless of sexual identity. Among 558 sexually experienced men surveyed, 15 percent reported a history of sex with other men. Compared to non-MSM, men ever reporting sex with men had lower educational levels; had greater numbers of sex partners; were more likely to engage in risk behaviors; had more sexually transmitted infections, including HSV-2; and were more likely to have used illegal drugs. Improved surveillance strategies are needed with regard to MESM and HIV in Latin America to prevent further spread of HIV.
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Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men
Pathela, P., Hajat, A., Schillinger, J., et al. Annals of Internal Medicine (2006), Vol. 145, pp. 416-425.
The researchers describe discordance between self-described sexual identity and behavior among MSM and the relationship between self-described sexual identity and risk behaviors. Of New York City men reporting a sexual identity, 12 percent reported sex with other men. MSM who self-identified as heterosexual were more likely than their gay-identified counterparts to belong to minority racial or ethnic groups, to be foreign-born, to have lower education and income levels, and to be married. Heterosexual or “straight-identified” MSM were more likely to report having only one sexual partner in the previous year than gay-identified MSM, but were less likely to have been tested for HIV and were less likely to have used condoms during their last sexual encounter. The authors conclude that medical providers cannot rely on patients' self-reported identities and that public health messages should target risky sexual activities rather than a person's sexual identity.
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Understanding the HIV/STI Prevention Needs of Men Who Have Sex with Men in Kenya
Population Council and the Institute of African Studies (IAS) at the University of Nairobi (2006)
MSM are often overlooked in reviews of the African AIDS epidemic. In 2004, the researchers undertook of more than 500 MSM in Nairobi and made 13 key findings, among them: 1) MSM in Nairobi come from diverse socioeconomic backgrounds, 2) more than two-thirds of the sample reported ever having sex with a woman, 3) more than 1 of 5 MSM report having been victimized by verbal, physical, or sexual violence, 4) three-quarters of MSM report using a condom at last anal sex, 5) sex with multiple partners is common, 6) men who have only one partner or experienced violence in the last year are significantly less likely to use a condom, 7) about half of MSM report ever having a sexually transmitted infection, and 8) more than half of MSM have been tested for HIV. Significantly, the researchers also found that MSM prefer not to discuss HIV issues with health providers, and vice versa.
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The "Down Low": More Questions than Answers
Willett, G. Presentation at the Presidential Advisory Council on HIV/AIDS (PACHA), Centers for Disease Control and Prevention, Conference on Retroviruses and Opportunistic Infections, San Francisco, California (2004).
This PowerPoint presentation provides an overview of the "Down Low" (DL) phenomenon, a term used in the black community in the United States describing heterosexually identified African American men who have sex with men without the knowledge of their primary female sexual partners. The author states that DL is a racially charged term based on sexual stereotypes about black men. Assumptions about African American men and drug abuse, imprisonment, and a supposed greater degree of prejudice within the African American community may play into the DL stereotype, and the author addresses each of these assumptions.
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Men Who Have Sex with Men (MSM), HIV, and the Road to Universal Access—How Far Have We Come?
This 56-page report provides the results of data submitted to the United Nations by 128 countries. Nearly half of the countries failed to provide any data on MSM. Despite a unanimous commitment by all UN member countries in 2001 to monitor HIV among high-risk groups, the report found that 71 percent of countries had no information on the percentage of MSM reached by HIV prevention programs. The report attributes this failure to a lack of leadership both from national governments and the institutions charged with leading the global response to HIV and AIDS. The report cites the criminalization of male-male sexual activity as a major driver of the epidemic among MSM in many countries. Seven of the ten countries with the highest reported HIV prevalence among MSM criminalize homosexuality. Institutionalized stigma and discrimination frequently prevent MSM from accessing even basic HIV and AIDS services.
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Off the Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa
Johnson, C.A. International Gay and Lesbian Human Rights Commission Report (2007)
This 125-page report with a seven-page executive summary explores the ways in which governments, donors, and nongovernmental organizations have failed to incorporate basic human rights protections for same-sex practicing Africans and how that failure affects efforts to combat the HIV and AIDS epidemic. The authors recommend that access to prevention, care, and treatment must be equal for all. Gaps in available research are discussed, including the need to better understand hidden male-male sexual behavior.
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HIV Prevention for Men Who Have Sex with Men
AmfAR Issue Brief (2006).
This 4-page brief provides an overview of strategies to mitigate the HIV epidemic in MSM, domestically and globally. Despite earlier success in reducing HIV among MSM in the United States, HIV incidence may be increasing. Barriers to effective interventions for MSM on a global level include difficulties in collecting accurate data on HIV infection in MSM, particularly in developing countries; confusion about the definition of MSM; and ongoing stigma and discrimination against gay, bisexual, and transgendered people. The brief provides an overview of three key types of intervention to reduce HIV transmission: individual-level behavioral approaches to reduce risk, community-level interventions to address social factors relevant to HIV transmission, and biomedical approaches, such as pre-exposure prophylaxis.
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MSM and HIV/AIDS Risk in Asia
AmfAR Special Report (2006)
This 82-page report discusses the vulnerability to HIV of MSM in Asia. Many Asian countries focus on such high-risk groups as female sex workers and injecting drug users, while ignoring MSM despite increasing HIV prevalence in the region. MSM may be overlooked because many are married and do not self- identify as gay or bisexual. Studies found HIV prevalence as high as 28 percent among MSM in Bangkok, Thailand; 14 percent in Phnom Penh, Cambodia; and 16 percent in Andhra Pradesh, India. MSM in Asia are often not organized, are hidden from society, and are persecuted by police. Sex between men is illegal in 11 of the countries examined. Many MSM have multiple partners, have sex with women, fail to use condoms, and have high rates of sexually transmitted diseases. This in-depth report provides research findings, country profiles, recommendations for politicians and non-governmental organizations, a directory of organizations, and extensive appendices for reference.
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HIV and Sex between Men
UNAIDS Policy Brief (2006).
This four-page brief overviews a number of studies regarding MSM and recommends actions for national and international policymakers and civil society partners. Among the findings: in parts of Asia, Africa, and Europe, between 3 to 20 percent of all men are estimated to have had sex with other men; in Senegal, 88 percent of MSM also had vaginal sex, and 20 percent reported anal sex with a woman; in India and Colombia, HIV prevalence among MSM was 17 and 20 percent, respectively. Recommendations include decriminalization of same-sex sexual behavior, engaging MSM in program design and implementation, and improved funding for MSM projects. The brief provides a summary of experiences of policymakers who have undertaken successful actions in the area of HIV prevention for MSM.
Read these summaries of promising interventions
Adapt and use these program materials, including tools, curricula, and models
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International HIV/AIDS Alliance, Understanding and Challenging HIV Stigma: Toolkit for Action
International HIV/AIDS Alliance (revised edition, 2007).
This toolkit evolved out of a two-year research project on stigma conducted in Zambia, Tanzania, and Ethiopia, and was originally published in 2003. The toolkit contains more than 100 participatory exercises that can be adapted to fit different groups and contexts. Various sets of pictures help to identify stigma, discuss the rights of HIV-positive people, and stimulate discussions around gender, sexuality, and morality issues linked to stigma. The toolkit is a collaboration among the International HIV/AIDS Alliance, the International Center for Research on Women (ICRW), the Academy for Educational Development (AED), and PACT Tanzania. The revised edition (2007) builds on the original toolkit and includes the experience of the International HIV/AIDS Alliance's Regional Stigma Training Project. New modules now address stigma as it relates to antiretroviral treatment, children, youth, and men who have sex with men. (9 booklets, each 30 to 50 pages)
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Rapid Assessment and Response Adaptation Guide on HIV and Men Who Have Sex with Men
Boyce, P., Aggleton, P. & Malcolm, A. World Health Organization (2004).
Stimson, G., Donoghoe, M., Fitch, C., et al. World Health Organization (2003).
This 61-page guide for working with MSM explains how to conduct a Rapid Assessment and Response (RAR) focusing on lifestyles, behaviors, and HIV concerns. It outlines a series of simple and practical activities that may be used to explore the circumstances, experiences, and needs of MSM across a variety of settings. It was designed to be used either in conjunction with the WHO Rapid Assessment and Response Technical Guide or as an independent resource. Chapters in the manual offer guidelines for carrying out a RAR with MSM, including specific guidance on planning, training, community participation, analysis, and action plan development.
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Between Men: HIV/STI Prevention for Men Who Have Sex with Men
International HIV/AIDS Alliance (2003)
This 61-page publication, one of the Key Population series, gives an overview of the issues for MSM related to HIV and other sexually transmitted infections. The report is designed primarily to support policymakers, donors, and nongovernmental organization support programs that are planning to work in communities in developing countries where few or no organizations already work with MSM. Drawing on experiences of the Alliance’s partner organizations in countries such as India and Costa Rica, the report addresses issues such as why and how men have sex with men, and presents strategies for developing prevention and care programs for men.
Link to important additional materials and websites
Global Forum on MSM and HIV
The Forum is comprised of a loose network of civil society groups, AIDS organizations, MSM groups, and other agencies, which together advocate at the national and global levels for improved HIV and AIDS programming for MSM. The initiative is a response to the shared concern that existing HIV strategies do not adequately address the needs of MSM. The Forum disseminates information on best practices in HIV prevention and treatment, advocates for improved access and funding for MSM services, and provides a forum for MSM around the globe to strengthen their regional, sub-regional, and national networks. Member organizations share a commitment to social justice, to human rights issues, and to improving the HIV and AIDS response to MSM and other sexual and gender minorities.
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