HIV Prevention for Hidden Men Who Have Sex with Men
What We Know
Summaries of Selected Background Research
The following selected articles highlight recent research findings on the global vulnerability of MSM to HIV and strategies that can be undertaken to provide responsive HIV-related services for MSM.
Research on HIV Vulnerability of MSM
Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000–2006, A systematic review
PLoS Medicine (2007), Vol. 4 No. 12, pp. e339
Baral, S., et al.
Recent reports of HIV infection rates from Asia, Africa, Latin America, and the former Soviet Union (FSU) suggest high levels of HIV transmission among men who have sex with men (MSM) in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, the researchers conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data. Analysis of the data showed that MSM have a markedly greater risk of being infected with HIV compared with general population samples. Odds ratios for HIV infection in MSM are elevated across prevalence levels by country and decrease as general population prevalence increases, but remain 9-fold higher in medium-high prevalence settings. MSM from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved.
Understanding the HIV Prevention Needs of Men Who Have Sex with Men in Nairobi
Population Council (2006).
Researchers from the Institute of African Studies (IAS) at the University of Nairobi and the Horizons and FRONTIERS programs of the Population Council undertook a study of MSM in Nairobi from 2003 to 2004. The researchers sought to understand the extent to which MSM are at risk of HIV and other sexually transmitted infections, to identify the factors associated with risk behaviors, and to describe MSM health needs in order to develop appropriate interventions. Findings suggest that the sexual behavior of MSM has implications for both men’s and women’s reproductive health. More than two-thirds of the sample (69 percent) report ever having sex with a woman. Many respondents remain sexually active with women; twenty percent of those who have ever had sex with a woman (sample size (n) = 344) report having vaginal sex in the past month, and seven percent report having anal sex with a woman in the past month. When asked to describe their sexual identity, nearly a fourth (23 percent) says they are bisexual.
Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men
Annals of Internal Medicine (2006), Vol. 145 No. 6, 416-425
Pathela, P., et al.
This study sought to describe: 1) discordance between self-described sexual identity and behavior among men who have sex with men (MSM), and 2) associations between identity and risk behaviors. Of New York City men reporting a sexual identity, twelve percent reported sex with other men. Men who had sex with men exclusively but self-identified as heterosexual were more likely than their gay-identified counterparts to belong to minority racial or ethnic groups, be foreign-born, have lower education and income levels, and be married. These men were more likely to report having only one sexual partner in the previous year than gay-identified MSM. However, they were less likely to have been tested for HIV infection during that time (adjusted prevalence ratio, 0.6 [95 percent Confidence Level (CI), 0.4 to 0.9]) and less likely to have used condoms during their last sexual encounter (adjusted prevalence ratio, 0.5 [CI, 0.3 to 1.0]). The survey found that only 22 percent of heterosexually-identified MSM used condoms compared with 55 percent of gay-identified men. Many MSM in New York City do not identify as gay. Medical providers cannot rely on patients' self-reported identities to appropriately assess risk for HIV infection and sexually transmitted diseases; they must inquire about behavior. Public health prevention messages should target risky sexual activities rather than a person's sexual identity.
The "Down Low": More Questions than Answers
Centers for Disease Control and Prevention (2004),
Millett, G.
A PowerPoint presentation from a June 2004 meeting of the Presidential Advisory Council on HIV/AIDS (PACHA) that explores the "down low" phenomenon and presents some of the difficulties in definition and response.
“Down low” is a culturally-specific term in the black community in the United States that describes heterosexually-identified African-American men who have sex with men without the knowledge of their primary female sexual partners.
Moving beyond "the Down Low": A critical analysis of terminology guiding HIV prevention efforts for African American men who have secretive sex with men
Social Science & Medicine (2009), Vol. 68 No. 3, pp. 533-543
Saleh, L. D. & Operario, D.
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," and this terminology has been used to label subgroups of African American men and to explain sexual risks for HIV infection in the African American community. This paper argues that use of this terminology for guiding public health and HIV prevention strategies can be problematic and counterproductive because it (a) stigmatizes and increases the exoticism of secretive same-sex sexuality as a unique issue among African American men, and (b) ignores the social conditions under which HIV transmission occurs. The authors explore historical roots contributing to current perspectives on African American men's sexuality, describe the use of the term "on the Down Low" and its application to same-sex behavior among African American men, and explain how this term can both clarify and potentially increase the ambiguity of the efforts to address HIV risk among African American men. Recommendations for research and HIV prevention strategies are also provided.
They see you as a different thing: the experiences of men who have sex with men with healthcare workers in South African township communities
Sexually Transmitted Infections (2008), Vol. 84 No. 6, pp. 430-433
Lane, T., et al.
This qualitative study aimed to describe interactions between men who have sex with men (MSM) and healthcare workers in peri-urban township communities in South Africa. MSM felt their options for non-stigmatizing sexual healthcare services were limited by homophobic verbal harassment by healthcare workers. Gay-identified men sought out clinics with reputations for employing workers who respected their privacy and their sexuality and challenged those workers who mistreated them. Non-gay-identified MSM presented masculine, heterosexual identities when seeking care for sexual health problems and avoided discussing their sexuality with health care workers (HCW). The strategies MSM employ to confront or avoid homophobia from HCW may not be conducive to sexual health promotion in this population. Interventions that increase the capacity of public sector HCW to provide appropriate sexual health services to MSM are urgently needed.
Prevalence of Same-Sex Sexual Behavior and Associated Characteristics among Low-Income Urban Males in Peru
PLoS ONE (2007), Vol. 2 No. 8, pp. e778
Clark, J. L., et al.
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 the sexually experienced men surveyed, 15.2 percent (85/558, 95 percent CI: 12.2 percent–18.2 percent) reported a history of sex with other men. Men ever reporting sex with men (MESM) had a lower educational level, had greater numbers of sex partners, and were more likely to engage in risk behaviors including unprotected sex with casual partners, paying for or providing compensated sex, and using illegal drugs. MESM were also more likely to have had previous STI symptoms or a prior STI diagnosis, and had a greater prevalence of HSV-2 seropositivity. Many low-income Peruvian men have engaged in same-sex sexual contact and maintain greater behavioral and biological risk factors for HIV/STI transmission than non-MESM. Improved surveillance strategies for HIV and STIs among MESM are necessary to better understand the epidemiology of HIV in Latin America and to prevent its further spread.
Sexual risk practices by sexual identity among men who have sex with men (MSM) in Bangalore, India
Poster Discussion: AIDS - XVII International AIDS Conference (2008), Abstract no. WEPE0717
Phillips, A., et al.
A cross-sectional survey of MSM in Bangalore in 2006 used face-to-face interviews to understand their self-reported sexual behavior. Identity and role behavior during sexual acts are highly interdependent among MSM in Bangalore. 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 as they influence partner choice and may shape the trajectory of the HIV epidemic.
Screening for genital and anorectal sexually transmitted infections in HIV prevention trials in Africa
Sexually Transmitted Infections (2008), Vol. 84 No. 5, pp. 364-370
Grijsen, M. L., et al.
This study demonstrated the value of routine, basic screening for sexually transmitted infection (STI) at enrollment into an HIV-1 vaccine feasibility cohort study and highlighted the importance of soliciting a history of receptive anal intercourse (RAI) in adults identified as "high risk". Participants had a high burden of untreated STI. Symptom-directed management would have missed 67 percent of urethritis cases in men and 59 percent of cervicitis cases in women. RAI was reported by 36 percent of male and 18 percent of female participants. RAI was strongly associated with HIV-1 in men (adjusted odds ratio (aOR) 3.8; 95 percent CI 2.0 to 6.9) and independently associated with syphilis in women (aOR 12.9; 95 percent (CI) 3.4 to 48.7). High-risk adults recruited for HIV-1 prevention trials carry a high STI burden. Symptom-directed treatment may miss many cases and simple laboratory-based screening can be done with little cost. Risk assessment should include questions about anal intercourse and whether condoms were used. STI screening, including specific assessment for anorectal disease, should be offered in African research settings recruiting participants at high risk of HIV-1 acquisition.
Research Strategies to Identify Hard-to-Reach MSM
Reaching African-American men on the down low: sampling hidden populations: implications for HIV prevention
Journal of Homosexuality (2008), Vol. 55 No. 3, pp. 437-449
Icard, L. D.
Studies on the impact of the HIV epidemic among African-American men who have sex with men (MSM) have largely neglected men who self-identify as heterosexual but engage in same-sex behavior. These men commonly referred to as “men on the down low,” pose formidable challenges to researchers conducting prevention studies. This article addresses the methodological issues that create limitations in sampling this population and proposes a methodological approach to sample African-American men on the down low successfully. The sampling approach was developed as part of a larger qualitative study to determine effective ways to promote testing and increase awareness of HIV and AIDS in hidden populations. Researchers placed emphasis on obtaining participants who would meet the general classification of men on the down low: men, who self-identify as heterosexual, actively engage in relationships with female sexual partners, and tend to seek male sexual partners outside venues predominantly frequented by gay-identified men. The sampling method relies on peers who are indigenous members of the hidden target population to recruit eligible study participants and on the involvement of professional recruiters to initially locate potential peer recruiters.
Conducting a bio-behavioral survey among men who have sex with men in Tehran using respondent driven sampling: lessons learned
AIDS- XVII International AIDS Conference (2008), Abstract no. MOPE0457
Feizzadeh, A., et al.
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 hidden populations that are small in number relative to the general population and for which no exhaustive list of group members exists. It is a variation on “snowball sampling” in which existing study subjects recruit future subjects from among their acquaintances. However, unlike snowball sampling, RDS analyzes the data collected using mathematical models that aim to compensate for non-random data collection biases. The RDS technique can also provide researchers with insights into the social network that connects members of the population. Although it is considered the best available solution for reaching probability samples of hidden or otherwise hard-to-reach populations, RDS is still very difficult to conduct among stigmatized, socially insecure groups like MSM and in cases where enrollment criteria are hard to verify such as sexual behavior.
Accessing men who have sex with men through long-chain referral recruitment
AIDS and Behavior (2008), Vol. 12 Supp. 1, pp. 93-96
He, Q., et al.
Men who have sex with men (MSM) may account for an increasing proportion of China’s HIV epidemic, but remain hard to reach for epidemiological studies due to high stigma. This study compared the composition of two samples of MSM obtained in Guangzhou, China, particularly with respect to reaching migrant, young, and lower-income MSM and those at higher risk for HIV. The first of the two studies used convenience sampling in 2004, while the second used long-chain referral recruitment in 2006. Convenience sampling is a type of non-probability sampling in which the study sample is selected arbitrarily and in an unstructured manner from a population that is readily accessible to the researcher. Long-chain referral is the basis of recruitment in Respondent Driven Sampling (RDS). RDS is a relatively new approach for sampling hidden populations that are small in number relative to the general population and for which no exhaustive list of group members exists. It is a variation on “snowball sampling” in which existing study subjects recruit future subjects from among their acquaintances, however unlike snowball sampling, RDS analyzes the data collected using mathematical models that aim to compensate for non-random data collection biases. The RDS technique can also provide researchers with insights into the social network that connects members of the population. Long-chain referral recruitment successfully reached segments of the MSM population in Guangzhou that were missed by convenience sampling, including subgroups of particular relevance to the HIV epidemic. The researchers conclude that long-chain referral recruitment may be more effective than variations of convenience sampling in tracking the epidemic among MSM in China, based on the efficiency of long-chain recruitment in the field and its ability to obtain a diverse sample of a relatively hidden or hard-to-reach population.
Reports and Briefs
The following selected documents present current policy approaches advocated by international organizations to address the HIV-related needs of MSM around the world, as well as challenges to meeting the needs of this population.
HIV and Sex between Men
Policy Brief (2006).
UNAIDS
The Policy Brief recommends actions for national and international policy makers as well as for civil society partners who influence the policy environment. Recommendations include empirical assessment of HIV infection among MSM in national epidemics, decriminalization of same-sex sexual behavior, adequate funding, and increased access to appropriate services. It also provides a summary of experiences of policy makers who have taken exemplary actions in the area of HIV prevention for MSM. The report builds on the 2001 UN General Assembly Special Session Declaration of Commitment that calls for addressing the HIV needs of MSM, and on the 2006 High Level Meeting on AIDS where Member States reiterated the commitment to eliminate all forms of discrimination against MSM.
Men who have sex with men (MSM), HIV, and the Road to Universal Access–How Far Have We Come?
AmfAR (2008).
This report studied 128 country reports submitted to the United Nations and found that nearly half of countries (44 percent) failed to provide any data whatsoever 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 also found that criminalization of male-male sexual activity is a major driver of the epidemic among MSM in many countries. Seven out of the 10 countries with the highest reported HIV prevalence among MSM criminalize homosexuality. This institutionalized stigma and discrimination frequently prevents MSM from accessing even basic HIV and AIDS services.
HIV Prevention for Men Who Have Sex with Men
AmfAR Issue Brief (2006).
This Issue Brief provides an overview of strategies to mitigate the HIV epidemic in MSM, both domestically and globally. Significant barriers persist to implementing effective interventions for MSM on a global level. These 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. Despite accomplishments in modifying risky behavior and reducing HIV infections in some MSM populations, many prevention efforts may be undermined by specific policies that contribute to stigma and discrimination against this group.
MSM and HIV/AIDS Risk in Asia
AmfAR Special Report (2006).
This report discusses the vulnerability of MSM in Asia to HIV and AIDS. This group has been largely ignored despite increasing infections in the region. Many Asian countries have addressed the HIV and AIDS epidemic in high-risk groups such as female sex workers and injecting drug users, but MSM have been neglected, often because many MSM 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 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 – all key factors contributing to increased HIV prevalence.
Off the Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa
International Gay and Lesbian Human Rights Commission Report (2007),
Johnson, C. A.
This report explores the ways in which governments, donors, and NGOs 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. By focusing on the effects of this discrimination, the report demonstrates 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.
NEXT>>
