WHRF - How can the law be used to scale up effective HIV responses among MSM ? Nadia RAFIF

Men Having Sex with Men, a key population
stigmatized and
criminalized, disproportionately affected by HIV
How can the law be used to scale up effective HIV
responses among MSM ?
Nadia RAFIF
The Global Forum on MSM and HIV (MSMGF)
Working world wide against HIV for the health & human rights of men who have sex with men

The MSMGF
What We Do
• Support front‐line organizations with deference to locally
defined needs, priorities and strategies
• Convene, coordinate, resource, train advocates and
providers (creating safe spaces)
• Watchdog/lobby/educate governments, donors and
policy makers
• Conduct, commission and support research (document
front‐line experiences)
• Facilitate information exchange, coordinate strategies
through coalitions

MSM are disproportionately affected by
Violence / Stigma
www.amsher.net
Forms of violence:
• Arbitrary arrest and detention
• Physical violence
• Extortion and blackmail
• Societal exclusion and
marginalization
Impacts of violence:
• Difficulty in accessing sexual
health services
• Increase asylum cases

“Our mission is to build a better world. To leave
no one behind. To stand for the poorest and the
most vulnerable in the name of global peace and
social justice.”
Ban Ki-moon United Nations Secretary-General

Epidemiology among MSM
• Men who have sex with men (MSM) bear a
disproportionately heavy burden of the global
HIV epidemic. This public health crisis is
indicative of broader, structural factors that
exacerbate vulnerability among MSM –
including laws, policies and practices that
sustain and entrench inequality.

HIV burden (Unaids report 2014)
•While HIV incidence is declining in most of the world, incidence among gay men
and other men who have sex with men appears to be rising in several regions,
including in MENA, where this mode of transmission is a major contributor to the
HIV epidemics in several countries.
•Worldwide, gay men and other men who have sex with men are 19 times more
likely to be living with HIV than the general population.
•The median HIV prevalence among gay men and other men who have sex with
men is 19% in western and central Africa and 13% in eastern and southern Africa.
•Men who have sex with men often acquire HIV while quite young—HIV prevalence
is about 4.2% for young (under 25 years) MSM
•Seventy-three countries did not report data on HIV prevalence among gay men
and other men who have sex with men.

HIV prevalence among gay men and other men
who have sex with men across regions, 2013 –
Unaids report 2014
Latin America
Middle East and North Africa
Western and central Europe and North America
Countries West and central Africa
HIV prevalence (%) HIV prevalence (%)
Source: Global AIDS Response Progress Reporting 2014.
by
region
Countries
by
region

HIV prevalence among men who have sex with men
and the general population by region, 2009–2013
- Unaids report 2014
Source: Global AIDS Response Progress Reporting 2014.
Region (number of countries reporting)

Tends in the new infection in the
MENA region, 2005 and 2013

HIV prevalence among MSM in
MENA

Context in the MENA region
• Several countries in MENA where adult consensual
same-sex sexual conduct is illegal and punishable by
death : Islamic Republic of Iran, Saudi Arabia, Somalia
(southern parts), the Sudan and Yemen. An additional
large number of the region’s countries either criminalize
adult consensual same-sex sexual conduct or have
criminally prosecuted lesbian, gay, bisexual and
transgender people under other laws on the basis of
their sexual orientation and gender identity :
Afghanistan, Algeria, Egypt, Iraq, Kuwait, Lebanon,
Libya, Morocco, Oman, Qatar, the Syrian Arab Republic,
Tunisia and the United Arab Emirates

Encouragingly, we know there are a
number of HIV interventions that ARE
effective for MSM
• An exciting proliferation of publications in recent
months/years establish standards for effective HIV responses
among MSM, including reports from the World Bank and the
World Health Organization detailing the evidence base for
each recommended intervention.
• In addition, promising advances are currently being made in
biomedical prevention with numerous clinical trials on Pre-
Exposure Prophylaxis.
• In short, a range of effective HIV prevention interventions for
MSM do exist.

Innovative interventions

Innovative
interventions

However, MSM have not been able
to access HIV services
• Research shows that access to MSM-targeted HIV
interventions in real-world settings has been extremely
problematic:
• A survey of over 3500 MSM (Global Health and Men Survey,
MSMGF, 2014) from around the globe found that less than
half could easily access HIV prevention services; that only 36%
were able to easily access treatment; and less than a third had
easy access to behavioural interventions and HIV education
materials. Regression analyses for multiple factors found that
experiences of homophobia were the most powerful
predictor of compromised access to HIV services.

However, MSM have not been able
to access HIV services
• Qualitative interviews with MSM from a diverse array of world
regions (Africa, Asia, the Caribbean, Eastern Europe, Central
Asia, Latin America, North America and Western Europe)
revealed a common set of factors that undermined access to
HIV services: 1) homophobia, 2) HIV stigma, 3) criminalization
and repressive policies, 4) lack of awareness among providers,
and 5) safety.
• The key role of structural barriers in hindering the HIV
response among MSM is echoed by a variety of research and
reports as well as regional submissions to the Global
Commission on HIV and the Law.

Treatment cascade (Aids & Clinical
Research, Issue 8, 2014)

Poor access to HIV and other health services (UNAIDS 2014)
•According to surveys, gay men and other men who have sex with men often have extremely
limited access to HIV prevention commodities, such as condoms, water-based lubricants, HIV
education and support for sexual risk reduction.
•According to reports from 20 countries in both 2009 and 2013, the percentage of gay men and
other men who have sex with men reached by HIV prevention programmes fell from 59% to
40%.
•One international review concluded that fewer than 1 in 10 gay men and other men who have
sex with men receive a basic package of HIV prevention interventions.
•There are also great disparities in access to HIV services and commodities among gay men and
other men who have sex with men across and within countries.
•This leads to questions regarding the effectiveness of mainstream HIV programmes in reaching
and addressing the specific needs of highly stigmatized, criminalized and lower-income gay men
and other men who have sex with men who have no other option than to rely on such services
for their health needs.

Percentage of gay men and other men who have sex with men
reporting that condoms, lubricants, HIV testing and HIV
treatment are easily accessible, by country income level, 2012
Unaids Gap report 2014)
*Access to HIV treatment was measured only among respondents who reported living with HIV.
Source: Access to HIV prevention and treatment for gay men or other men who have sex with men; findings from the 2012
Global Men’s Health and Rights Study (GMHR)—an internet survey of men from 165 countries.

Access to Basic HIV Services is Low (GHMS, MSMGF 2012)
(South Africa, Nigeria, Kenya, Namibia ,Cameroon, Zimbabwe , Uganda, Democratic Republic
of the Congo, Cote d’Ivoire, Tanzania, Botswana ,Burundi Ghana, Togo, Swaziland)
47%
19%
48%
27%
14%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Condoms
Lubricants
Testing
Treatment
Education
Materials
% Easy Access to Services

Access to services depends on barriers &
critical enablers
• Access to condoms, lubricants, testing, treatment, and HIV
education materials is predicted by:
+ Engagement with MSM Community
+ Connection to MSM Community
+ Comfort with Healthcare Provider
- Perception of Homophobia in Community
- Past experiences of homophobic violence
- Past experiences of provider stigma
Critical Enablers
Barriers

The law plays an important role in
access to HIV services
Impact on PROVISION and QUALITY of HIV programs
for MSM:
• Breaking the cycle of HIV transmission requires many
elements, including the availability of high-quality
HIV programs for MSM.
• Around the world, a common set of laws and policies
have been identified that render this work difficult or
impossible to carry out

Rejection of applications for legal registration
of NGOs focused on LGBT issues
• Grassroots organizations are often uniquely placed to
understand the needs of local MSM, and many have
developed networks and resources over time to provide high-quality
services.
• However, organizations that focus on MSM and other sexual
and gender minorities can be prevented from attaining legal
registration as an organization because of their target
populations.
• Effect: This leaves NGOs vulnerable to arbitrary closure by
government officials, and handicaps the ability of NGOs to
secure funding support, office space, and representation at
policy and program planning arenas.
• o Examples: Botswana,7 China,8 Kyrgyzstan,9 Mongolia,10
Mozambique,11 Turkey,12 Ukraine.13

Condoms and HIV education materials
become evidence for prosecution
• Condoms remain one of the best evidence-based forms of HIV
prevention available. Educational materials that contain explicit
information on how HIV is transmitted between men, including
effective steps for HIV prevention among MSM, are essential for
equipping MSM with the knowledge and power to negotiate for their
own safety. However, condoms and HIV prevention materials have
been seized by law enforcement officials as evidence of sex work and
the promotion of homosexuality.
• Effects: When possession of condoms and educational materials
becomes unsafe, service providers and individuals may abandon these
prevention tools, reasoning that the immediate threat of arrest takes
precedence over the potential threat of HIV. This exacerbates HIV risk
and undermines contact between HIV service providers and MSM.

Criminal laws against sex between men
undermine effective HIV program delivery
• According to the recent 2014 report by UNAIDS, 78 countries in the
world had criminal laws prohibiting same-sex acts between consenting
adults.
• A variety of laws around the world are used to enforce penalties against
sex between men , including offences for sodomy, buggery, gross
indecency, “unnatural sex”, and “carnal intercourse against the order of
nature
• These laws provide grounds for a range of actions that deter the
provision of quality HIV services for MSM.
• Criminal laws against MSM result in raids, harassment and arrests by law
enforcement at LGBT and HIV program sites. This discourages staff from
working in such programs, deters client participation in such programs,
and causes loss of valuable materials. Health service providers may also
face repercussions for providing HIV services to MSM.

Consensual, adult same-sex sexual conduct
is criminalized in 78 countries (Unaids gap report 2014)
• In some countries, laws also ban organizations that represent or
support lesbian, gay, bisexual or transgender individuals.
Source: International Lesbian and Gay Association (ILGA), UNAIDS Global Report 2012, and Baral S. et al. 2013.

Criminal laws against MSM hinder the
development of effective health policies
• Criminal status of MSM also contributes to underrepresentation of
MSM in the development and implementation of policies and
programs.
• Criminal status of MSM results in the development of inappropriate
policies and programs, lack of resources for research and programs,
lack of attention to MSM in national surveillance programs, failure
to include MSM in educational curricula (including medical training
and healthcare provider curricula).
• Examples: Lack of representation of MSM on Global Fund Country
Coordinating Mechanisms; lack of global funding dedicated to HIV
programs targeting MSM; lack of knowledge and training on MSM-specific
health issues in clinical curricula.

Inadequate investments
•The inadequate financing of HIV services for gay men and other men who have sex
with men impedes efforts to reach them with essential services. Most of this
investment comes exclusively from international donors rather than national spending.
•National commitments to respond to the HIV epidemic among gay men and other
men who have sex with men lag behind those for other populations. Only 11% of
global spending on programmes for gay men and other men who have sex with men
came from public domestic sources (with 26 countries reporting), while the remaining
countries fully relied on international funding (67 countries).
•Funding is especially limited in the Middle East and North Africa and across sub-
Saharan Africa.
•In sub-Saharan Africa, only 14 of 45 countries reported any spending on programmes
for gay men and other men who have sex with men, and only two countries reported
any public domestic spending.

Criminal laws against sex between men result in
the exclusion of MSM from decision-making
arenas
• Criminal prosecution legitimizes high-level, policy-related
homophobia.
• Effects: Decision-makers invoke MSM-criminalization
laws to justify a lack of surveillance, reporting and
HIV service coverage for MSM.
• Examples: Reporting on MSM-related UNGASS
indicators has been found to be statistically lower in
countries that criminalize sex between men.

Impact on ACCESS to and UTILIZATION of
HIV programs for MSM
• Even the highest quality HIV-related services in the world cannot
achieve maximum impact unless MSM can safely and openly access
them. Laws and policies that create hostile environments act as
powerful deterrents and barriers to universal access.
• Criminal prosecution legitimizes high levels of stigma against MSM
in communities and healthcare settings
• Even in contexts where criminal laws against MSM are not
enforced, the mere existence of such laws in the penal code serves
as justification for abuse, discrimination, stigma, and homophobia
against MSM.
• Effects: MSM avoid accessing health services owing to potential or
experienced abuse by clinic staff and community backlash if their
sexual behaviour is revealed.

Relationship with Provider Matters
(GMHS, MSMGF 2012)
• Highest level of Comfort with Provider vs. lowest
level:
– 5 x higher access to condoms
– 3 x higher access to testing
– 15 x higher access to HIV education materials
• Lowest frequency of Past Experiences of Provider
stigma vs. highest frequency
– 2 x higher access to testing

Homophobia and Violence in Wider
Community Matters (GMHS, MSMGF 2012)
• Lowest level of perceived homophobia vs. highest
level
– 13 x access to lubricants
– 13 x access to HIV testing
• Lowest frequency of experiencing homophobic
violence vs. highest level

Hostile environments contribute to disproportionately
high rates of depression, anxiety and substance abuse
among MSM
• Issue: Consistently hostile environments leave little room for
building healthy communities, connectedness and self-worth
among MSM.
• Effects: These conditions undermine the capacity of MSM to
access services and to protect themselves and their partners.
• Examples: Numerous studies have examined “syndemics”
among MSM, including mental health and HIV risk; depression
among MSM; changes in alcohol consumption; co-occurring
psychosocial health problems among MSM; cyclical re-incarceration;
as well as examining resilience as an untapped
resource for MSM programming.

How can the law be a ‘game-changer’ that
substantially changes the trajectory of the HIV
epidemic?
• Evidence shows that Universal Access for MSM can be a ‘game-changer’ — by
reducing the trajectory of the overall global epidemic
• An analysis (Projection of the Number of New HIV Infections with
Implementation of Three Intervention Scenarios for MSM, Peru, 2008-2001.
The World Bank) across four different HIV epidemic scenarios, representing
the major epidemic trends in low-and middle-income countries around the
world, found that achieving high rates of coverage of HIV prevention and
treatment services among MSM not only has positive impacts for this
concentrated epidemic, but it can also be the deciding factor in reducing the
HIV burden of an entire country
• This data has profound implications: achieving universal access to HIV
prevention, care, treatment and support services for MSM worldwide would
truly constitute a ‘game-changer’ in the HIV response, not just among MSM,
but for everyone infected and affected by HIV.

Addressing structural determinants is an
essential game-changer for the HIV
response
• Basic HIV program activities can achieve greater impact when
enhanced by structural interventions, including community-centred
design and delivery.
• Rights-based approaches that prioritize community systems
strengthening and the creation of enabling environments
should be prioritized in the response
• A study published by the Lancet (2011) call for a transition
beyond commodity –based, piecemal effort, to addressing
critical enables that affect the overall context in which HIV
services are delivered

WHO Consolidated Guidelines Chapter 5:
Critical Enablers

Stronger communities create higher access
(GMHS, MSMGF 2012)
• Highest level of feeling connected to a n MSM
community vs. lowest level
– 7 x access to condoms
– 10 x access to MSM-tailored HIV education materials
• Highest level of social engagement with other MSM
vs. lowest level
– 7 x access to MSM-tailored HIV education materials

Community-Led Interventions to improve
Relationship with Provider (GMHS, MSMGF
2012)
CBOs use a combination of strategies to increase
comfort and reduce stigma
• Community Delivered Services
• Peer Outreach Delivered Services
• Provider Sensitization
• Client Referrals

Community-Led Responses to Homophobia
and Violence (GMHS, MSMGF 2012)
CBOs have short-term and long-term strategies
to address homophobia and violence:
• Social Change
• Equipping MSM to Manage Risk of Violence
• Responding to cases of violence

Potential “game-changing” impacts of the
Law
• The World Bank, UNAIDS, the Global Fund, the President’s Emergency
Plan for AIDS Relief (PEPFAR), and the World Health Organization all
agree that addressing the impact of laws and policies is essential to the
success of HIV work among MSM. Opportunities for intervention
include:
• Review and repeal laws that undermine the HIV response among MSM
• We cannot and should not wait until full decriminalization is achieved
to roll out HIV programs for MSM. It is possible to enhance access to
HIV services for MSM even in criminalized contexts, and the long
process to repeal criminal laws is no excuse to delay the provision of
life-saving services.

Address the inappropriate enforcement of laws
that hinder access to HIV services for MSM,
through coordination, education and training
with the judiciary and law enforcement officials
• When law enforcement officials and other elements of the
legal system abuse laws that can be wielded against MSM, or
crack down on enforcement of normally ‘dormant’ laws in the
face of political upheaval, the ability of organizations to offer
HIV services to MSM is severely restricted, and client
utilization of those services is also negatively impacted

Integrate the law as a core pillar in all National
AIDS Reponses, and adopt a rights-based
approach to the HIV response
• The law plays a vital role in the creation of enabling environments
that facilitate universal access to HIV services for MSM.
• A comparison of HIV prevalence rates in various Caribbean
countries both with and without laws criminalizing homosexuality
revealed consistently higher HIV prevalence rates among MSM in
countries that outlaw same-sex behaviour
• An analysis of UNAIDS annual country reports found countries
whose laws did not criminalize homosexuality had a significantly
higher proportion of reporting on the five UNGASS indicators
relevant to MSM

Source: Adapted from UNAIDS Report on the Global Epidemic
2008 and UNAIDS Progress Report Toward Universal Access to
HIV Prevention, Treatment, Care and Support in the Caribbean.
Source: Adapted from UNAIDS Report on the Global Epidemic 2008 and UNAIDS Progress Report Toward Universal Access to HIV
Prevention, Treatment, Care and Support in the Caribbean.
Rights-based approaches that prioritize community systems strengthening and the creation of enabling
environments should be prioritized in the response.
Conclusion
The disproportionate prevalence of HIV among MSM, coupled with outrageous human rights violations that
continue to occur against gay men, illustrate a clear role for the law in creating enabling structural environments in
which MSM will be able to fulfil their right to health, including universal access to HIV prevention, care, and
treatment services. We request bold, action-oriented recommendations from the Commissioners toward this
end.

Work is happening, despite the law
but needs more support!
In difficult environments, community based organizations have a
range of interventions that address barriers and facilitators
There is need for scale up of interventions that deliver high-quality,
culturally competent care to MSM
This can be done by building from the work that community
based organizations are doing

How can Health Sector Build on CBO
programs?
Make greater and smarter investments in local Key
Population-led Community Based Organizations
Integrate Community Systems into Health Systems
Create an accountable environment that is conducive to
service access

Conclusion
• The disproportionate prevalence of HIV among MSM,
coupled with outrageous human rights violations
that continue to occur against gay men, illustrate a
clear role for the law in creating enabling structural
environments in which MSM will be able to fulfil
their right to health, including universal access to HIV
prevention, care, and treatment services.
• We request bold, action-oriented recommendations
from the international community toward this end.

• Disparities in HIV incidence and prevalence related to poor
access to HIV services among MSM require a multilevel
response.
• Specifically, collaborations are needed that work to find ways
to reduce and ultimately eradicate expressions of sexual
stigma at policy, institutional, community, and individual
levels.
• Researchers, community groups, community based
organizations, legislators, and funders who aim to improve
sexual health of MSM must work together to confront sexual
stigma, criminalization of homosexual behavior, and increase
investment in HIV services for MSM to effectively enhance
access to these life saving services.

Thank You!
Nadia RAFIF
Senior Policy Advisor
nrafif@msmgf.org
www.msmgf.org

References
• The Gap Report, Unaids 2014
• NAIDS Mena Report, 2012
• Special submission to the Global Commission on HIV and the Law : MSM
• Sexual Stigma, Criminalization, Investment and Access to HIV Services
among MSM worldwide. Aids and Behavior, August 3, 2014
• Homophobic legislation and its impact on Human security. African Security
review, May 14, 2014
• Access to Basic HIV related Services and PrEP Acceptability among MSM
worldwide : Barriers, Facilitators and Implications for Combination
Prevention, June 6, 2013
• HiV Treatment Cascades that Leak: Correlates of Drop Off from the HIV
Care Continuum among MSM. Aids and Cllinical Research, vol 4, Issue 8,
Augsut 2014
• Global Men’s Health & Rights Study (GMHR), 2012. MSMGF

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