Top Ten Key Global Policy Developments in 2010:
Reflections from the Global Forum on MSM & HIV (MSMGF)
The year 2010 saw both important progress and painful setbacks for communities committed to an effective global response to HIV. For those dedicated to promoting the health and human rights of men who have sex with men (MSM), the highs and lows have been particularly extreme. Tragic events have already scarred the first weeks of 2011, which promises to be an equally contentious and significant year.
In this tumultuous context, reflecting back on the significant policy developments of the last 12 months is a valuable exercise – both as a way to learn from past lessons and as a preparatory exercise for what lies ahead.
Focusing on issues concerning MSM, HIV and human rights at the global level, the MSMGF has developed a list of the 10 most significant policy issues and events of the past year. Although we have chosen to include developments that are not policies in and of themselves, all items have significant HIV policy implications at the global level for MSM. The list is based on the MSMGF’s five core operating goals, developed by MSM advocates from around the world serving on the organization’s Steering Committee. These goals are:
- Increased investment (funding) in effective HIV prevention, care, treatment and support programmes for MSM
- Expanded coverage of (roll out of and access to) quality HIV-related services for MSM
- Increased knowledge on MSM and HIV through the promotion of research and its broad-based dissemination
- Decreased stigma, discrimination, and violence against MSM
- Strengthened and linked regional, sub-regional and nation networks of MSM around the world, including networks of MSM living with HIV
The past year has seen a number of key developments that will provide resources and leverage necessary to make significant progress toward the goals above. New research made strong arguments for the importance of addressing MSM epidemics; the set of tools for tackling HIV among MSM was augmented; and several of the most influential organizations in the field made major commitments to the health and rights of MSM. Advocates have emerged from 2010 with stronger justification for our work, a clear set of tools to do it with, and more leverage at the highest levels to push this work forward.
Unfortunately, the year also saw a number of negative policy developments hindering the work of MSM advocates. Extreme violence and new criminalization legislation against same-sex acts represented a far-reaching backslide in recognition of the human rights of MSM and other sexual and gender minorities, battles raged within the UN over language concerning sexual orientation, and the ambitious target of universal access by 2010 failed miserably.
As advocates, we face many challenges in our work – from fiscal austerity measures, to culture wars, to politicians who do not understand our needs or ignore them altogether. It is incumbent upon us to be organized, efficient and effective in our work, even in these difficult circumstances. We hope that this policy roundup will trigger critical reflection, informed discourse, and more nuanced strategizing for advancing the health and human rights of MSM worldwide – ultimately leading to a better future for us all.
Number 10: Johns Hopkins Study Demonstrates Importance of Comprehensive HIV-Related Service Coverage for MSM
For the first time, data is emerging that substantiates the need to reach MSM with HIV services as a necessary component of any effective overall HIV strategy.
In July 2010, new epidemiological research presented by Dr. Chris Beyrer of the Center for Public Health and Human Rights at Johns Hopkins University’s Bloomberg School of Public Health demonstrated that providing 100% coverage of comprehensive HIV prevention, care, treatment and support services for MSM, sustained over time, would lead to declines in the epidemic among the general population.
In partnership with the World Bank, Beyrer and his team conducted modeling exercises with epidemiologic data from 133 prevalence studies, representing 130 unique reports with data from 50 countries. The data was categorized into four different HIV epidemiologic scenarios across low- and middle-income countries:
- Concentrated epidemics where MSM are the predominant exposure group
- Same-sex risk in the context of established HIV epidemics among Injecting Drug Users (IDU)
- Same-sex risks in the context of high prevalence and mature epidemics among heterosexuals
- Same-sex risks where heterosexual sex, injection drug use, and same-sex transmission all contribute significantly to the HIV epidemic
A single country was chosen from each of these four epidemic scenarios to model the expected impact of providing complete coverage of HIV services for MSM: Peru (Scenario 1), Ukraine (Scenario 2), Kenya (Scenario 3) and Thailand (Scenario 4).
Significantly, each of the four models demonstrated that reaching MSM had an impact on reducing the epidemic overall, even where HIV prevalence is high among the general population. The study concluded that much higher coverage of interventions and programs for MSM will be needed to change the trajectory of HIV across all regions and will be most effective when combined with HIV-related service coverage for people who inject drugs.
This is a powerful message that HIV program implementers, policymakers, and donors need to hear loud and clear: reaching MSM with comprehensive HIV services not only fulfills the human right to health, it also serves the broader public as a whole by greatly accelerating reduction in overall HIV burden.
See a full presentation of this research in two parts:
Number 9: iPrEX
Advocates pushing for new HIV prevention options received good news late in the year: in November 2010, researchers announced encouraging results from the first-ever clinical trial assessing the safety and efficacy of oral pre-exposure prophylaxis (PrEP) in preventing HIV infection among MSM and transgender women. With a reported efficacy rate of 43.8 percent among at risk MSM, the findings from this trial represent a significant step forward in the effort to expand the range of available HIV prevention options.
The Pre-Exposure Prophylaxis Initiative, or iPrEx, sought to determine whether a once-daily pill containing anti-retroviral medications (ARVs) – drugs that are currently used to treat people living with HIV – was safe and effective for reducing HIV risk among people who are HIV-negative. The pills were taken in combination with a full range of additional HIV prevention interventions, including HIV testing and counseling, management of STIs and access to free condoms. Over 2,400 participants took part across 11 sites in Peru, Ecuador, Brazil, South Africa, Thailand and the United States.
It is important to note that this study combined PrEP with a full suite of other proven HIV prevention interventions, which may have been an important contributing factor underlying these encouraging results. This is especially important in light of the fact that an estimated 90 percent of MSM globally lack access to even the most basic prevention services, indicating significant challenges ahead for the effective roll out of PrEP.
In addition to PrEP, there are signs that other new prevention technologies may be on the horizon. The CAPRISA 004 Tenofovir Gel Trial – a study to determine the safety and efficacy of a gel containing an antiretroviral drug for preventing HIV infection in women – reduced HIV infections by 39 percent when used before and after sex. These results raise important questions about the development of rectal microbicides, which could be an important HIV prevention tool for anal sex among both men and women.
As we advance our advocacy for the health of MSM, PrEP serves as a potentially useful prevention tool, as well as an important reminder that persistent barriers must be addressed if we are to make any progress in the fight against HIV among MSM.
Preexposure Chemoprophylaxsis for HIV Prevention in Men who have Sex with Men (study results)
(The New England Journal of Medicine)
iPrex Background, Fact Sheets, and other resources
CAPRISA Information and Fact Sheets
Number 8: Uganda & Laws Criminalizing Same-Sex Acts between Consenting Adults
Stigma, homophobia, violence, human rights violations against MSM, as well as laws criminalizing same-sex acts, are not new issues – yet 2010 may well be remembered as the year that these matters first entered into the consciousness of a broad global audience.
Though more than 70 countries still criminalize same-sex acts between consenting adults, the East African country of Uganda brought international attention to this issue, coming under intense international scrutiny over a proposed bill to expand existing penalties for same-sex acts to include life imprisonment and, in certain cases, death. The now-infamous “Anti-Homosexuality Bill” contains egregiously draconian provisions, including death sentences for same-sex acts in which one partner is a “serial offender” or living with HIV, extradition of Ugandan nationals abroad for prosecution in-country, and imprisonment and fines for individuals who fail to report suspected ‘offenders’ within 24 hours.
There is a long and sad history of social discrimination, stigma and violence directed at LGBT people around the globe, but Uganda’s situation was unique in that it captured the attention of the world. Debate reached a fever pitch, not only in policy circles but spilling over into the mainstream media and provoking statements by world leaders. A ripple effect caused two powerful but opposite effects: a) terrible backsliding in the area of human rights for LGBT people, as other nations cracked down on enforcing long dormant anti-sodomy laws, sometimes even seeking to pass new ones, and b) the galvanization of a vibrant grassroots LGBT, HIV and human rights movement that continues the long struggle for the health and human rights of all people.
For HIV advocates, it is vital that we speak to the negative impacts that laws criminalizing same-sex acts have upon the HIV response: fear of persecution for one’s perceived sexual orientation drives individuals underground, fueling HIV risk through covert encounters and deterring individuals from seeking the information and healthcare they may need.
There are important, complex, and ongoing lessons to be learned about the appropriate role of the international community in addressing criminal laws of sovereign nations. There is no advocacy formula that can be applied across contexts; the international community must take the lead of in-country activists to help ensure that any efforts match the complexity and demands of the local situation. What is clear, however, is that under no circumstances can laws, policies or other measures be allowed to impede the human rights of any individual.
The Anti-Homosexuality Bill, 2009 (text)
Number 7: UN Resolution on Extrajudicial Arbitrary Executions
In late 2010, a contentious debate erupted at the United Nations General Assembly that illustrated both the polarized views on human rights and sexual orientation held by various countries around the world, and the important role of civil society in influencing the voting record of their nations at the UN.
The platform for this debate centered around a resolution on Extrajudicial, Summary or Arbitrary Executions. Routinely updated and approved every two years, this resolution has included language condemning killings committed on the basis of sexual orientation since 1999. However, in a surprising move, this reference was unexpectedly stripped from the resolution in a vote by the “Third Committee,” the body that marks up human rights resolutions.
In response, civil society around the world mobilized rapidly to voice outrage over this huge step backwards, pressuring their home governments to revert back to the original language. At the end of December, U.S. Ambassador to the UN Susan Rice introduced an effort to restore the language on sexual orientation on the floor of the wider General Assembly. Ultimately the vote to restore the language passed, 93 to 55, with 27 abstentions and 17 absent or not voting.
It is important to note that on December 10, preceding the restoration of the language on sexual orientation, United Nations Secretary General Ban Ki-moon delivered an address calling for the complete and universal decriminalization of same-sex acts between consenting adults. This address was significant for at least two reasons: 1) it showed leadership on these issues at the highest level of the UN, and 2) the statement made very clear that human rights are absolute and supersede all other cultural considerations with regard to LGBT issues: “Where there is tension between cultural attitudes and universal human rights, universal human rights must carry the day.”
Our work to provide universal HIV services to MSM will never succeed until issues of sexual orientation and gender identity are understood and fulfilled as fundamental human rights. The events that took place around the resolution on extrajudicial killings were an important step on the road to fulfilling that promise. Though non-binding, this is the only UN human rights resolution that explicitly includes language on sexual orientation, and the support behind this language sets the stage for wider and stronger support in a broader range of United Nations policy vehicles in the future. Furthermore, the record of nations who voted against the re-insertion of the language on sexual orientation may be a helpful proxy indicator of the nations in which education and advocacy on sexual orientation, gender identity and human rights must be a priority going forward – especially with regard to the HIV response.
United Nations General Assembly voting record on the resolution on Extrajudicial, Summary and Arbitrary Executions
UN Secretary-General Ban Ki-moon: December 10 remarks on ending violence and criminal sanctions based on sexual orientation and gender identity
Number 6: Global Commission on HIV and the Law
Criminal laws and their impact on HIV transmission are often invoked as a complicating factor in the HIV response. Efforts to untangle and address issues of HIV and the law were elevated to new prominence this year when the United Nations Development Program (UNDP) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched The Global Commission on HIV and the Law. The Commission’s aim is to increase understanding of the legal environment’s impact on national HIV responses, including how laws and law enforcement can play a role in supporting, rather than blocking, effective HIV responses.
The structure of the Commission has three key components: 1) a 14-person Commission comprised of world leaders in law, human rights, public health and HIV; 2) a 22-member Technical Advisory Group charged with providing support to the Commission via technical review of material, developing regional issues papers, and other tasks; and 3) plans for four Regional Dialogues aimed at informing the deliberations of the Commission through regional submissions and policy dialogues.
The Commission is well placed to bring high-level attention to critical structural factors that hinder effective responses for MSM, including same-sex criminalization laws and harassment by law enforcement officials. The diversity of participants – from global leaders to civil society with all world regions represented – is reason to hope that the findings of the Commission will be widely promoted and used by advocates to push for more inclusive legal environments suited to an effective HIV response. Finally, by utilizing the UN as a space to convene this body, a more neutral space will exist to suggest legal reforms in sovereign nations – a tricky conversation that will quickly become politically charged, especially in relation to the criminalization of MSM, sex workers, people who use drugs and transgender people. The findings and recommendations of the Commission will be announced in December 2011.
The Global Commission on HIV and the Law
Launch of the Global Commission on HIV and the Law (June 2010)
Number 5: Pan American Health Organization Issues Blueprint for the Provision of Comprehensive Care for MSM
The Pan American Health Organization (PAHO), a regional office of the World Health Organization (WHO), released its Blueprint for the Provision of Comprehensive Care to Gay Men and Other MSM in Latin America and the Caribbean last year, offering guidelines and practical tools for healthcare professionals rolling out care and services for MSM. The report was based upon the proceedings of a regional consultation held in Panama City during the summer of 2009, attended by more than 50 experts from the region.
The blueprint was created as a guide for clinicians and health administrators in Latin American and Caribbean countries working in both the formal health sector as well as within specialized MSM health clinics. It is a resource intended to support planning and implementation of health services, health promotion and outreach services that are sensitive and tailored to the specific needs of self-identified gay and bisexual men as well as other MSM in the Latin American and Caribbean region. The document provides detailed guidance on a range of specific health management skills, including first clinical evaluations, HIV risk and infection, STIs, anal-rectal health, substance use, sexual concerns, emotional and mental health, consequences of violence, and special considerations for working with young MSM.
This blueprint is significant for a number of reasons, in particular: a) supportive, well-trained frontline health providers are vital to the success of HIV programming for MSM, and b) regionally-specific tools are essential for illuminating the nuanced context in which MSM health occurs, as well as for planning health services appropriately.
In order to achieve the overarching policy goal of universal access for MSM, practical training curricula must be developed and rolled out. This document is an excellent step in that direction and also sends a powerful message that MSM and HIV issues are being taken seriously by the public health sector at the at the highest levels of global policy. Health ministries and public health departments take their professional guidance from the WHO, which is charged with setting the international gold standard for health responses.
Blueprint for the Provision of Comprehensive Care to Gay Men and Other MSM in Latin America and the Caribbean
Number 4: WHO Publishes Priority HIV and Sexual Health Interventions for MSM and Transgender People in the Asia-Pacific Region
Defining a clear set of “priority HIV and sexual health interventions” for MSM has the potential to be an enormously beneficial policy tool – establishing core components for all effective HIV services for MSM, facilitating monitoring and evaluation of programs, and setting clearer fundraising needs and benchmarks, just for a start. Encouragingly, the WHO has made an important foray into articulating such a list, with the release of Priority HIV and Sexual Health Interventions in the Health Sector for MSM and Transgender People in the Asia-Pacific Region published last year in partnership with UNDP, UNAIDS, the Department of Health of Hong Kong, and the Asia Pacific Coalition on Male Sexual Health (APCOM).
Less of a how-to guide and more of an articulation of broad principles, this document provides a roadmap for scaling-up an effective response for MSM and Transgender people in the Asia-Pacific region. Key issue areas are defined, and a listing of resources is provided for those who would like more detail to carry out further work.
Significantly, civil society has been involved every step of the way. These recommendations build off a regional consensus statement developed by a broad cross-section of civil society, researchers and service providers in 2009. The consensus statement is remarkable in that it explicitly suggests framing HIV within the broader sexual health needs of MSM and transgender people, as well as integrating mass and targeted media (including the internet) in the delivery of prevention messages, health promotion, and social support services. This is important given the relative silence in the HIV sector on issues of sex and sexuality. The consensus statement goes on to emphasize targeted peer-led outreach, support groups, drop-in centers, referral mechanisms, and other community programs designed and implemented by and for MSM as important strategies for maximizing services utilization and coverage, access to sexually transmitted infection (STI) services, and HIV testing and counseling.
Priority HIV and Sexual Health Intervention in the Health Sector for MSM and Transgender People in the Asia-Pacific Region (Report)
Developing a Comprehensive Package of Services to Reduce HIV among Men who have Sex with Men (MSM) and Transgender (TG) populations in Asia and the Pacific (2009 Consensus statement)
Number 3: UNAIDS Revises Outcome Framework
While UNAIDS has made commitments to reaching MSM in the past, several new policy developments and decision points at the agency over the past year have advanced those commitments even further.
UNAIDS first released a strategy document focused on MSM in May 2009, entitled UNAIDS Action Framework: Universal Access on Men who have Sex with Men (MSM) and Transgender People. The document is centered on three strategic objectives: promoting human rights, strengthening evidence, and supporting capacity and partnerships for action. The mandate for making use of this document, however, was not explicitly articulated until UNAIDS revised its outcome framework in 2010 to include a specific outcome targeting MSM, sex workers and transgender people (see: The UNAIDS Outcome Framework 2009–2011).
In addition, MSM and transgender issues were formally agendized for the June 2010 meeting of the Programme Coordinating Board (PCB), the agency’s highest governing body. In advance of this meeting, a document was prepared, entitled “Reducing HIV Transmission among Men who have Sex with Men and Transgender People.” This report and subsequent debate on the floor of the PCB – including important testimony delivered in person by MSM activists from around the world – led to the PCB’s approval of several critical decision points to reduce stigma and discrimination, including a decision point specifically on MSM and transgender people.
The sum of these recent events – especially the addition of MSM to the UNAIDS Outcome Framework 2009-2011 – has led to a more robust and well-articulated directive for reaching MSM in the new UNAIDS Strategy 2011-2015. Adopted in December 2010, this strategy will guide the organization’s work over the next five years, indicating that MSM will be a top priority going forward. The strategy underscores the need for comprehensive and meaningful approaches to reaching MSM that involve partnership, legal reform and the mitigation of social discrimination, and also calls for a reduction of new infections among MSM by half before the year 2015.
As the international body responsible for coordinating the global response to HIV, we should not underestimate the significance of UNAIDS highlighting these priorities in their primary strategy document. Now, it is vital that advocates and allies make strong use of this tool to hold UNAIDS, global HIV implementers, and country governments accountable to following through on these commitments.
Getting to Zero: UNAIDS Strategy 2011-2015
Joint Action for Results: UNAIDS Outcome Framework 2009–2011
UNAIDS Programme Coordinating Board Document: Reducing HIV Transmission Among Men who have Sex with Men and Transgender People (June 2010)
Number 2: Global Fund Round 10 Funding for Most at Risk Populations
The best HIV policies and implementation strategies in the world can do little to reach MSM unless they are fully funded. In 2010, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) created a funding reserve to support HIV proposals that focus on most at risk populations (MARPs). This paved the way for the disbursement of funds to organizations and countries that are serious about addressing HIV among MSM, transgender people, people who use drugs and sex workers. The MARPs funding stream resulted in twelve successful MARPs grant applications, with a five-year value of over US$130 million. Specifically, the countries with approved MARPs proposals were: Argentina, Georgia, Kazakhstan, Macedonia, Malaysia, Panama, Peru, Syria, and Uruguay. A total of three regional proposals were approved, one each in Latin America, Asia-Pacific, and the Middle East & North Africa.
The Global Fund is the world’s largest multilateral financier of the AIDS epidemic. The successes of the Global Fund would not be possible without leadership from a broad range of funders, especially the G8 countries, which are the largest contributors to the fund. The Third Voluntary Replenishment Pledging Conference took place in October 2010 in New York to fundraise for the ongoing disbursement of awards and to leverage donor support. This meeting, chaired by UN Secretary-General Ban Ki-moon, successfully raised US$ 11 billion in pledges and projections for 2011-13, from a variety of contributors including country governments, foundations, the private sector, and innovative finance instruments. However, this amount fell short of projected funding needs presented by the Global Fund in March 2010, which would have allowed for the expansion of the program’s work.