Invisible men: action urged for gay men in the global South

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“This epidemic never ceases to surprise us. In every major city in Asia we have looked at, there are now epidemics of HIV among men who have sex with men (MSM) – epidemics that remind me of what we saw in the USA and Europe in the 1980s. HIV is now rising as fast in those men as it was then. This was the warning given by Peter Piot, retiring Director of UNAIDS, at the satellite meeting on gay men/MSM preceding the 2008 World AIDS Conference in Mexico City.

The Invisible Men: Gay Men and other MSM in the Global HIV Epidemic, a mini-conference organised by the Global Forum on MSM and HIV (see brought nearly 500 delegates from every continent to a two-day meeting featuring plenaries, 24 breakout sessions and posters on research, advocacy and HIV programme development for MSM, largely in the global South.

The meeting happened in advance of a World AIDS Conference which is widely expected to foreground MSM issues as never before.


disability-adjusted life year (DALY)

A method for measuring disease burden, often used in cost-effectiveness analyses, expressed as the number of years lost due to ill-health, disability or early death. A DALY represents one year of healthy life, and is usually expressed as DALYs lost compared with a life with maximum achievable life-expectancy and no disability or disease. 


The Joint United Nations Programme on HIV/AIDS (UNAIDS) brings together the resources of ten United Nations organisations in response to HIV and AIDS.


Cost-effectiveness analyses compare the financial cost of providing health interventions with their health benefit in order to assess whether interventions provide value for money. As well as the cost of providing medical care now, analyses may take into account savings on future health spending (because a person’s health has improved) and the economic contribution a healthy person could make to society.

exclusion criteria

Defines who cannot take part in a research study. Eligibility criteria may include disease type and stage, other medical conditions, previous treatment history, age, and gender. For example, many trials exclude women who are pregnant, to avoid any possible danger to a baby, or people who are taking a drug that might interact with the treatment being studied.


The study of the causes of a disease, its distribution within a population, and measures for control and prevention. Epidemiology focuses on groups rather than individuals.

David Wilson, head epidemiologist at the World Bank’s Global HIV/AIDS section, put Piot’s words into context with a wide-ranging plenary speech covering HIV epidemiology amongst gay men/MSM in all continents.

He told the conference that when populations of MSM were surveyed, the prevalence of HIV amongst them was without exception higher than in the general population, even in countries with large generalised epidemics.

The lower the HIV prevalence in the general population, the greater the disparity between this and the prevalence in gay men. Thus in the only four countries so far surveyed in Africa (Kenya, Senegal, Sudan and South Africa) gay men were 3.8 times more likely to have HIV than the general population; in Asia, 18.7 times more likely; and in the Americas, 33.3 times more likely.

Prevalence was high in gay men even in countries with virtually no HIV in the general population; a survey from Alexandria in Egypt, for instance, had found 6.5% prevalence in gay men in a country where general prevalence is 0.01%.

Concurring with Peter Piot, Wilson said that HIV prevalence in MSM in some parts of the world appeared to be rising sharply. Annual surveys from Beijing, for instance, showed that HIV prevalence in gay men had risen year-on-year from 0.8% in 2001 to 5.8% in 2006, and had jumped from 17% in Bangkok in 2003 to 28% in 2005 (in 1990 the rate amongst gay Thais was 3%).

These apparently new epidemics were occurring in countries that had often successfully reduced HIV prevalence amongst female sex workers (FSWs) and their clients, he added. In South America, HIV prevalence was dramatically higher in gay men than female sex workers, ranging from 7% to 27% according to country while nowhere exceeding 7% amongst FSWs.

In Thailand, for instance, HIV prevalence amongst FSWs and their clients had peaked in 1993. In a survey done in Mombasa, Kenya, comparing FSWs and MSM, HIV prevalence was higher in FSWs (32% versus 23%); but HIV incidence was considerably higher in MSM (8.6% a year versus 3.2% in FSWs).

“Epidemics amongst FSWs are old epidemics which are slowing down, whereas epidemics amongst MSM are gaining momentum,” he added. In countries where the initial burst of HIV occurred among injecting drug users (IDUs), there was evidence of spread from IDUs to MSM; in a study in Vietnam, for instance, HIV prevalence amongst MSM in general was 5-9%, but amongst MSM who also injected drugs it was 26-28%.

A surprisingly high rate of injecting drug use was also found in a new survey of MSM in Malawi in southern Africa (see separate report). This also found that bisexuality was the rule rather than the exception, and Wilson added that in surveys done in Asia, the proportion of MSM who also had sex with women ranged from 22% (in China) to 70% (in Cambodia). Conditions therefore exist for epidemics amongst MSM to seed a new wave of infection amongst women.

Gay men were less well-served by prevention interventions than any other vulnerable group, Wilson added. UNAIDS has calculated that 60% of FSWs, 46% of IDUs and 40% of MSM had ever been reached by any prevention programme. Programmes for gay men could be highly cost-effective, he added; it had been calculated that the estimated cost per Disability-Adjusted Life Year (DALY) gained for different interventions in Asia was $3 for work with FSWs (because they were comparatively easily reached and condom uptake was efficient), $39 for harm-reduction programmes in injecting drug users, and $74 in programmes for MSM. This compares with an estimated $2600 per DALY gained in HIV awareness programmes directed at general youth.

Evidence for the effectiveness of HIV prevention amongst MSM in the global south was only just beginning to be gathered, he added, but after the introduction of condom and HIV awareness programmes for MSM in Indonesia in 2002, condom use had doubled (from 30% to 60% in the last episode of anal sex) by 2004.

A poster to be presented at the main conference later this week will show that HIV and STI prevalence in MSM in Senegal has declined between 2004 and 2007, significantly in 21-25 year olds, that the proportion of MSM ever participating in HIV prevention programmes has increased from 23% to 60%, and that reductions in HIV risk behaviours correlate significantly with participation in prevention programmes (Wade).

Structurally, MSM work is being taken on for the first time ever by one of the United Nations bureaux, namely UNDP, the United Nations Development Programme, with the founding Executive Director of the International HIV/AIDS Alliance, Jeff O’Malley, chosen to direct it. Up till now, no UN agency has been willing specifically to take on working with MSM.

O’Malley asked, rhetorically: “How could it be that the AIDS world at large only just seems to have re-discovered yesterday that there is an HIV epidemic amongst MSM and trans people - in the global South as well as the global North?”

He continued: “The Washington Post thinks that the Mexico conference might be the conference that puts MSM and HIV on the world stage, just as the Durban conference did for the epidemic in Southern Africa.”

He commented that “UNDP’s democratic governance programme has prioritised the promotion of human rights of marginalised and excluded populations – and they are committed to ensuring that includes sexual minorities.”

Piot agreed. He concluded his speech by saying: “In many countries we may be reaching a tipping point where working with MSM is becoming possible and we may see results due to advocacy.”


Wade A et al. Reduction in risk behaviors amongst MSM in Senegal after targeted prevention interventions. XVII International AIDS Conference, Mexico City. Poster abstract THPE0349. 2008.