2020 is a critical year for gay and bisexual men to reclaim the HIV response, with the AIDS2020 and HIV2020 conferences beginning today, and the start of strategic planning for UNAIDS and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. While the strategic directions and 2020 goals set by UNAIDS and agreed to by all United Nations Member States are ambitious and appropriate to the tools we now have in hand, we are far off track to meet global targets. This post shares advocacy messages that advocates for gay and bisexual men and other men having sex with men should use while participating in these important forums.
By all accounts, the world is terribly off track to meet global targets to curb new HIV infections. This is especially true for gay and bisexual men and other key populations, who have been systematically denied rights, equity, and justice in the HIV response.
Globally in 2019, almost one quarter (23%) of new adult HIV infections were among gay and bisexual men. This population accounted for more than 40% of new infections in Asia and the Pacific and Latin America, and nearly two thirds (64%) of new infections in western and central Europe and North America. Available data suggest that the risk of HIV acquisition among gay and bisexual men was 26 times higher compared to all adult men, and new HIV infections are also on the rise among young men who have sex with men aged 15-29 in many place around the world. Other sexually transmitted infections are also alarmingly high among gay and bisexual men: nearly three-quarters of all syphilis cases in the United States were among gay and bisexual men, with new cases on the rise in gay men aged 15-19. Rates of syphilis, gonorrhea, and chlamydia were much higher among gay and bisexual men in Africa, Latin America, and Asia compared to the general population. Gay and bisexual men are also at increased risk of viral hepatitis, with a disproportionately high prevalence of Hepatitis B virus worldwide.
The health and human rights of gay and bisexual men are largely shaped by structural forces, including pervasive stigma and homophobia, transphobia, poverty, racism, xenophobia, violence, insufficient resources, curtailment of basic freedoms, among others. These forces are bolstered by punitive and discriminatory laws, policies, and practices that criminalize our existence, justify inaction and lack of political will, and result in inequities that will continue to fuel the epidemic.
For this reason, structural interventions to address upstream factors must be enacted to improve the quality, availability, affordability, accessibility, acceptability and safety of HIV services for gay and bisexual men. Investments in targeted, tailored, and comprehensive HIV prevention options, including PrEP (including injectable PrEP), must be commensurate with the data on new HIV infections: 62% of new infections are among key populations and their sexual partners, yet the HIV response among key populations is greatly underfunded.
Primary among our concerns for funding in the HIV response is the lack of funding for community-led responses and community-led monitoring. These initiatives are critical to provide adequate, quality, and targeted care to gay and bisexual men. Additionally, community-led services would offset the burden to health systems that have been overtaxed by the COVID-19 pandemic.
Centering communities in the response would also address the troubling lag between new science, such as injectable PrEP, and roll-out to our communities worldwide. At the same time, the world is still struggling to ensure immediate access to antiretroviral as well as Hepatitis C medications, due in large part to affordability and accessibility: access to medical interventions is hampered by the costs of medicines, health care, testing and monitoring, and the politics of funding. We also know that diagnostic capacity to monitor treatment outcomes at both the individual and community levels lags miserably behind current technologies, and communities have a key role to play in addressing this.
Finally, the COVID-19 pandemic has revealed our broken health systems and amplified unabated stigma and discrimination, as LGBTI people have been blamed for the pandemic. The COVID-19 pandemic has radically shifted the focus and availability of resources for addressing global health challenges. However, responses to COVID-19 should serve as an opportunity to fix what’s broken and to double down on the HIV response. Within this context, there is an even greater need for HIV resources targeted where they are needed most.
In consideration of the above, MPact created the below talking points for advocates for gay and bisexual men to utilize in forums to demand more equity and justice in the HIV response. These messages – representing a wide range of issues of concern for gay and bisexual men and other men who have sex with men – were developed based on inputs gathered by MPact, in collaboration with partners and regional networks worldwide, and vetted by MPact’s international steering committee.
Centering Communities in the HIV Response for Gay and Bisexual Men
Community-based and LGBTI-led organizations play an essential role in reaching gay and bisexual men and delivering high quality, stigma-free HIV prevention, treatment, and support services. An effective HIV response will center, safeguard, and fully fund communities as equal partners throughout the HIV cascade.
- Any and all data presented regarding the epidemic among gay and bisexual men should take into account whether or not there is an enabling environment (funding, freedoms of association and civil society space, autonomy from government-led services, absence of criminalization) for community-led services to thrive.
- The HIV response is most effective when community-based and LGBTI-led organizations are meaningfully consulted in every aspect of programming: research, design, implementation, evaluation, redesigning. Formalized positions and entities should exist to enable gay and bisexual men and other men who have sex with men to dialogue with National AIDS Commissions and donors regarding the HIV epidemic in each country context.
- Independent, routine community-led monitoring of service provision should be conducted at all public and private facilities. Community-led monitoring provides essential feedback that should be integrated into policy and programmatic decisions. Community-led monitoring can include activities designed to assess the acceptability, accessibility, affordability, quality of services, and client satisfaction, as well as document the impact of punitive laws and policies, experiences of stigma, discrimination, coercion, blackmail, and violence on the way to and/or at HIV service organizations and clinics.
Human Rights Violations and Structural Barriers that Impede the HIV Response among Gay and Bisexual Men
Governments must commit to protect, promote, and fulfill human rights for gay and bisexual men in an effective HIV response. Structural factors at the legal and policy levels greatly inhibit the realization of human rights and right to health for gay and bisexual men, and programs, resources, and mechanisms need to exist to address these factors.
- Poverty, racism, sexism, homophobia, transphobia, and xenophobia hurt health. These structural forces are exacerbated by extreme right-wing conservatism, fanning the flames of stigma and discrimination faced by gay and bisexual men. Gay and bisexual men with multiple, intersecting community affiliations are impacted on multiple fronts, leading to worse health outcomes.
- Discriminatory and punitive laws, policies, and practices hinder the HIV response for gay and bisexual men. Efforts and commitments to decriminalize consensual same-sex relations between adults should be understood as integral to the HIV epidemic. Critical attention should be given to epidemiological data presented from countries with laws that criminalize consensual same-sex relations between adults, gender non-conformity, sex work, drug use, and HIV exposure, non-disclosure and transmission.
- Violence perpetrated on the basis of sexual orientation and gender identity and expression particularly impacts the ability of gay and bisexual men to seek and continue services. Gender-based violence and HIV-related stigma data often do not include the experiences of gay and bisexual men. In addition, anti-gender-based violence services are not tailored for the unique needs of gay and bisexual men.
Effective Approaches that Combine HIV Testing, Prevention, and Treatment with other Holistic Sexual Health Services for Gay and Bisexual Men
HIV and other sexual health services with or led by gay and bisexual men are more likely to result in earlier, comprehensive, and more frequent service engagement, and improved retention in services, yielding better health outcomes.
- Gay and bisexual men are best equipped to help members of our communities because we: 1) share experiences of stigma, discrimination, and/or violence; 2) have knowledge about and access to supportive networks of gay men who can sensitively inform outreach and service implementation; 3) are more likely to be comfortable discussing sensitive matters concerning the lives of gay men; and therefore 4) can more easily establish trust with service users and gain their confidence. As such, we believe that the global HIV response should pivot its service direction from a for community stance to a by community
- Effective and tailored sexual health services must begin by sensitively and respectfully assessing the needs of gay and bisexual men, including the younger ones – and reaching them with prevention commodities and interventions through combination approaches.
- All services must be free from judgment, stigma and discrimination, sex-affirming, honor self-determination, and respect bodily autonomy. Individuals should feel empowered to exercise the right of choice for sexual health services. Healthcare professionals should always act in the interest of their clients, even when national or subnational laws or policies oppose human rights and conflict with public health approaches.
- We need comprehensive sexual health programs that bring PrEP to scale NOW! Countries must move beyond PrEP pilot programs towards scale-up of comprehensive PrEP programs for gay, bisexual and other men who have sex with men, inclusive of demand generation, risk reduction counseling, literacy, adherence, and support. With the advent of long-acting injectable PrEP, gay and bisexual men must participate in program planning to ensure its optimal access and uptake. PrEP in all forms must be made available at affordable prices in developing countries.
- All sexual health and HIV programming should emphasize a holistic approach to well-being that embraces pleasure and endorses harm reduction, including mental health, and should take in to account the psychosocial and structural factors that heighten health vulnerability. Biomedical responses to HIV can only represent a part of the solution: prevention programs should address upstream factors and support tailored strategies for community mobilization.
International Funding and Domestic Investment
Global funding and domestic investment in the HIV response is shrinking each year: in 2018, investment in the HIV responses of low- and middle-income countries decreased by US$ 900 million in just one year. COVID-19 is jeopardizing the existence of sufficient HIV resources, especially for key populations, and many national governments are reviewing or have already revised their budgetary allocations. Programming for key populations is often the first to get removed or reduced in these circumstances.
- Political will and insufficient engagement of the community remain the primary barriers to targeted resource allocation and investment for gay and bisexual men. Allocations must be proportionally based on HIV burden and based in evidence, human rights, and community engagement.
- More investment and financial support should be directed to core funding for community- and key population-led networks, coalitions, and consortia of HIV advocates, which are instrumental in championing an effective human rights response in regions of the world where civil society capacity is weak or uneven.
- More data must be collected and analyzed regarding funding needs and gaps, including: building capacities of civil society organizations to develop, implement, and evaluate service provision; domestic vs. international vs. private sector investment; cost disaggregation for programming.
- International funding must be met by scaled-up domestic investment in key populations, especially gay and bisexual men, particularly in countries that are transitioning from international donor support. Matching funds, designed to inspire innovation and ambitious evidence-based programmatic approaches, should be used to maximize impact in specific strategic priority areas for key populations.
- Due to pervasive stigma, discrimination, violence, and criminalization faced by gay and bisexual men, flexible emergency response funding and funding to support longer-term social change is necessary in all regions.
Global and National Targets and Commitments
Global and national targets have been agreed upon at the highest levels to end AIDS by 2030, as articulated in the United Nations General Assembly’s 2016 Political Declaration on Ending AIDS. However, many countries and entire regions are not on track to reach these targets, and most of these targets lack specificity for gay and bisexual men and disregard the unique needs of our communities.
- Governments must endeavor to disaggregate data by sexual orientation, gender identity and expression, as these data are critical to understanding the epidemic. Data collection and disaggregation must be conducted in a safe, responsive, and confidential manner that is vetted by communities. UNAIDS and other UN agencies should provide technical support for this effort.
- National reporting on targets often lack comprehensive indicators for achieving epidemic control among gay and bisexual men. Communities should be consulted to develop key indicators for measuring progress on the epidemic.
- More efforts and resources should go toward conducting community-based participatory action research (CBPAR), which involves community advocates in all stages to yield rigorous and robust data that are meaningful and relevant for the communities who are the focus of the research.
- Civil society organizations must actively participate in reporting to offer a counter narrative to State and UN documentation, through Global AIDS Monitoring, Voluntary National Review paragraph 89 parallel reporting, and Universal Periodic Review shadow reporting.
- Gay and bisexual men, sex workers, transgender people, and people who use drugs should be explicitly and more evenly involved across strategy development processes at UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
- Government commitments to achieve Universal Health Coverage (UHC) by 2030 must ensure that HIV services are not deprioritized and that gay and bisexual men are active participants in the definition of their health care.
COVID-19 and the HIV Response among Gay and Bisexual men
The COVID-19 pandemic has caused extreme hardship for gay and bisexual men and gay and bisexual men living with HIV. Government responses to the pandemic must safeguard HIV programming and protect marginalized and vulnerable gay and bisexual men.
- The world was already off track to reach 2020 global targets, and COVID-19 further threatens progress, particularly among gay and bisexual men and other key populations. We have to double down on targets through partnership with community-led and key population-led organizations, networks, and consortia.
- Gay and bisexual men and LGBT communities are being scapegoated, blamed, harassed, and targeted during the COVID-19 pandemic, including the raiding of some LGBT-led organizations. These factors undoubtedly impact the HIV response and deter gay and bisexual men from seeking services.
- Efforts to decentralize HIV services should bolster pre-existing community-led strategies, and increased support and investment should flow to community-led organizations to reach gay and bisexual men during COVID-19.
- The economic impact on gay and bisexual men and LGBT communities, sex workers, and others will also greatly impact the ability of some persons to seek health services and acquire medicine. Considerations should be made for income support.
- Governments must acknowledge barriers to meaningful participation of key populations in virtual meetings during the pandemic. Governments and multilateral agencies should develop a plan to overcome these barriers that is based on human rights and guided by principles of accountability, transparency, and equity. Special efforts should be made to provide financial and technological assistance to connect with civil society stakeholders who are less able to acquire the necessary technology and connectivity, so the groups farthest left behind are still meaningfully engaged.
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