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AIDSTAR-ONE WHITE PAPER Men Who Have Sex with Men (MSM) and HIV in the Anglophone Caribbean Contents 1.
Summary
2.
Situation Review
3.
Considerations for Improved Programming 3.3 Building evidence and subsequent action 3.1 Augmenting and targeting HIV interventions 3.2 Improving rights environments 3.4 Reinforcing leadership from governments 3.5 Reinforcing leadership from communities
4. Resources 5. References
Acknowledgments This document was researched, written, and produced by John Snow, Inc. (JSI) under AIDSTAR-One, USAID’s global HIV/AIDS project providing technical assistance services to the Office of HIV/AIDS and USG country teams. Consultant support for research and writing was provided by Sam Avrett, with input from Stef Baral, Rafael Mazin, and Will Rockwell. Thanks and credit especially go to the many people in the Caribbean who contributed ideas, content, and review for this document, including Robert Carr, Ivan Cruikshank, Marcus Day, Vince Gillen, Ian McKnight, Salim October, Caleb Orozco, Joel Simpson, and John Waters.
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AIDSTAR-ONE WHITE PAPER Men Who Have Sex with Men (MSM) and HIV in the Anglophone Caribbean 1. Summary Gay, bisexual, and other men who have sex with men (MSM) in the Anglophone countries of the Caribbean face a disproportionate share of the HIV epidemic.1 2 Only four of the twelve Anglophone Caribbean countries publicly collect HIV prevalence data among MSM, and in three of these four countries - Jamaica, Guyana, and Trinidad and Tobago - researchers report HIV prevalence of more than 20% among MSM.3 Good clinical and public health practice in HIV epidemics recommends targeting resources to preventing infections and illness in populations most at risk. Despite the known extent of HIV among MSM in the Anglophone Caribbean, there remains an underinvestment in HIV interventions that promote health, reduce risk, and increase access to and utilization of services by MSM. There is also a notable deficiency in human rights environments and a lack of protection of human rights that impedes efforts to improve the health of MSM. 4 This AIDSTAR-One White Paper on HIV programming for MSM in the Anglophone Caribbean provides summary information and a review of programming opportunities and resources for USAID Mission staff, U.S. government-funded health program planners and implementers, and other stakeholders, including governments, other international donors and agencies, and indigenous organizations involved in the response to HIV and AIDS. Definitions The Anglophone Caribbean is defined in this document as the twelve countries of (in order of population size): Jamaica, Trinidad & Tobago, Guyana, Bahamas, Belize, Barbados, Saint Lucia, Saint Vincent & the Grenadines, Grenada, Dominica, Antigua & Barbuda, and Saint Kitts & Nevis. The Anglophone Caribbean covers over 30 islands and two continental entities (Guyana and Belize), with a total population of approximately 6.5 million and an average annual per capita GDP of $12,000. The largest countries in the Anglophone Caribbean are Jamaica (with 2.8 million people) and Trinidad & Tobago (with 1.3 million). In terms of per capita GDP, the wealthiest countries of the Anglophone Caribbean are Trinidad & Tobago, Bahamas, and Barbados; the poorest are Jamaica, Guyana, and Belize. The acronym MSM stands for “men who have sex with men” is thus inclusive of all adult males who engage in consensual male-to-male sex, including those self-identifying as gay, bisexual, or heterosexual in their sexual orientation. 1
Baral S, Sifakis F, Cleghorne F, and Beyrer C. “Elevated Risk of HIV Infection among Men who have Sex with Men in Low- and Middle-Income Countries 2000-2006: A Systematic Review.” PLOS Medicine, Dec 2007, 4 (12) www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0040339 2
Caceres CF, Konda K, Segura ER and Lyeria R. “Epidemiology of male same-sex behaviour and associated sexual health indicators in low- and middle-income countries: 2003-2007 estimates.” Sex Transm Infect 2008;84:i49-i56. http://sti.bmj.com/content/84/Suppl_1/i49.abstract 3 UNAIDS. 2008 UNGASS Country Progress Reports. www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/2007CountryProgressCaribbean.asp 4 Waters J. “MSM, transgender persons, and sex workers in the Caribbean: A level ground look at underground behaviour and how it affects us all.” Background paper commissioned by PAHO and WHO (in press).
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2. MSM and HIV in the Anglophone Caribbean: A Situation Review 2.1 HIV epidemiology According to 2008 UNGASS Country Reports, three of the largest Anglophone Caribbean countries - Jamaica, Trinidad and Tobago, and Guyana -- report an HIV prevalence of 20 percent or more among MSM, indicating that at least one in five MSM tested for HIV is found to be HIV-infected. 5 These are startlingly high numbers, rivaling the highest HIV prevalence found in any population around the world. Calculations of odds ratios indicate that Caribbean men who engage in sex with other men are between 6 and 30 times more likely to be infected with HIV than a member of the general population. 6 The high HIV prevalence (above 5 percent) seen among MSM and consistently low HIV prevalence (below 1 percent) observed in general populations in the Anglophone Caribbean suggest that HIV epidemics in the Anglophone Caribbean may be concentrated rather than generalized (See Graph 1/2). This hypothesis is reinforced by a quarter-century of epidemiologic surveys and rapid assessments in which Caribbean researchers have documented the multiple and interdependent sub-epidemics characterized by sex between men, sex work, and drug use. Several researchers suggest that the twin drivers of the epidemic in the Caribbean may be men’s practice of multiple concurrent sexual partnerships combined with some men having sex with both men and women (also termed bisexual concurrency), amplified by concurrent factors such as high HIV prevalence among MSM, migration, poverty, sex work, drug use, gender identity, and incarceration. 7 8 9 One HIV expert in the region has recently combined available evidence about male sexual behavior and MSM-related HIV prevalence to calculate that male-to-male sex may account for 89 percent of all annual HIV infections (6750 of 7500) among men in Trinidad.10 Averaged data from the Caribbean Epidemiology Centre (CAREC) and evidence from many countries reinforce this observation, showing that a majority of new HIV cases in the Caribbean may derive from male-to-male sexual transmission that is simply unreported (Graph 3). 11 In all twelve Caribbean countries, research points to the following consistent patterns: •
Men engage in male-to-male sex in all countries of the Caribbean. Most Caribbean
5
UNAIDS. 2008 UNGASS Country Progress Reports. www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/2007CountryProgressCaribbean.asp 6 Correspondence with Dr. John Waters, COIN, March 2010. See also Baral S, et al. “elevated Risk…”PLOS Medicine, Dec 2007, 4 (12) 7
U. Wagner and B Camara, “More Effective HIV prevention through strengthening of epidemiological surveillance in the Caribbean”, Congress of the German Society for Tropical Medicine, Heidelberg, Germany (24-27 September 1997). 8
Desafíos y Lecciones Aprendidas: Prevención de las ITS, el VIH y el SIDA entre hombres gay y otros hombres que tienen sexo con hombres en América Latina y el Caribe latino. Asociación para la Salud Integral y Ciudadanía en América Latina y el Caribe, 2005. 9 Waters J. ibid. 10
Waters J, ibid.
11
de Groulard, M; Sealy, G; Brathwaite, B; Russell-Brown, P. A.; Wagner, H; O’Neil, C; Allen,C; Emmanuel, J. “Homosexual Aspects of the HIV/AIDS Epidemic in the Caribbean: A Public Health Challenge for Prevention and Control .” Int Conf AIDS. 2000 Jul 9-14; 13: abstract no. ThOrD732. http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102242026.html
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men who engage in sex with other men may identify as heterosexual or bisexual, may not self-identify with this behavior, and may have sex with both men and women. Bisexual concurrency - sex with both men and women – combined with lack of condom use and high HIV prevalence among MSM is likely a driver of many HIV epidemics throughout the Caribbean. •
Men in the Anglophone Caribbean live in environments of extreme and frequently violent social disapproval and rejection of homosexuality. Some supportive social environments for MSM do exist on every island, especially as facilitated by the internet, and gay social networks exist in the largest cities such as Kingston, Georgetown, and Port of Spain/Chaguanas, but in general, local contexts are homophobic and threaten MSM with social and economic marginalization.
•
Sexually-active gay, bisexual, and other MSM in the Anglophone countries of the Caribbean are disproportionately infected with HIV, with HIV prevalence of 20 percent or more reported in three major countries.
•
HIV-related vulnerability of these men is likely to be due not only to unprotected anal sex, but also to other contextual health and rights issues such as poverty, youth, migration, sex work, drug use, gender identity, homelessness, incarceration, and/or threat of violence or marginalization.
•
Most national health systems still have only weak quantified data for potential use in program design or funding allocations. Most country AIDS programs have no certain calculation of the number of MSM who might be at risk of HIV infection or in need of HIV-related health services. A recent literature review of published and unpublished surveillance and research data on the prevalence of same-sex sexual activity among adult males found that almost nothing had been published on MSM in the Caribbean and that what little did exist focused on male sexual identity rather than male sexual practice.12
12
Cáceres, C; Konda, K; Pecheny, M; Chatterjee A; Lyerla, R. Estimating the number of men who have sex with men in low and middle income countries. Sex Transm Infect 2006;82(Suppl III).
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Graph 1. Reported HIV Seroprevalence among MSM - 2008 UNGASS Country Reports
Note for graphics layout: combine information from Graphs 1 and 2 to make the contrast between MSM and the whole population yet more clear.
Graph 2. Reported Adult HIV Prevalence - 2008 UNGASS Country Reports
Graph 3. Male Risk Category by Year in Trinidad & Tobago – CAREC data 100%
Percentages
80%
60%
40%
20%
0% 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Years
Homo/Bisexuals
Heterosexuals
Unspecified
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Access to HIV prevention, treatment, care and support Global data suggest that sustained reductions in HIV transmission and improvements in HIV treatment outcomes require: •
A spectrum of combined HIV prevention, treatment, and care interventions at individual, network, and structural levels, at multiple access points, by multiple providers, designed in ways that are accessible and effective for their social contexts;
•
Community-centered programming, wherein individuals living in the targeted sexual and social networks can engage peers in regular sustained and trusted education and support; and
•
Sufficient scale, such that the entire community or network is reached with sustained health awareness and health care access.13
Data are limited with regard to MSM in the Caribbean, but all evidence shows that these three aspects of health programming are not yet in place. In 2008 UNGASS Country Progress Reports, Anglophone Caribbean countries reported that only 50 percent of MSM studied indicate that they know how to protect themselves against HIV (with this data possibly an over-calculation due to selection bias, respondent bias, and interviewer bias). A 2009 review of Global Fund grants to the Government of Jamaica and to the regional organizations of the Organisation of Eastern Caribbean States (OECS) and the Caribbean Regional Network of People Living with HIV/AIDS (CRN+) suggested that only a minimal portion of HIV funding was reaching organizations serving MSM.14 In its 2009 application to the Global Fund, the Pan Caribbean Partnership Against HIV and AIDS (PANCAP) noted that: “Despite the success of a number of peer-based outreach programs for MSM and for female sex workers in the Caribbean, effective strategies to address key vulnerable populations and to change their behaviors to lower the risk of HIV transmission have not been widely disseminated in the region. In part that is because different countries have very distinct levels of prejudice and tolerance.… In some places, very little has been possible.” A 2009 multi-country study on access to healthcare, conducted in Jamaica, Trinidad & Tobago, Belize, Antigua & Barbuda, and Saint Kitts & Nevis by the Caribbean Vulnerable Communities Coalition (CVC) Healthcare Working Group, also shows that gay, bisexual, and other MSM are not accessing healthcare for a range of reasons, including experiences of discrimination, judgmental and moralistic attitudes, and outright hostility of healthcare providers, concerns about privacy and confidentiality, shame, lack of healthcare services specific to MSM needs, and lack of money to pay for alternate private-sector healthcare. 15 13
Coates TJ, Richter L, and Caceres C. “Behavioural strategies to reduce HIV transmission: how to make them work better.” Lancet. 2008 August 23:372(9639):669-684. 14 International HIV/AIDS Alliance, Report on access to Global Fund resources by HIV/AIDS key populations in Latin America and the Caribbean, April 2009 15 Caribbean Vulnerable Communities Coalition (CVC) Healthcare Working Group. Access to Healthcare for Vulnerable Groups. (in press)
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The CVC study also found, across all countries in the study, that effeminate or “identifiably gay” men were more likely to describe stigma and discrimination as a major issue, but were also more likely to disclose their sexual behavior to healthcare personnel and thereby, in some instances, access additional STI screening and more relevant care as a result. Men identified as or presenting as heterosexual were far less likely to communicate with healthcare providers the specifics of their sexual behavior, which resulted in failure to detect STIs in these men. All men were reluctant to seek medical attention for anal/rectal STI symptoms, and in cases of these STIs, men were more likely to self-medicate or simply ignore the anal symptoms. One conclusion of the CVC study is that limited access by MSM to screening and treatment for HIV and STIs has major consequences, not only for the health outcomes of those individuals but also for the health of their partners.
Human rights environments Efficiency and effectiveness of HIV programming depend on people being able to seek essential services and support and to live their lives free from discrimination, blackmail, violence, and criminalization. HIV programs routinely report that supporting people in their human rights of rights is a necessary precondition to access to health services and personal negotiation of health. Several researchers have now documented the link between MSM rights environments and HIV prevalence.16 17 Unfortunately, every Anglophone Caribbean government criminalizes any sex between men, with the exception of Bahamas where buggery laws were repealed in 1991 and replaced by sanctions to "sex acts committed in public places". Most Caribbean countries are characterized in a recent UNAIDS-sponsored report as having ‘repressive’ legal systems in respect to homosexuality.18 Based on 2008 data, when compared to other regions in the world, the Caribbean comes in second-to-last in legal and policy environments that pose barriers to HIV programming.19 Governmental attempts to regulate sexual behavior, sexuality, gender identity, and gender expression through laws are usually ineffective and counterproductive in their professed aims, and contribute to people’s vulnerability to HIV. 20 Confirming this vulnerability, a multi-country CAREC study in nine Caribbean countries documented high levels of physical violence, stigmatization, and discrimination faced by MSM a decade ago, and more recent reports from CVC have repeated this funding: 21 16
Baral, S. et al. HIV Prevalence, Risks for HIV Infection, and Human Rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS One. 2008). 17 Caceres et al, Review of Legal Frameworks and the Situation of Human Rights related to Sexual Diversity in low and Middle Income Countries, Sex Transm Infect 2008;84;i49-i56), http://data.unaids.org/pub/Report/2009/20091215_legalframeworks_sexualdiversity_en.pdf 18 Caceres et al, ibid. 19
Gruskin, Ferguson. Ensuring an Effective HIV Response for Vulnerable Populations: Assessing national legal and policy environments. 20
Gruskin S and Ferguson L. Government regulation of sex and sexuality: in their own words. Reproductive Health Matters 2009;17(34):108118 21 de Groulard, M, et al ibid.
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In Jamaica, gay men and lesbians report verbal abuse by work colleagues, vicious beatings by police, relatives and community-members, and homelessness after being driven from their communities by angry neighbors. 22
•
Also in Jamaica, men and women with same-sex-partners report to health and social service providers that both homophobia and HIV/AIDS-related stigma discourage their use of testing, treatment and care services, and cause HIV-positive individuals less likely to reveal seropositive status to sexual partners.23
•
In Trinidad and Tobago: Business owners cite reluctance to having condoms present on their premises due to fear of being identified and prosecuted as prostitution establishments.24
•
In Belize: Observational data collected by a CDC research team revealed strong hatred for MSM in the country. They are viewed as men who engage in unnatural acts that are crimes against the church. Threats of violence and verbal harassment were experienced while walking the streets of Belize City.25
As stated in the recent PANCAP regional Round 9 funding proposal to the Global Fund, “Sexuality and repression are recurrent themes in Caribbean culture. Practices exist that are taboo and thus hidden, none more so than men having sex with men. Traditional small town and island societies, highly religious and prone to gossip, tend to strongly stigmatize those openly involved in male-to-male sex and sex work. As a result, men hide these activities, often migrating temporarily or permanently to gain anonymity. Discrimination can be extreme: violence is all too frequent in some places. Many who need testing and treatment services avoid them, since confidentiality is poorly guaranteed. Legal and regulatory systems reflect these barriers, as do the attitudes of some health service providers (as when AIDS patients are refused entry to public hospitals). Information on vulnerable populations is difficult to obtain due to their fears about lack of confidentiality.” 26
22
White R, Carr R; Homosexuality and HIV/AIDS stigma in Jamaica. Culture, Health & Sexuality, Volume 7, Issue 4 July 2005: 1–13 and 347 - 359 23 24
White, R, et al. ibid. From interviews carried out with business owners in Trinidad and Tobago in April 2008
25
Martin, C, Public Health Analyst, US Centers for Disease Control and Prevention, Multi Centric Study with Vulnerable Populations, Unpublished Final Report, Belize, July 2005. 26 Round 9 proposal. www.globalniyfond.org/grantdocuments/9MACH_1885_0_full.pdf
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3. Considerations for Improved Programming 3.1
Building evidence and subsequent action
As yet, HIV programs across the twelve Anglophone Caribbean countries lack substantial data about who is at highest risk for HIV infection or untreated illness due to AIDS. Extensive HIV biological and behavioral surveillance or social research is not yet in place in any of the 12 countries to establish a clear picture across the region of exactly which men are becoming HIV-infected or why. Furthermore, program reporting is also lacking; for example, in 2008 UNGASS reporting, of the twelve Anglophone Caribbean countries, only Guyana and Bahamas reported on three or more of the five indicators for MSM. This lack of data can be overcome. In surveillance, relevant methods and tools have been defined that are appropriate for use in Caribbean countries. 27 28 29 30 31 In programmatic scale-up and reporting, the Caribbean has undergone a massive scaling-up of programs to encourage HIV testing of pregnant women, and countries such as Trinidad & Tobago are able to report that a ten-year effort to promote HIV testing among pregnant women attending public antenatal facilities have resulted in 95 percent coverage by 2005, even while most cannot or will not report on similar efforts related to HIV interventions among MSM.32 33 The Global Fund has now articulated a strategy to encourage government partners to allocate funding for HIV-related research and data collection. The Global Fund has also recommended allocation of financial support for harmonization of data collection and M&E activities across health systems, including funding of personnel, equipment, and space to manage external research studies, ensure consistent and integrated questions and indicators in data collection, and improve capacity for data analysis and reporting. Under the Global Fund’s Strategy on Sexual Orientation and Gender Identities (SOGI Strategy), the Global Fund has committed to helping country partners overcome challenges in collecting and communicating data about HIV programming by and for MSM, transgender people, and sex workers. UNAIDS and PAHO are also a resource for Caribbean countries in this area, providing guidelines and e-training for international UNGASS reporting about HIV programming, 27
Magnani R, Sabin K, Saidel T, Heckathorn D. “Review of sampling hard-to-reach and hidden populations for HIV surveillance.” AIDS 2005, 19 (suppl 2):S67–S72 28 Mansergh G, Naorat S, Jommaroeng R, et al. “Adaptation of venue-day-time sampling in southeast Asia to access men who have sex with men for HIV assessment in Bangkok.” Field Methods 2006;18:135--52. 29
Liau, A; Millett, G; Marks, G. “Meta-analytic Examination of Online Sex-Seeking and Sexual Risk Behavior Among Men Who Have Sex With Men.” Sexually Transmitted Diseases: September 2006 - Volume 33 - Issue 9 - pp 576-584 30
Heckathorn, D. Respondent-Driven Sampling: A New Approach to the Study of Hidden Populations. SOCIAL PROBLEMS, Vol. 44, No. 2, May 1997 31
Behavioural and HIV Seroprevalence Survey e.g. Gayet, C; Fernández-Cerdeño, A. “Time Location Sampling and Respondent Driven Sampling: techniques implementation for monitoring concentrated HIV/AIDS epidemic in Mexico”. Presentation at the September 2009 IUSSP International Population Conference. iussp2009.princeton.edu/download.aspx?submissionId=93359 32
PAHO, WHO (2006). “Assessment report for the evaluation of national services for the prevention of mother to child transmission of HIV and syphilis, 2000–2005.” Washington, DC. 33 UNGASS 2008 Country Progress Report: Trinidad and Tobago.
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operational guidelines on monitoring and evaluation for HIV prevention among MSM, and regional in-person trainings for country HIV program managers on monitoring, evaluation, and reporting, focused on regional M&E frameworks and global UNGASS reporting. Box 3. Piloting new research methods to characterize HIV transmission in the Caribbean Much more can be done to increase the quality of data collection and reporting about the scale and attributable fraction of HIV risk and HIV burden related to MSM in the Caribbean to provide insight and guidance to the development and scale-up of appropriate and comprehensive HIV interventions for MSM populations. In the Caribbean, countries have enormous opportunity to adopt innovative research methods to define and better understand who is at highest risk for HIV infection or untreated illness due to AIDS, and thereby better target HIV programs. Biological approaches using recency assays and molecular surveillance, and survey methods such as venue-time sampling, respondent-driven sampling, and internet sampling are all discussed in published literature as ways to engage populations that are reluctant to participate in research due to stigma, discrimination, and even potential for arrest. As one example of innovation in HIV research in the Caribbean, a new epidemiologic modeling approach called Mode of Transmission (MoT), used successfully in Africa and Asia, has now been piloted in Jamaica and the Dominican Republic with the support of UNAIDS. 34 Epidemiological models are not a substitute for extensive population-wide surveillance. However, results from these new MoT pilot studies may provide those countries with a new way to calculate the expected number of new infections per year on the basis of currently observed distribution of infections and patterns of risk within sub-populations, and, if rolled out to other countries, may contribute to further understanding of the transmission dynamics in the region.
Box 4: Turning evidence into action Research and subsequent action need not be an expensive or lengthy process. After a young man working with the Caribbean Harm Reduction Coalition (CHRC) conducted a small behavioral
34
Colvin, M. Gorgens-Albino, S. Kasedde. “Analysis of HIV Prevention Response and Modes of HIV Transmission: The UNAIDSGAMET Supported Synthesis Process.” UNAIDS, 2009
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and sero-prevalence study (BSS) of MSM in Saint Lucia, the results motivated the creation of a shelter for young MSM as well as homeless and HIV+ MSM. The study identified a number of young MSM (ages 16 to 30) in need of support. CHRC now operates the shelter as both an overnight and long-term shelter in Castries, Saint Lucia, and has started a drop-in meals program in Vieux Fort, Saint Lucia and a new effort to create employment opportunities. This example from CHRC should that even with limited resources, a front-line program can demonstrate quick action in providing at at-risk population of men with a safe space to meet, discussion groups on HIV prevention, harm reduction counseling and shelter when needed. 35
3.2
Augmenting and targeting HIV interventions
In the Caribbean, HIV incidence and prevalence can be reduced among gay, bisexual, and other men who have sex with men (MSM) if a combination of proven HIV interventions are appropriately targeted, implemented, and brought to scale. This scale-up has not yet happened in any Caribbean country, but it is the clear recommendation of the Pan American Health Organisation (PAHO) and a number of other global health and HIV agencies (see Resources). The first priority for health program planners and implementers is to implement and scaleup what is known to work. International best practice recommends that the full range of proven HIV interventions always be implemented in combination, at multiple levels, from multiple providers, and at sufficient scale to have an impact.36 37 38 A range of interventions has been proven internationally to reduce the impact of HIV and AIDS on MSM. These interventions include providing access to and promoting condoms and water-based (or silicone-based) lubricants, providing men who may be sexually active with sufficient information, education, and support to negotiate safer sexual practices and safer drug use practices, and providing clinical and social services (Table 1).39 40 41 42 Interventions for the health and rights of MSM should also be implemented by both governmental health programs and community-based providers. Given the stigmatization of these populations, Caribbean health program planners and implementers should place special emphasis on investing in community-based HIV programs, following the principles and strategies provided in the International Association of AIDS Service Organizations’ 35
Communication with Dr. Marcus Day, Caribbean Harm Reduction Coalition (CHRC), May 2010
36
Piot P, Bartos M, Larson H, Zewdie D, Mane P. “Coming to terms with complexity: a call to action for HIV prevention.” Lancet 2008; 372(9641):845-859.
37
Coates TJ, Richter L, Caceres C. “Behavioural strategies to reduce HIV transmission: how to make them work better.” Lancet 2008; 372(9639):669-684. 38
Merson M, Padian N, Coates TJ, Gupta GR, Bertozzi SM, Piot P, et al. Combination HIV prevention. Lancet 2008; 372(9652):1805-1806. 39 WHO. “Priority interventions for HIV/AIDS prevention, treatment and care in the health sector.” April 2009. www.who.int/hiv/pub/priority_interventions_web.pdf 40 Global HIV Prevention Working Group. www.globalhivprevention.org 41
The Global Forum on MSM & HIV (MSMGF). “Reaching Men Who Have Sex With Men (MSM) In the Global HIV & AIDS Epidemic.” February 2010. www.msmgf.org/documents/MSMGF_ReachingMSM.pdf 42
Vermund SH, Allen KL, Karim QA. HIV-prevention science at a crossroads: advances in reducing sexual risk.” Curr Opin HIV AIDS 2009; 4(4):266-273.
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(ICASO) recommendations for Community Systems Strengthening (CSS) and in recommendations by researchers and community advocates.43 44 45 Additional considerations for focusing HIV program resources on this topic in the region:
43
•
Regional alignment and multi-country support of HIV interventions: Given the small populations of each country, relatively high inter-island migration, and the linkages and influences between the islands in economics, politics, culture, and religion, and the importance of existing regional institutions and initiatives, regional and multicountry efforts can facilitate local action in many Caribbean countries. 46
•
Relative epidemic size, recency, and transmission patterns: Caribbean populations and their HIV epidemics are not evenly distributed across the region. If the pattern of HIV infections among MSM mirrors the distribution and migration patterns of the general population, health program planners and implementers should consider several hypotheses that may help to target HIV interventions for MSM in the Caribbean: o An estimated half of all HIV infections among MSM in the Anglophone Caribbean are happening in Jamaica, Trinidad and Tobago, and Guyana; o Islands with smaller populations such as Saint Lucia, Saint Vincent & the Grenadines, Grenada, Dominica, Antigua & Barbuda, and Saint Kitts & Nevis may present strong opportunity for implementing HIV programming for MSM at a scale that can reverse and end those epidemics. These islands may have severe MSM epidemics – for example, one research study in Dominica found that 71% of all HIV cases were among MSM - but the total number of men to support in accessing comprehensive health promotion and care may be only in the hundreds on each island; o There is a substantial migration of MSM among the Caribbean countries and between the Caribbean and the United States, Canada, and the United Kingdom.
•
Synergy and scale-up across interventions: Recent evidence from Canada and elsewhere suggests that scale-up of comprehensive HIV interventions in specific locations and populations might be able to achieve sustained decreases in new HIV diagnoses and AIDS-related illnesses.4748 These interventions may not need to be
ICASO. Community Systems Strengthening. www.icaso.org/publications/csat_aa_Sept_09_EN.pdf
44
Carr, R. Value Added of Community Care for Marginalised Groups. Presentation given at the regional meeting: Universal Access by 2010: Addressing the Gap Castries, St Lucia, June 25 – 27, 2006 45
In many populations, there is strong evidence in tuberculosis, diabetes, hypertension, alcohol abuse, and HIV that investment in community literacy, empowerment, and mobilization to get people engaged in the concept of health promotion and into clinics are key factors to increase access and uptake of health services and messages. For example, in the United States, research networks such as the Antiretroviral Treatment Access Study (ARTAS) have shown that prevailing patient norms and empowerment, levels of patient health literacy, and contexts of social and economic rights have a measurable impact on access to and uptake of HIV services, and also that interventions such as peer navigators and case managers are effective and cost-effective means to help people follow through on health recommendations and intentions. 46 PANCAP proposal to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, submitted in 2009 under Round 9 call for applications. 47 Montaner J et al. “Association of expanded HAART coverage with a decrease in new HIV diagnoses, particularly among injection drug users in British Columbia, Canada.” 17th Conference on Retroviruses and Opportunistic Infections, San Francisco, abstract 88LB, 2010 48 Vancouver Initiative. www.sfu.ca/cs/community/a2c.htm
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expansive or expensive as much as they need to be well-targeted to people living with HIV and with high HIV exposure, with parallel support for addressing structural barriers of laws, institutional policies (such as at prisons), poverty-related issues such as housing and nutrition, and dynamics of gender, gender identity, sexuality, drug use, and race/ethnicity. Working from this understanding, several countries and cities are now beginning to evaluate significant scale-up of HIV interventions at a municipal or national level.49 50 51 National and municipal health authorities in the Caribbean may want to consider these international discussions and attempts to significantly curtail concentrated HIV epidemics. •
Structural sustainability and effectiveness: The long-term sustainability of the Caribbean’s HIV response may also be affected by the evolution of new global health architectures and attempts to create sustainable funding streams for international health and development, and the development and implementation of new health technologies, such as new fixed dose combinations for first-line and second-line antiretroviral therapy, new point-of-care STI diagnostics and HIV monitoring tools, and new HIV prevention technologies such as pre-exposure prophylaxis (PrEP). Health program planners and implementers in the Caribbean may want to pay attention to these large structural changes in the HIV response, looking for new opportunities to sustain health and rights programming for all.
49
AIDS Projects Management Group. “The policy and practice landscape for HIV prevention, treatment, and care among gay and other men who have sex with men—some lessons from the response among injecting drug users.” 2009. www.aidsprojects.com/01.Home%20page/IDU%20versus%20MSM%20policy%20and%20practice%20landscape.pdf 50
Castel A et al. “Monitoring the impact of expanded HIV testing in the District of Columbia using population-based HIV/AIDS surveillance data.” Seventeenth Conference on Retroviruses and Opportunistic Infections, San Francisco, abstract 34, 2010. 51 As a recent example of national leadership, in early 2010, South Africa has launched a national HIV Counseling and Testing Campaign (HCT) with intended outcomes including significant reductions of vertical HIV transmission, reduced cases of pediatric HIV, and reduced adult-adult HIV transmission rates. -- SA National AIDS Council (SANAC) HIV Counseling and Testing Campaign (HCT) – announced March 2010. allafrica.com/stories/201003180009.html
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Table 1: Components of effective combination HIV interventions for MSM 52 Proven HIV interventions and impact Promotion and distribution of and education about condoms and water-based or silicone-based lubricants can significantly reduce rates of HIV transmission.53
Approaches from the health sector to augment and target HIV interventions to address HIV among MSM in the Caribbean 1. Design and implement condom education, promotion, and distribution
campaigns directed specifically to benefit Caribbean MSM.54
2. Procure and distribute supplies of water-based and/or silicone-based
lubricant packets alongside condoms throughout the Caribbean.55
3. Expand MSM-focused STI and HIV testing, including healthcare
Early access to HIV and STI testing, treatment, and care can significantly reduce rates of illness and onward transmission.56 57 58 59 60 61 62
Counseling and sustained
provider-initiated (opt-out) testing in the public and private sector, accompanied by provider sensitization and training to avoid stigmatization, discriminatory care, or human rights abuses.63 64
4. Procure and distribute specific diagnostics for rectal STIs, such as self-
administered nucleic assay amplication tests (NAAT) swabs and rapid point-of-care syphilis Treponema pallidum (TP) testing, to facilitate accessibility and increase attractiveness of testing for MSM.65 66
5. Support community-based health literacy and mobilization campaigns
52
This table builds from (with permission) a similar table and data analysis constructed for a forthcoming World Bank report: Beyrer, C., Baral, S., Sifakis, F., Wirtz, A., Johns, B., Walker, D. The Global HIV Epidemics among Men who have Sex with Men (MSM): Epidemiology, Prevention, Access to care and Human Rights. The World Bank. Washington D.C. 2010. 53
Weller S, Davis K. “Condom effectiveness in reducing heterosexual HIV transmission.” Cochrane Database Syst Rev 2002(1):CD003255. 54
Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K, Buchbinder SP. “Per-contact risk of human immunodeficiency virus transmission between male sexual partners.” Am J Epidemiol 1999; 150(3):306-311. 55
Silverman B and Gross T. “Use and Effectiveness of Condoms During Anal Intercourse: A Review.” [Article]. Sex Transm Dis 1997; 24(1):11-17. 56 WHO HIV testing and counselling (TC) toolkit. www.who.int/hiv/topics/vct/toolkit/en/index.html 57
Denison JA, O'Reilly KR, Schmid GP, Kennedy CE, Sweat MD. “HIV voluntary counseling and testing and behavioral risk reduction in developing countries: a meta-analysis, 1990--2005.” AIDS Behav. 2008;12(3):363-73. 58
Holtgrave D, McGuire J. “Impact of Counseling in Voluntary Counseling and Testing Programs for Persons at Risk for or Living with HIV Infection.” Clinical Infectious Diseases 2007; 45(s4):S240-S243. 59
Marks G, Crepaz N, Senterfitt JW, Janssen RS. “Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs.” J Acquir Immune Defic Syndr 2005; 39(4):446-453. 60
Vernazza P, Hirschel B, Bernasconi E, Flepp M. “HIV transmission under highly active antiretroviral therapy.” Lancet 2008; 372(9652):1806-1807. 61
Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, et al. “Viral load and heterosexual transmission of human immunodeficiency virus type 1.” Rakai Project Study Group. N Engl J Med 2000; 342(13):921-929. 62
Pao D, Pillay D, Fisher M. “Potential impact of early antiretroviral therapy on transmission.” Curr Opin HIV AIDS 2009; 4(3):215221. 63 WHO. “Guidance on provider-initiated HIV testing and counselling in health facilities.” http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf 64 training manuals for the VCT Efficacy Study. www.caps.ucsf.edu/projects/VCT/ 65
Moncada J, Schachter J, Liska S, Shayevich C, Klausner JD. “Evaluation of self-collected glans and rectal swabs from men who have sex with men for detection of Chlamydia trachomatis and Neisseria gonorrhoeae by use of nucleic acid amplification tests.” J Clin Microbiol. 2009 Jun;47(6):1657-62. Epub 2009 Apr 15. 66 Lee D, Fairley C, Cummings R, Bush M, Read T, Chen M. “MSM prefer rapid testing for Syphilis and may test more frequently using it.” Sexually Transmitted Diseases: 22 March 2010,
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psychosocial support can significantly build motivations, skills, values, confidence, and trust to increase initiative to access HIV prevention and treatment services. 67 Social and structural interventions can significantly impact the ways that people access and benefit from HIV interventions.76 77 78 79
in communities of MSM to communicate the merits of knowing one’s HIV status and early diagnosis and treatment for STIs and HIV, as a crucial pathway to improved health.68 69 70 6. Sensitize and train healthcare providers to conduct sexual health
histories and counseling in ways that help identify men who may benefit from additional STI and HIV screening.71 72 73 74 75
7. Support community-based organizations to provide social services for
MSM, including mental health services, substance abuse services, drug treatment, legal and human rights support, and case management. 80
8. Improve policies and practices in healthcare settings to increase MSM
service accessibility and uptake, focusing on enforcement of confidentiality protocols, provider sensitivity, and non-discrimination regarding gender, gender identity, and sexual orientation.81
9. Improve policies and practices in institutions beyond the healthcare
sector to increase MSM service accessibility and uptake, including schools, prisons, the police, the media, internet sites, and communitybased organizations.82 83
67
UNAIDS. Sexual Behaviour Change and HIV/AIDS: Challenges and Experiences. In. Amsterdam: share-net: Netherlands Network on Sexual & Reproductive Health and AIDS; 2003. 68
2010 update of WHO guidance on STI interventions among MARPs
69
Herbst JH, Sherba RT, Crepaz N, Deluca JB, Zohrabyan L, Stall RD, et al. “A meta-analytic review of HIV behavioral interventions for reducing sexual risk behavior of men who have sex with men.” J Acquir Immune Defic Syndr 2005; 39(2):228-241. 70
Johnson WD, Holtgrave DR, McClellan WM, Flanders WD, Hill AN, Goodman M. HIV intervention research for men who have sex with men: a 7-year update. AIDS Educ Prev 2005; 17(6):568-589. 71
Koblin B, Chesney M, Coates T. “Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study.” Lancet 2004; 364(9428):41-50. 72 Makadon HJ, Mayer, KH, Potter J, Goldhammer H (eds.). The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. American College of Physicians, 2008. www.fenwayhealth.org 73
Gay and Lesbian Medical Association, Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health.San Francisco, 2001. 74
The University of Michigan Medical School. “Caring for Lesbian, Gay, Bisexual, and Transgender Patients.” A University of Michigan Resource Guide, Michigan, 2005. 75
Training materials at Fenway Community Health and for the CDC DEBIs focused on MSM - e.g. PoL, Mpowerment, 3MV, and d-up - www.effectiveinterventions.org/go/interventions 76
Gupta GR, Parkhurst JO, Ogden JA, Aggleton P, Mahal A. “Structural approaches to HIV prevention.” Lancet 2008; 372(9640):764775. 77
Kippax S. “Understanding and integrating the structural and biomedical determinants of HIV infection: a way forward for prevention.” Curr Opin HIV AIDS 2008; 3(4):489-494. 78
Ehrhardt AA, Sawires S, McGovern T, Peacock D, Weston M. “Gender, empowerment, and health: what is it? How does it work?” J Acquir Immune Defic Syndr 2009; 51 Suppl 3:S96-S105. 79
Peacock D, Stemple L, Sawires S, Coates TJ. “Men, HIV/AIDS, and human rights.” J Acquir Immune Defic Syndr 2009; 51 Suppl 3:S119-S125. 80
WHO (2010) Mental Health Gap Action Programme (mhGAP)
81
As stated 16 years ago in a University of West Indies (UWI) report, “Today's medical educators are challenged not only to provide students with the factual scientific and medical information known about AIDS, but also to instil in them the professional and ethical responsibilities of being physicians who must transcend the fears and irrationalities generated by the AIDS pandemic, using their knowledge in the patient's best interests, regardless of their own visceral reactions to the patient.” –Wickramasuriya, T. Attitudes of medical students at Cave Hill Campus towards AIDS West Indian med. j;43(suppl.1):22, Apr. 1994 82
Diouf D, Moreau A, Castle C, Engelberg G, Tapsoba P. Working with the media to reduce stigma and discrimination towards MSM in Senegal. Abstract WePeC6153. In: The XV International AIDS Conference, 2004 . Bangkok; 2004.
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10.
Consider national efforts to increase MSM service accessibility and uptake, such as social marketing of HIV prevention, condoms and lubricant, changes in national health program eligibility guidelines to increase access by MSM, and anti-homophobia campaigns.84 85
Box 5. Strengthening community-based MSM health service referral systems Community-based health referral networks for MSM are one effective and inexpensive way to improve access to basic medical and social services. Already piloted in Antigua, Trinidad and Tobago, and the Dominican Republic, these national and international referral systems have demonstrated an ability to link MSM to a wide range of resources, including primary health care, addiction services and drug treatment, legal services, and sources of accurate health and rights information. More can be done to build these referral systems, including supporting the creation of directories of MSMfriendly providers of core health and social services, standardized client referral and tracking procedures, and keeping of referral registers at participating sites. Model referral networks should also be funded to organize sensitization and technical trainings for participating providers and regular quality audits among providers. These trainings and audits should involve MSM who are health service clients, identified either through community-based organizations or through client advisory groups and employee resource groups.
Box 6: Client-centered continuum of care In Jamaica, the risk of HIV infection or AIDS is just one challenge among many. The ability for any person to negotiate safer sex, safer drug use, and access to HIV treatment and care is influenced by poverty, class, gender, drug use, and other factors such as incarceration, migration, homelessness, exposure to violence, stigma and discrimination, and, in many cases, simply the fact of being young. Jamaica's Forum for Lesbians, All-Sexuals and Gays (J-FLAG) works with gay men and other men who have sex with men with an approach that centers services on individual needs. Support for HIV counseling and testing and assistance with medical bills and medication are combined with other vital services, including peer-based support and case management, access to legal services, life-skills training, and emergency housing and stipends where needed. Importantly, J-FLAG is present at the moment of need, supporting dozens of people each year who call when expelled from all other sources of support, including local community and family. 86
Box 7: Under a façade of stigma, a foundation of capacity In Guyana, most people do not openly reveal homosexual behavior because of stigma and discrimination. 83
Niang C, Moreau A, Kostermans K, Binswanger H, Compaore C, Diagne M, et al. “Men who have sex with men in Burkina Faso, Senegal, and The Gambia: The multi-country HIV/AIDS program approach.” Abstract WePeC6156. In: The XV International AIDS Conference, 2004 . Bangkok; 2004. 84
Altman D. Rights matter: structural interventions and vulnerable communities. Health Hum Rights 2005; 8(2):203-213. LAC Regional Directors Group. “Joint call by ten UN agencies to eliminate homophobia in Latin America and the Caribbean.” http://content.undp.org/go/newsroom/2009/may/call-to-eliminate-homophobia-in-latin-america-and-the-caribbean.en 86 Communication with J-FLAG, May 2010 85
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To provide health services and support to men who may be at high risk for HIV, a 2010 UNDP situation assessment has recommended that programs need to work with community gate keepers while also sensitizing health providers and uniformed services. At least six community organizations (FACTS, GRPA, GuyBow, SASOD, U and Me, and United Brick Layers) now provide health services and other services to people who are homosexual, bisexual or transgender, despite discriminatory laws and social and institutional rejection of people based on sexual orientation or gender identity. According to several of these organizations, institutionalized stigma has been a major barrier to implementation of country HIV programming for MSM, but a foundation of capacity exists for significant scale-up of health outreach, peerbased counseling, targeted condom promotion, and social services to ensure access to health care. 87
3.3
Improving rights environments
All Caribbean countries are signatories to basic international agreements that reflect a global understanding of human rights, including the 1966 International Covenant on Economic, Social, and Cultural Rights (ICESCR) and International Covenant on Civil and Political Rights (ICCPR), the 2001 UN General Assembly Declaration of Commitment on HIV/AIDS, and the 2006 Political Declaration on HIV/AIDS. These documents are an affirmation of the rights of all people, including rights to freedom of expression, freedom of association and assembly, freedom against unlawful violence, and equal access to justice. By way of these documents, all countries should be called on to champion these rights wherever they are violated. As stated by U.S. Secretary of State Hillary Clinton in a speech about Ugandan anti-homosexuality legislation in December 2009, "When injustice anywhere is ignored, justice everywhere is denied.” Key components of rights-based program interventions to address HIV among MSM are described in Table 2. At a fundamental level, HIV program managers and implementers should consider how HIV programs: •
Advance positive norms about gender, diversity, pluralism, and human rights;
Provide people with basic information about human rights, and basic protections and security against violence, blackmail, arrest and incarceration, and social and economic marginalisation; •
•
Ensure standards of non-discrimination, safety, and confidentiality, and provide training, counselling, representation, support, and social mobilization and empowerment.
With regard to MSM in the Caribbean, the aims of rights-based HIV interventions should be to: •
87
Address the negative effects of masculine gender identities and gender roles: Researchers note that one factor in men’s engagement in multiple sexual relationships and unprotected sex is men’s need to prove or fulfill their perception of manhood and masculinity. Existing conceptualizations of masculinity in the Caribbean also condone and reinforce homophobia – i.e. social disapproval,
Communication with UNDP-Guyana, SASOD, and GuyBow, May 2010
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rejection, and exclusion of people based on their actual or perceived homosexuality or homosexual behavior. These social norms combine to encourage men to selfcamouflage, living a heterosexual life with marriage, children, and sex with women, while also having sex with men. This bisexual concurrency is a driver of HIV epidemics and yet is almost entirely hidden due to societal sanctions associated with homosexuality.88 89 •
Reduce and eliminate constraints on men’s health and health-seeking behaviors: Threat of social exclusion, violence, blackmail, or arrest leads many men to deny their homosexual behavior, avoid health services, and conceal their risk behaviors when they do access health services. This makes it difficult for health providers to target prevention messages and interventions and discourages people who may have been exposed to HIV from testing, counseling and ongoing treatment and care.
•
Engage expert stakeholders in program design, implementation, and monitoring: Although MSM live in every one of the Anglophone Caribbean countries, far too few of these men are in a position to provide informed input into national HIV program design or implementation. Country health programs therefore suffer from a lack of advice from target populations about the gaps and potential improvements to HIV interventions.
•
Strengthen health programming: Many national health programs may be sympathetic to science and sound public health practice, but national HIV strategies and programs face serious set-backs when opportunistic politics, sensationalist media, or discriminatory attitudes have the effect of curtailing rights to free expression, the freedom of association and assembly, freedom against unlawful violence, and equal access to justice. MSM in the region frequently find themselves unable to access these rights and more vulnerable to HIV.
Table 2: Components of rights-based interventions to address HIV among MSM Aim of intervention Support people in their efforts to overcome specific institutional barriers to HIV interventions
88
Approaches to improve rights environments related to HIV among MSM in the Caribbean
• Speak out about principles of human rights, including standards of diversity, pluralism, non- discrimination, confidentiality, and equal access to justice. • Support legal aid networks, legal clinics, legal aid service centres, emergency hotlines and human rights response desks.
Houston, R. The Down Low - Same Sex Infidelity - When the Other Woman is Another Man Available at : http://www.authorsden.com/categories/article_top.asp?catid=57&id=19318
89
Lee RK et al. (2006). Risk behaviours for HIV among men who have sex with men in Trinidad and Tobago. Abstract CDD0366. XVI International AIDS Conference. 13–18 August. Toronto.
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Integrate human rights expertise into health programming
• Support trainings and coalitions to build country-level and regional
Strengthen evidence and guidance about laws, legislation, and law enforcement
• Facilitate efforts to map and analyze existing legal frameworks and human rights environments as they impact access to HIV interventions. • Share guidance on international standards and models for rights related legislation and legal reforms to improve access to HIV interventions.
Caribbean expertise related to HIV among MSM, linking experts from all sectors, including governmental health, justice, police, and social welfare agencies, and individuals and organizations from civil society who have experience and expertise related to gender equality, gender identity, and sexual orientation.
Box 8: Providing non-discriminatory health screening and treatment In recent interviews in Antigua and Barbuda (population 86,000) conducted by the Caribbean Vulnerable Communities Coalition (CVC), e majority of men interviewed said that there are few places to go for HIV-related healthcare, especially when sexual health or anal STI symptoms are involved. Men identified only one doctor--the clinical care coordinator for HIV/AIDS in Antigua-as an accessible and “safe” provider, although some men said that his strong association with HIV on the island was a deterrent to access to care. Most gay-identified men in Antigua told stories about healthcare providers treating them and their friends with scorn or ignoring them completely. Some had been told by providers that their behaviors were responsible for their health problems. Many indicated that providers were uncomfortable during the medical exam, and one gay-identified man reported seeing four separate doctors before finding one who would provide an examination and counseling about anal STI symptoms. In each of his three earlier cases, the doctors refused to conduct a rectal exam and based their diagnoses and (inappropriate) prescriptions on the patient’s reported clinical history alone. One young man in Antigua who was interviewed by the CVC described being concerned about anal sores he had developed. Not knowing whom to turn to, he simply did nothing. Much to his relief the symptoms resolved spontaneously after a few days, and he resumed sexual activity. About a month later, he developed a body rash and wart-like patches in the anal area. Again the shame and fear of being “outed” caused him to do nothing. To his amazement, everything cleared up again, and he has remained symptom-free ever since. Following the interview with CVC, and after some medical counseling, he agreed to a syphilis test and tested positive. 90
Box 9: Accurate accessible HIV information delivered in 18 countries 90
2009 “Access to Healthcare for Vulnerable Groups” study by Caribbean Vulnerable Communities Coalition (CVC) Healthcare Working Group. (in press)
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A unique regional communication initiative, the website and publication Free FORUM delivers free HIV information throughout the Caribbean, distributing its print version at no cost to lowincome populations and those without access to the Internet. During 2009, three issues of Free FORUM published detailed educational articles about “Treatment and Care,” “Prevention,” and “Advocacy and Human Rights.” Produced by a not-for-profit organization MSM: No Political Agenda (MSMNPA) based in Trinidad and Tobago, Free FORUM is distributed to eighteen countries in the Anglophone Caribbean, including: Anguilla, Antigua & Barbuda, Bahamas, Barbados, Belize, British Virgin Islands, Dominica, Dominican Republic, Grenada, Guyana, Jamaica, Puerto Rico, St. Kitts & Nevis, St. Lucia, St Maarten, St. Vincent & the Grenadines, Suriname and Trinidad & Tobago.91
Several regional human rights initiatives are helping to affirm principles of human rights as foundations of HIV program effectiveness, and are seeking to facilitate local action and resilience.
91
•
In April 2009, the Commonwealth Lawyers Association (CLA) called on the SecretaryGeneral of the British Commonwealth to establish a working group of appropriately diverse membership and background and consult widely about the potential for decriminalization of sexual orientation in Commonwealth countries and to report back to the Secretary-General before the next Commonwealth Law Conference in 2011.
•
In June 2009, the Organization of American States (OAS) approved a resolution on human rights, sexual orientation, and gender identity in the countries of the Americas at its 39th General Assembly session. This non-binding OAS Resolution 2504 and a preceding Resolution 2435 was adopted by all Caribbean countries and called on all countries to condemn acts of violence and other crimes against people based on sexual orientation and gender identity, investigate and prosecute such crimes, and protect human rights defenders.
•
During 2009, a Caribbean Regional Task Force on HIV, Homophobia, Stigma and Discrimination, and Human Rights was formed, with key participating organizations including the PANCAP, the Commonwealth Lawyers Association, the UN Special Envoy on AIDS, UNAIDS, UNDP, and UNIFEM.
•
The Caribbean Broadcast Media Partnership (CBMP) has engaged its media partners in conversations about potential anti-discrimination campaigns, with a 2009 consultation suggesting a media campaign theme of "All of us are different, but all of us have rights" (to be adapted to the vernacular).
•
In keeping with the World AIDS Day 2009 theme of “Universal Access & Human Rights”, the Caribbean Vulnerable Communities Coalition (CVC) presented highlights of in-country human rights work being conducted in Jamaica, Dominican Republic, Belize, Suriname, St. Lucia, and Curacao, and recommitted to a central focus on human rights as a significant cross-cutting feature of the majority of issues that confront MSM and other vulnerable populations in the Caribbean region.
MSMNPA, www.msmnpa.org
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3.4
Reinforcing leadership from governments
To improve HIV programming for MSM in the Caribbean, leadership should be sought from national governments to enlist maximum support from all sectors and ensure strong decision-making and management. Caribbean Heads of Government bear ultimate responsibility for intensified and accelerated action against HIV. National governments can realize greater leadership on addressing HIV among MSM through intensified implementation of national HIV programming under the existing Caribbean Regional Strategic Framework (CRSF) and through multi-country action and regional coordinating mechanisms such as the Pan Caribbean Partnership against HIV/AIDS (PANCAP). 92 To support intensified leadership and action by governments, program implementers should work with national governments and regional mechanisms such as PANCAP to: • Consistently champion principles of human rights and evidence, specifically calling for respect of the rights and equality of all people regardless of sexual orientation or gender identity, and evidence-based policies and programs that respond to the documented needs of MSM in the Caribbean. • Advocate for effective, transparent, and accountable management of HIV-related programs and resources, with involvement of the communities who are the intended beneficiaries in key governance and decision-making bodies. • Support regional training, capacity building, and fundraising for HIV interventions targeted to MSM.
3.5
Reinforcing leadership from communities
From a community level, MSM and their advocates and allies are needed as both leaders and as technical experts. Gay men and their advocates and allies have always been at the forefront of the global response against HIV and AIDS.93 Throughout the Caribbean as well, individuals are working in every country with both discretion and perseverance to develop and sustain HIV programming for MSM. Even in the smallest Caribbean islands, these individuals provide counseling and/or health services, build peer support networks, and speak out in the media on behalf of the health and rights of MSM. During the past two decades, no Caribbean country has been spared from sensationalist media or local politics that threaten effective HIV programming targeted to marginalized populations. MSM and their allies have direct experience of such undermining forces but also have a strong and enduring stake in sustaining local services for HIV and addressing other health and rights issues. These leaders need to be supported for their contributions of courage and expertise to the effort against HIV and AIDS.
Gay men in the Caribbean are also inherently experts in health and rights programming for MSM. Despite the label of a “hard to reach” population, many men who have sex with men 92
www.caricom.org/jsp/projects/hiv-aidsstrategicframework.pdf
93
Merson MH, O'Malley J, Serwadda D, Apisuk C. “The history and challenge of HIV prevention.” Lancet 2008; 372(9637):475-488.
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in the Caribbean are not hard to reach. By definition, MSM are clearly quite able to find each other, and all Caribbean countries have networks of MSM with their own local social and economic contexts, identities, and patterns of behavior. HIV prevention cannot succeed in the Caribbean without an accurate understanding of the complex real-time dynamics of HIV exposure in local contexts. Scale-up of HIV testing, treatment, and care cannot succeed without accurate understanding of how these services might be accessed by target populations. For these reasons, MSM need to be involved as experts in the design and implementation of HIVrelated health and human rights policies, practices, and interventions. Health program planners and implementers should support intensified community leadership and action by and for MSM and their allies, following the strategies and recommendations of Caribbean MSM advocates themselves, to:94 95 • Support regional organizing and training of MSM HIV programs, to build human capacity and networks; • Support opportunities for MSM-led community groups to have input into HIV programs and to monitor and hold programs accountable to the needs and intended outcomes of community health and rights; and • Support core costs of community organizations, including personnel costs, space, information and communications technology, and management capacity. Box 10: Facilitating national attention to a concentrated HIV epidemic Before 2006, the focus of the Belize national AIDS effort was largely on the general population, based on an assumption that HIV was or threatened to become generalized. Subsequent data since 2006 has indicated that HIV is particularly concentrated in populations of sex workers and MSM. The community-based organization United Belize Advocacy Movement (UniBAM) has helped the country of Belize to gradually acknowledge and be more responsive to this new evidence. As a human rights organization, UNIBAM serves gay men in Belize, through referrals, policy analysis, research, advocacy, HIV counseling, testing, and treatment among other services. Building from this role, UNIBAM also is expanding its capacity to do more peer-based HIV counseling and testing and health promotion in several sites, including through a mobile delivery of services, and collaborates with the Belize Ministry of Health to enhance health nurses understanding about issues affecting MSM. Despite a history of being excluded from many national processes, UniBAM has now joined as a member of Belize's National AIDS Commission (NAC) Policy and Legislative subcommittee and IECC sub-committee, to support national AIDS planning and oversight. 96
Box 11: Community leadership in health training and organizing In September 2009, the first-ever Caribbean regional training and strategy consultation of 94
ICASO. Community Systems Strengthening. www.icaso.org/publications/csat_aa_Sept_09_EN.pdf
95
Carr, R. “Challenges in developing strong Global Fund proposals related to sexual minorities, and what to do about these barriers.” Global Fund Partnership Forum, December 2008. www.theglobalfund.org/documents/partnershipforum/2008/presentations 96 Caleb Orozco, UniBAM, Personal Communication, May 2010
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transgender people was organized in Curacao. Fifteen people of transgender experience attended from nine Caribbean countries, including Suriname, Guyana, Trinidad and Tobago, Barbados, St. Martin, Dominica, Curacao, Jamaica and Belize. Sponsored by the Caribbean Vulnerable Communities Coalition (CVC) and Caribbean Forum for Liberation and Acceptance of Genders and Sexualities (CARIFLAGS), this gathering was an historic milestone in the articulation of specific transgender health issues. The meeting was also a breakthrough for the creation of a regional resource network, resulting in the formation of the Caribbean Trans in Action Alliance (CTA) and the election of a founding regional governance board. 97
97
J. Simpson, I. McKnight, AIDS 2010 Abstract: "Caribbean Trans in Action": Building a Caribbean Regional Transgender Movement. XVIII International AIDS Conference. Vienna, 2010.
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4. Regional Caribbean resources and contacts Key regional organizations ASICAL (Asociación para la Salud Integral y la Ciudadanía de América Latina y el Caribe) A regional network of organizations supporting HIV programs among MSM, with participating groups from Mexico, Guatemala, Dominican Republic, Colombia, Ecuador, Peru, Brazil, Argentina and Chile. Contact: asical@uio.satnet.net CONGA (Congreso de Organizaciones Gay de Centroamérica) A Central American coalition of organizations in seven countries focused on anti-homophobia and LGBT rights, with HIV prevention work currently underway in Honduras, Nicaragua and Costa Rica. Contact: Norman Guttierrez, CEPRESI - cepresi@cablenet.com.ni
CARIFLAGS (Caribbean Forum for the Liberation of Genders and Sexualities) A non-incorporated affiliative group focused on health and rights issues of sexual and gender minorities, convening more than 35 advocates, allies and organizations in 16 Caribbean countries.
Contact: Mario Kleinmoedig (Curacao) - curamario@yahoo.com CTA (Caribbean Trans in Action) A non-incorporated affiliative group of transgender activists in more than 12 Caribbean countries advocating for the human rights and health of transgender persons in the region.
Contact: Mia Quetzal (Belize) - lovejunky78@yahoo.com
CVC (Caribbean Coalition of Vulnerable Communities) A regional network of community groups in more than eight Caribbean countries working with MSM, sex workers, drug users, prisoners and youth.
Regional hub (Jamaica) contact: Ian McKnight - gimcknight@gmail.com Regional hub (Dominican Republic) contact: Dr. John Waters - drjohnwaters@gmail.com PANCAP (Pan Caribbean Partnership Against HIV/AIDS) A Caribbean regional collaboration mechanism working to advance HIV/AIDS responses under the CARICOM Caribbean Regional Strategic Framework (CRSF)
Contact: Mr. Carl Browne, PANCAP Coordinating Unit Director - chokobrowne@gmail.com
Regional UNAIDS HIV/AIDS contacts in Latin America and the Caribbean UNAIDS Latin America: Cesar Antonio Nuñez, Regional Director – nunezc@unaids.org Caribbean: Michel de Groulard, Regional Programme Adviser - degroulardm@unaids.org UNDP Latin America: Maria Tallarico, RST HIV Cluster Leader – maria.tallarico@undp.org Caribbean: Salim October, Caribbean Subregional Focal Point - Salim.October@undp.org WHO / PAHO
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Rafael Mazin, Regional Advisor on HIV/AIDS - mazinraf@paho.org
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Key UNAIDS and UNAIDS-sponsored documents UNAIDS, 'Joint Action for Results: UNAIDS Outcome Framework 2009-2011,' April 2009. http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2009/2009042 1_Joint_Action.asp UNAIDS, ‘AIDS Epidemic Update,’ 2009. www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp UNAIDS, 'Action Framework: Universal Access for Men who have Sex with Men and Transgender People,' 2009. data.unaids.org/pub/report/2009/jc1720_action_framework_msm_en.pdf UNAIDS, ‘International Technical Guidance on Sexuality Education,’ 2009. data.unaids.org/pub/ExternalDocument/2009/20091210_international_guidance_sexuality_edu cation_vol_2_en.pdf UNAIDS. 'Review of Legal Frameworks and the Situation of Human Rights related to Sexual Diversity in Low and Middle Income Countries,' Cáceres C., Pecheny M., Frasca T., Raupp Rios R., June 2008. UNAIDS, 'Epidemiology of Male Same-Sex Behaviour and Associated Sexual Health Indicators in Low and Middle-income Countries: 2003-2007 Estimates,' Carlos Cáceres, Kelika Konda, Eddy Segura, Cayetano Heredia University School of Public Health, in Lima, Peru, and Rob Lyerla of UNAIDS, Geneva, Switzerland, 2008. www.msmandhiv.org/documents/Pre_Cáceres.pdf UNDP, 'A New Agenda for Mainstreaming HIV in Low-Prevalence Environments, Review and Summary of Main Papers and Presentation,' Dehli, India, November 2008. WHO, ‘Priority interventions for HIV/AIDS prevention, treatment and care in the health sector,’ World Health Organization HIV/AIDS Department. Version 1.2, April 2009. www.who.int/hiv/pub/priority_interventions_web.pdf PAHO, ‘Sexual health assessment and intervention algorithms for men who have sex with men’ (to be published in 2010). PAHO, ‘Provision of Care to Men Who Have Sex with Men (MSM) in Latin America and the Caribbean,' 2009. http://new.paho.org/hq/index.php? option=com_content&task=view&id=2120&Itemid=1952 PAHO, ‘Blueprint for the Provision of Comprehensive Care to Gay Men and Other Men Who Have Sex with Men (MSM) in Latin America and the Caribbean,’ 2009. new.paho.org/hq/index.php?option=com_content&task=view&id=2449&Itemid=1993
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