Category Archives: Epidemiology

Salaam to HIV – MSM HIV Epidemic in the Middle East

Salaam alakoom friends (hello in Arabic).   In the first study of its kind, researchers from Cornell University in Qatar have concluded that concentrated epidemics (infection rates above 5 percent in a certain group) among men who have sec with men exist in Egypt, Sudan, Pakistan and Tunisia.  There is little data on this region where homosexuality is considered taboo.  According to one researcher quoted in the article, the region is like a “black hole” in the global HIV data since such little data is available.  The research has found “considerable and increasing epidemiological evidence on HIV and risk behavior among men who have sex with men” in the region.

The findings are not surprising  – in  2008 researchers found that  HIV transmission via anal sex among men was responsible for more than a quarter of notified cases of HIV in several countries in the region.  This is not surprising given the fact that sex, let alone homosexuality is rarely if ever discussed in the region.  Men who have sex with men have no resources to turn to for sexual health services, and like in many societies must have underground sex.  In such scenarios without education and intervention and acknowledgement from NGOs and the government HIV spreads outside of the MSM population to the general public – although the article states that in Lebanon and Pakistan NGOs have emerged to deliver services to this highly hidden population.  Education, education, education – remove the stigma of homosexuality and the barriers to service that prevail.  It won’t happen overnight – but neither did the spread of HIV. Oh yeah – I forgot its also illegal for men to have sex with men in 18 out of 21 countries in this region.

Homofobia free Honduras?

Alto a la homofobia (Down with homophobia)

This past weekend I went to Tegucigalpa, which is the capital of the Central American country Honduras.  While cruising along down town (perhaps a bad choice of word – by cruising I mean walking) I luckily noticed some graffiti depicted in the images seen here.  One said “Alto a la homofobia” meaning “Down with homophobia”  and several others pictured a rainbow, the international symbol synonymous with the gay pride movement, with the words “Diversidad” (below), meaning diversity.  I was so taken aback, because such graffiti to me symbolized an awareness of gay rights and homophobia, and a desire to strive for equality.  I personally though this was huge in such a machismo society, where homosexuality is frowned upon, and rarely, if ever discussed.

So, how then does this relate to HIV transmission?  In the second poorest country in the Western Hemisphere, HIV remains a concentrated epidemic, meaning it is centered largely at-risk populations, such as men who have sex with men and sex workers, although it is beginning to spread to the general population.  According to USAID, while the general prevalence rate in Honduras is .7 %, estimates on prevalence among MSM range from 4.5% to 9.7%.  MSM are obviously disproportionally affected by HIV in Honduras.    Reasons for this would include stigma against homosexuality, lack of availability of education regarding HIV available to MSM and lack of MSM friendly healthcare resources and providers available.  Many MSM may be forced into having sex in secret places, and may not be able to negotiate condom use, because either condoms are not made available to them, or they do not have the education to understand that unprotected sexual contact between two men could result in HIV infection.

If some small groups continue to work like they are working, and spread such messages of tolerance to the general public such as graffiti (I’m generally not a fan of graffiti but here I’ll make an exception) and  homosexuality begins to”come out of the closet” in Honduras, meaning people are encouraged to show tolerance and accept diversity, perhaps MSM will feel more comfortable seeking health services, and HIV programmers and the government will begin to target HIV prevention messaging and education to this currently stigmatized group.  Diversidad!

How can Chinese MSM take action when there is such stigma?

So steering away from North American circuit parties, and the new HIV policy in the US, I turn to China.  While I must admit I have never been to China, recent articles in the news, (and here ) have noted the rising number of new infections among MSM (and the general population – China now records about 700,000 people who are HIV positive).  According to Dr. Yip, director of the Bill and Melinda Gates Foundation HIV program in China “We need the MSM group to engage their community to take part in the intervention.”   According the article, MSM transmission accounted for 32.5 percent of China’s total HIV/AIDS infections, up from only 0.4 percent in 2005.  The Gates Foundation has pledged $50 million USD to the China program, part of which will be used to fund NGOs that work with high risk populations such as MSM in large cities.

While Dr. Yip’s statement may be true, my problem is, is that such action is difficult for individuals to take in apolitically repressed nation (although there have been signs of openness such as lessening of restrictions on the Internet).  Gay rights have been known to be less than stellar in China, as police have been noted to shut down small gay and lesbian cultural gatherings and pageants and the government fails to screen gay media. While there is a “gay scene” in China with bars and all that accompany such things, the government discourages  gays in uniting for social change.  If gays can’t come together to socialize openly, they sure as hell won’t come together to be agents of health promotion.  So perhaps a good step would be to provide funding, in tandem with this HIV funding, to continue to advance the cause of gay rights in this communist state.  Then perhaps, gays can band together to fight the rising epidemic of HIV among the Chinese MSM community.

Men who have sex with men who have sex with men who have sex with women?

So according to the San Francisco Chronicle, a new study has found that almost half of gay men reported that they were in “open relationships”.  This, as we can gather pose a problem for HIV prevention.  While partners are free to make their own choices regarding the ground rules of their relationship, the investigator Colleen Hoff, states that HIV prevention efforts may need to address this growing population: partnered men who knowingly have sex outside of their relationship.  If I am partnered in a relationship for 5 years, am HIV negative, and go outside of the relationship with the knowledge of my partner, and have unprotected sex with an HIV positive man, I have contributed to the spread of the epidemic and put not only the myself but my partner at risk.  Presumably, there is no poster was up in the bath house that says  “Protect yourself when you have sex outside of your relationship” (although who knows there could be as I haven’t been to a bath house in ages).  Kudos to Ms. Hoff for receiving funding from NIMH to investigate HIV infection among these male couples

In the development world, there has been much talk about a similar theme – many have referred to the phonemon as “multiple concurrent partnerships” (MCP) (Here is a UNIADS article about MCP which actually contains a link regarding MSM underneath).  Generally, this has referred to “heterosexuals” who have more than one mate, and have sex with a partner outside their relationship.  This can be in the context of polygamy, or other arrangements.  As with the San Fran case described above, the same issues regarding HIV transmission present thenmselves.

Credit: http://misaccess.psi.org/bcc_catalog/web/files/sun02(1).jpgBUT, in the context of MCP in the developing  (AND devloped) world, I think public health programmers should realize that MCP can also occur when a “straight” identified man partnered with a woman has sex with other men.  And if the man is the receptive partner in anal sex, we know his risk of acquiring HIV is higher than if he is the insertive partner with another female (or another male), making these external male male relationships increase probablity of HIV transmission.  And in most cases, this is in secret, not openly nor discussed as in the case of Ms. Hoff’s research, so partners are not aware that they may need to be tested, or their partners are having sex outside of the relationship.  In the US we have referred to this as “on the down low”.  However, these arrangements have been documented to occur in South Africa (Note: HIV status has been associated with having a regular female partner), various parts of Asia (see p. 2 of APICOM articles), and probably hundreds of other places.

So not only men who are partnered with men have sex with other men, but men who have sex with women have sex with other men.  In both cases,  there needs to be appropriate and targeted HIV messaging.  While it is more difficult in the developing world due to to stigma and criminilization of homosexuality, it is clear that many men bring HIV into the relationship and to their female partners.

So, San Fransciscan gay males, you are not alone.  African, Asians, and Latin American males also have “open relationships”, which put both  female and male partners at risk for HIV.  However, as these relationships are not negotiated, many women may not know their husbands are sleeping with men and may not know they are at risk for HIV.

Solution: Education. Decriminilization and destigmatization of homosexual behavior. HIV prevention messaging targeted at those in open relationships/involved with MCPs: This includes gay open relationships, straight open relationships, and relationships where men are paired with women and have sex with other men outside of the relationship.