What the MSM community can do to stop the spread of HIV

Friday, December 1, 2006

What the MSM community can do to stop the spread of HIV

by Dr Tan Chong Kee
HIV/AIDS is hitting Asia in a big way, and MSM are now bearing the brunt of it. Dr Tan Chong Kee urges all MSM to ask ourselves what we can do to stop the spread of HIV among the community. In July 2004, Dr Bates Gill, the Freeman Chair in China Studies from the Center for Strategic and International Studies in Washington, testified to the Asia and the Pacific subcommittee of the US House of Representatives’ Committee on International Relations. He entitled his testimony “The Coming ‘Second Wave’: HIV/AIDS in Asia.”

When Dr Gill sounded that alarm more than two years ago, HIV/AIDS among Asian MSM (men who have sex with men) was not considered a serious issue. He made no mention of it in his testimony. In just two short years, the situation has completely changed. HIV infections among MSM in many parts of Asia are now showing a sharp rise.

Dr Gill states that: “The center of gravity of the global epidemic is shifting perceptibly eastward from Africa and increasingly affects Eurasia.” This shift that Dr Gill noticed is now in full swing. The most recent update released by UNAIDS, published on 21 November 2006, show that South and Southeast Asia is now in second place behind only Africa with a total of 860,000 new infections in one year, and about 7.8 million persons living with HIV/AIDS. Let’s take the smaller figure of 860,000 and think what it means. It means almost one new infection every 36 seconds. By the time you’ve read this far, two more people have already become HIV+ somewhere in South and Southeast Asia.

The situations in some of the hardest hit countries are staggering. In India, 12.5% of MSM in Mumbai are HIV+ while in Andhra Pradesh it is 18.2%. In Phnom Penh Cambodia, HIV prevalence among MSM in 2003 was already estimated to be 14.4%. In Indonesia, 22% of transgender sex workers (Waria) are HIV+. In Bangkok Thailand, more than 1 in every 4 (28.3%) MSM you meet is likely to HIV+. MSM also contribute to a disproportionately large amount of new infections. Being no more than 5-10% of the total population, they contribute to 22% of new infections in Singapore. In Japan HIV infections among MSM has recently seen a 64% increase.

If we compare the prevalence rate among the general population and among MSM, the difference becomes even more stark. In Ho Chi Minh City Vietnam, a MSM is 20 times more likely to be HIV+ than his heterosexual counterpart. In Hong Kong, MSM are 25 times more likely to be HIV+. In Japan, 44 times more likely. In China, 46 times more.

An even more worrying trend is how hard new infections are now hitting MSM youths. In Thailand, prevalence among youths between 16-21 years old rose from 13% to 23%. In Myanmar, prevalence among adult is 1.3% but among young people 15-24 years old is 2.2%. In Singapore, STD and HIV prevalence among youths are also rising sharply.

These high prevalence rates are the result of low rates of condom use among MSM. In Myanmar, 60% of young men use condom consistently. In Singapore only 42% of MSM use condoms for anal sex. In Thailand only 20-30% of sexually active young Thais use condom consistently. In Shenzhen China, authorities report that less than 20% of MSM use condom consistently. In Siam Reap Cambodia, MSM condom use rate is only 16%. In Philippines, only 6% of sex workers use condom with all their clients. In Japan, MSM anal sex is so ignored by the Japanese government that there is no data on MSM condom use. As a rule of thumb, consistent condom use needs to be 80% or more to prevent the rapid spread of HIV in a population.

If that is not scary enough, many governments across Asia are still dragging their feet in facing up to these staggering numbers of MSM afflicted by HIV/AIDS. Deep seated prejudice and stigma are causing many governments to refuse launching full-scale outreach and safe-sex public education programs for MSM or to impede those launched by NGOs. For example, police raids on saunas in Malaysia have caused owners to ban outreach workers.

This is extremely shortsighted because the cost of prevention is several orders of magnitude less than the cost of caring for an HIV+ patient, even before taking the loss of productivity into consideration. Dr Peter Piot, Executive Director of UNAIDS puts it very bluntly: “Asian nations face a choice. They can act now or pay later… There is no question about what needs to be done to fight AIDS in Asia. The only question is whether the governments and people of Asia will have the courage to do it.”

Government inaction on the one hand is exacerbated by the invisibility of MSM on the other. As the Therapeutics Research Education AIDS Training (TREAT) report on Asia (published Aug 2006) noted: “Safe sex practices are adopted and maintained only if they become normative behavior that is embraced by a community. But what if there is no MSM community to embrace them?”

In parts of Asia where MSM behaviours are still stigmatised, e.g., China, India, Indonesia, Malaysia, Japan, etc., apart from a younger generation of gay identified men, many older MSM in rural areas are married and engage in sex with men surreptitiously. They do not identify as gay nor admit to their extra-marital sexual practices. They are also less likely to practice safe sex. And they cannot be targeted for MSM outreach in the conventional way because they blend into the general population. This means that the many lessons learned in the West for outreach to gay-identified men are not easily applicable in such regions.

The state of Andhra Pradesh in India is now the leader in the race to find an effective prevention strategy suitable for Asia. Hindustan Times reported in August 17, 2006 that: “People in Andhra Pradesh recently woke up to find that the morning paper wasn’t the only thing being slipped under their doors. Along with it was a message of safe sex, a free three-pack of condoms. Looking for ways to popularise condom use in the face of the alarming spread of HIV/AIDS in the state, health officials had the condoms delivered along with the daily paper to 50 villages and four towns in the backward Telengana district.”

This is a brilliant strategy because it is a cheap way to deliver safe-sex public education to large segments of the population. The public education message can include information on all forms of safe-sex practices. In that way, even MSM who are hidden among the general population can be reached.

As the experience of America shows, if we ignore the HIV/AIDS epidemic among MSM, the result is the spread of the virus into the general population. The same pattern has already happened in Asia. The TREAT Asia report notes: “Many countries that neglected MSM prevention efforts are now struggling to contain HIV everywhere.” Politicians and the general public are reluctant to face the reality that sex happens across class, education, race and all other social divides. No social class can be an island. When the “It cannot happen to me” syndrome is influencing public health policy, it puts the whole country at risk.

Speaking at the Opening Session of the 16th International AIDS Conference in Toronto in Aug 2006, Bill and Melinda Gates challenged the world’s politicians to see sex workers not as vectors of HIV infection but as essential allies and crucially well-placed educators. Similarly, instead of blaming MSM, seeing us as essential allies and crucially well-placed educators will go a long way in preventing the kind of tragedy in Africa from descending onto Asia.

The key question for MSM all across Asia now is to ask ourselves what we can do to stop the spread of HIV among my community. Each of us could contribute in our own ways. Some of us could put pressure on our government to learn from Andhra Pradesh and act. Others could volunteer in their local HIV/AIDS agencies. Still others could talk about it with their friends and family to engender a ground swell of awareness to galvanise action. But above all, every one of us must start practicing safer sex consistently, tell all our friends of our conviction, and advise them to do the same. Yes, talk about safer sex with all your gay or MSM friends as often as you can. They might not listen to an outreach worker, but they certainly will listen to you. Tell them, in your own words, why you think it is important and why you are now doing it. It is up to each one of us to drive the condom use rate in our countries up to 80% and beyond.

We all know what must be done to prevent the spread of AIDS from crippling our community. So now go and do it!

Dr Tan Chong Kee holds a Ph.D. in Chinese Literature from Stanford University in the United States and is one of Singapore's best-known figures in civil society activism.