Over the 30 years of the AIDS epidemic, the disease has had a profound impact on every country in the world. And in each country, that impact is experienced a different way. But one reality remains: In nearly every country, HIV rates are disproportionately high in gay and bisexual men, as well as men who have sex with men (MSM) who do not identify as either. The full scope of the epidemic simply cannot be addressed until we recognize that there is no country in the world where we can overlook the MSM population.
This was one of the major themes of the International AIDS Conference, held in D.C. last month. Over 25,000 medical professionals, scientists, and people of all walks of life living with HIV attended from around the world. And the topics highest on people's minds were similarly global. The Fenway Institute held a conference on pre-exposure prophylaxis (PrEP), the new drug indication recently approved by the FDA, and how best to integrate it with existing methods of HIV prevention. Panelists from Kenya, Uganda, Brazil, and South Africa spoke up about the at-risk populations in their country and the challenges of reaching them. Just as much, an international perspective was evident when the conversation turned to reaching MSM.
Unfortunately, the scope of the epidemic has often been poorly understood, or left undiscussed, by those dedicated to HIV prevention. Too often, their portrait of those at risk of HIV splits into a false dichotomy: caucasian gay men, bisexual men, and MSM in wealthier countries, with the disease being a heterosexual epidemic in lower-income nations.
This portrait is profoundly inaccurate. For one, it overlooks the alarmingly high rates of HIV infection that new research has revealed in groups in the U.S. that fall outside the category, particularly young black MSM. Moreover, it does not confront a reality I work with every day: namely, that MSM are not only an at-risk population in wealthier countries but are present in every country in the world. Without addressing their needs, no approach to HIV prevention can be complete.
The Humsafar Trust has been serving MSM and transgender people in Mumbai since 1994, providing services including outreach and condom distribution (reaching more than 13,000 people per year), HIV testing, counselling, and a drop-in center in Mumbai that provides a vital safe space. India is a conservative nation where MSM and transgender individuals are deeply stigmatized; it was only in 2009 that the Delhi High Court struck down Section 377 of the Indian Penal Code, a law dating back to British colonial rule that criminalized homosexuality. (The Humsafar Trust filed a brief supporting the abolition of this law.) But that stigma runs deep throughout Indian society; in July of last year, India's minister of health, of all people, referred to homosexuality as a "disease" and "unnatural." And religious organizations have appealed the 2009 ruling, seeking to reinstate Section 377.
In such a climate, it should come as no surprise both that many MSM in India are not open about their sexual preference, and that HIV infection rates are extremely high. If these men are unwilling to discuss their sex lives with a doctor or another medical provider for fear of being revealed to their friends and families, how can they be reached?
That is why the Humsafar Trust has established a partnership with the Fenway Institute, a premier LGBT community health organization based in Boston. Working with Humsafar, Fenway has adapted its community-based approach to India. By pooling Fenway's research and Humsafar's knowledge of Mumbai's transgender and MSM communities, we have been able to create intervention programs that help us meet these people where they are, in known meeting places for these groups, and to frankly and confidentially discuss their sexual behaviors so that we can advise them on safe sex. We were also able to conduct the first-ever study of MSM mental health in Mumbai, which both illustrated the need for our services and allowed us to better tailor our work to reach these men and women.
Even in a conservative nation like India, our work has changed lives. India's state AIDS organization, NACO, has significantly scaled up its own targeted interventions for MSM and transgender persons. We have a long way to go in combating the stigma that drives many MSM and transgender people to engage in unsafe sexual practices, but we are reaching them, and more and more, our government is recognizing the fundamental reality of the HIV epidemic worldwide: We cannot end this epidemic if we ignore any at-risk population.
Vivek Anand is the Chief Executive Officer of the Humsafar Trust, a community-based grassroots organization addressing health and social concerns of the lesbian, gay, bisexual, and transgender communities in Mumbai.
Kenneth Mayer, M.D., is Medical Research Director of Fenway Health, Co-Director of the Fenway Institute, and an infectious disease specialist at Beth Israel Hospital and Harvard Medical School in Boston.