Global HIV program funding struggles to reach men who have sex with men

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The goal of an AIDS-free generation stands to fail unless critical changes are made to address stigma and discrimination against gay men and men who have sex with men (MSM). That’s according to a new report from the Foundation for AIDS Research (amfAR) and the Johns Hopkins Bloomberg School of Public Health, entitled, “Achieving an AIDS-Free Generation for Gay Men and other MSM: Financing and implementation of HIV programs targeting MSM.”

The report authors looked at reporting data related to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria HIV funding in eight countries – China, Ethiopia, Guyana, India, Mozambique, Nigeria, Ukraine and Vietnam. They found that with few exceptions HIV prevention and treatment funding intended for MSM consistently fails to reach the target population, particularly in countries that criminalize same-sex practices like Nigeria and Ethiopia.

“Same-sex sexual practices are punished as crimes in more than 80 countries, with penalties ranging from imprisonment to death,” according to the report, making MSM less likely to seek medical care. These countries also spend fewer resources on HIV-related health services for MSM, do less to track and understand the epidemic in their nations, and are more likely to repurpose donor funds intended to fight the epidemic among MSM. Even in countries with relatively progressive legal frameworks, stigma and discrimination still impede provision of and access to services for MSM.

This is particularly worrisome because, “In any setting where MSM have been studied, they carry a disproportional burden of HIV as compared to the general population,” said Owen Ryan, deputy director of public policy at amfAR, at a presentation of the report findings Wednesday in Washington, DC. Ryan also noted that similar findings applied to injection drug users and, to some extent, sex workers as well.

"Global Fund awards to China (Round 6), Guyana, India (Round 9), and the West Africa region had higher attrition for MSM programs than attrition in the budget overall."

The report looks at donor funding dedicated to MSM via the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program and the Global Fund to Fight AIDS, Tuberculosis and Malaria.  One example of repurposed funding, although the requested amount of Global Fund funding in Guyana’s Round 8 Phase I  proposal designated more than $50,000 to MSM, only $1,875 made it to that population in the final budget – a 96 percent attrition (See chart, right). Meanwhile, HIV prevalence among MSM is nearly 20 times that of the general population in Guyana, and like most countries receiving Global Fund funding, the country coordinating mechanism (CCM) making decisions about funding priorities lacks MSM representation.  

“Original analysis for this report reviewed the full grant approval cycle and found that attrition rates between application, grant approval, and actual funding for services were higher for MSM-related programming than programs overall in countries that criminalize same-sex sexual practices,” according to the report’s executive summary. The report also acknowledges that while the removal of legal and structural barriers that criminalize same sex practices may be critical to a robust response to the epidemic in this high risk population, it is not sufficient.

The authors did note that more efforts are being made by multilateral organizations to reach and prioritize programs for MSM, in turn positively impacting the number of countries seeking resources for MSM. Still, more needs to be done to collect data and analyze basic information to better understand and address the epidemic in this population, and to draw attention to under-funding. The report also warns against proposals to streamline and consolidate funding streams by these organizations, as broad health investments and reduced reporting requirements might harm efforts to direct funding to effective interventions in the MSM population.

Using data from the United Nations Program on HIV/AIDS biennial General Assembly reports – which track member nations’ progress against 25 indicators related to HIV funding, prevention, treatment and care – the report authors looked at reporting from the eight target countries on the five indicators relating to most-at-risk populations (MARPs), including MSM. The investigators sought, “to determine if punitive policies targeting MSM are correlated with reporting against UNGASS indicators or progress in the reported areas.”

The indicators relating to MARPs included:

  • Percentage of MARPs who received HIV testing in the last 12 months and who know the results
  • Percentage of MARPs reached by prevention programs
  • Percentage of MARPs who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission
  • Percentage of men reporting the use of a condom the last time they had anal sex with a male partner
  • Percentage of MARPs who are HIV-infected

While reporting of data from UN countries has been increasing (54 percent of countries reporting in 2004, 94 percent in 2010), and several other indicators have seen an uptick in reporting over that time frame too – e.g. responses related to blood safety and overall AIDS spending – the report shows responses related to MSM and HIV remain relatively low.

The report authors also flagged challenges associated with the use of the terminology MARPs.  While most of us think of drug users, MSM populations and commercial sex workers in this context, definitions vary on the country level to include every group from widows to school-aged children, making it even more difficult to evaluate what and how much a given program or country may be doing to respond to key populations, like MSM.

 “Gay men and other MSM pioneered the global response to HIV in developed countries and have contributed significantly to the development of programs globally,” said amfAR CEO Kevin Robert Frost in a press release. “However, they have been mostly excluded from these very services and programs in the developing world. This report lays out concrete steps that donors and national governments should take without delay to address the pandemic among MSM.”

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