HUMAN RIGHTS CONSIDERATIONSIN ADDRESSING HIV AMONG MENWHO HAVE SEX WITH MENTECHNICAL BRIEFNOVEMBER 2011This publication wa...
AIDS Support and Technical Assistance Resources ProjectAIDS Support and Technical Assistance Resources, Sector I, Task Ord...
INTRODUCTION                                                    the U.S. President’s Emergency Plan for AIDS Relief       ...
PEPFAR Technical Guidance onCombination HIV Prevention for MSM                          DEFINITIONS                       ...
and social contexts that may affect that vulner-         •	 Providing an obligation to act within, beyond, and   ability. ...
have sufficient information, abilities, or oppor tuni-                                                         LINKING HEA...
Strategy 1. Engage with Those Who                            men have the right to and oppor tunity for freeWould Benefit ...
Encourage peer-to-peer support, dialogue, and leader-       ments, the Pehchan program places strengthen-ship among MSM. A...
AJEM is to promote youth engagement and              to benefit from those effor ts, through advisor y or   leadership in ...
entation or gender identity. These fears present real     7. Counter harmful gender norms.barriers to health services, pub...
and carry out rights education programs. Health          commission, composed of 15 members recognizedprograms should link...
by the Bangladesh government (Ahmed 2011;             crease the number of MSM who access HIV ser-     Bandhu Social Welfa...
standards and management) to eliminate human             of international, regional, and national guidelines   rights viol...
including those who are MSM themselves, can be              neer HIV programming for MSM, Liverpool VCTessential par tners...
their peers do the same; and continually training    •	 In Zimbabwe, a community organization, Gays   and sensitizing staf...
Afshari, R. 2007. On Historiography of Human Rights.     confidentiality, or inappropriate refusal of health              ...
Churchland, P. 2011. Braintrust: What Neuroscience Tells   International HIV/AIDS Alliance and Commonwealth Us about Moral...
Robertson, J. 2010b. CEPEHRG and Maritime, Ghana:            U.S. Department of State. 2010. Remarks by Secre- Engaging Ne...
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AIDSTAR-One Technical Brief: Human Rights Considerations in Addressing HIV among Men who Have Sex with Men

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This technical brief provides a systematic global review and synthesis of practical approaches, program examples, and resources to support human rights as a core element of HIV programming for MSM. This document gives an overview of U.S. policies on and commitments to MSM and human rights, and outlines recommended approaches, including program examples in various countries, for linking health and human rights to address HIV among MSM. It also offers a synthesis of questions for developing and monitoring HIV programs for MSM, and a list of program resources.

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AIDSTAR-One Technical Brief: Human Rights Considerations in Addressing HIV among Men who Have Sex with Men

  1. 1. HUMAN RIGHTS CONSIDERATIONSIN ADDRESSING HIV AMONG MENWHO HAVE SEX WITH MENTECHNICAL BRIEFNOVEMBER 2011This publication was produced for review by the United States Agency for International Development. It wasprepared by the AIDSTAR-One project.
  2. 2. AIDS Support and Technical Assistance Resources ProjectAIDS Support and Technical Assistance Resources, Sector I, Task Order 1 (AIDSTAR-One) is funded by the U.S.Agency for International Development under contract no. GHH-I-00–07–00059–00, funded January 31, 2008.AIDSTAR-One is implemented by John Snow, Inc., in collaboration with Broad Reach Healthcare, Encompass,LLC, International Center for Research on Women, MAP International, Mothers 2 Mothers, Social and ScientificSystems, Inc., University of Alabama at Birmingham, the White Ribbon Alliance for Safe Motherhood, and WorldEducation. The project provides technical assistance services to the Office of HIV/AIDS and USG country teamsin knowledge management, technical leadership, program sustainability, strategic planning, and program implemen-tation support.Acknowledgments:This technical brief was written by Sam Avrett with additional review and content provided by Shale Ahmed,George Ayala, Stef Baral, Scott Berry, Jonathan Cohen, John Godwin, Kent Klindera, Krista Lauer, Lou McCallum,Joel Nana, Angus Parkinson, David Patterson, Jirair Ratevosian, Rebecca Schliefer, Andy Seale, and Alex Sorto. Addi-tional thanks to United States Government colleagues Billy Pick and Clancy Broxton who provided technical inputand direction to this work. Dedicated to Robert Carr.Recommended Citation:Avrett, Sam. 2011. Human Rights Considerations in Addressing HIV among Men Who Have Sex with Men. Arlington, VA:USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency forInternational Development or the United States Government.AIDSTAR-OneJohn Snow, Inc.1616 Fort Myer Drive, 11th FloorArlington, VA 22209 USAPhone: 703-528-7474Fax: 703-528-7480E-mail: info@aidstar-one.comInternet: aidstar-one.com
  3. 3. INTRODUCTION the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has issued guidance on developing compre-M en who have sex with men (MSM) face a dispro- portionate share of the HIV epidemic throughoutthe world (Baral et al. 2007; Cáceres et al. 2008), and hensive programming to reduce HIV among MSM. This AIDSTAR-One technical brief provides a system-in low- and middle-income countries bear a greater atic global review and synthesis of practical approach-burden of the epidemic relative to the general popula- es, program examples, and resources to support hu-tion. In many countries, the HIV risk to MSM is exac- man rights as a core element of HIV programming forerbated by social, cultural, and political factors. These MSM. The brief complements and is aligned with otherinclude cultural biases against MSM, limited access to global and regional publications that have relevanceinformation and services, low national investments in to human rights, health programming, HIV, and MSM.1health, and legal, institutional, or social barriers, includ- This document gives an overview of U.S. policies oning negative bias among providers, that make it difficult and commitments to MSM and human rights, andfor MSM to negotiate safe sex or obtain adequate outlines recommended approaches, including programservices for preventing and treating HIV and other examples in various countries, for linking health andsexually transmitted infections (STIs). This situation is human rights to address HIV among MSM. It also of-compounded by adverse human rights environments— fers a synthesis of questions for developing and moni-for example, in settings where same-gender sexual toring HIV programs for MSM, and a list of programrelationships are illegal—where MSM may fail to seek resources.treatment because doing so may lead to harassment,refusal of services, arrest, or violence. U.S. GOVERNMENT POLICY ONYet international consensus and recommendations— HIV AND MSMincluding the 2011 United Nations (UN) PoliticalDeclaration on HIV/AIDS, to which the United States The United States, like all governments, has anwas a signatory—recognize the vulnerability of MSM obligation to respect, protect, and fulfill its commitmentto HIV and endorse national and international efforts to universal human rights. The United States takesto include MSM in HIV programming and address this obligation particularly seriously, having ratified keydiscriminatory laws and practices that keep this group international human rights covenants and made humanfrom obtaining services. In keeping with this consensus, rights, including the right to HIV services, a central part of its foreign policy. This implies a commitment by the U.S. Government to promote all people’s rights to Just as I was very proud to say the speak, criticize, debate, seek and impart information, obvious more than 15 years ago in and associate in the way that they choose. As part of Beijing—that human rights are women’s this commitment, the United States strongly supports rights and women’s rights are human international commitments to help all people avoid HIV rights—let me say today that human infection and obtain needed HIV treatment and care in rights are gay rights and gay rights are agreement with internationally accepted human rights. human rights. 1 Other related AIDSTAR-One documents produced in 2010 and 2011 include case studies about MSM-focused programming in Ghana, India, and –Hillary Clinton, U.S. Secretary of State Nicaragua; a technical brief about MSM programming in the Anglophone (U.S. Department of State 2010) Caribbean; and a January 2011 technical brief about balancing MSM-related research with rights-based principles. All of these publications are listed in the AIDSTAR-One Resources section at www.aidstar-one.com/resources. H U M A N R I G H T S C O N S I D E R AT I O N S I N A D D R E S S I N G H I V A M O N G M S M 1
  4. 4. PEPFAR Technical Guidance onCombination HIV Prevention for MSM DEFINITIONS “Men who have sex with men” and “MSM” areIn May 2011, PEPFAR issued new guidance, Technical behavioral terms that refer to all men who engageGuidance on Combination HIV Prevention for MSM, in same-gender sexual behavior, in multiple con-to help country teams design and implement coun- texts and for multiple reasons.try-specific, evidence-based programming, using acombined approach (see Definitions) to address HIV Community refers to any group of people whoamong MSM. The guidance—which is consistent with share a perspective or identity. In many settings,public statements by the U.S. Global AIDS Coordi- communities of MSM may not be visible, unified, ornator, Ambassador Eric Goosby, and other PEPFAR well defined, and may also be identified with otherstaff—specifically directs programs to conform to labels and affiliations, including cultural or nationalthe U.S. mandate to eliminate violence and discrimi- identity, age, or religious belief. Men may also self-nation based on sexual orientation and gender iden- identify by their HIV status, their identity within thetity. In addition to calling for a comprehensive range spectrum of “alternative” sexual styles, or otherof services for MSM, the guidance recommends that identities that are seen as key populations in theprograms: HIV epidemic, such as people who inject drugs, sex workers, at-risk youth, or prisoners.• Address laws and environments that discriminate Human rights are those rights and freedoms to against MSM, and advocate for these issues at the which all humans are entitled. Though the concept national level of rights originated in ancient philosophical and legal traditions (Afshari 2007; Churchland 2011;• Support the capacity of MSM communities in the Lauren 2003), in the last century human rights have countries where PEPFAR works been codified in international declarations and• Support national-level dialogue about how HIV treaties such as the 1948 Universal Declaration of programs engage and retain clients in health Human Rights, the 1966 International Covenant interventions. on Civil and Political Rights, the 1966 International Covenant on Economic, Social and Cultural Rights,Other U.S. Commitments to Human the 1969 Convention on the Elimination of AllRights Forms of Racial Discrimination, and the 1987 Con- vention Against Torture.The 2011 PEPFAR Technical Guidance on Combina- Combined approach for health is a holistic ap-tion HIV Prevention for MSM is consistent with other proach to improving health outcomes, which en-commitments by the U.S. Government to address tails a broad spectrum of strategies (clinical care,the health and rights of MSM: services and treatment for mental health and sub- stance abuse, legal and human rights support, and• On June 10, 2011, the United States was a signa- case management). This is the approach that the tory to the 2011 UN Political Declaration on HIV World Health Organization and the Joint UN Pro- and AIDS which, for the first time ever, explicitly gramme on HIV/AIDS advocate for addressing HIV recognized the vulnerability of MSM to HIV and among MSM, and the recommended approach for urged governments to develop tailored responses PEPFAR-supported programs. that take into account national epidemiological2 A I D S TA R - O N E T E C H N I C A L B R I E F
  5. 5. and social contexts that may affect that vulner- • Providing an obligation to act within, beyond, and ability. outside of justifications and arguments related to health and public health• On June 17, 2011, the United States voted as a member of the UN Human Rights Council to call • Clarifying structural and non-medical approaches on the UN High Commissioner for Human Rights to addressing HIV and improving health to document discriminatory laws and practices • Furnishing a holistic framework for action, focused and acts of violence against people based on their on health as defined by WHO (i.e., health as a sexual orientation and gender identity. state of complete physical, mental, and social well- being and not merely the absence of disease orThese U.S. commitments align with other interna- infirmity [WHO 1946])tional documents, including the 2009 Joint UN Pro-gramme on HIV/AIDS (UNAIDS) Action Framework • Converting needs into state obligations and idealsfor MSM and transgender people; Amnesty Interna- into laws and accountabilitytional’s 2009 declaration on sexual orientation and • Showing how HIV programming contributes togender identity; the Sexual Orientation and Gender broader societal goals, including social and eco-Identities Strategy of the Global Fund to Fight AIDS, nomic development and efforts to reduce pov-Tuberculosis and Malaria (GFATM); the June 2011 ertyWorld Health Organization (WHO) guidance onpreventing and treating HIV and other STIs among • Empowering communities to demand accessMSM and transgender people; and the June 2011 to services and to seek redress for abuses thatWorld Bank report on HIV among MSM (Beyrer et increase their vulnerability to HIV and magnifyal. 2011). HIV’s spread and impact.The Link between Human Rights and HIV HIV and MSMamong MSM Globally, MSM experience a much higher share ofThe confluence of human rights and health has been the HIV epidemic relative to the general population.well described by leading HIV advocates since the In low- and middle-income countries where reliable1990s (Mann et al. 1999). In 2006, UNAIDS and the data have been collected, HIV prevalence amongOffice of the UN High Commissioner for Human MSM has surpassed 20 percent—for example, inRights published the International Guidelines on HIV/ countries as diverse as Bolivia, Ghana, Jamaica, Mex-AIDS and Human Rights. In June 2011, in the UN ico, Myanmar, Thailand, Trinidad, and Zambia (BaralPolitical Declaration on HIV/AIDS, the United States et al. 2007; Cáceres et al. 2008).and other UN member states reaffirmed the es-sential role of human rights in the fight against AIDS, In par t, high rates of infection stem from biologystating that the full realization of all human rights and and epidemiology (i.e., the efficiency of HIV trans-fundamental freedoms for all is an essential element mission through unprotected rectal sex and thein the global response to the HIV epidemic. Some likelihood of exposure in high-prevalence sexualof the many ways in which a human rights approach networks). However, another impor tant determi-provides a necessary framework for effective HIV nant of high HIV infection rates is the absence of anprogramming include: enabling environment for MSM, who often do not H U M A N R I G H T S C O N S I D E R AT I O N S I N A D D R E S S I N G H I V A M O N G M S M 3
  6. 6. have sufficient information, abilities, or oppor tuni- LINKING HEALTH AND HUMANties to negotiate safer sex, safer drug use, or accessto HIV treatment and care. Beyond limited health RIGHTS IN HIV PROGRAMMINGsystems and inadequate overall national invest- FOR MSMments in health, governments are failing to addressthe specific health needs of socially marginalizedgroups, including MSM. Evidence suggests that limiting HIV transmission among MSM can have a significant impact on theThese systemic weaknesses are compounded by global epidemic. Modeling by the World Bank, fo-adverse human rights environments. More than cused on four scenarios based on the epidemics in75 countries criminalize consensual same-gender Kenya, Peru, Thailand, and Ukraine, indicates that insexual activity as of 2011 (International Lesbian, many countries, effectively preventing and treatingGay, Bisexual, Trans and Intersex Association 2011). HIV among MSM is an essential factor in reducingIn these countries, fear of legal consequences may HIV among all people at risk for infection (Beyrerdeter MSM from seeking HIV information or servic- et al. 2011). Addressing the human rights environ-es—hence the continuing high HIV infection rates ment is thus fundamental to ensuring universal ac-among MSM. Punitive laws also facilitate harassment cess to services for prevention and treatment.of MSM and the organizations that provide ser-vices to them, promote violence against MSM, and To effectively reach MSM and other key populations,enable providers to limit the services available to HIV programs need to understand local humanthis population. Criminalizing same-gender sexual rights dynamics and pursue approaches that pro-relationships encourages a vicious cycle: adverse mote universal human rights while also suppor tinglegal conditions reinforce social stigma and discrimi- development, reform, and reinforcement of con-nation based on both sexual choices and HIV status. stitutional and legal commitments to human rights,This in turn diminishes the social and economic the rule of law, and the recognition that MSMautonomy of MSM and increases the risks of de- should be treated equally under the law.pression and substance use, which are documentedfactors in HIV incidence and HIV outcomes (WHO The following are three practical measurable strate-2011). gies that, if implemented in combination, can help to promote improved health and human rights en-Research from several countries correlates high vironments for MSM:rates of HIV infection with repor ted human rightsviolations (Baral et al. 2009). HIV programs and 1. Engage with those who would benefitadvocates routinely repor t that suppor ting humanrights is a necessary precondition for helping peo- 2. Remove barriers that limit access to HIV pro-ple access services and negotiate health care (Afri- grammingcan Men for Sexual Health and Rights 2011; WHO2011). Indeed, it is common sense that the success 3. Integrate rights approaches within health pro-of HIV programming depends on people’s freedom gramming and suppor t universal rights to health.to seek services and suppor t without encounteringdiscrimination, blackmail, violence, and criminaliza- Each strategy includes a justification, program ex-tion. This freedom must be extended to MSM. amples, and ways of measuring success.4 A I D S TA R - O N E T E C H N I C A L B R I E F
  7. 7. Strategy 1. Engage with Those Who men have the right to and oppor tunity for freeWould Benefit speech, open association, public assembly, ex- pression of their health needs, and negotiation of solutions to those needs.A first and frequently neglected step in rights-basedprogramming for HIV is to meaningfully engage • Engaging MSM aligns with international agree-with the populations who are intended to benefit ments: Over the past 20 years, internationalfrom new investments and programming. agencies have repeatedly emphasized the need for community par tnership, empowerment, andThere are several reasons to engage with the target community-centered HIV programming for MSM.community, as follows: In a June 2011 ar ticle from The Lancet propos- ing an updated global HIV investment framework,• Engagement mobilizes existing creativity and re- a global panel of exper ts recommended building sources: A primary reason for engagement is solidarity and social suppor t networks through practical—people are resourceful and resilient, community organizations, peer groups, and co- and where MSM face an HIV epidemic, they alitions for access to justice, health care, and have already invariably developed their own con- human rights (Schwar tländer et al. 2011). The cepts and strategies for negotiating to protect June 2011 WHO program guidelines regarding their health (Ayala 2011; Guzman et al. 2005). HIV and MSM call on governments to include No health program for MSM should proceed MSM and transgender people in health plans, in without some understanding of these local strat- accordance with medical ethics and the right to egies. health. These recommendations are consistent with previous literature about the impor tance• Data support engagement: Research shows that of rights-affirming health programming to ensure health outcomes improve when communities access for MSM (Peacock et al. 2009). take par t in effor ts to improve their own health (Latkin et al. 2010). This par ticipation yields a Numerous existing regional and subregional com- series of benefits: establishing locally appropriate munity networks can help HIV programs engage health norms, improving social connectedness with the MSM populations targeted for new pro- and enhancing peer-to-peer information and gramming. These networks can link national and lo- suppor t, increasing the input of community- cal community organizations, share intervention and relevant components into program design, and advocacy strategies, and facilitate linkages between increasing the visibility and perceived legitimacy community groups and national and international of the community’s health goals. Data from long- health programs and researchers. For more infor- term cohor ts of MSM have also shown since mation, see the “Key Resources and Contacts” sec- the 1980s that the availability of suppor tive peer tion. norms is consistently, significantly, and positively related to multiple measures of HIV-related out- Recommended Program Approaches comes (Joseph et al. 1987). The following two major approaches can help• Engaging MSM supports human rights: Effective health program planners and implementers engage HIV programming for MSM requires that those with their target communities: H U M A N R I G H T S C O N S I D E R AT I O N S I N A D D R E S S I N G H I V A M O N G M S M 5
  8. 8. Encourage peer-to-peer support, dialogue, and leader- ments, the Pehchan program places strengthen-ship among MSM. A first step for health programs ing community systems for MSM, transgender,seeking to engage with MSM is to invest in commu- and hijra populations at the hear t of effor ts tonities of men so that they can create and reinforce make government prevention interventions fortheir own networks of exchange and suppor t. Sup- these groups more effective and sustainable.por t may target existing social networks and events,community coalitions, and community organizations. • In Indonesia, the national network of MSM and transgender people, GWL-INA, is a rapidlyEncourage and support the involvement of MSM in expanding network created in 2007 to buildhealth and rights programming. Health programs comprehensive HIV prevention programmingshould employ or otherwise engage individuals for MSM and transgender people, and to buildfrom MSM networks and organizations in program community knowledge about health and rights.planning, design, implementation, and monitoring GWL-INA members represent the network inand evaluation. To be meaningfully engaged, those national consultations and meetings with theindividuals and their networks must be able to National AIDS Commission, the national GFATMinform themselves and to be honest and vocal in Technical Working Group, and other entities.their par ticipation. The organization, a member of the Indonesian National AIDS Commission (NAC), oversaw thePractical Examples roll-out of the NAC’s national MSM program and co-led a successful proposal for a U.S.$12• In India, one government repor t estimates a million multicountry GFATM grant. population of over 2.3 million MSM and trans- gender people, with an average HIV prevalence Also in Indonesia, HIV programs in six cit- among MSM of 7.41 percent as of 2007 (Rob- ies work with rights organizations to organize er tson 2010a). The Indian Government included events to coincide with the Q! Film Festival, a MSM as a prevention priority in the country’s large-scale, annual cultural event for lesbians, second National AIDS Strategy (1999), but MSM, bisexuals, and transgender people (UN implementation has not always been easy. For Development Programme [UNDP] 2011). The example, in 2000, personnel from Naz Founda- Q! Film Festival includes film screenings, panel tion International in Lucknow were arrested and discussions, interviews, ar t exhibitions, perfor- charged under obscenity and sodomy laws for mances, and public debates. HIV programs are conducting HIV prevention outreach and edu- discussing how to integrate health promotion cation for MSM. Since October 2010 and with campaigns within this event. suppor t from GFATM, a new program called Pehchan, led by the India HIV/AIDS Alliance and • In Honduras, the Asociación Jóvenes en Mov- including Naz Foundation International (now imiento (AJEM, or Youth in Movement Associa- known in India as Maan AIDS Foundation), Hum- tion) is an organization that promotes health safar Trust, Solidarity and Action Against the HIV and human rights among young people, including Infection in India, Sangama, and South India AIDS young MSM, in Tegucigalpa, Honduras. With a Action Program, is building the capacity of 200 volunteer network of over 80 young men and community-based organizations in 17 states to women, AJEM reaches approximately 1,000 reach more than 453,000 MSM and transgender young people with education about their right people with HIV prevention and related services. to health and practical information about sexual Working closely with national and state govern- health and HIV prevention. A central focus for6 A I D S TA R - O N E T E C H N I C A L B R I E F
  9. 9. AJEM is to promote youth engagement and to benefit from those effor ts, through advisor y or leadership in health, and the organization has in- planning groups and involvement of MSM as full creased young people’s capacity to be informed par tners and providers? and vocal about sexual health policies and pro- grams in Honduras. Indicators of success:• In Belize, the United Advocacy Movement is set- • MSM leaders involved as par tners or advisors ting up a shelter for young MSM who have been will repor t that they are informed and trained, kicked out of their homes, often because of their have structures and processes to ensure that sexual orientation or gender identity. The project they represent the community’s views, and are seeks to provide emergency housing to such held accountable to the communities for whom young people and to work with their families on they speak. reintegration as par t of broader programming for health and rights. • MSM in the target community will repor t that they are aware of and have access to govern-• In sub-Saharan Africa, although there is limited ment-funded health programs, and that those governmental suppor t for MSM programming, programs are safe, accessible, and relevant to HIV programs have engaged with MSM networks their needs. and organizations in many ways. In Ghana, the Centre for Popular Education and Human Rights Community-generated advocacy: Are community- is suppor ted through small GFATM and PEPFAR generated advocacy effor ts on HIV evident and subgrants and through several HIV and rights under way? programs (Rober tson 2010b). In Mozambique, Lambda, a sexual minority rights group, is recog- Indicators of success: nized by the Ministry of Health as a key player in the national HIV effor t and is engaged with the • National policymakers will repor t that this ad- National Human Rights Commission in an up- vocacy is helping to increase awareness of and coming review of the Constitution and the penal legitimize broader community health and rights code. issues, which in turn contribute to political and social commitments and action on health andMeasuring Success rights.The purpose of engaging communities of MSM is to • MSM in the target community will repor t that1) advance their collective needs and priorities for this advocacy is reinforcing their engagementhealth and rights, and 2) suppor t effective measures in their own health, including decisions aboutto prevent HIV and improve health in the commu- reducing exposure to HIV, testing for HIV, andnity. Programmers can use the following questions sustaining HIV treatment.and related indicators to measure engagement withthe MSM community. Strategy 2. Remove Barriers That Limit Access to HIV ProgrammingGuidance from the target population of MSM: Do thedesign, implementation, and evaluation of govern- In many settings, MSM want to seek health ser vicesment-funded health programs and health research but cannot access them without fear of stigma, dis-incorporate input from the communities meant crimination, or violence related to their sexual ori- H U M A N R I G H T S C O N S I D E R AT I O N S I N A D D R E S S I N G H I V A M O N G M S M 7
  10. 10. entation or gender identity. These fears present real 7. Counter harmful gender norms.barriers to health services, public health, humanrights, and the response to HIV. Recommended Program ApproachesInternational organizations recognize the impor- Health program planners and implementers mighttance of antidiscrimination laws and enforcement consider the following approaches to champion re-to the protection of both human rights and human moval of barriers to HIV programming and suppor thealth. The new WHO program guidelines for HIV protections against human rights violations.and MSM describe broad-based, routinely enforcedprotection from discrimination—through reform of Document policies and practices that present barriersboth laws and social norms—as a first good prac- to the HIV response. Program managers can com-tice recommendation about human rights and inclu- mission studies to understand and document howsive environments for MSM and transgender people. existing legal and human rights frameworks impedeThe guidelines call for policymakers to work with access to HIV interventions, and how adoption ofcivil society organizations to confront the realities international standards and models for laws, judicialof discrimination and transform punitive legal and practice, and law enforcement might improve thissocial norms into protective statutes (WHO 2011). access.A recent repor t from the World Bank likewise callsfor action to end the criminalization and social Promote literacy about human rights and supportivecensure of same-gender relationships. The repor t policies and practices. Health programs should in-warns that laws promoting universal access and tegrate locally appropriate “know your rights” pro-gender equality may fail if cultural, religious, or po- grams to inform key populations about nationallitical factions that stigmatize MSM remain in place laws and human rights, build literacy about human(Beyrer et al. 2011). rights, and help MSM obtain counseling, protection, and redress for human rights violations. EducationUNAIDS recommends that every national HIV should also include police, lawyers, and judges, whoresponse includes a package of seven key human may not understand the impact of punitive lawsrights programs that: and enforcement on public health and access to health services. Program implementers should work1. Reduce stigma and discrimination with judiciary and law enforcement agencies to promote policies and practices that suppor t effec-2. Sensitize police and judges tive health programs for MSM, including education on sexual health, HIV counseling, testing and treat-3. Provide legal services ment, distribution of condoms and lubricants, sterile injection equipment, and other health promotion4. Train health care workers on nondiscrimination, and harm reduction measures. confidentiality, and informed consent Support reporting of and response to rights viola-5. Monitor and improve the impact of the legal en- tions. As of 2011, approximately 110 countries had vironment surrounding HIV national human rights institutions, including legal aid clinics and networks, hotlines, and human rights6. Implement campaigns to promote understanding networks, that have a mandate to monitor the hu- of rights and laws and advance legal literacy man rights environment, take individual complaints,8 A I D S TA R - O N E T E C H N I C A L B R I E F
  11. 11. and carry out rights education programs. Health commission, composed of 15 members recognizedprograms should link with these organizations to for their exper tise and public service, providesfacilitate confidential repor ting about human rights leadership by compiling evidence on emerging is-violations and advocate for appropriate responses sues, building awareness, and promoting public dia-from relevant administrative and judicial authori- logue and civil society engagement in human rightsties. Some health programs can train peers from and legal issues related to HIV. Beginning in 2009,MSM communities in paralegal work and hire them UNDP also sponsored reviews of legal barriers toto link community members with legal and social HIV interventions for MSM in Asia and the Pacific,services, and to compile evidence for broader hu- Eastern Europe, and the Middle East and Nor thman rights action (American Foundation for AIDS Africa. UNDP has also published reviews showingResearch 2011; Csete and Cohen 2010). examples of how HIV service programs have sup- por ted law reviews, human rights literacy campaigns,Facilitate dialogue between MSM and policymakers. legal services, and linkages with human rights or-As HIV service providers, program managers and ganizations (Godwin 2010a, b, c; International HIV/implementers occupy a unique bridging role that AIDS Alliance and Commonwealth HIV and AIDSincludes both direct interaction with clients (includ- Action Group 2010).ing MSM) and direct interaction with ministries ofhealth and other governmental stakeholders. This Examples of initiatives to link HIV services and hu-gives them the vantage to identify gaps between man rights at local and national levels can be foundclients’ needs and health policies, including policies in many countries, including the following:that undermine access to HIV services for MSM(i.e., HIV monitoring and surveillance systems that • In Bangladesh, a nongovernmental organiza-do not collect data on MSM, or policies that al- tion, Bandhu Social Welfare Society (BSWS),low police to arrest MSM peer educators). When has worked since 1996 to promote the sexualstrategic oppor tunities arise, implementers should health and human rights of MSM and transgen-use their bridging role to bring clients together der populations. Beginning with two paid staff inwith policymakers to discuss problems, find work- 1997, the organization now employs more thanable solutions, and build the community’s informed 600 staff and provides services in 21 districtspar ticipation in health policy development. On in Bangladesh. BSWS suppor ts education andthe global stage, the Inter-Parliamentary Union has outreach among MSM and transgender networks,established an advisory group on HIV, and has pub- social and community-building activities, and HIVlished a handbook for parliamentarians working on prevention and sexual health programming. TheHIV (UNAIDS and Inter-Parliamentary Union 1999). group is also a strong advocate for human rights; since 2006, BSWS has had dedicated policy staff to document problems in law enforcement andPractical Examples human rights and to promote human rights with community leaders, police, lawyers, journalists,UNDP has recently developed impor tant re- and government policymakers. UNAIDS hassources for HIV program managers who want to cited the BSWS service model as a best practiceunderstand human rights considerations in rela- example, and the 2010 national UN Generaltion to MSM (UNDP 2007). One UNDP initiative Assembly Special Session repor t names one ofto suppor t health and human rights is the Global the BSWS advocacy programs, the District LevelCommission on HIV and the Law. This international Lawyers Group, as an example of a best practice H U M A N R I G H T S C O N S I D E R AT I O N S I N A D D R E S S I N G H I V A M O N G M S M 9
  12. 12. by the Bangladesh government (Ahmed 2011; crease the number of MSM who access HIV ser- Bandhu Social Welfare Society 2011). vices, thus increasing the propor tion of MSM who receive HIV counseling, testing, and treatment in• In Jamaica, where MSM face harassment and the context of combination HIV interventions, and violence due to social stigma and discrimination, ultimately reducing rates of HIV infections and im- the Jamaica Forum for Lesbians, All-Sexuals and proving the overall health of MSM. Programs can Gays (J-FLAG) provides financial, psychosocial, use the following questions and related indicators and other suppor t to dozens of people each to measure success. year who have been expelled from all other sources of suppor t, including their families and Measuring the status quo: What are the current bar- local communities. J-FLAG provides links to a riers for MSM seeking to prevent, test for, or treat range of services, including peer-based suppor t HIV? and case management, legal services, emergency housing and stipends, life skills training, HIV test- Indicators of success: ing and counseling, and assistance with medical bills and medication. Of par ticular impor tance is • Judicial and law enforcement authorities will that J-FLAG works from an advocacy framework repor t specific policies and practices, such as that ultimately aims at widespread understanding, professional or social stigma; lack of awareness respect, and promotion of universal principles and knowledge, appropriate guidance, standards, of human rights. J-FLAG also works with other or training; or lack of political, institutional, or community organizations, human rights organiza- peer suppor t. These factors can be targeted for tions, and UN agencies to build understanding change during interventions. about barriers to HIV programming and the need to protect human rights. • MSM in the target community will similarly re- por t specific policies, practices, discrimination,• In Senegal, a 2008 media-fueled controversy violence, or other human rights violations that and subsequent arrests of MSM temporarily they experience from health care providers or closed down GFATM-suppor ted HIV program- law enforcement, based on actual or perceived ming. Subsequent investigation by Senegalese sexual orientation or gender identity. These will researchers, suppor ted by Johns Hopkins Uni- change with successful intervention. versity and UNDP, showed a correlation be- tween these events and a negative impact on Assessing change: What are current actions to over- access to HIV interventions by MSM. Senegalese come structural barriers for MSM seeking to pre- health authorities and nongovernmental organi- vent, test for, or treat HIV? zations have used this research to argue for new national investment to address human rights as Indicators of success: a par t of public health, and to evaluate policies and practices that might overcome barriers to • As a result of rights literacy effor ts and rights-fo- the HIV response. cused dialogue, judicial and law enforcement au- thorities will understand the existing legal frame-Measuring Success work and human rights environment, alternatives for improving policies and practices, and effor tsThe intended outcome of removing rights-related to improve policies and practices (through activi-barriers to HIV programming for MSM is to in- ties such as training, education, and professional10 A I D S TA R - O N E T E C H N I C A L B R I E F
  13. 13. standards and management) to eliminate human of international, regional, and national guidelines rights violations. and training materials have been developed to sup- por t these practices both in institutional policy and• As a result of rights literacy effor ts and rights- by providers (Desmond Tutu HIV Foundation and focused dialogue, MSM in the target community Kenya Medical Research Institute 2011; Fenway In- will understand the existing legal and human stitute 2007; International Union Against Sexually rights environment, present options for alterna- Transmitted Infections 2006). tives or improvements to policies and practices, and par ticipate in dialogue on judicial, law en- At a minimum, providers who work with MSM forcement, and policy barriers to HIV services. should be required to adhere to protocols for en- suring safe and confidential health services, as well as clinically competent, suppor tive, and nonstigma-Strategy 3. Integrate Rights Approaches tizing provider-initiated sexual health counseling.within Health Programming and Support Health service institutions can be encouraged andUniversal Rights to Health funded to adopt a range of measures, including ap- propriate service locations and hours; appropriateRecently completed research showing that earlier signage; confidentiality and cultural competency ininitiation of HIV treatment can prevent HIV trans- intake, record keeping, and follow-up; referral tomission to sexual par tners (Cohen et al. 2011) social and legal services; and ombudsman ser vicesemphasizes the impor tance of ensuring that MSM and internal quality monitoring to meet standardsunderstand their right to health care and, specifi- for safety, confidentiality, nondiscrimination, and ac-cally, know their HIV status and where to obtain cessibility.HIV care and treatment. Public health effor tsshould be implemented in ways that respect, pro-tect, and fulfill human rights. Indeed, many govern- Recommended Program Approachesments already formally endorse universal access tocare and the right to health services. According to a Programs should consider the following approaches2010 WHO study, a total of 135 countries include to apply human rights considerations to improvethe right or commitment to health in their national the quality, effectiveness, accessibility, and scale ofconstitutions. Of these, 95 mention the right to ac- combination HIV interventions for MSM.cess health facilities, goods, and services; 62 referto equity and nondiscrimination; and 111 mandate Promote professional and institutional standards inthe right to equal treatment or freedom from dis- health care settings. Maintaining standards is impor-crimination (Perehudoff, Laing, and Hogerzeil 2010). tant to the advancement of human rights in healthHowever, MSM in many of these countries repor t care settings. Funders and providers should workdiscrimination and other barriers to obtaining with national health care accreditation and traininghealth care (Global Forum on MSM & HIV 2011). agencies to improve professional and institutional standards, including related training, cer tification,Yet many examples of programs, practices, and and recer tification requirements, to ensure qualityguidance exist. Several international studies review health care in relation to HIV and MSM.various models of HIV programs for MSM, describegood practices, and identify measures of HIV ser- Support peer-based health ser vices in both communityvice relevance, attractiveness, safety, and accessibility and clinical settings. Clinicians and other health pro-(AIDS Projects Management Group 2009). A range viders with direct experience in MSM communities, H U M A N R I G H T S C O N S I D E R AT I O N S I N A D D R E S S I N G H I V A M O N G M S M 11
  14. 14. including those who are MSM themselves, can be neer HIV programming for MSM, Liverpool VCTessential par tners, not only providing nondiscrimi- helped to create an environment that was con-natory health care but also serving as links to com- ducive to others publicly announcing ser vices. Bymunities of MSM, to ensure that HIV program de- 2009, the number of community organizationssigns match community needs. In its 2011 guidance, and research institutions openly working withWHO states that using trained individuals who the government to document HIV prevalencehave direct experience with the target community and health care access of MSM had increased.can enhance the delivery of combination services Star ting in 2005, MSM were listed as a target(WHO 2011). population in the National AIDS Strategic Plan for Kenya. PEPFAR funding now suppor ts anFund health programming for MSM at sufficient MSM clinic at the offices of the Gay and Lesbianscale. To change the course of the HIV epidemic Coalition of Kenya and its coalition par tner Ishtar.in any country, high-quality HIV programs must be The government has initiated national purchas-implemented in key populations at scale. Several ing of condoms and water-based lubricants forinternational publications show that in most regions, MSM outreach programs and has established anational health programs focused on MSM are not national target of reaching 71,000 MSM with HIVyet funded at a level matching their relative HIV services by 2013.burden and are not carried out at a scale sufficientto have a major impact on HIV infection rates, HIV Many other examples can be found at a smallertreatment rates, and health outcomes. National scale, where national and local health programs areresource allocations should be strategically allotted implementing rights-based training and peer-ledto achieve national public health goals, maximize health services focused on HIV and MSM:the benefit and fairness of health resource distribu-tions, and allow MSM to fully exercise their right to • In Mumbai, India, the Humsafar Trust has workedhealth. for almost two decades with MSM and transgen- der communities, linking advocacy and suppor t activities to HIV prevention and health ser vices.Practical Examples Humsafar Trust collaborates with a number of government clinics, providing training on the• In Kenya, a Nairobi-based organization, Liverpool needs of MSM, transgender patients, and people VCT, Care & Treatment, began offering space and living with HIV, and suppor ting clinic hours for a facilitator to provide MSM with a peer sup- these clients. por t group and access to HIV testing and clinical services. The organization launched the program • In the Dominican Republic, the organizations in 2004, responding to the requests of MSM Amigos Siempre Amigos (ASA, or Friends, Al- (mostly male sex workers). Over the next five ways Friends) and Centro de Orientación e years, Liverpool VCT established well-defined Investigación Integral (COIN, or the Center for professional and institutional standards for safe, Integrated Training and Research) have provided confidential, and nondiscriminatory care; trained health services to MSM for nearly 20 years. Their 75 staff on these standards; and recruited MSM success is based on their policy of engaging MSM clients as providers of peer outreach and health as outreach workers and advisors; encouraging services, ultimately reaching over 3,000 MSM clients to see health as a right guaranteed by in Nairobi. As one of the organizations to pio- national law, protect their own health, and help12 A I D S TA R - O N E T E C H N I C A L B R I E F
  15. 15. their peers do the same; and continually training • In Zimbabwe, a community organization, Gays and sensitizing staff and patients at government- and Lesbians of Zimbabwe (GALZ), has pro- run hospitals and clinics. ASA and COIN have vided a wide range of services for over two documented 10 years of success in involving decades. GALZ provides medical insurance, thousands of MSM in health promotion, increas- health care, and access to antiretroviral therapy ing men’s willingness to test for HIV and STIs, for members living with HIV; promotes safer and increasing service uptake and retention of sex; and advocates for social tolerance of sexual MSM in HIV treatment and care. minorities and the repeal of homophobic leg- islation. GALZ has protocols for orienting new• In Indonesia, the Jakar ta Planned Parenthood As- members and staff and for training health care sociation has connected MSM to health care and providers, and maintains a database of MSM- built a foundation for universal access by helping friendly doctors, health care workers, and clinics individuals from MSM and transgender organiza- throughout Zimbabwe. The organization, which tions sensitize staff in government clinics and is suppor ted by international donors, sustains hospitals, and to encourage others from their direct contact with the Zimbabwe Ministr y of communities to attend those sites for services. Health.• In Ukraine, the Penitentiary Initiative has worked in Ukrainian prisons since 2001, providing HIV Measuring Success prevention information to prison staff and inmates. The organization also provides HIV The goal of integrating rights approaches within treatment, care, and suppor t to inmates living health programming and suppor ting the right to with HIV, including those who inject drugs, who health is to increase access to and use of appro- constitute the majority of persons living with priate, nondiscriminatory, and easily available HIV HIV in Ukraine. To engage MSM, the Penitentiary services, with the ultimate aim of reducing the inci- Initiative formed a par tnership in 2008 with dence of STIs, HIV, and AIDS-related illness. the Nikolaev Association for Gays, Lesbians and Bisexuals (LiGA), which contributed funding for To assess progress toward this goal, program man- an initial pilot project and trained Penitentiary agers can use the following question and related Initiative staff in the specific needs of MSM. The indicators. Penitentiary Initiative staff then developed an outreach model for HIV prevention and psy- Integration of rights within HIV ser vices: How are HIV- chosocial suppor t and implemented the model related health services being implemented in ways in four prisons in the Nikolaev, Lugansk, and that respect, protect, and fulfill human rights? Cherkassy regions. The Penitentiary Initiative has employed multiple strategies, among them train- Indicators of success: ing prison staff, supplying HIV prevention kits to MSM, organizing suppor t groups, and providing • Health service providers will repor t specific poli- access to social and mental health counseling. cies and protocols, including professional cer tifi- The project also assists inmates on release from cation, recer tification, and training requirements, prison by linking them to LiGA’s social suppor t that ensure that health services are welcoming, and outreach programming and referring them safe, responsive, and free of discrimination based to MSM-friendly health services. on sexual orientation or gender identity, loss of H U M A N R I G H T S C O N S I D E R AT I O N S I N A D D R E S S I N G H I V A M O N G M S M 13
  16. 16. Afshari, R. 2007. On Historiography of Human Rights. confidentiality, or inappropriate refusal of health Human Rights Quarterly 29(1):1–67. services. Ahmed, Shale (Director of the Bandhu Social Welfare• MSM who use HIV-related health services, such Society). Direct correspondence, July 2011. as HIV testing, treatment, and care, will experi- AIDS Projects Management Group. 2009. Determining ence improved health outcomes. These clients Operational Research Priorities to Improve HIV Preven- will repor t that health services are welcoming, tion, Treatment, and Care Outcomes among MSM in safe, and responsive to their needs, and that they Asia and the Pacific. Newtown, Australia: AIDS Proj- experience no human rights violations, including ects Management Group. instances of discrimination, loss of confidentiality, American Foundation for AIDS Research. 2011. Inte- or refusal to provide health services. grating Rights and Health for MSM and other LGBT People: The Role of HIV Implementers and PEPFAR.• MSM in the target community who are not en- New York, NY: American Foundation for AIDS Re- gaged in care will be measurably less likely to search. repor t reduced rights-related barriers such as Ayala, G. 2011. Balancing Research With Rights-Based discrimination, loss of confidentiality, or refusal of Principles of Practice for Programming for Men Who services as reasons for not obtaining care. Have Sex with Men. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AID- STAR-One, Task Order 1.KEY RESOURCES AND CONTACTS Bandhu Social Welfare Society. 2011. 2010 Annual Report. Dhaka, Bangladesh: Bandhu Social WelfareGlobal: Global Forum on MSM & HIV, Society. www.msmgf.org Baral, S., F. Sifakis, F. Cleghorn, and C. Beyrer. 2007. Elevated Risk for HIV Infection among Men WhoAfrica: African Men for Sexual Health and Rights, Have Sex with Men in Low- and Middle-Income www.amsher.net Countries 2000-2006: A Systematic Review. PLoS Med 4(12):e339.Asia and the Pacific: Asia Pacific Coalition on Male Baral, S., G. Trapence, F. Motimedi, et al. 2009. HIV Sexual Health, www.msmasia.org Prevalence, Risks for HIV Infection, and Human Rights among Men Who Have Sex with MenLatin America and the Caribbean: Asociación para (MSM) in Malawi, Namibia, and Botswana. PLoS One la Salud Integral y la Ciudadanía de América 4:e4997. Latina y el Caribe, www.asical.org Beyrer, C., A. Wirtz, D. Walker, B. Johns, F. Sifakis, and S. Baral. 2011. The Global HIV Epidemics among MenEastern Europe and Central Asia: Eurasian Coalition Who Have Sex with Men: Epidemiology, Prevention, Ac- on Male Health, msmeurasia@gmail.com cess to Care and Human Rights. Washington, DC: The World Bank Global AIDS Monitoring and Evaluation Team.REFERENCES Cáceres, C., M. Pecheny, T. Frasca, and R. Raupp Rios.African Men for Sexual Health and Rights. 2011. Re- 2008. Review of Legal Frameworks and the Situation of port on the Link Between Human Rights and HIV for Human Rights related to Sexual Diversity in Low and MSM in Africa. Johannesburg, South Africa: African Middle Income Countries. Geneva, Switzerland: Joint Men for Sexual Health and Rights. UN Programme on HIV/AIDS.14 A I D S TA R - O N E T E C H N I C A L B R I E F
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