Issue Brief: MSM and the Global HIV/AIDS Epidemic - amfAR

The Foundation 

for AIDS Research 

July 2010 

ISSUE BRIEF 

MSM and the Global HIV/AIDS Epidemic: 

Assessing PEPFAR and Looking Forward 

The U.S. response to global HIV/AIDS has had an enormous 

positive impact in countries around the world hard hit by the 

epidemic. Under the President’s Emergency Plan for AIDS 

Relief (PEPFAR), the U.S. government has committed nearly 

$32 billion to bilateral HIV/AIDS programs, the Global Fund to 

Fight AIDS, Tuberculosis and Malaria, and bilateral tuberculosis 

programs 1 in 88 countries worldwide. 2 U.S. investments have 

directly supported antiretroviral treatment (ART) for more than 

2.4 million individuals and care for nearly 11 million affected by 

the epidemic. 3 

In spite of these unparalleled resource commitments and the 

substantial progress that has been made in low- and middleincome 

countries, HIV/AIDS-related services remain out of 

reach for the vast majority of men who have sex with men 

(MSM). In almost all regions, MSM have significantly higher 

rates of HIV infection than the general adult population—in 

low- and middle-income countries they are 19 times more likely 

to be infected with HIV. 4 Yet only one in 10 MSM worldwide 

has access to lifesaving HIV/AIDS prevention and treatment 

services. 5 

Stigma and discrimination have fueled the neglect of MSM 

and other vulnerable populations, including injection drug 

users (IDUs), sex workers, and transgender individuals. The 

inclination of governments and donor agencies to favor general 

population strategies over targeted interventions—even when 

the epidemic is concentrated within vulnerable groups—has 

exacerbated the severity of the epidemic among MSM. 

A global wave of homophobic rhetoric and violence is further 

undermining efforts to combat high rates of HIV/AIDS among 

MSM. Many countries criminalize and persecute men who are 

perceived to be homosexual, making it dangerous for them 

to access healthcare and HIV services. A recent report by 

the United Nations Development Programme revealed that 

more than 90% of MSM in the Asia-Pacific region do not have 

Key Points 

• MSM are 19 times more likely to be living with HIV 

than the general population in low- and middle-income 

countries, but only one in 10 MSM worldwide has access 

to HIV services. 

• Stigma, discrimination, and laws criminalizing sex 

between men undermine access to HIV/AIDS and other 

health services for MSM. 

• Grassroots, community-based groups are at the forefront 

of emerging efforts to provide HIV services for MSM 

worldwide. 

• Governments and international donors, including 

PEPFAR, have seriously neglected the HIV epidemic 

among MSM; services to effectively address the epidemic 

among this population remain wholly inadequate. 

• PEPFAR and other U.S. government programs have 

considerably expanded HIV/AIDS services for MSM in the 

last several years. 

• The U.S. government and other donors can build on 

recent progress by: increasing investment in communitybased 

services; supporting scale-up of community-led 

initiatives; improving epidemiologic tracking; monitoring 

access to services; and leveraging influence to 

encourage reform of laws criminalizing same-sex sexual 

behavior. 

access to HIV prevention and care because of discriminatory 

laws. 6 Even in settings where same-sex sexual behavior is not 

prohibited by law, MSM are still subject to harassment and 

violence. 

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MSM and the Global HIV/AIDS Epidemic: Assessing PEPFAR and Looking Forward 

Enormous opportunities exist for 

international donor programs, including 

PEPFAR, and for governments in affected 

countries to complement and augment 

grassroots efforts. 

While many barriers to HIV services for MSM are situated at 

the country level, PEPFAR’s original authorization in 2004 

imposed requirements on resource allocation that for years 

hindered HIV prevention efforts among vulnerable populations. 7 

In the last two years there have been notable advances, 

including a significant expansion in PEPFAR-supported MSM 

programming and important commitments from PEPFAR 

leadership in Washington. Still, as this analysis shows, HIV/ 

AIDS services through PEPFAR and other providers remain 

inadequate to address the epidemic among MSM. Severely 

lacking are interventions to tackle the formidable social, 

religious, legal, and policy barriers that stand between MSM 

and access to HIV health services. 

Grassroots, community-based organizations remain at the 

forefront of vibrant, emerging responses, leading efforts to 

provide urgently needed HIV/AIDS services to MSM and 

other vulnerable groups throughout the world. But enormous 

opportunities exist for international donor programs, including 

PEPFAR, and for governments in affected countries to 

complement and augment these efforts. By doing so, they 

can make important strides against the AIDS epidemic and 

significantly strengthen global health programming. 

KEY FINDINGS ON THE MSM EPIDEMIC 

AND HIV/AIDS PROGRAMMING IN PEPFAR 

COUNTRIES 

This issue brief provides a detailed analysis of PEPFAR’s 

response to MSM in eight countries: China, Côte d’Ivoire, 

Guatemala, Jamaica, Malawi, Ukraine, Vietnam, and Zambia. 

The eight countries represent a range of epidemiologic, 

geographic, and contextual landscapes. The analysis is based 

on publicly available documents and interviews with U.S. 

government staff, public health experts, healthcare and service 

providers, and members of civil society. It combines available 

data and estimates in journal articles and government reports 

with information from interviews to develop the most accurate 

assessment possible. The research reveals some of the 

challenges faced by global funders in providing services, as 

well as the paucity of MSM programming in some of the most 

severely affected countries in the world. The country profiles 

also offer numerous examples of expanded investment in 

services and promising new initiatives. 

A Note on Terminology 

• Men who have sex with men is a term that includes all 

men who engage in consensual male-male sex, including 

those who identify as gay, bisexual, or heterosexual, 

and including men who are sex workers. Some MSM 

have concurrent sexual relationships with both men and 

women. 

• Transgender describes people whose innate sense 

of gender identity is different from the male or female 

gender assigned to them at birth. 

• MSM and transgender categories include a wide 

range of identities, roles, and experiences, which can 

vary considerably from one culture to another; many 

people transition in and out of behaviors and identities 

throughout their lives. Recognizing this complexity is 

critical to addressing the barriers that often block access 

to healthcare for these populations, and to developing 

effective HIV interventions. 

Striking limitations exist in the quantity and quality of available 

information, including HIV prevalence among MSM and details 

on targeted program and service availaibility. In national 

statistics and some country-level PEPFAR data, MSM are 

often subsumed under the general category of “most-at-risk 

populations,” making it difficult to determine which services are 

targeting MSM specifically. 

While the AIDS epidemic and PEPFAR’s responses are different 

in each of the eight countries, several overarching themes 

emerge from this analysis: 

• High infection rates: Where estimates are available—and 

often little research has been conducted—HIV prevalence 

among MSM is very high. In all eight countries reviewed, 

HIV prevalence is significantly higher among MSM than 

the general population (see Figure 1). This is true even in 

generalized epidemic settings such as Malawi and Côte 

d’Ivoire, where HIV prevalence among MSM is reported to 

be as high as 21.4% and 18.5% respectively. 30,52 

• Incomplete epidemiologic data: In many countries, 

epidemiologic data on MSM are nonexistent, out of date, 

or inconclusive. In Côte d’Ivoire and Zambia, for example, 

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MSM and the Global HIV/AIDS Epidemic: Assessing PEPFAR and Looking Forward 3 

small sample sizes compromise the value of existing 

data. Many governments do not include MSM in routine 

HIV/AIDS surveillance and do not systematically gather 

or report data on MSM as a discrete group. None of 

the countries profiled officially tracks HIV incidence or 

HIV exposure risks among MSM—although most report 

results from sentinel studies in the 2010 UNGASS reports. 

While PEPFAR is supporting several research studies, for 

example in Côte d’Ivoire and Malawi, lack of funding and 

political will undermine efforts to strengthen surveillance 

mechanisms that would improve understanding of HIV 

prevalence among MSM. 

• Limited service coverage for MSM: Of the $2.2 billion 

spent in the eight countries between FY 2004 and FY 2009, 

the amount dedicated to MSM-specific interventions is 

indeterminate. PEPFAR does not report specifically on 

program financing that targets MSM, and tracking the 

flow of resources from U.S. agencies through the various 

funded organizations has proven to be extremely difficult. 

Still, key informants consistently remarked on the limited 

availability of HIV-related services for MSM in all countries 

surveyed here. It is also clear that in some settings, progress 

has been made through PEPFAR-funded and communityled 

activities, for example in China, Côte d’Ivoire, Ukraine, 

and Vietnam. Progress is being made in other countries not 

examined in this report. In Nigeria, for example, Heartland 

Alliance has launched a USAID-funded integrated MSM HIV 

prevention program. 8 In the eight countries examined here, 

community-based organizations are operating on the front 

lines of the AIDS pandemic, serving the HIV-related needs of 

MSM and other vulnerable groups. 

Although this issue brief does not examine transgenderspecific 

programs, research suggests that service coverage 

for this population is extremely limited. Studies indicate that 

transgender communities in many settings are particularly 

vulnerable to HIV, and scale-up of HIV related services for 

these communities is needed. 9,10 

• Widespread criminalization and severe punishment: 

Stigma, discrimination, and criminalization are major barriers 

limiting provision and uptake of HIV services for MSM. Three 

of the eight countries examined have laws criminalizing 

homosexuality. Consensual male-to-male sex is punishable 

by up to 14 years imprisonment in Malawi and Zambia, 

and by imprisonment and hard labor for up to 10 years in 

Jamaica. 23 All told, laws prohibiting same-sex sexual activity 

between consenting adults are on the books in more than 

half (48 of 88) of the countries with PEPFAR programs, 

including three that impose the death penalty (Mauritania, 

Sudan, and Yemen). 23 Even in countries without criminal 

Figure 1: HIV Prevalence Among MSM and General Populations 63 

penalties—such as China, Guatemala, and Ukraine—denial 

of full and equal rights for MSM and other sexual minorities 

exacerbates HIV risk by driving MSM underground and 

beyond the reach of HIV information and health services. 

• Civil society as a driving force for change: In all of the 

countries examined here, community-based efforts to 

advance MSM health and rights have been central to the 

successes that have been achieved. In countries such 

as Guatemala, Jamaica, and Zambia, local and national 

governments do not explicitly prioritize MSM in their HIV/ 

AIDS response and dedicate only limited resources for 

interventions targeting this population. Consequently, the 

AIDS response has depended on support from donors 

working in partnership with local nongovernmental 

organizations (NGOs), MSM-friendly champions in decisionmaking 

positions, and civil society. In all countries examined 

here, many NGOs that serve MSM appear to be highly 

motivated but need technical support in areas such as fiscal 

and personnel management, strategic planning, and the 

provision of basic public health information. 

Laws prohibiting same-sex sexual activity 

between consenting adults are on the 

books in more than half of the countries 

with PEPFAR programs, including three 

that impose the death penalty. 

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REACHING MSM: RECOMMENDATIONS FOR 

PROVIDERS AND GOVERNMENTS 

The urgency of scaling up HIV programs to reach MSM is 

widely recognized, even as programmers and funders struggle 

to implement long-overdue interventions. Because the HIV/ 

AIDS epidemic and the cultural, political, and economic forces 

that shape it are unique to every country, no two national 

responses can be exactly the same. Funders and program 

implementers need to be flexible in their approaches to local 

epidemics and social contexts. Nonetheless, research and 

direct experience point to a series of recommendations that 

are broadly applicable to HIV/AIDS funders and policy makers. 

Global institutions such as the Joint United Nations 

Programme on HIV/AIDS (UNAIDS) and the World Health 

Organization (WHO) recommend that certain core components 

be included in a comprehensive package of services for 

MSM: 12,13,14,15,16 

• MSM peer outreach and engagement in HIV care and 

treatment services; 

• Trained health providers with the specific knowledge, 

attitudes, and skills necessary for working with MSM, along 

with clinics that are MSM-friendly (with confidential intake, 

record-keeping, and follow-up); 

In Malawi, a Matter of Life and Death 

Stigma and discrimination toward MSM are on the rise 

in Malawi, driven in part by the case of two men who 

were arrested in late 2009 after publicly celebrating their 

engagement. Despite a presidential pardon in May 2010, 

the arrest, trial, and imprisonment of Steven Monjeza and 

Tiwonge Chimbalanga have generated widespread fear 

among MSM seeking health services and organizations 

that provide those services. In February 2010, the Center 

for the Development of People (CEDEP), which provides 

HIV testing, counseling, and outreach to MSM and other 

vulnerable groups in Malawi, was forced to close its office 

in Blantyre and relocate to the capital, Lilongwe, after 

two health workers from the organization were arrested. 

With the flare-up of homophobia in Malawi, CEDEP is 

facing new challenges in scaling up HIV/AIDS-related 

interventions for MSM. 

• HIV/sexually transmitted infection (STI) diagnostics 

at clinics serving MSM, including rapid tests for HIV and 

syphilis, screening for gonorrhea, and Pap smears to 

screen for anal dysplasia; 

• Immunizations against hepatitis A, hepatitis B, and 

human papilloma virus; 

• Promotion and distribution of water-based lubricants 

and condoms; and 

• Supportive interventions that include capacity 

building, community mobilization, stigma reduction 

programs, income-generating activities, and advocacy 

for legal/policy reform and human rights protections. 

Without MSM-specific HIV/AIDS services, MSM and 

transgender people can receive HIV services only through 

general health services. But many MSM are reluctant to 

disclose their sexual activities to healthcare workers who are 

untrained on MSM sexual health issues, limiting their access 

to HIV prevention interventions, voluntary HIV testing, and 

other recommended health services. 17 

Governments and donors have a responsibility to assess the 

degree to which government-run health facilities are able to 

meet the needs of MSM and other vulnerable populations. In 

some cases, community-based NGOs are better positioned 

to deliver services to MSM than government agencies. In 

others, clients may prefer to obtain services from public 

health systems. 

RECOMMENDATIONS TO ADVANCE PEPFAR 

PROGRAMMING 

PEPFAR’s recent efforts to address HIV among MSM have 

been limited but hold substantial promise. Legislation 

reauthorizing PEPFAR in 2008 recognized the importance 

of addressing the HIV service needs of MSM, calling for 

“appropriate HIV/AIDS education programs and training 

targeted to prevent the transmission of HIV among [MSM].” 18 

PEPFAR’s Five-Year Strategy, released in December 2009, 

acknowledges the disproportionate impact of HIV on MSM 

and notes that governments are “often reluctant to engage 

in outreach to these communities.” The strategy pledges 

to address stigma and discrimination against MSM and to 

support targeted HIV prevention and treatment services. 19 

Based on the PEPFAR country analyses in this report, a 

number of recommendations can be made for actions 

to strengthen this nascent response. With the epidemic 

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Governments and donors have a 

responsibility to assess the degree to 

which government-run health facilities 

are able to meet the needs of MSM and 

other vulnerable populations. 

among MSM continuing to expand, PEPFAR and the Obama 

administration’s Global Health Initiative must take the following 

concrete steps to more effectively reach MSM and vulnerable 

populations: 

1. Create an MSM-specific strategic fund to provide 

resources for PEPFAR countries beyond their baseline 

allocations. This fund should support research in countries 

with limited data, refinement of MSM population size 

estimates, and scale-up of proven cost-effective programs 

in countries with existing programs such as China, Ukraine, 

and Vietnam. 

2. Substantially increase financial support for 

community-based MSM groups and NGOs to provide 

HIV services to MSM and advocate for human rights. 

Beyond program support, funding should be dedicated to 

developing organizational capacity for front-line community 

groups, including core development such as fiscal and 

personnel management, strategic planning, and computer 

and social media training. 

3. Develop policies to guide expansion and uptake of a 

comprehensive package of health services tailored to the 

needs of MSM, both through general health systems and 

targeted initiatives that can be accessed by people who 

may not feel safe using general health services. In many 

cases, NGOs will be better positioned to deliver services to 

MSM than government-run public health settings. 

4. Provide training and guidance to help providers in 

local health sectors respond to the specific needs of MSM 

and offer appropriate services. Training should also be 

conducted for all U.S. government health and development 

staff, implementing partner agencies (both global and local), 

and key stakeholders. 

5. Help national AIDS control agencies and health 

ministries understand and prioritize the health needs of 

MSM using PEPFAR Partnership Frameworks, Partnership 

Framework Implementation Plans, and other agreements 

between the U.S. government and PEPFAR countries. 

Governments should prioritize strengthening surveillance 

to more closely track HIV among MSM, and to improve 

understanding of the social and behavioral risk factors that 

should inform programming. 

6. Appoint an MSM coordinator at the Office of 

the Global AIDS Coordinator (OGAC) to track and 

report MSM-specific PEPFAR programming, budget 

allocations, and policy and program outcomes. The 

MSM coordinator should provide timely, detailed, and 

comprehensive information on the budgeting, delivery, and 

monitoring of PEPFAR-supported MSM programs. PEPFAR 

should make these data publicly available. 

7. Increase financial and technical support for 

operations research that can identify interventions 

capable of reaching diverse MSM communities in different 

countries, and disseminate results to inform national and 

regional policies. 

8. Work with national governments, civil society 

coalitions, and multilateral partners including European 

governments, UN agencies, the World Bank, and the 

Global Fund to increase global resources for HIV/AIDS and 

related programs targeting MSM, and facilitate the direct 

and meaningful involvement of MSM in global and national 

decision-making bodies. 

9. Address the unique vulnerability of transgender 

people by expanding research and targeted HIV 

interventions for this population. 

10. Use diplomatic and financing leverage to encourage 

recipient countries to identify policy changes that impede 

effective HIV programs; repeal laws that criminalize 

consensual adult same-sex sexual practice; and reform 

policies that fuel stigma and discrimination. 

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MSM AND HIV IN EIGHT PEPFAR FOCUS 

COUNTRIES 

The country profiles that follow provide an overview of the 

most recent information available about the status of MSM in 

relation to the fight against HIV in eight PEPFAR countries. This 

analysis reviews the best available epidemiology, provides a 

snapshot of PEPFAR-supported services for MSM, notes the 

legal status of male-male sexual behavior, and summarizes 

priorities for improving the HIV response. The information on 

programming is based on a broad range of sources, including 

publicly available documents such as: 

• 2008 and 2009 PEPFAR Country Operating Plans (COPs) 

• Partnership Framework Agreements 

• Partnership Framework Implementation Plans 

• 2010 UNGASS country progress reports 

• Peer review and public health literature. 

In addition, 23 interviews with key informants were conducted 

between April and June 2010 by amfAR staff in Washington, 

D.C., including: 

• Field-based PEPFAR staff from USAID and the Centers for 

Disease Control and Prevention (CDC) 

• Country and program managers for major PEPFARsupported 

NGOs 

• Leaders from front-line community groups operating in each 

of the eight countries 

• Leading epidemiologists and experts on MSM issues. 

Photo credit: Piotr Bizior/SXC 

CHINA 

Snapshot of the epidemic 

With a 0.057% HIV 

prevalence among the 

general population, China 

is experiencing a lowprevalence 

epidemic, with 

higher prevalence in some 

regions. 20 At the end of 

2009, an estimated 740,000 

people were living with HIV, of whom 48,000 were newly 

infected. 20 

Estimates from 2009 indicate that heterosexual transmission 

accounted for 42.2% of new infections and male-male sexual 

transmission, 32.5%. 20 The latter figure represents a significant 

increase over 2007, when male-male transmission accounted 

for 12.2% of new cases. 20 A 2008 national MSM epidemiological 

survey carried out in 61 major cities reported an overall HIV 

prevalence of 5%, but HIV prevalence among MSM varies 

considerably in different parts of China. 20 Estimates range from 

1.5% in Shanghai, to 5% in Shenzen, 8.5% in Chongqing, 

and 9.1% in Chengdu. 21 More recent studies have shown HIV 

incidence rapidly increasing among MSM in China, including 

Nanjing, where a study reported an incidence of 5.12 per 100 

person-years. 22 

Legal status 

China does not criminalize homosexual activity. 23 However, laws 

in China do not bar discrimination or specifically protect MSM 

and other sexual minorities, which is a reality that presents a 

barrier to program scale-up in certain areas, according to key 

informants. 

Budget 

PEPFAR-approved FY09 funding for China is $10.3 million. 24 

Since 2004, PEPFAR has invested nearly $40 million to support 

HIV programming in China. 24 Financial information on MSMspecific 

programming is unavailable. 

Interventions 

China’s post-SARS leadership is alert to the pitfalls of neglecting 

the country’s public healthcare system. 25 The government’s 

change in attitude has ushered in increased spending on 

public health and improved HIV-related policies. 25 Government 

funding was mobilized specifically for MSM in 2004 and again 

in 2007, when MSM were added to China’s national strategic 

framework. 13 

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PEPFAR’s involvement has intensified in recent years, including 

support for a national MSM epidemiological survey and the 

development of a “minimum package of services” model 

for MSM. PEPFAR has also supported MSM-friendly STI 

clinics and the development of a model for clinic-based peerdriven 

behavioral interventions addressing STIs in Beijing, 

Heilongjiang, and Shandong. Capacity building with local 

partners has involved training local sub-partners, including 

community-based groups and other grassroots NGOs, in 

behavior change interventions, HIV prevention, and working with 

at-risk populations. 26 In Anhui, Beijing, Heilongjiang, Jiangsu, 

Shandong, and Yunnan, where HIV prevalence among MSM 

is growing, the U.S. supported the development of self-help 

groups among HIV-positive MSM networks, which helped to 

develop web-based support, telephone hotlines, and peer 

support services. 26 

While the U.S. has a relatively small presence in China’s 

overall HIV/AIDS landscape, USAID is currently supporting 

Family Health International (FHI), Health Policy Initiative 

(HPI)/RTI International, Management Sciences for Health 

(MSH), the University of North Carolina MEASURE Evaluation 

program, Pact (through a sub-grant to the International HIV/ 

AIDS Alliance), and Population Services International (PSI), all 

of which provide sub-grants to local governments and local 

community-based organizations. 26 PEPFAR also supports 

the Purple Sky Network, which works to reduce HIV among 

MSM by strengthening MSM community groups, improving 

clinical services, and engaging with governments to establish a 

supportive environment for HIV prevention. 13 

Priorities moving forward 

Despite efforts supported by the U.S. and other donors, many 

MSM in China remain beyond the reach of needed services. 

HIV interventions reach an estimated 70,000 MSM per 

month—only around 9% of estimated need. 27 Novel outreach 

mechanisms such as online resources need to be designed and 

adopted. 

Key informants identified the narrow focus of donor programming 

and inability to support a wide range of appropriate 

services as central challenges. Informants stressed the need for 

donors and program implementers to support a diverse range 

of options and service delivery mechanisms. Other challenges 

include increasing the capacity of health providers to identify 

and manage the sexual health of MSM and increasing financial 

and political support to build the capacity of community groups 

and peer education systems. 

CÔTE D’IVOIRE 


Côte d’Ivoire has a 

generalized HIV epidemic 

with an estimated 

prevalence of 3.7% among 

adults aged 15 to 49, 

one of the most severe 

outbreaks in West Africa. 28 

The epidemic is marked 

by striking gender and geographic differences, with multiple 

populations identified as high risk including serodiscordant 

couples, uniformed services and ex-combatants, sex workers, 

economically vulnerable women and girls, truckers and mobile 

populations, sexually active youth, and orphans and vulnerable 

children. 29 The country’s prolonged political-military crisis 

has probably exacerbated the epidemic among vulnerable 

groups including MSM, for whom epidemiological data remain 

extremely limited. To date, there has been no nationwide 

official study of MSM and HIV. A 2009 study with a sample size 

of 54 estimated prevalence to be 18.5%. 30 

Legal status 

While male-male sexual activity is not prohibited by law, 

MSM are not able to claim full equal rights, according to 

key informants interviewed in country. 23 Moreover, stigma, 

discrimination, and lack of MSM-friendly health staff prevent 

many MSM from accessing public health services. 

Budget 

Côte d’Ivoire was one of PEPFAR’s original focus countries. 

The U.S. remains the largest supporter of HIV/AIDS programs 

in the country, with $124.8 million approved for FY09 28,31 Since 

2004, PEPFAR has invested nearly $445 million to support 

HIV programming, 31 but financial information on MSM-specific 

programming is unavailable. In February 2010, the U.S. 

Department of Health and Human Services and the CDC 

announced a five-year award with a ceiling in the first year of 

$3.5 million to increase targeted research, capacity building of 

local organizations, and coverage of HIV/AIDS prevention and 

care services targeting highly vulnerable populations, including 

MSM. 32 

Interventions 

In 2009, the CDC supported a preliminary study that included 

interviews and focus group discussions with 32 MSM and eight 

health service providers in Abidjan. 33 The 2009 COP reports 

that PEPFAR will complete an assessment of risk behaviors 

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and seroprevalence among MSM in Abidjan, and “specific 

communications and interventions for this potential high-risk 

group will be developed based on early and final results.” 34 

A technical review committee has also been established in 

country, according to PEPFAR documents, and a working 

group on highly vulnerable populations, led by the Ministry of 

Health, is “spearheading the national effort, which includes 

international organizations, the Ministry of Health, and multiple 

implementing organizations.” 34 

Côte d’Ivoire has an extensive brothel- and bar-based sex 

worker population, which has been targeted for prevention 

services from many PEPFAR implementers, primarily FHI. 

With PEPFAR support, FHI provides prevention and care 

services to highly vulnerable populations, working with several 

national Ivoirian NGOs, including Clinique de Confiance, 

which serves male sex workers. 35 PEPFAR also supports the 

Johns Hopkins Center for Communication Programs (CCP), 

which provides technical assistance and support to national 

ministries and implementing partners, to develop communication 

tools on HIV prevention and risk reduction messages for 

MSM. 36 

As reported by U.S. government staff, PEPFAR is funding FHI 

in 2010 to conduct MSM-related studies in two additional sites 

beyond Abidjan, and the Global Fund is proposing plans for 

MSM-related HIV research and services. 37 


Through its support for the government and implementing 

organizations, PEPFAR has made progress in increasing 

the visibility of MSM in HIV/AIDS strategic plans. However, 

stigma and discrimination are widespread, and MSM are 

unable to access health services. To expand programming, key 

informants underlined the importance of increasing capacity 

of local organizations that provide MSM-tailored services and 

sensitizing healthcare workers in public of health settings. New 

resources are also needed to bring interventions to scale. 

GUATEMALA 


With a general population 

HIV prevalence of less 

than 1%, the HIV/AIDS 

epidemic in Guatemala 

is concentrated among 

certain vulnerable 

populations, including 

MSM. 39 According to 

Guatemala’s 2010 UNGASS report, transmission is primarily 

sexual (94%), followed by mother to child (5%). 38 In 2009, 

there was an average of 17 new HIV infections per day and 

reports estimated that two-thirds of people with HIV were 

unaware of their status. 38 According to official statistics, 63% 

of the 20,484 reported cases of HIV/AIDS are men, a majority 

of them between 20 and 39 years of age. 38 Migratory work 

patterns contribute to the spread of Guatemala’s epidemic, 

which means that the country’s HIV-infected population is 

concentrated along major transportation routes in urban 

areas. 39 

National HIV prevalence among MSM is estimated to be 10% 

but higher in some places, including Guatemala City, where it 

reaches 18%. 39 

Legal status 

Male-male sexual activity is not prohibited by law. 23 However, 

studies have documented homophobia and transphobia within 

Guatemalan culture, which cultivates exclusion and aggression 

towards MSM and other sexual minorities. 40 Strong social 

pressure to be heterosexual leads many gay and bisexual 

men to hide sexual identities and behavior from girlfriends 

or wives. 41 Negative attitudes among healthcare providers 

towards MSM and other high-risk groups have also been 

documented. 42 In the first half of 2010,13 transgender people 

were murdered in Guatemala. 43 

Budget 

Approved PEPFAR funding for Guatemala in FY09 is $3.55 

million, which includes $2.05 million in direct bilateral funding 

and $1.5 million through the Central America regional 

platform. 44 Since 2004, PEPFAR has invested nearly $15.8 

million to support HIV programming in Guatemala. 44 Financial 

information on MSM-specific programming is unavailable. 

Interventions 

USAID, through the Central American HIV/AIDS Regional 

Program (G-CAP), has been involved for several years in 

addressing the epidemic among vulnerable populations 

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through targeted behavior change programs and efforts to 

improve the treatment and care skills of medical personnel. 39 

Since 1995, USAID has funded PASCA (Central America HIV/ 

AIDS Prevention Program) to provide technical assistance to 

strengthen and expand the Central American response to HIV/ 

AIDS. 45 

USAID’s Health Policy Initiative supports efforts to defend 

the rights of HIV-infected and -affected individuals, including 

MSM and sex workers. 39 PEPFAR also supports the Pan 

American Social Marketing Organization (PASMO) through PSI 

to improve prevention services, including those aimed at MSM, 

through social marketing. 


PEPFAR’s modest support for the Central American region 

is not sufficient to meet the needs of MSM given the lack of 

funding from other sources for this work. In Guatemala, MSM 

and other high-risk groups face discrimination that undermines 

their use of public health services. Interviewees identified the 

lack of stigma reduction programs for health providers as a 

key barrier to scaling up HIV and STI prevention services for 

hidden MSM. U.S. government staff in Guatemala noted the 

government’s missed opportunity to clearly prioritize MSM 

in the country’s national AIDS plan, presenting a challenge 

expanding MSM interventions and epidemiological research 

in this population. Although MSM are not identified explicitly 

in the Central American HIV/AIDS Partnership Framework— 

signed in March 2010 by the U.S. and seven countries in 

the region, including Guatemala—promising provisions for 

prevention, health systems strengthening, strategic information 

collection, and policy-related work are included. 46 

JAMAICA 

and homophobia— continue to fuel the transmission of HIV in 

Jamaica. 47 

A 2007 survey found that approximately one in three MSM in 

Jamaica was HIV infected (32%). 48 MSM with reportedly low 

socio-economic status who had ever been homeless and were 

victims of physical violence were significantly more likely to be 

HIV positive. 48 The 2010 UNGASS report notes that the sexual 

activity of 40% of men with AIDS is unknown and may reflect 

an unwillingness to reveal sexual orientation. 47 

Legal status 

Male-male sexual activity is illegal and subject to imprisonment 

for up to 10 years. 23 This perilous legal environment, along with 

persistent fears among MSM of discrimination and violence, 

continues to hamper the implementation of services for MSM. 47 

Budget 

In Jamaica, approved PEPFAR funding for FY09 is $1 million. 44 

Since 2004, PEPFAR has invested nearly $9.38 million in direct 

bilateral support to the country. 44 Financial information on 

MSM-specific programming is unavailable. 

PEPFAR’s support for HIV programming is dwarfed by much 

larger contributions from the Global Fund and the World Bank. 

In April 2010, PEPFAR announced the Caribbean Regional 

Partnership, a five-year, $100 million strategy encompassing 

12 countries and two regional organizations. 49 

Interventions 

According to the country’s 2010 UNGASS report, MSM 

activities have been scaled up since 2008, reaching more 

than 2,000 men through a combination of outreach work and 

structured workshop interventions led primarily by Jamaica 

AIDS Support for Life and the Jamaica Red Cross. 47 


Jamaica has both generalized 

and concentrated 

epidemics, with an 

estimated 1.6% of the 

adult population infected 

with HIV and much higher 

HIV prevalence among 

vulnerable populations such 

as MSM. 47 Approximately 50% of people living with HIV are 

believed to be unaware of their status and are therefore not 

accessing appropriate services. 47 Behaviors such as multiple 

sex partners, high levels of transactional sex, and low age 

of sexual debut—combined with poverty, gender disparities, 

PEPFAR’s role in Jamaica to date has been very limited, 

supporting no direct programs targeting MSM. Encouragingly, 

a 2010–2014 country assistance strategy completed by USAID 

highlights the reduction of HIV transmission among at-risk 

populations as a key priority of HIV/AIDS prevention work. 50 


Underscored by key informants, expanded prevention and 

care programs that focus explicitly on reducing widespread 

discrimination are urgently needed in Jamaica. Approximately 

3% of MSM in Jamaica have access to HIV programs, 

according to U.S. government staff. Informants say that 

reducing stigma and discrimination remains critical for 

increasing access to these programs, along with sensitizing 

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stakeholders and building capacity among community partners 

and local institutions. Social and structural interventions to 

challenge homophobia and stigma-related violence have also 

been indicated as critical to program expansion. 

MALAWI 


HIV prevalence has 

stabilized at 12% in 

the 15–49 age group. 51 

Although prevalence is 

higher in urban and semiurban 

areas, the majority 

of HIV-positive people live 

in rural regions. 51 Official 

HIV prevalence statistics among high-risk groups in Malawi 

are slowly emerging. A 2009 cross-sectional study of 537 

men in Malawi, Namibia, and Botswana who reported ever 

having sex with a man revealed combined HIV prevalence of 

17.4%. 52 Among study participants in Malawi, prevalence was 

21.4%, 95% of whom were unaware of their HIV status. 52 In 

another report from the same study, a majority of MSM (53.7%) 

reported both male and female sexual partners, and 16.6% of 

MSM reported having concurrent relationships with both a man 

and a woman. 53 Further, HIV prevalence was 15.2% among 

MSM between the ages of 18 and 23; 21.6% among those 

aged 24–29; and, most notably, 35.3% among those older 

than 30, suggesting that this is not a new epidemic among 

Malawian MSM. 52 

Legal status 

Male-male sexual activity is punishable by law, with imprisonment 

up to 14 years. 23 The penal code criminalizes “carnal 

knowledge against the order of nature,” widely understood 

to mean anal sex. 23 In May 2010, the president of Malawi 

pardoned a male couple engaged to be married who had 

received the maximum sentence of 14 years in prison with 

hard labor when they were convicted of “unnatural offences” 

and “indecent practices between males (see page 4).” 54 

Interviewees expressed grave concern that this case may 

continue to have a negative impact on HIV prevention efforts 

for MSM in Malawi. 

is $43.2 million for FY09, and totals nearly $153 million since 

2004. 55 Financial information on MSM-specific programming is 

unavailable. 

Interventions 

Despite the high HIV prevalence among MSM in Malawi, there is 

no national HIV/AIDS programming targeting this high-risk group, 

supported by the Malawian government or other stakeholders 

including PEPFAR. With USAID funding, PSI in Malawi contracted 

the Center for the Development of People (CEDEP) to undertake 

formative research on MSM as part of the Evidence-Based 

Targeted HIV Prevention (EBT Prev) Project – Dwangwa Pilot 

Project. 56 

Supported by the evidence generated by CEDEP and colleagues, 

the National HIV Prevention Strategy of the Republic of Malawi: 

2010-2013 identified MSM as one of many most-at-risk populations. 

51 According to the 2009 partnership framework between 

Malawi and the U.S., PEPFAR will focus on reducing new HIV infections, 

improving the quality of treatment and care, and supporting 

systems needed to achieve these goals. 57 Although Partnership 

Framework activities mention targeting high-risk groups, interventions 

targeting MSM are not explicitly declared. 

Civil society groups remain the primary providers of MSM-related 

programming and outreach activities in Malawi. Research 2 Prevention 

(R2P), a USAID-funded project led by the Johns Hopkins 

Center for Communication Programs and CEDEP, plans to investigate 

effective interventions for preventing the spread of HIV among 

MSM in 2010. 58 


Many HIV service providers have serious concerns about breaking 

the law when providing services to MSM, according to key 

informants. Similar fears about Malawi’s laws may also explain 

why many MSM do not feel comfortable accessing public health 

services. Key informants identified the following priorities for 

expanding HIV services targeted to MSM: expanding MSM-friendly 

programs and specialized health centers; sensitizing public health 

service providers; and creating an enabling legal environment for 

intervention activities. 

Budget 

International funding accounts for nearly all (98%) support for 

HIV/AIDS programming, 71% of which comes from multilateral 

contributors such as the Global Fund. 51 PEPFAR funding 

www.amfar.org


Proposed Anti-Homosexuality Bill in Uganda 

Imperils AIDS Work 

In Uganda, consensual sex between adults of the same sex is 

punishable under law, including imprisonment for seven years 

or more. 23 The Anti-Homosexuality Bill, introduced in Uganda’s 

parliament on October 14, 2009, would have imposed a wider 

range of severe punishments for homosexual acts, including 

the death penalty for “aggravated homosexuality,” defined as 

any same-sex sexual activity by people who are living with 

HIV. 59 The proposed legislation also called for imprisonment 

for anyone who failed to report individuals engaging in 

homosexual acts—a provision that would effectively criminalize 

the efforts of all organizations working in LGBT communities, 

including those delivering HIV/AIDS prevention, treatment, 

and care. No matter what the ultimate fate of the proposed 

legislation, such efforts severely undermine ongoing public 

health efforts to combat HIV/AIDS among Ugandan MSM, a 

population at high risk of HIV infection. 60 

UKRAINE 


The expanding HIV epidemic 

in Ukraine continues 

to be concentrated among 

IDUs, sex workers, and 

MSM, the majority of 

whom are unaware of their 

HIV status. 61 Adult HIV 

prevalence is estimated at 

1.63%, the highest rate of any country in Europe. 61 

Surveillance data on HIV among MSM are limited. One recent 

study estimated HIV prevalence among MSM to be 8.6% 

nationally, and much higher in cities such as Lviv (18.8%), 

Donetsk (19.9%), and Odessa (21.7%). 62 In general, prevalence 

and population size estimates among MSM are thought to be 

under-representative given the difficulty of identifying MSM due 

to stigma and discrimination. 62 Although evidence suggests 

that the proportion of MSM who also inject drugs is relatively 

small, the high HIV prevalence among IDUs (which exceeded 

40% in 2007) puts the subset of MSM, albeit small, at very 

high risk of HIV infection. 63 

Legal status 

Ukraine was the first former Soviet state to decriminalize malemale 

sexual activity. 62 However, stigma and discrimination play 

a substantial role in limiting HIV testing, disclosure, and use 

of HIV services by MSM. 63 Key informants describe the lack of 

non-discrimination laws and protective regulations for MSM as 

a significant challenge to future program expansion. 

Budget 

Approved PEPFAR funding for FY09 is $16.7 million, a marked 

increase over previous contributions. 64 Since 2004, PEPFAR 

has invested nearly $47 million to support HIV programming in 

Ukraine. 64 Financial information on MSM-specific programming 

is unavailable. The Global Fund remains the largest external 

financing source of HIV/AIDS services, exceeding $45 million in 

2007–2008, followed by support from the World Bank and UN 

agencies. 62 

Interventions 

Ukraine’s national program to provide HIV prevention, support, 

and treatment to people living with HIV/AIDS did not include 

MSM as a priority group for targeted HIV prevention when 

enacted in 2004, although a 2008 update explicitly listed 

MSM. 65 According to interviews, the National Council on HIV/ 

AIDS has no representation from MSM communities. While the 

2010 UNGASS report states that 63% of MSM were reached 

with HIV prevention programs in 2009, program monitoring 

data are believed to be more accurate and suggest a coverage 

rate of only 13.5%. 63,65 

USAID involvement has been limited to interventions targeting 

IDUs and to certain geographic regions. 66 According to the 

country’s 2009 COP, U.S.-supported efforts have reached 

more than 13,000 MSM since 2002. 67 Since 2004, USAID 

has supported the SUNRISE Project, implemented by the 

International HIV/AIDS Alliance, which supports most-at-risk 

communities including MSM. As of 2009, the Alliance, which 

is also supported by the Global Fund, had 17 MSM projects 

in 16 regions, including four clinics that provide MSM-tailored 

services. 68 


Additional investments are needed to scale up interventions 

targeting MSM. Informants identified a variety of priorities that 

warrant urgent attention, including designing interventions 

to reach the growing population of MSM over 35 years of 

age; extending interventions beyond major cities, particularly 

in western regions that are reportedly more homophobic; 

sensitizing health providers in public and specialized clinical 

settings; developing anti-discriminatory laws to support and 

www.amfar.org

12 


protect MSM and other sexual minorities; and supporting 

capacity building among local community groups, peer support 

mechanisms, and regional networks. 

VIETNAM 


The HIV epidemic in 

Vietnam remains 

concentrated among 

IDUs, female sex workers, 

and MSM. 69 Estimated 

prevalence among adults 

aged 15 to 49 is 0.5%. 69 

Men accounted for 73.2% 

of all reported cases in 2009. 69 Several studies have tracked 

prevalence rates among MSM. Regional HIV prevalence 

estimates from 2006 vary from 9.4% of MSM in Hanoi to 

8.0% in Ho Chi Minh City. 13 According to more recent surveys 

conducted in four provinces (Hanoi, Hai Phong, Ho Chi Minh 

City, and Can Tho), HIV prevalence among MSM is increasing 

and is now up to 17.4% in Hanoi and 16.7% in Ho Chi Minh 

City. 69,70 

Legal status 

Male-male sexual activity is not prohibited by law. 23 Vietnam 

still faces considerable barriers in establishing and scaling up 

effective interventions to reach at-risk populations. Stigma 

and discrimination are prevalent throughout society and fear 

of being identified as MSM deters many men from purchasing 

condoms and lubricant in pharmacies or accessing public 

health systems. 75 

Budget 

One of the original PEPFAR focus countries, Vietnam has 

approved funding in FY09 of $89 million. 71 Since 2004, PEPFAR 

has invested nearly $322 million to support HIV programs in 

the country. 71 Vietnam remains heavily dependent on PEPFAR 

support, which accounted for nearly 90% of bilateral aid and 

66% of total national spending on HIV/AIDS in 2008. 69 Financial 

information on MSM-specific programming is unavailable. 

The U.S. funds a number of NGO partners to implement 

programs targeting MSM, including FHI, Pact (which subpartners 

with CARE), PSI, and the University of North Carolina 

MEASURE Evaluation program. 73 PEPFAR also supports UN 

agencies to increase coordination and advocacy of national 

and provincial MSM working groups and regional networks 

such as PSN. Through these partnerships, PEPFAR has 

supported FHI efforts to measure HIV prevalence among MSM 

and HIV interventions for MSM in six provinces—Hanoi, Ho Chi 

Minh City, Hai Phong, Da Nang, Khanh Hoa, and Can Tho. 73 

PEPFAR supports a range of interventions through its partners, 

including a condom social marketing program through PSI, and 

community, peer, and web-based outreach to MSM-friendly 

entertainment establishments. 73 Community-based groups 

are key partners in service delivery of PEPFAR programs. 

For example, the Sexually Transmitted Diseases (STDs)/HIV/ 

AIDS Prevention Center is running an FHI-funded male sexual 

health intervention in Hanoi and, according to interviews, has 

reached more than 5,000 MSM as of April 2010. Between 

2006 and 2008, PEPFAR supported a comprehensive 

evaluation of community outreach programs for most-at-risk 

populations, including MSM. 74 FHI, with funding from USAID, 

also conducted a rapid assessment to better understand the 

underlying personal, social, and environmental reasons for 

MSM risk behaviors. 75 


Although considerable progress has been made in Vietnam, 

prevention coverage for MSM still remains low, limited to 

only seven of 64 provinces, according to key informants. 

The following priorities were identified: developing a national 

strategy to address MSM; sensitizing public health providers 

to be more MSM-friendly; tailoring care and treatment 

services to meet unique needs and variations among rural 

and urban settings; supporting the growth and building the 

capacity of MSM community groups; and encouraging the 

direct participation of MSM in decision-making bodies in 

government. 

Interventions 

USAID began supporting HIV/AIDS programs in Vietnam in the 

mid-1990s. U.S. funds support interventions to prevent HIV 

transmission among most-at-risk populations, including IDUs 

and their partners, sex workers, male clients of sex workers, 

and MSM. USAID implements HIV/AIDS programs through 

13 primary and more than 50 sub-partners focused in nine 

provinces. 72 

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ZAMBIA 


Zambia has a generalized 

epidemic with an HIV 

prevalence rate of 14.3% 

among adults aged 15 to 

49. 76 Demographic and 

ecological variables put 

certain groups at greatest 

risk of HIV/AIDS. 76 Because 

Zambia has not systematically monitored HIV prevalence in 

high-risk populations, the country did not report on any of 

the five MSM-related UNGASS indicators in 2010. The few 

epidemiological studies that have been conducted have 

uncovered heightened HIV prevalence among MSM in Africa, 

including in Zambia, where a 2006 study revealed a selfreported 

HIV prevalence of 33% among 641 MSM. 77 

Legal status 

Male-male sexual activity is criminalized and subject to penalties, 

including imprisonment for up to 14 years. 23 Although the 

government of Zambia has acknowledged the need to reconsider 

criminalization of same-sex sexual activity so that MSM 

populations can be adequately targeted as a part of the response 

to HIV/AIDS, recent contradictory statements by prominent 

leaders and government officials, including the chair of 

the National AIDS Council in Zambia, have created a climate of 

fear among MSM, according to leaders of community groups. 78 

The Zambian National HIV and AIDS Strategic Framework 

2006–2010 covers key target populations, including women 

and sex workers, but not explicitly MSM. However, it does 

not openly address MSM. Encouragingly, the 2009 National 

Strategy for the Prevention of HIV/STI acknowledged that MSM 

constitute a particularly vulnerable risk group for HIV/AIDS and 

recognized the “urgent need” to include them in national AIDS 

strategies. 81 


Homophobia and widespread discrimination are rampant in 

Zambia. Strengthening community awareness and building 

the capacity of local partners, stakeholders, and community 

groups are major challenges identified by informants. For 

PEPFAR to have a meaningful impact, it must work closely 

with community groups within the country’s legal framework 

and place a greater emphasis on highlighting structural factors 

that can threaten public health and effective responses to HIV/ 

AIDS. 

Acknowledgments 

amfAR gratefully acknowledges the invaluable contributions 

of numerous organizations and individuals working on the 

front lines to combat the HIV/AIDS epidemic among MSM and 

without whose help and support this report would not have 

been possible. 

Budget 

An original PEPFAR focus country, Zambia receives most 

of its HIV/AIDS funding from PEPFAR. Approved funding is 

$270.4 million for FY09, and totals nearly $1.116 billion since 

2004. 79 Financial information on MSM-specific programming is 

unavailable. 

Interventions 

PEPFAR is not currently supporting any MSM-specific services 

in Zambia. MSM-related HIV services are almost exclusively 

provided by civil society organizations. PEPFAR’s at-risk 

population programming focuses on female sex workers. 

A 2007 CDC-funded proposal to study HIV among MSM 

was rejected by the University of Zambia Research Ethics 

Committee. Informants noted that the CDC could have done 

more to meaningfully engage government officials and civil 

society partners during the initial planning phases. To date, no 

formal study has evaluated HIV risk among MSM in Zambia. 

Friends of Rainka has received private foundation support to 

conduct an epidemiological probe of HIV among MSM in three 

urban sites and one rural site in four provinces of Zambia. 80 

www.amfar.org

14 


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66 USAID. Ukraine Country Health Profile. Available at: http://ukraine.usaid.gov/ukraine_health.shtml. 

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68 Interview with Alliance staff in Ukraine. April 30, 2010. 

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www.amfar.org

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Issue Brief: MSM and the Global HIV/AIDS Epidemic - amfAR

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