Many gay men and women have a deep and complicated relationship with the concept of omission. The choice to leave out information about our sexual orientation can be a useful strategy when faced with the potential for an awkward, painful, or violent situation. It placates sensitivities, prevents discord, and in some cases it saves our lives. However, it also preserves the status quo.
With such compelling reasons to bite our tongues, many of us choose silence as homophobia takes its toll around us. Lips sealed and hands tied, we watch in quiet pain as abuses are inflicted on our more visible kin. We become unwitting accomplices to those who wish to erase us. Realizing the effects of our own inaction, more and more of us have come to feel that this path of least resistance is not worth the violence and injustice it allows – and we speak up.
As the world prepares for the upcoming United Nations High Level Meeting on AIDS, taking place June 8-10 in New York, country missions at the UN are faced with a strikingly similar dilemma. With HIV rates among gay men skyrocketing across the globe, UN member states must decide how to present men who have sex with men in the meeting's final outcome document. They can appease anti-gay forces by omitting MSM entirely, or they can write MSM into their policies explicitly, no matter how polarizing the issue may be.
By all accounts, it's high time that global leadership gets real about the nature of the HIV epidemic. HIV prevalence among MSM has reached levels as high as 32 percent in Jamaica, 21.5 percent in Senegal, and 19.4 percent in Colombia. Despite this fact, nearly half of the 128 countries reporting HIV data to the UN have failed to include any data whatsoever on HIV among MSM. In addition, more than 70 countries around the world currently criminalize homosexual activity, forcing MSM underground and away from sexual health programs.
Facing such formidable structural barriers, it is not surprising that more than half of MSM globally find it difficult or impossible to access life-saving services like HIV testing, HIV education materials, and HIV treatment. Even in such dire circumstances, many key players in the global AIDS response – from the UN General Assembly to the national AIDS coordinating bodies in countless individual countries – have neglected to mention MSM explicitly in their AIDS control strategies and policies.
In both 2001 and 2006, the United Nations passed landmark consensus declarations designed to hold countries accountable to their commitments to addressing HIV and AIDS. Both documents fail to include any mention of MSM. Now that the UN is gearing up to renew its commitments yet again in June, advocates are locked in battle over whether specific language on MSM will be included, or whether they will be rolled into a broader category of "key populations" and rendered effectively invisible.
As the UN faces this decision, the efforts of other global health institutions to address this issue may provide some guidance. Both the U.S. President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria have grappled with the challenge of addressing HIV among MSM with varying degrees of success.
PEPFAR was first launched by the U.S. government in 2003 and it remains to this day the single largest bilateral funder targeting HIV around the world. When the program debuted, the law enacting PEPFAR also failed to mention MSM explicitly. It was only when the program was reauthorized in 2008 that a specific directive to prioritize HIV prevention efforts for MSM was added to the law. Most recently, PEPFAR took a major step forward just last week by issuing a technical guidance document on HIV prevention for MSM to be used by PEPFAR country missions.
While the inclusion of MSM in PEPFAR's legislation and guidance documents represents important progress, PEPFAR administrators have acted far too slowly and their current efforts are not comprehensive enough to ensure an impact. It took nearly 10 years after PEFPAR's initial launch to produce a guidance document on MSM, and still there are no systems to track PEPFAR dollars targeted to MSM, no official reporting indicators to measure progress on HIV prevention for MSM, and no mechanisms for ensuring that country missions actually implement programs for MSM at all. The result to date has been a piecemeal effort that varies widely from country to country, frequently excluding local MSM-led community-based organizations that are best positioned to reach this key population. All too often, country missions simply ignore MSM because they prefer not to deal with us or they feel unequipped to do so.
The Global Fund on AIDS, TB and Malaria presents a more successful example. Recognizing the importance of MSM and other key populations, the Global Fund launched its Strategy in Relation to Sexual Orientation and Gender Identity – more commonly known as the SOGI Strategy – in May 2009. This policy effort was complemented by the development of a funding pool specifically dedicated to addressing most-at-risk populations (MARPs), which was made available for the first time in Round 10. Success is in the numbers: since the launch of the SOGI Strategy and MARPs funding pool, the proportion of Global Fund-funded proposals that include care and support activities for MSM has risen from 29 percent to 44 percent. Funded proposals that include stigma and rights-related activities for MSM have received an even bigger boost, rising from 10 percent to 53 percent.
The lessons from these policy experiments are clear: without an explicit focus on MSM, service providers are left without the mandate, funding, knowledge and tools they need to respond to the specific needs of MSM. We look the other way as our brothers are laughed out of clinics by bigoted staff, delaying visits to the doctor until they are on death's door rather than endure the ridicule, incompetence, and confidentiality breeches that await them there.
The United Nations and other global health institutions must include specific language on MSM in their policy documents – and then follow these mandates with clear, measurable, time-bound, and well-resourced implementation plans that meaningfully engage local MSM-led groups. Failing to do so is not only poor public health practice; it creates a gaping silence that signals an absence of leadership on this issue, emboldening those who violate our human rights in the name of traditional values, religious conviction and plain homophobia.
Despite the personal dangers of speaking up, an increasing number of MSM advocates in all parts of the world are doing it every day. We rise up and make ourselves visible, because we know it is the only way we will be counted. Following the murder of Ugandan activist David Kato, it is clear what we are risking to claim our rights. Yet our colleagues, from the comfort of boardrooms in New York and Geneva, continue their omissions, unable to muster the courage to write our existence into policies. It is time they spoke up, too.
George Ayala, Psy.D., is the executive officer of the Global Forum on MSM and HIV. Ayala has worked in the nonprofit HIV/AIDS sector managing social service programs for 20 years, having conducted social science and community-based intervention research since 1996. His research has mainly focused on understanding the mechanisms through which social discrimination impacts health among gay men and other men who have sex with men.