By Christopher Mangum
Originally published on Advocate.com August 01 2009 12:00 AM ET
When President George Bush signed into law the U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act on July 30, he extends the President’s Emergency Plan for AIDS Relief (PEPFAR) for another five years. The bill also increases America’s financial commitment to fight against the global HIV/AIDS, tuberculosis and malaria epidemics from $15 billion under the old legislation to up to $48 billion through 2013.
Krista Lauer, manager of international policy at AIDS Project Los Angeles, was one of the influential voices shaping the reauthorization process, and successfully ensured funds would be for the first time allocated towards men who have sex with men (MSM). Laurer spoke with us at the International AIDS Conference in Mexico City, about lobbyist’s efforts to achieve “a moment for MSM.”
What is the difference between the 2003 and 2008 bills?
PEPFAR is not a perfect bill, but one of the biggest victories is that for the first there is language for prevention specifically targeting men who have sex with men.
How much does MSM impact the HIV epidemic globally?
Well going back to that 2007 study, it has been shown that MSM’s in low and middle income countries are nineteen times more likely to have HIV than the general population. It is really difficult to know. There are risks associated with disclosure, but what is clear is that MSM are at high risk of HIV and also that they are not being effectively reached right now with services. And there is also some misinformation because of that.
There was a session I was at this conference where a provider from West Africa indicated that some of the men accessing their health service felt they had no risk of HIV transmission because when they were asked how many women they had sex with they said none. They felt they no risk of HIV transmission because they didn’t know that HIV could be transmitted between men. That highlights this will go a long way to get desperately needed services to people who need them.
There are 15 focus countries that receive a combined $10 billion in aid. How were those chosen?
When the program was initiated in 2003 they were some of the hardest hit countries in the world such that more than half of the global AIDS burden was concentrated in those 15 countries
How long have you been working with the AIDS Project Los Angeles on PEPFAR?
When I came on board with APLA in December 2007, I linked immediately into global advocates in Washington D.C. who have been working on this. There are a lot of issues in this bill, but AIDS Project Los Angeles focused on the inclusion of men who have sex with men in the reauthorization.
What were the necessary steps in lobbying?
There were a lot of different issues in the language for intravenous drug users, or family planning, linkages for family planning services with HIV services, training for health care workers and I made sure to provide information on MSM and their role in the global epidemic. That also included condensing the research available, meeting with various congressional offices and key decision makers so they can be aware of what’s happening on the ground and why it is so vitally important to specifically target men who have sex with men with prevention education.
What were some of your largest obstacles?
One of the largest obstacles actually is in many countries worldwide same-sex consensual acts between men are criminalized, making data collection difficult. A lot of national HIV surveys don't collect data specifically on men who have sex with men for many reasons. Sometimes it’s not part of the surveillance system, other times it’s really putting men at risk to disclose their sexual behavior because not only is there a lot of stigma and discrimination but it is actually criminalized, as I said, in many countries. So there is not a whole lot of robust data. It’s of one of those circular chicken and egg things -- the people need to see the data to justify the data but without the programming it is difficult to get any of the data.
How then did you ultimately succeed in getting the MSM language incorporated in the bill?
Luckily there are some good studies. There was a 2007 study that looked specifically at the epidemiology of HIV among MSM in low and middle-income countries. There have also been good quality studies and experimental on the ground information, but again, it’s about getting that all together and making it real for decision makers.
Were there any organizations or groups that proved to be barriers to the inclusion of MSM in the legislation?
During the reauthorization process there were really big debates on family planning. There were big debates on the prostitution pledge. There were big debates on treatment and whether if treatment should have a specific allocation, but in terms of MSM there was really no big debate around MSM and perhaps maybe because other issues had more media attention.
You said the bill isn't perfect, what else would you have liked to see included in this bill?
There is still an emphasis on abstinence prevention methods. The prostitution pledge remains in the law which is programmatic. There needs to be better linkage between family planning programs and HIV services. It is a good opportunity because the one reliable time that women will certainly go into health services is during pregnancy.
Despite its shortcomings, what do you hope will result with this legislation?
I hope that the people who are desperately in need of services are able to get the information and services that they need. There have been various sessions [at the AIDS Conference] and various advocates and people from on the ground who are speaking on the ground who are speaking about the dual epidemic of not just HIV but the stigma discrimination homophobia. This is a high risk community that has had limited access to services and this really has the potential to make a life changing and life saving impact in the lives of so many.