Secretary of State Hillary Clinton made a landmark speech on
Tuesday declaring a new direction in the U.S. response to the global AIDS
epidemic. Citing a number of
recent studies on the efficacy of different biomedical approaches for
preventing HIV, Clinton announced that an HIV-free generation is now within
"While the finish line is not yet in sight," she said, "we
know we can get there, because we know the route we need to take."
The new U.S. commitment to an "HIV-Free Generation" -- and
the accompanying three-point action strategy centered around prevention of
mother-to-child transmission, medical male circumcision, and
treatment-as-prevention -- represents one of the first attempts to translate
this new HIV prevention science into a broad-scale policy priority.
It remains unclear, however, exactly how this new strategy
will impact epidemics among gay men and other men who have sex with men, as
well as other key populations like transgender people, sex workers and people
who use drugs. In fact, the speech
hardly mentioned them at all.
Global epidemiological data paints a clear picture of where
the epidemic is concentrated. HIV
prevalence rates among these key populations are higher than those of the
general population in nearly every country that accurately collects and reports
this data, including countries with generalized epidemics such as those in
HIV prevalence rates among MSM are skyrocketing around the
world, surpassing 20% in countries as diverse as Jamaica, Mexico, Myanmar and
Zambia, and infection rates of more than 70% have been observed in some
transgender communities. UNAIDS
currently estimates that people who use drugs account for 80% of all HIV
infections in Eastern Europe and Central Asia, and in parts of Africa, sex
workers and their clients are believed to make up as much as half of all
It is unfortunate that Clinton, herself a powerful ally who
has championed LGBT rights as human rights, failed to discuss the new strategy
in relation to MSM or any other key population. This omission was not lost on
those of us who understand and bear witness to the disproportionate HIV disease
burden being shouldered by key populations around the world.
Any viable global AIDS strategy must take into account the
needs of key affected populations if it is going to effectively reduce HIV
burden. Even the most promising
evidence-based intervention cannot succeed if it neglects the social, legal and
structural barriers faced by key populations.
Despite the fact that the virus was first discovered in gay
men over 30 years ago and continues to have an extreme impact on this
population, fewer than one in 10 MSM are reached by HIV prevention programs
worldwide today. Fewer than 40 out
of 184 countries report to UNAIDS that they have national targets for HIV
program coverage for MSM, and less than 2% of international funding for HIV is
targeted to MSM. Moreover, 78
countries still criminalize homosexuality.
Without explicitly targeting MSM and other key populations,
it is unlikely that any new strategy to address the global AIDS epidemic will
make a dent in these figures.
Stigma and discrimination remain high around the world, driving MSM and
other key populations away from life-saving prevention and treatment services
offered to the general population.
A recent survey of more than 5,000 MSM worldwide showed that, among all
variables, the strongest predictor of compromised access to HIV prevention
services was the level of homophobia experienced by participants.
Stigma, discrimination, and criminalization are extremely
important and complicated issues; they cannot be an afterthought. While biomedical approaches may present
useful new tools in the fight against HIV, we cannot use them as an excuse to
skirt the hard work of addressing the social, legal and structural barriers
that have prevented gay men and other key populations from accessing services
since the beginning of the epidemic.
Earlier this year, the President's Emergency Plan for AIDS
Relief (PEPFAR) issued technical guidance on combination HIV with MSM, one of
the first documents of its kind.
The U.S. State Department has also been a powerful force in the fight
for LGBT rights abroad. This work
is commendable and must be continued as the United States begins to roll out
its new global AIDS strategy.
The new AIDS strategy must be targeted and tailored to the
specific needs of communities most affected by HIV. To accomplish this, we must be able to openly name and
respectfully engage those communities.
All eyes now turn to President Obama to lend his support to reinforcing
U.S. commitments to the global HIV response, especially in the lead up to next
July's International AIDS Conference in Washington D.C.
The conference returns to U.S. soil for the first time since
1990, bringing with it 20,000 delegates and the expectations of millions. This presents a vital opportunity for
the president to take leadership in directly addressing the needs of those most
impacted by HIV and AIDS, including MSM, both in the U.S. and around the world.
GEORGE AYALA is executive officer of the Global Forum on
MSM & HIV (MSMGF) www.msmgf.org