The Washington Blade - Friday, January 22, 1999
Kai Wright

Officially, among the agencies involved in fighting the spread of AIDS, there is a clear consensus on the demographics and geography of AIDS. In North America and Western Europe, where AIDS deaths are declining, the virus has most viciously ravaged Gay and bisexual men. In Asia and Africa, in at least four countries where as many as one in five adults are believed to be infected, the virus is primarily transmitted via heterosexual sex largely commercial and mother-to-child infections. In Eastern Europe, injection drug use is the primary mode of transmission.

In Latin America, the virus is predominately transmitted via heterosexual intercourse, but men who have sex with men are still largely at risk. Money and resources are targeted according to these official demographics.

Unofficially, these demographics are just a best guess in the developing countries. And groups reaching out to men who have sex with men in Africa, Asia, and Latin America are saying that even the best guess misses the mark. They say HIV infections from sex between men are far underreported in many places. And as a result, they say, their organizations are largely ignored when the money and resources are distributed.

And thus the usual catch-22: The AIDS groups say there s a need to focus resources on men having sex with men; but the groups don t have enough money to do the studies necessary to prove that need, and governments don t have any interest in doing such studies.

"You have to have the interest and the need," said Ron MacInnis, director of the Global Health Council's AIDS program. "And a lot of these governments don't want anything to do with addressing homosexuality."

Betsy Leonard, human rights program director for the Heartland Alliance, a Chicago-based group that helps link Gay and AIDS groups throughout Central America, likened the problem to that faced by Gay human rights organizers in many places.

"People talk about Is there persecution [of Gays] or not? But before you can talk about persecution you have to acknowledge that they exist," she said with a sigh. One complication in trying to prove they exist, she explained, is that often, men having sex with men do not consider themselves homosexual. That fact creates all kinds of reporting problems. First, when they test positive for HIV infection, such men typically assert that they got the virus from having sex with women. Second, and probably more difficult to overcome, such men often assert that they haven't had sex with other men. Both hinder data collection on HIV transmission and prevention campaigns that reach out to educate the people most in need of HIV prevention information.

"Many of these men are bisexual and they are not going to go to a clinic and tell a health worker about this," said Richard Stern, Costa Rican man who coordinates a network of Central American AIDS service groups targeting men having sex with men. Stern notes that most countries do not have confidentiality laws protecting health information. "So most men simply act the macho part and say that they got infected through promiscuous heterosexual contact. I do not for a minute believe the accuracy of these figures."

Paul DeLay, chief of the U.S. Agency for International Development s HIV/AIDS division, acknowledged the paradox. While he said that, when considering a place like sub-Saharan Africa, his "gut feeling" is that the figures are accurate, he agreed that there are serious difficulties in collecting data on men who have sex with men because the governments assert that homosexuality doesn t exist in Africa.

"It doesn't exist in African society," explained DeLay. "And once you hve made that assumption, you re not allowed to do the surveys."

Moreover, he added, surveys asking people how they became infected not only must pass the muster of governments squeamish about homosexuality, they also must be careful not to scare off people answering the surveys people who are equally squeamish about publicly acknowledging they had same-sex sexual encounters.

Beyond data collection, both DeLay and MacInnis stress another problem in trying to fund programs to reach men who have sex with men in developing countries: There aren't very many such programs. Both men said that, particularly in Africa and Asia, their organizations have been unable to identify groups that can be counted on to use money in a way that meets their standards. Additionally, DeLay said, the few groups that do exist don't reach enough people to justify the associated costs of funding them.

But here, again, Leonard of the Heartland group noted, the solution is tangled up in the problem. How can a group build the record and infrastructure it needs to be eligible for international donor money if it does not have money to build with?

Another consideration DeLay stressed is that in many countries, such as Zimbabwe, to identify a group as reaching out to men having sex with men is to put that group at risk for government harassment. World Bank HIV/AIDS program director Dr. Debrework Zewdie said that overcoming this problem the hostility of local governments to allowing the involvement of certain sectors of civil society is a priority among the six health and development agencies that comprise UNAIDS the Joint United Nations Program on HIV/AIDS). She said too many governments want to call AIDS a "homosexual disease" for developed countries and a "heterosexual disease" for developing countries.

"This is a very different epidemic. Different in the sense that it questions everyone's sexual behavior," Zewdie said to a meeting hosted by the World Bank s Gay employees group recently. "The first thing that we have to put in place is human rights."

A 1996 Panos Institute of London survey showed that groups fighting HIV transmission via sex between men are underfunded. Panos sent surveys to the national health ministries of all 133 countries currently considered developing countries and asked them, among other questions, how much of their AIDS budgets went to work with men having sex with men. Of the 43 countries that responded, 84 percent said they allocated no money at all to fighting AIDS among men having sex with men. Panos made the point again in a book on AIDS and Men, released last month, urging local governments and international agencies to re-examine assumptions about the role sex between men plays in the developing world.

But there are groups in Africa and Asia which do exist to reach men having sex with men, and those groups are screaming for international money. In Zimbabwe, for instance, Gays and Lesbians of Zimbabwe begged throughout 1998 for international donations for their HIV prevention work albeit, mainly from private organizations.

And in India, the Humsafar Trust has been trying to reach out to Gay and bisexual men with HIV prevention since the late 1980s.

MacInnis, however, stressed that groups such as these reach only men who identify as Gay. He is looking for groups that reach men who have sex with men but don't consider themselves Gay. That is what he has found in India' s NAZ Foundation.

And in March, with USAID money funneled through MacInnis s Global Health Council, NAZ will host the first south Asian conference on men having sex with men and AIDS.

Similar advancements are easier to find in Latin America. USAID is launching a project that will help groups that seek to educate men having sex with men in Latin America to build their services. Stern s Central American network, while struggling financially, is still alive.

Beyond Latin America, USAID is also launching a "linkages program" that will match U.S.-based AIDS service organizations with groups that target similar populations in developing countries. Groups targeting Gay and bisexual men will be included in the project.

"Is it better to have a men having sex with men group in San Francisco to work with a men having sex with men group in Moscow versus us hiring a contractor to go out and work with the group in Moscow?" DeLay asked. "Intuitively," he said, it is. But the program will start small later this year and be closely monitored to bear that belief out with studies.

Programs like these may bring more money to the small organizations that are able to reach a group of people many developing country governments are not yet willing to or capable of giving help. They may also change the official demographics of the epidemic if they foster new data on modes of transmission.

"Lots of past researchers didn't want to ask these questions," concluded USAID s Cliff Cortez, who specializes in HIV/AIDS human rights issues and men having sex with men.

"We need to figure out how to get at this information." In the meantime, DeLay summed up best the latest catch-22 for groups dealing with the issues surrounding homosexuality in the developing world: "Our resources are so limited in these countries, " he said, "that we ve got to go where the largest mode of transmission is."
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