This is a feature I wrote in early 2009 as my final paper for a Global Health Reporting class. It was published in the newsletter of an NGO in Asia. I decided to re-post this as a reflection on World Aids Day. The way we've dealt with HIV/AIDS since the 80s is a reflection of how far we have come as a collective human race, from fear and prejudice to understanding, action, compassion and inclusion.
Pukaar January 2010 Issue 68
Waking up to AIDS in Asia...
Facing the fact that men are having sex with men
By Rebecca Lim
Shivananda Khan wakes up every morning in Lucknow, India, and goes to work angry. He is mad that in some Asian countries, only one in 10 MSM (men-who-have-sex-with-men) have access to HIV/AIDS services.
“It is a sense of righteous anger, like when you see someone beaten up for trying to speak the truth,” said the founder and chief executive of Naz Foundation International (NFI), a non-profit organization helping MSM groups in South and Southeast Asia develop sexual health and HIV prevention, support and care services.
Over in Kuala Lumpur, Malaysia, Andrew Tan goes to work behind a mask. Being a HIV positive MSM and Chinese in a predominantly Malay and Muslim country, he keeps his status and other life as an advocate and volunteer counselor for HIV/AIDS a secret from his co-workers, friends and even some of his family.
“You’ll get double discrimination,” he said. “Even within the gay community, you’ll be considered an outcast...a pariah of a pariah group!”
He sits on the board of advocacy group, the Asia Pacific Coalition On Male Sexual Health (APCOM), which Mr. Khan chairs and also founded.
Both men share a common concern about the gravity of the HIV/AIDS epidemic for MSM in Asia. Here, barriers to prevention, education and treatment are deeply rooted in cultural norms, religious beliefs and social stigma.
Dr Massimo Ghidinelli, the World Health Organization (WHO) Regional Adviser in HIV/AIDS and Sexually Transmitted Infections, said at a conference last year, that in many Asian countries, national strategic plans for HIV/AIDS do not include interventions for MSM and transgender persons.
He added that targeted preventive measures are reaching only 1% of the MSM population in Asia of an estimated 10 million men.
“Action needs to be taken now if a major increase in HIV/AIDS cases is to be averted,” he warned.
According to UNAIDS, an estimated 4.9 million people were living with HIV in Asia in 2007, and 300,000 died from AIDS related illnesses, making this the region with the second highest numbers next to Sub-Saharan Africa.
In an independent study published by TREAT (Therapeutics Research, Education, AIDS Training) Asia in 2006, HIV rates among MSM in Phnom Penh, Cambodia was reported to be at 14.4%, 16.8% in the state of Maharashtra in India, and 28.3% in Bangkok, Thailand. The report also predicted that MSM in Asia will “face a crisis more devastating than that experienced by gay men in the West during the epidemic’s earliest years” if the trend of infections is not stemmed.
Facing stigma and discrimination
One of the key reasons underpinning the lack of HIV/AIDS prevention and services for MSM is social prejudice and discrimination, said Mr Khan.
This deep-seated stigma stems from the social dynamics of sex between men in Asia, and the cultural pressure on males to marry and build a family, he added.
“We have a double jeopardy situation,” he explained.
Many MSM in Asia do not view themselves as homosexual as long as they are playing the dominant or penetrative role. A large number also have sex with women and end up getting married. They continue to have casual (and potentially unsafe) sex with men, putting the spouse and children at risk of HIV infection.
A study in Mumbai, India revealed that 25% of HIV positive men are married MSM. In Beijing, China, 29% of MSM respondents in a survey said they also had sex with women. “ There is a whole spectrum of MSM and this is almost invisible for many people in Asia who think that being gay means dressing up like a woman,” said Mr Tan.
While the “masculine and publicly married” men fall on the left of the spectrum, he added, the transgender fall on the right. In between, there are different groups, including those who are comfortably gay, and do not necessarily identify with gender roles.
For the men playing the receptive or feminine role, the stigmatization is even greater. Many are transgender sex workers or young men turning to sex work to fund drug addiction. While some intervention programs, such as the condom use campaign in Bangkok, have been successful, there is still exploitation and unsafe practices.
“It’s no secret,” he added. “Some men are willing to pay extra not to use condoms.”
More than half of MSM surveyed in the major cities of Beijing, Shanghai and Guangzhou in China admitted to unprotected sex with multiple partners. This is the same in Vietnam, where 69% of MSM surveyed in Hanoi and 63% in Ho Chi Minh City engage in unprotected sex. In Jakarta, Indonesia, 65% of male sex workers and 53% of other MSM do not use condoms regularly.
The situation is compounded by the fact that sex between men is illegal in 11 out of 23 Asian countries surveyed in the TREAT study. In countries such as Malaysia, Pakistan and Bangladesh, religious groups and authorities condemn homosexual activities. The fear of social persecution and legal prosecution make many unwilling to get tested or treated for HIV.
“I have come across cases where a doctor slapped someone because he was a homosexual,” said Mr. Khan. “Some doctors report people who go to them for treatment to the police.”
Mr. Tan is also seeing a trend of more men being infected at a younger age in Malaysia. “The youngest man I’ve counseled is 19,” he said. “He had all these high hopes of becoming a pilot but all of a sudden, his world crumbled.”
In the 80s, when AIDS meant death, he added, people took protection seriously. Now, some, especially the younger generation, may think that “it’s a matter of popping a few pills” if they should be infected.
“It’s not like taking vitamins!” he stressed. “You have to take responsibility, adhere to the treatment for the rest of your life, and prevent other people from being infected by you.”
Facing the need for intervention
It is estimated that without further intervention, HIV infection rates among MSM in Asia could double year-on-year in the next 20 years, said Mr. Khan.
Funding is also a major issue, added Mr. Khan. Even the most developed economies in Asia, such as Singapore and Japan, have made little investment in HIV services. International aid is not likely to increase, given current economic sentiments. He noted that last year, the Gates Foundation donated US$ 200 million to India and US$ 50 million to China in HIV funds.
“We will need another US$ 3 billion,” he added.
The impact on economic growth is perhaps a way to engage Asian countries in facing up to the HIV/AIDS crisis. The World Bank estimates that when the prevalence of HIV/AIDS reaches 8% (as is the case with 13 African countries), the cost to economic growth is about 1% a year.
Thankfully, there are success stories such as Cambodia’s. The country has seen a steady drop in HIV prevalence rate from 2.8% in 1998 to 0.9% in 2006 and 0.7% last year and aims to further decrease the rate to 0.6% by next year. The government has allocated US$45 to 50 million in annual funds to achieve this. It is estimated that more than 90% of the country’s at risk populations, including MSM, are aware of HIV/AIDS and 90% of sex workers use protection. Some 93% of the country’s HIV positive people have access to treatment and support services.
On a personal level, Mr Tan’s story illustrates that while it may be tough to change old beliefs and cultural practices, there are ways to overcome stigma.
Since being diagnosed with HIV in 1994, his constant support had been his boyfriend of 25 years (who is not HIV positive).
When he first told his family that he was seeing a man, they thought it was a passing phase. He continued to do his part as “a good son” by making an effort to be home for family meals and events. Eventually, his parents invited his boyfriend to their home for dinner on the eve of Chinese New Year.
“Since then my parents have referred to my boyfriend as their godson and he is with us at all family events,” he added.
It is stories such as these that keep advocates such as Mr Khan going.
“I like what Barrack Obama said about hope,” he said. “We live in hope. If we lose hope, we will drown.”
Rebecca Lim, a journalist from Singapore, is currently pursuing a masters degree at Georgetown University in Washington D.C. This article was produced last year as part of her coursework in global health reporting.