From marginal to marginalised: The inclusion of men who have sex with men in global and national AIDS programmes and policy

ABSTRACT

In the last decade, gay men and other men who have sex with men (msm) have come to the fore of global policy debates about AIDS prevention. In stark contrast to programmes and policy during the first two decades of the epidemic, which largely excluded msm outside of the Western countries, the Joint United Nations Programme on HIV/AIDS now identifies gay men and other msm as ‘marginalized but not marginal' to the global response. Drawing on archival data and five waves of United Nations Country Progress Reports on HIV/AIDS (2001–2012), this paper examines the productive power of international organisations in the development and diffusion of the msm category, and considers how international organisations have shaped the interpretation of msm in national policies and programmes. These data show that the increasing separation of sexual identity and sexual behaviour at the global level helped to construct notions of risk and disease that were sufficiently broad to accommodate the diverse interests of global policy-makers, activists, and governments. However, as various international and national actors have attempted to develop prevention programmes for msm, the failure of the msm category to map onto lived experience is increasingly apparent.

KEYWORDS:

• Men who have sex with men
• HIV/AIDS
• policy
• UNAIDS
• implementation

Disclosure statement

No potential conflict of interest was reported by the author.

ORCID

Tara McKay http://orcid.org/0000-0001-5076-6483

Notes

1. Throughout, I reflect the language that is used in a particular historical moment or by a given actor. In my own discussion and analysis, I have used msm in lowercase following Epprecht (2008) in order to describe elements of this mutable and contested category rather than the uppercase ‘msm’ which further reifies the category as stable and cohesive.

2. Word choice is deliberate here on the part of stakeholders who make a distinction between ‘bisexual’ – often used unreflexively to convey sexual preference, identity, or practice – and bisexual behaviour, which was deemed most important to HIV/AIDS transmission.

3. However, GPA continued to reiterate the need for more research throughout the 1990s. For example, the 1994–1995 Annual Report, which summarises all activities conducted by GPA from 1987 to 1995, identifies as one of 10 ‘Intervention Research Priorities for the 1990s’ the need to “determine the most feasible, relevant and effective interventions targeting homosexual and bisexual behaviours amongst various groups and situations of men who have sex with men in developing countries, including interventions with emphasis on: (a) reaching those persons practicing bisexual and/or homosexual behaviours who do and do not identify themselves as such; (b) situations with large numbers of male or transgender prostitutes; and (c) different forms of situational homosexuality (e.g. the military, migrant labour communities, prisons).” (GPA, 1997, p. 16) Yet, in contrast to detailed summaries of almost a decade of prevention activities targeting women, youth, and even drug injectors, the 74 page report does not include any additional discussion of the agency's activities targeting gay, bisexual, or other msm.

4. Because the composition of countries submitting reports varies each report year and missing data decreases with each subsequent report year, the percentage of countries at each level of prioritization should be read as demonstrating a general trend toward stronger prioritization rather than absolute gains or losses over time.

5. Buckley's (2008) report on estimating HIV prevalence in the Southern Caucasus provides an intriguing and commendable exception in this area.

6. Prior to amfAR's MSM Initiative, private foundations like the Ford Foundation and the Bill and Melinda Gates Foundation, and other development organizations such as Family Health International and Population Services International used their general mandates to improve health and prevent HIV to make several individual awards to local and national HIV and LGBT organizations working with gay men and other msm.

7. 2002 is used as it is the start date for the Global Fund; however, nearly all of the Global Fund's funding for msm is stacked towards the last few years of this time series.

8. Unfortunately, PEPFAR does not report specifically on program expenditures targeting msm, and tracking the flow of resources from US agencies is extremely difficult due to the number of sub-contracts to other international, national, and government organisations. Still, evaluations of PEPFAR note progress in targeting msm through PEPFAR-funded and community-led activities in some countries, for example in China, Côte d'Ivoire, Ukraine, and Vietnam (see amfAR's (2011) evaluation of PEPFAR). In Asia, PEPFAR also supports the Purple Sky Network, a transnational advocacy organisation which works to reduce HIV among msm by strengthening msm community groups, improving clinical services, and engaging with governments to establish a supportive environment for HIV prevention.

9. amfAR and others continue to criticize PEPFAR for its neglect of msm and a lack of transparency in where funds go once they get in-country (amfAR, 2011).

10. See also Martucci (2010) on how the ambiguity of the msm category has structured US blood screening policy.