Africa: New PEPFAR Guidelines Offer Respite to the Gay Community

By Henry Neondo

A new funding policy guidelines issued Saturday by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) could soon see countries like Kenya, Uganda and Zimbabwe who are strongly opposed to men having sex with men chew their word.

On Saturday in the US, PEPFAR, a major funder of funds to fight HIV and AIDS in 15 countries in sub-Saharan Africa released a new Technical Guidance on Combination HIV Prevention for men who have sex with men (MSM) designed to be used by Country Missions and calls measures be put in place to address human rights, legal barriers and homophobia in HIV response for MSM. 

The PEPFAR MSM guidance comes at a time when MSM in low- and middle-income countries are on average 19 times more likely to be infected with HIV than the general population.

Although Men who have sex with men (MSM) are considered by the National AIDS Control Councils or Commissions of such countries as Kenya, Uganda, Tanzania and Zimbabwe to be a “most at-risk population”, but because homosexual acts are illegal, there are no policies or services targeting HIV interventions towards them. AIDS activists say the bill would only drive an already stigmatized population further underground, leaving them even more vulnerable to HIV.

With a budget of $48 billion over five years to support programming for HIV, tuberculosis and malaria in low- and middle-income countries, PEPFAR offers an enormously powerful tool to address this worsening global crisis.

“We are very happy to see that OGAC has finally issued a guidance document for MSM,” said Dr. George Ayala, Executive Officer of the Global Forum on MSM & HIV (MSMGF).

Ayala said the MSMGF is encouraged by the Office of the U.S. Global AIDS Coordinator (OGAC) saying that the Forum has advocated for the development of technical guidance since 2009, bringing a delegation of MSMGF Steering Committee members from Africa to Washington to discuss the necessity of technical guidance as recently as last Tuesday. With the guidance now available, we will be looking closely at its implementation and how MSM prevention programs are funded.” 

Released early Saturday morning with no formal announcement, the guidance defines a set of six core elements to be used as part of a comprehensive package of HIV prevention services for MSM, including community-based outreach, condom and lubricant distribution, HIV counselling and testing, linkages to care and treatment, targeted information, and screening and treatment for sexually transmitted infections. 

The document also includes a number of recommendations for optimizing HIV prevention for MSM, such as ensuring confidentiality, and concludes by enumerating a set of activities that PEPFAR will support through country budgets. 

But MSMGF says while the document is quite clear on its recommendations for essential interventions, the guidance leaves vague a number of elements that are crucial to the document’s success.   

The guidance rightly highlights the importance of addressing key barriers like stigma, discrimination, human rights abuses and criminalization of same-sex activity, but it offers no specific recommendations on how to do so.  These factors have undermined HIV services for MSM since the beginning of the epidemic, leaving more than half of MSM around the world without access life-saving services like HIV education, testing and treatment. 

“If PEPFAR is serious about addressing barriers like stigma and criminalization, a clear set of steps must be offered for Country Missions to tackle these difficult challenges,” said Dr. Ayala.  “Any such strategy must include a plan to train front-line service providers and implementers about these issues.”

The guidance also emphasizes the importance of “involving MSM” in the planning, implementation and leadership of HIV prevention efforts for MSM, noting that the strengths and networks of local MSM are an indispensible resource for HIV prevention. 

However, the document focuses on “building the capacity” of local MSM organizations rather than explicitly recommending the use of PEPFAR funds to support them. 

In many PEPFAR countries, these groups have been the only organizations implementing programs for this population since the epidemic began. 

They have built an institutional memory and community presence that constitute two of our most powerful tools for addressing the epidemic among MSM.  MSM-led community-based organizations must be treated as full partners and they must be funded as such.