amfAR, The Foundation for AIDS Research

GRASSROOTS: The GMT Initiative Blog

Grassroots reports on the work of amfAR-supported research teams and advocates responding to the devastating impact of HIV among gay men, other men who have sex with men, and transgender individuals (collectively, GMT).

Fighting for Legal Recognition for Trans Individuals in Thailand

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Posted by Kent Klindera, August 3, 2015

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amfAR’s Kent Klindera (front right) attends the Thai Transgender Alliance’s consultation meeting.  

While Thailand is known for its relative tolerance of transgender individuals and as a major destination for people from across the globe seeking quality, low-cost gender reassignment surgery, Thai transgender individuals currently have no means to legally change their gender. This lack of legal recognition decreases their access to health services and stable employment and has a major impact on their ability to lead healthy, happy lives.

Last week, I attended a half-day consultation meeting sponsored by the Thai Transgender Alliance (TGA) as part of a project funded by amfAR, with support from the Arcus Foundation, to increase positive health outcomes among transgender people by securing legal gender recognition. TGA organized the consultation to raise national awareness about trans issues, share data collected through their project, and work with experts to formulate a strategy to move forward with their advocacy campaign.

As part of their amfAR-funded project, TGA members surveyed more than 275 transgender individuals throughout Thailand about their experiences with health services and human rights. During the meeting, they shared data from this year-long study that showed that more than 80% of the participants identified the lack of legal recognition as their greatest concern. Securing this right would also provide transgender individuals with legal recourse to combat the other challenges most cited in the survey—stigma and discrimination in healthcare settings, denial of educational opportunities, and workplace discrimination.

The consultation meeting, held at Bangkok’s Thammasat University, attracted over 120 participants, including academics, representatives from various government agencies—such as the Ministry of Health, Ministry of Justice, and Ministry of Defense, religious leaders, regional and national NGO representatives, and many transgender activists and individuals. Four media outlets were also represented, which created a buzz in the Thai media, and Ms.  Jetsada "Note" Taesombat, the Thai TGA director, and Dr. Ronnapoom Samakkeekarom, the lead researcher, have since participated in numerous interviews and talk shows. Most of the media coverage was positive, but reflected a general lack of awareness about trans issues in Thailand—a situation the attention garnered by the TGA campaign is already starting to improve.

During the consultation, participants offered recommendations about what a gender recognition law should look like in Thailand, and all agreed that a law similar to one adopted in Argentina in 2012 would be most appropriate. The Argentine law gave people the right to specify how their gender is legally listed at the civil registry when their physical characteristics don't match how they see themselves. Importantly, it also reduced a legal provision found in many areas of the world requiring that people undergo extreme mental health diagnostic processes before they are allowed to legally change their gender. In addition, unlike in some countries, the law does not require gender reassignment surgery before a legal change can be secured. This provision is vital to ensure that transgender individuals with little means to pay for the expensive surgery have the legal right to change their gender.

Following the meeting, a few prominent legal scholars offered recommendations to help TGA improve their advocacy during a special working session. Despite the fact that the current political climate in Thailand makes advocacy work a bit challenging, as there is a military installed government, Thai TGA has made the historic decision to move forward in their pursuit of the law. And using the advice and feedback they received during the consultation, they have mapped out a yearlong strategy for achieving their goal.

Twenty-five years ago, I lived in Thailand for four years. Back then, transgender individuals, while tolerated, were seen as a joke and often treated like children. It was therefore amazing for me to see transgender activists truly championing their own rights and standing proud of who they are and who they will become. amfAR’s investment has been well spent, and I have no doubt that the Thai government will overturn this denial of a basic human right in the next few years.

2015 GLAM Awards Promote Lube Access in Latin America

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Posted by Ben Clapham, July 13, 2015

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The chances of condom breakage during anal sex increase significantly without the use of silicone- or water-based lubricant.

For the past five years, I have worked with amfAR’s GMT Initiative grantee partners in Latin America, and throughout my travels in the region, I have seen firsthand that condom-compatible lubricants are either completely unavailable, cost prohibitive, or that the act of purchasing them carries stigma because it implies one is LGBT. Improving this access is critical to the fight against AIDS in the region, as the chances of condom breakage during anal sex increase significantly without the use of silicone- or water-based lubricant.

A number of analyses in various settings indicate that due to the high cost or unavailability of condom-compatible lube, many people use oil-based products—despite the fact that oil-based lube signi­ficantly reduces condom effectiveness. Others resort to non-condom-compatible home products like body lotion, soap, and cooking oil, which not only cause breakage, but can also damage a person’s health.

This summer, amfAR is making four new awards in the amount of $5,000 each to help four young and inspiring organizations in Latin America promote and increase access to lubricant for gay men, other men who have sex with men, and transgender individuals (collectively, GMT)  as part of the Global Lube Access Mobilization (GLAM) project. amfAR began GLAM three years ago in conjunction with Global Advocacy for HIV Prevention (AVAC) and International Rectal Microbicide Advocates (IRMA) to increase advocacy for lubricant availability. Awards in past years were made in Africa, so we are pleased to expand to Latin America this year.

lube promo

In June, we launched a call for GLAM proposals from current and past amfAR grantees in Latin America. I then assembled a small panel of peer reviewers living and working in the region to choose the recipients of the 2015 GLAM grants, and they selected Red Nacional de Mujeres Travestis, Transexuales y Transgeneros de Bolivia (RED TREBOL) in Cochabamba, Bolivia;Collaborative Network of Persons Living with HIV (CNET+) in Belize City, Belize; ALFIL Association, HGLBT, Identities in Dialogue in Quito, Ecuador; and Grupo Génesis Panamá + (GGP+) in Panama City, Panama.

ben from amfARamfAR’s Ben Clapham with C-NET+’s Erika CastellanosI have had the pleasure of working with all four of the organizations, and they are each fantastic. Rayza Torriani, the director of RED TREBOL, is a tenacious trans woman who has run for local office in Cochabamba and is known throughout the region as a formidable activist for trans rights. The director of C-NET+, Erika Castellanos, a trans women living with HIV, won a slot as one of four 2015 amfAR HIV Scholars (LINK). Rashell Erazo, the director of ALFIL has already successfully advocated for the Ministry of Health to send a government-paid doctor to their health clinic catering to trans individuals twice a week. And GGP+ director Miguel Sanchez and his entire team have been fearless leaders in improving GMT individuals’ access to health and HIV prevention, care, and treatment.

In all four of these countries, lube provision is not included in the National HIV Plan or in the national budget, so each group plans to use their GLAM grant to conduct a study to assess lube availability—or the lack thereof—in their country and to then use that data as part of an advocacy program to convince their government to institute a lube provision program. I feel confident that these awards will help counter the myriad issues GMT individuals face daily concerning lube access in Latin America.

For more information on strategies for improving lube access, download our GLAM Toolkit, available in both English and Spanish.

A Transgender Advocate’s Work to Develop a New Model for HIV Care in Peru

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Posted by Lucile Scott, June 2, 2015

Leyla (second from right) during a visit to the Fenway Institute in Boston.
Leyla (second from right) during a visit to the Fenway Institute in Boston.  

Last December, as part of the GMT Initiative’s new Implementation Science program,  amfAR awarded a three-year grant to a Peruvian study researching how integrating “gender-affirmative” medical services, including cross-sex hormone therapy, with HIV care will impact access to HIV testing and support services among all transgender women and adherence to  antiretroviral therapy  among those living with HIV. The project is a collaboration between two non-governmental organizations based in Lima, IMPACTA and EPICENTRO, and the Boston (U.S.A.)-based Fenway Institute. 

Around the world, transgender women often face violence and discrimination that deter them from seeking HIV and other health services, and the researchers hope the study will provide a model for improving the population’s access to appropriate, discrimination-free care worldwide. To find out how the study’s going so far, the GMT Initiative checked in with IMPACTA’s Leyla Castillo, a longtime transgender advocate and the study coordinator.

amfAR: How do you hope this study will impact transgender women in Peru?

Leyla: Currently, most trans women in Peru and throughout Latin American do not have access to quality health or gender-affirming services, and because of that there is a lot of death going on and a lot of disfigurement caused by women self-injecting hormones and oils that can be very dangerous if they are not used correctly.

Leyla (far right) and other Peruvian advocates pose in front of an IMPACTA poster. Leyla (far right) and other Peruvian trans advocates pose in front of an IMPACTA poster. In the past, HIV work in Peru has focused on men who have sex with men (MSM), not trans women, and we are just grouped in with them. This leads people to believe that we do not face different issues than MSM. It also means there is very little data about trans women. There has never been a national study about our HIV rate, but one study done with a very small sample size showed that the rate is 30%. Most trans women in Peru do not ask themselves the question, ‘will I get HIV,’ but ‘when.’

The legal framework doesn’t even acknowledge our existence, and this increases the discrimination we experience in healthcare settings. For example, we are often called by our legal name in a crowded doctor’s office. This attitude ridicules you and makes you feel worthless because people look at you and snicker, causing you not to want to go back.

We need this study so we can really prove that the lack of sensitivity among healthcare workers is fueling our lack of access to HIV testing and care. We also need the health center for trans women that we are opening for the study where we can access care created for just us.

amfAR: How is the study going so far?

Leyla: Great. I am a member of a study working group of eight trans women who are all leaders in the community, and we have been, and will continue to be, involved and consulted during every step of the study. Past studies among trans women in Peru have not worked out like we hoped because we were not involved, and we know best what is going on with trans women. In the end, the researchers left with their data, but health services didn’t change and stigma and discrimination were still being experienced in health centers.

This involvement will also increase the number of trans women who will be able to do this work in the future. I have been in this field for many years, and in the past, I have only worked with two other trans women who have the professional capacity to do this work.

Currently, the working group is holding focus groups with trans women to better understand barriers that prevent them from accessing care and their health priorities, and to increase awareness about the study among the community. We plan to start providing trans-specific services this summer. The women are all very excited about the study and having a center just for trans women, and we’ve learned many interesting things.

amfAR: What motivates you to do this work?

Leyla: Instead of giving my community something just for today, I am helping to capacitate them for the long term. I am very certain this study will create tools for trans women in Peru and offer trans-specific healthcare that responds to the issues we are seeing with retaining them in HIV care for the first time. Also, there is not much data about this anywhere, and I hope that the study will establish a model for trans programming that can be used in other parts of the world.

Treating Transgender Individuals in Lebanon

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Posted by Ben Clapham, May 18, 2015

The entrance to the clinic
The entrance to the clinic

Recently, I visited Johnny Tohme, a 2013 amfAR HIV Scholar, in Beirut, Lebanon, to find out how his GMT Initiative-supported research on HIV among GMT refugee populations from Syria, Iraq, and Palestine is going. While learning about Johnny’s interesting and groundbreaking project, I also had the opportunity to meet with Cynthia Al Khoury, who works for MARSA, a sexual health clinic serving many populations, but specifically targeting MSM and trans individuals. It is the only clinic in Lebanon doing this work, and it has so many clients that the healthcare workers could not meet with us until after hours.

Cynthia Al Khoury crosses the clinic lobby. Cynthia Al Khoury crosses the clinic lobby. The clinic’s trans health program is in its second year and grew out of Cynthia’s thesis for her Master’s degree in Public Health. I found it exciting that Cynthia was able to take her thesis from paper to reality—and so did she. “I never expected my thesis to grow into anything substantial, much less a formal health program for such a stigmatized population,” she said.

While being gay is criminalized in Lebanon, and there are strict social codes that forbid same-sex sexual behavior, it is considered to be one of the most LGBT-friendly Middle Eastern nations. There are LGBT bars and clubs—though they remain inconspicuous—and the younger generation seems more open to accepting LGBT people. In Lebanon, trans individuals are able to legally change their gender on their national identity documents, which is unusual in a country where homosexuality is illegal, and there are no laws against being transgender. However, societal stigma and discrimination against trans individuals is strong, causing barriers to education and employment. This leads many trans individuals in Lebanon to practice sex work to make a living, which puts them at high risk of HIV infection.

Johnny Tohme waits in the clinic lobby. Johnny Tohme waits in the clinic lobby. I asked Cynthia if there were any epidemiologic data about HIV among trans individuals, and she smiled, confirming what I already knew. There is no data available, and the government does not have any HIV programs targeting GMT individuals. But she reported that the HIV prevalence she has seen among the population seems to corroborate global data showing they have a higher prevalence than men who have sex with men (MSM) and a much higher rate than the general population. I asked her if she thought the Lebanese government would ever consider providing PrEP for trans individuals, and she said she hoped one day that conversation could be had, though it has not yet been a possibility. “I have tried to have that conversation, and it was shut down before the conversation was even begun,” she said sadly.

MARSA currently has 19 trans clients actively enrolled in medical care, and Cynthia happily reported that they are welcoming more trans clients each month. The MARSA trans health program has trained community leaders in the trans community to educate and mobilize trans individuals and to let them know that MARSA offers free HIV preventive and treatment services and free mental healthcare. And while MARSA cannot afford to offer hormone treatment (prescription hormone therapy and sexual reassignment surgery are legal but scarce and prohibitively expensive), they do provide risk-reduction counseling for those who self-administer hormones that can be purchased on the street, which are potentially dangerous.

Overall, I was encouraged to see that MARSA had a functioning program for GMT individuals in the Middle East that is gaining the trust of its clients despite the tough legal and social situation that many face. The clinic is beautifully maintained, with staff who are friendly and welcoming, and it is definitely a place I would go for health services.

Support Nepalese LGBTI in Need of Earthquake Relief

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Posted by Kent Klindera, May 1, 2015

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A community gathering for Blue Diamond Society members

Many of us have been saddened by the magnitude of loss caused by last week’s earthquake in Nepal. But daily I am heartened to hear about the tremendous relief efforts that are happening and workers’ success in finding individuals still alive after so many days. Earthquakes can be challenging for humanity, especially when they happen in low-income countries, but the rush to offer assistance is truly what makes us human.

To make a donation, visit FIAR or Rainbow Fund

However, I cannot help but think back to the discrimination experienced by LGBTI in Haiti in the wake of the terrible destruction caused by their 2010 earthquake. The relief community’s response was swift, but it lacked assistance targeted to LGBTI individuals and people living with HIV, who, due to extreme stigma and discrimination, often lack access to stable housing and familial support, making them especially vulnerable to the ravages of earthquakes and other natural disasters. 

When they sought help at general relief sites, many LGBTI experienced overt stigma and discrimination. This included horrendous sexual violence perpetrated against trans men and women and effeminate gay men in temporary housing and the exclusion of trans women and men from all gender-specific services. Despite this, aid agencies did not—and still do not—establish services targeting LGBTI as part of their disaster relief.

Unfortunately, amfAR is beginning to hear similar reports coming from Nepal of discrimination against LGBTI and people living with HIV. Since the earthquake, we have been in touch with colleagues at the Blue Diamond Society (BDS), a long-term partner and grantee of amfAR’s and the leading HIV advocacy and LGBTI rights organization in Nepal. They report that a few key staff members were killed or injured during the earthquake and that the building housing their main office and community center sustained structural damage.

Despite these losses, they have started taking action  to provide discrimination-free services for the Nepalese LGBTI community and advocate for aid agencies to recognize the unique challenges faced by marginalized people in society—namely LGBTI individuals and those living with HIV. Hopefully the larger aid and relief agencies will hear their call.

However, one way to help ensure that the response caters to the needs of all affected people in Nepal is to fund BDS directly. They have set up mechanisms for colleagues in other countries to support them through FIAR, the Foundation for Integrative AIDS Research, and the Rainbow Fund. (Be sure and write “Nepal–Blue Diamond Society” in the notes section on the Rainbow Fund site.)

And here is the call from Blue Diamond Society itself: april20310343Members of the Blue Diamond Society, the Health and Opportunity Network (HON), the Thai Transgender Alliance (ThaiTGA), Transgender and Intersex Africa (TIA), and the GMT Initiative during an advocacy exchange meeting in Nepal organized by amfAR

Dear All,

It’s as clear as the daylight that LGBTIs in Nepal are equally affected if not more. When disrepair hits, marginalized, excluded, and vulnerable communities suffer the most. The needs are enormous in Nepal and different aid agencies and government have their own priorities, but these priorities should be based on facts, needs, and urgency rather than based up on cultural/social biases or your own agency’s traditional approaches that have usually overlooked LGBTIs. For example, we have seen that some of the toilets constructed around relief camps are only based on binary gender mechanisms, excluding third gender propitiation. Queues for "Rashan" and other aid kits are the same, based on binary genders. 

We call on Nepal’s government, USAID, DFID, NORAD, UNDP, GIZ, Oxfam, and the other aid agencies to actively and purposefully include LGBTI in their response and rehab programmes. We also call our follow LGBTI rights organizations around the world to join forces to encourage USAID, DFID, Norad, UNDP, GIZ, Oxfam, and the other aid agencies to actively and purposefully include LGBTI in their response and rehab programmes. This might mean a joint communique or a statement.

Thank you very much for your kind thoughts, generosity, and solidarity.

Pinky Gurung, President
Manisha Dhakal, Executive Director
Sunil Babu Pant, Founding Director

Meet the 2015 amfAR HIV Scholars

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Posted by Lucile Scott, April 29, 2015

For the third consecutive year, the GMT Initiative has teamed up with the Center for LGBT Health Research at the University of Pittsburgh’s Graduate School of Public Health to offer scholarships to four researchers from low- or middle-income countries as part of the amfAR HIV Scholars program. The program aims to strengthen responses to HIV by offering leading GMT community-based researchers five months of graduate-level study on LGBT health research, study design, and grant writing.

“The strategies that work best for addressing HIV are those developed by community-based scholars and activists, and they have to have solid research skills and data or their brilliant strategies won’t get funding,” says Dr. Ron Stall, chair of the Department of Behavioral and Community Health Sciences at Pitt Public Health, who oversees the program. “The scholars are local heroes often doing this work at great risk to themselves, and we invest in them to help them get their programs off the ground.”

By the end of their stay, the scholars will have not only sharpened their research skills, but also drafted a proposal to investigate culturally appropriate strategies for improving HIV services for GMT individuals in their countries. Earlier this month, they travelled to New York City to present their proposals to amfAR’s staff for possible funding. Watch them discuss their work and the HIV Scholars program in the video above.

meet the scholars

The 2015 amfAR HIV Scholars (left to right): Sheryar Kazi associated with the Naz Male Health Alliance, Pakistan; Liesl Theron, a consultant supported by Gender DynamiX, South Africa; Erika Castellanos from the Collaborative Network of Persons Living with HIV (C-NET+), Belize; and Weibin Cheng from the Chinese Center for Disease Control and Prevention and GZTZ.org.

Research Collaboration in Rwanda and Burundi

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Posted by Kent Klindera, April 13, 2015

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LGBTI activists gather at Centre Remuruka, an LGBTI advocacy group and community center in Bujumbura, Burundi.

I recently returned from a research preparedness meeting in Kigali, Rwanda, where 25 LGBTI activists and HIV researchers from Rwanda and Burundi came together to discuss research design, questions, and priorities for health and human rights research among GMT individuals in the region. Too often, research performed among LGBTI populations is developed by researchers only. While grounded in science, they often neglect the role community should be playing in designing such studies, only seeking community involvement in the recruitment of research subjects. Due to this the lack of participation, opportunities are often lost to connect the research results with the communities’ advocacy efforts—a link that could result in a more effective HIV response among GMT populations.  

To bridge this divide, amfAR has been working with The Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health and the International AIDS Vaccine Initiative (IAVI) to connect more researchers with LGBTI community activists and vice versa. In 2011, we collectively developed a research guide called Protect, Respect, Fulfill, which offers concrete actions to overcome the gap between researchers and community leaders. We are currently adding new case studies and action checklists to the document and plan to release the updated guidance later this year. 

amfAR and IAVI have also been organizing meetings, like the one in Kigali, in several countries. Last year, we hosted a series of meetings in Kenya that resulted in the formation of a formalized LGBTI research network of both researchers and activists called the G10 that is now working to set research priorities and design studies in Kenya. This year, we have held meetings in Zambia and Rwanda and plan to support similar meetings in Belize, Paraguay, South Africa, and Tajikistan.

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Members of GMT Initiative grantee partner MOLI (Mouvement pour les Libertés Individuelles) at the organization’s offices in Bujumbura, Burundi  

One of the widest gaps between researchers and the LGBTI activists’ agendas is the fact that the activists represent a community whose ‘lived reality’ is more than just being an HIV disease vector. LGBTI people struggle with societal stigma and discrimination. Especially when living openly as LGBTI, this stigma and discrimination make it very challenging for them to receive a quality education, secure paid employment, maintain familial and romantic relationships, and access quality healthcare. However, from the HIV researchers’ perspective, it is only the health aspect that is important.

LGBTI activists often tune out if they think HIV researchers do not see them in the context of their lives, and I’ve heard them complain that the researchers seem not to care about the community. Similarly, I’ve heard researchers complain that LGBTI activists are not well organized and have unrealistic expectations. In Kigali, I was impressed at the sense of mutual admiration that the activists and researchers had for each other. As I have witnessed at every research preparedness meeting we’ve held, when both parties were brought together, camaraderie was shared, along with mutual understanding and trust.

The meetings also reveal how listening to activists is essential to designing an effective study. For example, in Kigali we discussed how using the word ‘recruit’ can be problematic and stigmatizing when performing research within LGBTI communities, as society accuses LGBTI leaders of ‘recruiting’ others into their ‘lifestyle.’ It was therefore agreed that saying ‘enroll’ or ‘engage’ research participants would be much more appropriate.

I was impressed by how truly engaged the attending activists were. I watched as they began to understand the power that solid research data can offer their advocacy efforts and the impact the community could have on shaping a future research agenda for LGBTI individuals in their area through collaboration with researchers. I was also impressed that the HIV researchers began to understand that HIV is not the most important concern of LGBTI leaders, but that the stigma and discrimination that permeate society and LGBTI individuals’ daily lives takes precedence.    

Much of the struggle we have around the HIV response among key populations is because, too often, their humanity is somehow diminished.  This may be the consequence of the irrational fear that causes societal homophobia and transphobia, or of seeing community members as data points, not vital voices in the research process. We need more gatherings and processes like this where everyone’s humanity shines through.

 

An amfAR Scholar Researches PEP Use Among MSM in Developing Countries

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Posted by Lucile Scott, February 26, 2015

  Johan 2Johan Hugo, an HIV clinician at the Ivan Toms Centre for Men’s Health in Cape Town, South Africa

In mid-January, four GMT scholars from Belize, China, Pakistan, and South Africa arrived in Pittsburgh to begin five months of graduate-level public health study at the Center for LGBT Health Research of the Graduate School of Public Health at the University of Pittsburgh. This is the third year amfAR has supported the scholars program, which aims to strengthen GMT community-based research and responses to HIV by offering  four researchers from low- and middle-income countries courses on LGBT health research, research methods, and grant writing. The scholarship also includes round-trip travel to the U.S., housing, and a modest stipend.

By the end of their stay, the scholars will have not only improved their research skills, but also drafted a proposal to investigate culturally appropriate strategies to improve HIV services for GMT individuals in their respective countries. As this year’s scholars began designing their own research projects, the GMT Initiative checked in with a graduate from the inaugural 2013 class of amfAR HIV Scholars, Johan Hugo, an HIV clinician at the Ivan Toms Centre for Men’s Health in Cape Town, South Africa, to see how his research was progressing. In an earlier post, we talked to another 2013 alum, Lebanon’s Johnny Tohme.

amfAR: Why did you choose to focus your research on Post-Exposure Prophylaxis (PEP) use among men who have sex with men (MSM) in South Africa?

Johan: PEP studies among MSM have been done in Amsterdam, Brazil, and San Francisco, but never before in Africa—despite the fact that in most of Africa MSM have one of the highest rates of HIV infection. I work at the Ivan Toms Centre for Men’s Health in Woodstock, Cape Town. It was one of the first men’s health clinics on the African continent to address the sexual health needs of MSM, and it currently has close to 7,500 patients. The clinic provides a platform to safely study this biomedical approach to HIV prevention in a developing world setting and determine if it will be useful. If it is, we will disseminate the knowledge throughout the developing world.

Also, South African physicians’ cultural competence and their PEP competence both urgently need addressing. I have heard many horror stories of doctors making moralistic pronouncements to MSM when they try to access PEP that make them feel like second-class citizens. Due to a lack of training and their own beliefs, many physicians feel that PEP should only be used for needle stick injuries and rape cases—and definitely not for MSM.  A lot of MSM don’t even know about PEP, and the ones who do might not go to healthcare facilities to get it because they fear facing homophobia and prejudice. Our clinic has also encountered MSM who have been prescribed dangerously outdated or contraindicated PEP regimens.

amfAR: What are the results of your research so far?

Johan: There are two components to the research. The first is a 116-question Internet survey looking at MSM’s attitudes and beliefs about PEP. It went live at the end of June 2014, and we have 326 completed surveys and 403 partially completed ones. I have some provisional data, but it is way too early to answer any of my questions.

The second component is a clinical study looking at barriers and facilitators to MSM accessing and adhering to PEP. It launched in November 2014 and will run over a 9–12 month period. Men are eligible to participate if they are older than 18 and report having had high-risk, or perceived high-risk, sexual contact with another male that resulted in requesting PEP. So far we have enrolled 12 participants. I feel it is going really well, and I am very excited to see the results.

amfAR: How did the HIV Scholars program impact your research?

Johan: My passion is sexual health, and even though it can be very challenging at times, working with the MSM population is very rewarding. My time in Pittsburgh was extremely valuable, from the coursework to the time spent with Ron Stall [chair of the Department of Behavioral and Community Health Sciences at Pitt Public Health and head of the HIV Scholars program]. It was great to be able to get to know the research language and to start speaking it. I also think I made very valuable connections for the future.

 

An amfAR HIV Scholar Breaks New Ground Reaching MSM Refugees in Lebanon

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Posted by Lucile Scott, January 29, 2015

 

Johnny-Tohme.jpgJohnny Tohme, a voluntary counseling and testing officer at the Marsa Sexual Health Center in Beirut, Lebanon, and executive director of the M-CoalitionIn mid-January, four GMT scholars from Belize, China, Pakistan, and South Africa arrived in Pittsburgh to begin five months of graduate-level public health study at the Center for LGBT Health Research of the Graduate School of Public Health at the University of Pittsburgh. This is the third year amfAR has supported the scholars program, which aims to strengthen GMT community-based research and responses to HIV by offering  four researchers from low- and middle-income countries courses on LGBT health research, research methods, and grant writing. The scholarship also includes round-trip travel to the U.S., housing, and a modest stipend.

By the end of their stay, the scholars will have not only improved their research skills, but also drafted a proposal to investigate culturally appropriate strategies to improve HIV services for GMT individuals in their country. As this year’s classes got underway, the GMT Initiative checked in with a graduate from the inaugural 2013 class of amfAR HIV Scholars, Johnny Tohme, a voluntary counseling and testing officer at the Marsa Sexual Health Center in Beirut, Lebanon, and executive director of the M-Coalition, to see how his research was progressing.

amfAR: Why did you choose to focus your research on MSM (men who have sex with men) refugees in Lebanon?

Johnny: Populations destabilized by armed conflict are at an increased risk of HIV infection, and this vulnerability is compounded among MSM refugees due to their sexual orientation, especially in a context where religious and cultural conservatism contributes to high levels of stigma and discrimination. Currently, in Lebanon we have one-and-a-half million registered Syrian refugees —plus those who are not registered, a half million Palestinian refugees, and at least 30,000 Iraqi refugees—though some speculate the number is up to 100,000.

In 2012, I was involved in a U.S. National Institutes of Health-funded behavioral study among MSM in Beirut. Of our sample of 213 MSM, 35 were refugees. Data collected from these 35 participants was not sufficient to establish trends, but judging from our field observations, it seemed they were much less likely than their Lebanese counterparts to have been exposed to sexuality education or information about HIV. We were not aware of any published studies focusing on MSM refugees, so I proposed research to assess their level of HIV risk behavior and identify both barriers to and facilitators of risk reduction and healthy sexual behaviors.

amfAR: How is the study going?

We are done with the first stage of the study, a qualitative exploration of the factors that influence MSM refugees’ sexual risk behavior and their access to HIV testing and healthcare. The data was gathered through three focus groups. In mid-September 2014, we started quantitative data collection through a 40-minute survey. This data collection is expected to be finished by mid-June.

I can’t share any specific numbers until we are done with the data collection and analysis, but general observation has shown that refugees do indeed have a different perception on sexual health than their Lebanese counterparts, especially those who arrived in Lebanon recently. It also shows that the longer they are in the country, the more they connect with Lebanese MSM and adopt their behaviors.

amfAR: How did the HIV Scholars program impact your research?

The program was a stepping stone to a new career. It wasn’t just about research methodology, but also understanding the importance of research and the whole research process— how to move from an observation to a theory to the conception and application of a study to project implementation. Knowledge about this process is much needed in my field of work and in my country and region, and I was able to convey much of what I learned to my colleagues back home.

Since finishing the program, I also helped found the M-Coalition, the first and only regional HIV/AIDS advocacy network specifically devoted to the needs of MSM in the Arab world. Due to my background in HIV research among key populations and the fact that Beirut was the safest place in the region to initiate the program, I was asked to become its executive director. We are two weeks away from celebrating our first year, and we couldn’t be prouder of the high visibility we have achieved and the support and encouragement we have received from major stakeholders in the region and internationally.

HIV Outreach and Conflict in the Congo

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Posted by Lucile Scott, December 12, 2014

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Aimée Furaha (left), head of AHUSADEC’s sex worker program, and Raphael Ngeleza, director of AHUSADEC.

Eleven years ago, the Democratic Republic of the Congo (DRC) was at the center of a brutal five-year conflict known as “Africa's world war" that resulted in millions of deaths and regional instability. While a peace accord was signed in 2003, fighting and violence persist in the eastern part of the DRC, where several armed militias continue to vie for control of the country’s wealth of minerals, including cobalt, gold, diamonds, and coltan, a metallic ore used in cell phones and laptops.

East-DRC is also home to GMT Initiative grantee partner Action Humanitaire Pour la Santé et le Développement Communautaire (AHUSADEC), which provides HIV testing, counseling, and outreach services to gay men, other men who have sex with men, and transgender (GMT) individuals and to female and GMT sex workers. It is the only group in this part of the country targeting GMT individuals with HIV services.

“East-DRC is a place where there have been many conflicts, rapes, and sexual violence and many public health problems in general, but now, thanks to AHUSADEC, with amfAR’s support, GMT individuals can benefit from HIV interventions for the first time,” says Freud Muciza, who works for the DRC’s national AIDS program and was contracted by amfAR to assist AHUSADEC in further developing its organizational capacity and impact.

While the mines in the East Congo produce substantial profit, the local population receives little of the economic benefits—but bears all the costs of the endemic violence. The widespread rape of women as a tactic of war caused a senior UN official to dub DRC “the rape capital of the world” in 2010, and the violence displaced more than 100,000 people throughout the country in 2013 alone.

Bukavu, the city where AHUSADEC is based, has a large United Nations and police presence, and many refugees, usually from the rural villages near the mines, often come there, further straining the city’s already taxed housing, employment, and health infrastructure. In the midst of all this instability and flux, successfully reaching GMT individuals, a highly marginalized, stigmatized, and often hidden population, is difficult. The severe stigma around homosexuality has also prevented other groups from using their resources, which are often limited, to target them.

And while many of the international humanitarian groups in Bukavu are operated by foreigners in headquarters enclosed by protective walls, AHUSADEC is run entirely by locals out of a white stucco house with a large, welcoming front porch. The building provides a place for GMT individuals, many of whom have been kicked out of their homes or denied jobs because of their sexual orientation, to feel welcome and like they are part of a community. “They trained me as a peer educator and I felt I had a direction and purpose,” says Daniel, 19, a client who has been performing peer outreach services for one year. “I am proud to be part of this important work.”

Data about GMT individuals in the country is limited, but according to the latest UNAIDS progress report, the HIV rate among men who have sex with men (MSM) is 18%. Due to limited services targeting MSM, few are reached with HIV prevention messaging, and the report also estimates that only about 15% use condoms regularly—meaning the rate could easily rise if more men are not accessed with testing and prevention messages, like those provided by AHUSADEC. Even more challenging, almost no data exists on transgender individuals. 

AHUSADEC is also working to combat the stigma, discrimination, and violence GMT individuals encounter, both in healthcare settings and in society in general. They have a program to train police to prevent violence against GMT individuals and they also accompany clients who test positive for HIV to the hospital to prevent them from experiencing discrimination. “amfAR has helped us respond to discrimination,” says Bienfait, a nurse who performs HIV tests and counseling at AHUSADEC. “Before GMT individuals would not go to the hospital because of discrimination, and now an AHUSADEC staff member or volunteer helps them navigate the services.”

And because many GMT individuals are not aware of AHUSADEC’s services or are hesitant to seek them out at AHUSADEC’s offices, the staff makes weekly visits to bars frequented by GMT individuals to perform mobile HIV testing. During one recent mobile testing visit, Bienfait and the staff set up in a fence-in dirt yard behind the bar, which, like most establishments in Bukavu, is subject to frequent electrical brownouts. A bartender announced over a loudspeaker that free HIV tests would be offered out back, and soon the bar patrons began to line up, and Bienfait, sitting behind a small plastic table in his white lab coat, began testing them one by one.

You can view photos of AHUSADEC and its mobile testing program below.

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