GRASSROOTS: The GMT Initiative Blog

amfAR's GMT Initiative supports grassroots organizations that respond to the devastating impact of HIV/AIDS among gay men, other men who have sex with men, and transgender individuals (collectively, GMT).

GMT and the New “Truths” in HIV Prevention

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Posted by Kent Klindera, November 13, 2012  

In July 2012, coinciding with the XIX International AIDS Conference in Washington, DC, scientific journal The Lancet launched a special issue focused on HIV among men who have sex with men (MSM).  I read this 30-year summary of success and failure with much hope, as it solidified what many researchers and community activists have been saying for the past year—that we can achieve an AIDS-Free Generation among gay men, other men who have sex with men (MSM), and transgender individuals—what we at amfAR collectively refer to as “GMT.”   

You may have noticed over the past few months that amfAR has been using the term “GMT” more often. Now, after five successful years of activity, we have formally re-branded our MSM Initiative to become the GMT Initiative.  Following the lead of our brothers and sisters in Latin America, we made the switch to better capture the diversity of populations served through our initiative and to emphasize the connection between rights-based policy and advocacy and successful service delivery to improve the health and well-being of GMT.  

In addition to the brand change, amfAR has expanded the scope of the initiative, focusing more on larger, systemic changes that are achieved through empowering local communities.

The GMT Initiative will focus on several core areas:

  • Funding and more formally evaluating combination HIV program models that can be scaled up
  • Emphasizing the connection between rights-based advocacy and successful service delivery
  • Supporting targeted advocacy to influence government and donor policies
  • Strengthening the capacity of GMT-led organizations to collaborate with and expand access to appropriate government-funded HIV programs
  • Supporting epidemiological, resource tracking, and other research to advocate for GMT-related health services

GMT 

As a research-focused foundation, amfAR has made this shift in order to recognize the potential of science-based efforts.  My colleague at The Center for Public Health and Human Rights (CPHHR) at Johns Hopkins, Dr. Stefan Baral, speaks of “truths” that The Lancet studies have indicated must be integrated into the next generation of HIV prevention programming. 

To me, these truths can be summarized as the following:

  1. Behavior Interventions work...BUT NOT ALONE!  As we have seen, interventions that focus on reducing individual HIV/STI-related risk behavior and increasing health-seeking behavior are powerful.  These programs, grounded in behavioral science, led the way to reductions in incidence among GMT in the early years of the HIV epidemic.  However, we have known for years that they are not necessarily effective in reducing HIV incidence for all GMT communities.  We will not achieve an AIDS-Free Generation if we focus solely on behavioral interventions.  We need to combine these strategies with new (and old) biomedical interventions, and address structural issues.  
  1. Biomedical Interventions work!  
  • Test and Treat:  New studies have confirmed that motivating individuals to get tested is still vital.  However, testing needs to be closely linked to treatment and care.  We have learned that lowering ”community viral load” means those GMT who are living with HIV need to know their status and actively seek treatment to lower their infectiousness.  The challenge is to motivate people living with HIV to take action, and to adhere to their medications.  And sexually active GMT need to regularly seek clinical services for STI diagnosis and treatment, as STIs are often a co-factor in the spread of HIV. 
  • Condoms and Lubricant:  An old intervention in our playbook, we need to continue condom promotion and increase access to quality condom-compatible lubricant—especially in the global south.  This includes advocating for lubricant to be part of national strategic plans, as well as creating sustainable channels to supply lubricant to community organizations.    
  • PrEP, Microbicides, Vaccines:  These newer science-based approaches are showing promise.  Pre-exposure prophylaxis (PrEP)—taking HIV medication to prevent an individual from contracting HIV—has already proven effective among GMT populations throughout the world.  Although the roll-out is challenging in many parts of the global south, we need to advocate for an increase in PrEP.  Down the road, we expect to have microbicides and vaccines that are effective as well.   
  1. Structural interventions are needed! The latest epidemiologic studies indicate that homophobia and transphobia play a significant role in increasing GMT individuals’ vulnerability to HIV.  We suspected this before, but now we have scientific models to prove the effects.  

A shortage of comprehensive, culturally competent health services for GMT is attributed to the stigma and discrimination associated with same-sex behavior.  Many GMT do not feel worthy of receiving health services that meet their needs, since they have been treated as second-class citizens by their families, communities, faith traditions, and health care providers.  Added to this victimization are other issues such as racism, classism, and sexism (especially for transgender individuals), which inflate these vulnerabilities.  The Lancet series refers to “political homophobia,” legal and economic frameworks that deny GMT basic human rights, including economic opportunities, which further increases their vulnerability to HIV.   

The structures that inhibit GMT from getting proper health care must be addressed.  We must challenge legal structures that violate human rights and challenge stigma and discrimination in the family, community, and health care setting through the empowerment of GMT community-led organizations. 

  1. Sexual and Romantic Relationships matter! Finally, one study from The Lancet that resonated with me was about relationships, and the importance of increasing GMT individuals’ abilities to communicate about HIV issues.  Notably, discussing one’s HIV status with sexual partners reduces risk.  Other factors that reduce risks include partner negotiation, “sero-sorting” (using condoms and lubricant when having intercourse with someone of another serostatus), and recognition of role reversal (not always being a top or a bottom).  

However, what stands out for me is the recognition that casual partners are associated with an increase in incidence rates, suggesting that the more long-term sexual relationships individuals have, the lower their risk.  I’m not sure that I needed to see the data on this one to know it is true. However, it represents an issue so often discussed among GMT.  So many GMT want boyfriends (or girlfriends), to be loved, and to be in a long-term health romantic relationship.  We need to help GMT individuals develop the skills to find and keep long-term romantic relationships. 

So, please join us in using the more inclusive term “GMT” as we work to achieve an AIDS-Free Generation among gay men, other MSM, and transgender individuals! 

Infighting in Sri Lanka

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Posted by Kent Klindera, September 25, 2012 

I recently left Colombo, Sri Lanka, after spending three lovely days with colleagues at Diversity and Solidarity Trust (DAST). amfAR is supporting DAST to work with the owners and staff at several male massage centers in Colombo, which at times can act as fronts for male sex work. DAST has proposed to assist the men in receiving formal massage therapy certificates, in order to increase their likelihood of receiving more money for their massage services. During my visit, they also discussed opening an English language class to assist the masseurs in providing services to higher paying clients. 

DAST is already promoting safer sex, HIV testing and counseling, and social support for the men on a regular basis. They are focusing on “test and treat” so that if someone is infected, they can make sure they are on treatment, lowering the probably of spreading HIV to others. I also met with a few masseurs who let me know they were from rural areas, and that their income from massage work assists with their studies, and supports family back home. They told me they “never” practice penetrative sex in their work, but I was not convinced. 

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An advertisement for a male massage parlor working with DAST.  

Unfortunately, several massage centers have recently been raided due to various issues, including illegal drug use. In an extreme case, some masseurs and clients were arrested. As a result, some male masseurs have shifted to off-site “house calls” for their effort, making it very challenging for DAST to implement their program.

However, a larger challenge for DAST is the infighting, back stabbing, and sabotage occurring between various Sri Lankan LGBT-identified organizations. There are a several other local organizations, which all seem to serve different populations amongst the LGBT community—LGBT of higher means, LGBT youth, lesbian women, openly identified gay men, transgender individuals, etc. However, to international donors and networks, it seems that at times these groups and individuals sabotage each other. Clearly, there is a history of corruption among some individuals, as well as years of built-up mistrust. It seems very self-defeating to me.

I also had a long and fruitful conversation with colleagues representing various UN agencies and The Family Planning Association of Sri Lanka—all of whom were very supportive of DAST’s and others’ work related to LGBT issues. However, they confirmed the infighting and were not sure what to do about it.

As many of us know, infighting like this is not unique to Sri Lanka. Such infighting exists nearly everywhere and can be destructive.  But as a seasoned activist, I recognize that such infighting is natural, especially when marginalized people are forced to fight over limited resources. However, as a movement, we need to unite our efforts to challenge a homophobic and trans-phobic world, and not allow internal conflicts slow our progress. 

I am honored to work with activists throughout the world and I have noticed that activists in places under extreme threat seem to be more likely to work together. In a way, having a crisis encourages more unity to defeat a common opposition. For example, the LGBT activist movement in Jamaica has had to deal with extreme violence against their community for years—both physical and verbal (especially in the form of popular music). I’m not sure exactly what the secret is, but, from my perspective, the Jamaican LGBT organizations seem to be united. 

Similarly, I look to Uganda, where groups who once struggled through severe infighting have come together to stand united against a religiously based, state-sponsored assault on their livelihoods (even more notable after the death of David Kato—one of their key leaders). 

Back to Sri Lanka—I also spent a lot of time chatting with a charming and peaceful gay activist who is working on “peace-building.” Sri Lanka is emerging from more than 25 years of civil strife. The government of Sri Lanka and global human rights donors have responded to this situation by investing in peace and reconciliation processes—working to build trust between ethnic groups. During our conversations, a huge light bulb went on in both our heads. We recognized that the work he was doing as a peace builder for the nation is sorely needed within the LGBT community in Sri Lanka as well. I left quite encouraged, as this activist seemed to be quite excited about applying his skills to build peace in the LGBT community. Time will tell, but I left with a whole lot of hope for this beautiful country.

Courage

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Posted by Kent Klindera, September 24, 2012 

Today, I’m in Dhaka, Bangladesh, meeting with colleagues at the Bandu Social Welfare Society (BSWS).  amfAR is funding BSWS as part our “Evidence in Action” project—funded by ViiV Healthcare Positive Action and the Elton John AIDS Foundation in order to increase the knowledge base about effective, community-based HIV/AIDS services for gay men, other men who have sex with men, and transgender individuals (collectively, GMT). 

The project is working with past amfAR grantees in need of more formalized evaluations to scale up their programs. BSWS is pretty amazing, having been around for 15 years serving sexual minorities. For their current project with amfAR, they are tackling very challenging issues in Bangladesh, working with gay men and other men who have sex with men (MSM) who are living with HIV. 

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Staff and beneficiaries at Bandu Social Welfare Society  

I was honored to have lunch with a male couple—very much in love, and both living with HIV. One was a bit more effeminate (he did ALL the talking) and he told me about their struggle to disclose their HIV statuses amongst their families and their community.  In fact, they are living openly as a couple and as HIV people. Pretty amazing considering the double stigma. That is why BSWS is engaging them—to figure out what has made them so courageous, and how they can inspire others

amfAR has secured an external evaluator to work with BSWS and conduct a formal evaluation of the project, which also includes helping GMT living with HIV adhere to medication and find social support. They will also be launching a campaign to reduce HIV stigma (sadly, 30 years into the epidemic, still quite strong in Bangladesh) among GMT individuals in general. Whatever the results of the evaluation, BSWS and amfAR will have data to offer to larger donors—including the Bangladesh Ministry of Health—which will hopefully encourage scale-up investment.  We should have results in about a year, so watch this space!