amfAR, The Foundation for AIDS Research

An Interview with Shivananda Khan—Standing Up for MSM in South Asia


Shivananda Khan
Shivananda Khan 

October 2006— Across Asia the prevalence of HIV/AIDS is rising among men who have sex with men (MSM), but few outreach, education, or prevention efforts have been launched
to reach this diverse community. Naz Foundation International (NFI) is working to change that.

NFI’s founder and chief executive, Shivananda Khan, joined the fight against HIV/AIDS in London after the virus took the life of a close friend in 1991. Five years later, Khan has shifted the focus of his work to South Asia, where he and the NFI staff provide technical support for MSM networks throughout the region. In recognition of Khan’s work with MSM in Asia, he was awarded the Order of the British Empire in 2005.

TREAT Asia Report: Naz Foundation International (NFI) is known for its work on sexual health issues, specifically HIV/AIDS among males who have sex with males in South Asia. As Naz’s founder and chief executive, could you tell us about the organization’s goals and the focus of your work?

Shivananda Khan: Our activities have always been focused on MSM. Our main goals involve developing HIV services by MSM themselves. We believe in ownership. We need to own the disease, own the virus, so we can deal more effectively with it. A second major part of our work involves advocacy and policy. There are laws against us [MSM], lots of violence is aimed at us, so we work hard to develop advocacy policy issues and to encourage governments, donors, and NGOs to take on board issues relating to MSM and HIV. And we push for more research because there’s a lack of knowledge—ethnographic, psychological, sociological, behavioral—relating to issues of male-male sex.

One of the important things about NFI’s work is how we define MSM as an issue, because one of the primary dynamics in South Asia and parts of Southeast Asia revolves around male-male sex in terms of gendered identities—“feminine” or “masculine.” We work with a lot of visible, self-identified MSM whom some Westerners might identify as “queeny”—feminized males who identify as “non-men.” Usually their sexual partners identify themselves as “real” men, as heterosexuals.

TA Report: When NFI began its work a decade ago, the prevailing attitude in India toward MSM was harsh and stigma was severe. In 2001, NFI staff were arrested in Lucknow. What transpired then and have attitudes in India changed since?

Khan: Three of my staff, including the director in our office in India, were arrested along with the manager of a local MSM HIV project that we were supporting. Our office in India was closed down for three months. We were challenged under a section of the Indian penal code about promoting illegal behavior through the distribution of condoms and literature on anal sex and HIV.

In January 2006, we received word of a perceived threat from the local police to raid the office again, so things haven’t changed too much. However, I must say that over the last two years there has been a stronger understanding and apparent desire to develop more sensitive approaches to vulnerable populations of MSM, female sex workers, and intravenous drug users. The media has shown greater flexibility in its ideas, and India’s National AIDS Control Organization [NACO] has undergone a radical change and intends to significantly increase its programming for MSM and HIV.

But India is a complex country with 32 states, so attitudes depend very much on where you’re located. Some states are very good in implementing the central government policy and some states are very bad—including the state where we happen to have our office.

TA Report:Is there any effective movement towards changing laws that make homosexual behavior illegal?

Khan: In India it’s being challenged in court. In Nepal there’s no specific law against homosexual behavior but it’s deemed a social disorder. And in Pakistan and Bangladesh, the Islamic religious attitude strongly condemns male-male sex. So it would be very difficult for Pakistan and Bangladesh to change their laws, particularly since in both countries the religious right is in power. In India, it might be difficult politically because of the Hindu right.

Still, while repealing the law may reduce some of the issues of concern, at the street level, at the level of the park and the places where MSM meet, it’s not going to have that much of an impact. The violence will continue because it’s gender phobia that these guys are experiencing. They behave in feminine ways to attract males and they bend the gender boundaries. So the violence and rapes against them are more akin to violence against women.

TA Report: Can you describe the greatest challenges faced by those fighting HIV/AIDS in South Asian MSM communities?

Khan: Number one is understanding and knowledge. Policymakers, donors, and NGOs don’t seem to have an understanding of male-male sexuality in the region, the diversity of male-male sexual behaviors, the issues of class and gender and education—they all play a very strong role in the configuration. They tend to see male-male sex in the region as a heterosexual-homosexual divide, which leads them to conclude that MSM is an identity and not a behavior. Whereas we argue that no, MSM is a behavior, and within that framework there are many different types of identities, including those who have no particular identity but just want to play—or whatever they call it.

The second challenge is estimating the prevalence of MSM activity. Supposedly, mapping has been done on all the countries in the region, and they’re developing funding mechanisms based on their estimates. But these are often totally inadequate because of inadequate knowledge and understanding. At times, India collects the data by asking, Are you heterosexual or are you homosexual? So a man who penetrates is going to say he’s heterosexual—he’ll never say he’s homosexual. And maybe he’s having sex with women and with men, so we don’t quite know where the virus is moving around.

The third is how you design community-based interventions. The debate in India and elsewhere questions whether NGOs from outside are more effective in implementing services for MSM—or can communities develop their own responses? The NGOs tend to focus on the medical aspects and public health strategy. They argue that the communities don’t have the knowledge or the skills or the capacity, so we’d better tell them what to do.

The fourth major challenge is that there’s not enough money available, and the fifth one is the human rights issue—the right to sexuality in an environment that says this behavior is not necessarily against the law but it is against cultural traditions and religious values. How do you tackle male-male sex in a Muslim country like Pakistan or Bangladesh? You have to do it very quietly. We don’t say these projects are about MSM, we say they are about male sexual health.

And then the sixth challenge is the issue of gender. Male-male sex plays out very much within a gender framework. Transgendered men identify very much with women and the feminine, and you know the issue of gender violence in the region. So we’ve been trying to push NGOs working with gender equity to take on board the issue of male-male sex within a gender framework.

TA Report: How can outreach and education efforts be framed so that they reach people who identify as MSM as well as partners who may not identify as such?

Khan: I’ve argued for two parallel, consistent strategies. One we’re calling identity-based intervention. That’s community building, community development, and community mobilization. And then a second strategy requires speaking of anal sex. In all education materials and presentations, anal sex has to be mentioned if you’re going to address it as a male behavior pattern.

As a sexual practice, it is very common between males here, without a “homosexual” identity framework. We can’t reach those unidentified populations through community-based interventions because they’re not part of MSM communities. So HIV education should always cover anal sex. And there’s the difficulty—you’re not allowed to talk about sex, never mind anal sex.

I can go to a truck stop on any Indian highway and some of those men are having anal sex with truck boys, and God knows with whom else. They don’t have an identity connected with their behavior; they have an identity around their occupation. And so you have to approach the strategy of reducing risk around anal sex outside of a community framework. I’m finding in India that people are having anal sex because they think it’s safer than vaginal sex, because no one’s told them that it’s much higher risk.

TA Report: Activists and governments across Asia are beginning to recognize the seriousness of the epidemic among MSM. As someone who’s been working with this community for many years, what lessons have you learned that could help as MSM programs are scaled up in the region?

Khan: I can give two key lessons. One is that a lot of people who are implementing MSM programs tend to be middle class and highly educated and English literate, and their knowledge level and self-identity are connected with a sort of Westernized framework of gay identity. We need to recognize that class and gender are part of the framework so that MSM is understood as a category of behavior and not just an identity.

And the other lesson is that how we conduct advocacy and policy initiatives needs to be very carefully thought through. We don’t scream and shout and wave banners, which is what some people have asked us to do. For example, when our staff was arrested in India there was enormous international support for raising this issue. But a lot of people wanted us to demonstrate outside Indian embassies. And I said, what is the point? The goal is to get these boys out and to make sure our program is ongoing. So we do quiet diplomacy.

Keep on raising those arguments, get your data, make it evidence based, use that data to argue with donors, argue with governments, argue with policymakers, argue with NGOs. Keep on pushing that envelope, but ACT-UP-type initiatives may not work in this region.

Pakistan just held its first national MSM and HIV/AIDS meeting in July, which was an enormously courageous act. I said, don’t advertise. Bring the people together, have a quiet meeting, and get the stuff done. There’s no point in demonstrating in Islamabad.

TA Report: The U.N. estimates that India now has the largest population of HIV-positive people in the world, although prevalence is still much lower than in sub-Saharan Africa. Statistically, what is the current situation among MSM in terms of the epidemic?

Khan: There are very few studies but the data still show that what we have in Asian countries is not a generalized epidemic like in South Africa, but very localized epidemics. There may be various reasons for that, one being that women’s sexual activities are much more limited here than in sub-Saharan Africa because of gender segregation and the social policing of women.

We think the epidemic amongst MSM is much higher than has been reported because there are very few HIV testing centers that are MSM specific and only urban people go for tests. Plus, the data collection, as I explained, is poorly done. To be frank, I suspect that the rise of the epidemic among MSM populations is not recent, it’s just been hidden. Only in the last three years have effective studies of MSM really been conducted, and suddenly this virus pops up.

TA Report: There is a growing recognition that MSM communities have really been neglected in Southeast Asia. Do you feel that you’ve seen any progress in the regions where you work?

Khan: I think so, yes. It’s slow, it’s disappointing, but we do see changes. If I could take you back to 1994, for instance, there was just one MSM HIV project in India. Now we have something like 200. That’s not enough because there are 1.1 billion people in India, but it’s better than nothing. As I mentioned, in Pakistan they held their first MSM national consultation meeting in July. To me, that is something to be really proud of. Bangladesh has had one of the largest MSM projects in Asia since 1997. So yes, there are positive signs that people are really taking notice and investing money.

I’ll illustrate it in a very simple way. When our staff members were arrested in 2001, the response of NACO and UNAIDS in India was very quiet and muted. We were told to do everything behind the scenes with the government. When we had a threat in 2006, UNAIDS Geneva, UNAIDS India, and NACO came out more publicly with support. And UNAIDS for the first time sent out a press release condemning potential arrests and harassment of people. NACO made a positive statement. They sent somebody to the city to talk to the police. That is an enormous change for the government here.

So, yes, more money is coming in, understanding is growing, more projects are available, and there’s more political and international support. I think we have some good news. We’re not going backwards, we’re moving forward. Maybe the train is picking up pace now.