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This discussion paper examines why Islam matters in prevention efforts for HIV, what Islam and Muslim scholars say about MSM and transgender people, as well as how this impacts on the lives of MSM and transgender people and their access to health services.
While Islam allows for difference of opinion, and the religious leaders disagree on many social issues, most orthodox Muslim scholars are vehemently opposed to homosexuality. However there are many progressive Muslim scholars with varied positive opinions about gender and sexual orientation. This discussion paper urges human rights organisations and policy makers to create a database of progressive religious leaders and lobby for their support.
The discussion paper includes 13 key recommendations for consideration of human rights organisations and defenders, gender activist and policy makers, including:
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in Mongolia. Mongolia hosts one of the region’s smallest HIV epidemics. It remained hidden until around 2007 when serological surveillance was performed after indications of rising incidence. From then until 2012, 75 HIV diagnoses were added to the HIV registry, bringing the total cumulative number of infections between 1992 and the end of 2011 to 100. Among these cases, 66 percent were reported cases among MSM. Given that between 1992 and 2007, data on sexual orientation were not collected, the 66 percent is probably an underestimation.
Similar to in neighbouring countries, MSM in Mongolia remain largely hidden because of widespread and institutionalised prejudice. Societal and family pressures lead many Mongolian MSM to marry and live secret ‘double lives’ with both male and female sexual partners. One survey meant to gauge levels of discrimination against MSM in Ulaanbaatar and Darkhan-Uul found that 53 percent of respondents thought of MSM as healthy people whose sexual behaviour is abnormal, meanwhile 14 percent thought MSM are mentally ill. Arbitrary detentions and physical abuse by law enforcement authorities have also been recorded.
A 2012 study discovered that stigma and discrimination against LGBT populations and MSM is common in Mongolia and creates significant barriers to health service access, employment, and social acceptance. The same study reported that 77.4 percent of MSM in Ulaanbaatar had experienced at least one of the following incidents in the last three years: forced sex or rape (14.7 percent); verbal harassment (54.8 percent); and physical harassment or beating (10.4 percent). Other key issues included: loss of employment upon discovery of sexual orientation or HIV status; being tested for HIV without consent; and blackmail by law enforcement.
The snapshot provides more information about priorities for Mongolia reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
Bangladesh is considered a low-prevalence country with 2,533 cumulative reported cases since 1989 and approximately 7,500 people living with HIV. Routine surveillance has consistently reported HIV prevalence of less than 1.0 percent among the general population and among MSM and male and female sex workers. The country’s epidemic is understood to be concentrated and disproportionately affects male people who use drugs, of whom 1.0 percent are believed to be living with HIV. Between 2008 and 2011, 19 cases of HIV among MSM were reported.
Given HIV patterns in South Asia and because of recent behavioural survey data of MSM in Dhaka, Bangladesh considers MSM one of the focal points in their HIV prevention efforts. In 2009 and again in 2010, the National STD/AIDS Programme and the International Centre for Diarrhoeal Disease Research (ICDDR) conducted a size estimation exercise of key affected populations that included MSM. Such efforts are beginning to shed light on what is otherwise a poorly understood demographic.
Little is known about the nature of male-male sexuality
in Bangladesh. Previous exploratory research has consistently found that approximately 2 percent of males engage in same-sex sexual behaviour. Research has found a
high prevalence of penetrative sex as well as related risk behaviours among MSM. Despite popular disapproval
of sexual relationships between men, intimate relationships between men are common and sexual boundaries are crossed with relative ease. The socio-cultural contexts
in which such interactions occur determine how MSM perceive and manage sexual risk and thus impact the uptake of HIV services.
The snapshot provides more information about priorities for Bangladesh reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
Bhutan’s HIV epidemic is small relative to its neighbours, with 270 cumulative reported cases since the first case was detected in 1993. Presently, an estimated 988 people (or below 0.1 percent of the adult population) are living with HIV in Bhutan, making it a low-prevalence country. A recent behavioural assessment in two major towns found evidence of high-risk behaviour among key affected populations, including MSM.
The National STI and HIV AIDS Prevention and Control Programme (NACP) was established in 1988, five years before HIV was first detected in the country. Bhutan’s HIV response continues to be led by the 2004 Royal Decree on HIV Prevention, delivered by the Fourth King, His Majesty Jigme Singye Wangchuck, and subsequent proclamations of support. In 2005, the Fifth King, His Majesty Jigme Khesar Namgyel Wangchuck, advocated for abstinence and urged Bhutan’s youth to use their strength of character to reject undesirable activities.
Homosexuality is a taboo subject in Bhutan, though younger generations are thought to be more accepting. Little is known about the nature of same-sex sexual activity in Bhutan. Anecdotes exist of sex between men occurring in army barracks, prison cells, and monk dormitories. Online chat rooms, cruising websites, and restaurants and bars are cited as key places where MSM meet in Bhutan.
The snapshot provides more information about priorities for Bhutan reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in India.
India accounts for approximately half of Asia’s HIV epidemic with approximately 2.4 million people living with HIV. In 2009, an estimated 87.4 percent of all infections were related to heterosexual sex and 1.7 percent was related to sex between men. India’s national HIV epidemic is concentrated, though a functional distinction is made between ‘core’ and ‘bridge’ populations. Both receive focused support in India’s National AIDS Control Programme but the intensity of the intervention varies between the two and across geographic areas. The 50 percent decline in incidence attributed to intensified programmatic attention in six high- prevalence states serves as possible evidence of the value of this approach.
In 2007, the third National AIDS Control Programme (NACP – III) articulated the need for enhanced programmatic attention to MSM and was the first to outline a strategy for HIV prevention interventions targeted at hijra and male sex workers. It is thought that funding for targeted prevention interventions for MSM, male sex workers, and hijra is insufficient to meet basic needs for condoms and water-based lubricant.
Much of HIV services in India are managed by community- based organisations. A 2008 organisation mapping exercise found that 65 percent of all organisations and networks working with MSM in India are community-based. A handful of LGBT-oriented organisations and networks also play a key role in the formulation of national policy and guidelines related to HIV. They include: the Indian Network for Sexual Minorities (INFOSEM), and MANAS Bangla in West Bengal state.
Whereas MSM are viewed as a ‘core’ population under NACP – III, there is emerging evidence of MSM as a ‘bridge’ population. The proportion of MSM that report recent sex with women varies greatly across states and reaches as high as 66 percent. Yet female partners of MSM are excluded from information, education, and communication programmes, a cornerstone of India’s HIV prevention strategy. India’s National AIDS Control Programme has demonstrated remarkable leadership in responding to the HIV prevention needs of MSM. Future policy advancements may depend on the extent of overlap between MSM and other risk groups and the ability for policy leaders to quickly recognise the need for greater spending on targeted programmes for MSM.
The snapshot provides more information about priorities for India reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in Nepal.
Nepal’s National Centre for AIDS and STD Control has officially recognised MSM as an important driver of the country’s HIV epidemic since at least 2003.
Infections among the general population and injecting drug users have declined in recent years. Meanwhile, infections among MSM and female sex workers appear stable. Nepal’s HIV programme is recognised as a ‘P1’ or first priority in the country’s Interim National Development Plan. The Government of Nepal prioritises P1 programmes over all other non-P1 programmes when determining budget allocations. However, there are popular concerns regarding the sustainability of Nepal’s HIV financing mechanisms.
Coverage among key affected populations has improved over the years as a result of focused interventions and increased community-based organisation involvement. Community-level interventions, some of which involve MSM, are central to Nepal’s National HIV/AIDS Strategy, 2011–2016.
MSM are stigmatised and socially marginalised in Nepal. The Blue Diamond Society (BDS), a prominent advocacy group for the rights of LGBTI Nepalis, reports of a prevalent ‘double stigma,’ or stigma related to sexual orientation and HIV infection. Faced with continued discrimination and threats of violent attacks, ‘metis,’ or persons of the third gender in Nepal, sometimes take to hospices.
Several policy and legal advancements have been made with regard to MSM and other key affected populations. Sunil Babu Pant, Director of BDS and member of the Contituent Assembly and Parliament of Nepal, led a campaign that demanded an end to all kinds of discrimination and violence against LGBTI populations. In 2007, the Supreme Court of Nepal ruled in favour of recognising the third gender in national identification cards, a same sex marriage law, and ending or amending discriminatory laws against LGBTI populations. The ruling allegedly led to a reduction in violence against LGBTI populations and greater acceptance among segments of society, media, and government.
Nepal’s political instability continues to be a major barrier to an effective national response. It threatens sustained leadership in the national HIV response and risks a reversal of progress on meeting Millennium Development Goals.
The snapshot provides more information about priorities for Nepal reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in Pakistan. Pakistan’s HIV epidemic is driven by key affected populations. In 1999, Pakistan, in partnership with UNAIDS, determined that it would prevent a generalised epidemic by targeting key vulnerable groups. Subsequent surveillance activities revealed disproportionate HIV risk among injecting drug users and hijra and male sex workers, who exhibit HIV prevalence of 37.8, 7.2 and 3.1 percent, respectively. Targeted HIV prevention interventions among these three groups continue to be the cornerstone of Pakistan’s HIV response. Hijra and male sex workers are commonly considered MSM by Pakistani AIDS authorities and so determining whether data correspond to MSM who self-identify as male and are not sex workers is at times difficult.
Sex other than that between husband and wife is strictly forbidden by Islamic law. Consequently, overt expressions of homosexuality carry the risks of social stigmatisation, class discrimination, ostracism from family and friends, and extreme physical punishment under current sodomy laws. Yet sex between men appears to exist among segments of society beyond those included in definitions of hijra and male sex workers. More overt examples of male-to-male sexual behavior include the practice of keeping boys for sexual gratification observed among rich elderly men in Khyber Pakhtunkhwa Province.
It will be important in the implementation of the forthcoming national strategic plan for efforts intended for MSM to cater to the specific needs of various subgroups. Significant overlap exists between MSM and other key affected populations such as migrants, truck drivers, and drug users. There exists an opportunity to improve the effectiveness of prevention efforts through better integration and nuance.
The snapshot provides more information about priorities for Pakistan reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in Sri Lanka. Sri Lanka’s HIV epidemic is considered low-level, with 1,544 cumulative reported cases and an estimated 3,000 people living with HIV. Infections related to sex between men account for approximately one-eighth of total reported cases. Other key affected populations include injecting drug users and female sex workers. HIV risk among men who have sex with men (MSM) is low relative to other countries in the region but is increasing, both in HIV prevalence and as a proportion of total infections. There is little evidence to suggest that Sri Lanka’s epidemic will become generalised in the future.
Since the first detected case in 1987, Sri Lanka has demonstrated a progressive commitment to a comprehensive response. Socio-economic and cultural factors are taken into account when designing programmes. To date, the National STD and AIDS Control Programme (NSACP) has been unsuccessful in scaling prevention programmes targeted to MSM and is yet to develop community sensitive clinical services. The NSACP’s attention to MSM is characterized by a non-continuous series of awareness programmes primarily in Colombo, Kandy, and Anuradhapura and occasional support to groups working for the human and political rights of LGBT communities in Sri Lanka. Despite strong civil society interest in operating targeted HIV prevention interventions, limited and inconsistent funding has limited the expansion of such activities. In addition, the limited capacity of MSM community groups in administration and financial management contributes to funding issues.
Sri Lanka’s laws are unsupportive of MSM and present significant challenges to effective HIV prevention programmes. A sodomy law that punishes sex between men with long-term imprisonment is used to extract bribes and threaten individuals and LGBT organizations. Negative societal attitudes towards homosexuality discourage access to critical health services targeted at MSM. In response to growing concerns of homophobic violence, the NSACP issued a ‘special policy statement’ to voice support for the protection of the rights of MSM and sex workers.
The snapshot provides more information about priorities for Sri Lanka reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in Malaysia. The composition of Malaysia’s HIV epidemic is changing rapidly. Whereas it was previously understood to be more heavily concentrated among people who use drugs (PWUD), sexual transmission appears to be on the rise. Women and MSM in particular are facing an increasing share of new infections. Given the emphasis that PWUD have received in research and prevention programmes in Malaysia over the last several years, some postulate that decreased transmission among PWUD enhances the vividness of risk among other populations.
Islam inevitably influences how homosexuality is viewed by the general public and may influence sexual risk taking behaviours in ways that are not entirely understood. Ostracisation from family and friends, class discrimination, and social stigmatisation are all common experiences for MSM in Islamic countries. Risk might also rise from the belief that adherence to religious teachings should suffice as protection from HIV; or in some cases, a view of HIV transmission as an inescapable fate. These hypotheses were confirmed by recent focus groups and are in line with data that indicate higher HIV risk among Malays as compared to their Chinese peers.
Together with key findings drawn from a series of epidemiological and behavioural studies released in the last few years, there is a compelling case for increased programmatic attention to MSM. Malaysia found that civil society groups such as the Pink Triangle (PT) Foundation are well positioned to scale up prevention programmes in key areas but suffer from scarce funding, legal conflicts, and general stigma. Malaysia simultaneously faces a situation where MSM within reach of venue-based outreach efforts are disproportionately educated and well off. Further work will need to be done to develop a more accurate understanding of HIV risk among Malays and lower socioeconomic classes. In the interim, Malaysia faces an opportunity to inspire the political will that could play a pivotal role in the future of the epidemic. Cooperation between government and a burgeoning LGBT civil society may indeed be the most promising path forward.
The snapshot provides more information about priorities for Malaysia reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in Myanmar. Myanmar’s HIV epidemic is highly concentrated among people who inject drugs, sex workers, men who have sex with men, and the sexual clients of these populations. People who inject drugs exhibited the highest HIV prevalence (21.9 percent) in the most recent serosurveillance, meanwhile MSM exhibited the second highest (7.8 percent). There is growing concern of a large-scale HIV epidemic among MSM amidst mounting evidence of it previously being underestimated.
One of the primary reasons for delayed progress in the national response to HIV risk among MSM is a highly restrictive legal environment. Sex between men in Myanmar is punishable by a prison sentence of up to 10 years. Although such laws are rarely enforced, they complicate the delivery of effective HIV prevention services to the extent that they prevent community-based organisations (CBOs) from being registered with the state and discourage programme beneficiaries from accessing basic HIV services.
Despite an unfavourable legal environment, Myanmar has identified MSM as a key target population since the previous National Strategic Plan (NSP) on HIV and AIDS (2006- 2010). It further elaborates that key target populations will be of ‘the utmost priority and will rely on high-intensity, sustained, and focused effective interventions.’
The challenge of responding to HIV risk among MSM is compounded by a limited ability to measure progress towards stated objectives. For instance, data on condom and lubricant distribution, sexually transmitted infection (STI) service provision, and reliable resource expenditure data are for the most part unavailable.
Several community-based organisations, some of which are not officially recognised by the state, are involved in health outreach although little is known of their operations. Other key actors in the response include international NGOs, most notably Population Services International (PSI) who reached over 37,000 MSM in 2011 with HIV prevention services.
Myanmar’s most recent NSP (2011-2015), like the previous one, lays out a comprehensive set of targets to be met by actors across several sectors. It simultaneously acknowledges the difficulty of fully implementing the plan with current levels of commitment and overseas assistance. What is certain is that there is crucial progress to be made, especially with regards to the restrictive legal environment, with careful use of planned resources.
The snapshot provides more informationa about priorities for Myanmar reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in the Philippines. The Philippines has among the lowest rates of HIV transmission in the region, with an estimated total of just over 10,514 infections between 1984 and August 2012. Its HIV epidemic is increasingly concentrated among men who have sex with men (MSM) and other key affected populations, with tremendous variation across sub-populations and location. Some attribute the relatively slow spread of HIV in the Philippines to its complex geography and isolation from the larger regional epidemic.
There is growing concern of an emerging epidemic among Filipino MSM. Sexual transmission between males has been the predominant mode of transmission since 2007. Serologic surveillance over the last few years indicates that HIV incidence among females is reaching a plateau but appears to be growing rapidly among males. Approximately six out of ten people living with HIV contracted the virus through sexual transmission between men. In 2011, about eight out of ten new infections were among MSM. HIV diagnoses have increased three-fold between 2003 and 2008, a fact that, in the context of other mounting evidence, suggests a forthcoming expansion of the HIV epidemic.
The central advisory, planning, and policy-making body of the government is known as the Philippine National AIDS Council (PNAC). It was established in 1992 to act as a multi-sectoral advisory body to the President on policy related to HIV. However, it remained crippled by a small budget until the Philippines Government enacted the Philippine AIDS Prevention and Control Act of 1998. Among the things it called for were a comprehensive nationwide HIV and AIDS educational and information campaign; greater recognition of the human rights of persons affected by HIV; and heightened involvement of local governments to provide community-based HIV services.
The National HIV and AIDS Strategic Plan for MSM and TG Populations 2012-2016, which is anchored on the 5th AIDS Medium Term Plan for 2011 to 2016, represents the most ambitious effort yet to combat HIV in the Philippines. It calls for policies and programmes informed by serologic surveillance data, a broader range of actors, and the integration of stigma reduction measures across the spectrum of HIV and AIDS services. There is indeed a precedent for a late-stage resurgence of HIV transmission in countries with historically low and stable HIV prevalence. But there is also little doubt that the epidemic’s future toll will depend in large part on how quickly and comprehensively the Philippines responds to rising HIV risk among men who have sex with men.
The snapshot provides more information about priorities for the Philippines reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in Thailand. Despite Thailand’s numerous innovations in the global AIDS response, men who have sex with men (MSM) have been virtually absent in national strategic plans until 2007. Once MSM entered routine national surveillance, evidence for a rapidly growing HIV epidemic among MSM became available. HIV prevalence among MSM in Bangkok was estimated to be 17.3 percent in 2003, 28.3 percent in 2005, 30.7 in 2007, and 24.7 in 2009.
Early in the response, MSM received HIV prevention services to the extent that male sex workers were targeted in the 100 percent Condom Use Programme. In 2003, the ‘Law and Order Campaign’ introduced punitive and legalistic policies that punished gay venue management for providing condoms and lubricant. The campaign is regarded as a significant setback to Thailand’s HIV response. Common HIV prevention tools rapidly disappeared from gay venues during this period. While the situation is much improved, barriers to offering effective prevention services still exist.
The rapid spread of HIV among MSM during 2003-2007 was gradually matched by an increase in attention from national and international stakeholders, including in Thailand’s National HIV Plan beginning in 2007. The ambitious new plan got to a slow start after the country’s HIV prevention budget was cut by approximately two-thirds in 2006. A revised budget for 2007-2011 allocated 8.1 percent of HIV prevention resources to HIV prevention services for MSM. Although only 0.8 percent of HIV prevention resources were spent on MSM programmes in 2009, this value increased to 5.4 percent in 2010 and 8.2 percent in 2011.
The snapshot provides more information about priorities for Thailand reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in Viet Nam. Men who have sex with men (MSM) in Viet Nam are at disproportionately high risk of HIV transmission. Research suggests that this is due in large part to multiple sexual partners, low condom use and low perceptions of risk. Not all MSM are at equal risk, however. HIV prevalence among MSM was found to be significantly higher in cities than in rural areas.
In 2006, a revised law on HIV passed by the Viet Nam National Assembly listed ‘homosexual people’ among the high-risk groups prioritised for HIV prevention programming. This represented the first time that MSM were recognised by the government of Viet Nam. However, funding for HIV services targeting MSM comes almost exclusively from donor programmes. As donors reduce their support to Viet Nam in the coming years, it will be critical for domestically funded programmes to target MSM as a population at high risk of HIV.
Men who have sex with men generally keep their sexual behaviours hidden in Viet Nam due to widespread stigma and discrimination. In 2002,Viet Nam’s state-run media declared homosexuality a ‘social evil’ equally as harmful as drug use and prostitution. Among the consequences of stigma and discrimination towards MSM are continuing programmatic neglect, relative difficulty reaching MSM, and false or low perceptions of HIV risk.
Communities of MSM in Viet Nam have been active in the response since as early as 2005, participating formally and informally in national and regional networks, including a national MSM and HIV working group founded in 2006. While there have been important indications of recognition and commitment to MSM in the HIV response, a coherent strategy for targeting MSM, including routine HIV surveillance among MSM, reporting of homosexual sex as a risk factor for transmission in case reporting, and ensuring meaningful participation in HIV response planning, remains to be seen.
This snapshot provides more information about priorities for Viet Nam reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.
This snapshot provides information on the current situation for HIV and LGBT rights and advocacy in China.
There is mounting evidence for a rapidly growing HIV epidemic among men who have sex with men in China. Over one-third of new infections across the country are among MSM, with HIV prevalence estimates in some south-western cities approaching 17 percent. A large-scale survey in 2008-09 that spanned 61 cities found an average prevalence in medium and large cities of about 5 percent.
Men who have sex with men have been largely absent from national AIDS strategies until recent years. Sentinel surveillance began to include MSM in 2002 and a specific strategy to implement a comprehensive response to HIV among MSM began being implemented in 2009.
Positive experiences in Chengdu, a city with one of the largest HIV epidemics among MSM as well as some of the best-organised MSM community-based organisations, are serving as a model for other large cities in China. The outcome of its role in the ‘Men who have sex with men and transgender populations Multi-City Initiative’ demonstrates the potential and importance of collaborative partnerships and networks of MSM in China’s HIV response.
Among the more immediate concerns facing China in the response to HIV among MSM is the need to understand the relative effectiveness of HIV prevention interventions by ensuring that strong evaluation mechanisms are in place.
However, MSM are recognised as a priority population in China’s national strategic plan and crucial work is underway to scale-up the response in key cities.
The snapshot provides more information about priorities for China reaching the three zeros, the most recent epidemiological data, behavioural information and programmatic information.