MSM-Targeted HIV Prevention


  1. Definition of the Prevention Area

    Globally, men who have sex with men (MSM) are disproportionately affected by HIV and urgently need increased coverage by quality prevention interventions. Evidence has shown that sustained combination approaches to HIV prevention that simultaneously address biomedical, behavioral and structural risks are most effective at reducing HIV transmission in generalized, concentrated, and mixed epidemic scenarios. Despite this evidence and the disproportionate epidemic burden that MSM shoulder, HIV prevention services remain sub-optimal in many countries.

    Not all MSM have an identity associated with their sexual preferences and behavior; and those who do not self-identify as MSM pose a formidable challenge to programs that seek to reach them. For example, the term "MSM" can include gay- or bisexual-identified men, transgender men who have sex with men, men who identify as completely heterosexual, men who identify through indigenous identities outside the largely Western concepts of hetero- or homosexuality, or men with no particular sexual identity at all. In many cultures, heterosexism (the assumption that everyone is heterosexual) is pervasive, and any behavior or identity that deviates from a heterosexual cultural norm is stigmatized and discriminated against, and in some cases is criminalized.

    Individual-level risks for HIV acquisition in MSM include unprotected receptive anal intercourse, a high frequency of male partners, a high number of lifetime male partners, injecting and non-injecting drug use, a high viral load in the index partner, and mental health issues. At the structural level, risks include criminalization of same-sex behavior, avoidance of health services out of fear of discrimination, and breaches of privacy and confidentiality. To succeed, HIV prevention interventions must take into account the complexities of MSM identity their multiple levels of risk. Combination approaches that simultaneously address behavioral, biomedical, and structural risks are an effective way to do this. At all levels, MSM individuals and communities must be involved in conceptualizing, planning, implementing, and evaluating research and programming.

  2. Epidemiological Justification for the Prevention Area

    Three decades into the epidemic, HIV continues to disproportionately affect MSM everywhere. Globally, MSM are 19 times more likely to be infected by HIV than the general population of reproductive age and have an overall HIV prevalence of 12 percent ( Many MSM also have female sexual partners and can function as a bridge, bringing HIV to other populations. Nevertheless, research and interventions focused at MSM are still under-prioritized by governments, donors, and civil society. Surveillance data, when available, is limited and likely underestimates both the size of the population of MSM and their HIV prevalence rates. Some estimates suggest that as few as 5 percent of MSM worldwide have access to basic HIV prevention services.

    There is evidence to show that prevention interventions aimed to engage MSM can reduce risk for HIV infection among MSM. Group- and community-level behavioral interventions among MSM have been shown to lead to up to a 43 percent decrease in unprotected anal sex; and group-level interventions have been shown to increase the odds of condom use by as much as 81 percent. A recent study suggested that behavioral interventions that reach 25 percent or more of non-self-identified MSM are more effective than those targeting self-identified MSM alone. Another study suggested that countries that combine MSM-specific community-based behavioral prevention interventions with condom and condom-compatible lubricant distribution can reduce new HIV infections among both MSM and the general population. Evidence also shows that episodic and/or single-track interventions tend to be less effective in the long term, which highlights a need for sustained combination prevention approaches.

  3. Core Programmatic Components

    The World Health Organization (WHO), with other global agencies, has identified a set of evidence-informed, mutually reinforcing biomedical, behavioral, and structural HIV prevention intervention components which, when combined, effectively reduce HIV infection among MSM. The following are some examples of strongly-recommended program components:

    • Biomedical approaches aim to reduce HIV transmission and acquisition risk. Current approaches that WHO strongly recommends include condom distribution with silicone- and water-based lubricants, combined with counseling and education, HIV testing services (HTS), sensitization of HTS sites to MSM needs, screening and treatment for sexually transmitted infection (STI) (for genital, oropharyngeal, and anorectal STIs), and antiretroviral therapy, including post-exposure prophylaxis. Though these are the current approaches, the combination prevention toolkit is growing as more research is done around pre-exposure oral prophylaxis (PrEP) and rectal microbicides.
    • Structural prevention activities aim to bring about social change in the general population by reducing stigma and discrimination and other barriers to effective prevention and treatment of HIV. Decriminalization of same-sex behaviors, policies that safeguard MSM and transgender rights, engagement with the media, and community and health systems strengthening are all examples of viable program components. However, none of these can be effective unless communities are successfully mobilized, engaged, and empowered. Community members must be involved in a collaborative, iterative process. Moreover, evidence-informed advocacy is an important step towards achieving positive structural change.
    • Behavioral approaches aim to promote safer behaviors to prevent HIV. Specifically, such approaches include sustained efforts to increase the use of condoms paired with water- and silicone-based lubricants; reduce the frequency of unprotected anal sex; and increase health-seeking behavior. Behavior change communication (BCC) can be delivered effectively at individual, group and community levels. BCC can include mobile phone messages, Internet-based strategies and social marketing campaigns, and other message delivery from diverse communication platforms, including sex venue "hot spots," health care facilities, and the general community.

    Accurate estimates of the size of the MSM population are essential to the design of prevention interventions. This poses a significant challenge, since many MSM do not self-identify or choose not to disclose their sexuality. A number of methods, including the relatively new network scale-up method, have shown effectiveness for use with MSM. UNAIDS recommends making estimates by triangulating results from more than one method, and cautions researchers and programmers to interpret data with care, and to clearly acknowledge sampling method biases.

  4. Current Status of Implementation Experience

    Regardless of which combination of prevention approaches is used, a number of overarching best practices are recommended to improve the reach and quality of all MSM-focused HIV programs:

    1. Involve MSM and MSM living with HIV in program design, implementation, and evaluation. The most deep-reaching and successful approaches to prevention interventions leverage the community ties and experiences of MSM, their networks, an understanding of factors affecting HIV risk and their ability to connect meaningfully with other MSM.
    2. Ensure confidentiality. Given the high levels of stigma and discrimination that MSM face, confidentiality is a key requirement.
    3. Provide training for both general health care staff and staff who work in HIV prevention, care, and treatment programs, to help them provide high-quality, stigma-free services.
    4. Reach beyond MSM groups. Interventions that target general audiences in addition to MSM audiences have been shown to also reach diverse subgroups of MSM, including non-self-identified MSM.
    5. Collect and use strategic information such as ongoing surveillance, research studies, and monitoring and evaluation data, and incorporate new knowledge and technological advances as they emerge.
    6. Link, integrate and co-locate services, especially to HIV care and treatment for HIV-positive MSM. This is particularly important, as anti-retroviral therapy has been identified as a key component of successful HIV prevention.

    Although many studies demonstrate the reproducibility of research and the effectiveness of behavioral interventions with MSM in the United States, far less information is available for program outcomes in other geographic areas, such as Africa and Asia, and among hard-to-reach subgroups of MSM. To inform future interventions, more investment must be made in conducting research in these other contexts and publishing findings widely.

UPDATED 7/2016

What We Know

HIV Epidemic and Human Rights Among Men Who Have Sex With Men in Sub-Saharan Africa: Implications for HIV Prevention, Care, and Surveillance

Abara, W.E., and Garba, I. Global Public Health (October 2015): 1–14 [Epub ahead of print], doi:10.1080%2F17441692.2015.1094107.

This article argued that HIV among men who have sex with men (MSM) in sub-Saharan Africa (SSA) is driven by many factors, and advocated for strategies grounded in social determinants and human rights. The authors reviewed available data on HIV among MSM; access to prevention, treatment, and care; and how the legal context affects MSM and contributes to their HIV risk. Data are limited, but indicate very high rates of HIV and multiple risks among MSM in SSA. However, HIV among MSM in SSA is largely unaddressed. Social determinants, including education, socioeconomic status, stigma, discrimination, and sexual and racial identity, shape vulnerability to HIV and access to prevention and care. Laws that criminalize MSM behavior contribute to the HIV epidemic; they promote stigma and discrimination, hinder policies and care to prevent and treat HIV, foster risk taking, and place organizations and providers that work with MSM in legal jeopardy. The authors summarized initiatives addressing the sexual risks and health needs of MSM through national policies and programs in Kenya and South Africa. They also described how human rights frameworks can be used to challenge discriminatory laws; and how international instruments can be used to hold governments accountable for reducing structural barriers and ensuring access to HIV prevention, treatment, and care.

The Global HIV Epidemics among MSM

Beyrer, C., Wirtz, A. L., Walker, D., et al. (World Bank, 2011).

This 300-page monograph provides one of the most comprehensive MSM-specific resources available on HIV epidemics among men who have sex with men (MSM) in low- and middle-income countries through 2011. The authors gave a detailed overview of epidemic scenarios among MSM across the globe, using selected country studies to describe and explore epidemiological variance across contexts. They developed a modified Goals Model for MSM to model the effects of MSM preventive services in the countries, as well as a costing exercise to estimate the cost-effectiveness of these services. They also included detailed information on combination HIV prevention interventions, graded using a novel adaptation of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for public health interventions, with recommendations for priority areas. There is a chapter on epidemic modeling of prevalence, incidence, and cost in MSM populations, as well as a chapter focused on policy and human rights.

A Systematic Review to Identify Challenges of Demonstrating Efficacy of HIV Behavioral Interventions for Gay, Bisexual, and Other Men Who Have Sex With Men (MSM)

Higa, D.M., Crepaz, N., Marshall, K.J., et al. AIDS and Behavior (May 2013), 17(4): 1231–1244. doi:10.1007/s10461-013-0418-z.

This article reported on a systematic review to identify reasons for the small number of evidence-based behavioral interventions (EBIs) for MSM. The review also identified challenges in demonstrating the efficacy of EBIs by comparing study characteristics. It first reviewed different types of behavioral interventions, and noted that while some have reduced risk behaviors, there is less evidence that they reduced actual rates of HIV or sexually transmitted infections. Newer biomedical prevention such as antiretroviral therapy and pre-exposure prophylaxis also have critical behavioral components, and HIV prevention approaches will increasingly be delivered in high-impact combinations, the authors said. The review comprised 33 three varied studies, and categorized 9 as EBIs and 24 as non-EBIs. The non-EBIs did not demonstrate a positive outcome, and had short follow-up, small samples, low retention, or other methodological limitations such as an inappropriate comparison group. These programs were also less likely to include peers, involve MSM in program design and testing, and include sexual communications in the program design or delivery. The authors recommend developing EBIs that are delivered to individuals and in health care settings, and for MSM subgroups, such as couples, those of color, or those who live in the South.

Incorporating Couples-Based Approaches Into HIV Prevention for Gay and Bisexual Men: Opportunities and Challenges

Purcell, D.W., Mizuno, Y., Smith, D.K., et al. Archives of Sexual Behavior (January 2014), 43(1): 35–46.  doi:10.1007/s10508-013-0205-y.

This article reviewed the challenges and benefits of couples-based interventions with men who have sex with men (MSM) in the United States. It outlined the multiple dynamics in MSM couples and how these influence HIV risk. The authors noted that this assessment was timely, given the emergence of biomedical HIV prevention approaches such as antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) and increased emphasis on high-impact combination prevention. Couples HIV testing and counseling (CHTC) is a proven strategy with heterosexual couples in sub-Saharan Africa, and has been adapted for homosexual couples in the U.S.  Early evidence suggests young MSM, men of color, and men with a main sex partner are especially interested in CHTC. CHTC could form the basis for a comprehensive package of prevention, treatment, and care for MSM couples. ART and PrEP are highly efficacious in reducing the risk of acquiring and transmitting HIV, and can help couples actively manage their risk. However, there is a need for more research on interventions to improve adherence in couples, and to further adapt and evaluate community-developed HIV prevention strategies such as serosorting, seropositioning, and negotiated safety. The authors noted that intervention development for MSM couples is still nascent; more research is needed to identify the best couples-based approaches among MSM in the rapidly evolving context of combination prevention. 

The Effectiveness of MI4MSM: How Useful is Motivational Interviewing as an HIV Risk Prevention Program for Men Who Have Sex With Men? A Systematic Review

Berg, R.C., Ross, M.W., and Tikkanen, R. AIDS and Behavior (May 2013), 17(4): 1231–1244, doi:10.1007/s10461-013-0418-z.

This article reported on a systematic review of behavioral interventions that use motivational interviewing (MI) to reduce HIV risk behaviors among men who have sex with men (MSM). Motivational interviewing is a directive and client-centered counseling approach for bringing about behavior change by increasing clients’ motivation and internal desire to change. The review included 10 randomized controlled trials with a total of 6,051 participants at baseline. Nine studies examined the effectiveness of MI on sexual risk behaviors, three its effectiveness on behaviors related to both sex and alcohol and other drugs, and one its effectiveness on HIV testing. Only one measured HIV acquisition. Some interventions incorporated other activities, and the dose of MI ranged widely, from one 30-minute session to 17 40-minute sessions. MI was generally equivalent to other interventions for reducing unsafe sexual and substance use behaviors, with only a small number of differences seen in individual studies. The meta-analysis did not find additional benefits of MI for HIV risk behaviors among MSM, confirming a previous meta-analysis. One large study suggested that incorporating MI into counseling and testing for some groups of MSM may be promising. The authors noted that MI for MSM should not be dismissed, and urged continued efforts  to identify effective strategies for MSM.

Associations Between Intimate Partner Violence and Health among Men Who Have Sex With Men: A Systematic Review and Meta-Analysis

Buller, A.M., Devries, K.M., Howard, L.M., et al. PLOS Medicine (March 2014), 11(3): e1001609, doi: 10.1371/journal.pmed.1001609.

This article reported on a systematic review and meta-analysis of associations between intimate partner violence (IPV) among men who have sex with men (MSM) and a range of risk behaviors and health outcomes. Eligible studies looked at MSM who had experienced IPV and those who were perpetrators of IPV. Nineteen studies describing 18 datasets were included in the review, and 17 were included in the meta-analysis. The studies varied on many factors, including sampling, recall time, types of violence studied, outcomes, and measurement. Exposure to IPV as a victim was high, and was associated with substance use, depressive symptoms, being HIV positive, and unprotected anal sex.  IPV perpetration was associated with substance use. This review had some limitations based on methodological weaknesses, including the lack of validated tools to assess IPV in MSM, and the wide range of recall periods and outcomes studied. The authors called for research on preventing IPV among MSM and validating tools to assess IPV in this group, and for studies with more representative samples. They recommended training providers to address IPV among MSM, and making available support services more visible. 

The Pre-Exposure Prophylaxis Revolution; From Clinical Trials to Programmatic Implementation

Mugo, N.R., Ngure, K., Irungu, E., et al. Current Opinion in HIV and AIDS (January 2016), 11(1): 80–86. doi:10.1097/COH.0000000000000224.

The translation of evidence into public health implementation and impact is often slow or absent. This article reviewed policy and programmatic considerations for implementing and scaling up pre-exposure prophylaxis (PrEP) in Africa. Demonstration projects have shown higher adherence and potential impact than clinical trials, indicating that people who perceive themselves at risk and participate in such projects can adhere to PrEP, remain in care, and avoid risk compensation. The authors recommended building national policies around World Health Organization guidelines while addressing specific country considerations, such as acceptability, cost, health system capacity, and cost-effectiveness. Delivery must complement treatment, and must reflect the different needs and drivers of risk for specific user groups; and the authors recommended testing both stand-alone and integrated systems for PrEP delivery. For many people, PrEP use may be time-limited and thus cost-effective overall. Concerns such as drug resistance, risk compensation, and competition for resources must be addressed. Evidence from PrEP demonstration projects should inform programs and additional efforts to bridge demonstration and actual implementation. Stigma and risk perception can be barriers to PrEP uptake; the authors suggested social marketing and working with couples as strategies. The authors urged focused advocacy to create awareness, mitigate against stigma, and realize PrEP’s significant potential in the fight against HIV. 

Psychosocial Vulnerability and HIV-Related Sexual Risk Among Men Who Have Sex With Men and Women in the United States

Dyer, T.P., Regan, R., Pacek, L.R., et al. Archives of Sexual Behavior (February 2015), 44(2): 429–41. doi:10.1007/s10508-014-0346-7. 

This article analyzed data from a nationally representative U.S. cohort to assess psychosocial vulnerability and HIV risk-taking among men who have sex with men and women (MSMW). Evidence suggests that MSMW are especially vulnerable to psychosocial issues that increase risk of HIV, and understanding these dynamics is important to reduce HIV transmission among MSM and to female partners. This study compared psychosocial vulnerability and HIV risk behaviors among 6,945 men in five categories based on ever having had sex with: women only (MSW), men only (MSMO), or MSMW; MSMW were sub-categorized based on sexual partners in the last 12 months: only female; only male; and male and female. Overall MSMO reported the highest levels of HIV risk, while MSMW reported more depression, suicidality, substance use, and history of incarceration than either MSW or MSMO. MSMW with current female partners reported more unprotected sex, exchange sex, and sexually transmitted infections, while MSMW with male partners in the past 12 months reported more multiple or concurrent partners. This analysis confirmed earlier studies showing that HIV risk and psychosocial vulnerability factors are higher among MSMW. The authors concluded that MSMW are a priority for HIV risk reduction interventions, which should address the range of differing identities, partnerships and risks among MSMW.

HIV Prevalence, Risks for HIV Infection, and Human Rights among Men Who Have Sex with Men (MSM) in Malawi, Namibia, and Botswana

Baral S., Trapence G., Motimedi F., et al. PLOS One (March 2009), 4(3): e4997.

This study of 537 men was the first cross-sectional study establishing MSM as a high-risk group for HIV infection and human rights abuses in the countries of Botswana, Malawi, and Namibia. In these contexts, a significant proportion of men identified as either heterosexual or bisexual, and were married or had at least one female partner in the previous six months. Over half of participants reported having both male and female partners, and 16.6 percent reported concurrent relationships. Over 40 percent also reported experiencing human rights abuses, including blackmail and denial of health services or housing. In an important finding, the study established the Internet as the predominant tool used by MSM to find male sexual partners. This was especially true in the contexts of these three countries, where homosexuality is criminalized and there is no safe, legal space for MSM to congregate. The authors suggested that the Internet may represent a powerful tool for efficiently reaching and delivering prevention messages to MSM.

Access to Basic HIV-Related Services and PrEP Acceptability Among Men Who Have Sex with Men Worldwide: Barriers, Facilitators, and Implications for Combination Prevention

Ayala, G., Makofane, K., Santos, G.M., et al. Journal of Sexually Transmitted Diseases (July 2013) 953123, 11 pages.

This article reported on a 2012 cross-sectional survey among men who have sex with men (MSM) to assess factors associated with the acceptability of pre-exposure prophylaxis (PrEP) and access to HIV prevention tools: condoms, lubricants, HIV testing, and HIV treatment. In the online Global Men’s Health and Rights Survey, 3,748 respondents from 145 countries gave sociodemographic and HIV-related clinical information, and answered questions on structural, community, and individual-level barriers and facilitators to HIV service access for MSM. Access was measured using a five-point scale. Condoms were accessible to 35 percent of all respondents, and lubricants were accessible to 22 percent. HIV testing was accessible to 35 percent of HIV-negative participants, and antiretroviral therapy was easily accessible to 43 percent of HIV-positive respondents. HIV-negative participants reported low (48%), medium (23%), and high (29%) levels of knowledge about PrEP. Limited access to services was associated with homophobia, "outness," and stigma from service providers; increased access was associated with community engagement, connection to the MSM community, and degree of comfort with service providers. The authors concluded that delivering combination prevention to MSM will depend on access to services, and understanding and addressing barriers to and facilitators of this access is key. 

Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men

Pathela, P., Hajat, A., Schillinger, J., et al. Annals of Internal Medicine (September 2006), 145: 416-425.

The researchers described discordance between self-described sexual identity and behavior among men who have sex with men (MSM) and the relationship between self-described sexual identity and risk behaviors. Of 9,802 New York City men reporting a sexual identity, 12 percent reported sex with other men. MSM who self-identified as heterosexual were more likely than their gay-identified counterparts to belong to minority racial or ethnic groups, be foreign-born, have lower education and income levels, and be married. Heterosexual or “straight-identified” MSM were more likely to report having only one sexual partner in the previous year than gay-identified MSM, but were less likely to have been tested for HIV and were less likely to have used condoms during their last sexual encounter. The authors concluded that medical providers cannot rely on patients' self-reported identities, and that public health messages should target risky sexual activities rather than a person's sexual identity.

They See You as a Different Thing: The Experiences of Men Who Have Sex with Men with Healthcare Workers in South African Township Communities

Lane, T., Mogale, T., Struthers, H., et al.Sexually Transmitted Infections (November 2008), 84(6): 430-433. doi:10.1136/sti.2008.031567.

This qualitative study described interactions between MSM and health care workers (HCWs) in South Africa and found that many men who have sex with men (MSM) felt their options for non-stigmatizing sexual health care services were limited by homophobic verbal harassment by HCWs. Gay-identified men sought out clinics with reputations for employing workers who respected their privacy and sexuality, and some challenged workers who mistreated them. Non-gay-identified MSM presented masculine, heterosexual identities and avoided discussing their sexuality with HCWs. The authors concluded that the strategies MSM employ to confront or avoid homophobia from HCWs may not be conducive to health promotion, and that initiatives to improve appropriate care from public-sector HCWs are urgently needed.

Reaching African-American Men on the Down Low: Sampling Hidden Populations: Implications for HIV Prevention

Icard, L.D. 2008. Journal of Homosexuality 55(3), pp. 437–449.

Studies of the impact of the HIV epidemic among African-American men who have sex with men (MSM) have largely neglected men who self-identify as heterosexual but who engage in same-sex behavior. These men, commonly referred to as “men on the down low,” pose formidable challenges to researchers conducting prevention studies. The authors discussed the benefits and drawbacks of various sampling methods to identify these hard-to-reach MSM and described a novel approach to reaching these men. Instead of relying on self-identified gay men or gay establishments, the researchers successfully used three recruiters who frequented known cruising areas (a park and the Internet) to find men who would meet the general classification of men on the down low.

Accessing Men Who Have Sex with Men through Long-Chain Referral Recruitment

He, Q., Wang, Y., Li, Y., et al. AIDS and Behavior (July 2008), 12(4 Suppl): S93-S96. doi:10.1007/s10461-008-9388-y.

The authors compared men who have sex with men (MSM) identified by two methods: convenience sampling and long-chain referral. Long-chain referral relies on study participants to recruit their acquaintances to the study, who in turn recruit their acquaintances. Long-chain referral identified more MSM who were migrants, young, from lower-income groups, and at higher risk for HIV than those identified by a convenience sample (such as all men attending a certain clinic). The authors said that long-chain referral can reach subgroups better than convenience samples. The article also reported behavioral risk outcomes associated with various subpopulations.

Reaching Men Who Have Sex with Men (MSM) in the Global HIV & AIDS Epidemic: A Policy Brief

Global Forum on MSM & HIV (November 2010).

This six-page policy brief succinctly argues that men who have sex with men (MSM) shoulder a disproportionate burden of HIV globally, and therefore countries need to increase their commitment to and coverage of MSM populations. It identifies the following strategic areas for increased work, with specific action recommendations for each: (1) increased investment in effective HIV treatment, care, and support for MSM; (2) expanded coverage of quality services for MSM; (3) increased MSM-related knowledge through research; (4) decreased violence, stigma, and discrimination against MSM; and (5) strong MSM networks linked to the Global Forum on MSM & HIV, or MSMGF. Quotes from MSM activists throughout the world are included.

A Novel Approach to Prevention for At-Risk HIV-Negative Men Who Have Sex with Men: Creating a Teachable Moment to Promote Informed Sexual Decision-Making

Eaton L.A., Cherry C., Cain D., et al. American Journal of Public Health (January 2011), 101(3): 539545. doi:10.2105/AJPH.2010.191791.

Serosorting provides an alternative to condom use and thus addresses the problem of safer-sex “fatigue.” However, there are challenges to this approach, which relies on informed decisionmaking regarding selection of lower-risk partners. This study, conducted in 2009, tested a brief, one-on-one, peer counselor–delivered intervention based on informed decision making to address the limitations of serosorting. In Atlanta, Georgia, 149 at-risk men were randomly assigned to standard care or an intervention arm that addressed serosorting. The intervention was based on conflict theory, which prepares people for informed decision making and creates a “teachable moment,” wherein participants are more open to change. The results at follow-up showed that men in the serosorting intervention reported fewer sexual partners, increased condom use, and greater efficacy in assessing HIV risk. The authors concluded that serosorting is feasible and low-cost and could have an impact on the HIV intervention.

Comparisons of Disparities and Risks of HIV Infection in Black and Other Men Who Have Sex with Men in Canada, UK, and USA: A Meta-Analysis

Millett, G.A., Peterson, J.L., Flores, S.A., et al. The Lancet (July 2012), 380(9839): 341-348.

The authors conducted a meta-analysis on factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the United Kingdom, and the United States from 1981 to 2011. They based  their findings on aggregated data from racial comparative studies with outcomes associated with HIV risk or infection from seven studies from Canada, 13 from the United Kingdom, and 174 from the United States. The analysis included a number of factors, including seropositivity, drug use, structural barriers, and access to prevention services, among others. The study found racial disparities in terms of HIV status, sexually transmitted infections, and initiation of antiretroviral therapy among MSM in the United Kingdom and the United States. The study concluded that eliminating these disparities will be impossible without addressing structural barriers that restrict access to clinical care.

Coming to Terms with Complexity: A Call to Action for HIV Prevention

Piot P., Bartos M., Larson H., et al. The Lancet (September 2008), 372(9641): 845-859

The authors presented a well-articulated, evidence-based argument for combination approaches to HIV prevention. They authors recognized the complexity of the HIV epidemic, but emphasized importance of not becoming overwhelmed by this complexity. They pointed out weaknesses in the HIV response, including insufficiently scaled implementation of proven approaches, funding limitations, and failure to address structural determinants. They also used available evidence to describe  key epidemic elements in a step-by-step manner, elucidating each with concrete examples; and concluded with an extensive call to action, listing detailed action steps for each element.

Understanding and Integrating the Structural and Biomedical Determinants of HIV Infection: A Way Forward for Prevention

Kippax S. Current Opinion in HIV and AIDS (July 2008), 3(4): 489-94.

This article offered the important argument that the successful integration of structural and biomedical approaches to HIV prevention depends on biomedical and social scientists working together. The authors compared successful and unsuccessful prevention interventions/programs, and highlighted the importance of structural factors in determining HIV risk. For HIV prevention programs to be effective, the focus must include both behavioral and structural factors, and must consider the cultural context in which behavior occurs. The authors concluded that multidisciplinary teams provide a good starting place for the development of effective prevention programs that take combination approaches.

Rights Matter: Structural Interventions and Vulnerable Communities

Altman, D. Interamerican Journal of Psychology (2007), 41(1): 87-92.

This is an edited version of the Jonathan Mann Memorial Lecture given at the XV International AIDS Conference in Bangkok, Thailand, on July 14, 2004, and makes a strong case for addressing the structural drivers of HIV.

Putting it Into Practice

Technical Guidance: Prevention for Men Who Have Sex with Men

U.S. President's Emergency Plan for AIDS Relief (PEPFAR) (2011).

As part of the U.S. President's Emergency Plan for AIDS Relief's (PEPFAR's) second five-year strategy, this technical document provides specific information to assist country teams in the development of HIV prevention programs for men who have sex with men (MSM) that respond comprehensively and effectively to specific epidemic scenarios. The document highlights the importance of combination prevention, which brings together structural, biomedical, and behavioral approaches. It provides in-depth information on community-based outreach; condom distribution; HIV counseling and testing; active linkages to health care and antiretroviral therapy; targeted information, education, and communication; and sexually transmitted infection prevention, screening, and treatment. The guidance document also recommends a set of best program practices to ensure the effectiveness of HIV prevention programs among MSM (i.e., involvement of MSM, confidentiality , staff training , strategic information , linking, integrating, and collocating services , and incorporating research advances and new technologies).

Human Rights Considerations in Addressing HIV among Men who Have Sex with Men

Avrett, S. (USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, 2011).

This technical brief provides a systematic global review and synthesis of practical approaches, program examples, and resources to support human rights as a core element of HIV programming for men who have sex with men (MSM). This document gives an overview of U.S. policies on and commitments to MSM and human rights, and outlines recommended approaches, including program examples in various countries, for linking health and human rights to address HIV among MSM. It also offers a compilation of questions for developing and monitoring HIV programs for MSM, as well as a list of program resources.

Achieving an AIDS-Free Generation for Gay Men and Other MSM: Financing and Implementation of HIV Programs Targeting MSM

The American Foundation for AIDS Research and Johns Hopkins Bloomberg School of Public Health (January 2012).

The goal of this comprehensive report is to evaluate the impact of legislation that criminalizes same-sex sexual practices on two key outcomes: (1) the efficiency of multilateral funding sources for HIV programming and (2) the effectiveness of programming for men who have sex with men (MSM). It also analyzes the evidence for the positive impact decriminalizing same-sex sexual practices can have on the delivery of comprehensive HIV programs for MSM. It is comprised of analysis of country case studies; in-country consultations with a wide range of stakeholders; and data from the UN General Assembly Special Session on AIDS (UNGASS), the U.S. President's Emergency Plan for AIDS Relief, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Countries of focus include China, Ethiopia, Guyana, India, Mozambique, Nigeria, Ukraine, and Vietnam.

Prevention and Treatment of HIV and Other Sexually Transmitted Infections among Men Who Have Sex with Men and Transgender People—Recommendations for a Public Health Approach

World Health Organization (WHO) (2011).

This guidance, intended for a broad audience, was developed to enhance the ability of countries to provide comprehensive HIV responses to men who have sex with men (MSM) and transgender (TG) populations, and comprises a thorough set of technical recommendations for STI and HIV treatment among MSM and TG populations. The document provides six good practice recommendations, focused on (1) prevention of sexual transmission; (2) HIV testing and counseling; (3) IEC; (4) HIV prevention focused on substance use; (5) MSM and TG people living with HIV; and (6) prevention and treatment of STIs. It is geared toward national public health officials, nongovernmental organizations (NGOs), and health workers.

UNAIDS Action Framework: Universal Access for MSM and Transgender People

Joint United Nations Programme on HIV/AIDS (UNAIDS) (May 2009).

This action framework seeks to go beyond "business as usual" approaches to articulate UNAIDS' specific commitments to men who have sex with men (MSM) and transgender (TG) communities worldwide. It provides direction for enhanced action by the UNAIDS Secretariat and UNAIDS Cosponsors. The framework is intended to serve as a foundation for articulating specific workplans and recommendations for better-coordinated action. It focuses on these key objectives: (1) improving human rights for MSM and TG populations; (2) strengthening and promoting the evidence base related to MSM, TG, and HIV; (3) promoting partnerships and ensuring better, broader responses for MSM and TG populations; (4) outlining roles, responsibilities, and partnerships within the UN related to MSM and TG groups; and (5) developing a monitoring, evaluation, and review plan.

Priority HIV and Sexual Health Interventions in the Health Sector for Men Who Have Sex with Men and Transgender People in the Asia-Pacific Region

United Nations Development Program (UNDP) (2010).

This 128-page Asia-Pacific-focused document articulates a set of priority health sector interventions needed to achieve universal access to HIV prevention, care, and support for men who have sex with men (MSM); summarizes recommendations from the World Health Organization; guides the selection and prioritization of HIV prevention, care, and support interventions for MSM; and directs readers to more resources. The target audience is wide, including national public health officials, nongovernmental organizations, community-based organizations, and health care providers. Chapters cover prevention; sexual health; care, support, and treatment; strategic information; and strengthening health systems.

Advancing the Sexual and Reproductive Health and Human Rights of Men Who Have Sex with Men Living With HIV

GNP+ the Global Forum on MSM and HIV (MSMGF) (2010).

This policy briefing was developed as an elaboration of Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: A Guidance Package, published jointly by the GNP+, the International Community of Women with AIDS, EngenderHealth, the International Planned Parenthood Federation, and the Joint United Nations Programme on HIV/AIDS in 2009. It is a set of principles, based on the original guidelines, specific to the needs and priorities of men who have sex with men who are living with HIV. The recommendations are intended for program managers and policymakers, sexual health advocates and health care workers, and community and civil society organizations.

Men Who Have Sex with Men (MSM), HIV, and the Road to Universal Access—How Far Have We Come?

The American Foundation for AIDS Research (amfAR) (August 2008).

This 56-page report provides the results of data submitted to the United Nations (UN) by 128 countries. Nearly half of the countries failed to provide any data on men who have sex with men (MSM). Despite a unanimous commitment by all UN member countries in 2001 to monitor HIV among high-risk groups, the report found that 71 percent of countries had no information on the percentage of MSM reached by HIV prevention programs. The report attributes this failure to a lack of leadership both from national governments and the institutions charged with leading the global response to HIV. The report cites the criminalization of male-male sexual activity as a major driver of the epidemic among MSM in many countries. Seven of the ten countries with the highest reported HIV prevalence among MSM criminalize homosexuality. Institutionalized stigma and discrimination frequently prevent MSM from accessing even basic HIV services.

MSM and HIV/AIDS Risk in Asia

Foundation for AIDS Research (2006).

This 82-page report discusses the vulnerability to HIV of men who have sex with men (MSM) in Asia. Many Asian countries focus on such high-risk groups as female sex workers and injecting drug users, while ignoring MSM despite increasing HIV prevalence in the region. MSM may be overlooked because many are married and do not self-identify as gay or bisexual. Studies found HIV prevalence as high as 28 percent among MSM in Bangkok, Thailand; 14 percent in Phnom Penh, Cambodia; and 16 percent in Andhra Pradesh, India. MSM in Asia are often not organized, are hidden from society, and are persecuted by police. Sex between men is illegal in 11 of the countries examined. Many MSM have multiple partners, have sex with women, fail to use condoms, and have high rates of sexually transmitted diseases. This in-depth report provides research findings, country profiles, recommendations for politicians and non-governmental organizations, a directory of organizations, and extensive appendices for reference.

Off the Map: How HIV/AIDS Programming Is Failing Same-Sex Practicing People in Africa

Johnson, C.A. International Gay and Lesbian Human Rights Commission (IGLHRC, 2007).

This 125-page report, published by the IGLRC, explores the ways in which governments, donors, and nongovernmental organizations have failed to incorporate basic human rights protections for same-sex practicing Africans and how that failure affects efforts to combat the HIV epidemic. The author recommends that access to prevention, care, and treatment must be equal for all. The reports discusses gaps in available research, including the need to better understand hidden male-male sexual behavior.

Reaching Men Who Have Sex With Men for HIV Prevention Messaging with New Media: Recommendations from an Expert Consultation

Lewis M.A., Uhrig J.D., Ayala G., et al. Annals of the Forum for Collaborative HIV Research (October 2011), 13(3): 11-18.

The Internet and other technologies are increasingly used by men who have sex with men (MSM) for a variety of purposes, including meeting sexual partners. This article reports the results of an expert consultation led by the U.S. Centers for Disease Control and Prevention on the potential role of the Internet in delivering HIV prevention messaging to MSM. The report summarizes group discussion around how use of specific channels, technologies, and websites differed between groups; characterizes the strengths and weaknesses of those channels in terms of their potential for delivering HIV prevention messages; and discusses how online tools might be developed to help reduce HIV risk and promote overall health for MSM.

Global Epidemiology of HIV Infection in Men Who Have Sex with Men

Beyrer, C., Baral, S. D., van Griensven, F., et al. The Lancet (July 2012), 380(9839): 367-377. doi:10.1016/S0140-6736(12)60821-6

This article looked at the epidemiological drivers of the global epidemic in men who have sex with men (MSM) and why it continues unchecked. It was based on a review of available data for HIV prevalence, incidence, risk factors, and the molecular epidemiology of HIV in MSM from 2007 to 2011, and on an agent-based simulation that was used to model the dynamics of HIV transmission. The article showed that unprotected anal intercourse plays a central role in explaining the disproportionate disease burden in MSM, that HIV can be transmitted through MSM networks with speed and efficiency, and that prevention strategies that lower biological risks, such as antiretroviral therapy (ART), offer promise for controlling the expanding epidemic in MSM. It also found that the potential effectiveness of ART is limited by structural factors that contribute to low levels of health-seeking behavior in populations of MSM.

Comprehensive Clinical Care for Men Who Have Sex with Men: An Integrated Approach

Mayer, K. H., Bekker, L.-G., Stall, R., et al. The Lancet (July 2012) 380(9839): 378-387. doi:10.1016/S0140-6736(12)60835-6.

This article highlighted the importance of developing culturally sensitive and respectful clinical care programs that address health disparities in communities of men who have sex with men (MSM), such as depression, anxiety, and substance abuse. The authors carefully detailed structural and biomedical drivers of HIV risk, including mental health and substance abuse, making a case for culturally competent care. They also pointed out that research is required to understand more clearly how MSM can live positively in the face of societal discrimination and other structural factors that negatively affect health outcomes.

Successes and Challenges of HIV Prevention in Men Who Have Sex with Men

Sullivan, P. S., Carballo-Diéguez, A., Coates, T., et al. The Lancet (July 2012) 380(9839): 388-399. doi:doi: 10.1016/S0140-6736(12)60955-6.

This article suggested a detailed conceptual framework for packaging HIV prevention interventions for men who have sex with men (MSM) and modeling the potential effect of scale-up. It contained a review of MSM-focused HIV prevention interventions, and made a strong case for combination interventions. The authors underscored the importance of innovative study designs, increased resources for scale-up, and bringing more focus to low- and middle-income countries.

From Personal Survival to Public Health: Community Leadership by Men Who Have Sex with Men in the Response to HIV

Trapence G., Collins C., Avrett S., et al. The Lancet (July 2012), 380(9839): 400-410. doi:10.1016/S0140-6736(12)60834-4.

This article reviewed the key role that community leadership has played in HIV responses since the beginning of the epidemic. It outlined a history of participation by men who have sex with men (MSM) and gay men, as well as new opportunities for community leadership and participation in HIV programming, research, and advocacy.

Common Roots: A Contextual Review of HIV Epidemics in Black Men Who Have Sex with Men across the African Diaspora

Millett, G. A., Jeffries, W. L. IV, Peterson, J. L., et al. The Lancet (July 2012) 380(9839): 411-23. doi:10.1016/S0140-6736(12)60722-3.

This article examined HIV infection in black men who have sex with men (MSM) across the African diaspora and the extent to which these men report access to HIV prevention and care services. The authors assessed whether these findings are associated with increased susceptibility to HIV infection; examined genetic and biological explanations for disproportionate rates of HIV infection in black communities compared with other populations; and used meta-analytic methods to assess differences in the prevalence of HIV infection between black MSM and general populations. They presented recommendations based on study findings.

A Call to Action for Comprehensive HIV Services for Men Who Have Sex with Men

Beyrer, C., Sullivan, P. S., Sanchez, J., et al. The Lancet (July 2012), 380(9839): 424-438. doi:10.1016/S0140-6736(12)61022-8.

This article sounded a call to action for comprehensive HIV services for men who have sex with men (MSM) based on the articles in the special MSM edition of The Lancet from July 2012. The call addressed governments, health ministries, donors, providers, researchers, and community members, and covered the following issues in some detail: prevention, clinical resources, youth, health disparities, mental health, health care provision, community, resilience, and structural changes. The authors concluded with a detailed strategy for action, with a timeline for action from 2012 to 2014.

Technical Guidance Series: HIV Prevention among Vulnerable Populations-The Pathfinder International Approach

Israel, E., Laudari, C., and Simonetti, C.(Pathfinder International, 2008).

This 40-page publication provides a background to the risks faced by populations especially vulnerable to HIV and outlines effective strategies to prevent HIV among sex workers, men who have sex with men (MSM), and people who inject drugs. Programs described include peer education, comprehensive health services and quality of treatment, provider referral networks, and in-service training and sensitization.

Best Practice Collection: HIV and Men Who Have Sex with Men in Asia and the Pacific

Winder, R. (Joint United Nations Programme on HIV/AIDS, 2006).

This 70-page report describes programs for men who have sex with men (MSM) in Asia and the Pacific region. The authors show that even in conservative societies and in countries where there are legal constraints, MSM may play an important role in the response to HIV. This publication examines six programs that offer insights into how HIV interventions for communities of MSM have been designed and implemented in this part of the world, as well as lessons learned from these programs. Elements from the programs have been consolidated by topic to facilitate access and illustrate practical options.

Lessons from the Front Lines: Effective Community-Led Responses to HIV and AIDS among MSM and Transgender Populations

The American Foundation for AIDS Research (amfAR) and The Global Forum on MSM & HIV (MSMGF) (2010).

This resource profiles successful men who have sex with men (MSM)- and transgender-community-led HIV-related interventions, all grantees of amfAR's MSM Initiative. The 10 organizations are geographically diverse, and work to promote health and human rights through a number of projects, including (but not limited to) MSM in prisons, leadership development, network building, working in challenging environments, and health. The sections profiling each organization draw on quotes from organization members themselves. The report also articulates six major themes that community service providers identify as key to program success: addressing basic needs, creating a safe space, establishing and maintaining community trust, providing a range of integrated services, tailoring and revising services on an ongoing basis, and collecting process and outcome indicators.

Tackling HIV-Related Stigma and Discrimination in South Asia

Stangl A., Carr, D., Brady, L., et al. (World Bank, 2008.

This 200-page monograph is a compendium of strategies for addressing stigma and discrimination (S&D) in South Asia, although the content is applicable to other contexts as well. It profiles South Asia Regional Development Marketplace Award grantees' anti-S&D projects, highlighting community-centered, innovative approaches to fighting S&D to help create an enabling environment for health and wellbeing. The volume contains examples specific to men who have sex with men (MSM), including strategies for reaching challenging populations and innovative approaches to MSM-led advocacy. It also contains a list of evidence-informed recommendations for action.

Characteristics of Men Who Have Sex With Men in Southern Africa Who Seek Sex Online: A Cross-Sectional Study

Stahlman, S., Grosso, A., Ketende, S., et al. Journal of Medical Internet Research (May 2015), 17(5): e129. doi: 10.2196/jmir.4230.

This cross-sectional study identified prevalence and correlates of online sexual partner-seeking among men who have sex with men (MSM) in Lesotho and Swaziland. Previous studies indicated that MSM who seek sex online have elevated sexual risk behavior, and that the Internet may be an effective tool for providing information and education on HIV and sexually transmitted infections (STIs). Study participants (530 in Lesotho and 322 in Swaziland) were identified through respondent-driven sampling. They underwent HIV testing and completed a questionnaire that addressed sociodemographic characteristics, discrimination and stigma, mental health and substance use, and HIV-related knowledge, attitudes, and behaviors. The authors reported that a high proportion of the men sought sexual partners online: 39.4 percent in Lesotho and 43.8 percent in Swaziland. In both countries, factors associated with seeking partners online included: younger age, more education, and a higher number of male sexual partners. The authors noted that male homosexual acts are criminalized in Swaziland, and Lesotho prohibits sodomy as a common-law offense; in addition, stigma and discrimination against MSM are prevalent in both countries. This may have influenced the sample and reported behaviors. The authors recommended additional research to assess the potential of online HIV interventions among MSM in Africa.

Applying Innovative Approaches for Reaching Men Who Have Sex With Men and Female Sex Workers in the Democratic Republic of Congo

Mulongo, S., Kapila, G., Hatton, T., et al. Journal of Acquired Immune Deficiency Syndromes (March 2015), 1(68 Suppl 2): S248–51. doi:10.1097/QAI.0000000000000449.

This case study described an innovative program to reach men who have sex with men (MSM) and female sex workers (FSWs) in the Democratic Republic of the Congo. These marginalized groups are at highest risk of HIV but have least access to services. The Projet Intégré de VIH/SIDA au Congo (ProVIC) provides linked community- and facility-based prevention, counseling and testing, and treatment programs. ProVIC adapted its participatory approach, Champion Community (CC), to reach MSM and FSWs. The program conducted mobilization through peer educators and recruiters, and mapping to identify HIV vulnerability and beneficiaries; this process informed messaging and counseling. ProVIC worked with the national AIDS program to include prevention, care, and treatment information for MSM and FSWs in peer counseling training. ProVIC offered mobile counseling and rapid HIV testing at night in venues frequented by MSM and FSWs; those who tested positive were referred to "friendly" clinics. In 2013, ProVIC reached 2,621 MSM and 12,746 FSWs with prevention messaging; the program provided testing and counseling services to 4,366 MSM and 21,033 FSWs between October 2012 and June 2014. This example, the authors said, demonstrates that HIV prevention, referral, care and treatment are feasible even for marginalized key populations in complex and unstable environments.

Estimation of the Size of High-Risk Groups and HIV Prevalence in High Risk Groups in Concentrated Epidemics

Joint United Nations Programme on HIV/AIDS (UNAIDS) (May 2009).

This technical report and set of recommendations came out of a meeting of the UNAIDS Reference Group on Estimates, Modelling and Projections held in Amsterdam, the Netherlands, December 9–10, 2008. The goal of the meeting, which brought together 29 experts, was to draft recommendations on the topic of population size and HIV prevalence estimation for sex workers, people who inject drugs, and men who have sex with men. The report provides a detailed list of methods for various epidemic scenarios and risk groups, with accompanying recommendations.

It All Starts Here: Estimating the Size of Populations of Men Who Have Sex with Men and Transgender People

Asia-Pacific Coalition On Male Sexual Health (March 2010).

This policy brief explores key issues related to the diversity of men who have sex with men (MSM) and transgender (TG) populations and implications for size estimation exercises; identifies other key considerations for the estimation of MSM and TG population size; and makes key recommendations on how MSM and TG diversity, population sizes, and risk levels can be taken into account for sensitive programming in Asia and the Pacific. Although the brief focuses on the Asia-Pacific region, it can be used by any group interested in understanding more about the complexity of size estimation for MSM and TG groups.

Estimating the Size of Populations at Risk for HIV: Issues and Methods

Joint United Nations Programme on HIV/AIDS, Implementing AIDS Prevention and Care (IMPACT) Project, and FHI (2003).

This guide provides a detailed overview of population size estimation for groups at high risk for HIV, and treats populations of men who have sex with men (MSM) with specificity and detail. The guide gives a general overview of the importance of size estimation; issues regarding size estimation for high-risk groups; methods of size estimation; and approaches for selecting the best method. It also contains exercises that allow readers to test their understanding through case examples, which could also be used in a workshop setting. It contains a resource list for further reading.

The Bruthas Project: Evaluation of a Community-Based HIV Prevention Intervention for African American Men Who Have Sex with Men and Women

Operario D., Smith C.D., Arnold E., et al. AIDS Education and Prevention (February 2010), 22(1): 37-48. doi:10.1521/aeap.2010.22.1.37.

This article described an evaluation of the Bruthas Project, a community-based HIV prevention intervention for men who have sex with men (MSM) who do not form an identity around their sexual behavior. Thirty-six African American MSM completed the pilot intervention, detailed in the article. Analysis found significant reductions in unprotected anal sex with male partners, reduced numbers of unsafe sex partners (both male and female), and decreased sex while under the influence of drugs. Men also reported significantly increased social support, self-esteem, and reduced loneliness at follow-up. The positive outcomes, the authors said, suggest that this is a promising approach for reducing HIV risk in this population, and perhaps other non-gay-identifying groups.

Tools and Curricula

Understanding and Challenging Stigma: Toolkit for Action (revised edition)

Kidd, R., and Clay, S. (International Center for Research on Women, 2007).

This toolkit evolved out of a two-year research project on stigma conducted in Zambia, Tanzania, and Ethiopia, and was originally published in 2003. The toolkit contains more than 100 participatory exercises that can be adapted to fit different groups and contexts. Various sets of pictures help to identify stigma, discuss the rights of HIV-positive people, and stimulate discussions around gender, sexuality, and morality issues linked to stigma. The toolkit is a collaboration among the International HIV/AIDS Alliance, the International Center for Research on Women, the Academy for Educational Development, and PACT Tanzania. The revised edition (2007) builds on the original toolkit and includes the experience of the International HIV/AIDS Alliance's Regional Stigma Training Project. New modules now address stigma as it relates to antiretroviral treatment, children, youth, and men who have sex with men. (9 booklets, each 30 to 50 pages)

Understanding and Challenging Stigma toward Men Who Have Sex with Men: Toolkit for Action, Cambodia Edition

Pact and International Center for Research on Women (ICRW) (2010).

This 300-page resource was developed in Cambodia, where the HIV epidemic is concentrated among key populations at higher risk, including a diverse community of men who have sex with men (MSM). The toolkit, adapted and tested with local organizations in Cambodia, includes participatory, educational exercises that can be used with a wide range of individuals and groups to fight stigma and discrimination toward MSM. Although it is Cambodia-specific, it can be adapted to other contexts, and may serve as a useful tool for groups who are challenging MSM-related stigma and discrimination in their particular contexts

Understanding and Reducing Stigma Related to Men Who Have Sex with Men and HIV: Toolkit for Action, Hanoi

Institute for Social Development Studies (2010).

This toolkit, developed in Vietnam, is intended to guide action on understanding and challenging stigma related to men who have sex with men (MSM) and transgender (TG) people, with HIV prevention as one goal. It is designed to equip individuals and agencies working in HIV prevention with the knowledge and tools to understand basic issues related to gender, sexuality, and the sexual health of MSM and TG people, and to combat stigma. The toolkit comprises four sections. Part A includes exercises aimed at building knowledge and skills related to gender and sexuality; part B is designed to increase understanding of MSM- and TG-specific stigma and discrimination; part C guides planning activities geared toward reducing stigma; and the annexes provide concrete ways to use the toolkit in a workshop setting. Although it is Vietnam-specific, the toolkit can be adapted to other contexts, and may serve as a useful tool for groups who are challenging MSM- and TG-related stigma in their particular contexts.

Rapid Assessment and Response Guide on HIV and Men Who Have Sex with Men

Boyce, P., Aggleton, P. & Malcolm, A. 2004. World Health Organization.


Stimson, G., Donoghoe, M., Fitch, C., et al. World Health Organization (2003).

This 61-page guide for working with MSM explains how to conduct a Rapid Assessment and Response (RAR) focusing on lifestyles, behaviors, and HIV concerns. It outlines a series of simple and practical activities that may be used to explore the circumstances, experiences, and needs of men who have sex with men (MSM) across a variety of settings. It was designed to be used either in conjunction with the WHO Rapid Assessment and Response Technical Guide or as an independent resource. Chapters in the manual offer guidelines for carrying out an RAR with MSM, including specific guidance on planning, training, community participation, analysis, and action plan development.

Between Men: HIV/STI Prevention for Men Who Have Sex with Men

International HIV/AIDS Alliance (2003).

This 61-page publication, one of the Key Population series, gives an overview of the issues for men who have sex with men (MSM) related to HIV and other sexually transmitted infections. The report is designed primarily to support policymakers, donors, and nongovernmental organization support programs that are planning to work in communities in developing countries where few or no organizations already work with MSM. Drawing on experiences of the Alliance's partner organizations in countries such as India and Costa Rica, the report addresses issues such as why and how men have sex with men, and presents strategies for developing prevention and care programs for men.

Speaking Out: A Toolkit for MSM-Led HIV & AIDS Advocacy

Ripley J., Laurer K. Men Who Have Sex with Men Global Forum (MSMGF, 2011).

This advocacy toolkit was created to address the urgent need for men who have sex with men (MSM) everywhere to engage in advocacy locally, nationally, and globally to end the HIV epidemic and promote their human rights. The toolkit equips individuals and organizations with tools and techniques enabling them to become advocates right now, whoever and wherever they happen to be. It builds on advances made in past toolkits from around the world, with some key differences: (1) it is specifically MSM-focused, with exercises and ideas that serve as conduits for the energy and contributions of MSM communities; (2) it is built on the belief that organizations can start where they are, and assumes that the skill sets of individual advocates and organizational maturity of MSM groups are wide-ranging and take time to develop; and (3) it approaches HIV from a broad human rights framework, balancing public health and human rights approaches toward addressing MSM community susceptibility to HIV. The toolkit is designed to be participatory and contains facilitation tools, including handouts.

Respect, Protect, Fulfill—Best Practices Guidance in Conducting HIV Research with Gay, Bisexual and Other MSM in Rights-Constrained Environments

The American Foundation for AIDS Research, International AIDS Vaccine Initiative, Johns Hopkins University Center for Public Health and Human Rights, and United Nations Development Program (2011).

This guidance document was developed for both researchers and community-based organizations (CBOs) in rights-constrained environments. It is intended to help both groups to better design and conduct meaningful research on HIV among men who have sex with men (MSM) in challenging social, political, and human rights contexts. The guidance provides a checklist of factors for researchers and CBOs to consider in the design, conduct, and implementation of research studies, and offers lessons learned from case studies of research and community partnerships, recent successes, and challenges. It contains a user-friendly set of appendices with questions for researchers and CBOs to ask as they engage in MSM-focused research to ensure that they are on the right track.

Supporting Community-Based Responses to AIDS, Tuberculosis & Malaria: A Guidance Tool for Including Community Systems Strengthening in Proposals for the Global Fund to Fight AIDS, Tuberculosis & Malaria

Joint United Nations Programme on HIV/AIDS (2011).

Community Systems Strengthening (CSS) is about building the capacity of community-based organizations to become active participants in the HIV response. Although this tool is primarily intended for use by those planning, advocating for, or drafting proposals to the Global Fund, it includes concrete CSS activities and models that can be applied in other contexts. Building on the information provided in the Global Fund’s 2010 CSS Framework and additional updates to the CSS indicators, this document aims to (1) increase understanding of CSS; (2) provide practical guidance on developing CSS activities for Global Fund proposals, advocating for including CSS in national and regional proposals; and (3) suggest ways to more effectively implement CSS activities in successful proposals.

Operational Guidelines for Monitoring and Evaluation of HIV Programmes for Sex Workers, Men Who Have Sex with Men, and Transgender People—Volumes I and II, National and Sub-National Levels

MEASURE Evaluation (2012).

This document provides guidance in planning, monitoring, and evaluating programs for men who have sex with men, sex workers, and transgender people for national, subnational (volume I), and service delivery (volume II) levels. The first volume is intended for country- and national-level bodies and donor agencies, while the second is intended for networks, nongovernmental organizations, and other civil society groups. The guidelines are organized using the "eight steps" model for HIV prevention, and contain summary information, methods and tools, and resource lists.

Engaging Men Who Have Sex with Men in the Clinical Setting: A Primer for Physicians, Nurses, and Other Health Care Providers

Alaya G., Do T., Semugorna P., et al. Men Who Have Sex with Men Global Forum (MSMGF, 2011).

This document serves as a primer on health care provision for men who have sex with men (MSM) for physicians, nurses, and other health care providers in diverse clinical settings. It outlines the roles and responsibilities of health care providers regarding MSM; debunks myths commonly associated with homosexuality; and takes up key issues that affect MSM health, such as mental health, sex work, physical and sexual violence, drug use, and family relationships. The document contains an extensive resource list for health care providers interested in deepening their skills and knowledge about providing care for MSM.

Blueprint for Provision of Comprehensive Care to Gay Men and Other Men Who Have Sex with Men (MSM) in Latin America and the Caribbean

World Health Organization/Pan American Health Organization (2010).

This document offers a set of tools to support planning and implementation of health promotion and health care activities for men who have sex with men (MSM) in Latin America and the Caribbean (LAC) region. It reflects recommendations emerging from the expert Regional Consultation on Health Promotion and the Provision of Care to Men Who Have Sex with Men in Latin America and the Caribbean, held July 14-16, 2009, in Panama City. The document contains a compendium of management algorithms, or step-by-step procedural diagrams, that encompass the essential elements of a variety of approaches to MSM health, such as first clinical evaluation, HIV risk and infection, ano-rectal health, substance use, sexual concerns, emotional and mental health, consequences of violence, and community-clinic interaction. Although developed for the LAC region, it is a tool that can inform health care provision in other contexts.

Reducing HIV Stigma and Discrimination: A Critical Part of National AIDS Programs

International Center for Research on Women (2007).

This document presents strategies, program examples, and research findings about how governments, the UN system, donors, and civil society can make the reduction of HIV-related stigma and discrimination central in the national response to AIDS. Section 1 explains why stigma and discrimination serve as major roadblocks to universal access to HIV prevention, treatment, care, and support; section 2 discusses how national AIDS control programs can reduce stigma and discrimination; and section 3 lays out steps toward effective responses to HIV stigma and discrimination. Annexes include examples of successful programs, tools for measuring stigma and discrimination, resources for stigma reduction, and key points for advocacy.

Legal Aspects of HIV/AIDS: A Guide for Policy and Law Reform

World Bank (2007).

This 250-page document is intended as a practical guide to legal reform to enable effective action against HIV. It seeks to alert those working on HIV strategies and projects to opportunities for legal and policy reform and to provide them with tools to undertake these challenges. The guide identifies key issues, discusses the pertinent legal and policy considerations for each issue, and provides at least one good practice example for each, as well as resources for continued research and reading. A section focused on men who have sex with men  discusses gender orientation in general antidiscrimination statutes, sexual offenses, vague or overly broad criminal statutes and police harassment, and rights of association and expression.

MSM: An Introductory Guide for Health Workers In Africa

The Desmond Tutu HIV Foundation (2009).

This 102-page manual is designed to provide counselors and health care providers who work in Africa with a detailed understanding of men who have sex with men (MSM), issues that affect the health of MSM, and how to approach MSM in clinical settings. It is an interactive guide with group exercises, summaries, and tools to assess understanding and develop commitment. Topics covered include an overview of MSM and HIV in Africa; stigma, sexual identity, coming out and disclosure; anal sex and common sexual practices; HIV and STIs; mental health; condom and lubricant use; and risk reduction counseling. Although the guide is Africa-focused, it can be adapted for use in other contexts.

From Top to Bottom: A Sex-Positive Approach for Men Who Have Sex with Men

Annova Health (2011).

This manual, developed in South Africa but relevant in regions across the world, was put together with health care providers in mind. The manual is divided into six sections: introduction to the manual; overview of men who have sex with men (MSM) in terms of sexuality and sexual identity and key terminology; the broader public health strategies relating to MSM; the role of the health care provider in terms of providing quality, competent MSM services; the potential mental health problems that affect MSM; and practical guidelines in relation to the medical management of sexual health problems that may affect MSM.

Additional Resources

Global Forum on MSM and HIV

The Forum is comprised of a loose network of civil society groups, AIDS organizations, MSM groups, and other agencies, which together advocate at the national and global levels for improved HIV programming for MSM. The initiative is a response to the shared concern that existing HIV strategies do not adequately address the needs of MSM. The Forum disseminates information on best practices in HIV prevention and treatment, advocates for improved access and funding for MSM services, and provides a forum for MSM around the globe to strengthen their regional, subregional, and national networks. Member organizations share a commitment to social justice and human rights, and to improving the HIV response to MSM and other sexual and gender minorities.

Fundraising Toolkit—A Resource for HIV-Related Community-Based Projects Serving Gay, Bisexual, and Other Men who have Sex with Men (MSM) and Transgender Individuals in Low- and Middle-Income Countries

The American Foundation for AIDS Research (2012).

This guide provides fundraising guidance for CBOs that provide HIV-related programs and services for gay men, TG individuals, and other MSM in low- and middle-income countries. It offers information about the funders of MSM/LGBT groups, snapshots of what those grant programs look like, how to approach funders, and what projects those grant makers have supported in the past. It lists U.S.-based and non–U.S.-based funding sources. The guide also offers general tips on fundraising, from networking to proposal writing, and includes templates to help organizations and activists get started.

The Global Fund Strategy in Relation to Sexual Orientation/Gender Identities (SOGI) Strategy

Global Fund to Fight AIDS, Tuberculosis and Malaria (n.d.)

This document outlines the Global Fund’s SOGI strategy. The intent of the strategy is to augment and reinforce the efforts of the Global Fund in realizing outcomes and impact against the three diseases (AIDS, tuberculosis, and malaria); recognizing the vulnerabilities of MSM, TG peoples, and sex workers; and recognizing the imperatives to minimize harm. Actions are recommended that can be implemented in ways that are gradual, careful, built upon current positive efforts and good intents, and respectful of the varying contexts in which the Global Fund operates.

International Rectal Microbicide Advocates (IRMA)

IRMA. (n.d.)

IRMA works to advance a robust rectal microbicide research and development agenda, with the goal of creating safe, effective, acceptable, and accessible rectal microbicides for the women, men, and TG individuals around the world who engage in anal intercourse.