Community-based responses to HIV in developed Asia: challenges and approaches for lesbian, gay, bisexual and transgender (LGBT) people

HIV Australia | Vol. 12 No. 2 | July 2014

By Laurindo Garcia and Jane Koerner

Challenges and approaches for lesbian, gay, bisexual and transgender (LGBT) people.

Developed Asia is a sub-region within Asia, and has been referred to by the Asia-Pacific Coalition on Male Sexual Health (APCOM) in its regional strategy and response to HIV among gay men, other men who have sex with men (MSM) and transgender people since its inception in 2007.

The countries/territories of developed Asia include Hong Kong, Japan, Macau, Singapore, South Korea and Taiwan – settings with similar characteristics including relative socio-economic prosperity, rapid uptake of internet and other technologies, and high rates of regional travel.

While a basic level of universal health care is provided by governments across developed Asia, free access to treatment for people living with HIV is not necessarily a given.

In addition, recent prevention options such as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) are not available in developed Asia and there is little open debate about their implementation, indicating the difficulties in getting HIV prevention for gay men and MSM on the public health agenda in this sub-region.

Consistent with many countries in Asia, strong cultural taboos exist in relation to homosexuality and sexuality in general, and many gay men, MSM and transgender people are not openly visible in society.

Although we use the terms gay and bisexual, MSM and transgender throughout this paper, we acknowledge that for many of these people, these identities may be irrelevant to their lived experience.

Despite the recognition by UNAIDS that human rights for lesbians, gay men, bisexual and transgender people (LGBT),¹ access to LGBT friendly health services, and protection from discrimination are critical enablers in any effective HIV response²^, ³ – it is clear that these elements are missing in developed Asia and the rights of people from sexual and gender minorities including LGBT are far from assured.

This paper will outline the epidemiology and response to HIV in developed Asia in relation to gay men, other MSM and transgender people; identify barriers to scaling-up testing and treatment; and present some examples of community-based responses.

Finally, we give suggestions on what is needed for an effective response to HIV among gay men, other MSM and transgender people in developed Asia.

Epidemiology and response

In Asia, the HIV epidemic disproportionately affects men who have sex with men. Where data exists on transgender people, HIV prevalence is significantly higher.⁴^, ⁵

Modeling by the Commission on AIDS in Asia predicted by 2020, 50% of new infections in Asia would be among MSM and transgender people⁶ and this trajectory was confirmed in the UNAIDS Global report 2013 data on HIV in Asia and the Pacific.⁷

In most low and middle income Asian countries there is now reasonably robust epidemiology on HIV prevalence, risk behaviours and HIV prevention program coverage, with most research funded by international donors.

Despite having relative wealth, developed Asia lacks nationally coordinated data on HIV prevalence and incidence, rates of HIV testing and condom use, and on the percentage of gay men and other MSM reached by prevention activities.

Virtually no data is available on transgender people in these countries/territories.

While HIV prevalence rates among MSM in developed Asia are low by global comparisons with prevalence ranging from 3.1% to 5.8%, the numbers of annual infections are increasing steadily.⁸

The few behavioural studies among MSM in developed Asia point to low rates of condom use and HIV testing, high rates of regional travel and high numbers of sexual partners enabled by the internet, as well as drug use during sex as implicated in HIV transmission.^{9 – 13}

Low levels of advocacy to address HIV among gay men, other MSM and transgender people are reflected in the fact that few countries/territories in developed Asia have national AIDS plans, and HIV activities focus on general heterosexual transmission even though HIV transmission rates in heterosexual populations are comparably low.

The poor visibility of these groups is evident in a lack of risk assessments in national epidemics, and low levels of funding and political will to affect a community-level response.

Community-based organisations exist but their scope and number are nowhere near sufficient to reach the recommended 80% of MSM to affect a reduction in HIV infections (including condom use during anal sex, and regular HIV and STI testing).¹⁴

The situation faced by MSM in Taiwan, Bangkok and Manila in the 2000s shows how rapidly HIV infections among MSM can increase in the face of poor epidemiological surveillance, inadequate funding of community responses, and inadequate government leadership, investment and action.

In Thailand, HIV prevalence increased from 17.3% in 2003 to 30.8% in 2007. This was mirrored in Taiwan, when between 2005 and 2010 HIV prevalence among gay men and other MSM increased from 17% to 71%.^{15 – 17}

In the Philippines, HIV diagnosis among MSM increased by 114% and 214% respectively between 2003 and 2008.¹⁸

These rapid increases show the importance of adequate monitoring of HIV prevalence, incidence and sexual behaviours as well the necessity to increase community-based programs targeting MSM and transgender people.

Barriers to scaling-up testing and treatment

Increasing infection rates indicate an inadequate response to date, and government policies as well as prevailing cultural and social norms have been barriers to scaling-up HIV testing and treatment. These include:

Criminalisation of people living with and most-affected by HIV, which discourages people from key affected populations from engaging with government health services. Policies requiring reform include: 377A of the Singaporean Penal Code, which criminalises sex between men; criminalisation of HIV transmission in Singapore and Taiwan; criminalisation of non-disclosure of HIV status to sexual partners deemed high-risk in Singapore; and criminalisation and forced rehabilitation of people who use drugs, including non-injecting drug users, in all countries/territories.
Institutionalised discrimination against people living with and most-affected by HIV – for example: travel restrictions on foreigners living with HIV to enter Singapore; forced deportation of migrants living with HIV in Singapore and Taiwan; cases of denial of employment and/or insurance for people living with or affected by HIV in Singapore, South Korea and Taiwan; and restrictions that prevent positive portrayals of same-sex attracted people in Singaporean media, this entrenching intolerance and stigmatisation against these groups.
Inadequate investment, capacity-building and leadership for advocacy and support services for people living with HIV and people most-affected by HIV, which has inhibited meaningful participation in policy debates about access to treatment, government subsidies for testing and sexual health services, and the quality of health services.
Cultural taboos and stigma, which make public discourse about sex, drug use, safer sex, risk reduction, harm reduction and positive portrayals of sexual minorities problematic and difficult to scale-up.
Poor visibility and advocacy of transgender communities in all countries in developed Asia, which is facilitated by a poor understanding of the complexitites of transgender and intersex identities which render many people invisible.
The conflation of gay and bisexual men and transgender populations despite their distinct health issues. There is a need to increase accessibility to gay, MSM and transgender-friendly HIV, STI and sexual health services.
Lack of a multisectoral response. In East and South East Asian countries, international development assistance builds capacity for community-based service-providers. Strengthening community systems is acknowledged as an essential activity by the Global Fund to Fight AIDS, TB and Malaria and the US Government’s PEPFAR program. Strong community systems are also acknowledged as critical enablers in achieving Millennium Development Goals (MDGs) by UNAIDS in its investment framework guidance to domestic governments.

Community level approaches

Despite the barriers identified above, there are groups mobilising to increase the visibility of LGBT issues and affect a response to HIV in developed Asia.

For sexual minorities stigmatised within Asian societies, the internet plays a valuable role in helping LGBT people to meet and access HIV and sexual health information, while also serving as a source of LGBT news.

There are a number of LGBT portal sites in developed Asia; examples include Fridae, Utopia Asia, and Gay Star News.

While the internet has been identified as a possible facilitator of risk, in that higher frequency of meeting sexual contacts by internet may be related to higher rates of unprotected anal sex, it also has significant potential to provide information on HIV prevention and treatment, and facilitate organisation of networks for care and support.

Due to the lack of government support, community-based groups in developed Asia have had to be creative in instigating support and sponsorship from private and corporate donors. Often the sources of these have been companies and individuals from LGBT communities.

While private sector engagement provides a significant entry-point for LGBT community groups to work in partnership to raise the issues they face, private sector engagement is not without its challenges.

These include difficulties in engaging business leaders, and the lack of discourse on HIV care and support for people living with HIV and reduction of HIV-related stigma and discrimination within current ‘diversity and inclusion’ activities.

This private sector support is commendable, but it cannot be relied on to fund national-scale prevention programs and treatment and support for gay men, other MSM and transgender people.

Significant resources, planning and coordination is needed in order to have a significant and lasting impact on HIV incidence in key populations.

Where to from here?

While the community responses to HIV in developed Asia are nascent, there is growing interest and potential to increase organisation on LGBT health and human rights. Initiatives such as DAN (Developed Asia Network on Sexual Diversity and HIV) and others that actively transfer good practice are a valuable source of innovation and support for groups concerned with LGBT health and should be replicated across developed Asia.

The pressing need is to increase funding and political commitment to community-based HIV prevention, care, treatment and support.

Links need to be strengthened between organisations, local health providers and other government agencies to facilitate dialogue on the problems and challenges faced by LGBT people in order to increase inclusiveness of existing programs and reduce stigma.

Increased efforts are needed to share data and monitor prevalence and incidence among gay men, other MSM and transgender people.

In order to reduce HIV infections among gay men and other MSM and a relatively unknown epidemic among transgender people, increased community-based capacity is needed to: increase access to and promote the use of condoms with lubricant; provide LGBT-friendly harm reduction services for people who use alcohol and drugs; offer reliable HIV testing and treatment; and offer general mental health support for an often marginalised community.

Invisible populations such as non-gay identified MSM and transgender people are in urgent need of tailored interventions.

Furthermore, new prevention methods including rapid HIV testing, PEP and PrEP need to be investigated for implementation within developed Asia.

The steady increase in annual HIV infections among gay and bisexual men underscores the urgent need for action.

The failure of most developed Asian governments to sufficiently allocate HIV expenditure toward evidence-based inventions alongside policies that enable communities is, ironically, contributing to an expansion of concentrated HIV epidemics among their citizens who are gay, MSM or transgender.

Considering that the cost of antiretroviral HIV therapy in this region are among the world’s highest – due to a lack of access to generic medicines – the cost of HIV treatment significantly outweighs the cost of prevention.

These costs are largely avoidable – but the failure to invest in strengthening and sustaining a community-based response leaves developed Asia lagging behind its low and middle income neighbours.

A paradigm shift towards more regular HIV testing, earlier initiation of treatment, the use of new prevention technologies and increased funding for community-based approaches that serve key populations has gained traction in the emerging economies of the world. It is high time that developed Asia matches its economic success with comparable public health outcomes for all its citizens.

Acknowledgements

The authors would like to thank Dennis Altman, Don Baxter, Seiichi Ichikawa and Joe Wong for their comments on an earlier version of this paper, and acknowledge any omissions or errors as our own.

References

1 We use the terms ‘lesbian, gay, bisexual, transgender’ (LGBT) to describe what is actually a much wider range of identities and sexualities, and also acknowledge that such terms may not be relevant to the lived experience of many people in developed Asia. Many LGBT groups in developed Asia are conscious of the labelling problems associated with the use of foreign and local terms and some use language and imagery to show inclusiveness which would be difficult to adequately describe in the scope of this paper.

2 UNAIDS. (2012). Investing for results. Results for people: A people-centred investment tool towards ending AIDS. UNAIDS, Geneva.

3 Schwartländer, B., Stover, J., Hallett, T., Atun, R., Avila, C., Gouws, E.,, et al. (2011). Towards an improved investment approach for an effective response to HIV/ AIDS. Lancet, 377(9782), 2013–2041.

4 van Griensven, F., van Wijngaarden, J. (2010). A review of the epidemiology of HIV and prevention responses among MSM in Asia. AIDS, 24(Suppl 3), S30-S40.

5 United Nations Development Programme (UNDP). (2012). Lost in transition: Transgender people, rights and HIV vulnerability in the Asia-Pacific region. UNDP Asia-Pacific Regional Centre, Thailand.

6 Commission on AIDS in Asia. (2008). Redefining AIDS in Asia: Crafting an effective response. Commission on AIDS in Asia, New Dehli.

7 UNAIDS (Joint United Nations Programme on HIV/AIDS). (2013). HIV in Asia and the Pacific in UNAIDS Global Report 2013, UNAIDS, Geneva: 33-41.

8 Onitsuka, T., Koerner, J., Kaneko, N., Tsuji,H., Cho, Y., Shiono, S., et al. (2009). HIV infection rates, risk and preventive behaviours of MSM in Asia: How does Japan compare? 9th International Congress on AIDS in Asia and the Pacific, Bali Indonesia, 9–13 August 2009. Retrieved from: http://www.msm-japan.com

9 Hidaka, Y., Kimura H., Ichikawa S. (2008). Internet survey into HIV risk and preventive factors among MSM – REACH Online 2008. In Hidaka, Y. (Ed.) Monitoring HIV prevention among internet users – 2009 Research Report. Department of Health, Labour and Welfare AIDS Research Grant, Tokyo, 7–33. (In Japanese)

10 Lau, J., Wong, W. (2000). Behavioural surveillance of sexually-related risk behaviours for the cross-border traveller population in Hong Kong: the evaluation of the overall effectiveness of relevant prevention programmes by comparing the results of two surveillance surveys. International Journal of STD & AIDS, 11(11), 719–27.

11 Lee, S., Ma, E., Tam, D. (2007). Report on the assessment of recently acquired HIV infection in men who have sex with men in Hong Kong. Stanly Ho Centre for Emerging Infectious Diseases, Chinese University of Hong Kong.

12 Wei, C., Lim, S., Guardamuz, T., Koe, S. (2012). HIV disclosure and sexual transmission behaviors among an internet sample of HIV-positive men who have sex with men in Asia: Implications for prevention with positives. AIDS and Behavior, 16(7), 1970–1978.

13 Wei, C., Guardamuz, T., Lim, S., Huang, Y., Koe, S. (2012). Patterns and levels of illicit drug use among men who have sex with men in Asia. Drug and Alcohol Dependence, 120, 246–249.

14 Chen, Y., Lin, Y., Huang, S., et al. (2011). Risk factors for HIV-1 seroconversion among Taiwanese men visiting gay saunas who have sex with men. BMC Infectious Diseases, 11, 334.

15 Low-Beer, D., Sarkar, S. (2008). Catalyzing HIV prevention in Asia: from individual to population level impact. AIDS, 24(Supp 3), S12–S19. 16 van Griensven, F., Thanprasertsuk, S., Jommaroeng, R., Mansergh, G., Naorat, S., Jenkins, R., et al. (2005). Evidence of a previously undocumented epidemic of HIV infection among men who have sex with men in Bangkok Thailand. AIDS, 19[5] pp. 521-526.

17 Farr, A., Wilson, D. (2010). An HIV epidemic is ready to emerge in the Philippines. Journal of the International AIDS Society, 13, 16. doi: 10.1186/1758-2652-13-16

18 See: (AIDS coalition pushes civil interests in amendment of AIDS law). TSSD News/ Yahoo. Retrieved from http://bit.ly/TqQkiR

Laurindo Garcia is a civil society and social justice advocate based between the Philippines and Singapore, who is often called to give a perspective of people living with or affected by HIV in the Asia-Pacific region. He is coordinator for two regional community networks, including the Developed Asia Network for Sexual Diversity, and founded a regional tech-based, social enterprise group called B-Change.

Jane Koerner started working with HIV-related community-based organisations in Australia in 1989. She has been a research associate with the Japanese Ministry of Health, Labour and Welfare funded ‘Study group on the development of community-based prevention interventions for men who have sex with men’ at Nagoya City University since 2005 and currently works at the Australian Catholic University in Canberra as a public health researcher.