Hope, struggle and the city: scaling-up HIV services for men who have sex with men and transgender people across Asia’s megacities

If I understand it correctly, that decision was taken at least in part because global estimates have shown that as many as 50% of all people living with HIV reside in cities.

Rural to urban migration is now the dominant pattern of human movement across the world, placing intense pressure on municipal systems to respond to the human condition in urban settings.

Cities are important sites in the struggle to ensure comprehensive HIV services for those most vulnerable to HIV.

In 2010 Lou McCallum of the AIDS Projects Management Group and I were approached by the UNDP Asia Pacific Regional Centre to develop a methodology for and then implement a city-level inquiry in order to mobilise municipal actors and encourage the scale-up of HIV services for men who have sex with men (MSM) and transgender people in Asia’s megacities.

Together with USAID and UNAIDS, Lou and I undertook city-level inquiries in six Asian megacities: Bangkok in Thailand, Yangon in Myanmar, Ho Chi Minh City in Vietnam, Manila in the Philippines, Jakarta in Indonesia and Chengdu in China.

The result was the production of a series of city-level reports linked to city work plans, a regional report aimed to provide advice on the scale-up of HIV services and a regional meeting to share promising municipal practices among city actors.

In 2012, with the help of Dr Sai Pye of The HIV Foundation and, again, with the UNDP Asia Pacific Regional Centre, we undertook the Myanmar 5 Cities Initiative for MSM and transgender People.

This initiative used appreciative inquiry techniques to identify promising practices, no matter how small or informal they may be, across the comprehensive package of HIV services for MSM and transgender people in Asia and the Pacific.

We recruited local MSM and transgender leaders, provided training in appreciative inquiry and appreciative questioning and sent them in to their cities to collect information, to run meetings and groups and to create an environment for increased momentum towards scaling up good practice.

Asia’s megacities as sites of struggle

‘We have a number of transgender sex work clients who have been detained, sometimes in female camps and sometimes in male camps. Either way, their health needs are not being met.’ — Lawyer at a legal service in Ho Chi Minh City

Cities offer the chance to relieve poverty and that hope draws great numbers of people from rural settings. But rural-to-urban migration is, in reality, migration from the country to urban slums or to poorer city suburbs.

Slums and poor suburbs are places of overcrowding, crime, violence and reduced quality of life for most of their residents. Cities are dangerous places. Where poverty is endemic, corruption and graft are not far away.

We see this connection in national laws that aim to reduce crime across a nation by criminalising drug use, sex work or same-sex relations between citizens.

These laws, filtered through the complex social and economic dynamics of a city, lead to graft and corruption. The beneficiaries of that graft can include the very people who enacted the laws in the first place and the losers are the poor and those most vulnerable to HIV.

It can be difficult for national policies that aim to improve HIV health to find their way into practice in local hospitals and clinics and, where corruption is endemic, these sites may require ‘danger money’ from their patients with HIV.

Even HIV community services can be affected. Multiple laws interacting in city contexts can create exactly the opposite effect to that for which they were individually and collectively aiming. For example, national health departments encourage condom use among sex workers and among MSM and transgender people, and they encourage a ‘clean fit for every hit’ among people who inject drugs.

Yet police in some cities make arrests based on prevention paraphernalia found on citizens – ironically, the same paraphernalia distributed and promoted by their own governments.

Prisons and rehabilitation camps are places of intense HIV risk in some of Asia’s cities. Those who are HIV-negative at the time they are incarcerated are likely to emerge from those closed settings HIV-positive.

Asia’s megacities as places of hope

‘We also want to run this event to let people know more about [gay, lesbian, bisexual and transgender] GLBT life . . . GLBT people come to see movies at the festivals and sometimes they bring their friends and families from outside the GLBT community who are interested. This can help change people’s opinions and views about us.’ — Volunteer leader of Q! Film Festival – Jakarta, Indonesia

A key strategy for improving this situation is to attempt to ‘turn it on its head’ – that means creating opportunities for the poor and most vulnerable to influence those who make decisions about policy and law related to HIV.

In this regard, Asia’s megacities provide opportunities that wouldn’t be possible in rural settings. They have become important sites for building networks and connections between MSM and transgender people and for providing and advocating for essential services and human rights, often in the absence of effective services provided by the state.

Community-based organisations and their services are crucial to the scale-up of services for MSM and transgender people in Asia’s megacities because they are flexible, innovative and can act quickly to implement new ideas.

Yet governments in the region remain ambivalent about the strengthening of civil society and many community organisations receive short-term funding from international donors rather than their national or city governments.

In spite of this, large-scale annual community events, MSM and transgender-led community services and public-private partnerships can be found in all the cities we worked in.

‘Without great care and attention to the needs and concerns of clinical staff . . . meeting with nursing teams, learning about their practice concerns and working out how to alleviate the pressure on these teams … it would be impossible to make a program like [ours] work effectively.’ — Aek, The Poz Home Centre, Bangkok

Public health services are vital to the HIV-related health and rights of MSM and transgender people, especially with regards to providing accessible and high quality HIV prevention, treatment, care and support. Yet a key theme across Asia’s megacities is the gap between demand and supply for these services.

In a number of cities the supply of voluntary counselling and testing services is there but the lack of sensitivity towards MSM and transgender people means that demand for these services has yet to be generated.

This results in late presentations of AIDS-defining illnesses among MSM and transgender people living with HIV. A key strategy is to increase the dialogue and cooperation between those most vulnerable to HIV on the one hand and public health practitioners on the other hand.

The need to scale up clinical and community collaborations for shared delivery of services will help to rectify the lack of demand. People living with HIV are a visible source of leadership, participating in small-scale yet innovative community-clinic partnerships to deliver HIV treatment, care and support services.

Active collaboration between public health services and MSM and transgender people’s community services is essential to achieving scale.

‘We [at the Ho Chi Minh City Provincial AIDS Committee] see communication with all our partners and listening to each other as key. In terms of programs for MSM we should not stop at condom provision but also provide MSM and transgender people with more service options.’ — Thi Thu Tran Hue, Ho Chi Minh City Provincial AIDS Committee

The reality is that governments at different levels play an important part in supporting or undermining efforts to prevent HIV spread and support those living with HIV.

Governments are part of the solution to HIV among MSM and transgender people in municipal settings, even when they uphold and enforce punitive laws.

In all the cities we scanned we found champions in government services who were willing to support and advocate for MSM and transgender people. City-based inquiries such as this one can help to identify government champions and better utilise them.

One key challenge is that expertise, resources and power most often exist at the national level within the HIV departments of ministries for health.

City governments have mostly been ignored and a key goal is to make HIV programming resources and expertise more available to them.

Where to from here?

The UNDP Urban Health and Justice Initiative has been making strides that set the scene for more hope than struggle on HIV in urban settings in the future.

The Initiative has been leading citybased inquiries for key populations in Africa, Latin America, the Caribbean and Eastern Europe. The Urban Health and Justice Initiative is about to release a guidance note for implementing an inquiry into municipal-level scale up of programs and services to key populations for HIV.

This guidance offers a four-stage model of inquiry with some new and useful elements incorporated into the methodology. The first stage of the model involves engaging with city governments to ensure their active leadership, liaising with groups and organisations representative of key populations and facilitating forums for dialogue between parties.

The second stage involves collecting available literature and discussing that literature with all the city players.

A third stage involves fieldwork, presenting preliminary results and building consensus on the next steps to be taken towards scale-up.

A new and important addition to the municipal inquiry model is a fourth stage aimed at facilitating ongoing urban cooperation through sustained dialogue, sourcing funds for city governments and city actors to deliver innovations, and sustaining cooperation with key populations at municipal level.

This anticipated guidance note offers cities a blueprint for undertaking municipal inquiries of this kind. As a desired result, the number of city governments in Asia and the Pacific, and other regions, actively engaging in the advocacy shall increase.

Scott Berry is an international HIV development practitioner based in Bangkok, Thailand and currently working on USAID projects in South-East and Central Asia through AIDS Projects Management Group and the non-profit organisation The HIV Foundation.