HIV and gay rights activists say new guidelines released by the UN World Health Organization (WHO) on HIV programming for men who have sex with men (MSM) will not only improve health service provision for MSM, but will also act as an advocacy tool in the fight for the rights of this marginalized population.

"The document provides well-researched and evidence-based recommendations for HIV prevention and treatment of MSM, which will be useful for clinicians," said Kevin Rebe, a doctor with Health4Men, a South African health service provider which caters specifically for MSM. "The language of the paper is couched in human rights, and makes a strong call for decriminalization of same sex sexual activity, so it will also be useful for activists seeking to end discrimination."

The guidelines are designed for use by national public health officials and managers of HIV/AIDS and STI (sexually transmitted infections) programmes, NGOs and health workers. They contain MSM-specific programme activities such as the use of water- and silicone-based lubricant for the correct functioning of condoms during anal sex.

The guidelines do not advise medical male circumcision - a measure WHO recommends for HIV prevention among heterosexual men - for HIV prevention among MSM due to the lack of sufficient research on its effect of its use in MSM sexual activity.

They further recommend that health services adhere to the principles of medical ethics and the right to health, and ensure that MSM feel comfortable enough to seek medical care, with MSM-specific health needs catered for within national health systems.

"Like many other African countries, all men in South Africa are assumed to be straight, so health workers are not aware of the need to identify people of different sexualities during consultations; outside of centres like ours, there is little competency in providing health care to MSM," said Rebe. "By availing this knowledge, the guidelines will empower health workers to provide better care to MSM."

Wake-up call

In countries like Uganda, where homophobia is deeply entrenched both within society and the law, gay rights groups hope the new guidelines will serve as a wake-up call to the government about the need to include MSM in HIV programming.

"I hope the new guidelines will be an eye-opener to the government, who have so far ignored MSM within HIV prevention, treatment and support; it should show them that MSM exist in Uganda and are at high risk," said Frank Mugisha, executive director of the NGO Sexual Minorities Uganda. "They therefore cannot be ignored and urgently require HIV interventions."

Mugisha noted that the WHO document added to growing pressure from other international organizations calling for MSM to be included in HIV programmes - including UNAIDS and the Global Fund to fight AIDS, TB and Malaria - and would hopefully persuade the Ugandan government to change its policies.

According to WHO, criminalization of same-sex sexual activity plays a key role in the vulnerability of MSM and transgender people to HIV; more than 75 countries currently criminalize same-gender sexual activity.

Rebe noted that even in countries like South Africa, where MSM had their human rights enshrined in the law, widespread stigma and ignorance about their needs existed, even within the medical fraternity.

"Rights on paper only"

"These [MSM] rights are very much rights on paper only, they are not guaranteed; homophobia remains widespread, with politicians frequently making openly homophobic statements," he added. "If used widely, these guidelines have the potential to help reduce stigma and improve the level of care MSM receive."

Policymakers say the guidelines will help to inform planned HIV programming for MSM. "One of the biggest problems we have for MSM seeking health care is the attitude of health workers - these guidelines will build on the body of knowledge we have on supporting this group," said Nicholas Muraguri, head of Kenya's National AIDS and STI Control Programme.

Muraguri noted that although the Kenyan penal code still criminalized same sex sexual activity, the Constitution's Bill of Rights laid out the right of every Kenyan to health.

"MSM don't live on the outside of society, they live with us and deserve the same treatment as other members of society; recent studies show that in Kenya MSM HIV prevalence is as high as 25 percent - and many of these men are married and have girlfriends, so ignoring them is totally impractical," he said. "HIV programming for MSM is not a matter of choice - it is a necessity."

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