Key points from Think Tank on the Lancet special issue on MSM and HIV

January 2013 

• There is no excuse for inaction in tackling the global HIV epidemic among gay men, other MSM, and transgender individuals (GMT).  Epidemiology shows that GMT epidemics are expanding in many places, even as the epidemic slows gradually for other populations.  Today, a core part of being strategic is addressing the needs of key populations.  For organizations working broadly on global AIDS, addressing the epidemic among GMT should be a priority function.

• Act immediately to significantly expand access to services.  In many settings, basic tools and services are not available to GMT.  There is a need for urgency in scaling up delivery of services, including condoms, lubricant, HIV testing, information about sexual risk reduction, and HIV treatment.  There are many complex challenges in effectively addressing HIV among GMT, but these complexities must not stand in the way of immediate action to significantly expand delivery of basic services.  Increased funding to address GMT & HIV is essential to make this possible.

• Expand and improve the work of donors and technical partners.  UNAIDS, WHO, the Global Fund, PEPFAR and the World Bank need to be encouraged to expand their work on the HIV epidemic among GMT.  This includes dedicated staff and “champions” within each organization that are committed to strategic planning, new service and funding targets, epi surveillance, and the necessary advocacy and diplomacy to ensure success.  Each of these organizations can push for more leadership from their country offices.  They can establish non-discrimination policies.  A meeting like this Think Tank is needed in Geneva, coupled with a day-to-day advocacy presence as well.

• Manage transition so key populations are not abandoned.  PEPFAR and other US Government programs are in the process of transitioning relationships to advance country ownership.  Metrics and benchmarks are needed to gauge progress on rights and health services for key populations so these transitions do not lead to the abandonment of marginalized. 

• Expand accountability and advocacy. Donors and governments should set targets that are designed to motivate implementers and policymakers. Donors should document how they are spending funds to advance the response among GMT; ongoing assessments of this funding and the coverage levels achieved is needed.  Donors can advance accountability in several ways, for example by instituting conditions on grants.

• Make basic data available.  The lack of data on services and funding flows hampers accountability and planning.  Perfect information is not necessary, but at present there is a dearth of even basic information on the epidemic and the response among GMT.  Donors and health officials need to gather and make public basic information about service provision.

• Expand community involvement.  Civil society engagement in planning and implementation of HIV programs for GMT is at the heart of both the PEPFAR Blueprint and the Global Fund’s Five-Year Strategy. These commitments must be operationalized and implemented. Create a guide for civil society advocates to influence PEPFAR Country Operational Plans (COPs), Global Fund Country Coordinating Mechanisms (CCMs), and other planning processes.  PEPFAR and other programs can require representation of civil society and key populations on planning bodies. Financial support is vital to engage these partners in service delivery and advocacy.

• Scale up provider education.  Identify and train providers who can effectively retain GMT in clinical settings; different approaches should be implemented and evaluated.  Include more GMT-related training into the PEPFAR MEPI and NEPI programs.  Expand curriculum in medical schools globally. 

• Better define how to fight stigma.  Homophobia, criminalization and stigma are an enormous part of the problem.  Donors often face challenges in identifying effective interventions to address stigma.  Compile best practices. Build linkages to human rights and LGBT groups where possible.  

• Expand research. Priorities include implementation science to understand how to reach different GMT groups, effective combinations of services, strategies to overcome stigma, and how to achieve scale in the most cost-effective manner.  Better diagnostics for acute infection are needed.  Rectal microbicide research is a top priority.

• Make a plan for PrEP. There is a need for a PrEP implementation plan for GMT that is highly targeted, actionable, and costed.

• Communicate the urgent need.  Use multiple communications tools to make the severity of the epidemic and the serious underinvestment in GMT & HIV much more visible.  The successful political argument will be focused on clear outcomes: lives saved, infections averted.  Articulate where programs for GMT are working and the factors that determine success.