Dennis Altman

A call to action for comprehensive HIV services for men who have sex with men

Where surveillance has been done, it has shown that men (MSM) who have sex with men bear a disproportionate burden of HIV. Yet they continue to be excluded, sometimes systematically, from HIV services because of stigma, discrimination, and criminalisation. This situation must change if global control of the HIV epidemic is to be achieved. On both public health and human rights grounds, expansion of HIV prevention, treatment, and care to MSM is an urgent imperative. Effective combination prevention and treatment approaches are feasible, and culturally competent care can be developed, even in rights-challenged environments. Condom and lubricant access for MSM globally is highly cost effective. Antiretroviral-based prevention, and antiretroviral access for MSM globally, would also be cost effective, but would probably require substantial reductions in drug costs in high-income countries to be feasible. To address HIV in MSM will take continued research, political will, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

The increase in global HIV epidemics in MSM

Epidemics of HIV in MSM continue to expand in most low, middle, and upper income countries in 2013 and rates of new infection have been consistently high among young MSM. Current prevention and treatment strategies are insufficient for this next wave of HIV spread. We conducted a series of comprehensive reviews of HIV prevalence and incidence, risks for HIV, prevention and care, stigma and discrimination, and policy and advocacy options. The high per act transmission probability of receptive anal intercourse, sex role versatility among MSM, network level effects, and social and structural determinants play central roles in disproportionate disease burdens. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiologic data show marked clustering of HIV in MSM networks, and high proportions of infections due to transmission from recent infections. Prevention strategies that lower biological risks, including those using antiretrovirals, offer promise for epidemic control, but are limited by structural factors including, discrimination, criminalization, and barriers to healthcare. Subepidemics, including among racial and ethnic minority MSM in the United States and UK, are particularly severe and will require culturally tailored efforts. For the promise of new and combined bio-behavioral interventions to be realized, clinically competent healthcare is necessary and community leadership, engagement, and empowerment are likely to be key. Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

Men who have sex with men: stigma and discrimination

Faculty of Humanities and Social Sciences, School of Social Sciences, La Trobe University, Melbourne (Bundoora), VIC, Australia (D Altman MA); National Centre in HIV Social Research, University of New South Wales, Sydney, NSW, Australia (P Aggleton PhD); Michael Kirby Centre for Public Health and Human Rights, Monash University, Melbourne, VIC, Australia (M Williams LLB); University of Hong Kong, Pokfulam, Hong Kong (T Kong PhD); Human Sciences Research Council, Pretoria, South Africa (V Reddy PhD); Grupo Dignidade, Curitiba, Brazil (D Harrad MA); Associacao Brasileira de Lesbicas, Gays, Bissexuais, Travestis e Transexuais, Curitiba, Brazil (T Reis PhD); and Mailman School of Public Health, Columbia University, New York, NY, USA (R Parker PhD)

Globalization, political economy, and HIV/AIDS

The rapid spread of HIV/AIDS particularly in southern Africa southeast and southern Asia and the Caribbean represents for many of the countries involved a major threat to their social and economic fabrics and hence to their survival. Increasingly the world will face issues like HIV/AIDS which by their very nature go beyond the ability of the national government to control. The particular nature of disease transmission raises questions about appropriate public health responses and the balance between human rights and respect for existing religious and cultural norms. In developing countries AIDS poses a challenge to existing social economic and gender relations. Attempts had been made to put HIV/AIDS epidemic in the social and economic contexts. However there is another strand of analysis that seeks to place HIV/AIDS within broader scopes to link its spread impact and governance to the sociopolitical changes of the post-Cold War world and to the rapidly growing literature of globalization. Hence features of the contemporary world linked to globalization-economic development such as population movements and the breakdown of traditional ways of life also further the spread of HIV. However there remains an uncommon perspective on the disease. Therefore there is a need to combine two strands of academic discourse and integrate them with programs of nongovernmental sectors against HIV/AIDS in order to find ways to stop the epidemic.

AIDS and Security

The war on terrorism has drawn attention to non-conventional threats to security, even as it led to conventional warfare in the case of the attack on Iraq. HIV/AIDS is arguably an even greater threat to security, with the effect of destabilizing the social and economic order to the extent that the very survival of entire nations is at stake. This article examines both the security implications of AIDS, and the various international responses aimed at slowing its spread and mitigating its impact.

AIDS: Taking a long-term view

Twenty years ago AIDS politics were marked by the fury of ACT UP, itself a response to the failure to find effective treatments. The rapid development of Anti Retroviral drugs (ARVs), and their roll out in many parts of the world, reminds us how quickly and dramatically politics and biomedicine can change. A book promising ‘a long term view’ and edited by a ‘2031 consortium’ can be expected to hypothesise a future which is radically different from the present. Less than a decade ago the conservative scholar, Nicholas Eberstadt, warned of a major pandemic in Eurasia that ‘will alter the economic potential of the region’s major states and the global balance of power’ (Eberstadt 2002). The tragedy of AIDS today is that it is unequally affecting the most vulnerable and marginalised, both in terms of geography and behaviour, and it is increasingly difficult to persuade most people that it is a global priority on the same level as climate change, food and water shortages and the growing collapse of viable states across many parts of the world. It is a basic maxim that if one wants to assess long-term developments, the worst people to do it are those with a stake in immediate programmes and institutions. AIDS: Taking a long-term view is written by a consortium, all of whom come from deep involvement and commitment to the fight against HIV. Reading the book I longed for a sceptical voice, for someone who might have pointed out that there is a widespread view that the importance of HIV/AIDS has been overstated and needs to be reconceptualised. Readers not already persuaded that AIDS is a major global priority would find little in this book to convince them. The authors have done a great job of synthesising present data and policy prescriptions. But if we are to be serious about forecasting 20 years into the future we need a more convincing sense of where AIDS fits in the changing global demands and priorities. The book comes closest to this in several references to climate change, which is correctly seen as demanding increasing attention and resources. In comparing the two the book suggests that a crucial difference is that AIDS has been treated as an emergency, not a ‘long-term undertaking’. This may be true. But surely the crucial difference is that climate change affects everyone, whereas outside sub-Saharan Africa HIV is not a major threat to the great majority of people. The authors assert that: ‘We jettison old ways of doing business and venture out in new directions’. Apart from the rather obvious point that if they were aware of Global Public Health Vol. 6, No. 8, December 2011, 920 922

International norm polarization: sexuality as a subject of human rights protection

International norm polarization is a rare but recurring process within international norm dynamics. Polarization describes the most combative response to attempted norm change: ‘a candidate norm is accepted by some states but resisted by others, leading to a period of international disputation between two groups in which socializing pressures pull states toward compliance with rival norms’. We identify several cases of polarization and explain this phenomenon by elaborating the constructivist model of the norm life cycle to processes of international resistance to norm change as well as to norm acceptance. We also draw on social identity theory (SIT) to examine group-psychological responses where disputed norms become closely linked to state identity. We illustrate these dynamics with reference to conflict over the norm that recognizes sexual orientation and gender identity as subjects of international human rights protection. Over the past decade this candidate norm has become increasingly contentious internationally, and bitter debates over resolutions concerning extra-judicial killings and discrimination have divided the United Nations General Assembly and Human Rights Council. The article makes a primary contribution to analysis of international norm change and also contributes to an emerging literature concerning sexuality and international relations.

AIDS and the globalization of sexuality1

This article builds on the authors book, Global Sex, to consider how globalization has impinged upon changing sexual mores and behaviours, and how these, in turn, are related to the spread and control of HIV and AIDS. AIDS has made the sexual possibilities of social and economic change more central to public policy, and concentrated political attention on the ‘breakdown’ of traditional cultural and social structures, whether these are the idealized nuclear family in the west or more traditional extended families in many non-western societies. Both the needs for effective public health and a respect for human rights require an insistence on the right to sexual diversity as part of a wider move towards the recognition of difference as an essential part of the human condition.

Thinking politically about HIV: political analysis and action in response to AIDS

AIDS has a uniquely political history. Its early association with stigmatised homosexual behaviour and more liberating gay identity activism set the precedent for highly effective mobilisation. The results were unparalleled in global health. AIDS was briefly treated as high politics and attracted increased funds to achieve the ambitious goal of universal access to HIV prevention and treatment. If AIDS is to maintain its visibility and contribution to global solidarity, human rights and dignity, its politics must evolve to reflect the profound geo-political, economic and social transformations currently underway. ‘Thinking politically about HIV’, an initiative of UNAIDS and the International AIDS Society, was convened in recognition of the need to better understand these politics and consider how the political sciences can further engage. This paper, and the edited volume it introduces, provides some insights into the Thinking Politically discussions as well as the wider scholarship on the challenges facing the AIDS response. The authors argue that while mainstream political science has largely ignored the epidemic, other disciplines and traditions provide rich accounts of the exceptional response. Given the changing context, the authors present an agenda of practically oriented, politically informed research to identify the levers that can be used to maintain the viability of the response.

The primacy of politics: organizing around AIDS.

The strongest community-based AIDS organizations were initially established in northern Europe, North America, and Australasia where politically-organized gay communities, which were first affected by HIV/AIDS, had political and economic resources. In countries where AIDS is not as clearly linked to specific communities, mainly in Africa and the Caribbean, the shape of HIV support organizations is very different, with much of the leadership coming from preexisting grassroots organizations not based in any particular community. Even more significant than the epidemiology of the pandemic may be the extent of political space conferred to nongovernmental organizations (NGO), which in many parts of the world are regarded with great suspicion by governments. AIDS-related organizations face considerable governmental obstacles in many countries due to a governmental desire to control all aspects of public health, governmental hostility to any attempts to create groups outside of the direct control of the state, religious opposition to discussing AIDS, and/or antipathy between NGOs and government. The paper discusses community-based AIDS organizations in Western countries, community organizing in Southeast Asia, AIDS in Asia/Pacific, and the importance of community-based organizing.