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The HIV epidemic among MSM in Latin America and the Caribbean: A hidden epidemic


Men in these subcultures interact sexually among themselves and with men not identified as gay. ... of homosexuality: a gender-based model in the popular ... – PowerPoint PPT presentation

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Title: The HIV epidemic among MSM in Latin America and the Caribbean: A hidden epidemic

The HIV epidemic among MSM in Latin America and
the Caribbean A hidden epidemic?
  • Carlos F. Cáceres, MD, PhD
  • Cayetano Heredia University, Lima, Peru
  • and
  • Research Network on Sexualities and HIV/AIDS
  • In Latin America
  • A study supported by UNAIDS

Background (1)
  • As of December, 2001, in Latin America /
  • 378,413 AIDS cases reported
  • 156,228 AIDS-related deaths reported
  • 1.82 million infections estimated in general
  • 190,000 infections estimated in last 12 mo.

Background (2)
  • Sexual transmission accounts for 78 of reported
    AIDS cases
  • Homosexual transmission at least as important as
    heterosexual transmission
  • Homosexuality is not a clear-cut category and its
    operationalization is complex
  • Sex between men very frequent in the region
  • Homosexual behaviour does not imply homosexual or
    bisexual identities

Background (3)
  • Enormous diversity among MSM
  • Complex interrelation between identity, desire,
    behaviour and gender roles
  • Political implications of sexual identities in a
    region where sexual identity is still a source of
    stigma, discrimination and abuse of human rights
  • A behavioural category such as MSM is used at
    present for inclusiveness
  • Conversely, interventions and community
    organizing must consider identity and politics.

Methods (1)
  • Limitations of information available
  • Epidemiological surveillance underdiagnosis,
    delayed reporting, underreporting of AIDS
  • Likely underreporting of homosexual transmission
    (e.g. Central America)
  • Dilemmas if multiple risk factors present
  • Only a few studies limited diffusion
  • Methodological challenges intrinsic to the study
    of stigmatised (and sometimes illegal) activity

Methods (2)
  • Sources of information
  • AIDS case reporting to PAHO/WHO
  • Epidemiological studies (HIV/AIDS surveillance
    database, U.S. Census Bureau personal
    communications from U.S. NMRCD, PASCA)
  • Brazilian Ministry of Health

Geographical strata
  • Andean Area (Bolivia/Colombia/Ecuador/Peru/Venez)
  • Brazil
  • Caribbean (19 countries)
  • Central America (Gua/Nic/Hon/ElSalv/CRica/Pan)
  • Latin Caribbean (Cuba, DRep, Haiti)
  • Mexico
  • Southern Cone (Argentina/Chile/Paraguay/Uruguay)

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AIDS cases who are MSM
  • Area of total of cases with
    cases known risk category
  • __________________________________________________
  • Andean Area 42.6 48.3
  • Mexico --- 54.5
  • Brazil 26.7 35.0
  • Southern Cone 31.5 32.9
  • Latin Caribbean 9.0 13.8
  • Other Caribbean 10.3 12.4
  • Central America 12.3 13.6
  • TOTAL --- 35.2

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MaleFemale Ratio 1995-2001
Findings on AIDS case reporting
  • Along the 1990s, proportion of AIDS cases who
    were MSM decreased, but total numbers remained
  • Increase in female cases, but many of them were
    sexual partners of MSM and IDU
  • Increase in cases among IDU in Brazil and,
    especially, the Southern Cone.
  • Interaction of IDU, heterosexual and MSM
  • Slight increase in perinatal cases
  • Stabilisation/reduction of blood-borne cases

HIV seroprevalence data among MSM
  • Andean Area NMRCD studies 10-20 (99-00)
  • Brazil 7-14 in Rio, São Paulo and Belo
    Horizonte (1994-1997)
  • Caribbean Best data from DR, 8-12 (1994).
  • Central America Recent PASCA studies 8-18 in
    Hon,ElS,Pan,Gua (00-01) 5 in C.R (95).
  • Mexico 16 (91-96)
  • Southern Cone Only data from Argentina (11-13)
    (91-00), Uruguay (18 in MSW, 1999), and Paraguay
    (9, 1990)

HIV seroincidence data
  • Data available from Brazil and Peru
  • City N Period P.I.
    Incidence rate
  • Rio 753 7/95-5/97 Schechter 3.10
  • SPaulo 1028 8/94-4/99 Carvalheiro 1.51
  • BHoriz. 470 9/94-5/99 Greco 1.99
  • Lima 1140 6/98-2/00 Sánchez 3.3

Social/cultural context
  • A large proportion of MSM in the region do not
    identify themselves as gay or bisexual
  • Diverse forms of gay identities emerge from, and
    help consolidate, gay subcultures in urban areas.
  • Men in these subcultures interact sexually among
    themselves and with men not identified as gay.
  • Class mediates understandings of homosexuality a
    gender-based model in the popular classes and a
    medical model in the middle classes.
  • Increasing diversification of options, and
    emergence of new sexual communities which are
    constructing the notion of sexual citizenship

Context of unsafe behaviour
  • Need to understand sexual meanings Unprotected
    sex and intimacy risk and physical stereotypes.
  • Need to take social vulnerability into account
    Low self-esteem due to self-denial and
    discrimination contributes to sexual risk class
    and ethnic segregation early stages of community

Social response (1)
  • In most countries some kind of response.
  • Level of response has depended on the type and
    magnitude of epidemic, but also on status of
    rights (and of sexual rights in particular) in
    each society.
  • Brazil represents a success story. Other
    countries with governmental work on MSM
    Argentina, Colombia, Chile, Mexico, Peru, D.R.
  • A broad range of programs information provision,
    skills building, social norm change, community
    organising (from individual to structural focus).

Social Response (2)
  • Key UNAIDS role
  • (1) Special consultation on HIV/AIDS prevention,
    care and support programmes for MSM, 1997
  • (2) Design of Strategic Planning Guide, and
    Process of Strategic Planning in 14 countries
  • (3) Constitution of a Research Network on
    Sexualities and HIV/AIDS and preparation of a
    volume and CD-ROM with research catalogue for
    decision-makers (released in this conference)
  • (4) Constitution of the Task Force on MSM and
    HIV/AIDS in Latin America

  • MSM is still the constituency most affected by
    HIV in the region, and seems to account for 1/3
    of cases in the region (and 50 sexual
  • HIV is concentrated in MSM populations in most
    urban centres (HIV prevalences between 8 and
  • Seroincidence rates, available for Brazil and
    Peru, vary between 1.5 and 3.1 new cases per 100
  • Multiple methodological challenges for the
    analysis of the HIV situation among MSM in LAC
  • MSM in the region are characterised by their
    cultural diversity, heavily permeated by social
    class, gender, ethnicity and education.

Conclusions (2)
  • Individual risk must be understood from the
    perspectives of sexual meaning and vulnerability.
  • Social response to the AIDS epidemic has depended
    on the level of involvement of all sectors and
    diversification of funding sources, strongly
    related to gay community integration into larger
    society and citizenship consciouness.
  • Efforts are needed from governments and
    communities for culturally sensitive prevention
    work integrated into processes of empowerment and
    promotion of sexual rights.
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