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

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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

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Background (1)

• As of December, 2001, in Latin America /
  Caribbean
• 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.

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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

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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.

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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

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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

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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
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Findings on AIDS case reporting

• Along the 1990s, proportion of AIDS cases who
  were MSM decreased, but total numbers remained
  steady
• 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
  epidemics.
• Slight increase in perinatal cases
• Stabilisation/reduction of blood-borne cases

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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)
  
  

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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

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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

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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
  development.

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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).

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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

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Conclusions

• 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
  transmission).
• HIV is concentrated in MSM populations in most
  urban centres (HIV prevalences between 8 and
  20).
• Seroincidence rates, available for Brazil and
  Peru, vary between 1.5 and 3.1 new cases per 100
  P-Y.
• 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.

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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.