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Combination Approaches: Enhancing the Reach & Effectiveness of MSM-Targeted Combination HIV Prevention Interventions
I. Definition of the Prevention Area
Men who have sex with men (MSM) are globally disproportionately affected by HIV and urgently need increased coverage by quality prevention interventions. Evidence has shown that sustained combination approaches to HIV prevention that simultaneously address biomedical, behavioral and structural risks are most effective at reducing HIV transmission in generalized, concentrated, and mixed epidemic scenarios. Despite this evidence and the disproportionate epidemic burden MSM shoulder, HIV prevention services remain sub-optimal in many countries.
Not every MSM has an identity associated with their sexual preferences and behavior and therefore may remain non-self-identified, posing a formidable challenge to programs that seek to target them. For example, the term "MSM" can include gay- or bisexual-identified men, transgender men who have sex with men, men who identify as completely heterosexual, men who identify through indigenous identities outside the largely Western concepts of hetero- or homosexuality, or men with no particular sexual identity at all. In many cultures, heterosexism (the assumption that everyone is heterosexual) is pervasive, and any behavior or identity that deviates from a heterosexual cultural norm is stigmatized and discriminated against, and is in some cases criminalized.
Individual-level risks for HIV acquisition in MSM include unprotected receptive anal intercourse, a high frequency of male partners, a high number of lifetime male partners, injecting and non-injecting drug use, a high viral load in the index partner, and mental health issues. On the structural level, risks include criminalization of same-sex behavior, MSM avoiding health services out of fear of discrimination, and breaches of privacy and confidentiality. In order to succeed, HIV prevention interventions must address the complexities of MSM identity and take into account multiple levels of risk. Combination approaches that simultaneously address behavioral, biomedical, and structural risks are an effective way to do this. At all levels, MSM individuals and communities must be involved in the conceptualization, planning, implementation, and evaluation of research and programming.
II. Epidemiological Justification for the Prevention Area
Three decades into the epidemic, HIV continues to disproportionately affect MSM everywhere. Globally, MSM are 19 times more likely to be infected by HIV than the general population of reproductive age and have an overall HIV prevalence of 12%. Many MSM also have female sexual partners and can serve as a bridge to other populations. Despite these facts, research and interventions targeted at MSM are still under-prioritized by governments, donors, and civil society. Surveillance data, when available, is limited and likely underestimates both MSM population size and their HIV prevalence rates. Some estimates suggest that as low as 5% of MSM worldwide have access to basic HIV prevention services.
There is evidence to show that MSM-targeted prevention interventions can reduce risk for HIV infection among MSM. Group- and community-level behavioral interventions among MSM have been shown to lead to up to a 43% decrease in unprotected anal sex, and group-level interventions have been shown to increase the odds of condom use by as high as 81%. A recent study suggests that behavioral interventions that reach 25% or more non-self-identified MSM are more effective than those targeting self-identified MSM alone. Another study suggests that countries that combine MSM-specific community-based behavioral prevention interventions with condom and condom-compatible lubricant distribution can reduce new HIV infections among both MSM and the general population. Evidence also shows that episodic and/or single-track interventions tend to be less effective in the long-term, which highlights a need for sustained combination prevention approaches.
III. Core Programmatic Components
The World Health Organization (WHO), together with other global agencies, has identified a set of evidence-based, mutually reinforcing biomedical, behavioral, and structural HIV prevention intervention components which, when combined, effectively reduce HIV infection among MSM. The following are some examples of strongly-recommended program components:
- Biomedical approaches aim to reduce HIV transmission and acquisition risk. Current approaches the WHO strongly recommends include condom distribution with silicone- and water-based lubricants combined with counseling and education, voluntary counseling and testing (VCT), sensitization of VCT sites to MSM needs, sexually transmitted infection (STI) screening and treatment (for genital, oropharyngeal and anorectal STIs) and antiretroviral therapy, including post-exposure prophylaxis (PEP). Though these are the current approaches, the combination prevention toolkit is growing with as more research is done around pre-exposure oral prophylaxis (PrEP) and rectal microbicides.
- Structural prevention efforts aim to bring about social change in the general population by reducing stigma and discrimination and other barriers to effective prevention and treatment of HIV. Decriminalization of same-sex behaviors, policies that safeguard MSM and transgender rights, engagement with the media, and community and health systems strengthening are all examples of viable program components. However, none of these are unless communities are effectively mobilized, engaged, and empowered. Community members must be involved as a collaborative, iterative process. Moreover, evidence-based advocacy is an important step towards achieving positive structural change.
- Behavioral approaches aim to promote safer behaviors to prevent HIV; specifically, sustained efforts to increase the use of condoms paired with water- and silicone-based lubricants, reduce the frequency of unprotected anal sex, and increase health-seeking behavior. Behavior change communication can effectively be delivered at individual, group and community levels and can include mobile phone messages, Internet-based strategies and social marketing campaigns; and other message delivery from diverse communication platforms, including sex venue "hot spots", health care facilities, and the general community.
MSM population size estimation is essential to prevention intervention program design. This poses a significant challenge, as many MSM do not self-identify or choose not to disclose their sexuality. A number of methods, including the relatively new network scale-up method, have shown effectiveness for use with MSM. UNAIDS recommends making estimates by triangulating results from more than one method and cautions that data should be interpreted with caution and sampling method biases should be clearly acknowledged. Finally, more research should be done on the viability of all methods for use with MSM.
IV. Current Status of Implementation Experience
Regardless of which combination of prevention approaches is used, a number of overarching best practices are recommended to improve the reach and quality of all MSM-targeted HIV programs:
- 1. Involve MSM and MSM living with HIV in program design, implementation, and evaluation. The most deep-reaching and successful approaches to prevention interventions leverage community ties and experiences; their networks, an understanding of risk-related issues, and their ability to meaningfully connect with other MSM.
- 2. Ensure confidentiality. Given the high levels of stigma and discrimination MSM face, confidentiality is a key requirement.
- 3. Provide training for both general healthcare staff and staff who work in HIV prevention, care and treatment programs to help them provide quality, stigma-free services.
- 4. Reach beyond MSM groups. Interventions that target general audiences in addition to MSM audiences have been shown to also reach diverse subgroups of MSM, including non-self-identified MSM.
- 5. Collect and use strategic information such as ongoing surveillance, research studies, and monitoring and evaluation data, and incorporate new knowledge and technological advances as they emerge.
- 6. Link, integrate and co-locate services, especially to HIV care and treatment for HIV-positive MSM. This is particularly important, as anti-retroviral therapy has been identified as a key component of successful HIV prevention.
Although many studies demonstrate the reproducibility of research and the effectiveness of behavioral interventions with MSM in the United States, far less information is available for program outcomes in other geographic areas, such as Africa and Asia, and among hard-to-reach subgroups of MSM. To inform future interventions, more investment must be made in conducting research in these other contexts and publishing findings widely.
HIV in Men Who Have Sex with Men in Sub-Saharan Africa
Sabin M.L., Lazarus J.V. Frescura L., et al. 2012. Lancet. Vol. 12, No. 7, p. 505-506.
This article is a brief yet poignant comment on MSM in sub-Saharan Africa. The article states that 32 of 45 sub-Saharan African countries reported that MSM indicators were relevant to their country; however, no data were available for any of them. There are huge surveillance gaps, and of the 1 percent of governmental spending earmarked for special populations only 8 percent of those funds are budgeted for programs targeting MSM.
The Global HIV Epidemics among MSM
Beyrer, C., Wirtz, A. L., Walker, D., et al. 2011. Washington, DC: World Bank.
This 300-page monograph is one of the most comprehensive MSM-specific resources available to date focusing on MSM HIV epidemics in low- and middle-income countries. It provides an up-to-date, detailed overview of epidemic scenarios among MSM across the globe, using selected country studies to describe and explore epidemiological variance across contexts. A modified Goals Model for MSM was developed to model the effects of MSM preventive services in the countries, as well as a costing exercise to estimate their degree of cost-effectiveness. The monograph also contains detailed information on combination HIV prevention interventions, graded using a novel adaptation of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for public health interventions, with recommendations for priority areas. There is a chapter on epidemic modeling of prevalence, incidence, and cost in MSM populations, as well as a chapter focused on policy and human rights.
The Global Epidemics of HIV among MSM in 2010: Epidemiology, Responses, and Human Rights
Beyrer, Chris. 2010. Presentation at Global Forum on MSM and HIV Preconference, Vienna, Austria, July 17, 2010.
This presentation, given at the Global Forum on MSM and HIV Preconference in Vienna in 2010, contains these key findings related to HIV prevention among MSM: (1) MSM-specific prevention interventions can have an impact on the rate of new infections in the general population but must include access to antiretrovirals for MSM; (2) where people who inject drugs play a major role in the epidemic, needle-exchange programs and substitution therapy programs can have a major impact on the rate of new infections in the general population; and (3) human rights–based approaches and science are in agreement. The presentation provides a detailed overview of four distinct epidemic scenarios, recognizing that HIV epidemics among populations of MSM occur together with those affecting other exposed groups (i.e., people who inject drugs, heterosexuals).
The Effectiveness of Individual-, Group-, and Community-Level HIV Behavioral Risk-Reduction Interventions for Adult Men Who Have Sex with Men—A Systematic Review
Herbst J.H., C. Beeker, A. Mathew, et al. 2007. American Journal of Preventive Medicine. Vol. 32, No. 4 (Supplement), p. 38-67.
This article presents the results of a systematic review of the effectiveness and cost-effectiveness of individual-, group-, and community-level HIV behavioral prevention interventions for MSM. Of 664 titles screened, the article presents 31 candidate studies as a body of evidence, with each evaluated according to a series of parameters, including intervention effectiveness, applicability, economic efficiency, and barriers to implementation. The review shows that individual-level, group-level, and community-level HIV behavioral interventions can reduce the odds of unprotected anal intercourse (by 27 to 43 percent) and increase the odds of condom use for the group-level approach (by 81 percent). Group- and community-level interventions were found not only to be cost-effective, but also to result in cost savings. The review can be used as a tool in HIV policy and program work to help secure resources and commitment for implementing interventions among MSM. v
Behavioral Interventions to Reduce Risk for Sexual Transmission of HIV among Men Who Have Sex with Men
Johnson W.D., Diaz R.M., Flanders W.D., et al. 2008. Cochrane Database Systematic Review. Vol. 3.
This review considers behavioral interventions as a means for reducing risk for sexual transmission of HIV among MSM. It analyzes 44 studies evaluating 58 interventions, including small group-, individual-, and community-level approaches. Interventions reviewed include individual counseling, peer education, group counseling, and interventions in community areas, among others. The review found that behavioral interventions can lead to significant reduction in risk for HIV transmission among MSM; however, it highlights the need for further analysis to understand in greater detail which interventions are most effective for which groups. One interesting finding is that interventions that included greater than 25 percent non–gay-identifying MSM were more effective than those that did not. This suggests that, when they can be reached, these men may be more responsive to risk reduction efforts.
Mental Health and HIV Risk in Men Who Have Sex with Men
Safren S.A., Reisner S.L., Herrick A., et al. 2010. Journal of Acquired Immune Deficiency Syndrome. Vol. 55, Suppl. 2., p. S74-S77.
Using the early monotherapeutic AZT HIV treatment as a metaphor, this article makes the point that current behavioral approaches to HIV risk reduction among MSM have shown short-term effects but have not shown effectiveness in the long term. Looking at recent articles that have explored the effect of diverse psychosocial factors interacting to produce elevated risk behavior among MSM—called a syndemic—the authors hypothesize that psychosocial and mental problems may moderate the ability of existing interventions to reduce risk. Addressing co-occurring psychosocial risk factors may improve the effect sizes of current HIV prevention interventions, allowing for more effective intervention uptake by MSM. The authors advocate for combination approaches to prevention.
Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000–2006: A Systematic Review
Baral, S., Sifakis, F., Cleghorn, F., et al. 2007. PLoS Medicine, Vol. 4 No. 12, e-pp. 339.
MSM in low- and middle-income countries in Asia, Africa, Latin America, and the former Soviet Union experience high levels of HIV transmission. The authors examined the relationship between HIV prevalence among MSM to that of the general population in countries with low to high HIV prevalence overall. After conducting a meta-analysis of studies in low- and middle-income countries, the authors found that HIV prevalence among MSM was 58 times as high as the general population in nations with very low prevalence. In medium-high prevalence settings, HIV prevalence among MSM remained high, at nine times that of the general population. MSM from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved, due in part, say the authors, to the criminalization of sex between consenting adult men in 85 countries as of 2007.
Review of Sampling Hard-to-Reach and Hidden Populations for HIV Surveillance
Magnani R., Sabin K., Saidel T., et al. 2005. AIDS. Vol. 19, Suppl. 2, p. S67-S72.
Surveillance is crucial to containing HIV epidemics, including groups that are "hidden" and difficult to reach with conventional methods such as snowball, time-location sampling, and facility- and survey-based sampling methods. This article critically reviews alternative sampling strategies for undertaking research among such difficult-to-reach subpopulations. Many of the preexisting methods carry challenges, limiting their applicability. The article concludes that respondent driven sampling shows promise for research among MSM subpopulations; however, further evaluation is required regarding its applicability in resource-poor settings.
HIV Prevalence, Risks for HIV Infection, and Human Rights among Men Who Have Sex with Men (MSM) in Malawi, Namibia, and Botswana
Baral S., Trapence G., Motimedi F., et al. 2009. PLoS One. Vol. 4, No. 3.
This study of 537 men is the first cross-sectional study establishing MSM as a high-risk group for HIV infection and human rights abuses in the countries of Malawi, Namibia, and Botswana. In these contexts, a significant proportion of men identified as either heterosexual or bisexual, and were married or had at least one female partner in the previous six months. An important finding of the study establishes the Internet as the predominant tool used by MSM to find male sexual partners. This is especially true in contexts like Malawi, Namibia, and Botswana, where homosexuality is criminalized and there is no safe, legal space for MSM to congregate. The authors suggest the Internet may represent a powerful tool for efficiently reaching and delivering prevention messages to MSM.
Recruiting Hard-to-Reach Drug-Using Men Who Have Sex with Men into an Intervention Study: Lessons Learned and Implications for Applied Research
Grov C., Bux Jr. D., Parsons J.T., et al. 2009. Substance Use and Misuse. Vol. 44, No. 13, p. 1855-1871.
This study presents a unique, effective, and cost-effective, two-stage recruitment strategy for enrolling high-risk MSM in research studies. It analyzes data from two years of recruiting injection-drug-using gay and bisexual men into a research study. It presents and contrasts the results of the two prongs of the study recruitment process. One used a strategy of marketing the research study itself to men; the other followed a two-stage recruitment strategy that began with an initial low-commitment survey, followed by a subsequent invitation into the trial upon completion of the first visit.
Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men
Pathela, P., Hajat, A., Schillinger, J., et al. 2006. Annals of Internal Medicine, Vol. 145, pp. 416-425.
The researchers describe discordance between self-described sexual identity and behavior among MSM and the relationship between self-described sexual identity and risk behaviors. Of New York City men reporting a sexual identity, 12 percent reported sex with other men. MSM who self-identified as heterosexual were more likely than their gay-identified counterparts to belong to minority racial or ethnic groups, to be foreign-born, to have lower education and income levels, and to be married. Heterosexual or "straight-identified" MSM were more likely to report having only one sexual partner in the previous year than gay-identified MSM, but were less likely to have been tested for HIV and were less likely to have used condoms during their last sexual encounter. The authors conclude that medical providers cannot rely on patients' self-reported identities and that public health messages should target risky sexual activities rather than a person's sexual identity.
They See You as a Different Thing: The Experiences of Men Who Have Sex with Men with Healthcare Workers in South African Township Communities
Lane, T., Mogale, T., Struthers, H., et al. 2008. Sexually Transmitted Infections. Vol. 84 No. 6, pp. 430-433.
This qualitative study describes interactions between MSM and health care workers (HCWs) in South Africa and found that many MSM felt their options for non-stigmatizing sexual health care services were limited by homophobic verbal harassment by HCWs. Gay-identified men sought out clinics with reputations for employing workers who respected their privacy and sexuality, and some challenged workers who mistreated them. Non-gay-identified MSM presented masculine, heterosexual identities and avoided discussing their sexuality with HCWs. The strategies MSM employ to confront or avoid homophobia from HCWs may not be conducive to health promotion. Initiatives to improve appropriate care from public sector HCWs are urgently needed.
Reaching African-American Men on the Down Low: Sampling Hidden Populations: Implications for HIV Prevention
Icard, L.D. Journal of Homosexuality. 2008. Vol. 55 No. 3, pp. 437–449.
Studies of the impact of the HIV epidemic among African-American MSM have largely neglected men who self-identify as heterosexual but who engage in same-sex behavior. These men, commonly referred to as "men on the down low," pose formidable challenges to researchers conducting prevention studies. The authors discuss the benefits and drawbacks of various sampling methods to identify these hard-to-reach MSM and describe a novel approach to reaching these men. Instead of relying on self-identified gay men or gay establishments, the researchers successfully used three recruiters who frequented known cruising areas (a park and the Internet) to find men who would meet the general classification of men on the down low.
Accessing Men Who Have Sex with Men through Long-Chain Referral Recruitment
He, Q., Wang, Y., Li, Y., et al. 2008. AIDS Behavior, Vol. 12 No. 4, pp. S93-S96.
The authors compared MSM identified by two methods: convenience sampling and long-chain referral. Long-chain referral relies on study participants to recruit their acquaintances to the study, who in turn recruit their acquaintances. Long-chain referral identified more MSM who were migrants, young, from lower-income groups, and at higher risk for HIV than those identified by a convenience sample (such as all men attending a certain clinic). The authors state that long-chain referral can reach subgroups better than convenience samples. The authors report behavioral-risk outcomes associated with various subpopulations.
Reaching Men Who Have Sex with Men (MSM) in the Global HIV & AIDS Epidemic: A Policy Brief
Global Forum on MSM & HIV. (2010).
This policy brief succinctly argues that MSM shoulder a disproportionate burden of HIV globally, and therefore countries need to increase their commitment to and coverage of MSM populations. It identifies the following strategic areas for increased work, with specific action recommendations for each: (1) increased investment in effective HIV treatment, care, and support for MSM; (2) expanded coverage of quality services for MSM; (3) increased MSM-related knowledge through research; (4) decreased violence, stigma, and discrimination against MSM; and (5) strong MSM networks linked to MSMGF. Quotes from MSM activists throughout the world are included.
A Novel Approach to Prevention for At-Risk HIV-Negative Men Who Have Sex With Men: Creating a Teachable Moment to Promote Informed Sexual Decision-Making
Eaton L.A., Cherry C., Cain D., et al. 2011. American Journal of Public Health. Vol. 101, No. 3, p. 539-545.
Serosorting provides an alternative to condom use and thus addresses the problem of safer-sex "fatigue." However, there are challenges to this approach, which is reliant on informed decision making regarding selection of lower-risk partners. This study tested a brief, one-on-one, peer counselor–delivered intervention based on informed decision making to address the limitations of serosorting. The intervention was based on conflict theory, which prepares people for informed decision making and creates a "teachable moment," wherein participants are more open to change. The results showed that men in the serosorting intervention reported fewer sexual interventions at follow-up.
Comparisons of Disparities and Risks of HIV Infection in Black and Other Men Who Have Sex with Men in Canada, UK, and USA: A Meta-Analysis
Millett, G. A., Peterson, J. L., Flores, S. A., et al. 2012. Lancet. Vol. 380, No. 9839, p. 341-348.
This article is a meta-analysis that assesses factors associated with disparities in HIV infection in black MSM in Canada, the United Kingdom, and the United States from 1981 to 2011. The authors base their findings on aggregated data from racial comparative studies with outcomes associated with HIV risk or infection from seven studies from Canada, 13 from the United Kingdom, and 174 from the United States. It looks at data related to a number of factors, including seropositivity, drug use, structural barriers, and access to prevention services, among others. The study finds that there are similar racial disparities in terms of HIV status, STIs, and ART initiation among MSM in the United Kingdom and the United States. The study concludes that elimination of these disparities cannot be accomplished unless structural barriers to clinical care access are addressed.
Coming to Terms with Complexity: A Call to Action for HIV Prevention
Piot P., Bartos M., Larson H., et al. 2008. Lancet. Vol. 372, No. 9641, p. 845-859.
This article is a well-articulated, evidence-based argument for combination approaches to HIV prevention. The authors recognize the complexity of the HIV epidemic, and discuss the importance of not becoming overwhelmed by this complexity. They cover key epidemic elements in a step-by-step manner, elucidating each with concrete examples. The article ends with an extensive call to action, listing detailed action steps for each element.
Understanding and Integrating the Structural and Biomedical Determinants of HIV Infection: A Way Forward for Prevention
Kippax S. 2008. Current Opinion in HIV and AIDS. Vol. 3, No. 4, p. 489-94.
This article makes the important argument that the successful integration of structural and biomedical approaches to HIV prevention depends on biomedical and social scientists working together. It compares successful and unsuccessful prevention interventions/programs, and highlights the importance of structural factors in determining HIV risk. For HIV prevention programs to be effective, the focus must include both behavioral and structural factors. The article concludes that multidisciplinary teams provide a good starting place for the development of effective prevention programs that take combination approaches.
Rights Matter: Structural Interventions and Vulnerable Communities
Altman D. 2005. Health and Human Rights. Vol. 8., No. 2. p. 203-213.
This is an edited version of the Jonathan Mann Memorial Lecture given at the XV International AIDS Conference in Bangkok, Thailand, on July 14, 2004, and makes a strong case for addressing the structural drivers of HIV.
Technical Guidance: Prevention for Men Who Have Sex with Men
As part of the President's Emergency Plan for AIDS Relief's (PEPFAR's) second five-year strategy, this technical document provides specific information to assist country teams in the development of HIV prevention programs for MSM that respond comprehensively and effectively to specific epidemic scenarios. The document highlights the importance of combination prevention, which combines structural, biomedical, and behavioral approaches, and provides in-depth information on community-based outreach; condom distribution; HIV counseling and testing; active linkages to health care and antiretroviral therapy; targeted information, education, and communication; and sexually transmitted infection prevention, screening, and treatment. The guidance document also recommends a set of best program practices to ensure the effectiveness of HIV prevention programs among MSM (i.e., MSM involvement; confidentiality; staff training; strategic information; linking, integrating, and collocating services; and incorporating research advances and new technologies).
Human Rights Considerations in Addressing HIV among Men who Have Sex with Men
Avrett S. 2011. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.
This technical brief provides a systematic global review and synthesis of practical approaches, program examples, and resources to support human rights as a core element of HIV programming for MSM. This document gives an overview of U.S. policies on and commitments to MSM and human rights, and outlines recommended approaches, including program examples in various countries, for linking health and human rights to address HIV among MSM. It also offers a compilation of questions for developing and monitoring HIV programs for MSM, as well as a list of program resources.
Achieving an AIDS-Free Generation for Gay Men and Other MSM: Financing and Implementation of HIV Programs Targeting MSM
amFAR. (2012).
The goal of this comprehensive report is to evaluate the impact of legislation that criminalizes same-sex sexual practices on two key outcomes: (1) the efficiency of multilateral funding sources for HIV programming and (2) the effectiveness of programming for MSM. It also analyzes the evidence for the positive impact decriminalizing same-sex sexual practices can have on the delivery of comprehensive HIV programs for MSM. It is comprised of analysis of country case studies; in-country consultations with a wide range of stakeholders; and data from the UN General Assembly Special Session on AIDS (UNGASS), PEPFAR, and the Global Fund. Countries of focus include China, Ethiopia, Guyana, India, Mozambique, Nigeria, Ukraine, and Vietnam.
Prevention and Treatment of HIV and Other Sexually Transmitted Infections among Men Who Have Sex with Men and Transgender People—Recommendations for a Public Health Approach
These WHO-published guidelines are intended to enhance the ability of countries to provide comprehensive HIV responses to MSM and transgender (TG) populations, and comprises a thorough set of technical recommendations for STI and HIV treatment among MSM and TG populations. This document provides six "good practice recommendations," focused on the following: (1) prevention of sexual transmission; (2) HIV testing and counseling; (3) IEC; (4) HIV prevention focused on substance use; (5) MSM and TG people living with HIV; and (6) prevention and treatment of STIs. It is geared toward national public health officials, nongovernmental organizations (NGOs), and health workers.
UNAIDS Action Framework: Universal Access for MSM and Transgender People
This action framework seeks to go beyond "business as usual" approaches to articulate UNAIDS' specific commitments to MSM and transgender (TG) communities worldwide. It provides direction for enhanced action by the UNAIDS Secretariat and UNAIDS Cosponsors. The framework is intended to serve as a foundation for articulating specific workplans and recommendations for better-coordinated action. It focuses on these key objectives: (1) improving human rights for MSM and TG populations; (2) strengthening and promoting the evidence base related to MSM, TG, and HIV; (3) promoting partnerships and ensuring better, broader responses for MSM and TG populations; (4) outlining roles, responsibilities, and partnerships within the UN related to MSM and TG groups; and (5) developing a monitoring, evaluation, and review plan.
Priority HIV and Sexual Health Interventions in the Health Sector for Men Who Have Sex with Men and Transgender People in the Asia-Pacific Region
This 128-page Asia-Pacific-focused document articulates a set of priority health sector interventions needed to achieve universal access to HIV prevention, care, and support for MSM; summarizes WHO recommendations; guides the selection and prioritization of HIV prevention, care, and support interventions for MSM; and directs readers to more resources. The target audience is wide, including national public health officials, NGOs, community-based organizations (CBOs), and health care providers. Chapters cover prevention; sexual health; care, support, and treatment; strategic information; and strengthening health systems.
Advancing the Sexual and Reproductive Health and Human Rights of Men Who Have Sex with Men Living With HIV
This policy briefing was developed as an elaboration of Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: A Guidance Package, published jointly by the GNP+, the International Community of Women with AIDS, EngenderHealth, the International Planned Parenthood Federation, and UNAIDS in 2009. It is a set of principles, based on the original guidelines, specific to the needs and priorities of MSM living with HIV. The recommendations are intended for program managers and policy makers, sexual health advocates and health care workers, and community and civil society organizations.
Men Who Have Sex with Men (MSM), HIV, and the Road to Universal Access—How Far Have We Come?
amfAR. (2008).
This 56-page report provides the results of data submitted to the United Nations by 128 countries. Nearly half of the countries failed to provide any data on MSM. Despite a unanimous commitment by all UN member countries in 2001 to monitor HIV among high-risk groups, the report found that 71 percent of countries had no information on the percentage of MSM reached by HIV prevention programs. The report attributes this failure to a lack of leadership both from national governments and the institutions charged with leading the global response to HIV. The report cites the criminalization of male-male sexual activity as a major driver of the epidemic among MSM in many countries. Seven of the ten countries with the highest reported HIV prevalence among MSM criminalize homosexuality. Institutionalized stigma and discrimination frequently prevent MSM from accessing even basic HIV services.
MSM and HIV/AIDS Risk in Asia
amfAR. (2006).
This 82-page report discusses the vulnerability to HIV of MSM in Asia. Many Asian countries focus on such high-risk groups as female sex workers and injecting drug users, while ignoring MSM despite increasing HIV prevalence in the region. MSM may be overlooked because many are married and do not self- identify as gay or bisexual. Studies found HIV prevalence as high as 28 percent among MSM in Bangkok, Thailand; 14 percent in Phnom Penh, Cambodia; and 16 percent in Andhra Pradesh, India. MSM in Asia are often not organized, are hidden from society, and are persecuted by police. Sex between men is illegal in 11 of the countries examined. Many MSM have multiple partners, have sex with women, fail to use condoms, and have high rates of sexually transmitted diseases. This in-depth report provides research findings, country profiles, recommendations for politicians and non-governmental organizations, a directory of organizations, and extensive appendices for reference.
Off the Map: How HIV/AIDS Programming Is Failing Same-Sex Practicing People in Africa
Johnson, C.A. 2007. International Gay and Lesbian Human Rights Commission Report.
This 125-page report with a seven-page executive summary explores the ways in which governments, donors, and nongovernmental organizations have failed to incorporate basic human rights protections for same-sex practicing Africans and how that failure affects efforts to combat the HIV epidemic. The authors recommend that access to prevention, care, and treatment must be equal for all. Gaps in available research are discussed, including the need to better understand hidden male-male sexual behavior.
Reaching Men Who Have Sex With Men for HIV Prevention Messaging with New Media: Recommendations from an Expert Consultation
Lewis M.A., Uhrig J.D., Ayala G., et al. 2011. Annals of the Forum for Collaborative HIV Research. Vol. 13, No. 3, p. 11-18.
The Internet and other technologies are increasingly used by MSM for a variety of purposes, including meeting sexual partners. This article reports the results of an expert consultation led by the U.S. Centers for Disease Control and Prevention (CDC) on the potential role of the Internet in delivering HIV prevention messaging to MSM. The report summarizes group discussion around how use of specific channels, technologies, and websites differed between groups; characterizes the strengths and weaknesses of those channels in terms of their potential for delivering HIV prevention messages; and discusses how online tools might be developed to help reduce HIV risk and promote overall health for MSM.
HIV Prevention with MSM: Balancing Evidence with Rights-Based Principles of Practice
This brief challenges the silence at the global level about the disproportionate impact that HIV has on MSM and calls for ethically implemented and methodologically sound surveillance, along with epidemiological and social science research that can sensitively inform HIV prevention and advocacy responses around the world. It highlights contemporary approaches to HIV prevention among MSM, new HIV prevention strategies and key issues, and UNAIDS-recommended components for comprehensive HIV prevention programs with MSM.
Global Epidemiology of HIV Infection in Men Who Have Sex with Men
Beyrer, C., Baral, S. D., van Griensven, F., et al. 2012. Lancet. Vol. 380, No. 9839, p. 367-377.
This article looks at the epidemiological drivers of the global epidemic in MSM and why it continues unchecked. It is based on a review of available data for HIV prevalence, incidence, risk factors, and the molecular epidemiology of HIV in MSM from 2007 to 2011, and on an agent-based simulation that is used to model the dynamics of HIV transmission. The article shows that unprotected anal intercourse plays a central role in explaining the disproportionate disease burden in MSM, that HIV can be transmitted through MSM networks with speed and efficiency, and that prevention strategies that lower biological risks, such as ART, offer promise for controlling the expanding epidemic in MSM. It also finds that the potential effectiveness of ART is limited by structural factors that contribute to low levels of health-seeking behavior in populations of MSM.
Comprehensive Clinical Care for Men Who Have Sex with Men: An Integrated Approach
Mayer, K. H., Bekker, L.-G., Stall, R., et al. 2012. Lancet. Vol. 380, No. 9839, p. 378-387.
This article highlights the importance of developing culturally sensitive and respectful clinical care programs that address health disparities in MSM communities, such as depression, anxiety, and substance abuse. The authors carefully detail structural and biomedical drivers of HIV risk, including mental health and substance abuse, making a case for culturally competent care. They also make the point that research is required to understand more clearly how MSM can live positively in the face of societal discrimination and other structural factors that negatively impact health outcomes.
Successes and Challenges of HIV Prevention in Men Who Have Sex with Men
Sullivan, P. S., Carballo-Diéguez, A., Coates, T., et al. 2012. Lancet. Vol. 380, No. 9839, p. 388-399.
This article suggests a detailed conceptual framework for packaging HIV prevention interventions for MSM and modeling the potential effect of scale-up. It contains a review of MSM-focused HIV prevention interventions, and makes a strong case for combination interventions. It underscores the importance of innovative study designs, increased resources for scale-up, and bringing more focus to low- and middle-income countries.
From Personal Survival to Public Health: Community Leadership by Men Who Have Sex with Men in the Response to HIV
Trapence G., Collins C., Avrett S., et al. 2012. Lancet. Vol. 380, No. 9839, p. 400-410.
This article reviews the key role that community leadership has played in HIV responses since the beginning of the epidemic. It outlines a history of gay and MSM participation, as well as new opportunities for community leadership and participation in HIV programming, research, and advocacy.
Common Roots: A Contextual Review of HIV Epidemics in Black Men Who Have Sex with Men across the African Diaspora
Millett, G. A., Jeffries, W. L. IV, Peterson, J. L., et al. 2012. Lancet. Vol. 380, No. 9839, p. 411-23.
This article examines HIV infection in black MSM across the African diaspora and the extent to which these men report access to HIV prevention and care services, assesses whether these findings are associated with increased susceptibility to HIV infection, examines genetic and biological explanations for disproportionate rates of HIV infection in black communities compared with other populations, and uses meta-analytic methods to assess differences in the prevalence of HIV infection between black MSM and general populations. The authors present recommendations based on study findings.
A Call to Action for Comprehensive HIV Services for Men Who Have Sex with Men
Beyrer, C., Sullivan, P. S., Sanchez, J., et al. 2012. Lancet. Vol. 380, No. 9839, p. 424-438.
This article is a call to action for comprehensive HIV services for MSM based on the articles in the special MSM edition Lancet from July 2012. The call is directed specifically governments, health ministries, donors, providers, researchers, and community members, and covers the following issues in some detail: prevention, clinical resources, youth, health disparities, mental health, health care provision, community, resilience, and structural changes. The authors conclude with a detailed strategy for action with a timeline for action from 2012 to 2014.
Technical Guidance Series: HIV Prevention among Vulnerable Populations-The Pathfinder International Approach
Israel, E., Laudari, C., & Simonetti, C. 2008. Pathfinder International.
This 40-page publication provides a background to the risks faced by populations especially vulnerable to HIV and outlines effective strategies to prevent HIV among sex workers, MSM, and people who inject drugs. Programs described include peer education, comprehensive health services and quality of treatment, provider referral networks, and in-service training and sensitization.
Best Practice Collection: HIV and Men Who Have Sex with Men in Asia and the Pacific
Winder, R. 2006. Joint United Nations Programme on HIV/AIDS.
This 70-page report describes programs for MSM in Asia and the Pacific region. The authors show that even in conservative societies and in countries where there are legal constraints, MSM may play an important role in the response to HIV. This publication examines six programs that offer a variety of insights into how HIV interventions for communities of MSM have been designed and implemented in this part of the world. Lessons learned are provided. Elements from the programs have been consolidated by topic to facilitate access and illustrate practical options.
Lessons from the Front Lines: Effective Community-Led Responses to HIV and AIDS among MSM and Transgender Populations
amfAR & MSMGF (2010).
This resource profiles successful MSM- and TG-community-led HIV-related interventions, all grantees of amfAR's MSM Initiative. The 10 organizations are geographically diverse, and work to promote health and human rights through a number of projects, including (but not limited to) MSM in prisons, leadership development, network building, working in challenging environments, and health. The sections profiling each organization draw on quotes from organization members themselves. The report also surfaces six major themes that community service providers identify as key to program success: addressing basic needs, creating a safe space, establishing and maintaining community trust, providing a range of integrated services, tailoring and revising services on an ongoing basis, and collecting process and outcome indicators.
Tackling HIV-Related Stigma and Discrimination in South Asia
Stangl A., Carr, D., Brady, L., et al. 2010. Washington, DC: World Bank.
This 200-page monograph is a compendium of strategies for addressing stigma and discrimination (S&D) in South Asia, although the content is applicable to other contexts as well. It profiles South Asia Regional Development Marketplace Award grantees' anti-S&D projects, highlighting community-centered, innovative approaches to fighting S&D to help create an enabling environment for health and well-being. The volume contains MSM-specific examples, including strategies for reaching challenging populations and innovative approaches to MSM-led advocacy. It also contains a list of evidence-based recommendations for action.
Effect of an Online Video–Based Intervention to Increase HIV Testing in Men Who Have Sex with Men in Peru
Blas M.M., Alva I.E., Carcamo C.P., et al. 2010. PLoS One. Vol. 5, No. 5.
The Internet is often listed as a tool for targeting MSM for HIV prevention interventions for "hidden" populations; however, there are few examples of concrete ways to use it as a public health tool. This article provides a concrete example of an Internet-based intervention, conducted in Peru, to reach hidden populations who might otherwise not seek care or be targeted for health interventions. It describes a randomized, controlled trial of 272 gay-identified and 187 non-gay-identified MSM, who were selected to receive a text or video intervention. The study suggests that video-based online interventions can improve HIV testing uptake among non-gay-identified MSM.
Use of Respondent Driven Sampling (RDS) Generates a Very Diverse Sample of Men Who Have Sex with Men (MSM) in Buenos Aires, Argentina
Carballo Dieguez A., Balan I., Marone R., et al. 2011. PLoS One. Vol. 6, No. 11.
Respondent driven sampling (RDS) has been identified as a promising new method for recruiting non-gay-identifying MSM. This study provides a concrete example of RDS application in Argentina. Study results conclude that RDS can be used to generate a very diverse sample of MSM. Of the 500 MSM recruited using RDS, only 24.5 percent identified as gay, 36.2 percent identified as bisexual, 21.9 percent identified as heterosexual, and 17.4 percent were classified as "other." The study also presents lessons learned, which may be useful for researchers who plan to use RDS for MSM recruitment in the future.
Estimation of the Size of High-Risk Groups and HIV Prevalence in High Risk Groups in Concentrated Epidemics
This technical report and set of recommendations came out of a meeting of the UNAIDS Reference Group on Estimates, Modeling and Projections held in Amsterdam, the Netherlands, December 9-10, 2008. The goal of the meeting, which brought together 29 experts, was to draft recommendations on the topic of population size and HIV prevalence estimation for sex workers, people who inject drugs, and MSM. The report provides a detailed list of methods for various epidemic scenarios and risk groups, with accompanying recommendations.
It All Starts Here: Estimating the Size of Populations of Men Who Have Sex with Men and Transgender People
Asia-Pacific Coalition On Male Sexual Health. (2010).
This policy brief explores key issues related to the diversity of MSM and TG populations and implications for size estimation exercises; identifies other key considerations for the estimation of MSM and TG population size; and makes key recommendations on how MSM and TG diversity, population sizes, and risk levels can be taken into account for sensitive programming in Asia and the Pacific. Although the brief is Asia-Pacific-focused, it can be used by any group interested in understanding more about the complexity of size estimation for MSM and TG groups.
Estimating the Size of Populations at Risk for HIV: Issues and Methods
UNAIDS, IMPACT, and FHI. (2003).
This guide provides a detailed overview of population size estimation for groups at high risk for HIV, and treats MSM populations with specificity and detail. The guide provides a general overview of the importance of size estimation, issues regarding size estimation for high-risk groups, size estimation methods, and methods for selecting the best method. It also contains exercises that allow readers to test their understanding through case examples, which could also be used in a workshop setting. It contains a resource list for further reading.
The Bruthas Project: Evaluation of a Community-Based HIV Prevention Intervention for African American Men Who Have Sex with Men and Women
Operario D., Smith C.D., Arnold E., et al. 2010. AIDS Education and Prevention. Vol. 22, No. 1., p. 37-48.
This article is an evaluation of the Bruthas Project, a community-based HIV prevention intervention for MSM who do not form an identity around their sexual behavior. Thirty-six African American MSM completed the pilot intervention, which is detailed in the article. Analysis found significant reductions in unprotected anal sex with male partners, fewer numbers of unsafe sex partners (both male and female), and decreased sex while under the influence of drugs. Men also reported significantly increased social support, self-esteem, and reduced loneliness at follow-up. The positive outcomes suggest that this is a promising approach for reducing HIV risk in this population, and perhaps other non-gay-identifying groups.
International HIV/AIDS Alliance, Understanding and Challenging Stigma: Toolkit for Action
International HIV/AIDS Alliance. (revised edition, 2007).
This toolkit evolved out of a two-year research project on stigma conducted in Zambia, Tanzania, and Ethiopia, and was originally published in 2003. The toolkit contains more than 100 participatory exercises that can be adapted to fit different groups and contexts. Various sets of pictures help to identify stigma, discuss the rights of HIV-positive people, and stimulate discussions around gender, sexuality, and morality issues linked to stigma. The toolkit is a collaboration among the International HIV/AIDS Alliance, the International Center for Research on Women, the Academy for Educational Development, and PACT Tanzania. The revised edition (2007) builds on the original toolkit and includes the experience of the International HIV/AIDS Alliance's Regional Stigma Training Project. New modules now address stigma as it relates to antiretroviral treatment, children, youth, and men who have sex with men. (9 booklets, each 30 to 50 pages)
Understanding and Challenging Stigma toward Men Who Have Sex with Men: Toolkit for Action, Cambodia Edition
ICRW and Pact. (2010).
This 300-page resource was developed in Cambodia, where the HIV epidemic is concentrated among key populations at higher risk, including a diverse community of MSM. The toolkit, adapted and tested with local organizations in Cambodia, includes participatory, educational exercises that can be used with a wide range of individuals and groups to fight stigma and discrimination toward MSM. Although it is Cambodia-specific, it can be adapted to other contexts, and may serve as a useful tool for groups who are challenging MSM-related stigma and discrimination in their particular contexts.
Understanding and Reducing Stigma Related to Men Who Have Sex with Men and HIV: Toolkit for Action, Hanoi
Institute for Social Development Studies. (2010).
This toolkit, developed in Vietnam, is intended to guide action on understanding and challenging stigma related to MSM and TG people, with HIV prevention as one goal. It is designed to equip individuals and agencies working in HIV prevention with the knowledge and tools to understand basic issues related to gender, sexuality, and the sexual health of MSM and TG people, and to combat stigma. The toolkit is comprised of four sections: part A includes exercises aimed at building knowledge and skills related to gender and sexuality; part B is designed to increase understanding of MSM- and TG-specific stigma and discrimination; part C guides planning activities geared toward reducing stigma; and the annexes provide concrete ways to use the toolkit in a workshop setting. Although it is Vietnam-specific, the toolkit can be adapted to other contexts, and may serve as a useful tool for groups who are challenging MSM- and TG-related stigma in their particular contexts.
Rapid Assessment and Response Guide on HIV and Men Who Have Sex with Men
Boyce, P., Aggleton, P. & Malcolm, A. 2004. World Health Organization.
Stimson, G., Donoghoe, M., Fitch, C., et al. 2003. World Health Organization.
This 61-page guide for working with MSM explains how to conduct a Rapid Assessment and Response (RAR) focusing on lifestyles, behaviors, and HIV concerns. It outlines a series of simple and practical activities that may be used to explore the circumstances, experiences, and needs of MSM across a variety of settings. It was designed to be used either in conjunction with the WHO Rapid Assessment and Response Technical Guide or as an independent resource. Chapters in the manual offer guidelines for carrying out a RAR with MSM, including specific guidance on planning, training, community participation, analysis, and action plan development.
Between Men: HIV/STI Prevention for Men Who Have Sex with Men
International HIV/AIDS Alliance. (2003).
This 61-page publication, one of the Key Population series, gives an overview of the issues for MSM related to HIV and other sexually transmitted infections. The report is designed primarily to support policymakers, donors, and nongovernmental organization support programs that are planning to work in communities in developing countries where few or no organizations already work with MSM. Drawing on experiences of the Alliance's partner organizations in countries such as India and Costa Rica, the report addresses issues such as why and how men have sex with men, and presents strategies for developing prevention and care programs for men.
Speaking Out: A Toolkit for MSM-Led HIV & AIDS Advocacy
Ripley J., Laurer K. 2011. MSMGF.
This advocacy toolkit was created to address the urgent need for MSM everywhere to engage in advocacy locally, nationally, and globally to end the HIV epidemic and promote their human rights. The toolkit equips individuals and organizations with tools and techniques enabling them to become advocates right now, whoever and wherever they happen to be. It builds on advances made in past toolkits from around the world, with some key differences: (1) it is specifically MSM-focused, with exercises and ideas that serve as conduits for the energy and contributions of MSM communities; (2) it is built on the belief that organizations can start where they are, and assumes that the skill sets of individual advocates and organizational maturity of MSM groups are wide-ranging and take time to develop; and (3) it approaches HIV from a broad human rights framework, balancing public health and human rights approaches toward addressing MSM community susceptibility to HIV. It is designed to be participatory and contains facilitation tools, including handouts.
Respect, Protect, Fulfill—Best Practices Guidance in Conducting HIV Research with Gay, Bisexual and Other MSM in Rights-Constrained Environments
amfAR, IAVI, JHU-CPHHR, and UNDP. (2011).
This guidance document was developed for both researchers and CBOs in rights-constrained environments. It is intended to help both groups to better design and conduct meaningful research on HIV among MSM in challenging social, political, and human rights contexts. It provides a checklist of factors for researchers and CBOs to consider in the design, conduct, and implementation of research studies, and offers lessons learned from case studies of research and community partnerships, recent successes, and challenges. It contains a user-friendly set of appendices with questions for researchers and CBOs to ask as they engage in MSM-focused research to ensure that they are on the right track.
Supporting Community-Based Responses to AIDS, Tuberculosis & Malaria: A Guidance Tool for Including Community Systems Strengthening in Proposals for the Global Fund to Fight AIDS, Tuberculosis & Malaria
Community Systems Strengthening (CSS) is about building the capacity of CBOs to become active participants in the HIV response. Although this tool is primarily intended for use by those planning, advocating for, or drafting proposals to the Global Fund, it includes concrete CSS activities and models that can be applied in other contexts. Building on the information provided in the Global Fund's 2010 CSS Framework and additional updates to the CSS indicators, this document aims to (1) increase understanding of CSS; (2) provide practical guidance on developing CSS activities for Global Fund proposals, advocating for including CSS in national and regional proposals; and (3) suggest ways to more effectively implement CSS activities in successful proposals.
Operational Guidelines for Monitoring and Evaluation of HIV Programmes for Sex Workers, Men Who Have Sex with Men, and Transgender People—Volumes I and II, National and Sub-National Levels
MEASURE Evaluation. (2012).
This set of guidelines provides guidance in planning, monitoring, and evaluating programs for MSM, sex workers, and TG people for national, sub-national levels (volume I), and service delivery (volume II) levels. The first volume is intended for country- and national-level bodies and donor agencies, while the second is intended for networks, NGOs, and other civil society groups. The guidelines are organized using the "eight steps" model for HIV prevention, and contain summary information, methods and tools, and resource lists.
Engaging Men Who Have Sex with Men in the Clinical Setting: A Primer for Physicians, Nurses, and Other Health Care Providers
Alaya G., Do T., Semugorna P., et al. 2011. MSMGF.
This document serves as a primer on health care provision for MSM for physicians, nurses, and other health care providers in diverse clinical settings. It outlines the roles and responsibilities of health care providers regarding MSM, debunks myths commonly associated with homosexuality, and takes up key issues that affect MSM health, such as mental health, sex work, physical and sexual violence, drug use, and family relationships. The document contains an extensive resource list for health care providers interested in deepening MSM care provision knowledge and skills.
Blueprint for Provision of Comprehensive Care to Gay Men and Other Men Who Have Sex with Men (MSM) in Latin America and the Caribbean
This document offers a set of tools to assist planning and implementation of MSM-oriented health promotion and health care activities in Latin America and the Caribbean (LAC) region. It reflects recommendations emerging from the expert Regional Consultation on Health Promotion and the Provision of Care to Men Who Have Sex with Men (MSM) in Latin America and the Caribbean, held July 14-16, 2009, in Panama City. The document contains a compendium of management algorithms, or step-by-step procedural diagrams, that encompass the essential elements of a variety of approaches to MSM health, such as first clinical evaluation, HIV risk and infection, ano-rectal health, substance use, sexual concerns, emotional and mental health, consequences of violence, and community-clinic interaction. Although developed for the LAC region, it is a tool that can inform health care provision in other contexts.
Reducing HIV Stigma and Discrimination: A Critical Part of National AIDS Programs
This document presents strategies, program examples, and research findings about how governments, the UN system, donors, and civil society can make the reduction of HIV-related stigma and discrimination central in the national response to AIDS. Section 1 explains why stigma and discrimination serve as major roadblocks to universal access to HIV prevention, treatment, care, and support; section 2 discusses how national AIDS control programs can reduce stigma and discrimination; and section 3 lays out steps toward effective responses to HIV stigma and discrimination. Annexes include examples of successful programs, tools for measuring stigma and discrimination, resources for stigma reduction, and key points for advocacy.
Legal Aspects of HIV/AIDS: A Guide for Policy and Law Reform
World Bank. (2007).
This 250-page document is intended as a practical guide to legal reform to enable effective action against HIV. It seeks to alert those working on HIV strategies and projects to opportunities for legal and policy reform and to provide them with tools to undertake these challenges. The guide identifies key issues, discusses the pertinent legal and policy considerations for each issue, and provides at least one good practice example for each, as well as resources for continued research and reading. An MSM-focused section discusses gender orientation in general antidiscrimination statutes, sexual offenses, vague or overbroad criminal statutes and police harassment, and rights of association and expression.
MSM: An Introductory Guide for Health Workers In Africa
The Desmond Tutu HIV Foundation. (2009).
This 102-page manual is designed to provide counselors and health care providers who work in Africa with a detailed understanding of MSM, issues that affect MSM health, and how to approach MSM in clinical settings. It is an interactive guide with group exercises, summaries, and tools to assess understanding and develop commitment. Topics covered include an overview of MSM and HIV in Africa; stigma, sexual identity, coming out and disclosure; anal sex and common sexual practices; HIV and STIs; mental health; condom and lubricant use; and risk reduction counseling. Although the guide is Africa-focused, it can be adapted for use in other contexts.
From Top to Bottom: A Sex-Positive Approach for Men Who Have Sex with Men
Annova Health (2011).
This manual, developed in South Africa but relevant in regions across the world, has been put together with health care providers in mind. The manual is divided into six sections: introduction to the manual; overview of MSM in terms of sexuality and sexual identity and key terminology; the broader public health strategies relating to MSM; the role of the health care provider in terms of providing quality, competent MSM services; the potential mental health problems that affect MSM; and practical guidelines in relation to the medical management of sexual health problems that may affect MSM.
Global Forum on MSM and HIV
The Forum is comprised of a loose network of civil society groups, AIDS organizations, MSM groups, and other agencies, which together advocate at the national and global levels for improved HIV programming for MSM. The initiative is a response to the shared concern that existing HIV strategies do not adequately address the needs of MSM. The Forum disseminates information on best practices in HIV prevention and treatment, advocates for improved access and funding for MSM services, and provides a forum for MSM around the globe to strengthen their regional, sub-regional, and national networks. Member organizations share a commitment to social justice, to human rights issues, and to improving the HIV response to MSM and other sexual and gender minorities.
Fundraising Toolkit—A Resource for HIV-Related Community-Based Projects Serving Gay, Bisexual, and Other Men who have Sex with Men (MSM) and Transgender Individuals in Low- and Middle-Income Countries
amfAR. (2012).
This guide provides fundraising guidance for CBOs that provide HIV-related programs and services for gay men, TG individuals, and other MSM in low- and middle-income countries. It offers information about the funders of MSM/LGBT groups, snapshots of what those grant programs look like, how to approach funders, and what projects those grant makers have supported in the past. It lists U.S.-based and non–U.S.-based funding sources. The guide also offers general tips on fundraising, from networking to proposal writing, and includes templates to help organizations and activists get started.
View Toolkit (PDF, 1.87 MB)
The Global Fund Strategy in Relation to Sexual Orientation/Gender Identities (SOGI) Strategy
Global Fund to Fight AIDS, Tuberculosis and Malaria. (n.d.)
This document outlines the Global Fund's SOGI strategy. The intent of the strategy is to augment and reinforce the efforts of the Global Fund in realizing outcomes and impact against the three diseases (AIDS, tuberculosis and malaria); recognizing the vulnerabilities of MSM, TG peoples, and sex workers; and recognizing the imperatives to minimize harm. Actions are recommended that can be implemented in ways that are gradual, careful, built upon current positive efforts and good intents, and respectful of the varying contexts in which the Global Fund operates.
View Report (PDF, 2.24 MB)
International Rectal Microbicide Advocates (IRMA)
IRMA. (n.d.)
IRMA works to advance a robust rectal microbicide research and development agenda, with the goal of creating safe, effective, acceptable, and accessible rectal microbicides for the women, men, and TG individuals around the world who engage in anal intercourse.


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Find hotels & motels in Grand Mere using the list below. Search for the cheapest discounted hotel and motel rates in or near Grand Mere, QC for your upcoming personal or group travel. Discover the best Grand Mere Quebec hotel rooms. Review the Grand Mere hotel list below to find the perfect lodging. We also have a map of the Grand Mere hotels. Need 5+ Rooms? Secure Grand Mere Group Hotel Rates
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Meet Daniel.
He's the Brand Manager of Baldwin Denim in Kansas City, Missouri.
Daniel is one of the gentlemen who have been mentors, friends and upstanding fellows in my life. A stand-up guy who is passionate about leading people, companies and brands—and doing it well with integrity and honesty. He's one of the guys who's helped nourish my own passions and dreams, menswear and blogging aside.
And he's a man of classic style with subtle details that add a nice touch to his look.


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Reid: Small steps on sequester
Senate Majority Leader Harry Reid said today that he prefers to deal with sequestration in a series of steps.
"What we think would be a better effort would be to move forward and, on short increments, to pay for the sequestration," Reid told reporters in the Capitol.
"There are many low-hanging pieces of fruit out there that Republicans have said they agreed on previously. I'm not going to go into detail, but one of them, of course, is to deal with oil companies," he said, adding that he wants any sequester-avoidance deal to include revenue.
Read more about: Harry Reid, Sequester, Sequestration
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IMAGE: Copier
Main Hall Faculty SupportBarb Elsass
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Faculty Copying Requests
Kent State Stark FacultyFor your convenience, you can attach and submit materials to be copied by the faculty secretaries with the online forms below.
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Important: Your materials are being submitted to the designated faculty secretaries in Main Hall and Fine Arts (see right column).
If they are out of the office, the form submission is NOT going to their replacements. It is best to always have a hard copy of your request available for the replacement in case it is needed.
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Step 1: Wash Hands
Step 3: Get some water
Step 5: Wait for the water to Boil
For a hard boiled egg, boil for 7 minuets
For a soft boiled egg, boil for 3 minutes
I attached a video of the egg at a full boil
Here is the video (I also posted It on youtube)
Step 6: How To Get the egg out without burning yourself
1. Put the pot with water and egg under the sink on an angle (so the water dumps out)
2. Turn your sink on cold and let it run for a few second
3. Remove egg, the egg will be cool to touch but still really hot on the inside
Step 7: How to de-shell the egg
1. First take your egg then hit in on a hard surface so you get a nice crack in it.
2. Put your nail under the crack and begin to pull away the shell. There should be a shell layer then under that there should be a "skin" type layer. You want to get under the skin layer.
3. I find it easier to rotate the egg while I'm shelling it.
If eggs are a week or more old. Boil them.
Sure you can still fry or omlete them...
But a fresh egg is better for omletes and such.
Granted if you are making a quiche or a soufle' it is fine to use older eggs as the flavor is not based on the egg itself. The egg is more of an binding ingrediant, yet adds some flavor too.
Perfect EVERY time, no fuss, no counting minutes .. .. ..
Way too easy.
Ya forgot to mention to have the egg(s) in the water from the start,
Bring to rolling boil and turn off heat - leaving egg(s) in water till cool.
Like Guarana said.
Works every time, My Grandma taught me that, and she was a full Sioux
Hard to control High and Medium on a full blown fire pit ...So when it boiled = off to the side to cool
You should catch a viewing of Penn & Tellers Bullshit on the Organic Movement. Not a pretty sight.
I always boil my water first, drop in the eggs (don't forget to pierce the large end with an egg poker so the air can escape) and time for 12 minutes for very moist yolks, 13 minutes for most yolks and 14 minutes for solid yolks.
On the time, drain eggs and run lots of cold water for at least 5 minutes. This keeps the membrane under the shell from sticking and also drives out the sulfurous compounds from the yolk keeping them yellow.
Done. Crack the shells and they split right open - fresh or old eggs, doesn't matter.


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Tuesday, June 18, 2013
Representative Patsy Knight, far left, and Senator John Matthews, far right, present a check for $50,000 to the Dorchester County Council Monday. The money is for Tri-County Link, specifically the Dorchester Connector Commuter Bus. The funds are from the Upper Dorchester County Economic Development Fund and were given to assist with providing public transportation for people to go to work, find jobs, go to doctor's appointments and obtain goods and services.
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Star Planetarium
Product Rating
(4 reviews)
(4 reviews)
Sale Price:
List Price: $34.95
You Save: $15.98 46% off
- Additional Details
- Ages: 8+
- Batteries: 3 AA and 3 AAA (not included)
Learn about astronomy, grids, planets, constellations, and much more with this Star Planetarium kit that turns your home into a star theater with its bright halogen light. Gather the whole family and friends to enjoy 3D virtual tours and uncover the locations of stars and planets. This toy comes with an activity guide for hours of play. Like a star projector, it is portable and suitable indoors or out.


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A few more choice posts:
Funny how finding out someone's nickname can be a complete game changer.My fiance is at USP Lewisburg serving a 41 year sentence. He's been down for 4 yrs and 9 mos. We are fighting, to this day, for justice because of the lies the feds told to put him there with no help from his public defender, who had to be, as he stated, "the devil's advocate":fb: . There WILL be justice! May God bless you all.
Skinny's Baby:love:,
I wish I could reach out to this woman to tell her to kill herself also. Her son would be much better off without her.I am awaiting sentencing and will serve around 40 months. My husband was to serve the same sentence but took his life instead- almost a year ago. So now I am clinging on to Blakely "hopes" so I lose only 2 years of my 7 year-old sons life instead of three. The federal sentencing guidelines and the system itself have impacted my life and my sons in more than ways I could have ever imagined.
This is one of my absolute favorite comments. Gotta hand it to the guy, whoever he is. He managed to get this woman to go from **** buddy to support group without having to deal with any of the relationship crap in between.my man is in a fed prison and it is good to know that u all feel the same way i do and it is refreshing to know that u all stick by your men. mine has 11 yrs and has been in there for 8mths so far and it sucks. we really didn't fall in love until after he went but were real good friends and a little more before that. its a long time but hopefully with prayer and good behavior he will not have all that time. i do have a question though..... did your men find god while they are there or did they have god before? just a question, i think its great that they find god just don't know why this is how they have to do it.
LOL.My man did 10+ Fed Max time & various SHUs. As a result, he has no marketable skills out here on the streets, PLUS he has "issues" like crowds bother him a lot, he just likes to stay home so he won't get into trouble, and other stuff that can be hard to deal with, but we're getting through it. He's spent half his life incarcerated in one place or another, so he's learning how to live out here. I have to remember that it's like he's only 17 for "out on the streets" social skills because he's only been on the streets for a total of about 17 years from birth.
Mother of the year, right here.Two son's in the Federal System. One has been locked up and is at Chicago MCC, since Dec of 2006 (188 months) and the other reports to Terre Haute June 2 (131 months).
Jesus Christ. How much is this one family costing the ****ing taxpayers?They have my man, my dad (he'll be home this yr) they HAD my mom and my aunt, they have my uncle as well as a few cousin's.....and they HAD a few more of my cousin's. As well as a few childhood friends that are still in. Needless to say I'M AFFECTED!!!!!!


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81-02 Research exposition (monographs, survey articles)
- Krein space (1)
- Pontrjagin space (1)
- Schwinger model (1)
- quantum field theory (1)
- Mathematical problems of gauge quantum field theory: A survey of the Schwinger model (2002)
- This extended write-up of a talk gives an introductory survey of mathematical problems of the quantization of gauge systems. Using the Schwinger model as an exactly tractable but nontrivial example which exhibits general features of gauge quantum field theory, I cover the following subjects: The axiomatics of quantum field theory, formulation of quantum field theory in terms of Wightman functions, reconstruction of the state space, the local formulation of gauge theories, indefiniteness of the Wightman functions in general and in the special case of the Schwinger model, the state space of the Schwinger model, special features of the model. New results are contained in the Mathematical Appendix, where I consider in an abstract setting the Pontrjagin space structure of a special class of indefinite inner product spaces - the so called quasi-positive ones. This is motivated by the indefinite inner product space structure appearing in the above context and generalizes results of Morchio and Strocchi [J. Math. Phys. 31 (1990) 1467], and Dubin and Tarski [J. Math. Phys. 7 (1966) 574]. See the corresponding paper: Schmidt, Andreas U.: "Infinite Infrared Regularization and a State Space for the Heisenberg Algebra" and the presentation "Infinite Infrared Regularization in Krein Spaces".


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Plus, embroidery is a nice relaxing thing to do after a long day. :D
Below are some of my embroideries - I sell them on etsy in my shop, making jiggy.
Step 1: Tools or hardware, if you prefer.
- embroidery hoop - this is a ring consisting of two parts. You put the fabric in between the hoops - this helps keep it taut, making the embroidering easier.
- small, sharp scissors. You can find these under many names.
- your fabric of choice! In most cases, this shouldn't be loosely woven or too stretchy. Simple quilting cotton will work fine.
- embroidery floss. This is cheap and comes in TONS of colors.
- embroidery needles. These have bigger eyes than normal needles to accommodate the size of the floss.
Step 2: Using the embroidery hoop.
Cut a square of fabric slightly larger than your hoop.
To start, loosen the nut at the top of the hoop. You'll then separate the hoops. Put the one that has the nut and bolt to the side, you don't have to worry about it just yet.
The other part of the hoop will have a lip, so place it lip side up, and drape the fabric you're using over it.
After you have the fabric over the bottom hoop, push the top hoop down over the bottom one. The lip of the bottom hoop will rest on the top hoop. This will sandwich the fabric between them. Now you'll want to tighten the nut a bit and begin pulling the fabric taut. The fabric floating between the hoops should not give very much - this will make the embroidering much more complicated than it should be.
After the fabric is taut, keep tightening the nut until it feels secure to you.
How do you get the floss to stop falling out of the needle when you make a stitch?
Keep a tail of about 2-3 inches long through the eye of the needle and try to hold your needle very close to the eye. The long tail and the pressure from your fingers will help keep it in place.
Once you've done it for a while, you can embroider with hardly any tail - it'll become second nature to constantly check to make sure you won't pull the thread out. :)
please check it out my site
Thank you for doing this. It looks like you put a lot of work into it, and it is fantastic.
Hi there! I am really new to this so I have really enjoyed reading your instructions but I am a little confused with this.. So, on the 4th picture (or the 1st one in the row of three) would you then put the needle back left and go through the fabric right next to the first stitch that is there? Then after this would you need to make a double long stitch on the back so it stretches out far enough for you to do the same thing again?
Hi tlouisa, from what I understand you to be saying, I think you are right. Just to make sure, in the photo below the black arrow shows where the needle goes back in, and the green dot shows roughly where the needle should come back up. Then the need would go back in where you see the thread coming up in this picture.
Hello! I just began embroidering, and I have a question about transferring patterns. Is there a way to transfer your own, hand drawn patterns onto fabric? I searched the internet and all I could find were pre-made iron on designs. Thanks!
Thank you for taking the time to create this great easy-to-understand instruction page. I've been wanting to start an embrodery project for a while now and now I feel like I can do it! I'm so excited to get started on a pillow cover. I'm heading over to Michael's right now to get my supplies. :o)
I know this is old but I thought answering might help someone later one...embroidery hoops come in MANY different sizes. The smallest I have personally are 2 inches in diameter (across the middle of the circle) and the biggest is 14 inches in diameter. I think the sizes are available in 2 inch increments, but I could be wrong and there are likely larger/smaller hoops than what I have. Hope that helps!
Any advice?
If that's not what's happening, I'd make sure to wrap it at least two times, and hold the thread taut until the thread loop forms and starts to goes through the knot. Sometimes it can be tempting to let go too early. I've done that too and had it unravel. :)
This is a good video, too, if you think watching it being done might help: