A TECHNICAL BRIEF
15218- HIV and young men who have sex with men-Topic 19-Version 2.indd 3
27/10/2015 20:18
WHO/HIV/2015.8
World Health Organization 2015
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
GLOSSARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Definitions of some terms used in this technical brief.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
YOUNG MSM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
HIV RISK AND VULNERABILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Unprotected sex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drug and alcohol consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Changes during adolescence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Homophobia, stigma and discrimination. . . . . . . . . . . . . . . . . . . . . . . .
Lack of information and misconception of risk. . . . . . . . . . . . . . . . . . . .
Relationship status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Selling sex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vulnerability to homelessness or to living and working on the streets. .
Migration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Racial and ethnic marginalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Annex 1. The United Nations Convention on the Rights of the Child (1989). . . . . . . . . . . . . . . . . . 22
REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
HIV and Young men who have sex with men: A technical brief
ACKNOWLEDGEMENTS
This technical brief series was led by the World Health
Organization under the guidance, support and review of
the Interagency Working Group on Key Populations
with representations from: Asia Pacific Transgender
Network; Global Network of Sex work Projects; HIV
Young Leaders Fund; International Labour Organisation;
International Network of People who use Drugs; Joint
United Nations Programme on HIV/AIDS; The Global Forum
on MSM and HIV; United Nations Childrens Fund; United
Nations Development Programme, United Nations Office on
Drugs and Crime; United Nation Educational, Scientific and
Cultural Organization; United Nations Populations Fund;
United Nations Refugee Agency; World Bank; World Food
Programme and the World Health Organization.
The series benefited from the valuable community
consultation and case study contribution from the
follow organisations: Aids Myanmar Association Countrywide Network of Sex Workers; Aksion Plus; Callen-Lorde
Community Health Center; Egyptian Family Planning
Association; FHI 360; Fokus Muda; HIV Young Leaders
Fund; International HIV/AIDS Alliance; Kimara Peer
Educators and Health Promoters Trust Fund; MCC New
York Charities; menZDRAV Foundation; New York State
Department of Health; Programa de Poltica de Drogas;
River of Life Initiative (ROLi); Save the Children Fund;
Silueta X Association, Streetwise and Safe (SAS); STOP
AIDS; United Nations Populations Fund Country Offices;
YouthCO HIV and Hep C Society; Youth Leadership,
Education, Advocacy and Development Project (Youth
LEAD); Youth Research Information Support Education
(Youth RISE); and Youth Voice Count.
GLOSSARY
Definitions of some terms used in this technical brief
Children are people below the age of 18 years, unless, under the law applicable to the child, majority is attained earlier.(1)
Adolescents are people aged 1019 years.(2)
Young people are those aged 1024 years.(3)
Young men who have sex with men in this document refers to males 1024 years, including boys 1017 and men
1824 who have sex with other males.
While this technical brief uses age categories currently employed by the United Nations and the World Health Organization
(WHO), it is acknowledged that the rate of physical and emotional maturation of young people varies widely within each
category.(4) The United Nations Convention on the Rights of the Child recognizes the concept of the evolving capacities of
the child, stating in Article 5 that direction and guidance, provided by parents or others with responsibility for the child,
must take into account the capacities of the child to exercise rights on his or her own behalf.
Key populations: are defined groups who due to specific higher-risk behaviours are at increased risk of HIV, irrespective
of the epidemic type or local context. They often have legal and social issues related to their behaviours that increase their
vulnerability to HIV. The five key populations are men who have sex with men, people who inject drugs, people in prisons
and other closed settings, sex workers, and transgender people.(5)
MSM (men who have sex with men): In this technical brief, MSM refers to all males of any age who engage in
sexual and/or romantic relations with other males. The words men and sex are interpreted differently in diverse
cultures and societies, as well as by the individuals involved. Therefore, the term men who have sex with men
encompasses the large variety of settings and contexts in which male-to-male sex takes place, across multiple motivations
for engaging in sex, self-determined sexual and gender identities, and various identifications with particular community or
social groups.
For the sake of clarity, the abbreviation MSM is used throughout this technical brief to avoid the confusion that would
arise by spelling out men who have sex with men in the frequent references to males under the age of 18 years.
Sexual abuse of boys1: Where MSM involves one or more males who are children, the act may constitute child sexual
abuse, as defined by the WHO, if it includes the involvement of a child in sexual activity that he or she does not fully
comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared, or else that
violates the laws or social taboos of society. Boys can be sexually abused by adults or other children who are by virtue
of their age or stage of development in a position of responsibility, trust or power, over the victim.(6) The CRC protects
children from all forms of sexual exploitation and sexual abuse (for more information, see Annex 1 below).
Sexual exploitation of boys: The sexual exploitation of boys includes the exploitative use of children in prostitution,
defined under Article 2 of the Optional Protocol to the CRC on the sale of children, child prostitution and child pornography
(2000) as the use of a child in sexual activities for remuneration or any other form of consideration.
Homosexuality refers to an enduring tendency to form emotional, romantic and/or sexual attractions to people of the
same sex.(7) The term gay is sometimes used to refer to people with a homosexual orientation.
Homosexual sex or same-sex behaviour refers to sexual behaviour between people of the same sex, regardless of their
sexual orientation.
HIV and Young men who have sex with men: A technical brief
INTRODUCTION
Young people aged 1024 years constitute one-quarter
of the worlds population,(8) and they are among
those most affected by the global epidemic of human
immunodeficiency virus (HIV). In 2013, an estimated
4.96million people aged 1024 years were living with
HIV, and young people aged 1524 years accounted for an
estimated 35% of all new infections worldwide in people
over 15years of age.(9)
Key populations at higher risk of HIV include people who
sell sex, men who have sex with men (MSM), transgender
people and people who inject drugs. Young people who
belong to one or more of these key populations or who
engage in activities associated with these populations
are made especially vulnerable to HIV by widespread
discrimination, stigma and violence, combined with the
particular vulnerabilities of youth, power imbalances in
relationships and, sometimes, alienation from family and
friends. These factors increase the risk that they may
engage willingly or not in behaviours that put them
at risk of HIV, such as frequent unprotected sex and the
sharing of needles and syringes to inject drugs.
1 In this series of technical briefs, young people who sell sex refers to people 10-24
years of age, including children 1017 who are sexually exploited and adults 18-24
years who are sex workers. For further information, please see HIV and young
people who sell sex: A technical brief (Geneva: WHO, 2014).
HIV and Young men who have sex with men: A technical brief
YOUNG MSM
The HIV epidemic among young MSM is not well defined.
There is a lack of global data on the number of young
MSM, their levels of risk for HIV and their protective
behaviours. This is due in part to a lack of research and
surveillance, and also to the difficulty of reaching young
MSM who may fear disclosing their same-sex behaviour.
Estimates of lifetime prevalence of sex between males
in some low- and middle-income countries range from
320%.(14) However, virtually no data is available for all
of Africa, the Middle East, and the Caribbean. Similarly,
isolated studies indicate wide variation in the reports of
same-sex behaviour or sexual orientation among young
people, and the glimpse they provide of the numbers of
young MSM is not globally representative:
A study of 857 street young people aged 1217 years in
Greater Cairo and Alexandria, Egypt, found that among
the sexually active street boys, 44.2% reported having
had sex with a male partner in the previous 12 months,
and 15% reported being raped by a male partner. (15)
In Canada, a study of 11 000 secondary-school students
in three grades (aged about 12, 14 and 16) found that up
to 1.7% of the boys reported being attracted exclusively
to the same sex, and up to 3% to both sexes. (16)
In New Zealand, of 8 000 secondary-school students
(of both sexes) surveyed anonymously, 0.9% reported
exclusive attraction to the same sex and 3.3% to both
sexes. (17)
One of the challenges in reaching young MSM with sexual
health education and other services is the stigmatization
of same-sex behaviour. MSM may have sex with other
males in secret and may be reluctant to disclose such
activity to others. Some MSM are married to or partnered
with women. A further factor is that some young people,
particularly adolescents, have fluid and changing
understandings of their sexual identity and behaviours
and may not accept the categories used by research
and surveillance, particularly if they perceive these as
stigmatizing within their particular social context.(18,19)
Nevertheless, it is clear that young MSM are often at
greater risk of acquiring HIV than young heterosexual males
or older MSM.(20,21,22,23) Despite this, there is relatively
little funding for HIV prevention and treatment programmes
specifically targeting this population.(24)
Where data are available, HIV prevalence and incidence
are consistently found to be higher among MSM than in
the general population, especially in some urban areas.
In much of Central and South America and in multiple
Unprotected sex
Transmission of HIV is 18 times more likely to occur
through unprotected receptive anal sex (between MSM or
between heterosexuals) than through unprotected vaginal
intercourse.(39) Frequency of unprotected sex increases
risk of exposure to HIV, and some younger MSM are more
sexually active than their older counterparts. For example,
in Cairo, Egypt, 25.9% of MSM aged 1525 years reported
having sex more than once per day, compared to 6.7% of
MSM aged 25 years and above.(40) Young MSM have also
been found to be more likely than older MSM to report
unprotected anal intercourse with partners of unknown HIV
status.(41)
The community consultation revealed that many young
MSM remain unaware that unprotected anal sex can
transmit HIV and other STIs, and do not know the
importance of condom-compatible lubricants in HIV
prevention.(42) A study of MSM and transgender persons
in northern Thailand found low rates of consistent condom
use in both insertive and receptive anal sex (33.3%
and 31.9%, respectively).(43) Community consultation
participants in Albania noted that condoms and lubricant
were not always available.(44) In other places, cost prevents
some MSM from obtaining them.
HIV and Young men who have sex with men: A technical brief
Relationship status
MSM, like heterosexuals, practise unprotected intercourse
more often in steady than in casual relationships,(81) and
this trend is particularly pronounced among young MSM:
in one study, considering the relationship to be serious
was associated with a nearly eightfold increase in the rate
of unprotected sex.(82) Where there is a high turnover
of primary partners, the risk of HIV transmission is even
higher.(83) Younger MSM are also significantly more likely
than older MSM to engage in unprotected anal intercourse
with casual partners while also being in a steady sexual
relationship.(84)
Some young MSM in the Asia-Pacific consultation reported
unprotected sex as a way to express their love for their
boyfriend or partner (as well as for increased sexual
pleasure).(85) Not using a condom was seen as an act
of trust in the other person, even if their HIV status or
relationship history was unknown.(86) Young MSM in
relationships with older partners are more likely to have
unprotected sex than those in relationships with partners
of the same age,(87) and are more likely to be HIV positive.
Some young MSM with older partners said they sometimes
lacked the confidence to insist that their partner use a
condom.(89)
Selling sex
In some contexts of social marginalization a significant
proportion of young MSM engage in selling sex. A 2001
study in St Petersburg, Russian Federation, found that
22.7% of MSM reported selling sex.(90) In Paraguay, 29%
of MSM (median age 21 years) indicated that they were
currently engaging in selling sex, and more than half of
these reported having begun to do so when they were
children.(91) Among MSM, selling sex is often associated
with an increased likelihood of being younger, unemployed,
having less education, using drugs, engaging in high-risk
sexual practices and being raped, compared to MSM who
do not sell sex.(92,93,94,95,96,97)
Selling sex can lead to higher rates of HIV among young
MSM. A study among MSM and transgender people aged
1524 years in Thailand found that HIV prevalence was
13% for the group as a whole, but even higher (15%)
among those who sold sex. Among males aged 15 years
and above engaged in selling sex in Ho Chi Minh City, Viet
Nam, those aged 1524 years were less likely than older
MSM to understand sexual and reproductive health, reduce
their risk behaviours or take an HIV test.(98)
Forced displacement and refugee settings can increase the
pressure on young people to exchange sex for material
goods or protection. This is frequently a direct consequence
of gaps in assistance, lack of adequate mechanisms
to prevent and address sexual exploitation, failures of
registration systems or family separations.(99)
10
HIV and Young men who have sex with men: A technical brief
Migration
Some adolescent males who migrate from rural to urban
areas within their home countries, or to other countries,
may sell sex to other males for economic survival,
regardless of their sexual orientation. For example, among
237 young male migrants in China migrating from villages
to Shanghai, and who were selling sex to other males,
about one-fifth of the group self-identified as non-gay
and the rest as gay. More than half had left home before
the age of 20 and many before the age of 15, suggesting
initiation of same-sex behaviour at a young age. The gayidentified group was more likely to engage in anal sex and
less likely to use condoms. There was a high prevalence
of depression among the young MSM and a low level of
knowledge about HIV, and only half of them had ever been
tested for HIV, even though free testing was available.(104)
11
12
HIV and Young men who have sex with men: A technical brief
13
Funding
Recent reports indicate that less than 2% of global
HIV prevention funding is directed towards MSM.(135)
International funding vastly outweighs domestic spending
on focused prevention services for MSM globally, including
in all regions except the Caribbean.(136) Funding for HIV
prevention services for MSM is especially limited in East
Asia, the Middle East and North Africa, and across subSaharan Africa.(137) In response, outreach in some of these
regions is led primarily by civil-society organizations rather
than the government. While this means that they can apply
international guidelines to their outreach, finding adequate
support and legal coverage for their work is challenging.
14
HIV and Young men who have sex with men: A technical brief
Competing priorities
Insensitivity or discrimination on
the part of health-care providers,
exacerbated by lack of training
and awareness, can deter young
MSM from seeking not only HIV
testing and counselling but also
treatment for other STIs, especially
if they feel they will need to
disclose their same-sex behaviour
to service-providers.
15
16
HIV and Young men who have sex with men: A technical brief
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18
HIV and Young men who have sex with men: A technical brief
19
Provide developmentally
appropriate information and
education for young MSM from an
early age, focusing on skills-based
risk reduction.
20
HIV and Young men who have sex with men: A technical brief
1 Protect transgender children from all forms of sexual exploitation and sexual
abuse, criminalizing all forms of sexual exploitation including the offering,
obtaining procuring and providing of children for sexual exploitation, in line with
international law.
2 Ensure that the rights of children survivors and witnesses are safeguarded and that
children are exempted from arrest and prosecution. Children should be treated as
survivors and not as offenders, and not be placed in unlawful or arbitrary detention,
and be designated with an appropriate legal guardian or other recognized
responsible adult or competent public body when identified or placed in any shelter
or other care facility
21
3) Funding
Increase funding for research, implementation and scaleup of evidence-informed initiatives addressing young
MSM.
Ensure that there is dedicated funding in national plans
on HIV, child protection, and sexual exploitation of
children for programmes that target young MSM, and for
programmes that address overlapping vulnerabilities.
Recognize overlapping vulnerabilities of key populations
in funding and delivery of services.
22
HIV and Young men who have sex with men: A technical brief
23
1 The rights of children to protection from sexual exploitation, and the obligation
of States parties to prohibit such crimes, are also reflected in other international
treaties, including the International Labour Organizations Convention No. 182 on
the Prohibition and Immediate Action for the Elimination of the Worst Forms of
Child Labour (1999) and the Protocol to prevent, suppress and punish trafficking in
persons, especially women and children (2000), supplementing the UN Convention
against Transnational Organized Crime.
24
HIV and Young men who have sex with men: A technical brief
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pone.0069137
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33
NOTES
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34
HIV and Young men who have sex with men: A technical brief
NOTES
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WHO/HIV/2015.8