Lessons from the Front Lines: Effective Community-Led Responses to HIV and AIDS among MSM and Transgender Populations

This report from amfAR, The Foundation for AIDS Research, in partnership with The Global Forum on MSM & HIV (MSMGF), profiles efforts by small, grassroots community-based organisations worldwide that are leading work to provide HIV prevention, education, care, support, and advocacy services to men who have sex with men (MSM) and transgender people. The organisations profiled here are all current or former grantees of amfAR's MSM Initiative, whose evaluation process facilitated the selection of organisations. The profiled organisations reflect a broad and diverse range of geographic settings. The services they provide are equally diverse and include: condom and lubricant distribution and other prevention interventions; HIV counselling and testing; support groups; linkages to care; direct HIV care and treatment; legal assistance; policy advocacy; community organising; life skills training; vocational training; and media campaigns. But they do share this in common: The vast majority "conduct their work within contexts of severe discrimination, harassment, violence, and criminalization."

In preparing these profiles, six major themes emerged that characterise the work of these organisations and that service providers say are key to programme success:

1. Addressing basic needs is often a necessary step in order to provide HIV services that people can utilise. Helping them acquire simple life and job skills such as computer training or cooking, for example, can allow MSM to build more stable lives, which in turn makes it easier for them to protect themselves against HIV.
2. Creating a safe space for MSM and transgender people is central to an organisation's capacity to deliver HIV services.
3. Establishing and maintaining trust with community members is an essential element of effective programmes. MSM and transgender people need to be meaningfully engaged and consulted about their needs and preferences, and given a voice in programme design, implementation, and evaluation.
4. Providing a range of integrated services creates synergies that can optimise programme success - for example, combining HIV prevention education for MSM and transgender communities with sensitisation initiatives designed to reach law enforcement agencies and healthcare providers. This is especially true in settings where MSM and transgender people are stigmatised and discriminated against, and are the
   targets of violence.
5. Tailoring and revising services on an ongoing basis is crucial to ensuring effective responses and service utilisation. Organisations should be prepared to adapt their programmes to the diverse and changing needs of community members.
6. Routinely collecting process and outcome indicators provides organisations with opportunities to track progress, build on strengths, and respond to changes in their local environment by making programme modifications as needed.

In addition, the profiles presented in this report highlight a few common challenges faced by community-based organisations - most notably, poverty, stigma and discrimination, and the diversity of community members' identities and needs. Another common thread is the lack of resources to address the HIV epidemic among MSM - especially in light of epidemiological data that point to dramatically higher infection rates among this population. "Relatively few countries have reliable data on the size of the HIV epidemic among MSM within their borders, and without that, authorities too often have chosen to ignore the problem."

Outlined at the end of this report are recommendations highlighting major issues - among them, stigma and discrimination, resource needs, and the inclusion of MSM and transgender groups in planning and decision making - that must be addressed to ensure an effective and sustained community-based response to HIV among MSM and transgender people. The report notes that health communication and social marketing strategies (e.g., targeted messaging using posters, pamphlets, T-shirts, videos, the internet, etc.) can be effective in promoting healthy behaviour. Another communication-related recommendation: "Advocacy must be initiated at both the grassroots and national levels for policies that effectively address the HIV-related needs of MSM and transgender people. Advocates must demand significantly increased investment in peer-led community-based HIV programming."