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Chhoueng Sovannarith is a technical officer at FHI 360 in Cambodia, where he’s responsible for M-Style, an umbrella brand covering a range of programs.
Being a man who has sex with a man (MSM) is very new in Cambodian culture and the general population finds the idea difficult to accept. When people meet MSM here, they tend to be uneasy or even unwilling to believe that the person has a natural inclination toward someone of the same sex. Imagine how much harder it is to be “sok veng” (“long hair,” transgender). Kim Houch knows this all too well.
Kim Houch was a single child in the family in Banteay Mean Chey Province, in northwest Cambodia, near the Thai border. He tells me that he has felt like a woman since he reached the age of having sex. He never thought of himself as a man. That’s difficult for both Houch and his parents, particularly when people in the community do not recognize a man as a woman. Even when he went to school in a boy’s uniform, he disliked it.
In school, it is very strange for a man to wear a woman’s uniform, or even just keeping his hair long. The difficulty in either complying with the norms around you, or publicly acknowledging who you are makes it difficult for MSM students to participate in their studies. Another young person, Srey Khoy, recalls, “I felt very shy when the other students are looking at me and calling me names, or when the teacher called my name to answer a question in the class because the other students laugh at me.”
That’s where M-Style fits in. We have outreach workers and M-Style clubs in several different provinces in Cambodia. Our teams are there to promote HIV and sexual health services, but they also provide a link to other MSM who are going through the same challenges. M-Style clubs provide drop-in facilities for MSM, where they can relax and find someone to talk to.
Srey Khoy continues, “but now it is different. My classmates do not laugh at me anymore. I feel very confident now that I’ve met the M-Style club manager and participated in the training of the MStyle program. Now I’ve even become a peer educator in my community. My parents accept that this is my nature so they just think that they have the twin children.”
Srey Khoy’s renewed confidence gained through his links with M-Style has enabled him to continue his studies. “Now I am at the second year at university in the faculty of business management. I have a partner and we promise to live together after I graduate, and I’m able to look for a job for our future life.”
In recognition of changes M-Style has led in Cambodia, the government recently asked FHI 360 to pioneer FASTest, a rapid HIV testing service. In the past, M-Style referred MSM to government-run clinics, but many opted not to go because of stigma and discrimination. Making FASTest available at the M-Style club now means many more are willing to access that service. And that’s what we’re about!
To learn more about working with young men who have sex with men, check out the archive of our recent e-forum “Lives at Stake: Meeting the Needs of Young People Most at Risk of HIV.”
Sokunny Muth is a senior technical officer with FHI 360 in Cambodia and is responsible for the SMARTgirl program, which works with sex workers.
Siem Reap is in the north of Cambodia, and the nearest city to the historical wonder of the vast, carved stone temples of Angkor Wat. The temples are covered in intricate images of life from 800 years ago. Today, Siem Reap bustles with modern life, including a thriving sex industry. A recent law prohibits brothels, so instead, young Cambodian sex workers work in the many beer gardens, karaoke clubs, and massage parlors.
As the electricity cut out – and the ceiling fan with it – the natural Cambodian heat reasserted itself once again. I sat with one of our frequent visitors, as one of the SMARTgirl team used a presentation to recount the fictional life of how a young woman falls into sex work, and the dangers she then encounters. Through sessions like these, SMARTgirl helps these young women, euphemistically called “entertainment workers,” to understand more about HIV, other STIs, and contraception.
Across the country, SMARTgirl assists more than 12,000 entertainment workers every quarter, equating to around 1 in 3 of the nation’s sex workers. SMARTgirl clubs provide an opportunity for young women to take a few hours of respite while staff and peer educators offer advice on health and non-health services, such as social safety net protection, occupational training, treatment for drug use, and support for those who encounter gender-based violence. Recently SMARTgirl piloted a government initiative to offer FASTest, an HIV rapid test, in SMARTgirl clubs, which improves access and reduces the stigma of attending a government health center.
As the electricity came back on, and the fan spun back to life, we had a chance to talk with 13 women from local massage parlors, karaoke clubs, and beer gardens. In just a few hours they would be back in make-up, high heels, and short dresses. In the meantime, they were relaxing, chatting, and telling our guest more about the realities of life for them.
“How does the SMARTgirl program help you?” she asked, regaining her composure as the breeze from the fan caught her glistening face.
A woman who works at a massage parlor responded with smiling face, “Well, I like SMARTgirl. Before I met SMARTgirl I didn’t know about HIV, STIs, or contraception or what that meant to me. Now I know what they are. I can get free STI and HIV testing and now I know where to find out about family planning at clinic.”
Another woman who is working at a beer garden said that she’d been for an HIV test twice and STI screening several times. “In addition I also got information about reproductive health and family planning. These services I never got before I knew the SMARTgirl team and even when I talked to others about it.”
A third woman from a karaoke club added, “Before, I didn’t dare to say ‘no’ to a client that I didn’t want, but SMARTgirl taught me brilliant negotiation skills. Now I know about legal services that I should talk to if I have any problem.”
At the end of the visit, my guest was clearly moved by what she heard. “I am proud of seeing you all here. You are all very beautiful and brave. All of you are really SMARTgirls!”
To learn more about FHI 360’s SMARTgirl program, read our previous blog entry, “Accelerating the Global Health Initiative: Cambodia’s HIV/AIDS Efforts Put Women in the Driver’s Seat”
To learn more about working with young people who sell sex, take part in our e-forum, Lives at Stake: Meeting the Needs of Young People Most at Risk of HIV, July 26 through July 28, 2011, or join the conversation on Twitter #IYWGMAR.
Elizabeth Futrell is an associate technical officer at FHI360, where she works on activities related to community-based family planning and youth sexual and reproductive health.
According to the Council for Global Equality, as of June 2011, homosexuality is criminalized in more than 80 countries around the world, most of them low- and middle-income nations. In Uganda, for example, where homosexual acts are already illegal, a controversial bill was introduced earlier this year that would increase the penalty for those convicted to life in prison. The penalty for “aggravated homosexuality”—defined as when one of the participants is a minor, HIV-positive, disabled, or a “serial offender”—would be the death penalty. In addition, anyone who failed to report a person they knew to engage in homosexual acts would also face prosecution. While international pressure prevented a vote on the bill this spring, it will likely be reintroduced next year. Uganda is not alone. Homosexual acts are also punishable by death in Nigeria, Iran, and Yemen, and are considered criminal activity in 37 countries in Africa, 22 in Asia, two in Europe, 15 in the Middle East and North Africa, and 11 in the Americas and Caribbean.* Even in countries without explicit laws against homosexual activity, men who have sex with men often face arbitrary persecution.
The stigma, discrimination, homophobia, violence, and criminalization often faced by men who have sex with men—and particularly young people within this population—can prevent them from accessing the services they need for HIV prevention, treatment, and care. Not only is it challenging for young men who have sex with men to be honest about their behaviors, but it is also difficult for organizations that serve this population to operate and stay funded. As a result of these challenges and the high biological risk—transmission of HIV is five times more likely to occur through unprotected anal intercourse than through unprotected vaginal intercourse—men who have sex with men are considered one of the populations most at risk of HIV. In fact, men who have sex with men are on average 19 times more likely to be infected with HIV than the general population, yet fewer than one in 20 has access to HIV care. In many places such as Russia and the United States, young men who have sex with men have a significantly higher HIV prevalence than older men in this population.
Worldwide, great strides must be taken to prevent the spread of HIV among young men who have sex with men. Evidence-based sexuality education materials focused on same-sex behaviors are sorely needed. One unintentional but widespread consequence of heterosexually-focused HIV prevention education is that some young people report that they consider anal intercourse to be risk-free. It is important that HIV prevention programming for young men who have sex with men focus on behaviors and avoid labels, as many people who engage in same-sex partnerships do not consider themselves “gay” or “homosexual.” Organizations that serve young men who have sex with men must find creative ways to reach those who need services using media and technology, social networks, and peer education. Perhaps most integral to the ability of the public health community to meet the needs of young men who have sex with men is a cultural and political shift away from criminalization of same-sex sexual activity and of HIV-infection and toward tolerance and equal rights, including access to services, for all. The direction this pressing human rights issue—and the HIV pandemic—will take lies in the hands of today’s young people.
Want to learn more about HIV risk and young men who have sex with men?
FHI 360 is hosting an e-forum on behalf of the IYWG to discuss the sexual and reproductive health needs of young people most at risk of HIV (young men who have sex with men, young people who use injecting drugs and young people who sell sex). Click here to view the sub-topic pages and read the bios of our experts from UNICEF, amfAR, Youth R.I.S.E., and the Nossal Institute for Global Health at the University of Melbourne. This forum will give participants an opportunity to discuss ways to meet the sexual and reproductive health and HIV needs of most-at-risk young people and to ask questions about the report Young People Most at Risk of HIV.
Join the conversation, online: http://deck.ly/~Us3Aw, or on Twitter: #IYWGMAR.
* For a complete list, see http://www.globalequality.org/component/content/article/166.
On Wednesday, July 13th, a 2-1 ruling by the US 2nd Circuit Court of Appeals found that the U.S. government cannot force organizations receiving U.S. funding for HIV and AIDS programming to denounce prostitution and sex trafficking. The court found that the U.S. federal rule, commonly referred to as the “anti–prostitution loyalty oath,” violates the first amendment by “restricting privately funded speech and forcing organizations to adopt the government’s viewpoint” (Pathfinder International). Organizations that provide HIV prevention, care, and treatment services hail this ruling as a step forward in combating stigma and other barriers that make it difficult to reach this vulnerable population. This case was originally brought to court in 2005 by Pathfinder International and the Alliance for Open Society International.
The “anti-prostitution pledge” requires organizations to denounce both prostitution and trafficking. Yet, some organizations working with most-at-risk populations, specifically with sex workers, believe the anti-prostitution pledge adds to the challenges they face in meeting the needs of those who sell sex. Jamie Alexis of Pathfinder International explains, “I have never met anyone in the development community who is not firmly opposed to or horrified by trafficking…. One problem with the anti-prostitution pledge, however, is that it conflates prostitution and trafficking, which ignores realities on the ground. In many developing countries, there are individuals who sell sex for their livelihood–food and shelter. And these individuals require and deserve access to health and social services, including HIV prevention and care. Condemning and judging them by denouncing their livelihood can drive them further from the help they need [and] limit their ability to access services.” Pathfinder International “works with sex workers to organize and empower them so that they can advocate for their rights (which is both an effective HIV prevention strategy as well as an effective means of reducing other harms of sex work, including violence and exploitation.)” She asks, “Is that ‘promoting prostitution?’”
Daniel E. Pellegrom, president of Pathfinder International, says, “[This] victory has profound implications not only for the rights of private, nongovernmental organizations to operate without undue government interference, but for the health of vulnerable women, men, and adolescents in less developed countries.”
Read more about this story:
- US 2nd Circuit Court of Appeals Opinion
- Pathfinder International News: “Victory for Free Speech and Public Health.”
- Care 2 make a difference Blog: “Victory! Court Overturns ‘Anti-Prostitution Pledge.’”
Want to learn more about young people most at risk of HIV?
FHI 360 is hosting an e-forum on behalf of the IYWG to discuss the sexual and reproductive health needs of young people most at risk of HIV. Click here to view the sub-topic pages and read the bios of our experts from WHO, UNICEF, amfAR, Youth R.I.S.E., and the Nossal Institute for Global Health at the University of Melbourne. This forum will give participants an opportunity to discuss ways to meet the sexual and reproductive health and HIV needs of most-at-risk young people and to ask questions about the report Young People Most at Risk of HIV.
The following post was adapted from a UNICEF article written by Daniela Silva entitled, “Teenagers and Young People Living with HIV/AIDS and UNICEF together for the rights to prevention, protection and participation.”
¨Adolescents and youth who live with HIV have the right to study, work, have a family, and access antiretroviral treatment (ART). We want to be treated as subject to the system of law and not as victims. We are participants; we are much more than HIV/AIDS.”
These words, spoken by 18-year-old José, were met with enthusiastic applause at the 5th National Meeting of Adolescents and Youth Living with HIV/AIDS in Amazonas, Brazil last month. Approximately 120 adolescents and young people living with HIV or AIDS attended. At the meeting, youth participants discussed issues of health care, education, human rights, and political advocacy. Here are some of the stories young participants shared about their experiences:
After suffering severe pneumonia and constant diarrhea, 12-year-old- José received the diagnosis his family so feared: he was HIV-positive. José, now 18 years old, played a major role in planning the 5th National Meeting of Adolescents and Youth Living with HIV/AIDS.
Lucas, 21 years old, was diagnosed with HIV two years ago. Lucas was preparing to join the Air Force when he went to the public health clinic for his physical exam. Lucas remembers the doctor saying to him, “Lucas, you are HIV-positive. But that is not the end of your life; I will send you for other appointments.” Lucas recalls, “It was very hard to tell my family. I hid it for two years, I had to stand it on my own, with no one else to help me. When I had pain, I kept in silence; I would go to the medical station on my own. I was ashamed. I wanted to tell, but I was afraid of discrimination. I even thought of killing myself. I left home three times to live on my own and hide.” Eventually, with the help of a friend, Lucas decided to tell his aunt. “I felt relieved for telling it. My medicines were always hidden. Now my aunt reminds me the time to take the medicine and treats me with care. That was the support I lacked,” he acknowledges.
Melany, 18 years of age, grew up knowing she had HIV. As a child, Melany often faced stigma. She remembers how the parents of her classmates met with her school director and tried to have her banned. The school maintained Melany’s right to remain in class, but many classmates were advised by their parent to stay away from her. “I was helped by my teachers, psychologists and my family. But I am still afraid of the prejudice,” confesses Melany.
Thais, 18 years old, also faced discrimination at school. It was break time when her classmates started shouting she had AIDS and started physically abusing her. The abuse was eventually stopped by a teacher, but Thais refused to go back to school. She spent many years out of school and returned only recently, thanks to the insistence and support of her family.
The National Network of Adolescents and Youth living with HIV/AIDS
These young people and many more are united by the National Network of Adolescents and Youth living with HIV/AIDS. The organization was started three years ago and has already held five national meetings. “Joining the network is the basis for us to accept ourselves, live together with other young people living the same reality and help other young people prevent HIV so they will not suffer the way we do. The quality of life is better when we are all together in the network,” says Melany
UNICEF, along with the Ministry of Health, were the major sponsors of this event. One of UNICEF’s top priorities is to guarantee the right of every child and adolescent to protect themselves, be protected from, and to live healthfully with HIV and AIDS.
“AIDS does not impede us from living, innovating, struggling, creating, studying, working, and dating. We can lead a normal life like anyone else, we have the same rights. I live happily.”-José
There are so many amazing organizations out there dedicated to improving the lives of young people. At the IYWG, we love connecting with these organizations, whether it is through Facebook, Twitter, email, or through our blog. Just the other day, we received an email from Treasureland Health Builders, a youth reproductive health and economic empowerment NGO in Nigeria. We were thrilled to hear from them! They also sent us some great pictures of the work they are doing:
Thanks, Treasureland, for the amazing photos!
Millions of young people around the world face a high risk of HIV infection as a result of behaviors that they adopt or are forced to adopt. Three groups of young people considered most at risk of HIV are young men who have sex with men, young people who sell sex, and young people who inject drugs.
Most -at-risk young people are among society’s most marginalized groups. They general have few connections with social institutions such as schools and organized religion, where many youth programs are provided. Behaviors such as injecting drug use, sex work, and even homosexuality are illegal in many countries. Furthermore, young people in general are more easily exploited and abused than adults and have less experience coping with marginalization and illegality. Young people most at risk of HIV can be difficult to reach and most sexual and reproductive health programs fail to meet their unique needs. Young people may be less willing to seek out services, and service provides may be less willing to provide services to most-at-risk young people because of legality concerns.
Young people account for a large proportion of the three most-at-risk populations. Approximately 70 percent of the world’s injecting drug users and the majority of sex workers are under 25 years of age. Young people not only constitute large proportions of most-at-risk populations but also many have higher HIV infection rates than older people within these groups. According to the Asia Commission on AIDS approximately 5 percent of young people are considered high risk; yet , most-at-risk young people account for 95 percent of the new HIV infections among young people in Asia. For example, the highest rates of HIV infection in Myanmar occur among most-at-risk young people; 41 percent of female sex workers and 49 percent of injecting drug users age 20 to 24 are HIV positive. Among children commercially exploited by traffickers, HIV infection rates range from five percent in one study conducted in Vietnam to 50 to 90 percent among children rescued from brothels elsewhere in Southeast Asia. In some countries, such as Thailand and Russia, HIV incidence is increasing faster among young MSM than among older MSM.
Worldwide, the HIV infection rate among most-at-risk young people is staggering. If we, the sexual and reproductive health community, are truly dedicated to meeting the needs of young people and curbing the HIV epidemic, we need to take the sexual and reproductive health needs of young people most at risk seriously. More advocacy efforts are needed at both the policy and program levels on behalf of most-at-risk young people. Better statistics at the country level would help highlight how many young people are most at risk. More research and more evidence on program success are needed. Policies need to be developed and implemented that protect vulnerable young people and ensure that they have access to the services they need. Finally, most-at-risk young people need to be engaged in planning and implementing programs that address their unique needs.
Join our online discussion Lives at Stake: Meeting the Needs of Young People Most at Risk of HIV July 26-July 28, 2011. This e-forum, hosted by FHI 360 on behalf of the IYWG, will bring together experts who work with young people most at risk of HIV from WHO, UNICEF, amfAR, Youth R.I.S.E., and the Nossal Institute for Global Health at the University of Melbourne.The e-forum will give participants an opportunity to discuss ways to meet the sexual and reproductive health and HIV prevention needs of most-at-risk young people.