Maldives MSM profile 2010 ~ The Rainbow Maldivian

HIV/AIDS among men who have sex with men and transgender populations in Maldives: the current situation and national response

MALDIVES (Revised April 2010 GR)

1. The Context

1. 1. Overview of the HIV epidemic

The first case of HIV in the Maldives was reported in 1991. The latest data show 14 Maldivians have been diagnosed with HIV/AIDS, and of these 10 have died. 1 In addition, 243 expatriates working in the Maldives were diagnosed with HIV, but most likely they acquired HIV elsewhere. HIV prevalence among resort workers was found to be 0.2% in 2008. 2 All infections were reportedly acquired through heterosexual transmission. An HIV situational assessment in the Maldives conducted in 2006 highlighted risk behaviors among female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), sea- farers, migrant workers and youth. 3 Mobility, geographically dispersed populations (across 196 inhabited islands), migration (from India and Sri Lanka) due to employment opportunities and external tourism were among the HIV vulnerability factors identified. 4

1.2 Magnitude of the MSM and Transgender population

The size of the MSM population was estimated to be 1 600 – 4 200.5 A biological and behavioural survey (BSS) on HIV and AIDS in 2008 in the Maldives, recruited 126 MSM. The same study also found that among PWID (N = 276) 4% had sexual experiences with other men. 6 Whether the PWID had same-sex sexual experience in exchange for drugs was not able to be confirmed. The extent of male sex work and its significance in relation to HIV prevention was not known. 7 Information about transgender was not available.

1. 3 Typologies of MSM and TG populations

Apart from the terms ‘MSM’ and ‘male sex workers’ used in government documents, no other labels or identities of same-sex attracted males were mentioned in the available HIV-related literature from Maldives. No details about transgender people in the Maldives were available.

2. Epidemic situation analysis

2.1 Prevalence of STIs among MSM

The BSS in 2008 focused on the most at risk populations: FSW, MSM, PWID, sea-farers, migrant workers, resort and construction workers and youth. MSM were surveyed at two sites, Male’ (capital city) and Addu. No MSM tested reactive for syphilis. However STI- related symptoms were reported by 17% of MSM sampled in Male’ and 12% in Addu. 8 Hepatitis B was reported among MSM with prevalence at 6% and 1% in Addu and Male respectively. 9 The detection of Hepatitis B among MSM may be a result of unprotected anal sex, sexual linkages with PWID or an involvement in injecting drug use behaviour. The BSS 2008 found all such behaviours among MSM and this may have contributed further to the risk of acquiring Hepatitis B.

2.2 Prevalence of HIV among MSM

The BSS, 2008 indicated that among MSM the HIV prevalence was 0.0%.

2.3. HIV-related risk behaviours of MSM

In 2006, a situational assessment was commissioned by the UN Theme Group on HIV/AIDS to support the Ministry of Health’s Department of Public Health (DPH) in the development of a national strategic plan on HIV/AIDS for 2007-2011. 11 A gap that was identified at the time was a lack of active surveillance system to provide a warning device of the epidemic status of the country. Only qualitative data on MSM was available through key informant interviews. The report identified low levels of HIV knowledge and high risk sexual behaviors among MSM who use the internet to find potential sexual partners

In the BSS report 2008 a high prevalence of unprotected sex among FSW, MSM, PWID and youth was found. Reasons why MSM participants did not perceive themselves to be at risk of HIV included not often changing sex partners, always using a condom, not injecting narcotics, convinced partner is healthy or not having anal sex. Only 32% and 21% of MSM at Male’ and Addu respectively perceived themselves to be at risk of HIV. Regarding knowledge of HIV in various groups surveyed, between 67-80% of respondents correctly identified ways to prevent sexual transmission of HIV except the construction workers. Among MSM 48% in Male’ and 47 % in Addu reported that HIV decreases by using condom every time they have sex The BBS in 2008 found that all among MSM participants 48% had sex with a male in the past month. 12

2. 3. 1. Casual male sex partners

The BSS report 2008 found that most MSM had sex with a man in the past year and in the past month it was nearly half (48%) where no payment was exchanged. However, 44% in Male’ and 18% in Addu had sold sex to another man and 29% in Male’ and 18% in Addu had bought sex from a man. In addition, 16% of MSM in Male’ reported that they had met a sex partner on the Internet (see Figure 1). It has been suggested that among the MSM the potential lack of marriage possibility, and social recognition of a long term commitment, led to a situation where it was more convenient to keep sexual relationships casual and have a high number of partners. 13

2. 3. 2. Male sex work

The BSS 2008 reported that 44% in Male and 18% in Addu had sold sex to another manand 29% in Male ’ and 18% in Addu had bought sex from a man in the past 12 months. (see Figure 1)

2. 3. 3. Condom use with men

The BSS 2008 reported that while 31% of MSM sold sex to men, 72% did not use condoms. Additionally it was reported that 58% of MSM have sex with other men (consensual or paying) but 77% do not use condoms. A separation of the two survey sites show unprotected anal sex with consensual and paid male partners was greater in Addu (86%) compared to Male (67%) and in paying male partners it was 78% in Addu and 67% in Male. (see Figure 2)

2. 3. 4. Bisexual behavior and condom use with women

A considerable proportion of MSM in the BSS 2008, were married to women (29% in Male’ and 26% in Addu). The study found that 75% of MSM have sex with women and 90% do not use condoms. Unprotected sex was higher with women in Addu (98%) compared to Male (82%). (see Figure 2). Many MSM have had casual female partners as well as paid and paying female partners (see Figure 1). More than two-thirds of MSM (62% in Male and 67% in Addu) reported having had sex with women without any money being exchanged. Less than one-third of MSM (29%) reported having sold sex to women, and 49% reported having bought sex from women in Male.

2. 3. 5. Injecting drug use

The BSS report 2008 shows that one-fourth (25%) of MSM in Addu and 16% of MSM in Male’ reported having ever injected drugs. Recent qualitative research has also found that MSM do use drugs, and often in connection with sex. 14

2. 4. Potential for rapid transmission

Several high risk behaviours were found among MSM in the Maldives: high rates of unprotected sex with men and women (wife, girl friend, and FSW ); selling sex to men and women; buying sex from men and women; injecting drugs; consuming drugs and having sex; and ha ving sex with injecting drug users (see Figure 3). None of the MSM survey participants tested HIV positive. However, there can be little doubt that once HIV enters the MSM population, the potential for HIV transmission spreading rapidly across the various high risk groups, and their sexual partners, will potentially be rapid.

Figure 1. Sexual partners of MSM, Maldives, 2008

(Source: National Bio logical and Behavioral survey, 2008)

Figure 2. Unprotected sex (%) among MSM in Male’ and Addu, Maldives, 2008

Source: BSS 2008

3. National responses

3. 1. Policy and legal environment

Sex between same-sex adults remains criminalized in the Maldives. According to the Section 15, clause 173 (8a) “Sexual activity with a member of the same sex”, under the “Rules of adjudication”, the punishment is to be lashed (tha’zeer) between 19 to 39 times and banished or imprisoned for a period between 1 to 3 years, taking into account, the severity of the offence.

The HIV situational assessment reports that Maldivian MSM were constantly afraid of disclosure and largely maintain two strictly separate lives. 15 In Maldives, as in many other societies, issues surrounding sexuality, especially same-sex sexuality, and sex work were not openly discussed.

The national strategic plan (2007- 2012) indicates that a comprehensive package of HIV prevention services will be offered for MSM. 16 It was reported that a target of 80% of MSM by 2011 will receive comprehensive HIV prevention services. It has been reported by the United Nations Development Programme that there were few non- government organizations (NGOs) in the Maldives. Those that were active have provided HIV educational services through weekly radio programs, peer education, and seminars. 17 World Health Organization, and United Nations Population Fund (UNFPA) have provided funding and technical assistance for HIV/AIDS awareness and prevention programs. Few civil society organizations and basically no known networks and self- help groups of affected communities, such as PWID, MSM or sex workers were found in the Maldives.

3. 2. Interventions available

The national strategic plan notes that the capacities of NGOs and governmental institutions will need to be built to provide comprehensive HIV prevention services for MSM, including: outreach activities for HIV education, including peer education, and behaviour change communication; condom promotion; HIV testing; and STI diagnosis and treatment. However, the specific number of targeted interventions for MSM was not mentioned. It was possible that after the BBS 2008 findings targeted interventions for MSM would be initiated. It was found that UNODC supported a sensitization programme for the prison officers about drug use and HIV and MSM issues. Lastly the UNDP, with support from the Global Fund, conducted sensitization programmes for law enforcement officers, including prison officers about MSM.

3.3. Coverage of interventions

According to the BBS in 2008, 16% of MSM in Male’ and 2% in Addu had tested themselves for HIV. Information as to those being tested and receiving the results was not known. In Male 48% and 21% of MSM in Addu had received information on HIV/AIDS/STI in the past 12 months. In absence of targeted interventions, HIV and STI information was received mainly through television, radio, newspapers and magazines. Despite the apparent lack of targeted interventions the BBS in 2008 reported that condom distribution was highest among MSM compared to other groups that were surveyed: 65% in Male’ and 72% in Addu. It was not clear whether condoms were distributed to MSM by some NGOs. Information of the distribution of lubricants was neither known, nor about detection and management of STIs among the MSM population.

3. 4. Current gaps in responses

Despite the lack of HIV detection among MSM, high level sexual risk behaviours within the MSM population, and their sexual relations with women, remains a cause for concern. The lack of targeted interventions for MSM remains largely unaddressed. The widespread lack of condom use with all types of sexual partners shows a lack of information, education and communication, and counseling services, on sexual health and ways of reducing risk behaviours. Lack of capacity among existing NGOs to implement targeted interventions with the MSM population was identified, as was the lack of community

groups among MSM to serve their broad based needs. Criminal laws against consensual same-sex relations and negative societal attitude were also important structural barriers that need to be examined further and addressed.

Recommendations

Need to ensure there was a periodic HIV sero-surveillance and behavioural survey among MSM, and to consider expand ing the number of sites.
Need to intensify behaviour change through information, education and communication among MSM in order to promote consistent condom use with both male and female partners. Expand substantially the provision of condoms and lubricants for MSM to compliment the message fo r behaviour change.
Condom use was not common among MSM with female sexual partners consequently increasing the risk of sexual transmission of HIV. Greater focus upon the needs of spouses and female partners of MSM require greater attention.
Need to increase monitoring and raise awareness of drug injecting and other drug use among MSM as an increase in drug use, specifically drug injecting, has the potential to escalate a HIV epidemic among MSM.
Need to increase detection and management of STIs, and where it was possible provide education and the provision of hepatitis B vaccination to all MSM.
Need to advocate for increased access to health care services for MSM, particularly those related to men’s sexual health. This will involve advocacy and sensitization of health care providers, local community including religious leaders. This will contribute towards raising an awareness of the issues and potentially improve overall HIV prevention response
Need to strengthen the capacity of NGOs to work with MSM populations, including adopting appropriate outreach programmes by NGOs to meet the sexual health needs of all men, but ensuring there is a specific awareness and focus with services for MSM.
Need to review, and where required, improve Internet-based HIV educational interventions designed to outreach to MSM in the Maldives.