provision have been identified. These include: other HIV

While the health sector has been providing MSM-dedicated services since 1997 (starting with an explicit priority to
provide condoms to MSM), a number of barriers to service provision have been identified. These include: other HIV
interventions taking priority over the needs of MSM; denial of the risk to MSM among some individuals and lack of
health service capacity to address the issue of MSM. Overlying these barriers is a culture of machismo in Mexico,
which may impede both provision of and equitable access to services. Mexico held an anti-machismo campaign
in 2004, but the problems remain. Nonetheless, there is a high degree of political support for equitable policies
and provision of services for MSM. In 2000, the President of Mexico stated that discrimination on the grounds of
sexual orientation is wrong, and in 2001 the national constitution was amended to outlaw discrimination on the
grounds of sexual orientation.
5.1.4 The Netherlands
The Netherlands has been addressing HIV prevention and treatment for the past 25 years, and has had MSMfocused
programmes since then. From an early position of wishing to avoid potential discrimination against MSM
(thus initially avoiding undertaking prevalence studies among MSM), to the current position of openly recognizing
and addressing the higher risks faced by MSM, the programme in the Netherlands has evolved alongside the
evolution of the epidemic itself.
Current priorities for HIV programmes recognize that MSM are disproportionately affected by the HIV epidemic,
and are a priority group for the national programme (along with young people, sex workers and people from ethnic
minorities). From the extensive experience of the Dutch programme, several important lessons emerge:
• Civil society engagement is crucial to programme response, but one should be wary of equating civil society
engagement with involvement of the whole community.
• A multisectoral approach is important.
• Prevention is most effective when behavioural prevention is linked to access to testing, with a guarantee that
treatment will be available to all who are HIV-positive.
• Research is important as it helps to “know your epidemic”.
• The epidemic is constantly changing, and responses should be innovative to keep pace with the epidemic.
• Linkage of HIV interventions and programmes with the general health system is important.
• Adequate resources for programme implementation are vital.
5.1.5 Uganda
Programme responses for MSM in Uganda are compounded by the relative “invisibility” of this population in
society. Major obstacles to more targeted and relevant programmes for MSM include high levels of perceived and
actual homophobia. Cultural and social norms that invoke “morality” result in high levels of stigma and discrimination,
and are perpetuated by those who fear a loss of political capital.
Although the Ministry of Health recognizes that MSM are among the most-at-risk populations in Uganda (along
with sex workers, fishing communities, truckers and others), sufficient resources are currently not devoted to MSM
in the national programme. This may change in the future; small-scale interventions are currently under way and
consultations with “MSM leaders” are in place.
5.1.6 High-income countries: the “one-stop shop” model
“One-stop shopping” clinics for MSM have been established in many cities in high-income countries. In these
clinics, all services that may be needed are provided at one visit. Each visit is also used as an opportunity to
reinforce basic prevention messages. The one-stop shop is usually a gay-identified service. How well the service
works for MSM who do not identify themselves as gay has always been a question in these countries, and may be
even more important in low- and middle-income ones, where exclusive MSM behaviour is less frequent and where
social identification as being “gay” is less common than the behaviour.
The Consultation heard two presentations on the “one-stop shop” model in high-resource settings – London, UK
and Seattle, USA.