Even in the United States—where the epidemic was first identified among gay men more than 25 years ago and more than half of all infections are attributed to male/male sexual contact—there continues to be a downplaying of that fact. Prevention resources are not proportionally allocated to reach this affected population.

The situation is even worse in most of the developing world, as was made clear at a conference on MSM and HIV in Mexico City, prior to the XVII International AIDS Conference.

'What we are seeing today in Asia, in every single major city that we have looked at, are epidemics of HIV of men who have sex with men that remind me of what we saw in the US, and Western Europe, and Australia in the 1980s,' said Peter Piot, executive director of UNAIDS. Modeling suggests that by 2020, half of all new infections in Asia will be among MSM.

But the response with targeted prevention 'is not there at all.' Piot pointed to 'homophobia in all its forms' as 'one of the top five obstacles to really stopping this epidemic.'

David Wilson, who heads up the World Bank's HIV efforts, said within the last five years we have come to realize that 'HIV epidemics are far more concentrated than we had believed. General population heterosexual transmission is only the major source in two regions, Africa and the Caribbean.'

'Everywhere else we are facing concentrated epidemics of sex workers, drug users, and men who have sex with men. They are the norm, not the exception. And our programs globally need to reflect this.'

In the countries of Latin America, MSM constitute anywhere from half to 90 percent of local infections. 'It is massively higher than in sex workers,' said Wilson. 'I don't think that is sufficiently understood.'

Identity and persecution

Kenneth Mayer, with Fenway Community Health in Boston, said a study of MSM that they collaborated on in Mumbai ( formally Bombay ) , India' largest city, found that married men were more likely than gay-identified men to be infected with HIV.

'In India, and I think it is probably true in other countries, if you are male identified, you are not effeminate at all, and you are married to a woman, you have met societal goals. It means that the man can do what he wants. He feels that I'm not really gay because I'm not like these other people; I have sex with a woman and I'm married.'

Mayer thinks it likely that prevention messages developed for gay men probably don't resonate with MSM who do not identify as gay.

Wilson pointed to one survey of 10,000 people in Saigon where 'not a single person acknowledged having sex with another man.' It is as emblematic of the problem that agencies and officials face in even understanding patterns of infection.

The situation is even worse in most of Africa. The Republic of South Africa does offer legal protection and equality to gays, but the law is far ahead of social attitudes. Elsewhere on the continent, homosexual acts often are illegal and the laws are enforced.

Three gay, lesbian and trans activists were arrested in Uganda at a June meeting organized by PEPFAR, the international U.S. AIDS effort, when they protested their nation's lack of HIV prevention services for those communities.

After the release one of them, Usaam 'Auf' Kukwaya, was abducted, held for 24 hours and tortured by persons claiming to be police. But at least he wasn't killed; in Iraq, religious zealots are hunting down and executing gays.

In Botswana, the government initially even refused to allow a study of MSM proposed by local researchers in collaboration with Johns Hopkins University.

'Men who have sex with men are systematically missing in most of our national surveillance systems,' said Wilson. The scant data available shows that even in the heart of the generalized epidemic in Africa, MSM are about four-fold more likely than heterosexuals to be infected with the virus.

He pointed to a recent study from the port city of Mombasa, Kenya showing recent infections among MSM as being 'three times higher than female sex workers. It suggests that the female sex work epidemic is an old epidemic and is slowing down, but epidemics among MSM are new epidemics which are gaining momentum.'

Changing the dynamic

'As a straight man, I have difficulty understanding this obsessive homophobia. It tells me that there is something going on in the heads of people—that must mean that they are having major problems with their own sexuality,' Piot said to laughter and applause. 'It is totally absurd, but it is also true.'

He said, 'A gay-rights movement, for lack of a better term, is really essential, but we are nowhere on this in many, many countries. AIDS is now creating a small hole in this wall of homophobia,' allowing more opportunity for people to express their sexuality.

'We need to do all that we can to support the emerging gay groups and activities … we need to make sure that is not killed. Third, where we are still in the dark ages, we have to develop strategies that not only support it, but also not put our colleagues at risk,' said Piot.

David Winters, a manager with the Global Fund for AIDS, TB, and Malaria, said that over the first five years of the program, 'while there was never a resistance to funding MSM programs or gender—women and girls—neither have been very visible.'

A core principle of the Global Fund is country ownership, with the initiative coming from the national governments. 'That sounds all well and good, but when you are being excluded from the country level program, it doesn't mean a heck of a lot.'

Funding guidelines on gender recently have been revised so that the default position is for the inclusion of programs for women. Winters said the assumption should be that MSM everywhere are disproportionately affected by the epidemic; 'Make that the given and ask countries to prove otherwise' in their competition for funding.

Jeffrey O'Malley, who runs the HIV programs for the United Nations Development Program, said the UN family of agencies is assembling a unified approach to the HIV and MSM, which should be in place by the end of the year.

'We need to speak up for ourselves and allow other populations to speak for themselves,' said the openly gay O'Malley. 'We need to focus on sexual minorities, but we have to do it in a way that governments with concentrated epidemics don't use this as an excuse to walk away from AIDS fighting.'

'We also have to make sure that we avoid the backlashes that can put people at real risk of violence and death.' In the most oppressive countries not only is homosexuality illegal, but there are huge legal barriers and cultural barriers to even providing services. 'In those environments we need to work carefully and not put people's lives at risk.'

'The way to do that is lead through the health service and health professionals.'