HIV Among MSM in Perú: A Hidden Population, A Confounding Epidemic

By Brian Holoyda

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Published on March 2009

"Gay means transvestite, which means promiscuous, which means prostitute, which means HIV-positive." This statement, spoken by the director of Perú’s one and only chartered LGBT organization, is the stereotypical view of openly homosexual men that pervades modern Peruvian society. In a nation where homosexuality, bisexuality, and transsexuality are poorly understood and openly stigmatized, the lines between what it means to be gay or a transsexual or a drag queen are blurry, if seen at all. Unfortunately, the same lack of understanding extends to what it means to have HIV. Homosexuality and transsexuality are equated with being HIV-seropositive, which both legitimizes and intensifies stigmatization of individuals who identify as members of the broad spectrum of the gay, lesbian, bisexual, and transsexual (LGBT) community that are more open and expressive in nations like the United States, Canada, and those of Western European. Furthermore, this social outcasting of LGBT individuals has led to the significant problems of “underground” homosexual intercourse and a resultant HIV epidemic that challenges and frustrates public health officials. In the spring of 2008 I traveled to Lima, Perú on a research grant offered through Northwestern University to study HIV-related nongovernmental organizations in Perú and their efforts to reach out to the men who have sex with men (MSM) community. What I found was a set of NGOs experiencing an overwhelming lack of community in the populations they are meant to serve and a resultant difficulty reaching these individuals.

The HIV epidemic in Perú is similar to that found in many other Latin American nations, and so are the techniques that nongovernmental organizations have employed in efforts to stem the HIV epidemic. Recent research into HIV and MSM in Perú has focused on epidemiological considerations, with little assessment of how best to approach at-risk groups and establish a working rapport with at-risk individuals. This research confirms that men who have sex with men constitute the primary risk group. According to the United Nations HIV/AIDS Programme (UNAIDS), an estimated 0.6% of the total adult population and 18.5% of MSM in Lima were infected with HIV by the end of 2005¹. An epidemic is not considered a “generalized epidemic” (meaning that it affects the general population) until prevalence levels become greater than 1%, so Perú’s epidemic is “entrenched” within the MSM community². Most Latin American nongovernmental organizations’ efforts at stemming HIV infection in these vulnerable populations have involved the use of educational campaigns, voluntary counseling and testing services, and stigma reduction campaigns³.

I became interested in the Peruvian HIV epidemic after reading a journal article which suggested that research NGOs in the nation were experiencing auspicious circumstances for developing programs and behavior-modification campaigns among MSM there⁴. The article’s author attributes this success to the organizations’ “good relationship” with the MSM community. After researching the topic further I remained at a loss as to what this “good relationship” entailed. I wanted to know exactly what these organizations are doing to reach the MSM community in Lima, Perú, a place where stigmatization, homophobia, and machismo are consistent social norms. I surmised that NGOs in Perú are helping to construct a cohesive gay community in Lima despite significant social barriers. My research goal was two-fold. I endeavored to both define the success that Peruvian HIV NGOs are having at reaching the MSM community and also discover if a cohesive gay culture in Lima is contributing to MSM’s utilization of these NGOs’ services.

Upon my arrival in Perú, I first visited the LGBT-focused community organization in Lima, el Movimiento Homosexual de Lima (MHOL), in order to gain an understanding of the social underpinnings of life for Peruvian MSM. Sñr. Jorge Chávez Reyes, the director of MHOL, astonished me by saying that there is almost no gay community in Perú at all. MHOL is the only LGBT organization in Perú and, despite being established 20 years ago, only has around 200 consistently active members. Two hundred members of an LGBT organization serving a city with a population of ten million is an exceptionally small number, especially considering that Lima is the largest and most cosmopolitan city in Perú. Sñr. Chávez Reyes described to me the lack of a true gay identity in Perú and gay and bisexual men’s preference to marry and have kids, while having sex with men outside of marriage, as a way of avoiding stigmatization. The fact that gay individuals comprise an underground population, he said, makes it nearly impossible to try to target MSM and educate them about HIV/AIDS and how to protect themselves.

Dismayed and disheartened (and beginning to question my research proposal), I next visited a local, community-based HIV nongovernmental organization in Lima called Programa de Soporte a la Autoayuda de Personas Seropositivas (PROSA). This organization is based in a beautiful, large building in downtown Lima and offers a variety of services for patients suffering from HIV/AIDS, including workout equipment, educational and counseling services, and even a massage parlor! Sñr. Culís Arias, the director of PROSA, also had fascinating information to share with me. He identifies a significant difference between organizations like his that are community-based and patient-focused and the research organizations that I had read about when developing my proposal. When questioned about the journal article, he said that those organizations are “having success” because they have money. They are “reaching the community” because they are offering free food, housing, ARV treatment, and stipends to their research participants. Worse yet, these organizations are not specifically targeting the MSM population, which is the population most at-risk for HIV infection. Sñr. Culís Arias delineated the difference between organizations like his that actually could have a real impact on self-identified gay individuals in Perú and those like Impacta Perú that are focused on performing basic HIV research.

After making these initial contacts I visited two of the research-focused organizations, Vía Libre and Impacta Perú, whose operations and focus supported what I had learned from Sñrs. Reyes and Arias. The truth of the matter is that these are organizations dedicated to performing research on HIV drug therapies and measures to prevent transmission of HIV, not on serving the afflicted community. When asked about the community with which these organizations work, administrators simply responded “los que sufren del VIH” (“those who suffer from HIV”). Their clients are subjects, not patients. Though frustrating, one cannot blame these organizations for their approach to the epidemic, as they have specific goals to reach and results to produce as dictated by the organizations that fund them. I quickly realized that the primary premises upon which my research was based – that there does exist a true MSM community in Perú and that NGOs are having success at reaching MSM – are not even true. I thus decided to change my research goals to identifying the primary challenges facing these community-based NGOs and potential ways to overcome these challenges.

After spending a month in Perú, mostly at PROSA and MHOL, I was able to identify three primary challenges in the social and organizational structures of Perú that are contributing to the MSM HIV epidemic. The nongovernmental organization challenge is the division between the local organizations that could have a potential impact on the MSM population and even possibly help construct an MSM community and identity and the research-focused organizations that do not target MSM in their efforts. The differences between these two types of organizations are the services they provide, the perception of their clients as actual clients or as research participants, and the funding they receive. The organizations that HIV-positive MSM turn to for education, counseling, and support are the most poorly-funded and self-sufficient, while the research organizations do not reach out to the MSM population are those supported by institutions like the Global Fund.

The second challenge is to be found within the MSM population itself. I use the term “population” because, as Sñr. Chávez Reyes stated, there is no MSM community in Perú. Not only are machismo, intolerance, and homophobia salient in Peruvian culture, but also there is no cohesion amongst individuals who, in the United States, would be considered part of the “LGBT community.” Transsexuals, openly gay individuals, secretly bisexual men, and lesbians do not operate in the same strata of society and therefore do not see any relation or similarity among themselves. This separation of “unmentionable” peoples, behaviors, and lifestyles results in a lack of homosexual, transsexual, or LGBT identity. What individuals may consider themselves to be in a nation like the United States, they do in Perú. This view of “other” sexualities as behaviors rather than as acceptable aspects of life results in the lack of community that makes it nearly impossible for organizations to target and educate at-risk populations about HIV/AIDS.

The lack of cohesion among LGBT individuals is one particular problem caused by the societal conditions and norms in Perú, on which one could write a whole book. The social perception of MSM individuals is so negative that it prevents the formation of a “gay identity” or a “gay lifestyle” in Perú. This social perception, exacerbated by Catholic values and education and governmental refusal to acknowledge the existence of gay individuals, creates a stifling environment for progress toward homosexual liberation. Without tolerance, without openly gay cultural icons or role models, and without gay “safe spaces,” one cannot expect the development of a gay lifestyle or communal gay identity to develop.

Unfortunately, many of the social underpinnings and structural factors contributing to these challenges preclude serious efforts at halting this epidemic. Were the government willing to acknowledge the epidemic and the community it is afflicting, perhaps research and caretaking efforts could be organized into a concerted program to maximize the impact of these organizations’ activities. Since the government does not seem likely to do this anytime soon, it remains up to the different organizations to coordinate their efforts and perhaps make an impact on this epidemic, at least in Lima. As physicians, medical students, and researchers, we can learn from this situation. We should always recognize the societal milieu in which we carry out our activities – whether it be research, clinical medicine, or public health work – and work to positively impact the communities we serve, in addition to the individuals. In this case, it is difficult to expect an individual to completely change the hundreds of years of social norms that have molded and defined Peruvian society. Sharing my own insight with the individuals with whom I interacted, however, was instructive for both parties. I was able to share my understanding of LGBT life in the United States, and in so doing realized how far from perfect it truly is. My hosts were able to share with me the challenges that they face and recognize the progress that has been made in their lifetimes, and the great progress that they hope to see in the future in both their communities and the HIV epidemic.

Brian Holoyda is a first-year medical student at Northwestern University’s Feinberg School of Medicine in Chicago, Illinois. His interests include infectious disease, LGBT health, and nutrition sciences. He may be reached with any questions or comments at holoyda@md.northwestern.edu.

References:

¹ UNAIDS Joint United Nations Programme on HIV/AIDS. “Peru: Country Situation Analysis.” http://www.unaids.org/en/regions_countries/countries/peru.asp

² Cáceres, Carlos & Stall, Ron. “The human immunodeficiency virus/AIDS epidemic among men who have sex with men in Latin America and the Caribbean: It is time to bridge the gap.” International Journal of Epidemiology. 2003: Vol. 32, Issue 5, 740-743.

³ Lewis, Steve. “The need to scale up HIV/AIDS programmes for gay men and other MSM in Latin America and the Caribbean.” Sexual Health Exchange. 2005: Vol. 2005, Issue 1, 2-5.

⁴ Cohen, Jon. “A New Nexus for HIV/AIDS Research.” Science. July 2006: Vol. 313, Issue 5786.

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