Promoting New Models of Masculinity to Prevent HIV among MSM in Nicaragua
In Nicaragua, HIV prevention for "sexually diverse" populations, including men who have sex with men (MSM), is made significantly more difficult by societal norms that stigmatize same-sex sexual activity and favor conformity to strict gender roles. Centro para la Prevención y Educación del SIDA (CEPRESI) is addressing this issue by both working to change perceptions of masculinity in Nicaragua's general population and educating MSM on HIV prevention and treatment.
Download the CEPRESI Case Study (PDF, 833 KB).
Traducción en español (Spanish Translation) (PDF, 833 KB).
Текст на русском языке (Russian Translation) (PDF, 833 KB).
Visit our Case Study Series page to see other recent publications.
Promoting New Models of Masculinity to Prevent HIV among Men Who Have Sex with Men in Nicaragua
By Joan Tallada
Centro para la Prevención y Educación del SIDA
Jorge is a serious young guy, married with two children. He and his co-worker Javier, an openly gay man of the same age, are standing in the lobby of a small movie theater in Managua that screens heterosexual adult-content movies nonstop for an audience of only men. As customers walk through, Jorge or Javier approach them for a short chat about life, emotions, and safer sex. These conversations last no more than 10 minutes and end with condoms, lubricants, and information and referral flyers changing hands.
Jorge and Javier are HIV peer educators for Centro para la Prevención y Educación del SIDA (Center for HIV Prevention and Education) (CEPRESI), a Nicaraguan community-based organization, and they spend many evenings in theater lobbies. There are several adult-content movie theaters in Managua, and their clientele often includes men seeking other men for sexual encounters, either on- or off-site. In addition to theaters, men who have sex with men (MSM) also rendezvous in public parks, lakeside piers, transportation hubs, and night clubs. Some of these men are openly gay or engaged in a process of self-identifying as gay. However, many MSM are far from identifying themselves as homosexuals, a label that invites stigmatization in Nicaraguan society.
For self-identified gay men, peers like Javier offer support and counseling on HIV prevention as well as referrals to services that can help them deal with violence and discrimination. For men who identify themselves as heterosexual or bisexual, or decline to declare a sexual identity, talking to Jorge is a way to engage in conversations on real sexual practices without the fear of being stigmatized.
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Also, inclusion in pictures or video does not denote HIV status.
HIV and Men Who Have Sex with Men in Central America
Available HIV surveillance data show that Central America's HIV epidemic is concentrated primarily in large urban areas and Caribbean coastal areas. The epidemic appears to be growing in this region, with HIV prevalence in some countries among the highest in Latin America. Social, cultural, and political factors drive the transmission of HIV within communities of MSM in the region (U.S. Agency for International Development [USAID] 2008a).
MSM in Central America experience homophobia, persecution, restrictive laws and limited human rights, stigma, and discrimination, which all contribute to their increased vulnerability to HIV. This discourages them from seeking out the few HIV prevention, treatment, and other essential services that are available, which are rarely adequate to cover the needs of this population (USAID 2008a).
HIV in Nicaragua: HIV prevalence among adults in Nicaragua is among the lowest in Central America, estimated at 0.2 percent. However, social factors that include multiple sex partners, gender inequality, and widespread poverty (after Haiti, Nicaragua is the second poorest country in the Americas) place the country at risk for a broader epidemic. Sexual activity is the primary mode of HIV transmission in Nicaragua. Unprotected heterosexual intercourse is reported to account for 72 percent of new HIV infections, and unprotected sex between men is estimated to account for 26 percent of new infections (USAID 2008b).
Among MSM, HIV prevalence is significantly higher (9.3 percent) than among sex workers or the general adult population (0.2 percent in both groups; Joint U.N. Programme on HIV/AIDS [UNAIDS] 2008). This means that MSM are 46 times more affected by HIV than the rest of the population, a disparity that is much higher than the 19-fold average in low- and middle-income countries (Baral et al. 2007).
The sexual practices of MSM are a fluid dynamic that can significantly affect the spread of HIV within the larger population. In Nicaragua, up to 32 percent of MSM interviewed in a recent study reported having sex with women in the previous six months (Sánchez Bermúdez and Roca 2009). In a study done in 2002 in Nicaragua, 51 percent of MSM reported having had sex with a woman at least once in the past (Román and Soto 2003).
Masculinity, homosexuality, and HIV in Nicaragua: Gender norms and inequalities influence behavior, societal status, and access to resources—all of which impact the global HIV epidemic (USAID 2009). Although the term gender approach is mostly used to address the specific vulnerability of women and girls, attention must also be given to how concepts of masculinity influence the way societies respond to the HIV epidemic (Dunkel and Jewkes 2007).
Masculine roles and higher socioeconomic status entitle men to determine the conditions of affection and sexual relationships. Fueled by self-perceptions of power and invulnerability, many men engage in multiple partnerships, both stable and occasional, with women, with other men, and with transgender (TG) people (Cáceres, Fernández, and Silva-Santisteban 2009). In Nicaragua, power inequities affect men's relationships with women but also with other men, particularly with effeminate younger men and transvestites (Sánchez Bermúdez and Roca 2009).
Nicaragua's record on MSM and sexual diversity(1) has been one of slow and mixed progress. In 1999, the country approved a law protecting the rights of people living with HIV, but there was no effort to protect MSM or other sexual minorities from stigma and discrimination. Same-sex sexual activities were decriminalized only in 2008 in Nicaragua; at the same time, a ban on discrimination based on sexual orientation was first introduced in the penal law. Following those legal changes, lesbian, gay, bisexual, and TG (LGBT) rights groups have been asked to join the National AIDS Response Commission and other HIV-related coordinating structures. Also, on November 30, 2009, an openly lesbian lawyer was appointed Commissioner for Sexual Diversity as part of the Human Rights Commissioner's Office. Despite these advances, social, cultural (particularly religious), and institutionalized stigma and discrimination against homosexuality is still common and fuel Nicaragua's HIV pandemic, which disproportionately affects MSM.
CEPRESI: Putting Men Who Have Sex with Men on the National HIV Agenda
CEPRESI was founded as a voluntary community group in 1993 to respond to the lack of HIV prevention programs for MSM in Nicaragua. In 2005, the organization was awarded a grant from the Swedish International Development Cooperation Agency (SIDA) to start educational programs on sexual and reproductive health targeting young men in secondary schools. This was the first time the organization was able to professionally address the complex social and health issues of masculinity, risk, and HIV.
CEPRESI began focused efforts on HIV prevention in MSM in 2007. Before that, CEPRESI concentrated on advocating for the repeal of the Nicaraguan law criminalizing homosexual acts. According to Executive Director Norman Gutiérrez, "We spent several years of precious time fighting criminalization, efforts that could not be openly devoted to HIV prevention in MSM: it was legally impossible." The group produced nationally broadcast television spots(2) and billboards demanding respect for human rights and acceptance of sexual diversity, a strategy that national stakeholders recognize as a key factor in winning legal changes in 2008 and a turning point in the national HIV policies addressing MSM.
In the early years of the new millennium, HIV prevalence in Nicaragua stubbornly remained unchanged despite the increasing number of preventive interventions. At that time, it became clear to Gutiérrez that the prevention approaches being implemented were not having the desired impact and that traditional models of masculinity were likely responsible. Many studies show that dominant masculinity roles are linked to higher health-related risk behaviors, including HIV risk taking (Barker et al. 2010). Gutiérrez and his team decided to embark on a novel approach to addressing HIV among Nicaraguan men, and MSM in particular, by questioning and addressing traditional attitudes about how a man should act and by offering alternative models of masculinity for those ready and willing to change.
In Nicaragua, as elsewhere, traditional gender roles assign health-seeking behavior to women. Men are less likely than women to actively engage in changing behavior and accessing health care, particularly preventive services (Brittle and Bird 2007). As a consequence, health services are not prepared to handle the needs of men in general and the needs of MSM in particular. This organizational bias reinforces the psychological and practical barriers men encounter while trying to gain access to health services, contributing to a vicious cycle: when men are thus discouraged from seeking services, there is less pressure to modify those programs (UNAIDS 2000).
CEPRESI developed an approach that addresses these challenges and focuses on HIV prevention in the male community for a spectrum of sexual practices: heterosexual, bisexual, and homosexual practices, as well as male sex with TG people. The organization decided to build programs from a gender-based perspective, taking into account the way masculinity is socially constructed and assessing how dominant views of masculinity are a key social factor driving HIV transmission in the general population. Thus the organization focuses on safer-sex practices, linking them to the promotion of healthier models of masculinity.
Although HIV prevalence among Nicaraguan MSM was many times higher than among the general population, in 2004, funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) for Nicaragua allocated no more than 3 percent of the resources to HIV prevention with MSM (Gutiérrez 2010). This prompted CEPRESI to address two challenges: identifying MSM as a target group for HIV prevention in the national strategy and generating evidence on the evolving impact of HIV on MSM in Nicaragua. Advocacy efforts and media campaigning against homophobia and for recognition of sexual diversity, led mostly by CEPRESI, resulted in an increase of up to 10 percent for resources for MSM in the GFATM Round 8 grant of January 2010. This funding increase was due also to ongoing research that demonstrated higher-than-expected HIV prevalence among MSM.
To ensure that services are available for MSM, CEPRESI has implemented an HIV prevention program targeting young MSM aged 18 to 35 years, the most-at-risk age group,(3) as part of the country's GFATM support activity (Ministerio de Salud de Nicaragua 2009). The first phase of the program took place from December 2006 to February 2009, targeting 8,000 MSM in the six regions of the country with the highest concentrations of MSM. Program activities focused on how men self-identify and promoted healthier alternative models of masculinity. For the second phase of the GFATM Round 8 proposal (2009 to 2012), CEPRESI is providing HIV prevention services for men in general and MSM in particular, and establishing a new clinic offering sexual health services to men in Managua, Nicaragua's capital.
With substantially increased funding and other support from GFATM, CEPRESI has implemented activities for MSM within this paradigm. The organization's strategic goal is to "provide gay men and other MSM with the knowledge and skills needed to develop low or zero risk behaviors related to [sexually transmitted infection] STI/HIV transmission" (CEPRESI 2010).
In response to the specific needs of MSM in Nicaragua, CEPRESI has developed a tailored, four-pillared conceptual framework:
- Promote structural changes and attitude changes at the community level via mass media and social marketing to accept sexual diversity.
- Educate male adolescents about new models of masculinity based on respect, self-esteem, and care.
- Reach out to MSM for HIV prevention and human rights support.
- Offer men culturally-appropriate sexual health services.
Each of these pillars of intervention is described subsequently.
Changing community perspectives: Television spots produced by CEPRESI to disseminate these messages have been widely popular. In one of them, for instance, a man in love with a girl is depicted as overwhelmed by peers telling him that "men should have multiple sexual partners" and "real men don't cry, they are strong." This is followed by new, happier images where he is told, "You have the right to be different—you can be nonviolent." The message ends with the call, "Together we can construct a new masculinity." In another one, a young man is hesitant about revealing his sexuality, while the off-camera voice says, "It doesn't matter if you are in or out of the closet, your option should be respected"; finally out of the closet, he meets another man, while the voice offers a reminder: "If you are a man having sex with other men, always use condoms."
Television spots, radio programs, road billboards, participation in festival parades, education fairs, and in some cases protest demonstrations have been used to provoke public discussions on the role of men in Nicaraguan society. These direct and straightforward examples show how CEPRESI has aggressively used media and social marketing both to advocate for respect for sexual diversity and to call on men to think about the consequences of their actions, stressing the benefits of behavior change.
Educating the men of the future: With the support of the U.N. Children's Fund (UNICEF), CEPRESI implements the Teenagers in Action in Favor of Sexual and Reproductive Health Thanks to a New Vision on Masculinity program, targeting up to 9,600 teenagers in the eastern region of the country. Currently, the program reaches 7,470 teenagers attending six schools in four villages; the remaining 2,130 teenagers are reached after school hours via community activities. The program also offers training to education administrators and teachers on sexuality, sexual diversity, HIV, and gender roles, and then works with them to facilitate implementation of activities in schools. Parents participate in workshops and create their own self-support networks and activities.
Although some activities target both genders and others are offered separately to boys and girls, most of them target boys. Male teenagers are invited to attend a series of sessions (workshops, video forums, knowledge contests) to discuss male roles, gender inequities, ethics and values, sexuality, and HIV transmission and protection; with the help of teachers, selected male students are invited to become sexual health peers or "promoters." These promoters become an ongoing source of information and leadership for the student body throughout secondary school life.
The school program for boys includes four thematic areas: men's sexuality, gender and masculinity, men's sexual and reproductive health, and sexual and reproductive rights. Each thematic area is subdivided into four to seven units, with each offering a workshop lasting around 45 minutes (the same as a regular class). For instance, as part of the gender and masculinity theme, typically 15 boys attend a session entitled "A Disease Called Machismo," where they learn about Mario, a boy who is aggressive in relationships and lacks respect for others and for himself. The boys are then divided into three subgroups to discuss such issues as, "How is Mario's behavior socially influenced and why?" "Is Mario like most Nicaraguan men?" and "According to you, what is manhood?" After the breakout sessions, the students come back to the larger group and share their views. The session ends with the facilitator asking the boys if they feel they themselves practice machismo and, if so, what emotional and other costs are associated with it.
In post-intervention tests conducted after each session, boys declared that their view of masculinity, gender relations, sexual behavior, prevention methods, and respect for sexual diversity changed after the workshop discussions.
Engaging men who have sex with men on their own turf: A combination of personal experience and knowledge and mapping exercises have been used to identify where MSM in Nicaragua meet. Three sectors are the most relevant. They include the following:
MSM informal networks: Outside the capital, informal networks of MSM represent an important means of engaging MSM. In the provinces, the population is semi-rural, and personal connections have two functions: as a way to socialize with other MSM and as a protection against violence and marginalization. In Masaya, a village half an hour from Managua, William, who works with the CEPRESI office as a facilitator, is the key contact for a small but dynamic MSM community. He is a visible peer who provides information on HIV transmission modes, advises on prevention strategies, supplies condoms and lubricants, and orients and accompanies MSM to report abuse and hate crimes. He also organizes informational and group support gatherings at his home that address a variety of issues, from negotiating safer sex with partners to family difficulties. Finally, he also goes to reach MSM cruising in the outskirts of Masaya.
Parents and others who support MSM are also targeted and eventually create their own networks. They participate in training workshops and informal gatherings where they can chat. Skill-building sessions on sexual diversity, human rights, ethical values (respect, equity, non-discrimination), self-esteem, and assertive communication help them face community criticism. The facilitator eventually suggests having discussions on domestic and gender violence, normally taboo subjects.
Cruising areas and points of encounter:
- Cruising areas: Markets, public parks, transportation hubs, and cinemas are common places where MSM gather to socialize and identify potential sexual partners. CEPRESI has trained safer sex promoters who regularly meet MSM in these settings to provide HIV information and prevention services. The safer sex promoters first introduce themselves, then talk about the organization and why they are there. Clients are not initially approached as being MSM, as they often do not openly declare they are. As a 16-year-old boy in Managua's Central Park said, "I am here because in a short while nice girls will show up and I may meet one of them." All men and boys, regardless of sexual orientation, are counseled on the transmission of HIV and STIs and how to protect themselves. If they self-identify as gay or as engaging in same-sex behavior, CEPRESI outreach staff offer proper advice and practical tools (such as where to find legal and peer support).
- Points of encounter: Sex cinemas, night clubs, bars, billiard halls, and motels are common points of encounter. CEPRESI outreach promoters visit these venues daily and talk to clients about safer sex. To have a more permanent presence in these gathering places, the organization embarked on a new program to place permanent displays with HIV prevention material in 45 MSM settings by the end of 2010. Each display was to be stocked weekly with three boxes that each contain 144 condoms and the same amount of lubrication sachets, plus prevention and referral brochures. The organization is also engaging business owners and staff by raising awareness and providing training on HIV prevention, which helps ensure access and a favorable atmosphere for outreach activities.
- Transportation professions: Bus drivers and conductors and taxi and truck drivers are a specific focus of MSM programming in Nicaragua. Men working on the road have a reputation in Nicaragua for having multiple partners of both genders in different cities and villages. CEPRESI works in close collaboration with the powerful taxi trade unions and transportation cooperatives. Drivers and conductors participate in training sessions on safer sex for all types of sexual practices, including correct use of condoms. The idea is to educate these men to change behavior but also to be able to engage in conversations with other male passengers about various prevention topics, including safer sex.
Taking care of men's sexual health: As part of the second phase of the GFATM Round 8 proposal, CEPRESI is refurbishing its offices in Managua to open a men's health clinic that will offer STI, HIV, and other sexual and reproductive health services in a friendly environment, run by staff trained in and sensitive to the sexually-diverse client population. Initially, services will be free, but to promote sustainability, CEPRESI plans to implement a dual financing mechanism, using both government/donor financing and direct consumer payments for those who can afford them. The clinic in Managua is the pilot project; if it is successful, CEPRESI will open new health centers for men in other regions.
What Worked Well
Addressing the social drivers of HIV among MSM: Extensive research by CEPRESI has shown that masculinity in Nicaragua is traditionally associated with risk taking, power use and abuse, violent reactions, perceptions of sexual might and invulnerability, and the repression of feelings (Sánchez Bermúdez and Roca 2009). All these factors constitute drivers of HIV spread as well as barriers to effective HIV prevention programs for MSM and other vulnerable groups. It became clear to CEPRESI that no HIV prevention efforts in the country will succeed without addressing these issues.
Combining large- and micro-scale interventions: Recognizing that HIV prevention strategies need to expand from the top down as well as the bottom up, CEPRESI simultaneously implemented media and social marketing campaigns to address social determinants of risk and outreach programs that targeted youth as well as communities and settings where data revealed concentrations of men at greatest risk. CEPRESI achieved this by developing and putting into practice a comprehensive strategy with four angles: social communication and advertising to deconstruct the traditional role of masculinity and to promote a new one based on more positive values; educational sessions and peer-based actions for boys in public schools that link models of masculinity to gender equality, healthier sexuality, and HIV and STI prevention; outreach activities for MSM to promote sexual behavioral changes in community-based settings, social networks, and community spaces; and—starting in late 2010— comprehensive sexual health services for men in a friendly atmosphere.
Recruiting and training sensitive and representative staff: CEPRESI welcomes professionals regardless of personal beliefs and sexual orientation, but does not tolerate homophobic attitudes. All personnel receive intensive training on sexual diversity, human rights, and positive values. Creating a friendly and empathic context for a conversation on delicate issues requires that the program staff represent the diversity of MSM and general communities.
Collecting and using data for program management and advocacy: CEPRESI routinely collects client-level data to monitor and evaluate program activities, document the impact of interventions targeting MSM, and improve services. The organization is particularly proud of the fact that all evaluations are performed by external, independent evaluators.
For example, at the end of the first GFATM-funded project, CEPRESI conducted end-of-line data collection and analysis to evaluate the impact of its activities on MSM knowledge, attitudes, and behavior. The evaluators interviewed 500 individuals who had participated in CEPRESI's program activities and organized six discussion groups with an additional 90 men. Findings include the following:
- A total of 32 percent of individuals interviewed reported having sex with both men and women in the past 30 days.
- Ninety-eight percent reported being exposed to HIV prevention information produced by CEPRESI.
- Of those who received a message, 30.4 percent reported use of condoms and water-based lubricant in all sexual encounters.
- Nearly 55 percent reported increased measures to prevent HIV and improve their health habits.
- Of the interviewees, 42 percent reported that they reduced their number of sexual partners (Sánchez Bermúdez and Roca 2009).
Despite its limitations, this research shows that CEPRESI's efforts to address the role of socially dominant ideas of masculinity can be particularly useful for increasing HIV-preventive habits in the MSM population.
Disseminating promising practices in the region: CEPRESI's unique gender-based approach to MSM programming has only recently gained broad recognition in the Latin American region. As part of its regional networking, CEPRESI has actively engaged in discussions with other MSM and LGBT groups in Latin America and the Caribbean, advocating for a shift in HIV prevention approaches for MSM. As a result, new regional proposals being submitted to donors for grant consideration increasingly include formative research on social determinants of HIV transmission among men and implementation of innovative programs to promote new models of masculinity.
Addressing social determinants of HIV risk is long-term and costly: Using new models of masculinity to address the HIV prevention needs of MSM show great promise, but changes in social and cultural behaviors deeply rooted in communities need time to take hold. Obtaining buy-in from national stakeholders, who must understand, share, and adopt a similar genderbased framework for HIV prevention in MSM, is also time-consuming. When resources are limited, opting for a two-prong (macro and micro) approach may not be feasible. In addition, reliance on international funding alone to implement such an approach requires early discussion and implementation of a sustainability plan.
Masculinity norms are only part of the picture: Untangling traditional masculine norms and promoting new, more positive behavioral models is key to building an effective HIV prevention program for MSM. However, program approaches sometimes take a narrow perspective of the lives and behaviors of MSM and do not take into consideration the fact that many MSM also have sex with women and TG people or engage in relationships with other men where unequal gender roles are clearly assigned. In these cases, traditional gender norms associated with femininity may push men to avoid behaviors considered to be feminine, such as expressing emotions or being monogamous. This may also reinforce traditional male behaviors that are associated with sexual risk-taking. Asking men to change while others demand or expect them not to do so is counterproductive and will generate more confusion than relief. For MSM-focused groups like CEPRESI, it is essential to engage in shared analysis and interlinked strategies and programs with organizations for women and TG people, as well as sexual and reproductive health groups. Building coalitions with a wider variety of concerned gender stakeholders will ultimately reflect the complex and diffuse nature of MSM activity.
Community violence fueling HIV must be addressed: One area that needs coordinated action from the public sector and civil society is gender-based violence against vulnerable groups, including MSM. Informants in Nicaragua report frequent occurrence of physical and sexual violence by men against women, sexual abuse of children, and verbal attacks and violence against MSM and, especially, TG people. Violence is so common that affected individuals tend to justify it; as peer educator William Caballero from Masaya, Nicaragua, put it, "Some of the girls [TG individuals] really think that if they have been [abused] it is because something they did provoked it."
Gender-based violence has multiple implications for HIV prevention programming (Betron and Gonzalez- Figueroa 2009). Approaches that do not take into account how violence affects MSM vulnerability to HIV may have limited effectiveness in reducing overall HIV incidence in the long-term. While community organizations such as CEPRESI may feel overwhelmed by the dimension of the task, coalition development and coordinating strategies with both public authorities and other civil society groups will result in broad, synergistic responses to gender violence and HIV.
Growing up fast is tough: In some countries, funding and resources from international donors have escalated very rapidly, leading to a dramatic increase in program demands. In only six years (from 2004 to 2010), CEPRESI has evolved from an exclusively volunteer group to a highly professional institution, which has required strengthened technical and managerial capacities. Currently, it has a staff of 45 people conducting 200 activities every month in 50 of 150 municipalities in Nicaragua. Overall, the group estimates that in 2009, its interventions reached 13,000 MSM. This has required CEPRESI to strengthen further both its technical and managerial capacities. As it expands into providing direct clinical services, the organization will soon need to recruit, train, and supervise an entirely new cadre of staff at the men's health clinic in Managua, including 12 caregivers. Managing a clinic may pose new challenges, including monitoring and evaluation (M&E) systems, development of organizational structure, and institutional strengthening. To meet both technical and managerial technical assistance needs, and ensure quality clinical services, CEPRESI is partnering with the U.S. Centers for Disease Control and Prevention and with USAID, from whom CEPRESI has received funding in the past as a member of NicaSalud, an umbrella organization of health organizations in Nicaragua.
Facing an uncertain HIV funding environment: CEPRESI's international cooperation funds are secured until early 2015, but funding beyond that time is unclear. Donors are experiencing resource restrictions and starting to exclude middle-income countries from funding for HIV interventions. While still poor, Nicaragua's gross national product has been rising steadily. However, increases in national wealth do not necessarily benefit vulnerable groups, such as MSM, that are culturally—and often economically—marginalized.
Recognize the plurality of experiences and options of MSM: The term men who have sex with men was created to overcome the limitations of such categories as "gay men" and "bisexual men" and focus on behavior and practices rather than identity (Dowsett 2008). Sexuality is complex and cannot be reduced to social or epidemiological categories, and same-sex activities between men may or may not represent an individual's sexual identity. While many gay men in developing and developed countries struggle with the social environment and self-stigma—a conflict that has individual and collective consequences that should by no means be underestimated—many other MSM engage in same-sex activities as part of sex work, transactional sex, power relationships, or sexual pleasure-seeking. In Nicaragua and elsewhere, programmers need to recognize the realities of people's sexual activity beyond standard behavioral categories when designing and implementing HIV prevention interventions.
Clarify the position of TG people in MSM support programming: MSM often have an unclear and at times ambivalent relationship with TG communities. TG people are also extremely vulnerable to HIV (International HIV/AIDS Alliance 2008) and may benefit from some components of HIV programs for overall MSM communities, but they also require specific support. As a Nicaraguan TG peer educator explains, "TG people suffer from double discrimination: as TG and as women—and we do not fit well in men-centered approaches." Programmers should be aware that a spectrum of support services—from MSM focus organizations to TG peer-led groups—are needed to cover the diverse range of vulnerable populations highly affected by HIV.
Use real peers to promote risk-taking reduction and safer sex: Peer-based HIV prevention programs require integration of as many types of peers as there are "types" of MSM. CEPRESI's decision to hire MSM outreach promoters regardless of their sexual orientation resulted in a rich plurality of staff that mirrors the reality of the communities they must work with. Including openly gay men is also critical, as are, for instance, heterosexual men with children and men who do not feel their identity must be primarily based in their sexual preferences, whatever those preferences are.
Maximize findings from formative research: Organizations working with MSM may not have in-house expertise to perform M&E studies and analysis or may prefer, like CEPRESI, to proactively ask external evaluators to do the job. Both options are valid, provided that M&E and data use are part of a strategy that is designed from the beginning and comes from a broad range of sources, including epidemiological data, qualitative findings, routine monitoring data, and special studies, including end-of-project assessment. Of equal importance, is the use of data for decision making and program improvement.
Support emerging leaders: MSM-based organizations in Latin America share a history of struggle. Strong leaders have been needed to ensure human rights advocacy and to push for inclusion of MSM HIV prevention programming in national health agendas. Once the public starts to recognize and respect MSM and their health needs, a broader, more participatory grassroots leadership should be encouraged. Program planners have to use sensitivity in managing leadership replacement and continuity, balancing the value of the most experienced with the fresh view of emerging leaders.
Prepare for donor exit: As international donors modify their priorities and cut funding, programmers and policymakers in middle-income countries will need to take advantage of international financing while it is still available to strengthen local capacity and ensure long-term sustainability. How this is done will vary depending on the country context, but offering technical assistance for intervention viability and institutional development, as the local USAID mission is planning to do with 20 additional Nicaraguan nongovernmental organizations working in sexual and reproductive health, will no doubt have a remarkable impact. Capacity development should benefit both civil society groups and government institutions, balancing the support of a dynamic and democratic community with the reinforcement of public policies and civil servants to take responsibility for national health problems.(4)
Nicaragua and other countries should integrate a focus on the role of masculinity into a wide range of health issues, including those that have historically focused on women and children. For example, in the central region of Nicaragua, CEPRESI has been asked to participate in maternal and child health programs as a way to engage men in family planning and care.
The Nicaraguan experience addressing HIV in MSM through questioning gender inequalities and roles illustrates how supporting community groups that represent sexual diversity and commit to wellplanned, implemented, and evaluated projects in a permanent learning process will pay off in terms of overall society benefits.
If, and how, HIV prevention and care for the most affected subpopulations remains a priority in Nicaragua will depend on the direction national policies take. Local informants fear that some of the human rights achievements for sexually diverse people and the positive consequences of those advances for HIV programs will disappear if less sensitive policymakers take over. Nicaraguan civil society is active and experienced, but it is also fragmented. Building and strengthening sexual and reproductive health coalitions that can act as social auditors of government actions are fundamental to ensuring long-term national commitment to programming for HIV and related diseases.
Centro para la Prevención y Educación del SIDA (CEPRESI)
Altamira D'Este. Semáforos del BDF, 20 varas abajo.
Casa No. 214
Baral, Stefan, Frangiscos Sifakis, Farley Cleghorn, and Chris Beyrer. 2007. Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries, 2000–2006: A Systematic Review. PLoS Medicine 4(12):e339. .
Barker, Gary, Christine Ricardo, Marcos Nascimento, Adepeju Olukoya, and Carlos Santos. 2010. Questioning Gender Norms with Men to Improve Health Outcomes: Evidence of Impact. Global Public Health 5(5):536–553.
Betron, Myra, and Evelyn Gonzalez-Figueroa. 2009. Gender Identity and Violence in MSM and Transgenders: Policy Implications for HIV Services Washington, DC: Futures Group International, USAID | Health Policy Initiative, Task Order 1. (PDF, 661 KB) (accessed July 8, 2011).
Cáceres, Carlos, Percy Fernández, and Alfonso Silva-Santisteban. 2009. Men Who Have Sex with Men and the HIV Epidemic in Latin America and the Caribbean. Lima, Peru: Unit of Health, Sexuality and Human Development, Cayetano Heredia University, Lima. (PDF, 148 KB) (accessed July 8, 2011)
Dowsett, Gary. 2008. The Problematic Category of MSM: Masculinity, Sexuality, and HIV/AIDS. Oral communication, Session "HIV Prevention among Men Who Have Sex with Men (MSM)." XVI International AIDS Conference, Toronto, Canada, August 17.
Gutiérrez, Norman. 2010. Personal communication, August 20.
International HIV/AIDS Alliance. 2008. The Hidden HIV Epidemic: Transgender Women in Latin America and Asia. Buenos Aires, Argentina: Regional Representative Office for Latin America and the Caribbean, International HIV/AIDS Alliance.
Román, Matilde, and Ramón Jeremías Soto. 2003. Estudio Multicéntrico Centroamericano de Prevalencia de VIH/ITS y Comportamientos en Hombres que tienen Sexo con otros Hombres en Nicaragua (EMC). Managua, Nicaragua: Ministerio de Salud de Nicaragua Programa Nacional de Prevención y Control de las ITS/VIH/SIDA. (PDF, 530 KB) (accessed July 8, 2011).
Sánchez Bermúdez, Armando, and Sonia Mejía Roca. 2009. Resultados de Impacto de la Estrategia IEC en HSH en Seis Departamentos del Pacífico de Nicaragua. Managua, Nicaragua: CEPRESI. (PDF, 1.8 MB) (accessed July 8, 2011).
UNAIDS. 2008. Epidemiological Fact Sheet on HIV and AIDS. Core data on epidemiology and response: Nicaragua. Geneva, Switzerland: UNAIDS. (PDF, 690 KB) (accessed July 8, 2011).
USAID. 2008a. HIV/AIDS Health Profile: Central America. Fact Sheet, September 2008. Washington, DC: USAID.
USAID. 2009. Technical Issue Brief: Gender and HIV/AIDS. (PDF, 346 KB) (accessed July 8, 2011).
The author owes a debt of gratitude to the leadership and staff of CEPRESI for their support in the development of this case study. Special thanks also to USAID in Nicaragua and Washington, DC, for their assistance, advice, and helpful feedback. Other stakeholders also provided valuable input that contributed to the development of this document, particularly Dr. Ximena Gutiérrez Gómez from the family planning nongovernmental organization Profamilia and Samira Montiel, Special Ombudsperson on Sexual Diversity and HIV/AIDS, Nicaragua's National Office of Human Rights. Finally, this case study would not have been possible without the generosity and courage of CEPRESI's programs beneficiaries who agreed to be interviewed: young students, community leaders, TG people, and anonymous MSM. Their contribution is much appreciated.
Tallada, Joan. 2011. Promoting New Models of Masculinity to Prevent HIV among Men Who Have Sex with Men in Nicaragua: Centro para la Prevención y Educación del SIDA. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.