HIV continues to spread among MSM on a global level. Current prevention efforts have been unable to contain or reduce HIV transmission in this population. Additional behavioral and biomedical interventions are urgently needed.

Enlarged HIV prevention coverage and increased financial investment are necessary to reduce the spread of HIV infection among MSM in Asia.

This study describes the experiences of 10 young feminised men in Pakistan. They face high levels of stigma, violence and sexual abuse. The average age of first sex was 11 years old and all reported having been been raped during childhood and early adolescence, often several times. While some mothers and siblings were quietly supportive, young feminised men often end up running away from home, finding support as a member of a hijra dera, a 'pseudo-household' led by an older feminised man or guru, in which they find employment as dancers or sex workers. After their entry into sex work there is little or no opportunity to use condoms. The hijra dera offer an important entry point for improved social support and sexual health programmes, including efforts to ensure young feminised men postpone their sexual debut and/or improve their sexual health, retain access to education, explore alternative forms of employment and improve access to health care.

A probability sample of 206 men who have sex with men from 16 sites in Phnom Penh were surveyed about sexual behaviors and tested for HIV and sexually transmitted infections (STIs). HIV and syphilis prevalence was 14.4% and 5.5%, respectively. Out of the total sample, 81% reported anal sex with any male partners in the past 6 months, and 61.2% reported having had vaginal sex. In the past 6 months, 82.8% of the sample reported having male partners who paid them to have sex. Self-reported sexual orientation did not match well with self-reported sexual behavior. Significant risk factors for HIV infection were anal sex with multiple partners, unprotected vaginal sex with commercial female partners in the past month, and any STI. Complex sexual networks indicate that men who have sex with men act as a bridge between higher and lower HIV prevalence populations. Better prevention efforts structured around behaviors rather than sexual identities are needed.

The names and identities of the individuals in the case studies have been altered, and the narratives extensively redacted, to preserve their confidentiality.Dr. Newman was supported in part by the Canada Research Chairs program (Canada Research Chair in Health & Social Justice) and the Canada Foundation for Innovation. We thank Dr. James Burford for proofreading and commenting on a draft of this chapter.

The Philippines faces a severe HIV epidemic among gay and other men who have sex with men (MSM). HIV testing uptake remains low. A case series of 12 men from Metro Manila were interviewed to explore barriers to uptake of HIV testing services. Most did not see the need to get tested for HIV despite significant risk, based on the misconception they were feeling well or showed no symptoms. Being of a higher socioeconomic class, feeling morally superior to other gay men, distance of the testing facility, fear of what will happen once infected, fear of HIV- and sexual stigma, fear of side effects of antiretroviral drugs and fear of high health care expenses after testing positive for HIV were key reasons why MSM kept postponing their test. Misconceptions about HIV risk, disease, and treatment and care need to be addressed in order to increase uptake of HIV services in this population.

In Asia Pacific, most countries have expanded HIV treatment guidelines to include all those with HIV infection and adopted antiretroviral treatment for prevention (TFP) as a blanket strategy for HIV control. Although the overall epidemic development associated with this focus is positive, the HIV epidemic in men who have sex with men (MSM) is continuing unperturbed without any signs of decline or reversal. This raises doubt about whether TFP as a blanket HIV prevention policy is the right approach. This paper reviews currently available biomedical HIV prevention strategies, national HIV prevention policies and guidelines from selected countries and published data on the HIV cascade in MSM. No evidence for efficacy of TFP in protecting MSM from HIV infection was found. The rationale for this approach is based on assumptions about biological plausibility and external validity of latency-based efficacy found in heterosexual couples. This is different from the route and timing of HIV transmission in MSM. New HIV infections in MSM principally occur in chains of acutely HIV-infected highly sexually active young men, in whom acquisition and transmission are correlated in space and time. By the time TFP renders its effects, most new HIV infections in MSM will have already occurred. On a global level, less than 6% of all reports regarding the HIV care cascade from 1990 to 2016 included MSM, and only 2.3% concerned MSM in low/middle-income countries. Only one report originated from Asia Pacific. Generally, HIV cascade data in MSM show a sobering picture of TFP in engaging and retaining MSM along the continuum. Widening the cascade with a preventive extension, including pre-exposure prophylaxis, the first proven efficacious and only biomedical HIV prevention strategy in MSM, will be instrumental in achieving HIV epidemic control in this group.

Young Thai men who have sex with men continue to have high HIV prevalence and incidence in spite of much investment in community-based prevention approaches. To make HIV services more appropriate for same-sex attracted young men in Thailand, it needs to be considered how target groups view themselves and manage their identities. This paper derives from a qualitative study of 25 same-sex attracted rural young Thai men. It identifies five tactics men employed to manage the discrepancy between their preferences and parental/societal expectations regarding gender and sexuality, and discusses how the young men viewed themselves in the wider context of Thai society, including whether they felt part of a separate gay community. Participants usually did not adopt a gay social identity and were reluctant to join in gay community activities beyond dating. Hence, they would likely experience barriers in accessing gay community-based HIV services. HIV services targeting young same-sex attracted Thai men need to be diversified if they are to be more inclusive, appropriate and effective.