Before turning to the essence of the problem, we want to explain three concepts that will be discussed later in the text.
1. Men Having Sex with Men (MSM) This term is widely used in the texts published by international organizations working in the sphere of HIV control. A man having sex with other man may not identify himself as gay or bisexual. It means that number of MSM is always greater than number of gays and bisexuals.
2. Concentrated HIV Epidemic Almost nobody says about it unfortunately, but there is officially confirmed concentrated epidemic in Kazakhstan. This means that HIV is spread rapidly in one or several population groups, but not in the overall population.
3. 90-90-90 UNAIDS has an ambition to take HIV under control. With this aim in mind they offered to the international community plan for ensuring that by 2020 90% of all people living with HIV know about their diagnosis, 90% of them take antiretroviral therapy, and 90% have undetectable viral load. It is impossible to get the virus from infected person with undetectable viral load.
Care and Worries of the Ministry of Health
It should be noted that Kazakhstan's Ministry of Health is the only ministry that deals directly with the LGBT population that is associated with men having sex with men. The reason is quite simple: when the first HIV epidemic outbreak occurred in the United States in the 80s people believed that the virus was spread only among homosexuals. It turned out later that this was not visitation of God for sodomy, but a new challenge for the mankind. Homosexuals were the first victims just because they used less safe sexual practices than heterosexuals. MSM used condoms rarely because they were perceived as contraceptives first of all, due to widespread homophobia supported by the state and society homosexuals were a marginalized group not included in sexually transmitted diseases prevention programs. Nowadays sexual education is available for anyone in European countries, but at that time it was impossible.
That's why homosexuals or, more specifically, MSM became one of risk groups where HIV is spread faster. Other affected groups are: sex workers and people who inject drugs (PWID). These three groups attract special attention of health professionals, they are included in the protocols of the World Health Organization (WHO), and therefore all the UN member states and states that recognize the authority of WHO are obliged to implement standards and protocols. Kazakhstan is one of such states. That is why our Ministry of Health is the only state body that works with this portion of LGBT community routinely, mainly through the Republican Centre for AIDS Prevention and Control (RC AIDS) - principal organization responsible for HIV and AIDS prevention and control. RC AIDS prepares preventive action and treatment plans for all Kazakhstani citizens, including the three high risk groups.
Fighting All Together
However our health officials are not alone - they cooperate closely with UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria. UNAIDS coordinates activities related to fight against HIV internationally and the Global Fund provides financial support to agencies and organizations in the sphere of healthcare for fighting against the diseases specified in its name.
In this spring Kok.team published a series of interesting articles. The first was article written by our columnist named "Where is the Global Fund Money?" where the author asked Kazakh officials about the large tranche provided by the Global Fund to Kazakhstan. We'd like to remind that the Global Fund provided grant amounting to $ 4.5 million for the period 2018-2020 for HIV component No. 1578 KAZ-H-RAC Preparing Framework for Sustainable Response to HIV in Kazakhstan. The author's principal complaint is about the fact that he is an LGBT activist working in Kazakhstan, but he has never seen any activities performed by non-governmental organizations that are the final recipients of grant funds. This rather serious complaint against officials and HIV-service NGOs entailed a series of publications by other LGBT activists and the Country Coordination Committee (CCM) established with the aim of supporting the grant implementation.
In order to resolve this problem there was held Skype conference where representatives of the RC AIDS, three NGOs that had won the grants, and other parties concerned explained how the Global Fund's money was spent, who was responsible for what, and which activities were performed.
Alla Yelizarieva - Specialist of the Global Fund Grant Implementation Group (RC AIDS) said: "We need to cover 20% of the estimated number of MSM, which is 62,000, by 2020". She presented data on number of MSM in the regions covered by the grant program: Almaty - 6,000, Astana - 3,300, Karaganda region - 4,900.
These data gave rise to concerns about the Ministry of Health's capability of implementing UNAIDS 90-90-90 Strategy successfully.
Count off!
Number of MSM is estimated in order to determine how many there are men having sex with men in the country. It is impossible to make plans without knowing how much work you have to do. In order to prepare a plan you need some initial data which predetermine almost all or all details: terms, budget, technical infrastructure, staffing pattern, partners, etc.
This is the same situation: RC AIDS needs to know at least approximate number of PWID, sex workers, and MSM in the country.
It is hard to determine precise number, it is almost impossible. It is hard even to conduct a simple sociological survey, when it comes to a stigmatized, marginalized group, calculation becomes a real challenge. Imagine an interview where you ask a Kazakh man if he had sex with men in the past six months? What is the probability that he will honestly say that he had sex with another man, if homosexual contacts are not just condemned in the society, but can even result in discrimination or even hate crime against MSM? Meanwhile anonymous sociological survey is one of the ways to obtain data for making estimates. The next part describes the types of data used for estimating the number of MSM.
Kinsey, You are Wrong
According to the RC AIDS there are 62,000 MSM among 5,460,378 men aged from 16 to 62 in Kazakhstan. Let's try to understand how this figure was obtained.
In case of MSM we could choose the simplest way and use the results of studies performed by Alfred Kinsey, who claimed that number of LGB population is 5-10%. Based on these data we could conclude that number of MSM in Kazakhstan ranges from 273,018 to 546,037! But Kinsey performed his studies in the middle of the twentieth century, and such extrapolation is not used actually.
We can use another similar method and extrapolate the results of more recent studies conducted in societies with lower level of homophobia, where respondents are not afraid to declare their orientation or speak about their sexual practices more or less honestly. For example results of study performed by Dr. Jeremy A. Gray from the Department of Epidemiology of the Rollins School of Public Health (University of Amory, USA) in 2016 show that percentage of MSM varies from state to state and ranges from 1.5% in Wyoming to 6.0% in Rhode-Island. Based on data on all the states average number is 3.9%. If we extrapolate these data to Kazakhstan, we will get 212,955 people.
Here is another study conducted by the National HIV Center (Atlanta, USA) in 2012. They performed meta-analysis of the results of seven studies conducted in the US. Obtained data show that number of men who had sex with men in 2011 was 2.9%, in the previous five years - 3.9%, and number of those who experienced gay sex - 6.9 %. Extrapolation of these data to Kazakhstan shows that there are 212,955 to 376,766 MSM, i.e. 3.9% and 6.9% respectively.
Results of study (2011) conducted in American schools show that 3.8% of students identified themselves as LGBT. As for the adult population, meta-analysis of a series of surveys conducted at The Williams Institute show that 3.5% of Americans identify themselves as LGBT people. Results of studies conducted in developed countries where degree of homophobia is lower and LGBT people are much more open you can find in in Wikipedia.
Extrapolation of research data shows that there are at least 212,955 MSM (3.9%) in Kazakhstan - 3.4 times more than Kazakhstan's RC AIDS says.
Pay and Forget?
When it comes to data on Kazakhstan it turns out that studies conducted in different periods by different authors provide drastically different results.
In 2003 UNAIDS gave to external consultant Robert Oostvogels task to determine the number of MSM in Shymkent, Astana, and Pavlodar. He used Kinsey scale, but suggested that number of MSM is with 5% rather than 10. Results showed that there are 10,000 MSM in Shymkent, 6,000 in Pavlodar, and 12,000 in Astana.
In 2005 in the World Bank's document Reversing the Tide. Priorities for HIV/AIDS Prevention in Central Asia” there was stated that approximate number of MSM in Kazakhstan was 31,000. Unfortunately the authors did not specify the study they referred to. According to these data number of MSM in the whole country is slightly higher than in three cities according to Oostvogels. This is impossible.
Rapid assessment performed in 2010 showed that number of MSM in 9 cities in Kazakhstan was 37,500. This information is shown in Survey of Epidemiological Situation with HIV and Results of Sentinel Surveillance in the Republic of Kazakhstan for 2010-2011.
This document contains also the results of assessment of MSM number conducted by 9 AIDS Centres (Aktyubinsk, East Kazakhstan, Zhambyl, Karaganda, Kyzylorda, Pavlodar, South Kazakhstan oblasts, Almaty, and Astana) in 2011 in accordance with unspecified "methodological recommendations". Number of MSM was 30,870.
RC AIDS apparently was not satisfied with a huge difference in results of previous studies and decided to spend a portion of the Global Fund's grant on a new study. RC AIDS financed Preliminary Assessment of Number of Men Having Sex with Men (PRIME) conducted in 2011-2012 was financed using the Global Fund's money. Final version of report on the results of the study was prepared by team of scientists headed by Dr. Elwin Wu from the School of Social Work at Columbia University. The main objective of the study was preliminary assessment of number of men having sex with men (MSM) in Almaty, Astana, Pavlodar and Shymkent, and Kazakhstan in general, study and suggestion of the most accurate and convenient methods for future nation wide studies. Results showed that 3.2% of men aged 18-59 years in the country are MSM, i.e. 174,732 men at the age of 16-62.
RC AIDS spent a lot of money on a large scale research that produced results correlating with the results of studies conducted in the US, but according to program documents published in 2018 number of MSM is 62,000 for some reason.
This means that the RC AIDS uses estimated number that is almost three times less than the figure calculated in independent research ordered and paid by the RC AIDS.
Why did the RC AIDS reject these data? And the most important - how the figure 62,000 was calculated? We addressed this question to the General Director of the RC AIDS Mr. Bayserkin in our journalist request. We received response letter signed by specialist Vladimir Kazakov: "Specialists of the RC AIDS are preparing a summary report on the results of epidemiological surveillance of HIV prevalence among men having sex with men (MSM) for 2017. Data on assessment of number of MSM represent a structural part of this document and will be included in the summary report at the end of 2018. Summary report will be publicly available on the RC AIDS web-site (www.rcaids.kz) in the fourth quarter of 2018”. In other words, they didn't answer, they just said - wait.
Do we have time to wait?
90-90-90 a la Kazakh
Guide issued by the RC AIDS "HIV - Yesterday, Today, and Tomorrow ..." (2017, p. 54) states that 16,229 people are under regular medical check up, i.e. 0.1 percent of the total population. Nevertheless concentrated epidemic of HIV has been registered in Kazakhstan. This means that infection is spread rapidly within a particular group. According to the RC AIDS the most common way of infection transmission in Kazakhstan is parenteral connected with use of injectable drugs - 9.2% of the estimated number of people who inject drugs (PWID) are HIV carriers. As to MSM, according to official data 3.2% of their estimated number, that is about 1,984 people, are infected.
But what if we admit that estimated number is 174,732 rather than 62,000, as the study conducted by Elwin Wu showed? It turns out that the prevalence among the MSM population is 1.06%. In this case we can make two assumptions:
- either epidemiological situation in the MSM group is three times better than it seems;
- or we do not know anything about the actual epidemiological situation in the MSM group.
We tend towards the second assumption due to 4 reasons.
First, it's hard to rely on the data when we see apparent inconsistency of figures presented as estimated numbers of MSM - it's no laughing matter - only 6,000 people in Almaty taking into account not only gays and bisexuals, but all MSM.
Second - can we believe that there are only 1,984 MSM out of 16,229 registered HIV positive people? Given the level of homophobia in Kazakh society and stigmatization, some men could not admit that they are bisexuals or that they had sex with man.
Third, data provided by RC AIDS give rise to concerns: in the period from 2009 to 2016 rate of detection of HIV among MSM in Kazakhstan increased 5.5 times (!), meanwhile it decreased or remained unchanged in other groups. What does this suggest? This suggests that work with MSM has become more effective and they agree to be tested more willingly, or, conversely, it is failure of the RC AIDS and HIV-service NGOs which are unable to organize work with this risk group?
Fourth, according to the abovementioned working paper of the World Bank study results show that only 20% of MSM in Kazakhstan use condoms, which increases already high risks connected with sexual behaviour to the maximum extent.
If strategic prevention plans are prepared based on the estimated number of MSM that is three times lower than the actual figure, scope of information campaigns standards for outreach workers, requirements for budget, staff, and purchase of condoms will be three times lower.
Is it possible to accomplish the principle of 90-90-90 with such a controversial data on MSM - one of the key risk groups?
And finally Kazakhstan may face the problem that occurred in Russia where HIV epidemic is spread rapidly, but people, except for activists, do not want to talk about epidemic publicly for various reasons.
In conclusion we want to say that development of HIV prevention and treatment program based on wrong data is like building of a house on foundation made of glass instead of stone.
We call on the RC AIDS and other governmental bodies, HIV service organizations, international and national NGOs to revise the data on estimated number of MSM in Kazakhstan, because use of data, which are understated by more than three times, is a fundamental mistake that may be fatal for Kazakhstan's healthcare.