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Ugandan bill could hinder progress on HIV/AIDS

2009; Elsevier BV; Volume: 374; Issue: 9707 Linguagem: Inglês

10.1016/s0140-6736(09)62139-5

1474-547X

Zoe Alsop,

Adolescent Sexual and Reproductive Health

Health workers in Uganda are concerned that a draft bill to criminalise homosexuality will hamper efforts to fight HIV/AIDS in the country. Zoe Alsop reports from Kampala. Speaking before a packed auditorium at Uganda's Makerere University in Kampala, a storied institution where many of today's African leaders came of age, the young parliamentarian was warming to his topic. “There are studies showing that if you are a homosexual, you are more likely to contract AIDS!” said the honourable David Bahati, as his young audience cheered him on. “If you are a homo, you can reduce your lifespan by close to 20 years!” When Bahati explained that his new bill would punish acts of “aggravated homosexuality”, or sex with minors or disabled people whether consensual or not, with the death penalty, his young audience clapped with glee. This is the state of play in modern day Uganda where homosexuality is outlawed and people who are gay already live in hiding. Now things are only getting worse. In November, Bahati introduced his antihomosexuality bill in parliament, which could be enacted by the end of this year. Tightening an existing ban on homosexuality, the law prescribes prison terms and fines for people who do not turn gays, lesbians, bisexuals, and transgender people over to the police. Groups convicted of discussing homosexuality would be sent to prison and fined. Bahati's law would impose the death penalty for an HIV-positive man proven to have had sex with another man, at a time when researchers are only beginning to study the prevalence and transmission of HIV among men who have sex with men in sub-Saharan Africa. Before ceding the podium, Bahati had one last point to make. “This is not a Ugandan thing”, he said, his chest swelling with indignation. “Homosexuals are using foreign aid organisations to promote this. If an organisation is found to be promoting homosexuality, then their licence should be revoked.” Shoulder to shoulder with Bahati's supporters a half dozen or so Ugandans listened quietly. Several were doctors who had spent much of their careers toiling against a disease that has taken the lives of more than a million Ugandans. Their faces were stoic as they contemplated the implications of Bahati's bill for the fight against HIV/AIDS not just among gay men but also among the wives and children of men who also have sex with men. They considered the long, lean years that had been spent quietly setting up networks to disburse information on HIV/AIDS to lesbian, gay, bisexual, transgender, and intersex Ugandans. “As a doctor, the law infuriates me”, said one general practitioner, who is much sought after by sexual minorities for his willingness to treat them, and who asked that his name not be used for fear that he would be arrested for working with sexual minorities. “We are only now getting to a point where people understand there is a problem. This law is going to erase all of that.” Results from studies of the modes of transmission done this year in neighbouring Kenya showed HIV prevalence among men who have sex with men to be 26%. Findings that as many as 15% of new infections in Kenya were among men who have sex with men helped to topple longstanding assumptions that, in Africa, HIV/AIDS is a heterosexual disease. Yet, as millions of foreign dollars continued to pour into the country's fight against HIV/AIDS, most programmes targeting sexual minorities were not allowed to register with the government and did not qualify for funding. The two biggest players in the global fight against HIV/AIDS, the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, contributed nearly US$300 million dollars into Uganda last year. Only one group seeking to do prevention work among sexual minorities was able to register with the government, and it received just $5000. “The mere fact that you are applying as an LGBT [lesbian, gay, bisexual, transgender, and intersex] organisation in Uganda—is illegal, you will just get arrested for [the] reason that you are gay or you are working with gays”, said Dennis Wamala, of Icebreakers Uganda, a group set up 5 years ago to make HIV/AIDS prevention and care accessible to sexual minorities. “When we deal with funders we tell them, look, here in Uganda it is illegal but we need help and so if you give us your funding, you shall do it through another organisation.” For many years they did not even know that they needed it. The general practitioner who spoke to The Lancet on condition of anonymity remembers his years as an intern in the early 1990s. As much as he learned his trade he has learned its futility in the presence of HIV/AIDS. At the time, palliative care was all that was on offer for most of patients on his ward who were dying of the disease. Yet, even as a doctor immersed in a disease that had gained notoriety for its devastation of gay men in the west, he believed that HIV/AIDS was transmitted only through heterosexual sex. International health bodies and donors had striven to make it clear: in Africa HIV/AIDS was a heterosexual epidemic. The interpretation of that message for the doctor and millions of other gay and bisexual men on the continent was slightly different: anal sex is safe. “In Uganda, they say we don't have gay people”, said the doctor. Nobody ever talked about sex between men or sex between women. There were no programmes. People said, I will only get HIV if I sleep with a woman and I never sleep with women.” It was in 2000 that he got a call from a friend in Uganda's close-knit, clandestine gay community, who said he had tested positive for HIV/AIDS. At the time the connections to the internet were still rare in Uganda but the doctor, still sceptical that his friend could have HIV, accessed the net from a terminal at his hospital. What he found horrified him. “I was overwhelmed by all this information about gay men and HIV”, he said. “I was incredulous. How come there was this much information? How come I didn't know? Why didn't I know? And then, I started thinking about all the others who didn't know what I knew then. I lived in a community that didn't know the risk, believed and lived like there was no risk.” A British colonial administration banned homosexuality in Uganda half a century ago and, as in 29 other countries in Africa, it remains illegal today. The burden of proof is so high that the law has rarely been enforced but its existence supports a stifling and sometimes deadly taboo. In past years, Wamala says, Icebreakers travelled around Kampala to meet with sexual minorities and sex workers. They offered counselling, condoms, lubricant, and medical referrals. This year, though, has been different. People seen attending meetings were blackmailed by neighbours, who threatened to report them to the police. “Nowadays, people are hiding”, Wamala said. “The blackmail and the arrests skyrocketed and we saw that it was not safe. At meetings we saw the number had really fallen, and even for those who came we were not sure whether we should be able to come the next time.” Other groups say they have been able to work as long as their activities are carefully disguised. Thomas Muyunga, a doctor in the Most at Risk Populations Network, says he always makes sure that testing and counselling events include people who are heterosexual. “Originally we wanted to go to these people directly”, Muyunga said. “We realised that it was impossible. So the disguise is to address that. That's why we have managed to even work today.” If passed, the antihomosexuality bill would not only endanger men who have sex with men, but also for the women they so often marry. “Uganda would be the first country to ever criminalise working and providing services for men who have sex with men”, said Stefan Baral of Johns Hopkins' Center for Public Health and Human Rights, Baltimore, MA, USA. “It will propagate risk. From the evidence we know many men are married, and on a molecular level we know that the strains of HIV circulating among MSM [men who have sex with men] are the same ones circulating in the community as a whole. It shows you can't just magically cut off this epidemic by criminalising them.” An official with the Ministry of Health acknowledged that the current draft of the bill could be problematic for HIV prevention work in Uganda. Ironically, early PEPFAR support for faith-based groups in Uganda may have helped some of the most prominent religious groups backing the antihomosexuality bill. “Religious organisations had never received any form of funds until it was Bush's time”, said Muyunga. “8 years is big for an organisation to get on its feet and to be able to say something. All of a sudden you are here and they have mobilised in getting over 300 people in the street. Within 3 days you see a street covered with anti-homosexuality posters and pamphlets. Every time there is that we get a drop in the number of attendances.” On a recent stormy Sunday afternoon, Wamala ducked out of the Icebreakers secret resource centre a couple of hours after a support group for men who have sex with men was supposed to have started. Nobody had shown up. Of late, Wamala says he has spent less and less time discussing HIV and more and more trying to help people in trouble. “We cannot keep on providing services if the situation is not allowing us”, Wamala said. “Once this bill is out of the way, we can go back to our work.”