The speaker, a member of Uganda’s Parliament, hurled those words into the crowded room. His tone defiant, he was looking directly at me. It was May 9, 2011; the Parliament building in Kampala. The occasion: a hearing on Uganda’s proposed Anti-Homosexuality Bill by the Committee on Legal and Parliamentary Affairs.
A number of groups had attended to oppose the bill, which criminalized “homosexual touch,” punished “promotion of homosexuality,” criminalized renting housing to gay people. I was there with the Civil Society Coalition for Human Rights and Constitutional Law, discussing public health implications of HIV prevention and care, citing research from Uganda. Earlier, the Uganda Human Rights Commission had offered objections to the bill. Colleagues weighed in on legal grounds, and UNAIDS Country Representative, Mr. Musa Bungudu, reminded everyone of Uganda’s huge HIV burden.
I was nervous. Gay and Ugandan, I was not ‘out’ at the time. Mine was a professional presentation, but the subject was risky, the audience potentially hostile. I spoke directly to the Parliament member. “This bill is not an HIV-prevention measure,” I said.
Despite the arguments that day, Parliament passed the bill. President Museveni signed it into law in February 2014. At the time, the health minister asserted there would be no discrimination in health care.
Within two months, an HIV clinic run by an international research organization was raided. Police suspected it of “recruiting young men,” and “training them into homosexuality.” The organization’s stellar international reputation and world-class research didn’t matter. That Ugandans were receiving life-saving HIV treatment and volunteered for research didn’t matter. That relevant oversight bodies had cleared it didn’t matter. Police declared their research “unethical” and “a promotion of homosexuality.”
Homosexuality is taboo in many countries. HIV has made us confront our tendency to keep sex and sexuality from public discourse. With friends, relatives, and neighbors dying, we needed to talk openly. Yet, increased visibility of socially marginalized populations has led to backlash. Some legislators are reacting with knee-jerk laws to keep these “un-African,” “Western” imports in check. Concerns for HIV are forgotten in a rush to ban and banish people not fitting the norm.
Uganda has an estimated 1.2 million people living with HIV, half a million of them on treatment. Our health system is in shambles, stock-outs of drugs common. Across southern Africa, generalized HIV epidemics have stabilized at high levels, hiding high rates of infections among gay men. In Senegal, where overall prevalence of HIV is less than 1 percent, prevalence among men who have sex with men (MSM) is over 20 percent. Communities are invisible. They are stigmatized, criminalized and punished by prison and death.
Oppressive legal and social ramifications force MSM underground, un-reached and under-researched. In many places, programming for care and prevention is absent, or meager. But organizations, agencies and researchers must not give into complacency and fear. With dwindling resources, we need to prioritize what is available and use it effectively.
We need to self-educate. It is not enough to be MSM-friendly. We need to know why MSM are a key population, why they need targeted HIV prevention and care, how they can be reached, and best practices. There are many African educational MSM resources available, free and online. They range from sexuality education, MSM sensitivity training, programming, and monitoring and evaluation. Health workers need MSM cultural competence, to appreciate the range of concerns of MSM clients.
Knowledge enhances our effectiveness at advocacy, and advocacy is necessary even in the toughest environments. Research is crucial. Local epidemics need to be studied, quantified and understood. Yet, across Africa, this research is lacking. Anti-gay laws and policies make research harder, necessary permissions almost impossible to get and respondents harder to access.
Targeted, prioritized funding is also necessary. Broad programming for heterosexual majorities doesn’t trickle down. Targeting key populations is both responsible and cost-effective because this is where the disease burden lies.
In Uganda, the raided clinic re-opened with scaled-back services. MSM clients dispersed. In communities, a few outreach services are continuing muted. We are challenging the law in Constitutional Court, hoping to scale it back. We must not stop advocacy. Silence is death.