Shortly after President Yoweri Museveni signed Uganda’s notorious anti-gay bill, making homosexuality punishable by long prison sentences, I worked with members of the HIV Medicine Association to draft a letter to President Obama requesting that he back up our government’s words of outrage with meaningful action. Signed by nearly 1,000 HIV health care providers, the letter was well received among infectious disease and HIV colleagues … with one exception. I heard from a physician member of both the Infectious Diseases Society of America and HIVMA who felt that Museveni was entirely within his rights to enact such a measure, and that it was a reasonable approach to HIV prevention in a country where HIV is so prevalent.
Creation of barriers to prevention
I was stunned by this response because of its callous disregard for human rights and the glaring flaws in its reasoning. First, the stated purpose of the Uganda bill had nothing to do with HIV prevention; it was to protect “innocent children” from “homosexual predators.” It has long been a widely held belief among African doctors and leaders that the African HIV epidemic is entirely heterosexual. Therefore, in the minds of the Ugandan leadership, criminalizing homosexuality would do little to control their epidemic.
I can think of no example of criminalization of risk behaviors that has successfully prevented infectious disease transmission or benefited public health. In fact, criminalization has been identified as a barrier to comprehensive prevention programming for gay men — a population with an estimated 13% HIV prevalence in Uganda’s capital city, Kampala.
To put a human face on it, imagine the case of Joseph, a young man living in Kampala. Joseph is secretly having sex with other men. He is married because marriage is expected by his family and within his culture. He has two children, and his wife, who is unaware of his secret sex life, is pregnant with a third child. Although he has never been tested, Joseph is infected with HIV, and he now develops syphilis and gonococcal proctitis, which also go undiagnosed. He assumes he has an STD, but because his symptoms are anorectal, he avoids medical care, knowing that he could face 7 years in prison if he’s found to have had receptive anal sex.
Because Joseph doesn’t know he has HIV, he’s unaware that he could face life imprisonment for “aggravated homosexuality,” which includes engaging in homosexual sex while HIV-positive. He also has legitimate fears about blackmail by medical staff, who themselves could be liable for “promoting” or “aiding and abetting” homosexuality, which itself carries a prison sentence of 5 to 7 years. Joseph suffers through his symptoms, taking random antibiotics purchased from local pharmacies, until he gradually recovers. He has unknowingly transmitted HIV and syphilis to his wife, who will in turn transmit both infections to her unborn baby.
Lack of effective approach
No physician could view this as an effective approach to disease control and HIV prevention. But the emphasis of the Ugandan government has been on sexuality, not public health. They rationalize their legislation with long discredited, pseudoscientific arguments about the dangers of homosexuality and the mutability of sexual orientation. Recent events in Kampala indicate that pseudoscience has given way to government-sanctioned disruption of lifesaving health care with a raid on the Makerere University Walter Reed Project (MUWRP) by Ugandan authorities that ended in the arrest of one of the facility’s employees for “conducting unethical research” and “recruiting homosexuals.” MUWRP operations have been temporarily suspended to protect staff and patients. Notably, the clinic at this Kampala facility provides antiretroviral therapy among other HIV services. The Ugandan government action makes it clear that the anti-homosexuality law poses a direct threat to HIV patients and providers. As infectious disease physicians, public health experts and HIV providers, we must respond.
Call to action for ID physicians
First, we should use our expertise to provide evidence to the Ugandan leaders — and to the Western governments that provide them aid — that the criminalization of homosexuality will be a public health disaster, undoing many of the gains made by a country once held up as a model for its forward thinking approach to HIV treatment and prevention.
Second, we must insist that the US government take steps to ensure the safety and continued care of patients served by US-funded programs and to protect providers at these clinics. In addition, we must urge the US government to support clinicians working in countries who may be forced to engage in acts of civil disobedience, despite significant personal risk of prosecution and incarceration for “promoting, aiding, or abetting” homosexuality. Clinicians must embrace the higher laws of medical ethics, which protect confidentiality and prioritize the best interests of the patient over the perceived interest of the state.
Third, we should support basic human rights, including for lesbian, gay, bisexual and transgender individuals, and advocate non-discrimination policies at medical clinics and facilities worldwide. There is no room for cultural relativism in this debate. Such legislation is a fundamental evil that has no place in the global community of the 21st century.
As a postscript, here in the United States, we also criminalize risk behavior at the expense of public health and the rights of US citizens. We treat drug use as a crime rather than a medical and public health problem. We ignore the evidence that needle exchange saves lives. Thirty-two states have HIV criminalization laws, and there are people with HIV now serving time in US prisons for the crime of consensual sex — including disclosure of HIV status — in which no transmission occurred.
Our outrage about what is happening in Africa will be hypocritical unless we advocate for ethical and scientifically sound public health policy here at home and abroad.
Hladik W. PLoS One. 2012;7:e38143.
Semugoma P. SAHARA J. 2012;9:173-176.
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Joel Gallant, MD, MPH, is Chair of the HIV Medicine Association and Associate Medical Director of Specialty Services at Southwest CARE Center in Santa Fe, N.M. Gallant can be reached at email@example.com.
Disclosure: Gallant reports no relevant financial disclosures.