HIV, human rights, and men who have sex with men, LANCET INFECTIOUS DISEASES,UK

[emeraldize]

HIV, human rights, and men who have sex with men
Lancet Infectious Diseases, UK

July 2010



Volume 10, Issue 7, Pages 448 - 449,

Kathryn Senior



The issue of human rights for men who have sex with men and how
national and local attitudes can affect the spread of HIV and AIDS was
highlighted last month when Steven Monjeza and Tiwonge Chimbalanga, a
male couple in Malawi, were sentenced to 14 years hard labour for
sodomy, after they held the country's first known same-sex commitment
ceremony. International outcry followed, and after pressure from UN
Secretary General Ban Ki-moon during a visit to the country, Malawi's
president, Bingu wa Mutharika, granted an unexpected pardon. “This was
a very courageous decision by President Mutharika. I highly applaud
the President's leadership. Distinguished members of the Parliament, I
am confident that you will take appropriate steps to update laws
discriminating based on sexual orientation in line with international
standards”, Ban announced at a press conference shortly afterwards.



In the 20 years since homosexuality was removed from the list of
mental health disorders by the World Health Assembly, there has been
substantial progress in North America, western Europe, and more
recently in Latin America, towards greater public acceptance and legal
protection for men who have sex with men. In many parts of the world,
however, denial of health care, stigmatisation by health-care workers,
and the continued “pathologisation” of homosexuality is still a
reality. Highly publicised cases of arrests and imprisonment of gay
men in Egypt, Senegal, and Malawi often required doctors to carry out
examinations and provide evidence confirming homosexual conduct for
prosecutors on the basis of spurious scientific knowledge. “Many
serious cases of human rights abuses against men who have sex with
men, such as killings, torture, violence, harassment, and sexual
abuse, are also reported every year in many countries”, reported
Cheikh Traore, Senior Adviser on Sexual Diversity at UN Development
Programme (UNDP), New York, USA.



“Around 86 countries worldwide still have laws that criminalise sexual
relationships between two consenting adults of the same sex, according
to the International Lesbian and Gay Association (ILGA), which tracks
this”, says Chris Beyrer, Professor of Epidemiology, International
Health, and Health, Behavior, and Society at Johns Hopkins Bloomberg
School of Public Health (Baltimore, MD, USA). According to a study
being prepared for publication by the UNDP, male-to-male sex between
adults is criminalised in 19 of the 48 Asia—Pacific countries and
territories. “These are all jurisdictions with common law traditions;
some countries also apply traditional or local religious law, which
imposes severe penalties including death (in Afghanistan and parts of
Pakistan), whipping, and life imprisonment”, explained Mandeep
Dhaliwal, Cluster Leader: Human Rights, Gender & Sexual Diversities,
UNDP, New York, USA. Countries such as Vietnam, Cambodia Laos,
Philippines, and Indonesia all follow civil-law traditions that do not
criminalise male-to-male sex, except in provinces where Sharia law
applies.



“Offences may be rarely prosecuted, but the existence of these laws
significantly impedes HIV responses by adding to stigma and acting as
a strong deterrent to men who have sex with men identifying themselves
to HIV services”, notes Dhaliwal. When prosecutions do occur, the
effects are immediate and take a long time to recover. “What we've
seen in Senegal, for example, when the leaders and staff of a
programme set up to support men who have sex with men were sentenced
to 5 years for sodomy (they were later released on appeal due to lack
of evidence) was that testing and use of HIV and STD services
plummeted among this group due to fear of persecution. Anecdotal
evidence suggests the same thing has happened in Malawi, Kenya, and
Uganda in the face of homophobic attacks and court decisions”, Beyrer
told TLID. But he believes that the worst places for human rights
abuses against men who have sex with men are currently Iran and Iraq,
where the situation has worsened recently. “Iraq had become more
tolerant but there has been a real decline in rights, which has been
attributed to the influence Iran has had with the new regime in
Baghdad. In Iran the state is executing gay people with impunity. In
Iraq there have been more clandestine and extrajudicial killings than
state death penalties, but the death toll has been high and the fear
very real”, he said.



Men who have sex with men and transgender people face daunting
barriers if they seek access to any HIV interventions, whether
prevention or treatment. Societal stigma, homophobia, transphobia,
active discrimination, criminalisation, and violent attacks are
commonplace, hampering the ongoing global battle against the spread of
HIV and AIDS. The UN Joint Programme on HIV/AIDS (UNAIDS) data from
the Caribbean (where many countries have recently decriminalised
consensual sex between adult men) suggest that legal prohibition of
sodomy and sex between men could be a contributing factor to the
higher levels of the epidemic. “The success or failure of HIV
programming is highly dependent on the legal and social environments
of a country. Criminalisation increases stigma, drives behaviours
underground, and discourages vulnerable groups from accessing testing
and other HIV-related services”, explained Dhaliwal. “Where
non-discriminatory laws and regulations exist to protect the rights of
men who have sex with men, a remarkably higher proportion of this
high-risk group can be reached by HIV prevention services”, she added.



In sub-Saharan Africa, the enforcement of criminal penalties on sex
between men has limited the ability of health-care workers to provide
essential HIV-prevention services. “In Senegal and Malawi, men who
have sex with men are not getting the necessary education. They are
not being provided with condoms and water-based lubricants and
voluntary counselling; HIV testing and treatment of sexually
transmitted infections is in short supply”, says Traore. Similar
problems are likely in Uganda if the proposed anti-homosexuality bill
becomes law. “Even in regions where services are available, active
enforcement of these laws limits uptake of essential programmes among
entire communities of men who have sex with men—this has the direct
result that the vulnerabilities among these men, and the population as
a whole, are increased”, he commented. “It is also critically
important to counter the aggressive efforts of evangelical and other
conservative Christians; it is difficult to admit, but many in the USA
are actively working to increase homophobic attitudes and to demonise
lesbian, gay, bisexual, and transgender people. US evangelicals have
played prominent roles in the effort to draft the new
anti-homosexuality bill in Uganda, for example”, cautioned Beyrer.



In the Asia—Pacific region, successful efforts to remove punitive laws
and policies through court judgments have been driven by collaborative
efforts between communities and legal and human-rights professionals
in partnership with government health officials and parliamentarians.
“Recent court judgments have played a significant role in improving
the legal environment in Nepal, India, Pakistan, Philippines, Fiji,
South Korea, and Hong Kong”, said Edmund Settle, Regional HIV Policy
Advisor for UNDP based in Bangkok. Another positive development is
that national HIV policies now identify men who have sex with men as a
priority, even though the legal environment in many countries remains
repressive. “Health departments in 22 countries in the Asia—Pacific
region have identified men who have sex with men as a most-at-risk or
priority population in the national HIV policy for the purposes of HIV
prevention and four countries have specific national strategic plans
or action plans on male—male sex and HIV—Cambodia, China, Indonesia,
and India”, commented Settle. He does admit, however, that these are
exceptional developments, and that examples of high-level political
action to address repressive legal environments through legislative
reform are rare.



Against the background of legal, cultural, and societal barriers, it
is not surprising that, globally, only one in 20 men who have sex with
men gain adequate access to HIV prevention and care. Recent policy and
programme guidance from UNAIDS acknowledges that to prevent and
control HIV, there is an urgent need to empower men who have sex with
men, sex workers, and transgender people to protect themselves from
HIV infection and to seek testing and retroviral treatment as
necessary. The UNAIDS Action Framework Universal Access for Men who
have Sex with Men and Transgender People andJoint Action for Results
2009—11 recommends better access to comprehensive and appropriate
packages of HIV prevention, treatment, care, and support services, and
that law enforcement agencies and the judicial system protect the
rights of these vulnerable groups.



Lack of proportionate funding adds a further layer of complexity that
impedes access to comprehensive HIV services. Global estimates
indicate that sex between men accounts for between 5% and 10% of HIV
infections worldwide, yet only 1·2% of all HIV prevention funding is
targeted toward this at-risk group. Recent policy guidance from both
the Commission on AIDS in Asia (2008) and in the Pacific (2010)
highlights a major gap between policy and practice. “This is
especially striking when one compares this to the recent experience of
the response to H1N1 in the USA, where the response was pretty
immediate in terms of allocating resources to those most at
risk—pregnant women, children, and health workers”, comments Traore.
One useful lever is to work through HIV donors, including the Global
Fund to Fight AIDS, Tuberculosis and Malaria, the UN system, the World
Bank, bilateral donors (eg, AusAID, the UK Department for
International Development, and USAID), and other players who can push
for the inclusion of men who have sex with men and transgender people
in country programmes. “The reality is the funding for lesbian, gay,
bisexual, and transgender rights is tiny globally, but HIV funding is
comparatively huge (by at least several orders of magnitude), so this
has much more traction with governments”, concluded Beyrer.

 

Jirair Ratevosian, M.P.H.

Deputy Director, Public Policy

 

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