Laws which criminalise homosexual behaviour – such as those recently passed by Nigeria and Uganda – are not just symbolic or rarely put into practice, a global survey shows. One in twelve men who have sex with men (MSM) who responded to a global survey had been arrested or convicted of same-sex behaviour, and arrest rates were even higher in respondents who lived in African countries. Men who had been criminalised had poorer access to HIV prevention services than others.
Yesterday, the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia, also heard striking data from Nigeria, showing that the passing of a harsh and wide-ranging law six months ago has already deterred men who have sex with men from accessing health services.
There are at least 76 countries in the world that criminalise some form of same-sex intimacy, affecting an estimated 2.79 billion people.
Glenn-Milo Santos of the San Francisco Department of Public Health presented data from a global internet survey of over 4000 men who have sex with men, conducted in 2012 – before the most recent laws were passed. This was a convenience sample of men recruited through the Global Forum on MSM and HIV (MSMGF)’s networks and ties to community-based organisations focused on advocacy, health, and social services. The vast majority of respondents (82%) were university educated and 17% were living with HIV.
A quarter lived in North America or Western Europe; a quarter in the Asia Pacific region; with substantial proportions in Eastern Europe and Latin America. While fewer participants (6%) lived in sub-Saharan Africa, the data from those men are striking.
In North America, Western Europe or Australasia, 2% of respondents had ever been arrested or convicted for homosexual behaviour, rising to 4% of those in Asia Pacific.
In Latin America, 9.7% of men had been arrested or convicted, as had 15.0% of those in the Caribbean, 13.2% in the Middle East and North Africa, and 18.1% in Eastern Europe and Central Asia.
In sub-Saharan Africa, 23.6% had been subjected to arrests and convictions for their sexuality.
What’s more, the data suggested that these men had less access to HIV prevention interventions and services. This would confirm that structural barriers and legal discrimination impede access to services, with a probable impact on public health.
The survey asked about access to condoms, HIV testing and other services, comparing those respondents who had ever been arrested and those who had not. The analysis controlled for known confounders such as age and education, and also took into account clustering by country, but may not have been able to account for all other factors that could affect the results.
Nonetheless, men who have been arrested or convicted had statistically significant lower access to condoms (odds ratio 0.77); sexually transmitted infections testing (0.79) or treatment (0.82); HIV testing (0.80); medical care (0.68) or mental health services (0.74), compared to other respondents. Among those living with diagnosed HIV, having been arrested or convicted was associated with lower access to HIV treatment (0.48) than other HIV-positive MSM.
Nigeria is the latest country to have toughened its legal discrimination of men who have sex with men. Sodomy was already illegal but a January 2014 law has further criminalised:
- “public shows of amorous same-sex relationships”,
- any attempt to enter into a same-sex marriage,
- same-sex civil unions (i.e. cohabiting couples),
- participation in clubs, organisations or meetings of men who have sex with men, and
- any person who supports such organisations or meetings (this puts health service providers at the risk of imprisonment).
Nigerian men who have sex with men are already disproportionately affected by HIV, with an estimated HIV prevalence of 17%, in comparison with the 3% prevalence in the general population. Nigeria has the second largest population of people living with HIV in the world, accounting for 10% of all people living with HIV.
Ifeanyi Orazulike of the International Center for Advocacy on Rights to Health (ICARH) and Sheree Schwartz of the Johns Hopkins School of Public Health told the conference that the law has already had a marked impact on men living in the capital city, Abuja.
Since March 2013, they have been recruiting men who have sex with men into a prospective cohort study of health and behaviour. Whereas around 60 men had come forward each month in 2013, enrolment has dropped to less than ten men a month since January. Those men who have taken part since January are more likely to report being afraid to seek health care (36%) than during interviews before the law was passed (25%). Similarly, there have been statistically significant rises (all p<0.01) in the proportion of men avoiding using health care, being verbally harassed, being blackmailed or feeling that there are no safe spaces where they can socialise with other men who have sex with men.
Ifeanyi Orazulike recalled men saying they would prefer to “die in the comfort of their beds” rather than risk arrest or mob justice by attending a service that made their sexual behaviour more apparent. Men have been tortured while in police detention, been dismissed from their jobs and forced to move out of their neighbourhoods. HIV prevention outreach workers had also been arrested.
He said that the law is supported by many Nigerians and was introduced by an unpopular government, attempting to shore up its support ahead of elections in 2015. Attempts to change the law must include engagement with public attitudes.
The World Health Organization’s guidance for key populations, launched at the conference, states that the protection of human rights is fundamental to HIV prevention and care. More specifically, WHO recommends that:
- countries work towards implementing and enforcing anti-discrimination and protective laws;
- health services are available, accessible and acceptable to men who have sex with men;
- community empowerment programmes are provided; and
- violence is prevented and addressed.