In Kampala, Uganda, men who have sex with men who have suffered homophobic violence or abuse are five times more likely to be HIV-positive than other men, Joseph Barker told the Eighteenth International AIDS Conference on Tuesday. Just under 40% of men had ever been physically abused, four out of ten had been blackmailed at some point, and a quarter had been forced to have sex.
Human rights for men who have sex with men in Africa has been a major theme of the conference. Attention has been drawn to laws criminalising same sex activity, police harassment, stigmatising media reporting and denial of healthcare. Researchers and activists have debated the best ways to advance the human rights of men who have sex with men and other marginalised groups.
In fact, Uganda is a country that has been repeatedly cited in these discussions, with particular reference to a recent backlash against men who have sex with men. As well as retaining colonial laws against sex between men, the Ugandan parliament is currently considering an 'anti-homosexuality' bill that proposes the death penalty for sexually active HIV-positive gay men. Parliament is also considering a separate HIV law which would undermine the human rights of people at risk of HIV infection. In general, homosexuality is socially stigmatised in Uganda and the issue is politically charged.
In order to better understand the Ugandan HIV epidemic, researchers have been conducting studies with six ‘most at-risk populations’, one of which is men who have sex with men.
Owing to the hostile social environment, men who have sex with men can be difficult to reach. The researchers therefore used respondent-driven sampling in order to recruit research participants. This is a modified form of snowball sampling – an initial set of respondents recruit people they know, who then recruit other people they know, and so on. A mathematical model is then used to weight the sample to compensate for non-random recruitment patterns, so the results should be less prone to bias.
The survey began in May 2008 and only a few weeks later LGBT activists were arrested at an HIV conference in Kampala. Recruitment slumped at this point, but did recover by July and August. When a wave of arrests and alleged police abuse occurred in September recruitment slumped once again, never to fully recover before the survey closed in April 2009.
Despite these incidents, the researchers were able to recruit 303 men who had had anal sex with a man in the previous three months. Those participating were predominantly young (50% under 25), with a median of eleven years of schooling, and almost all were Ugandan.
To protect confidentiality, no names or contact details were collected from participants (they were identified with a number and a fingerprint). Information was collected using a self-completion computer survey (ACASI), in either English or Luganda.
The vast majority (78%) had had sex with a woman at some time; 29% had fathered children; and 16% were currently living with a female partner.
There was often a mismatch between the sexual orientation terms that men most identified with and their reported attraction to men and women:
Commercial or transactional sex was common: 42% had ever sold sex to a man, and 25% to a woman.
Whereas overall HIV prevalence amongst adult males in Kampala is 4.5%, it was 13.7% in this sample.
Men often had inaccurate perceptions of their own HIV status – only one in ten of those with HIV were aware of the fact. Moreover, one in ten of the whole sample thought they had HIV when in fact they were HIV-negative.
Men also lacked basic information about HIV transmission risks. When asked whether insertive or receptive anal sex was riskier, 11% answered that neither activity posed a risk. Only 11% correctly answered that receptive sex is riskier.
One quarter never used condoms. Condom use was higher with male partners than female partners; higher with steady partners than casual partners; and lowest of all with commercial sex partners. Most men used lubricants although these were very frequently oil-based.
The researchers wished to identify the demographic or behavioural characteristics that were most strongly associated with HIV infection. In multivariate analysis, factors such as condom use or numbers of partners were not significantly associated with having HIV. In fact, only two factors were: age and homophobic abuse.
Men aged 25 or over were four times more likely to have HIV (odds ratio 4.3, 95% confidence interval 1.5 to 12.8). Amongst men over 25, HIV prevalence was 22.4%.
Men who had ever experienced violence or abuse because of their sexuality were five times more likely to have HIV (odds ratio 4.8, 95% confidence interval 1.8 to 13.1). Of the whole sample, 37% had been physically abused at some point, 37% had been blackmailed and 26% had been forced to have sex.
Speaking earlier in the week, Joel Nana of African Men for Sexual Health and Rights noted that countries such as Tanzania, Kenya, Namibia, South Africa and Nigeria have in recent years incorporated men who have sex with men in their national HIV strategies. While strongly welcoming these advances, he also said that men need more than narrowly defined HIV prevention work.
“The life of men who have sex with men doesn’t only revolve around health or the lack of health,” he said. “There are other issues such as extortion, harassment, expulsion from schools, unlawful arrest and detention, disownment by families and economic disenfranchisement that deserve equal attention.”
A number of speakers commented on countries where there is a mismatch between sometimes supportive health policies and an extremely hostile social and legal environment. Some attributed this to governments making cosmetic changes to obtain health funding from international donors. Others suggested that activists cannot limit themselves to working with ministries of health, but also need to find allies in their ministry of justice. The lack of access to justice can be as problematic as the lack of access to healthcare.
An argument that was brought up in session after session (and not just in those concerned with men who have sex with men) was whether strengthening the rights of disenfranchised groups should be justified for its public health benefit, or because they are fundamental and universal human rights.
Speakers recognised that framing the issue in health terms could sometimes make strategic sense – it can be a way of getting policy makers to pay attention to the issue. But treating human rights instrumentally, as a means to an end, could limit the extent to which rights are truly advanced.
It can also leave a space open for other actors to propose alternative public health policies (such as coercive or compulsory testing), which impinge on rights.
The human rights lawyer Anand Grover said that HIV provides a possibility to push human rights forward. He said it wasn’t an either/or choice between discussing health and discussing human rights – both arguments should be put forward together.
Law reform matters, Jeff O’Malley of the United Nations Development Programme said, and improvements in law enforcement matter even more. Nonetheless, he said, that there are numerous examples of countries with hostile laws but accepting social attitudes and, conversely, of countries with neutral or supportive laws and negative social attitudes.
Several speakers rejected the claim that contemporary homophobia could be traced back to colonial-era laws. Joel Nana said that naming and analysing homegrown homophobia was the first step to tackling it. The law is just one way of expressing homophobia, and it has more deep-seated roots, he said.
Kapya Kaoma, an Anglican priest from Zambia who is now conducting research in the United States, analysed the contradictions in the current Ugandan debate on homosexuality. It is described as 'un-African' and a Western import, but there is strong evidence that the backlash against men who have sex with men was inspired by American evangelicals. African countries were now being recolonised with socially conservative American thought, he suggested.
View abstract and slides from this session on the official conference website
Several webcasts are available of sessions that may be of interest. You can view the following sessions on the Kaiser Family Foundation website:
Know your epidemic, know your response: MSM and their needs in low- and middle-income countries.
Law Reform in the Context of HIV: Are Human Rights Protected or Compromised?
Barker J et al. HIV infection among men who have sex with men in Kampala, Uganda. Eighteenth International AIDS Conference, Vienna, abstract TUAC0304, 2010.
