"All movement is acutely painful and distressing. Intestinal worms are back again. Atria's limbs are stiffening and his back is covered with ulcers that leak and bleed but do not heal, impossible to manage in a small hut. His issues are controlling pain, managing extreme distress, reducing humiliation, creating dignity, reducing multiple infections, reducing cross-infection to others.
But the worst thing is loneliness.
To die of AIDS in Africa is an intensely humiliating ordeal, slow and obscene. Atria is now in his last days of life. His tear ducts have dried up, his hair has fallen out, his bones are brittle. He has no muscle or fat and his heart is 70 per cent weaker than pre-HIV. He has been eaten alive and he has no resistance. All of Atria's senses are shutting down.
His fingernails and toenails have fallen out. His skin is blistered and scaly, and scabs cannot form. The bedsores and ulcers have spread, sources of multiple deep infections. Breathing is almost impossible and the slightest movement is slow and full of dreadful anxiety. I give him water drop by drop through a straw.
I hold his frail, stiffened hand. He is cold, he has no tears. I look into his eyes. I whisper to him, and kiss him. He slowly inhales, half closes his eyes. He breathes out, very slowly."
That is part of an account I wrote more than ten years ago that was printed in the Journal of the American Medical Association, describing the experience of a young gay boy who died of HIV, rejected by his family and community. But it could just as well have happened yesterday.
One of the problems with things like World AIDS Day (Sunday, 1 December) is we often forget about it the rest of the year. We all face big issues in our communities around the increase in unsafe sex, especially among the young, and the increase in sexually transmitted infections in the gay community and other sexual minorities. An equally dangerous thing is a complacency and indifference to emerging trends that are quietly spreading. The persecution and cleansing of the voiceless, this time not an ethnic or religious minority, but a sexual one.
It is a fact that in countries that criminalise homosexual acts, gay people are left outside the protection of the law and health services and are more vulnerable to contracting HIV. Take the Caribbean for example, in countries that criminalise homosexuality, gay people have a 1 in 4 likelihood of contracting HIV, while in countries that do not criminalise, the prevalence is only 1 in 15.
More than 70 countries still criminalise consensual homosexual sex, or "sodomy" as it's often called, including most African and Arabic countries.
In my thirty something years working as a doctor in Africa, I have seen many examples of heart-breaking cruelty against minorities. Meanwhile more and more of them are contracting HIV.
My goal in recounting Atria's story was to express the reality of what it means to die of AIDS, alone, as a gay person. I wanted to put a person, not a statistic, before us.
The tragedy I see in my work is that so many of these people live in fear and anguish, rejected and vilified. In many countries there is a rising tide of hatred being fed by lies and fear, ignorance and increasing violence.
A few weeks ago I was with a young man who could not stop trembling, his recent HIV diagnosis had caused him to flee his village in Uganda and he had nowhere to stay, no one to help him, he was vomiting with fear. I was able to put him in touch with a growing network of support and he is now, I am delighted to say, safe and among friends, but he is one of many.
We can all do something, we can all get personally involved and help. We need to work directly with these groups, provide practical support and helplines, technology, and advice and health services. Organisations like the International Gay and Lesbian Human Rights Commission and their partners are among the growing co-ordinated efforts making a difference. Meanwhile the Human Dignity Trust works with local partners in countries where homosexuality is still criminalised, and uses international law to uphold the human rights of sexual minorities.
There are also a myriad of small local NGOs quietly campaigning, supporting small groups of gay and lesbian people who are in danger and living in fear. The issues of these rights concerns each one of us and I hope that the flickering flame of hope can be nurtured and kindled by our own personal action.
There is still too much trembling alone and too many tears, but we can all do something to help.Suggest a correction