THE BLOG
23/05/2014 11:54 BST | Updated 22/07/2014 06:59 BST

From Hero to Zero: Uganda Fails Its HIV Test, and What We Should Do About It

2014-05-22-HIVUganda19902012.png

HIV Prevalence in Uganda, 1990-2012. Source of data. UNAIDS

Openness and Success

At the turn of this century, Uganda was widely praised for its AIDS policies. Among the African countries with a generalized AIDS epidemic, Uganda was the first to see a decline in the rate of new HIV infections. By 1995, there was already a series of studies documenting a decline in HIV prevalence among certain population groups in Uganda (helpfully summarized by Joseph K. Konde-Lule). [1] When they studied the causes of this decline Daniel Low-Beer and Rand Stoneburner identified significant changes in behaviour. [2] There was some increase in condom use but what distinguished Uganda from some of its African neighbours was that a significant proportion of young adults reported reducing their number of concurrent sexual partners. Surveys of Knowledge, Attitudes, Beliefs and Practices relating to sexual activity, showed that a very large proportion of the population knew of someone with AIDS or who had died of AIDS. Low-Beer and Stoneburner found that in spreading information about AIDS in Uganda, interpersonal communication was more important than official channels. They argued that in this way, AIDS seemed more like a personal risk than in societies where there was much less open conversation about the reality of the epidemic. In Uganda, the threat of AIDS seemed real and personal rather than distant and deniable.

This openness about AIDS was fostered by the political leadership offered by President Yoweri Museveni. In 1991 Musevini spoke to the First AIDS Congress in East and Central Africa, held in the capital city of Uganda. [3] Musevini's claim was justified: 'Our government has had no qualms about being frank to our people on issues of national catastrophe such as the AIDS epidemic (p. 253). In 1991 Musevini was skeptical of HIV prevention strategies what were only about condoms but he did affirm that "condoms have a role to play as a means of protection" (p. 252). By the late 1990s, Uganda's success in fighting AIDS was important in attracting foreign assistance for its health programmes in 2000 Musevini boasted that in Uganda "condom use increased from 57.6 percent in 1995 to 76 percent in 1998. [...] Most important of all, the stigma attached to people living with HIS/AIDS has virtually evaporated" (p. 7). [4] One study found that condom procurement in Uganda went from 10 million in 1994, to 30 million in 1997 and 120 million in 2003. [5]

The War on Condoms

But this focus on safe-sex and on fighting stigma was reversed in the next decade and this was in significant part the consequence of the international influence of conservative Christian forces in the United States. The disbursements from international agencies were very significant. In 2004, according to a report from the Center for Global Development, Uganda probably received about $86m from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), $24m from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and $10m from the World Bank's Multi-Country HIV/AIDS Program for Africa (MAP). [6] PEPFAR disbursements to Uganda increased in each of the following three years, and in 2006, this made up 73 percent of all AIDS spending in the country, with a further 22 percent of AIDS spending in Uganda that year coming from other international aid. PEPFAR was shaped in three ways by the evangelical Christian ideology of Bush and his political supporters. One-third of the funds spent on prevention had to be devoted to programmes promoting sexual abstinence. The fund was allowed to fund faith-based groups and to let them refuse to implement elements of an AIDS programme that they considered objectionable, such as promoting condoms. Finally, no funding could go to any institution that provided advice on or access to abortion, which would include the provision of emergency contraception. The result of these restrictions was that during the Bush presidency two-thirds of PEPFAR-supported outreach programs did not promote condom use at all. [7]

The consequences for Uganda were evident. A report produced for the Council for Global Equality reported on changes to sex education in schools: 'In contrast to a government policy document of the 1990s that read, "Correct information on condom use should be provided to young people," a new teacher resource book advised, "The use of condoms among unmarried young people ... does not arise. Young people do not need condoms; they need skills for abstaining from premarital sex"' (p. 24). [8] This was also the message of Janet Museveni, the wife of the president, who suggested that distributing condoms was 'pushing [young people] to go into sex [and] it is not the law that our children must have sex' (p. 24). Her office was funded by PEPFAR. She was also a close associate of pastor Martin Ssempa, like herself an evangelical Christian. Ssempa publicly burned boxes of condoms, saying ' burn thee condoms in the name of Jesus' (p. 25). The government responded by withdrawing certain brands of condoms from the market expressing doubts about their effectiveness even though the brands had been tested in other countries and found safe.

Brutality and Homophobia

2014-05-22-David_Kato.jpg

David Kato with the newspaper in which he was targeted. Credit: Dady Chery

Alongside the attack on condoms, there was, from 2007, an intense campaign by Ssempa and others against LGBTI people. Uganda had affirmed colonial anti-sodomy laws, as with its Penal Code Act of 1998 (ch. 120, sec. 145), which permitted a life sentence for 'Any person who has carnal knowledge of any person against the order of nature ... or permits a male person to have carnal knowledge with him or her against the order of nature.' [9] In 2007 Ssempa insisted that 'Homosexuals should absolutely not be included in Uganda's HIV/AIDS framework. It is a crime, and when you are trying to stamp out a crime you don't include it in your programmes' and he led a march through the Kampala demanding the use of the law against gay people. [10] He also published pictures of gay activists on his website, inciting violence against them. In October 2010, a Kampala newspaper published photographs of 100 people it claimed were gay and followed up with even more incendiary reporting with a front page showing a photograph of David Kato, under the banner headline, 'Hang Them.' As reported in the Huffington Post, in January 2011, Kato and two others sued the paper 'over claims it had violated their constitutional rights to privacy,' securing 'an injunction banning the publication of the identities and personal details of alleged homosexuals.' [11] Within a fortnight he was dead, brutally assaulted by a man wielding a hammer. Kato was the most prominent gay rights activist in Uganda, as Andrew Tucker of Cambridge University and South Africa's Health4Men noted: 'He was singularly committed to bettering the lives of all gay people. We have lost a giant of the stature of Simon Nikoli and Harvey Milk.' [12]

Again, the United States was a source of encouragement. After Kato's death, Val Kalende, the chair of a gay rights group in Uganda claimed that 'David's death is a result of the hatred planted in Uganda by U.S. evangelicals in 2009. The Ugandan government and the so-called U.S. evangelicals must take responsibility for David's blood.' [13] In March 2009, Scott Lively, Caleb Lee Brundidge, and Don Schmierer, three evangelicals Christians from the United States came to Uganda to paint a bleak picture of the U.S., showing, according to a report in the New York Times, 'how "the gay movement is an evil institution" whose goal is "to defeat the marriage-based society and replace it with a culture of sexual promiscuity."' [14] Lively helped his local hosts draft an Anti-Homosexuality Bill although he subsequently claimed he did not approve of its including the death sentence. International uproar saw the bill shelved, but on 20 December 2013, shorn of the death-sentence, the Anti-Homosexuality Act was passed by the parliament and after ratification by President Musevini in February 2014 came into Law in March 2014. This made lesbian and gay men liable to imprisonment. For 'aggravated homosexuality,' they were now vulnerable to a life behind bars, and this most serious of crimes, as Amnesty International reported, included being HIV positive and having 'sexual relations with a person of the same sex-even when such conduct is consensual and protected.' [15] So far, according to Human Rights Watch, 17 people have been arrested on suspicion of engaging in same-sex conduct or of appearing to be LGBTI, a rate two-and-a-half times that of the period 2007-2011 when there were 23 arrests and no prosecutions. [16] Many more gay people have fled the country in fear, others have been evicted by landlords who claimed they would be breaking the law in having an illegal person as a tenant, and now an LGBTI person seeking an HIV test is potentially opening themselves to prosecution for having engaged in 'aggravated homosexuality.' Research from South Africa suggests that marginalizing LGBTI persons has serious consequences for their mental health, and that the depression and lack of self-respect makes care of the self less likely, undermining the resolve to practice safer sex and enhancing reckless risk-taking. [17]

Stigma and Criminalization

And now Uganda is poised to take a further step away from the policies of openness for which it was praised in the 1990s and that were at the heart of its earlier success in addressing the epidemic. The Parliament has passed and now the President must consider ratifying the HIV Prevention and Control Act. Human Rights Watch warns that: 'The bill includes mandatory HIV testing for pregnant women and their partners, and allows medical providers to disclose a patient's HIV status to others. The bill also criminalizes HIV transmission, attempted transmission, and behavior that might result in transmission by those who know their HIV status.' [18] Criminalizing HIV transmission undermines prevention by discouraging people from getting tested and by giving those fancying themselves uninfected the false impression that they can safely have unprotected sex with others confident that there are no HIV-positive people willing to join them. Yet the marginalization and legal sanctions mean there were will be more HIV-positive people ignorant of their own status and, among those who are positive, fewer with the self-esteem to take the care of themselves that would include a lifetime spent refusing unsafe sex.

Evident Failure of Christian Agenda

Uganda's AIDS Commission claims that the epidemic is stable, taking comfort from a reported national adult HIV prevalence of 5% in 2000, 6.4% in 2004/5 and 6.7% in 2011. [19] Yet it would be reasonable to assume that stigma and fear are dissuading at least some at-risk adults and certain groups from seeking testing. In response to the uniform tabulation requested by the Joint United Nations Programme on HIV and AIDS the Commission reports for the 'Percentage of men who have sex with men who are living with HIV'-No Data; and likewise for 'Percentage of sex workers who are living with HIV'-No Data (p. 4). Given the systematic attempt to stigmatize people with HIV it is perhaps reassuring that the 2011 AIDS Indicator Survey produced by Uganda's Ministry of Health finds that only about one-in-five adults believe that people with HIV should be ashamed of themselves or that they should be blamed for bringing the disease to the community; the prejudice is highest among male adolescents and young adult males, suggesting a worrying trend. [20] It is perhaps also reassuring that despite stigma there has been a general increase in HIV testing among adults aged 15-49, covering 13 per cent of women and 11 percent of men in 2004/5 but 66 percent of women and 45 percent of men in 2011 (p. 123).

But the picture with regard to HIV prevalence gives no comfort. The AIDS Indicator Survey reports a prevalence rate among adults of 7.3 percent for 2011, making the trend since 2000 more clearly one of rising incidence (p. 101). To some extent this reflects improved survival due to the wider availability of Anti-Retroviral Therapies, but the failure to reduce HIV prevalence among young adults is not explicable in this manner. Thus it must be accounted a singular failure of the HIV prevention policies themselves that between 2004/5 and 2011 Uganda has seen HIV prevalence for teenagers and young adults increasing: for people aged 15-19 from 1.5 to 2.4 percent, and for those aged 20-24 from 4.7 to 5.4 percent. Despite the very public emphasis upon being faithful (zero grazing), among the 4,706 couples in the survey, there were five where in separate interviews the man and the woman affirmed that they had other sexual partners during the past year, 15 in which the woman alone did so and 1,229 where the man alone did so (p. 118). The double standard is evident and it may have serious health implications because of the 6,375 men who reported sexual intercourse in the previous twelve months, 5,420 had not used a condom at last sexual intercourse; similarly for 7,404 of 8,181 women (p. 111). As reported in the New York Times, this 2011 data establishes that 'Uganda is one of only two African countries, along with Chad, where AIDS rates are on the rise.' [21]

International Solidarity

The stories of truly horrific brutality against LBGTI people, perpetrated by police and by vigilantes, have brought unwelcome attention to the government of Uganda. After the murder of David Kato, there was condemnation from the U.S. government with Obama calling for the prosecution of the murderer. [22] While the initial response of police in Uganda was that this murder was part of a robbery, ultimately Sidney Nsunbunga Enoch was convicted and sentenced to 30 years in prison, after he had failed to establish his claim that he had been propositioned by Kato (an acceptable legal defence in Uganda). [23]

The links between evangelical Christians in Uganda and in the United States have been close. Not only did Martin Ssempa study in the United States (receiving in 1996 a Masters in Christian Counselling from Philadelphia Biblical University, now Cairn University), but he cultivated close links with Rick Warren's mega Saddleback Church, particular with its international HIV and AIDS Initiative, emphasizing 'moral purity.' But the links also allow U.S. courts to intervene in matters that relate to the conduct of U.S. citizens. The Alien Torts Act (1789) allows foreigners to use U.S. district courts to bring cases against U.S. citizens for actions overseas that contravene international law or the treaty obligations of the United States. [24] In March 2012, Sexual Minorities Uganda brought such an action against Scott Lively, the individual who had spoken in Uganda on the gay assault on the family and whose talking points had been incorporated into the preamble of the Anti-Homosexuality Act. As described by the Southern Poverty Law Center, the lawsuit alleges that 'Lively conspired with political and religious leaders in Uganda beginning in 2002 to incite anti-LGBT hysteria with warnings about the dangers of LGBT people to children and homosexuality to Ugandan culture.' [25] A review of Lively's work in Mother Jones, quoted extensively from Lively's televised five-hour talk in Kampala in 2009, in which he introduced Uganda to the gay agenda and the gay evangelists from the United States who would come to their country, recruiting vulnerable youth to a gay lifestyle. These gay 'monsters,' he said, 'are so far from normalcy that they're killers. They're serial killers, mass murderers. They're sociopaths. There's no mercy at all, there's no nurturing, no caring about anybody else. ... This is the kind of person it takes to run a gas chamber.' [26] Lively subsequently disavowed the inclusion of the death penalty in the Anti-Homosexuality Bill but averred, on balance, that even with that provision it would be better to pass the bill than let, as he told one documentary maker in the US, 'the American and the European gay activists to continue to do to that country what they have done here'. [27] Although asking for further evidence of the links between inflammatory statements by Lively and specific actions against individuals in Uganda, at a hearing in Springfield MA in August 2013, U.S. District Court Judge Michael Ponsor allowed the case to go forward, and it is still pending. [28] Scott Lively is currently a candidate for governor in Massachusets. [29]

Sanctions

The retrograde steps in Uganda's HIV policies could be challenged by the international agencies that contribute so much to healthcare in the country. It may very well be that the openness about condoms in the sex education materials of the late 1990s reflected pressure from the UN agencies and that it was PEPFAR that allowed, even encouraged, the Ugandan government to revert to something much narrower from the middle of the first decade of the present century. Bilateral trading relations might also be a way of bringing pressure. At present Uganda benefits under the African Growth and Opportunity Act (2001), some of its goods being allowed duty free into the United States, but that Act requires that beneficiaries not 'engage in gross violations of internationally recognized human rights.' [30] Uganda is a signatory to the International Covenant on Civil and Political Rights (ICCPR) and while the treaty does not explicitly refer to sexuality, Lucy Heenan Ewins remarks that its provisions about non-discrimination on grounds of status, and protecting against interference with privacy, family, honor or reputation, are now taken to uphold the rights of LGBTI people and the supervisory body of the ICCPR has recently adjudged anti-sodomy statutes to be in breech of its privacy regulations. [31] In June 2013 the EU foreign ministers adopted Guidelines for Supporting LGBTI People's Human Rights. [32] At present this involves little more than observing, encouraging, and in a few cases funding civil society groups in foreign countries (although not at present in Uganda). Thus, after Uganda passed the Anti-Homosexuality Act, EU High Commissioner, Catherine Ashton reminded Uganda that it had 'international human rights obligations.' [33] This really is not very much.

Asylum

At the very least, countries that claim to support human rights should give very generous consideration to applications for political asylum from LGBTI people from Uganda. For example, John Adbdallah Wambere is currently in Massachusets requesting asylum. He has been subject to death threats in Uganda and was a friend of David Kato. Wambere says he fears death or imprisonment should he return home. Although Scott Lively expresses skepticism about any risks faced by Wambere, rational reflection and solidarity with the persecuted LGBTI people in Uganda alike suggest that Wambere's request should be granted. [34] The materials collated by asylumlaw.org on the repression of folk in Uganda on grounds of sexual orientation or HIV status are distressing. In the face of these, it is disturbing that in December 2013 the United Kingdom sent back to Uganda a lesbian asylum seeker, Prossie N, who had suffered abuse and homelessness. [35] It beggars belief that even now, after the passing of the Anti-Homosexuality Act, the British government plans to deport Aida Asaba, another lesbian asylum-seeker, who had suffered abuse in Uganda, as reported in Pink News: 'It's claimed her sexual orientation was reported to the [Ugandan] authorities, who are now actively looking for her, and she received death threats and abuse from neighbours and the local community.' [36] Reviewing cases such as that of Anne Nassovi, deported in April 2014, who had fled Uganda after a mob attacked her house where she was giving sanctuary to other lesbians, some of whom were killed by the mob, Samira Shackle asks 'Why is Britain deporting LGBT asylum seekers to Uganda.' [37] Why indeed? Humza Yousaf, Scotland's Minister for External Affairs has 'vowed to offer asylum to gay Ugandans facing life-imprisonment under the country's new oppressive set of laws,' and he asked UK Foreign Secretary William Hague to do the same. [38]

Notes

[1] Joseph K. Konde-Lule, 'The declining HIV seroprevalence in Uganda: what evidence?' Health Transition Review 5, supplement (1995) 27-33.

[2] Daniel Low-Beer and Rand L. Stoneburner, 'AIDS communications through social networks: catalyst for behaviour changes in Uganda,' African Journal of AIDS Research 3:1 (2004) 1-13.

[3] Yoweri Kaguta Museveni, 'AIDS is a socioeconomic disease' [1991], in Musevini, What is Africa's problem? (Minneapolis MN: University of Minnesota Press, 1997) 247-255.

[4] Joseph Tumushabe, 'The politics of HIV/AIDS in Uganda,' Social Policy and Development Programme Paper Number 28 (Geneva, Switzerland: United National Research Institute for Social Development, August 2006).

[5] S. Okware, J. Kinsman, S. Onyango, A. Opio, and P. Kaggwa, 'Revisiting the ABC strategy: HIV prevention in Uganda in the era of antiretroviral therapy,' Postgraduate Medical Journal 91:960 (2005) 625-628.

[6] Nandini Oomman, Michael Bernstein, and Steven Rosenzweig, Following the funding for HIV/AIDS: a comparative analysis of the funding practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia (Washington DC: Center for Global Development, 10 October 2007).

[7] John W. Dietrich, 'The politics of PEPFAR: the President's Emergency Plan for AIDS Relief.' Ethics and International Affairs 21:3 (2007) 277-292.

[8] Scott H. Evertz, How ideology trumped science: why PEPFAR has failed to meet its potential (Washington DC: Center for American Progress, January 2010).

[9] Michael Hollander, 'Gay rights in Uganda: seeking to overturn Uganda's Anti-Sodomy laws,' Virginia Journal of International Law 50:1 (2009) 219-266.

[10] Alok Gupta, This alien legacy: the origins of "Sodomy" laws in British colonialism (New York: Human Rights Watch, 2008) 4.

[11] Max Delany and Godfrey Olukya, 'David Kato, Uganda gay activist, brutally slain,' World Post (27 January 2011).

[12] 'Health4Men condemns recent murder of Ugandan activist,' ANOVA Health Institute. News (28 January 2011).

[13] Jeffrey Gettleman, 'Ugandan who spoke up for gays is beaten to death,' New York Times (27 January 2001).

[14] Jeffrey Gettleman, 'Americans' role seen in Uganda anti-gay push,' New York Times (3 January 2010) A1.

[15] 'Uganda: Anti-Homosexuality Bill must be scrapped,' Amnesty International. News (20 December 2013).

[16] 'Uganda: Anti-Homosexuality Act's heavy toll. Discriminatory law prompts arrests, attacks, evictions, flight,' Human Rights Watch. News (15 May 2014).

[17] Andrew Tucker, Jose Liht, Glenn de Swardt, Geoffrey Jobson, Kevin Rebe, James McIntrye and Helen Struthers, 'Homophobic stigma, depression, self-efficacy and unprotected anal intercourse for peri-urban township men who have sex with men in Cape Town, South Africa: a cross-sectional association model,' AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 26:7 (2014) 882-889. Tucker gives a summary of the findings here.

[18] 'Uganda: deeply flawed HIV Bill approved. President should reject discriminatory measure,' Human Rights Watch. News (14 May 2014).

[19] Global AIDS Response Progress Report. Country Progress Report, Uganda (Kampala: Uganda AIDS Commission, April 2012).

[20] Uganda. AIDS Indicator Survey 2011 (Calverton MD: Demographic and Health Surveys, August 2012) 62.

[21] Josh Kron, 'In Uganda, an AIDS success story comes undone,' New York Times (2 August 2012).

[22] Barack Obama, Statement by the President on the killing of David Kato (Washington DC: White House, 27 January 2011).

[23] Hanna Ingber, 'David Kato murderer sentenced to 30 years,' Global Post (10 November 2011).

[24] Doug Cassell, 'Suing Americans for human rights torts overseas: the Supreme Court leaves the door open,' Notre Dame Law Review 89:4 (2004) 1773-1812.

[25] 'Scott Lively,' Southern Poverty Law Center. Intelligence Files (Montgomery AL: Southern Poverty Law Center, 2014).

[26] Mariah Blake, 'Meet the American pastor behind Uganda's anti-gay crackdown,' Mother Jones (10 March 2014).

[27] 'Scott Lively,' Southern Poverty Law Center.

[28] Peter Montgomery, 'Scott Lively defends anti-gay Uganda work in federal court,' Religion Dispatches (21 May 2014).

[29] Michelangelo Signorile, 'Scott Lively, anti-gay evangelical past, on LGBT rights, running for Governor and Obama,' Huffington Post Gay Voices (13 March 2014).

[30] Trade and Development Act of 2000, Sec. 104 (a) (3).

[31] Lucy Heenan Ewins, '"Gross violation": why Uganda's Anti-Homosexuality Act threatens its trade benefits with the United States,' Boston College International and Comparative Law Review 34:1 (2011) 147-171.

[32] Council of the European Union, Guidelines to promote and protect the enjoyment of all human rights by lesbian, gay, bisexual, trangender and intersex (LGBTI) persons (Luxembourg: EU Foreign Affairs, 24 June 2013).

[33] Statement by EU High Representative Catherine Ashton on anti-homosexuality legislation in Uganda (Brussels: European Union, Foreign Affairs and Security Policy, 18 February 2014).

[34] Maria Sacchetti, 'Gay Ugandan hopes to find refuge in US. As native country changes laws, he seeks asylum here,' Boston Globe (7 May 2014).

[35] Tris Reid-Smith, 'Seriously ill lesbian asylum seeker deported by UK to Uganda,' Gay Star News (13 December 2013).

[36] Scott Roberts, 'Lesbian Ugandan asylum seeker "begs UK government" not to deport her,' Pink News (21 May 2014). There is a petition about this case here.

[37] Samira Shackle, 'Why is Britain deporting LGBT asylum seekers to Uganda and Nigeria?', New Humanist (15 April 2014).

[38] Mia de Graaf, 'Scotland vows to offer asylum to Ugandans persecuted by country's new "oppressive" anti-gay laws,' Daily Mail Online (22 May 2014).