WHA Approves Strategy on HIV, Hepatitis B and STIs – After Prolonged Debate Over Sexual Health Terminology
Saudi delegate in heated WHA debate Saturday over sexual rights and terminology

In a final, late-night session on the World Health Assembly’s last day, the WHA adopted a new global strategy on HIV, hepatitis B and Sexually Transmitted Infections 2022-2030 (GHSS) by a vote of 61-2 – but with 30 absentions and 90 delegations skipping the vote altogether. 

The vote Saturday evening, after hours of painful debate, was the final act of the WHA before it closed a rollercoaster week of unprecedented debates over issues ranging from pandemic reform to the war in Ukraine.

The fact that 120 delegates abstained or were absent from the final vote on the new strategy – as compared to 60 that had supported the measure – was almost unprecedented for a WHA vote on a technical matter. Cumulatively, the two days of time taken in debate was even more than the hours expended discussing a resolution condemning Russia’s invasion of Ukraine, approved by another rollcall vote on Thursday.

In closing the WHA just after the vote and shortly before midnight, WHO Director General Dr Tedros Adhanom Ghebreyesus said he wished the Assembly could have reached consensus on the strategy. “But in my view we should not be afraid of voting when needed to press ahead with global health strategies.” 

Approval of the strategy came over strenuous objections by socially conservative countries, led by Saudi Arabia to terms used in the strategy and in its annexed glossary on sexual health and target populations for HIV treatment – language regarded by many experts as standard for HIV treatment and care.  

Speaking on behalf of WHO’s 22-member state Eastern Mediterrannean Region (EMRO), the Saudi delegate and other EMRO nations catalogued the terms that they found objectionable, including references to: “sexuality”, “sexual orientation”, “”sexual rights”. There also were objections to the strategy’s reference to “men who have sex with men” as a target population for HIV treatment.

And, member states objected to definitions of terms contained in an annexed glossary, including a definition of “sexual health”, that stated: “for sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” 

Glossary of terms removed in last-minute compromise 

WHO legal counsel explain voting choices regarding ammendments proposed by member states from the draft WHO strategy on HIV, hepatitis B and STIs.

In a compromise that was approved shortly before the final vote, Mexico’s delegation offered to remove the glossary of terms altogether, as it included much of the language that had become a flashpoint for many of the conservative member states’ objections.

The measure was accepted in a 58-0 vote, but with 95 delegations absent and 30 abstaining. The compromise also added language specifying that “national context should be considered” in relation to strategy and called upon WHO’s director-general to report back to the Assembly over the next decade. 

Ultimately, however, the Mexican-brokered concession didn’t go far enough for Saudi Arabia, Egypt, Nigeria and other leading critics. Along with deleting the glossary, they demanded the removal of sexual rights terms from the strategy, per se, as well as a reference to an International Technical Guidance on Sexuality Education, which makes use of the same terminology. 

In the final rollcall vote, shortly before midnight, not only the entire EMRO region, but also most sub-Saharan African nations abstained or were absent from the vote – with the notable exception of South Africa, which voted in favor.

Similarly, the Russian Federation, Ukraine, as well as India and Indonesia abstained from the vote on the strategy, supported by most countries in Europe, as well as the United Kingdom, Ireland and Israel, along with North America, Latin America, and parts of Asia and the Western Pacific Region.

Dismay among many member states over the lack of consensus

Nigeria disassociated itself from language in the strategy after the final vote.

After the final vote, some member states, including Egypt and Nigeria disassociated themselves once again from the language around sexual health and rights, contained in the strategy.

But member states on both sides of the divide also expressed dismay that the WHA had not managed to reach consensus on such an important technical document. Countries that had vigorously objected to terms used just a few hours earlier, including Egypt, Djibouti and Syria, saying that they would support the strategy’s implementation – but on their own terms.

“Process and procedures should be more inclusive,” said the delegate from Djibouti, adding that it would implement the strategy “with full respect for the religious and ethical values, and cultural background of its people, and in comformity with universally recognized international human rights.”

Countries voting in favour also expressed regrets about the failure to find consensus, and the need to resort to a rollcall vote on a technical document covering diseases that continue to represent a huge burden of disease for so many countries worldwide. Said Monaco, “We consider this deeply disappointing. And we think this will have consequences in the future because of the precedent created.”

US makes spirited defense

“We should not need to hold a vote on the existence of entire communities of people,” Loyce Pace, US Assistant Secretary of State for Global Public Affairs, HHS

But Loyce Pace, US Assistant Secretary of State for Global Public Affairs in the US Department of Health and Human Services, defended the decision by the prevailing group of member states to leave references to “sexuality,” and “sexual education” intact in the final Strategy document, along with a reference to the International Technical Guidance on Sexuality Education, as well as mention of a key target population of HIV work as “men who have sex with men.”

“We appreciated those member states acted in good faith as part of these deliberations. Unfortunately this has served as a painful reminder of the need to reinforce our focus on evidence, human dignity and decency.

“We should not need to hold a vote on the existence of entire communities of people,” Pace asserted. “We have a strategy on critically important global health issues, yes. But at what cost to those we risk leaving behind? So to gay, lesbian, bisexual, queer, intersex, transgender and gender non-conforming people around the world, the United States government sees you, and will continue to support you.  Stay strong.”

Clock ran down as debate dragged on

As the debate dragged on into the evening hours, Dr Hiroki Nakatani, presiding over the Assembly committee discussing the issue, puzzled over whether to push for consensus, break to confer with capitals or give delegates more time to negotiate a compromise. He decided breaking for informal consultations, resumed and then broke again for more consultations on the Assembly floor, before resorting to a vote.

Earlier in the afternoon, he had seemed more hopeful. “I heard there is a very rich discussion,” Nakatani told the committee. “Proposals are being generated.”

WHA in final hours Saturday – Committee A breaks twice in effort to hammer out agreement.

Conservative WHA members backed another Saudi-led proposal to delete all sexual rights language or references

Diplomats from the UK, Monaco, Argentina, Canada, Chile, Dominican Republic, Uruguay, Peru, France, Slovakia, Denmark, Australia, US, Norway, Germany, Brazil, Italy, Ireland and Netherlands all favored Mexico’s compromise proposal.

The Saudi delegation’s proposal, however, wanted to go further, with the insertion of footnotes in the strategy expressing reservations about the use of terms like “sexual orientation” other sexual health and sexual rights terms used there and in the International Technical Guidance on Sexuality Education. That proposal, however, was defeated in a show of hands. 

Some diplomats argued for more time to study the proposals. Regardless of which proposal they favored, however, most diplomats seemed to agree that further delay on the draft strategy would only bring harm to global efforts to eliminate HIV/AIDs and other sexually transmitted diseases. 

Untenable we don’t reach agreement

“It is an untenable prospect that we don’t reach agreement on the strategy,” a UK diplomat said earlier in the day when hopes of a consensus were higher.

“I hope we will be able to conclude our discussions and WHA session on a positive note and at the end of these consultations and discussions to have consensus,” a Djibouti diplomat agreed, saying. “How can we combine the two proposals so that we would have a less divided room?.”

“We have to take a decision today because the WHA is closing today and we need a decision on this strategy … hopefully by consensus,” said a French diplomat. “If not, then we have to make a decision.”

A  German diplomat echoed the French view: “We are running out of time and given the views expressed, it seems the Mexican proposal is the best opportunity for consensus.”

A day earlier, Suriname on behalf of 56 countries including South Africa, Thailand, the UK and US stressed that health strategies had to be based on data and evidence. The US pointed out that a number of concessions had been made to the GHSS in the interest of reaching consensus. 

“Important subjects central to addressing these diseases have been removed from the document or caveat, including comprehensive sexuality education, gender identity, gender-responsive approaches, intimate partner violence that’s not limited to heterosexual partnerships and gender-based violence,” said Loyce Pace, a top U.S. health official.

The International Federation of Medical Students Associations, International Federation on Ageing, International Planned Parenthood Federation, and Women in Global Health have all told the Assembly that they “deeply regret the removal of terms like comprehensive sexuality education (CSE) and intimate partner violence (IPV) from the text.”

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