Despite significant compromises to a draft strategy on HIV, hepatitis B and STIs, conservative World Health Organization (WHO) member states used a debate at the World Health Assembly on Friday to object to the inclusion of such as “sexual orientation”, “sexuality” and “men who have sex with men”.

The objections were led by Nigeria, Egypt, Pakistan, Jordan and Saudi Arabia, who claimed that some of the sexual health and rights terms referred to in the Global Health Sector Strategies (GHSS) on HIV, viral hepatitis and sexually transmitted infections 2022-2030 – terms standard for many years in HIV treatment and care – was an affront to their culture.

This led to a delay in WHA approval of the GHSS – whose finalization also was delayed by disputes over references to comprehensive sexuality education and gender identity, despite the expiration of a previous strategy in 2021.

A last-minute compromise was proposed on Friday night by Saudi Arabia. This involves deleting the entire GHSS glossary and inserting two footnotes. One footnote would record that some countries have reservations about the term “sexual orientation”. The other would note objections to a reference to the International Technical Guidance on Sexuality Education.

But a number of member states said that they needed to first check with their principals before accepting the last-minute compromise. While none of the member states voiced objections to Saudi Arabia’s compromise, Monaco’s delegate expressed disquiet at the delay, which she said was unprecedented in her many years at the WHO.

The Africa region did not object to the text, with Namibia and Senegal expressing support for science-based approaches. Neither did Russia which is renowned for leading the anti-LGBTQ charge at international forums, but in this case described the GHSS text as “balanced”.

Science-based policies

Earlier in the debate, Suriname on behalf of 56 countries including South Africa, Thailand, the UK and US, stressed that while consensus was important, health strategies had to be based on data and evidence.

“We recognise that achieving consensus at the World Health Assembly depends on compromise balancing national priorities and contexts with the global epidemiological context, but it is the WHO’s role to put forward normative guidance that follows and aligns with the most current science-based knowledge,” Suriname asserted.

“We must continually adjust and replace outdated or ineffective interventions with those that can reach key populations and vulnerable populations,” added Suriname. “Effective approaches must promote equity, gender equality, and protect and fulfil the human rights and dignity of all.”

The US, represented by Loyce Pace, Assistent Secretary for Global Affairs at the US Department of Health and Human Services, praised the “comprehensive and transparent consultation process” that took place over the strategy throughout 2021 and 2022. 

“The US would like to underscore the important role WHO plays in developing strategies,” said Pace.

“These strategies are used widely across all regions to guide the provision of health services and interventions. To ensure the greatest impact they must be based on the most current science responding to the diverse needs of different populations, especially those who are excluded from health services due to stigma and discrimination.”

Pace added that “effective approaches must promote equity, gender equality, and protect and fulfil the human rights and dignity of all”. 

Concessions

She also 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 Pace.

“The current scientific evidence clearly supports the inclusion of these terms and effective strategies to address HIV, viral hepatitis and STIs,” said Pace, but added that the US “remain satisfied that the strategy is preserved the importance of core interventions and populations of focus”. 

France on behalf of the European Union (EU) noted that, “despite the scientific nature of the work on the strategy, some states are reluctant to recognise some realities on which this guidance is based, even though they could adapt them to their national situation”.

“We underscore the importance of ensuring universal access to complete education and good information on health connected with sex, your sexual health and complete sexual and reproductive health support,” added France.

Cultural objections

Among African nations, Nigeria was most vocal in its complaints about terminology used in the strategy documents.

“Spirited efforts were made by the delegation of Nigeria to engage the Secretariat where these concerns can be addressed. Nevertheless, and despite the demonstration of openness and best intentions by Nigeria, it is disappointing and most unfortunate that some of these terms and phrases – which are totally objectionable, and inimical to our cultural and social well being as a sovereign state – are still broadly reflected in the text,” said the Nigerian delegate.

“Nigeria hereby without ambivalence and or intended ambiguity, objects and dissociate itself from the following terms and phrases in the text: ‘sexual orientation, transgender, men who have sex with men’.”

Nigeria also objected to the reference to the International Technical Guidance on Sexuality Education and the definition of sexual health in the glossary.

“Let it be placed on record that Nigeria has not accepted these terms and phrases in the past. I will not accept them today,” he declared.

Jordan said that “some of the expressions and some of the language used in the text does not conform to the culture and tradition in our country and the countries of the region” and “remain unacceptable to us”. 

Pakistan objected to  “non-consensual terminologies about gender, sexual orientation, sexual rights, comprehensive sexuality education, among others”. 

Egypt, Indonesia, Bahrain and Bangladesh also raised objections.

Science not ideology

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

“We emphasise the need for WHO to adopt strategies that are evidence-based, rather than based on politics and ideology. The objective and functions of WHO as defined in its constitution are very clear. We call on the director-general of WHO to stand firm behind science and not ideology.”

Meanwhile, Cedric Nininahazwe, the advocacy manager of the Global Network of People Living with HIV, praised the new strategy, saying that it gave hope to communities.

The Global #Health Sector Strategy on #HIV, viral hepatitis & STIs gives hope. It promises to engage communities in all our diversity, deliver people-centered services, invest in HIV cure, generate & use evidence to inform decisions. #WHA75 @gnpplus @UNAIDS @WHO @gpvanmourik pic.twitter.com/6prwHzoplc

— Cedric Nininahazwe (@cedricnini) May 27, 2022