How Criminalisation and Prejudice Is Undermining HIV Prevention
South Africans in Pretoria protest against Uganda’s Anti-Homosexuality Act just before it was signed into law in 2023.

In January, Ugandan LGBTQ activist Steven Kabuye was stabbed multiple times by two men travelling on a motorbike and left for dead on the outskirts of Kampala, the country’s capital city.

The 25-year-old, who had received several death threats after Uganda’s Parliament passed its Anti-Homosexuality Act last May, criminalising LGBTQ people, said that the attackers made no effort to rob him but were intent on stabbing him in the neck.

Uganda’s new law is one of several global examples of growing repression against sexual minorities. Earlier, Indonesia outlawed extramarital sex – effectively also criminalising same-sex sexual relationships. Last year, Russia banned the “international LGBT movement,” and some US states have introduced anti-transgender laws.

A multitude of countries are making it harder for women and girls to participate in everyday life as autonomous citizens independent of male relatives. Many don’t allow harm reduction strategies for people who inject drugs, such as offering them less harmful substitutes. Numerous others are making it harder for civil society organisations to get foreign grants.

International alliance of conservatives coalescing to roll back rights

Leaders of US conservative Christian group Family Watch International meets with Uganda’s first lady and other government officials in April 2023 to encourage passage of a new Ugandan anti-homosexuality law.

Internationally, an alliance of socially and religiously conservative countries is coalescing around efforts to roll back a range of sexual and reproductive rights already won in international agreements and meetings – with countries such as Russia, Iran, Syria and Nigeria acting as the ringleaders.

At the recent World Health Organization’s (WHO) executive board meeting, for example, Russia objected to a reference to the “WHO LGBTIQ+ community” in a routine report from the WHO Director-General to the International Civil Service Commission that covers issues such as WHO administration-staff relations, pay scales and benefits.

A reference to the LGBTIQ+ community in a routine WHO civil service report drew the ire of some conservative member states at the January 2024 WHO Executive Board meeting

Russia described the phrase as “terminology which spreads concepts which are not recognised by everyone and which contradict the values and religious beliefs of quite a large number of countries.”  Russia was supported by a bloc of African member states, and Syria, speaking on behalf of WHO’s Eastern Mediterranean Region. After nearly three dozen other countries, including the US, Canada, Europe and a number of Latin America countries,  expressed support for the Director General’s commitment to diversity equity and inclusion, and gender equality in the workforce, the EB agreed to “note” the report “along with the divergence of views that exist on the board as a whole.”

Also at the EB, six other draft World Health Assembly decisions and resolutions that underwent preliminary review were challenged by a group of member states “over language on gender equality” – primarily objecting to “gender-responsive” health systems, Women in Global Health also noted.

These concerted attacks on LGBTQ people, women and girls and other groups designated as key populations at heightened risk of HIV (sex workers and people who inject drugs) have made it harder for HIV advocacy groups to reach people most at risk of HIV infection, sexual and reproductive health experts and advocates say.

The war between ideology and science

Andriy Klepikov, Alliance for Public Health

“It is a war between ideology, prejudice and stereotypes on the one side and evidence-based science on the other side,” said Andriy Klepikov, executive director of the Alliance for Public Health, one of the largest HIV and TB NGOs in Ukraine and Eastern Europe.

“Countries like Russia are neglecting all the evidence [which shows] where the HIV epidemic is going up as a result of punitive law and repressive policies,” he added. He was speaking at a World Health Summit event on Ending the AIDS Epidemic in Light of the Shrinking Civic Space in October, 2023.

“We even have UNAIDS data showing how vulnerable people who use drugs, men who have sex with men, sex workers, and transgender people are.”

According to the UNAIDS 2023 global summary, almost a quarter of new HIV infections (23%) were in Asia and the Pacific, where “numbers of new HIV infections are rising alarmingly in some countries.”

Winnie Byanyima, the executive director of UNAIDS, launching the 2023-Global AIDS update report in July 2023.

“Steep increases in numbers of new HIV infections have continued in eastern Europe and central Asia since 2010 (49% increase) and the Middle East and North Africa (61% increase). These trends are due primarily to a lack of prevention services for people from marginalised and key populations and to the barriers posed by punitive laws, violence and social stigma and discrimination,” according to UNAIDS.

“The vast majority of countries (145) still criminalise the use or possession of small amounts of drugs; 168 countries criminalise some aspect of sex work; 67 countries criminalise consensual same-sex intercourse; 20 countries criminalise transgender people; and 143 countries criminalise or otherwise prosecute HIV exposure, non-disclosure or transmission.”

Global Fund notes’ increasingly hostile laws’

Meanwhile, the most recent report of the Global Fund’s Technical Review Panel, released in October 2023, notes “increasingly hostile laws, policies, and practices in several countries.”

“These include new or increased enforcement of laws criminalising same-sex sexual relationships, high levels of stigma, barriers to organisational registrations, and acknowledgement of harmful norms by applicants, which are greatly risking the fragile gains that have been made over the years.”

Twenty-two countries where the Global Fund supports programmes are classified as “closed” by the CIVICUS 2023 National Civic Space Ratings.

These are “mostly in the Middle East, North Africa, and Central and South Asia, where repression is extreme, and any criticism of the state is met with severe penalties.”

“Another 42 are classified as repressed, mostly in Africa, Asia, and Central America, and 32 are classified as obstructed, mostly in Africa and Asia.”

Thousands protest anti-LGBTQ laws in Budapest, Hungary in 2021.

Some want to ‘extinguish’ key populations

Civil society groups trusted by critical populations have traditionally been the most successful in bringing marginalized groups and individuals into the circle of HIV prevention, diagnosis and treatment, using non-judgmental advocacy and frank, science-based language.

“AIDS has always been seen in the minds of people as a dirty lifestyle,” explained Peter Wiessner from Action Against AIDS based in Germany, also speaking at the World Health Summit session.

“To prevent HIV transmissions, we thought it was necessary to address the cause of the transmission. So all of a sudden, there were discussions on anal intercourse, on oral sex and all of that,” he added.

“Luckily, our government understood that officials don’t have the language. They don’t have the knowledge. They don’t know how the communities live. So they invited and provided this open space for the communities to develop programmes and to finance these.”

But Wiessner adds that countries such as Iran, Russia and some Gulf states want to “extinguish” key populations and fight against their recognition at international health forums in ways that sometimes make the consensus-based policy and strategy agreements “almost meaningless.”

“The UN high-level meeting’s declaration on Universal Health Coverage does not even mention key populations that are so important in the fight against HIV, like gay men, drug users, and sex workers. They are not mentioned because some of the governments don’t want these groups to exist,” Wiessner added.

HIV infections growing most rapidly in eastern Europe and central Asia

Eastern Europe and Central Asia have seen the fastest-growing HIV epidemic in the world, with an increase of nearly 50% in newly infected people since 2010.

HIV prevalence is 1.2% amongst adults (15–49 years) but 7.2% amongst people who inject drugs, a significant driver of infection. However, a shortage of data from Russia makes it difficult to draw definite conclusions.

“Russia has neglected all evidence-based interventions, like methadone-based opiate treatment as part of a harm reduction programme for people who use drugs,” said Klepikov. “[Last] August, the parliament voted for the prohibition of transgender people.”

Maximina Jokonya, Y+ Global

Maximina Jokonya, a leader of Y+ Global, the global network of young people living with HIV, warns that “we haven’t been paying attention to what has been brewing underground in anti-rights groups.

Key populations have become scapegoated by laws and criminalisation across sub-Saharan Africa, warns the South African-based Jokonya.

“It is embedded in issues around culture, religion and traditional norms, where the downside is coercion around gender roles and social norms.”

The anti-rights groups are well-funded, adds Jokonya, which enables them to “influence laws and politicians,” she says.

Space is shrinking all over the world

UNAIDS deputy executive director Christine Stegling

And while Uganda’s Anti-Homosexuality Act has become a kind of poster-child for shrinking civil society space, this is happening to a lesser extent all over the world, UNAIDS deputy executive director Christine Stegling warned.

Often, discriminatory laws are only repealed when civil society organisations are litigated, such as the repeal of anti-LGBTQ laws in Botswana.

Furthermore, many NGOs are barred from “accepting money from the outside” or made to register as “foreign agents” if they do, and “these are ways of stifling civil society engagement,” Stegling adds.

The AIDS response has shown the power of communities to address infection and drive development and human rights, and this is an essential lesson for new pandemics, Stegling concludes.

Editor’s note: Stegling, Jokonya and Wiessner also were addressing a session of the World Health Summit in Berlin on “Ending the AIDS Epidemic in Light of the Shrinking Civic Space.”

Image Credits: Alisdare Hickson/Flickr, WHO/EB 154 , Lydia Gall/ Human Rights Watch.

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