DAR ES SALAAM, Tanzania — “What on earth have I done to deserve this suffering?” weeps Joha* a gay transgender woman, tears blurring her eyeshadows after she was refused a dose of life-prolonging antiretroviral medicine for HIV/AIDS at a local clinic because of her ambiguous gender identity.

Joha is among a few people in Tanzania’s bustling commercial city whose gender identity, expression and behavior does not conform to the sex to which they were assigned at birth.

Distraught, the 31-year-old Joha, who was born male but realised as being a woman, has since been facing an uphill struggle to access badly-needed HIV/AIDS care due to stigma and discrimination.

Sitting on a wooden bench outside Boko dispensary — one of the local clinics catering to AIDS patients — her handbag tightly clutched under her armpit, Joha, who is living with HIV for five years, ponders what the future holds.  Sexual health care for transgender women is lacking in Tanzania with policymakers and service providers often failing to address specific needs of the group as compared to men-who-have-sex-with men (MSM).

“I am fearing for my life, if I don’t get the medicines, my health will decline,” Joha told Health Policy Watch in an interview.

Like many other lesbian, gay, bisexual and transgender (LGBT) people living in constant fear in the east African country, Joha has repeatedly experienced barriers in accessing healthcare due to widespread social stigma and discrimination against the minority group.

Despite decades of public awareness campaigns against the deadly scourge, negative attitudes towards people living with HIV has persisted in Tanzania partly due to their gender identity and sexual orientation.

For Joha, the growing animosity against the minority gay community in Tanzania is a setback likely to fuel her vulnerability to sexually transmitted diseases associated with HIV/AIDS as she’s unable to access the healthcare she needs.

“I don’t tell people I’m transgender whenever I go to hospital. I can’t even say I ever felt like a boy, but they keep suspecting me and refuse to serve me,” Joha said as a gush of tears rolls down her cheeks.

According to her, most HIV positive trans people don’t get their medications whenever they visit local clinics because everyone think they are evil or stupid.

“I want to live a happy life like everyone else, but as long as I am trans, that seems impossible,” she said.

Tanzania’s policy on HIV/AIDS broadly recognises the vulnerability of key populations, including trans people, to HIV infections. But many people in the targeted group are often invisible in many state-run interventions since their specific needs often elicit strong public reactions such as fear, hatred and disgust.

“We don’t see many LGBT patients seeking treatment for sexually transmitted infections these days, they don’t even come for testing and counseling,” said Theopista Mabuga, a senior medical officer at Boko dispensary.

Homosexuality is illegal in Tanzania, with the country’s penal code prescribing gay sex to at least 30 years imprisonment.

The anti-gay rhetoric in the east African country started to heighten when President John Magufuli took power three years ago with officials publicly vowing to identify and arrest suspected gay people.

Human rights campaigners have documented dozens of cases in which LGBT people are violently abused by police, subjected to anal examination and openly discriminated whenever they seek healthcare in public hospitals.

The changing social and political dynamics against LGBT people in Tanzania have pushed the embattled group on the wobbly edge due to rising social stigma that restricts their access to healthcare, housing, employment, and sees expulsion from school and isolation from family members, gay rights campaigners said.

“Living in a rented accommodation is always a challenge for me, very often landlords don’t accept renters who are gay,” said Joha.

In February this year, Tanzania Health Minister Ummy Mwalimu shut down 40 gay-friendly drop-in health clinics for “key population”- a category comprising people at high risk of HIV infections, while banning water-based lubricant gel to “deter gay sex” and “curb the spread of HIV/AIDS.”

In an interview with Health Policy Watch, Neela Ghoshal, a researcher in the LGBT rights division of Human Rights Watch, said Tanzania’s policy of closing health centres that target LGBT people is extremely damaging to public health and is completely out of step with globally recognised best practices on HIV prevention and treatment.

“We know of many cases of gay and bisexual men who no longer seek out HIV testing or treatment for sexually transmitted infections because they cannot find a friendly health centre to go to,” she said.

“The government knows better. It is letting homophobic ideology take precedence over rational public policy,” said Ghoshal.

There are 1.4 million people living with HIV/AIDS in Tanzania, about 5 percent of the country’s population, according to the 2012 census conducted by the National Bureau of Statistics.

“I don’t think the government will succeed in the ongoing war against HIV/AIDS if its policies continue to discriminate against minority groups,” said John Kashika, of a Community Health Education Services & Advocacy organisation whose services had been terminated.

Confronted by the fear of attacks, LGBT people are devising intelligently crafted coverups, tricks and socially acceptable disguises such as faking personalities to avoid backlash and public humiliation.

At the bustling Kinondoni suburb in Dar es Salaam, the air is a mix of boiling recycled cooking oil, traffic fumes and dust from the passing motorists.

Husna Kessy is in high alert as she sits on a plastic chair under a thatched roof of a local food & drinks joint — waiting for her Chipsi Mayai, a dish made of scrambled eggs mixed with fries — to be prepared.

She’s wearing a burqa – a traditional Arabic dress entirely covering her body — to reduce chances of being arrested.

“The best way is remain silent, if someone knew you’re gay or trans they simply hate you or report you to the police,” she said.

The 26-year-old hair dresser who is transgender but known among her friends as a woman is increasingly worried for her safety as Dar es Salaam authorities have launched a manhunt against LGBT people.

“A lot of people think that I simply wake up and decide to be gay. It’s not a choice,” said Joha.

Names have been changed to protect the identities of the interviewees

*Not her real name.

Image Credits: Kizito Makoye.