Uganda's gay rights and sex worker activists answer your questions about HIV prevention
As HIV infections and AIDS-related deaths around the world fall, rates in Uganda have been on the rise in recent years. Part of the problem, according to many of the world's top public health experts, is that the populations most at risk for HIV infection — including gay men and sex workers — face laws that do little but increase stigma, drive these groups underground and make them reluctant to seek life-saving diagnosis and treatment. Among the most problematic laws, they say, are the the U.S. "anti-prostitution pledge" and Uganda's Anti-Homosexuality Act. (The law was ruled invalid by a Ugandan court on Aug. 1 due to a technicality but is likely to resurface.)
The PBS NewsHour explored the issue in July:
After the NewsHour segment aired, we put the call out for your questions for four activists and human rights workers who deal specifically with at-risk populations in Uganda.
Daisy Nakato is a Ugandan sex worker and founder of WONETHA, an organization that seeks to educate and empower sex workers in Uganda, and Megan Schmidt-Sane is a former WONETHA staff member who now works for the Sexual Health and Rights team at American Jewish World Service.
Asia Russell is the director of international policy at Health GAP, a nonprofit dedicated to improving access to care for people living with HIV/AIDS.
Isaac Mugisha from Spectrum Uganda — an LGBT advocacy group based in Kampala — also planned to answer your questions. Unfortunately, he is currently recovering in the hospital following a brutal attack in which he was targeted for his associations with the LGBT community. If he is able to provide an update after his recovery, we will add his comments here.
The answers below are the opinions of the activists and do not necessarily reflect the views of PBS NewsHour.
NewsHour Viewer 1: Can you address how religious institutions in the country are either assisting to mitigate HIV contraction or driving the rise in HIV contraction through rhetoric or policy? How do connections to U.S. evangelical communities contribute to this either in helping or hurting the situation?
Most recently, a lot of attention has been given to the Anti-Homosexuality Act. A recent film, called "God Loves Uganda," details the connection between the U.S. evangelical community and Ugandan religious institutions, policy and practice. It especially talks about the impact of U.S. pastor Scott Lively's proselytizing in Uganda and his address to the Ugandan Parliament in 2008. His intolerant speeches have been tied to the most recent wave of anti-homosexuality sentiment and to the subsequent passage of the Anti-Homosexuality Act.
There is one innovative way that we have been able to hold U.S.-based individuals accountable for fomenting hate in other countries. On March 14, 2012, the Center for Constitutional Rights (CCR) filed a federal lawsuit on behalf of Sexual Minorities Uganda (SMUG), a non-profit umbrella organization for LGBT advocacy groups in Uganda, against Scott Lively. The case was filed with the United States District Court in Springfield, Mass., and alleges that Lively's involvement in anti-gay efforts in Uganda, including his active participation in the conspiracy to strip away fundamental rights from LGBT persons, constitutes persecution.
Asia Russell: Some religious groups are providing life-saving health service delivery in Uganda — but others actually increase harm by promoting stigma and bigotry, providing inaccurate and harmful information about HIV prevention and contributing to lack of information among Ugandans about how to prevent HIV transmission. "Abstinence until marriage" HIV prevention programs, for example, do not work and can actually increase the risk of infection for the reasons stated above.
Comprehensive and accurate knowledge about HIV and how it is transmitted has increased from 35 percent to only 38 percent among men and from 30 percent to only 37 percent among women between 2006 and 2012. We need religious institutions to deliver comprehensive, accurate, evidence-based and human-rights-supporting HIV services, or else Uganda's HIV response will continue to be woefully off track. In 2012, an analysis by Health GAP showed that Uganda was enrolling fewer people in treatment than other countries in the region, and the stakes could not be higher — new evidence shows that earlier access to treatment for everyone with HIV is critical to creating an AIDS-free generation.
But more than any other factor, the Anti-Homosexuality Act — now nullified in Constitutional Court — was about scapegoating an unpopular segment of the population for political purposes — and to increase President Museveni's chance of reelection.
NewsHour Viewer 2: To protect sexual health, what do you find to be the most successful interventions for sex workers, and for those who are LGBT?
Daisy Nakato: As a sex work organization, WONETHA can answer the first part of this question. Those of us who have worked on sex worker rights issues know from experience that the most successful interventions need to be community-based (led by sex workers) and rights-based (an approach that recognizes our right to engage in sex work and to live free from discrimination and violence) as well as structural and not solely biomedical (such as medication or HIV testing). Sex workers need to have a meaningful voice in programming, at all stages of planning and implementation; sex workers need to be recognized as experts in their own lives.
In addition, sex workers need to be empowered to access health services that are free from stigma and discrimination. We have long known that structural interventions such as the decriminalization of sex work would go the furthest in improving health for sex workers.
Recent research using statistical modeling in The Lancet Special Issue on HIV and Sex Work confirms what activists and sex workers have long known — that the "decriminalization of sex work would have the greatest effect on the course of HIV epidemics across all settings reviewed by the paper, averting 33—46 percent of HIV infections in the next decade."
Russell: First, sex workers must be engaged as equals in designing and implementing programs. When sex workers themselves are trained and supported to provide services–such as educating other sex workers and clients in safe sex and providing HIV testing and treatment–behaviors change and communities become more resilient to HIV and other sexually transmitted infections. LGBT communities also need supportive prevention and treatment services, where they can be free from the threat of retaliation or persecution. Model programs typically combine training for health workers in non-discrimination, along with supportive clinical services that include peer-based outreach, prevention, care and patient follow-up.
Unfortunately, shrinking budgets for treatment and prevention programming, including PEPFAR, a U.S. initiative that is the biggest funder of the HIV response in Uganda, mean efforts to expand human rights based interventions are not being scaled up fast enough and are at risk of budget cuts.
NewsHour Viewer 3: Is there any outside pressure, a leader of another country, a prominent activist figure, who could change Ugandan President Yoweri Museveni's idea that sexual identity is a "choice"? Who could influence him to reject such harsh discriminatory laws?
Nakato: To be quite honest, what is needed is an amplification of indigenous LGBT voices from Uganda to speak out against these ideas. Many activists from the community have long been engaged in changing Museveni's mind, and this tactic was working. When U.S. or European leaders get involved in a public way, it plays into the anti-LGBT rhetoric that "homosexuality" is a Western import, and this may actually do more harm than good. What is needed is more private, sustained engagement to put pressure on Museveni to change his mind.
Russell: All leaders have a role to play in holding policymakers accountable for harmful laws such as the Anti-Homosexuality Act. The actions of one leader on his or her own are never enough to result in societal change. But ultimately, national and global pressure led by civil society will become too intense, and we will see a day when all discriminatory laws are repealed and leaders are accountable to all their people—including minorities. For example, the decisive victory in nullifying the Anti-Homosexuality Act [in court] was only possible because of successful, smart advocacy.
NewsHour Viewer 4: I'm telling you, gay people in Uganda can register for services like the rest. No one is denied services in Uganda because they are gay, no service cuts! We're tired of your lies! Health care is for all. [Response?]
Russell: Unfortunately, you are mistaken. Discrimination in the health sector is alive and well for LGBT Ugandans. The police raid on the Makerere University Walter Reed Medical Research Centre showed that beyond a shadow of a doubt. Many clinics providing outreach services for LGBT groups also had to close because they were afraid to be accused of "promoting" homosexuality." In a High Court ruling on whether the Ugandan government was in violation of the constitution when the Minister of Ethics and Integrity shut down a meeting of human rights defenders in 2012, the court sided with the government in equating talking about health rights of gay men with the criminalized act of same sex activity between adults.
Clearly, the real question is how we overcome both the fear of discrimination that keeps gay people from seeking services and the actual discrimination at the level of service delivery. Decriminalization is a vital step.
NewsHour Viewer 5: What proof do you have that people aren't getting the services they need? Do you have numbers that show a drop in treatment for gay people?
Health service delivery for LGBT communities was only getting started in 2013, when the bill was signed–people were just beginning to feel comfortable seeking services. Even so, the U.S. government-funded PEPFAR program in Uganda reported an almost immediate decline in use of LGBT clinics following passage of the bill into law.
NewsHour Viewer 6: How have things changed for the gay community since the Anti-Homosexuality Act was passed? Given that homosexuality was already illegal, did this new law really have that big of an impact?
Russell: Unfortunately it has had a huge impact — from calls in communities for mob violence to landlords evicting gay tenants to outings of gay Ugandans in the news tabloids. A recent report released by Sexual Minorities Uganda, or SMUG, showed a dramatic increase in reports of abuse, violence and extortion in the five months after parliament passed the bill.
Importantly, the existing anti-sodomy law had not been enforced in recent memory — until parliament stepped up its homophobic, human-rights-violating stance. In addition, the Anti-Homosexuality Act included sweeping new provisions and harsh new penalties. For example, the bill criminalized the provision of services to members of the LGBT community, whereas the previous law had only criminalized same sex activity between consenting adults.
NewsHour Viewer 7: What role does stigma play in preventing people from receiving services for the LGBT community and for sex workers?
Nakato: Stigma has caused the death of WONETHA members too afraid to seek treatment for fear of being attacked or rejected by the very health care workers supposed to assist them.
Stigma and discrimination are broadly recognized factors that contribute to the spread of HIV/AIDS globally, and both stigma and discrimination very much prevent sex workers from accessing legal, social, economic and health services. This kind of exclusion is particularly detrimental and visible in the HIV/AIDS epidemic — where 11.8 percent of female sex workers globally (The Lancet Special Issue on HIV and Sex Work, 2014), and 33 percent of female sex workers in Kampala, Uganda (Crane Survey Report, 2010), are living with HIV.
Whorephobia, homophobia, transphobia and other prejudices may be demonstrated by health care workers as well as other service providers. In Uganda, health care workers may ask invasive questions about an individual's occupation, sexual history and other questions that are unnecessary and inappropriate. Indeed, many of our sex workers report health care workers requiring an individual to seek treatment with their partner. Sex workers may feel that a health care facility or other service provider is not friendly or open, and they may refuse to seek services because of this.
Russell: Stigma is a completely unnecessary but substantial barrier to accessing health services for sex workers, LGBT individuals, and people with HIV who are not part of those vulnerable groups. In Uganda, and in many other countries, criminalization of populations achieves nothing except to drive people further from essential services because of fear of widespread intolerance.
Transforming attitudes and beliefs toward the LGBT community and sex workers as quickly as possible, and demanding policy makers uphold their rights and prosecute violations of those rights are essential steps in ending the HIV epidemic in Uganda and around the world.
NewsHour Viewer 8: What impact do the tabloids and media outlets have in fueling discrimination at the moment?
Nakato: Tabloids and media outlets portray sex workers in a negative light, accusing us of fueling the HIV epidemic and of being vectors of disease and moral decay. At worst, the media publishes our faces without our consent, which leads to outright violence and stigma from the rest of the community. This kind of "outing" is incredibly harmful and has damaged many lives — both emotionally and physically. Indeed, David Kato, an activist from Sexual Minorities Uganda, lost his life in 2011 in the wake of being published in the Rolling Stone. (Editor's note: Rolling Stone was a weekly tabloid published in Kampala, Uganda, with no affiliation with the American magazine of the same name.)
In addition, when police raid a "red light area" in Uganda, they often call the media, like Bukedde News, to accompany them. This practice is harmful and unjust. Under the Ugandan Constitution, everyone is entitled to a free and fair trial. Putting people on trial and judging them in the public eye, before this happens, is unfair and unconstitutional. This practice needs to be stopped.
Russell: Hateful media reporting in Uganda foments violence, ignorance and intolerance among ordinary Ugandans, as well as politicians, religious and cultural leaders, and all sectors of society. In general, media outlets — with only a few exceptions — use homophobia to sell papers, and use sensationalist coverage to intensify hatred. Educating the media and demanding accurate and sensitive coverage, along with prosecuting media outlets that promote hate speech and violate Ugandans' constitutional right to privacy, are essential steps in transforming society.
NewsHour Viewer 9: The government of Uganda says it's important to offer services to "at-risk groups" in its wider effort to push down HIV rates. So what services is it offering to LGBT people and sex workers after this law was passed?
Nakato: Right now, the government of Uganda only offers services to "at-risk groups" through the Most-at-Risk Populations Initiative (MARPI) Clinic at Mulago Hospital. This is just one small clinic serving the entire country — this model should be scaled up to other areas of Kampala and up-country as well.
NewsHour Viewer 10: Is it possible for these groups to work directly with the government (including police) toward the goal of reducing HIV? If so, what strategies have worked?
Nakato: Yes, we have worked closely with police in terms of sensitizing them on how to work with sex work communities. In most cases where we have built relationships with police and local leaders, we have been able to successfully engage them on a wide range of issues, and we have even halted much of the harassment that is going on. However, this relationship building requires time, patience, and resources — we need to work with police and local leaders in all areas of the country, but also at the higher levels. We have been doing so, slowly, but with limited time and resources.
Schmidt-Sane: Building off of what Daisy has said about WONETHA's work in Uganda, most sex work organizations around the world are able to effectively engage police and local leaders; this has often led to a reduction in harassment, and increased cooperation between sex workers and law enforcement in terms of addressing other important issues and crimes.
NewsHour Viewer 11: Can't sex workers receive treatment like anyone else? What's stopping them from going to clinics and receiving the care they need?
Nakato: In Uganda, the main barriers to receiving treatment are structural and financial. Even if sex workers wish to receive treatment for any number of things, the issue is that the criminalization of the industry makes it nearly impossible to do so. Sex workers are rightfully afraid of arrest or being laughed at or talked about when they go to a health center. In addition, because of constant police harassment and arrest, sex workers find themselves in a cycle of imprisonment, poverty and housing insecurity and increased risk of contracting HIV and then sustaining treatment. Taking ARVs (antiretroviral drugs) is not as simple as one might expect — it requires proper nutrition, abstinence from alcohol and drugs, overall well-being and most importantly, a consistent schedule in terms of taking medication at the same time each day.
Much of the HIV/AIDS funding in Uganda comes from the U.S. government, and with that comes restrictions on giving funds to sex worker rights organizations — the very organizations that are most likely to reach sex workers. Therefore, those who are most in need of treatment are not often able to access it. At WONETHA, we have peer educators in the field who are constantly in touch with the community and who are aware of those who need treatment. Our model is evidence-based and it works. However, we are unable to access U.S. HIV funding because of the anti-prostitution loyalty oath.
In 2003, the U.S. Congress passed a piece of legislation titled the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act. More commonly referred to as the Global AIDS Act, it established the President's Emergency Plan for AIDS Relief (PEPFAR) as well as the State Department's Office of the Global AIDS Coordinator. Specifically, the act provided funds for assistance to foreign countries in order to combat HIV/AIDS, tuberculosis and malaria. Congressman Christopher Smith (R-NJ) included a limitation in the law that prohibited the use of federal funds to "promote, support, or advocate the legalization or practice of prostitution." It required organizations that received HIV/AIDS funding to adopt a policy explicitly opposed to prostitution. Often referred to as the "anti-prostitution loyalty oath," this amendment has been a contentious part of the Global AIDS Act. However, all evidence has shown that isolating sex workers is not effective public health policy. Organizations that work with sex workers have been successful in combating HIV/AIDS rates and have even taken direct measures to identify trafficking victims.
For a global perspective on this question, see this Global Network of Sex Work Projects briefing paper.
NewsHour Viewer 12: WONETHA advocates for the decriminalization of sex work. But would decriminalizing sex work have any impact on public health? Wouldn't that encourage more people to engage in this kind of work, more people to purchase sex, and therefore increase the potential for the spread of disease?
Nakato: When sex work is considered a criminal act, sex workers have less power to negotiate openly with their clients about practicing safe sex. They become easy prey for police or others looking to extort money or gain sexual favors because sex workers are seen as having no rights under the law. The stigma of being classified as a criminal means that sex workers either face abuse and ridicule when accessing health and social services or stay away from them altogether. Decriminalizing sex work would make our work safer, would make it possible for us to seek justice when violence is committed against us and make it easier for us to access the health care services we need to protect our health and that of our clients. Removing the criminal laws around sex work is not about promoting the sex industry, it is about treating it like any other industry that provides basic rights and protections for workers.
It is also incorrect to place the blame on sex workers as "vectors of disease." It is about making our work safe and free of violence, stigma and discrimination — decriminalization would go a long way toward reducing the high prevalence of HIV.
Russell: Sex workers in Uganda have some of the highest HIV rates in the world — 33 percent prevalence. They are in urgent need of prevention and treatment, delivered through programs that rely on their expertise and leadership. Evidence shows that decriminalization dramatically reduces the risk of HIV transmission for sex workers and their clients — a benefit that is passed on to their other sex partners, as well. Decriminalization has not been shown to result in greater prevalence of sex work. Instead, it is associated with sex workers having more power to demand safe sex, as well as protection on the job from physical and sexual violence, and extortion and blackmail by police — all extremely common occurrences in Uganda.
NewsHour Viewer 13: U.S. lawmakers say the anti-prostitution pledge is in place, in part, to help prevent trafficking. If it's removed, wouldn't that be a problem?
Schmidt-Sane: The U.S. anti-prostitution pledge restricts funding from going toward groups that work on sex worker issues from a rights-based perspective. Unfortunately, sex work is conflated with trafficking not only in this pledge definition, but by many other people working to end trafficking.
Despite the new international standard for trafficking, there is still an obfuscation of the distinction between trafficking and prostitution by abolitionist and religious members of the anti-trafficking movement. This conflation of sex work with trafficking can be questioned when we examine the wide range of reasons why a person can be trafficked. Globally, there is a disproportionate focus on trafficking into forced prostitution, with many conflating sex work and trafficking to the point where it is believed that all sex workers have been trafficked (see Ahmed & Seshu, 2012). In fact, numbers cited in the anti-trafficking movement are often estimates, or are simply fabricated. One report on trafficking in Cambodia points out that numbers on sex trafficking are inflated. Local anti-prostitution organizations claimed the existence of 80,000 to 100,000 persons trafficked for sexual labor in the country. The author reasons that is highly unlikely that Cambodia, with less than 0.2 percent of the world's population is also home to 11 to 14 percent of the world's persons trafficked for sex (see Steinfatt, 2011).
NewsHour Viewer 14: Wouldn't it be better to rehabilitate sex workers or help them find a different profession, rather than helping them simply stay safe while continuing sex work?
Nakato: Buying sewing machines for sex workers has never and will never work. The idea that working in a factory for 18 hours a day just to make a fraction of the pay is misguided. That said, WONETHA fully supports sex workers who willingly want to exit sex work, and we are committed to helping them find a way to do so. In addition, we encourage sex workers to save money in case of health or other emergencies, and to supplement their income with other kinds of businesses. We are not in the business of rehabilitation, and we do not make the issue of sex work a moral one. It is a labor-rights issue for us.
Schmidt-Sane: If a sex worker wants to engage in sex work, then that is their choice. For what other profession do we, as a society, so completely and patronizingly question one's reasons for entering into that profession? Society needs to accept sex work as work.
Brothel raids and rescue tactics — the preferred method of extraction from sex work and subsequent "rehabilitation" — have resulted in documented human rights abuses such as rape, violence, unlawful detention and death while in custody of police or NGOs (see Cheryl Overs, 2009). Rehabilitation centers are simply a euphemism for jail — many of these places are overcrowded, dirty and uninhabitable and sex workers have died and suffered abuse while in custody.
NewsHour Viewer 15: Didn't the U.S. Supreme Court strike down the anti-prostitution pledge last summer?
Schmidt-Sane: Yes, but this Supreme Court ruling only applied to U.S.-based groups. It does not apply to groups outside of the U.S., who apparently are not afforded First Amendment freedoms of speech that are guaranteed to those within the U.S.
NewsHour Viewer 16: If these "at-risk" groups, like sex workers, gay men and drug users choose to engage in high-risk behaviors, why should everyone else help them stay healthy?
Russell: Everyone has a human right to health, regardless of whether society accepts those people or not. But beyond this, the nature of public health means denying services to some of the population affects the health of us all—regardless of sexual identity or gender orientation.
NewsHour Viewer 17: Uganda was once known as a success story in fighting HIV, but that seems to have changed now. It's one of the few places in sub-Saharan Africa where HIV rates are rising. What's behind that trend and do laws against the most-at-risk groups play a role?
Russell:Uganda's response to HIV has been woefully off track for years, and the country's lack of investment in prevention and treatment for gay men and sex workers is one direct cause. Discriminatory laws and policies also fuel the epidemic. In addition, lack of action by the lawmakers and implementers has caused Uganda to lag behind in testing and connecting HIV-positive people to care and treatment. Advocacy and pressure from civil society groups means this is slowly changing. Hopefully Uganda will embrace a more sound approach.
Editor's note: Activists' answers have been edited lightly for style and clarity.
This series was produced with the support of the International Center for Journalists.