This article is the 8th in 50.50's series on the World AIDS 2014 Conference taking place this week in Melbourne
The International AIDS Conference is a chance to reflect on where we’ve come from and what we’ve learned along the way in terms of HIV prevention, care and support. The growth of inspirational AIDS rhetoric, as well as significant medical advances, might imply that progress is inevitable, or that it’s simply a question of time until we end the AIDS pandemic. But moving forward doesn’t automatically constitute movement in the right direction. Hajjarah Nagadya’s article highlighted the regressive implications of Uganda’s new HIV laws upon the “little success already achieved” for women in relation to HIV. This comes only months after the introduction of the harsh, anti-homosexuality act, which can specifically penalise homosexuals living with HIV. At the same time, Uganda is one of only three countries - together with Angola and Mozambique - on the continent where HIV prevalence is rising instead of falling.
But only two decades earlier, Uganda’s HIV response was heralded as the bravest and smartest in Africa. Incumbent president, Yoweri Museveni, was once globally admired for mobilising an HIV response founded upon compassion and shared responsibility. So what happened? This article looks back in time in order to comprehend the real, devastating scale of Uganda’s backslide in HIV prevention, care and support.
“Brother, you have a problem.”
These were the legendary words of advice given from Fidel Castro to the only recently sworn-in president of Uganda, Yoweri Museveni, in 1986. They came after Museveni sent 60 soldiers from his army to Cuba for further military training. Routine HIV testing in Cuba discovered that 18 of these tested HIV positive. In fact, we now know that approx. 30% of the entire population of Uganda was estimated to be living with HIV at this time. Some months after testing, Castro took Museveni aside during a conference in Zimbabwe and delivered the news in person. The Ugandan president’s response was ground-breaking. He called for action at all levels, from schools to churches and mosques. This made Museveni the first leader in Africa to acknowledge the epidemic publicly and Uganda the first country in Africa to make the HIV pandemic a national, political priority.
Uganda soon implemented the famous ABC programme (Abstain, Be faithful, Use condoms). Billboards were erected urging people to “love carefully” to practice “zero grazing” (not to look outside of their own pen for a different mate). Bishops and Imams united against the threat of HIV. Condoms became widely accessible, even from shop corners of remote areas. The candid discussion about sex and condoms that it stimulated was unprecedented.
It was this environment that enabled the formation of The AIDS Support Organisation (TASO). It was the first community support programme of its kind and it could only have existed under Museveni’s presidency. TASO created the justly famous, and widely replicated, model of Positive Living: “creating systems and structures that take care of and support people living with HIV to lead meaningful, productive and happier lives while at the same time supporting people not living with HIV to remain HIV free.” In other words, TASO promoted a system of mutual support and acceptance, care and mindfulness. What was so progressive about Uganda’s national HIV response, apart from the fact that it was led by the highest office in the land, was that the movement was grounded in compassion, social justice, dignity and treatment access for all. Later, Uganda became an early pioneer of antiretroviral treatment (ART) scale-up in 2004, allowing people living with HIV to live much longer and healthier lives. As a result of all of these advances, Uganda saw massive drop in the number of HIV transmissions. The rate of people living with HIV in Uganda was reduced from approximately 30% of the population, in 1986, to 6.4% in 2006.
To put the significance of Museveni’s open and pro-active approach to HIV into perspective, we have to understand the context. Uganda’s ‘love carefully’ revolution was happening whilst the epidemic was being casually ignored or actively discredited by most other political figures in Africa. Even Nelson Mandela never fully addressed HIV until after his retirement. He remarked to the BBC in 1994 that, "I wanted to win, and I didn't talk about AIDS." But even after winning, and despite governing a country that was home to some of the highest numbers of people living with HIV anywhere in the world, Nelson Mandela remembered how he did not have “time to concentrate on the issue". It was Museveni’s original support for public discussion and action about HIV that paved the way for the extraordinary community-based leadership and innovation that continues to thrive today.
But now, over two decades later, the global community of activists, scientists, policy makers are again crying out - “Brother, you have a problem” – albeit to a less receptive Museveni. 13th May saw the passage of the HIV Prevention and Control Act by the Ugandan Parliament. It was yet another devastating blow to the HIV agenda and to human rights. The act includes Mandatory HIV testing for pregnant women and their partners, as well as for victims of sexual abuse. It also allows medical providers to disclose a patient’s HIV status to others. Both of the above contravene international best practices and violate fundamental human rights.
Mandatory HIV testing unfairly targets women, as they are more likely to be tested in antenatal clinics. This makes them vulnerable to violence; from their partners, their communities, the health service providers and now also; the law. The same law also intends to criminalise the transmission of HIV - as well as ‘attempted’ HIV transmission. It is a move that contradicts evdience, logic and human rights. Puntive laws instil fear and blame. There is no evidence that links them to beneficial public health outcomes. Instead, research has shown that it de-incentivises testing and heightens stigma. Stigma then reinforces further discrimination against people living with HIV. What then, is the justification of these laws?
The introduction of the act seems to be part of a larger and worrying trend in which Uganda is moving away from the foundation of care and support that was present in its initial public health campaigns. Homosexuality has long been illegal in Uganda, as it is in a large number of African countries, despite its existence before the British imposed stringent homophobic laws on their colonial territories. But on Tuesday 25th February 2014, the “Anti-Homosexuality-Act” was signed by the president. The bill included the creation of new crimes, to be imposed alongside brutal and arbitrary punitive measures. “Aggravated homosexuality”, for example, carries a life sentence and penalises “homosexual acts committed by a person living with HIV.” “Aiding and abetting homosexuality” carries a seven-year sentence and looks likely to inhibit key public health services from operating in the country. The Ugandan government officially refutes this but Avert claims that HIV services supporting men who have sex with men (MSM) are effectively non-existent and we have already heard from colleagues that organisations supporting gay rights are being closed down. This act includes lesbians for the first time. Current data on HIV prevalence among MSM in Uganda are unknown; data is not even being collected in order to understand the full impact that these laws will have upon HIV transmission. Museveni, who was the first African leader to speak out about the HIV epidemic, now seems content to shut his eyes to it.
Persecution of LGBTI people is increasing. Sexual Minorities Uganda (SMUG) and the National LGBTI Security Team documented 162 reported incidences of persecution perpetrated against Ugandan “LGBTI people” between 20 December 2013 and 1 May 2014. Even if we cannot yet know how the Anti-homosexuality-law is affecting HIV transmission rates among this key population in Uganda, this study gives us a grim picture of how it may already be manifesting by way of violence and discrimination.
The real tragedy of this situation is the historical regression. For more than a decade Ugandan political leadership and the tremendous accompanying community response was an exemplar of best public health practice. Yet in 2011 Uganda was recognised as one of only three countries on the continent in which rates of HIV prevalence are rising. And the long-term impacts of both the Anti-Homosexuality laws and the HIV Prevention and Control Act look set to worsen this. “Brother, you have a problem” remains astute counsel for Museveni.
Executive Director of Uganda Network on Law, Ethics & HIV/AIDS. Dorah Kiconco, calls for a holistic approach to human rights and health care. “For Uganda to address its HIV epidemic effectively, it needs to partner with people living with HIV, not blame them, criminalize them, and exclude them from policy making.”
Let’s hope the people of Uganda who have worked for decades to make sure that care and support formed the basis for HIV prevention campaigns can regain their president’s ear. Meanwhile, we must all hope that whilst Uganda still leads with discrimination and fear, it will not become again the public health role model for other African countries.
The author's name has been withheld at her request
This article is part of 50.50's long running series on AIDS Gender and Human Rights. We are publishing articles daily during the 2014 World AIDS Conference in Melbourne July 20-25