Calling for a You-Turn for Public Health: Don’t Criminalize Gays, People Living with HIV

Since HIV was first identified in sub-Saharan Africa, Uganda has distinguished itself as a leader in developing and implementing an effective HIV response. In recent years, however, HIV incidence has been increasing in the country, and a series of restrictive, punitive measures have replaced the common sense, public-health approach that had set this beautiful country apart.

This year, Uganda joined Nigeria and a handful of other sub-Saharan African countries that have passed, or are considering, repressive, egregious laws criminalizing HIV transmission and homosexuality–laws that are regressive and disastrous from a public health point of view.

Among other things, the anti-homosexuality law in Uganda requires Ugandans to report anyone who may be homosexual to the authorities. Anyone. This means mothers turning in sons, fathers turning in daughters. Anyone.

Meanwhile, the Ugandan “HIV Prevention and Control Act” criminalizes “attempted” or “intentional” transmission of HIV, with fines of up to ten years in prison, and mandates testing for HIV of pregnant women, their partners, and for all accused of rape, not convicted, accused. It further allows for court ordered disclosure of HIV status—in some circumstances without the individual’s consent. While Ugandan President Yoweri Museveni has not yet made it official, it is likely he will sign the HIV bill any day.

MSH has worked in Uganda for over 15 years, measurably improving the health of Ugandan women, men and children, and helping to save the lives of people needing HIV & AIDS prevention and treatment. The new law’s restrictions on “abetting” homosexual relations will impair efforts by healthcare providers and development organizations like MSH to provide comprehensive prevention, counseling, testing, and clinical care and treatment services for vulnerable people living with HIV or those at risk of HIV infection.

Some say that far-right US interests have fueled the fear and fomented discrimination of gay people in Uganda and elsewhere. Regardless of the source, sadly some anecdotal reports suggest that many Ugandans do not see a problem with the new laws.

The LGBT communities in Africa, Asia and elsewhere are unfortunately no strangers to these insults; and I have been trying to formulate a response to these unfortunate turn of events. My conclusion, in light of such intolerance against a select group of people for petty political gains, is simply to stand up and be counted. So in solidarity with those who suffer from these crude attempts at discrimination, I state proudly what my family, friends and colleagues have long known and supported: I’m a gay man. And, as a gay man, I will only be able to participate in the rebuilding of Uganda’s HIV response from afar. So, while MSH has multiple projects working in Uganda, serving hundreds of thousands of Ugandans, if I were to go and help my MSH colleagues on the ground, they would be compelled to turn me into the authorities or face prosecution themselves. I cannot put my colleagues at risk.

How many others face this quandary?  And what of our gay and lesbian friends and colleagues working and living in Uganda, shrouded in secrecy? What will become of them?

What about the Ugandans who must hide who they are—even if it means not getting tested for HIV, or not adhering to antiretroviral treatment for fear of this specific sort of stigma and discrimination that the Ugandan laws have created?

More people will go underground. More will hide their HIV status. Fewer people will get tested. More HIV transmission will occur.

I stand with those whose courage is head and shoulders above mine: Uganda’s own Frank Mugisha, executive director for Sexual Minorities of Uganda (SMUG), Uganda’s umbrella LGBT rights organization, who was out of the country when President Museveni signed the anti-homosexuality law but then chose to return knowing full well that he might be targeted for persecution, prosecution or worse.

I stand with Dr. Paul Semugoma, winner of this year’s International AIDS Conference Elizabeth Taylor Human Rights Award. Dr. Semugoma remains in exile from Uganda, his home country, because him being gay and having the temerity to state it, unashamed, publicly, put him in grave danger in his country of birth.

I stand with Binyavanga Wainaina, the wonderful Kenyan author who decided to tell the world he was gay in response to Uganda’s and Nigeria’s laws. His book , “Someday I will write about this place,” is as universal a coming of age memoir as any I’ve ever read.  Following their example, willing to proclaim simply who they are, raising my hand and adding to their voice seems a paltry response.  But it’s the most potent tool I can think of.

I stand with the anonymous men and women—gay and presumed gay—who are languishing in fear or in prison and those who are ill who don’t feel they have the option of seeking care for fear of the response from those in their communities, the clinics, or the authorities.

I stand with the many others who have the courage to stand up and say, this is who I am. Do not criminalize me.

In speaking up, gay and straight, we say: all people deserve the opportunity for a healthy life – living with HIV, at high risk of infection, in any country or region—no matter how far from a health center you may have been born: you are worth seeing, testing, and treating. You have as much right to life and health as President Museveni of Uganda, President Jonathan of Nigeria, those who make the laws, and every one.

We will continue to work with global and local partners to support Uganda’s and Nigeria’s efforts to strengthen their health systems. But, these laws will make reducing HIV transmission, and preventing maternal and child deaths much harder.

Health includes dignity. We hope that as more people—gay and straight, living with HIV, and allies–stand and work together, more people in Uganda and around the world will believe: All people deserve the opportunity for a healthy life.  One thing is clear:  we do not improve health and humanity by stigmatizing and criminalizing sexuality or living with HIV.

Scott Kellerman, MD, MPH, is the Global Technical Lead for HIV & AIDS in the Center for Health Services at MSH.

{Photo credit: Rui Pires/MSH.}

{Photo credit: Rui Pires/MSH.}

Related

Anti-Homosexuality Act is a Step Backward for Uganda

New law in Uganda likely to set back gains made in HIV & AIDS

AIDS Community Mourns Loss of Colleagues Aboard MH17

On behalf of Management Sciences for Health (MSH), we send condolences to all the families, colleagues, and friends of the passengers killed on Malaysian Airlines Flight 17.

Many of us are still in shock at the senseless loss of life—all too common among those fighting HIV & AIDS.

(Read International AIDS Society statement.)

From my time at the World Health Organization (WHO), I remember vividly Joep Lange’s passion and determination for ending HIV & AIDS. In 1999 and 2000, when the scale-up of AIDS treatment was still considered unaffordable, unfunded, and—in many people’s minds—undoable, he pioneered AIDS treatment and brought people together in united action. We also lost Glenn Thomas, the WHO spokesperson, and others committed to ending HIV & AIDS.

We are missing our friends and colleagues this week in Melbourne, Australia, at the 20th International AIDS Conference. On Friday evening, Michel Sidibé of UNAIDS shared a conversation he had with Joep a week ago about the conference. He said that Joep told him:

We must never miss the opportunity to transform Melbourne as the beginning of the journey ending AIDS.

Indeed, we must remain determined to continue the fight to end HIV & AIDS and work together toward a more just world.

Jonathan D. Quick, MD, MPH, is President & CEO of Management Sciences for Health (MSH).

Related

AIDS2014.org: Opening session includes tributes to lost colleagues aboard MH17  (PDF)

Mourning

We send our heartfelt condolences to the families of everyone lost on MH17, including our HIV & AIDS colleagues en route to Melbourne.

The International AIDS Society released this statement today (Friday, July 18):

The International AIDS Society (IAS) today expresses its sincere sadness at receiving news that a number of colleagues and friends en route to attend the 20th International AIDS Conference taking place in Melbourne, Australia, were on board the Malaysian Airlines MH17 flight that has crashed over Ukraine earlier today.

At this incredibly sad and sensitive time the IAS stands with our international family and sends condolences to the loved ones of those who have been lost to this tragedy.

 

 

Stepping Up the Pace on Pediatric HIV & AIDS: “Treatment is Prevention”

This post also appears in the MSH Global Health Impact Blog.

On the eve of the 20th International AIDS Conference (AIDS 2014), Rachel Hassinger, editor of MSH’s Global Health Impact Blog, spoke with Dr. Scott Kellerman, global technical lead on HIV & AIDS, to discuss his latest research on prevention of mother-to-child transmission (PMTCT) of HIV and pediatric HIV & AIDS. Kellerman and colleagues will be attending AIDS 2014, July 20-25, in Melbourne, Australia. (Read more about the conference.)

RH: What is the state of HIV & AIDS globally?

[Scott Kellerman]
SK: We are at the threshold of a sea change. In the beginning, our HIV prevention tool box was sparse. We could offer extended counseling and condoms, and impart information, but not much else. Behavioral change was the cornerstone of tackling the epidemic. It worked sometimes, but, not consistently.

Now biomedical advances are propelling treatment as prevention—even what I call “treatment IS prevention”.

Where we used to see mothers unable to access treatment and die, now, more often than not, we see mothers, even in remote communities, survive. We also see infants of HIV-positive women born HIV-free.

RH: That’s inspiring—a decade or two ago, that wasn’t the case.

SK: Yes, overall, our global response to HIV & AIDS is maturing and recent advances are extremely exciting—but not fast enough. We still fall far short of our treatment and, by extension, our prevention goals.

As I think about previous AIDS conferences, I recall a palpable tension between the “prevention” camps who were advocating for more prevention funding and the “treatment” camps who saw the future of control of the epidemic in more treatment funding.  Cries of “you can’t treat your way out of this epidemic!” rang out in conference halls. Perhaps the most striking thing about the maturation of our response is that our community is coming to the conclusion that treatment IS prevention.

Take PMTCT and Option B+.

Option B+ is an approach to preventing mother-to-child transmission [MTCT] that offers all HIV-infected pregnant and breastfeeding women antiretroviral therapy [ART] for life, regardless of CD4 count.

PMTCT has long been “treatment is prevention.” By treating the mother during pregnancy and breastfeeding with ART, we are preventing her infant from acquiring the virus from her. That much isn’t new—both Options A and B use treatment of the mother to prevent mother-to-child transmission.

Option B+, developed in 2011, takes this a step further. The government of Malawi, with technical support from MSH—including my colleague, Dr. Erik Schouten—developed Option B+ out of necessity. Fertility rates are high in Malawi, and CD4 testing capabilities are minimal—and slow, at best. By offering treatment for life to an HIV-positive pregnant or breastfeeding woman regardless of CD4 count, it has raised the standard for other countries to follow.

We now see many countries in Africa and elsewhere adopting this strategy.

Option B+ also says: the country understands that the woman’s life is critical for the well-being of the children and commits to treating the mother for her HIV infection, as well as providing prophylaxis for the infant. It really raises the emphasis on the health of women as key to the health of the family, the community, and the nation. It’s the right thing to do.

RH: At the AIDS 2012 conference two years ago, Option B+ was the talk of the conference! What’s happening now?

SK: Global support for Option B+ is building—but only recently. The WHO [World Health Organization] included B+ in the 2013 treatment guidelines.

RH: So, how close are we to reaching an AIDS-free generation?

SK: Honestly, I feel that we are close to an AIDS-free generation—it is within our human reach—if the international community addresses the epidemic together from every angle, and thinks outside the box.

The end is in sight for eliminating maternal to child transmission [MTCT] and pediatric HIV.  But even if we reach this lofty goal, how will we know?

RH: That’s what you and colleagues are testing now, correct?

SK: Exactly. There’s several promising approaches to measure the effectiveness of PMTCT—and Option B+, in particular—that MSH and colleagues are pursuing. In one study, published in PLOS ONE last month, we show the potential for routine testing at immunization clinics to monitor mother-to-child transmission (MTCT) of HIV in Malawi.

The study also shows the potential of regular data collection as a surveillance tool to assess changes in effectiveness of prevention of MTCT (PMTCT) as Option B+ is scaled-up across the country.

RH: Is this a new method for monitoring transmission?

SK: Yes, it is. We [MSH and colleagues] derived population-based estimates of the HIV vertical transmission rate (VTR) by testing a sample of infants less than 3 months old at their first immunization visit at 53 randomly chosen clinics in four Malawian districts. Comparing the population-based estimate of VTR to the results of subsequent evaluations of the national program will allow Malawi to assess trends in the effectiveness of the national PMTCT program, and by extension, the effectiveness of Option  B+.

The approach can be expanded to track programming effectiveness for young infants over time in Malawi, and in other countries adopting Option B+. You can read more about the study in the press release or directly in PLOS ONE where it’s downloadable for free.

We’re also partnering with the CDC [US Centers for Disease Control and Prevention] on a four-year research evaluation to determine HIV-free child survival following Malawi’s initiation of Option B+. The study will follow 37,000 Malawian mother-infant pairs and measure the rates of mother-to-child transmission in HIV-exposed infants at 4 to 12 weeks, 12 months, and 24 months of age, and HIV-free survival at 6 to 12 weeks, 12 months, and 24 months of age. In addition to supporting this research evaluation of Option B+, we support district-level health systems strengthening and country efforts to provide HIV testing, counseling, and treatment to the prison population.

We’re supporting the Governments of Ethiopia and Uganda to scale-up their roll-out of Option B+, too. In Ethiopia, for example, we’ve supported implementation of Option B+ in 276 health centers.

RH: So, we’re supporting progress on implementation and research of Option B+ for PMTCT.

SK: Yes, but reaching an AIDS-free generation is not just about PMTCT.

Even with an absolutely perfect PMTCT system—that identifies and treats every infected mother presenting for antenatal care—there are many women who never make it into antenatal care, are never seen by a health worker during their pregnancy, and never get a chance to be tested or understand how to protect their children from being born with HIV.

The AIDS Journal featured a series of papers on pediatric HIV, written by an amazing array of researchers and thinkers. In the set of articles, we show, among other things, that the infrastructure and health systems that are responsible for caring for kids are really suffering. It comes down to health systems strengthening, not only for adults but also for pediatric care systems—which are separate from those for adults, and are often much less resourced. I guest edited the supplement last fall—and its downloadable for free.

Until now, the primary response to pediatric HIV has been to further strengthen PMTCT programming, which is a critical intervention, and one that is close to my heart. But a lot of kids are missed by PMTCT.

There’s no PMTCT without antenatal care and HIV testing. There’s no PMTCT without stronger health systems.

RH: Can you give an example?

SK: Our HIV work is part of our whole systems approach in many countries. In Ethiopia, for example, about 790,000 Ethiopians are living with HIV. Through one of our projects [ENHAT-CS], we’re supporting the government’s efforts to scale-up comprehensive HIV & AIDS services at health centers and integrate them with other health services, such as maternal, newborn, and child health. ENHAT-CS supports mother support groups in over 80 health centers. HIV-positive women—“mother mentors”—lead the groups. Data show a beneficial effect of mother mentors and mother support groups on uptake of and adherence to HIV care and support and reduced vertical transmission rates among HIV-positive women. And four of the mother mentors in Ethiopia received international recognition for their life-saving work.

Through the SIAPS program, [Systems for Improved Access to Pharmaceuticals and Services Program], we’re partnering with the Ethiopian Government to improve information systems at hundreds of ART clinic pharmacies to improve HIV patient care and adherence to treatment.

We’ve actually been working in partnership with Ethiopia saving lives for 10 years.

Watch video

RH: The state of global funding is shifting. Since the creation of PEPFAR [the US President’s Emergency Plan for AIDS Relief], the US and global communities have concentrated a lot of money into reducing the HIV & AIDS epidemic, more than for any other area of global health. This year, newly appointed Ambassador Deborah Birx, MD, US Global AIDS Coordinator, reiterated this shift, noting that PEPFAR’s congressional mandate calls for half of funds to go directly to treatment.

If there is a continued push toward treatment, what happens to the other parts of the whole? 

SK: We’ve built an incredible system around fighting AIDS: structures of concentric programming circles with HIV prevention and treatment programs aimed at the individual in the middle, but with considerable resources directed at the myriad societal structures that often inhibit people in need of basic care and treatment.

With flat lined or diminishing resources, there’s a renewed focus on increasing the efficiency and getting back to basics—putting pills into people’s mouths, focusing on key populations: men who have sex with men, sex workers, IV-drug users; and eliminating pediatric HIV. It is time that we shift our thinking from a vertical siloes approach, to a cross-cutting, diagonal whole.  When it comes down to it, HIV is an infectious disease and we know how to treat it. We can’t keep funding everything.

The question is: How do we increase the efficiency of the AIDS response? And how can we leverage these structures to improve other health areas—the whole person?

We can integrate HIV & AIDS services with other health services—like maternal and child health, tuberculosis, and family planning. Instead of building three separate clinics–a reproductive health clinic next to a tuberculosis (TB) clinic next to an HIV & AIDS clinic–build a clinic that provides quality, integrated services for all of these essential needs. Train community drug shop owners, so that a person living with HIV in a rural community, can pick up pills safely. We’re not the only ones who are doing this well. Many of my colleagues in other organizations are working hard to integrate services and increase efficiencies, too. We can work together to leverage these systems to provide services for multiple health areas, MNCH, TB, family planning, and chronic diseases.

The cost of AIDS medicines has decreased, and coverage for treatment is the norm in many low- and middle-income countries. And, we still have more to do to ensure access for the poor and most vulnerable. Programs like the Malawi prison effort, and the Ethiopian religious leaders and mother mentors are helping to ensure that more and more, people are testing voluntarily for HIV, and getting treatment. But stigma and discrimination are still major issues.

RH: What about HIV & UHC?

SK: We’ll be talking a lot with partners and colleague about universal health coverage (UHC) in the post-2015 development framework at the AIDS 2014 conference. There’s a breakfast on Tuesday [July 22] on building UHC on lessons learned from the AIDS response. You can learn more about the UHC breakfast, and other MSH AIDS2014 events.

RH: What else will you and colleagues be talking about at AIDS 2014?

SK: We’re co-sponsoring three evening sessions [6:30 pm] on Monday, Wednesday, and Thursday. On Monday [July 21], the conversation will focus on women, HIV & AIDS, and non-communicable diseases; on Wednesday [July 23], supply chain for HIV & AIDS medicines and commodities; and on Thursday [July 24], HIV & TB.

And, before the conference begins, I’ll be speaking at an event about PMTCT and pediatric HIV—and on the importance of research and development for stepping up the pace. Our data systems are still primarily designed to count the number of things done, not measure progress toward goals.

We need more research on pediatric HIV, like the article in PLOS ONE outlining a design to measure population-based vertical transmission rates; the AIDS journal supplement focused on PMTCT and pediatric HIV; and the ongoing CDC-supported evaluation to measure the efficacy of Option B+.

As we get closer to our goals of eliminating mother-to-child transmission, these studies could help numerous sub-Saharan Africa countries measure progress toward keeping infants HIV-free.

Follow Scott Kellerman and MSH colleagues throughout AIDS 2014

 

AIDS 2014: High-level Speakers Announced, Mark Your Calendars

This post also appears in the MSH Global Health Impact Blog.

Guess who’s coming to the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia, July 20-25?

President Bill Clinton, 42nd President of the US and founder of the Clinton Foundation; activist Sir Bob Geldof; Michel Sidibé, Executive Director of UNAIDS; and Ambassador Deborah Birx, US Global AIDS Coordinator of US President’s Emergency Plan for AIDS Relief (PEPFAR), are among confirmed high-level speakers.

MSH is coordinating three satellite events with partners, presenting numerous posters, hosting a booth (#312) at the exhibition hall, and providing live blog coverage of the conference. And, MSH President & CEO, Dr. Jonathan D. Quick, will introduce the Hon. Michael Kirby for the Jonathan Mann Memorial Lecture during the Opening Plenary Session. Be sure to add these MSH events as your build your online itinerary with the program-at-a-glance.

Subscribe to our email list and we’ll send more details closer to the conference about how you can connect with us at AIDS 2014.

Visit the MSH conference blog for updates in realtime. (We’ll be tweeting @MSHHealthImpact with hashtag #AIDS2014.)

Ian Lathrop contributed to this content.

Related

New Study by MSH Published by PLoS One Evaluates Impact of Option B+ for PMTCT in Malawi through Immunization Clinic-Based Surveillance

Watch video: 10 Years of Partnership to Save Lives in Ethiopia

More about our work on HIV & AIDS