The Global Picture: A sliver of hope

Helen quietly escaped from her apartment in Kampala, Uganda’s capital, on a moonless night. Save for the darkness of the lonely night and a veil, there was not much else to rely on for refuge from detection. Her flight to safety required abandoning her home and traveling 700 kilometers (about 435 miles) to Burundi to stay alive. Had she waited another night in Kampala, the transphobic mob that laid siege to her house might not have spared her life. It would be several months before the 28-year-old founder of one of the few remaining trans-led and -focused institutions providing HIV care and prevention services could return to her country. Earlier that day, a blogger had posted Helen’s personal information on social media, exposing her identity as a transwoman living in the city, leaving her open to the dangers of transphobic neighbors. Her attackers, encouraged by news of an anti-gay law in the final stages of parliamentary approval, went from house to house, searching for members of the LGBTQ+ community to harm.

Yuwore Museveni, Uganda’s homophobic president who has ruled the country since 1986, had vowed to criminalize same-sex relationships. In May 2023, he made his threats a reality by signing into law the harshest anti-homosexuality bill ever seen on the continent. With passage of this law, Uganda has joined the list of 65 countries that have criminalized being gay. It prescribes the death penalty for LGBTQ+ people while criminalizing belonging to or registering an organization that provides services to gay people. To Museveni watchers, this law comes as no surprise, as Museveni gained global notoriety by describing gay people as “disgusting” in a CNN interview.

With the stroke of his pen, Museveni rolled back years of gains made in the fight against HIV in Uganda. “Before the law, we provided follow-up services for people on antiretrovirals and PrEP. Now, our clients are too scared to attend appointments,” Helen told me. The situation is dire, as the organization she leads has begun to see increased rates of new diagnoses. Helen’s return to Kampala meant seeking accommodation elsewhere, far removed from her previous apartment and running her organization secretly. Considering the prevailing security situation, the alternative to not being extra careful could be fatal. “If they catch me,” she said, “I risk going to jail. No one is safe providing the services we do, but we have to find a way.”

The situation is equally dangerous for people who access preventive services. Helen said that in the month following the passing of the law, two gay men living together were reported to Ugandan police by their neighbors, suspected of “aggravated homosexuality.” At night, while they slept, their house was broken into by the police, who illegally searched their apartment, confiscating condoms and lubricants as material evidence of homosexuality. The men were led away amid jeers by neighbors and have not been heard from since.

The United States ambassador to Uganda said that Uganda’s HIV rate is still one of the highest in the world. “Evidence shows that laws and policies, such as the criminalization of HIV transmission and same-sex relationships, hamper HIV response and people’s access to stigma-free sexual and reproductive health services,” said ambassador William S. Popp last November.

[Update: On April 3, 2024, Uganda’s constitutional court upheld the country’s newly-passed anti-gay law. “This ruling is wrong and deplorable,” said Frank Mugisha, of Sexual Minorities Uganda. “Uganda’s Constitution protects all of its people, equally. We continue to call for this law to be repealed.”]

ON FEBRUARY 28, the Ghanaian parliament passed an equally insidious anti-gay bill. The country’s two major political parties in a rare show of bipartisan unity passed the act, which imposes a three-year prison sentence for anyone convicted of identifying as LGBTQ+, and 10 years for running or funding LGBTQ+ groups or organizations. While the president, Nana Akufo Addo, is expected to sign it into law, this piece of legislation already has far-reaching consequences.

I spoke with Sam, a gay man who works in the Ghanaian municipal government, to understand the current attitudes of healthcare providers. He said that violence against queer people has noticeably increased in the last few months, and access to HIV services has suffered. Some organizations providing HIV services to the LGBTQ+ community in Accra, Ghana’s capital, have been raided by angry mobs who accuse them of recruiting people into homosexuality, forcing them to close shop.

Accessing health care from the government hospital is not seamless for gay people. Sam said that at any regular government facility, the default assumption is that you are heterosexual, and your treatment and diagnosis are based on this flawed premise.

“Some doctors and nurses in these hospitals are sympathetic to us,” Sam said. “However, they are primarily worried about their own safety and prefer not to help us access quality and queer-friendly health services on many occasions. HIV centers are supposed to be queer-friendly, but they are not in this country.”

Both countries are at risk of going the way of Nigeria, which passed its own Same-Sex Marriage Prohibition Law, a blanket law that criminalizes gay expression and equal rights, in 2014. The effect of the law on access to queer-focused health care, mainly HIV services, was instant. After the law was passed, preliminary reports suggested that it limited access to HIV care, as gay people reported being increasingly stigmatized in public health facilities, making them reluctant to access treatment and prevention services.

I SPOKE WITH Kizza, a clinical service associate at one of Uganda’s remaining LGBTQ+-led and -focused NGOs (non-governmental organizations, known in the U.S. as non-profit agencies). According to Kizza, they are lucky to stay active despite the continuous raids and evictions of similar organizations by the police in Uganda. Kizza’s clinic remains one of the few places in Kampala where members of the LGBTQ+ community can access testing, PrEP and other related services in a safe space. However, they have had to adapt to the hostile environment by switching to online services, offering consultations with clinicians. They found this easy because they already had the virtual consulting option set up before the law was passed, so it was a case of simply switching their walk-ins to virtual clients.

However, this option has its shortfalls. Kizza said that online consultations were less effective than in-person visits. “You have to understand,” she said, “that most of our clients are young adults living with their parents. To speak on the phone with us, they inadvertently would say something that would identify them as gay or living with HIV. They are usually not out to their families, and they risk being outed by anyone listening to their conversation. The physical clinic was a safe space for them, and now they no longer have that.”

I asked Kizza if members of her community could not simply access HIV services at government hospitals. She said that while on paper, the government had put out a circular to the effect that no one should be denied health services irrespective of the provisions of the law, the reality is quite different. It is significantly worse for masculine-presenting women and feminine-presenting men. In her experience, there have been cases where healthcare workers in government hospitals deny services to people who present this way. Usually, the targets of this neglect would rather sit at home and wait out whatever symptoms they are experiencing instead of going to the government hospital. In many cases, the disease progression rate is relatively high.

“The government does not even recognize the existence of other sexual and gender identities,” she said. “In official documents, they prefer to use men who have sex with men (MSM) rather than gay men, and female sex workers (FSW) to refer to lesbian or bisexual women. You do not expect a government that does not recognize your existence to make space for you,” she said.

ANOTHER CHALLENGE affecting the ability to provide services is brain drain. Several peer educators in various organizations have sought asylum to escape the oppressive regime. “In our organization alone, five of the seven peer educators we had are out of the country on asylum,” Kizza said. “We cannot be sure that the remaining will not do the same. How are we supposed to operate in a situation like this?”

Bad as the situation may be, the air of optimism about the future displayed by each person I spoke with was unnerving. And there is cause to hold out hope. A group of activists, law professors and two legislators from Museveni’s political party filed suit to overturn the law in Uganda’s constitutional court, and the hearing began in December. On the part of the healthcare providers, Kizza said there is a need to find a way to collaborate with government health services. “Some clinicians can be sympathetic to our cause; we can only hope that we find a way of building a connection with them so they can help our people,” she said. Asked if she was sure that could work, she said, “We can only hope. It would seem that despite the country’s situation, the people still have a sliver of hope.” 

EDITOR’S NOTE: All names have been changed to protect the safety of the interviewees.