Homophobia and 'Morality' Driving HIV

I recently wrote that some men who have sex with men (MSM) also have sex with heterosexuals. But research shows that a majority of MSM in some countries also have sex with women (82% in Senegal). This research was carried out in three African countries and in Tamil Nadu state, India. So MSM there are not a relatively isolated group that has little relevance to heterosexually transmitted HIV. Rather, MSM are very much a part of sexual networks as a whole and their sexual health is as important as the sexual health of communities and nations.

This needs to be emphasized because MSM, along with intravenous drug users (IDU) and women who have sex with women (WSW), are often treated as separate and even completely ignored by HIV policy. The probability of HIV transmission is much higher among MSM and IDUs for several reasons. Therefore, the fact that they are also part of a sexual network that includes heterosexuals means that HIV policy cannot afford to continue to ignore these issues.

One may think that WSW are not very likely to contract HIV, but this is not so. Firstly, they may sleep with men sometimes, for various reasons. But they are also subject to discrimination, persecution and physical and sexual violence. In South Africa, there have been instances of what has been called 'corrective rape', where women are raped because they are, or are suspected of being, lesbians. The physical trauma that rape usually involves makes transmission of HIV and other sexually transmitted infections (STIs) many times more likely. The result is that rates of HIV and STIs are high among WSW.

In most African countries, male/male and female/female sex is illegal and, even where it is legal, such as in South Africa, it can still meet with stigma and violence. In Uganda, where an early and severe HIV epidemic gave rise to a lot of frank discussion of HIV at all levels of society, homosexuality is still illegal and HIV positive MSM are denied care. Organisations involved in providing information, advice and care for MSM have been intimidated and people who have male/male or female/female sex are now reluctant to seek advice.

Even the practical side of protecting yourself from HIV and other STIs is affected by such attitudes. Ugandan men who have sex with men have complained of lack of access to lubricants, for example, and resort to using common household products, such as cooking oil or margarine, instead. This can cause the condom to break but it is also an absurd indignity, especially considering that anal sex and the need for lubricants is not just confined to men having sex with men.

Likewise, lesbians are denied information about and access to things like dental dams. Oral sex is not just practised by lesbians and many others need to know about dental dams. Come to think of it, I have never been counselled about such devices, either here in East Africa or anywhere else.

Nigeria is currently debating a bill that would ban same sex marriage and make gay rights protests a crime, punishable by a five year prison sentence. The mere discussion of the bill has given rise to an increase in homophobic attacks and people suspected of being gay have been discharged from the army. Nigerians can content themselves that non-heterosexual sex is immoral and against the teachings of their religion, whether they are Muslim, Christian or probably anything else. Sodomy is already against the law and carries a long prison sentence or even a death sentence. Discussion of any form of non-heterosexual sex would be a crime if the new bill becomes law.

HIV is higher in Nigeria than in many other West African countries. Driving some of the most vulnerable people underground will not help the country tackle this problem. One of the most important things a country can do is to understand the magnitude of their HIV epidemic, how widespread it is, where it is affecting most people, how it is spreading and how it may spread in the future. This requires as much testing and monitoring as possible. People will be very reluctant to be tested if they are afraid they may be branded as immoral or criminal as a result.

Another important implication of the above research is that countries and areas which, up to now, have only had relatively low levels of HIV, may well experience increasing levels later on. Senegal and Thailand are often discussed because they are said to have been successful in containing their HIV epidemic. Senegal is one of the few African countries to have a 'concentrated' epidemic, as opposed to the 'generalised' epidemics found in many African countries.

A concentrated epidemic is one where HIV rates are low in the general population and only high in specific groups, thought to be at high risk. These groups include MSM and IDU. A generalised epidemic is one where HIV rates are significant in the population as a whole. If 82% of MSM in Senegal also have sex with women, HIV may well spread beyond high risk groups and the epidemic may become more concentrated. MSM in Senegal are particularly vulnerable right now, after 9 gay men who worked for a HIV prevention agency were imprisoned in January. They were accused of “acts against nature and the creation of a criminal organisation”. They have just been released, but it remains to be seen what will happen over time. I hope this sort attitude towards HIV prevention agencies is not widespread but I suspect it is.

Thailand has also received praise for limiting the spread of HIV, but among MSM now, the rate of spread is increasing rapidly. In Kenya, the Northern areas have low HIV prevalence, lower than those of Ukraine (about 1.6%) or Washington DC (about 3%). However, prevalence among pastoral communities, previously thought to be at less of a threat of HIV, is now rising. These communities are isolated from health and other social services. School attendance, achievement and literacy are very low. So if HIV starts to spread rapidly this area will be even less able to react than other Kenyan provinces.

HIV prevention requires a lot more research into what may happen in the future, rather than concentrating on what has happened. We need to analyse the data that is available, not just use it for good news publicity or shock media campaigns.

And those who choose to see HIV as a moral issue may like to consider the morality of the poverty, inequality, discrimination, injustice, exploitation and numerous other outrages that go on in their country. Punishing innocent people, such as MSM and WSW, will not protect others and will, sooner or later, become a threat to everyone.

HIV is the Problem, Except for Everything Else

The received view about men who have sex with men (MSM) and women who have sex with women (WSW) in African countries is that it is not common and certainly not as common as outside Africa. I have yet to come across any evidence that these phenomena are really less common in Africa than in other continents. However, most African countries have laws against such practices.

In Kenya, Tanzania and Uganda, for example, MSM have been persecuted. WSW are even less often talked about, but they face many dangers and often have to go to great lengths to keep their sexuality hidden. Thus, MSM and WSW often get married, to pretend they are heterosexuals. In marriage, some repress their sexuality, some don’t.

And that’s where some of the mystery about the numbers of non-heterosexuals in African countries arises. It’s not that long ago that in Western countries, non-heterosexuals would pretend to be heterosexual and behave accordingly, at least for some of the time. In East Africa numbers are a matter of speculation, really. People who choose to be frank about their sexuality face abuse, even imprisonment.

Those who choose to keep their sexuality a secret, and who could blame them, also face dangers. They may follow their sexuality and put their partner and themselves at risk; they may be exposed at any time, etc.

In countries where HIV prevalence is high, everyone needs to be careful. As an advertising campaign pointed out, if you sleep with someone, you also sleep with all that person’s partners. MSM, WSW, intravenous drug users (IDU) and other groups who face special risks are not as neatly compartmentalised as such acronyms may suggest. As to the percentage of people who are actively bisexual, either through orientation or necessity, it’s anyone’s guess.

HIV is often exceptionalised as if it were more threatening than any other health issue. This is not the case; sexual health in developing countries is a much bigger issue. HIV is only a small part of sexual and reproductive health, which itself is only a small part of the health of whole populations. And more people’s lives and welfare are threatened by the manipulation of a few rich multinationals than by HIV; the same could be said for the manipulation of a few international institutions, a few rich countries, global warming, etc.

One of the problems with exceptionalising HIV is that other important messages get lost. In some age groups in Kenya, nearly half of all sexually active people have herpes simplex virus (HSV), many others have various sexually transmitted infections (STI) and there are so many reproductive health problems, why concentrate on HIV at the expense of all others?

There’s a particularly horrifying statistic about human papilloma virus (HPV) among gay men in Asutralia; nearly 80% of them were found to have some form of HPV in a recent study. This virus causes anal cancer, although anal cancer is rare. HPV is particularly common among those already infected with HIV, standing at 94% in the Australian study. One wonders what the prevalence of HPV is among gay men in African countries. The same question could be asked about other STIs that are associated with anal sex, especially where gay men either need to or choose to sleep with women as well.

Things must be very different in Australia. Non-heterosexuals are free to express their sexuality, there are laws against discrimination and persecution, they have access to health services, legal protection and support of various kinds. This is not the case in East African countries, where men in Uganda who protested recently about the lack of HIV services for gay men were arrested. Non-heterosexuals continue to be excluded from HIV prevention and other services that are aimed at almost entirely at heterosexuals.

In addition to decriminalising commercial sex work (discussed elsewhere), those who are not heterosexual and who wish to express their sexuality need the protection of the law. They need access to health services, especially sexual health services. They are not isolated ‘groups’. They are, ultimately, an integral part of the whole network of people that make up a country. Their sexual health is everyone’s sexual health, just as the sexual health of the heterosexual community is also part of the sexual health of non-heterosexuals.

Persecuting people for their sexuality, denying them the protection of the law and access to health and social services, is as damaging as persecuting commercial sex workers and denying them some of their most basic human rights. The moral crusade against whatever target happens to present itself is doing more to spread HIV than the groups of people who are being targeted.