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.