Between 2004 and 2008, the United States has provided 1.2 billion dollars to the East African nation of Uganda through the President's Emergency Plan for AIDS Relief (PEPFAR). Instigated by President George W. Bush, PEPFAR's results have been striking. According to a 2009 Annals of Internal Medicine research report, an estimated 1.2 million lives have been saved. The AIDS rate has dropped dramatically. PEPFAR funds three components of AIDS education and prevention: Abstinence education, Be faithful in marriage or to one partner, and Condom usage (ABC).
However, a bill proposed in the Ugandan parliament in early October may add a D to this policy and compromise Bush's good work. The D stands for the death penalty for homosexual offenses, including multiple homosexual acts and engaging in sex while HIV positive.
Introduced by MP David Bahati, the Anti-Homosexuality Bill, 2009 would impose the death penalty on some homosexual behaviors, and maintain life in prison for others. Even touching someone of the same sex could be considered an offense if the intent is sexual. Homosexuality is already illegal in Uganda but this bill cracks down harder on offenders as well as anyone with any relationship to a homosexual. The bill requires persons in authority (pastor, teacher, missionary, physician, parent, etc.) to report any knowledge of any offense covered by the act within 24 hours upon pain of 3 years in jail or a hefty fine. Thus, parents could be expected to turn in same-sex attracted children. Relevant to AIDS relief work, there is no exemption in the bill for professionals. If a patient reveals homosexual behavior in the course of AIDS treatment or education, then those hearing the revelation must report.
As might be expected, the bill is receiving condemnation from human rights groups, including those within the AIDS prevention and treatment community. However, the bill has divided two former collaborators on AIDS policy in Uganda - Martin Ssempa and Edward Green. The story of this divide illustrates the complexity of developing a workable AIDS policy when cultures clash.
Martin Ssempa is a Pentecostal pastor from Kampala and Dr. Edward Green is Director, AIDS Prevention Research Project at Harvard University. They worked together to craft AIDS prevention policy in 2004. At the request of the Uganda AIDS Commission, they and four others authored a paper detailing evidence for what worked in prevention and developed a plan for implementing those strategies in Uganda. In an email, Green explained,
In various forms, the ABC approach has been implemented in Uganda since the mid-1980s. By 2004, there were condom strategies but no fidelity strategies. Ssempa and I (and 4 others) just laid out the evidence of what worked and made plans to include some of that in a package of otherwise ineffective medical services masquerading as AIDS prevention.
Ssempa received a Masters of Arts degree in counseling from Philadelphia Biblical University and boasts on his website that he is "a passionate voice in the global fight against HIV/AIDS." His DVD on sexual abstinence is promoted by Wait Training, a Colorado-based abstinence education organization. However, he is actively campaigning for the Anti-Homosexuality Bill. Ssempa told me in an email, "I am in total support of the bill and would be most grateful if it did pass."
According to Harvard's Green, Ssempa's support for the bill and the ramifications to AIDS prevention and treatment efforts are deeply troubling. Green said, "The bill sounds dangerous and completely inhumane. As a practical matter, such a bill is unenforceable and would only drive homosexuality underground, terrorize gay men and women and their loved ones, and justify witch hunts."
AIDS workers on the ground in Uganda agree. In practice, such a law will create ethical conflicts for pastors, health care providers and educators, and heighten stigma for patients. Karen Moul, spokesperson for Catholic Relief Services, a major PEPFAR grantee, told me that if the bill becomes law, it could dramatically inhibit patients presenting for treatment and/or to discuss risky behavior of any kind. "It will only make it harder to get services. The stigma of AIDS is bad enough. Anything that increases stigma will make getting treatment harder. Patients may avoid coming in altogether," Ms. Moul said.
The bill directly contradicts the approach to primary prevention of AIDS advocated by Dr. Green. Writing in a professional journal, Green summarized the principles in working with stigmatized groups, saying,
Working with marginalized, high-risk groups in any meaningful way involves accessing such people, gaining their trust and developing some level of sympathy for their plight. These groups are often looked down upon, perhaps despised, perhaps more openly in the tradition bound and/or religious societies in the less developed world.
Somehow what seems obvious to Green and Moul is not registering with Ssempa and supporters of the bill. Despite the draconian restrictions and requirements, the bill seems likely to pass due to support from religious leaders like Martin Ssempa. Ssempa told me, "This bill seeks to put Africa and Uganda to be custodians of values and family knowledge as handed down from our fathers and our faith."
Policy makers in the US and elsewhere will need to confront this impulse. Adding D to ABC in Uganda will not reduce HIV/AIDS and may make matters worse. For the sake of human rights and a working AIDS policy, ABC is enough.
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