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Harsh laws continue to undermine the fight against HIV worldwide

Kenyan gays and lesbians and others supporting their cause wear masks to preserve their anonymity as they stage a rare protest, against Uganda's increasingly tough stance against homosexuality outside the Uganda High Commission in Nairobi, Kenya. (AP Photo/Ben Curtis, File)

With rates of HIV that are substantially higher than in the general population, men who have sex with men (MSM), sex workers and intravenous drug users are a key focus of the fight against HIV. Around the world, however, repressive laws continue to push these individuals into the shadows and deprive them of preventive care and treatment for the disease.

One year after a widely criticized anti-gay bill was struck down by the courts, politicians in Uganda announced plans to introduce a new anti-gay law before the end of the year. According to Al Jazeera, the new law punishes the promotion of homosexuality with up to seven years in prison.

Other sub-Saharan African countries also criminalize homosexuality, many of which are a legacy of British rule (see map below). In January 2014, Nigeria imposed an even harsher law sentencing same sex couples to 14 years behind bars. More extreme examples include Sudan, Mauritania, Saudi Arabia and Yemen, where homosexuality is punishable by death.

Criminalization of same-sex sexual activities, 2014

Source: UNAIDS

Source: UNAIDS

Laws criminalizing homosexuality can deter lesbian, gay, bisexual and transgender (LGBT) people from seeking health care, and contribute to the spread of HIV worldwide by discouraging testing, seeking access to treatment (which reduces viral load and can prevent HIV transmission) and disclosure to partners.

A study of MSM in Botswana, Namibia and Malawi, three countries where homosexuality is illegal, found that MSM who had experienced discrimination, such as being denied health care or being blackmailed, were more likely to be afraid to seek medical care. In the study, 21 percent of MSM reported being blackmailed while 5 percent had been denied health care services. Even if MSM do not disclose their sexual orientation to health care providers, certain types of sexually transmitted infections can make health workers suspicious.

Laws prohibiting sex work also undermine efforts to prevent transmission of HIV and can make it harder for sex workers to insist that their clients wear condoms. The map below from UNAIDS identifies the countries where sex work is illegal.

According to research conducted by the Sex Workers’ Rights Advocacy Network in Central and Eastern Europe and Central Asia, police often use possession of condoms as grounds to arrest suspects, which make sex workers fearful of carrying them on the job.

A qualitative study of sex workers in Serbia, where sex work is illegal, found that they frequently reported being raped by police to avoid arrest or fines. Summarizing existing scientific literature, a 2012 study by Johns Hopkins’ Dr. Stefan Baral noted that community empowerment of sex workers, ensuring their safety, and condom promotion and provision can reduce the risk of HIV infection in these groups.

Legality of sex work, 2014


Similar to sex workers being targeted by police for carrying condoms, police often arrest people for carrying syringes in countries where drug use is prohibited, effectively blocking an essential tool for preventing transmission of HIV. A report by the Global Commission on HIV and the Law at the United Nations Development Program describes how two cities in Scotland in the 1980s had starkly different policies governing the purchase and possession of syringes. In Edinburgh, it was illegal to buy and possess syringes without a prescription, but Glasgow allowed purchase and possession without a prescription. HIV prevalence among intravenous drug users was greater than 50 percent in Edinburgh, but was between 1 percent and 2 percent in Glasgow.

A previous Humanosphere post examining the toll of illicit drug use discussed how intravenous drug use is the most important contributor to the HIV epidemic in Russia. The Russian government places heavy restrictions on needle exchanges and prohibits opioid substitution treatment, and HIV death rates continue to rise.

Despite the persistence of laws criminalizing homosexuality, sex work and drug use, there are signs of progress. Peru abolished laws and policies that punished LGBT populations and has invested in outreach to MSM, but social stigma against these groups remains a challenge. The Cambodian government recently recognized the labor rights of entertainment workers, which includes people working in settings such as massage parlors, discotheques and hotels. Previously, Malaysia and Indonesia would imprison drug users and subject them to involuntary treatment, but the two nations recently embraced a community-based, voluntary-treatment model.

Increased investment in HIV prevention and treatment is vital to further reduce death and suffering from the disease, but legal reforms are essential to ensure that vulnerable groups can access these services.

Katie Leach-Kemon is a regular contributor to Humanosphere, usually in connection with her work (see below). This post was submitted as an independent and freelance contribution as Katie is now on maternity leave.  



About Author

Katie Leach-Kemon

Katherine (Katie) Leach-Kemon is a policy translation specialist at the Institute for Health Metrics and Evaluation (IHME). Katie specializes in two of IHME's research areas, the Global Burden of Disease and health financing. Katie has helped produce IHME's Financing Global Health report since it was first published in 2009. She received an MPH from the University of Washington and served as a Peace Corps volunteer in Niger. Her work has been published in The Lancet, Health Affairs, and the Journal of the American Medical Association. You can follow her on Twitter @kleachkemon.