It was early evening when he slouched into my office. Medium height, thin, brown, he had lost some weight recently. There was a nervousness to his eye, a lack of comfort intimating the visit was not to his liking.
Slight hesitation, then the plunge. He had been advised to take the HIV test. It had come back positive. The unvoiced fright in his face was palpable. HIV was a death diagnosis at the time. Drugs had just been discovered, but ours was one of the few clinics prescribing them. He would never be able to afford them.
But I was his doctor. We talked, for a long while, trying to ease his fear. We talked prevention, diet, exercise. We talked doctors, medicines. Then he dropped the bombshell.
He was gay. How would he protect his boyfriends?
His being homosexual didn't faze me. But, I didn't know the answer. What was safer sex for a gay man?
In Africa, what most of us know about homosexuality is that it's a political taboo. That had carried over into my medical education. I did all my training in Africa. I was used to wards filled with patients, male and female, dying of AIDS. I knew HIV was spread by sex. To me, it was a heterosexual disease. I'd never been taught or told much about prevention or treatment for men who had sex with men.
Now what I didn't know turned out to be an amazing ocean. Over the next few days, I taught myself about this significant area in HIV. I realized that most doctors never asked questions about anal sex. We assumed all our patients were straight.
In the next few weeks, I came up with a plan. I was fired up, but the next hurdle was a concrete wall. How does one tackle HIV and gay men in a country like Uganda?
Uganda is undergoing a crisis of homophobia. In the 1990s, the country had an effective HIV/AIDS prevention program. Broad-based partnerships and targeted public education campaigns meant that the number of people living with HIV actually declined dramatically. That's over. In this decade, ideology and prejudice shouldered aside science to drive Uganda's anti-AIDS campaign.
The US bears much of the blame. The US President's Emergency Program for AIDS Relief (PEPFAR) surrendered to homophobia and reinforced the invisibility of gay men. It preached "abstinence until marriage;" since gays can't marry, they were excluded from HIV outreach. The US Agency for International Development, responding to Congressional pressure, barred use of the term "men who have sex with men." In Uganda, these programs funded faith-based organizations -- many with no experience working on HIV prevention or treatment, many openly spreading hatred of lesbians and gay men.
Gay Ugandans struggled for visibility. After they held a news conference in 2007, preachers and parliamentarians demanded they be punished. Police arrested gays who protested the lack of inclusive HIV prevention programs at an international meeting in 2008.
In March, 2009, three Americans arrived, led by evangelist Scott Lively. They held a packed seminar, spoke at churches and rallies, lobbied parliament Their themes: homosexuals were a danger to Uganda. The 'Homosexual Agenda' would corrupt youth. Gays had lots of money, and backing from America and Europe.
The evangelists' well-funded junket led to months of hysterical witch hunts. Newspapers published lists of "homos." Accusations and counter-accusations flew.
Now, a member of Parliament of the ruling party has drafted a bill to deal with the "threat." The "Anti-Homosexuality Bill," introduced in Parliament in October, has a simple purpose: to wipe out homosexuality in Uganda.
If the proposed law passes, the effects will be devastating. Life in prison or the death penalty will be the punishment for gay sex. "Promotion of homosexuality" will be a crime. Giving out water-based lubricant for safer sex would be "promotion." Citizens are required to inform on friends or family members who are gay. If the bill had been law, I should have handed my gay patient over to the police within 24 hours of our consultation.
Another bill before parliament is supposed to prevent the spread of HIV. Under this one, as a doctor, I am supposed to tell a patient's wife or sexual partners if he has HIV. If it passes, people living with AIDS will fear the very doctors they need to trust.
My own efforts to work on HIV among gay men in Uganda ran up against pervasive ignorance and silence. When I asked members of Kampala's gay community what they knew about AIDS and how to prevent it, I found the most frightening myths. Meanwhile, Uganda's HIV service organizations were quite literally terrified of the subject. And the more I spoke out about gay men and HIV, the more I became a suspect.
In Uganda, our once-lauded AIDS programs are failing. They refuse to serve major vulnerable populations like gay men. Puritanism may make attractive politics, but it's deadly policy.
The US government, and US evangelicals, have a huge responsibility for the failure. The Bush administration promoted narrow-minded policies. Meanwhile, preachers imported their own American brand of hate into our borders.
The Obama administration has a chance to turn things around -- but it must act fast. It must press Uganda's government to bring science and human rights back into HIV prevention. Otherwise, my patient, and thousands like him, will die from the deadliest diseases: silence and fear.
Dr. Paul Semugoma is a Ugandan physician in private practice in Kampala. He has researched the prevalence of HIV/AIDS in vulnerable Ugandan communities.