There has been appropriate moral condemnation of Uganda's proposed anti-gay law that originally included the death penalty. Evangelical uber Pastor Rick Warren led the way with a moving and powerful video directed to clergy in Uganda, followed by the Holy See, conservative Senator Tom Coburn and the Obama Administration. It is good to see ecumenism and bipartisanship. But in addition to the clear human rights issues, there are important public health principles at stake - as the current US Global AIDS Coordinator, Ambassador Eric Goosby, has rightly noted.
Gay men and women cannot be legislated out of existence. The practical impact of the law will be to undermine Uganda's efforts to combat its HIV epidemic. That would be a tragedy in any country, but perhaps more so in a place with a record of leadership and success on HIV prevention. UNAIDS launched a "know your epidemic" campaign a few years back. It makes great sense - if there is insufficient knowledge about the drivers of the spread of HIV in a country, or areas of a country, it is impossible to dedicate resources to the programs that are most likely to be effective. Recently, Ugandan officials have embraced that approach regarding discordant couples - where one person in a relationship is HIV positive and another is negative - because data show that transmission in such pairs was contributing significantly to the spread of HIV in their country.
What is unknown in Uganda, and much of Africa, is the contribution of men who have sex with men (MSM) to HIV transmission. While it is commonplace for officials to say MSM does not contribute significantly to HIV in Africa, the fact is that we do not know. The US President's Emergency Plan for AIDS Relief began to support MSM surveys in several African countries during the Bush Administration. Progress was slow and difficult due to cultural issues, which must be understood and respected to effectively move forward. The Ugandan law requires anyone who is aware of the homosexuality of any person to report them to authorities. Rick Warren was right to note that the requirement would make pastors policemen. But it also prevents public health officials from assessing the factors driving the spread of HIV. Without adequate knowledge of the drivers of the epidemic, it is not possible to effectively plan and implement programs to combat it.
In a related way, outlawing gay people, especially in such a draconian way, simply drives them underground where they cannot or will not access prevention, care and treatment services. Public health officials would not only be handicapped from effectively directing programs, the law would directly contribute to the spread of HIV and lead to increased sickness and death. That would counter the laudable gains Uganda has made in prevention and more recent advances in expanding treatment and care. Even if MSM do not currently contribute significantly to the HIV epidemic, if they are pushed away from services that could quickly change. This is a lesson learned the hard way in the US. While the epidemic has been stable or declining in previously high-risk populations, there has been an explosion in the inner cities and among African Americans, in particular women, who are often beyond the reach of prevention and care programs. For these reasons, President Bush talked about the need to deal with HIV in inner cities and prisons in a State of the Union Address and President Obama is developing a national HIV strategy.
Which brings us to the final point - stigma and discrimination are rarely good for public health. In addition to driving away people in need and at risk of spreading infection, stigma and discrimination cause others genuinely at risk to believe they are safe and need not act to protect themselves. And by ghettoizing a disease among what are considered marginalized populations, it lightens the pressure on policymakers to act quickly. We saw this phenomenon in the early days of HIV in the US, and we are seeing it today in Eastern Europe and parts of Asia.
Stigma and discrimination have in no small part fueled the HIV pandemic at the level of person-to-person interaction and at the highest levels of policymaking. It is also just wrong. For these reasons, President Bush directed his team to work to do away with one of the vestiges in the US - the unnecessary restrictions and bureaucratic hurdles for HIV-positive people to enter the US: a process that President Obama completed.
Sadly, Uganda is not the only country considering stigmatizing and discriminatory laws. Opposition to such measures pulls together a unique confluence of conservatives and liberals, people of deep religious faith and those more secular in outlook and principles of human rights and good public health. Seems like something worth standing up for.