StephanieMTopp_HighResStephanie M. Topp
Emerging Voice 2013
Research Associate and Health Systems Adviser.

The ICASA conference has been punctuated by various discussions about where the focus of national and international efforts should lie over the next few years, and in an era where the end of AIDS has been predicted, Africa is now facing a social and political tipping point.  For, in addition to continuing to scale up prevention and treatment to the millions of adults and children affected by the disease, there is a growing public health imperative to address the epidemiological drivers of the epidemic, so-called ‘key populations,’ including men who have sex with men (MSM), injecting drug users (IDU) and female and male sex workers.

Over the past 20 years, the nomenclature used to refer to MSM, IDU and sex workers has shifted from ‘high risk’ groups to ‘most as risk populations’ and now to the more politically correct ‘key populations’.  From a rights based perspective, the response to key populations in Africa has always been problematic.  Larger social and structural forces including the criminalization and stigmatization of same-sex relationships and sex work have resulted in systemic persecution and victimization, hindering access to badly needed psycho-social, preventive and treatment services.  In Monday’s plenary session Nigerian lawyer and activist Kene Esom pointed out that 35 Africa nations criminalise same sex relationships, effectively ‘driving HIV infection amongst MSM by making it impossible to reach out to those who are already vulnerable.  In prison settings where these legal provisions enable governments to deny inmates access to condoms the situation is tragically hypocritical as inmates are subsequently allowed to access anti-retroviral treatment (at least nominally) once infected.

 Nonetheless, as Hon. Prof James McINntrye of Anova Health Institute pointed out in a session on interventions relating to MSM, an enabling legal environment does not necessarily translate into a secure service environment.  To achieve this requires not only a sympathetic constitutional and legislative framework, but an enabling social environment, including social and workplace norms that produce non-discriminatory service delivery.  In South Africa, despite a protective constitutional framework, key populations continue to experience high levels of community and service-based victimization.  Key populations’ access to information about, and services for, HIV and related issues (recognized to be essential pillars in any public health and risk-reduction strategy) thus remain elusive.  Where the constitutional guarantees found in South Africa are absent, such experiences are only heightened.

Key populations have an immutable right to non-stigmatising, non-discriminating, competent services, and, in this second decade of the 21st century, the emerging public health imperative associated with a comprehensive response to HIV seems likely to bolster this case.  Dr Andrew Tucker from Cambridge University and Anova Health Institute, presented findings from a model demonstrating how experiences of homophobia contributed to depression and low self-efficacy amongst gay men in townships in Western Cape, South Africa.  Critically, the study demonstrated the way depression and low self-efficacy increased the likelihood of gay men engaging in (highly risky) unprotected anal sex, as they sought to overcome feelings of isolation and loneliness and rejection.  The public health implications of such findings for a continent where MSM amongst others experience systemic legal, political and religious discrimination and social stigma, are significant.

In his closing address to the conference Executive Director of the Global Fund Mark Dybul identified the need for ‘openness to human dignity…respect for everyone no matter who you are…and promoting and advancing the human spirit’.  This, having already noted the ‘end [of] an era of paternalism and …[the need for] shared responsibility and mutual accountability’.  Perhaps more significantly, the First Lady of Zambia, Christine Kaseeba-Sata also appealed for an end to discrimination based on sexual orientation and made an open commitment that in matters of public health issues, the gay community had the support of her husband, Zambian President Michael Sata.

Statements such as these signal growing recognition of, and willingness to engage with a HIV response inclusive of key populations.   Notwithstanding such rhetoric, in the near and mid-term future same-sex relationships and sex work are likely to remain illegal in Zambia and a majority of the other high-burden sub-Saharan African countries.  Given this reality, who will ‘share the responsibility’ of shifting prevailing social and cultural norms that continue to act as both direct and indirect barriers to promoting safer and healthier expressions of sexuality that could prevent new HIV infections?  And who will hold governments, health providers and communities to account, for the laws and norms that are currently impeding both a rights-based and comprehensive public health oriented response to HIV on this continent?  

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