Sexual transmission of HIV

While running a legal clinic for refugees 10 years ago, Kene Esom, former Director of African Men for Sexual Health and Rights (AMSHeR), saw how difficult it was for marginalized or vulnerable people to access health-care services. “That is where I realized that as a lawyer and a human rights defender, I could play a role in increasing access to health-care services and defending human rights.” In his more recent role as Strategic Initiatives Adviser to the AMSHeR Board, he is still at the forefront against discrimination, especially discrimination against gay men and other men who have sex with men in Africa.

Mr Esom makes it clear that when he is talking about human rights in the context of HIV, it is not just the right to health that matters. “There is a pattern of human rights violations towards gay men in many countries, owing particularly to the criminalization of consensual same-sex conduct,” said Mr Esom. “For example, when a newspaper decided to publish a sensational story about gay men having a party, the men were arrested. detained and forcibly tested for HIV. All their due process rights were violated and their right to privacy breached to the extent that their names, addresses and pictures were published in the newspaper.”

Mr Esom said that incidents such as this can roll back years of progress in providing HIV services for key populations. “You cannot provide health services without taking into consideration the human rights context of the populations you are providing the services for. You can build the best health-care facility, but gay men will not come to that facility if they are worried that police will arrest them or that doctors will report their sexual behavior.”

Globally, gay men and other men who have sex with men are 24 times more likely to acquire HIV than adults in the general population. Stigma, discrimination, violence and the criminalization of same-sex sexual practices make it more difficult for these men to access HIV prevention, testing and treatment services.

AMSHeR supports human rights organizations to undertake evidence-informed advocacy. “Human rights defenders play a key role in bringing these issues to light and showing the impact that human rights violations can have on HIV responses, especially on services targeting key populations,” said Mr Esom.

Although there is still a lot of silence around issues surrounding sexuality, sexual orientation and gender identity, there is hope. “When I started this work six years ago it was a completely different context. There were very few people who wanted to advocate on these issues. Now, we have a greater pool of people in countries all over Africa and the world, and the communities are standing up for their rights and demanding access to services and a rights-based approach to service delivery.”

In its work, AMSHeR emphasizes the role of communities in advocating for change and speaking directly to policy-makers. “They are the voices and faces of the issues that affect them.”

The right to come together is key. “Many gay men think they are alone. Isolation increases their vulnerability. Bringing people together to discuss their issues creates a community that is empowered to speak up. If that space is not there, engaging policy-makers and service providers becomes more challenging.”

Mr Esom will be speaking about the promotion and protection of human rights in the context of HIV and other communicable disease at the Human Rights Council Social Forum, which is being held from 2 to 4 October. To hear more from Mr Esom and other human rights activists, register to participate at the Human Rights Council Social Forum at https://reg.unog.ch/event/6958/.

Although new HIV infections and AIDS deaths among young people have decreased, in many places knowledge about how to prevent HIV remains worryingly low. Ahead of International Youth Day UNAIDS spoke to four young people about the challenges they face around HIV.

Pavel Gunaev is 16 years old and lives in St. Petersburg, where he is part of the youth-led network of adolescents and young people living with HIV Teenergizer! Pavel said that in his city young people are not aware about HIV.

“AIDS isn't talked about so young people don’t know about the risks or how to protect themselves from HIV,” he said. “As a result, so many uninformed young people are acting and making decisions based on rumors.” Pavel believes that if everyone does more to inform adolescents and young people and dispel the myths around HIV, ending AIDS will be possible.

Chinmay Modi was born with HIV twenty-three years ago. He is a member of the National Coalition of People Living with HIV in India and country focal point for the Youth LEAD Asia Pacific Network.

“The biggest problem is raising awareness and giving young people age-appropriate information,” he said. In his view, parents are not comfortable talking with their children about sex and society shies away from it too. As a result, he explained, young people are engaging in sex and experimenting new things but with little knowledge of the risks involved.

“Condoms need to be promoted and partners should support youth empowerment so that everyone is held accountable,” Chinmay said. He is also frustrated because in India people cannot access stigma-free HIV services at an early age.

In his view, self-stigma is hampering efforts to tackle discrimination, violence and inequalities related to HIV. That’s why, he explained, he wants more people to share their stories and be positive about being positive.

Moises Maciel couldn’t agree more with Chinmay. He is a 20-year-old LGBT and HIV activist. He became a  member of the National Network of Adolescents and Youth Living with HIV/AIDS in Brazil after discovering his positive HIV status two years ago. Since then, he has been on a journey against HIV-related stigma. He has also been motivating his peers to get tested.

“Young people are still at great risk of HIV infection due to a variety of factors such as social marginalization related to gender and racial inequalities,” he said. “In Brazil, young transgender and gay people are particularly targeted,” he explained.

He said that it baffles him to see how stigma and prejudice still dominate despite people living with HIV living healthy lives with the help of antiretroviral therapy. “We should start talking to young people in an open and responsible way about sexuality, sexually transmitted infections, teenage pregnancy and life responsibilities,” Moises said.

Lorraine Anyango, a Boston-based youth health and rights advocate, works to ensure that young people's voices, specifically around HIV, get heard.

“Young people continue to be left out of spaces and discussions on issues that impact their lives,” Lorraine said. “Their autonomy as individual human beings continues to go unacknowledged, leaving them susceptible to the risk of HIV infection.”

In her opinion, young people’s participation in decisions that affect their health can contribute to strengthen national-level accountability, by ensuring that programmes are effectively responding to their needs. Lorraine concluded by saying, “Recognizing youth sexual and reproductive health and rights, and continuing the conversation on HIV will get us closer to ending AIDS by 2030.”

The 2030 Agenda for Sustainable Development takes ​to scale ​what the AIDS response has been working towards for 30 years—a multisectoral, rights-based, people-centred approach that addresses the determinants of health and well-being. The individual stories in this series highlight the linkages between HIV and related Sustainable Development Goals (SDGs), each told from the personal perspective of people affected by HIV. The series paints a picture of how interconnected HIV is with the SDGs and how interdependent the SDGs are with each other. Most importantly, the stories show us the progress we have achieved with the AIDS response and how far we have left to go with the SDGs.  

Klinika Bernardo, popularly known as the Sundown Clinic, is located along a bustling highway. It operates from 15:00 until 23:00, allowing a maximum number of clients to visit. “We cater to men who have sex with men from all over the Philippines,” said Leonel John Ruiz, head physician at Klinika Bernardo. “Only 40% of our clients are from Quezon City.”

In 2012, Quezon City became the first city in the Philippines to open a clinic providing services for men who have sex with men and transgender people. From the start, demand for services at the Sundown Clinic was high. Almost 250 HIV tests and pre- and post-test counselling services were carried out in its first two months of operation, and 18 people tested positive for HIV.

Although same-sex relationships are legal in the Philippines, there is a high degree of stigma and discrimination towards men who have sex with men. Fear of being outed and ostracized prevents many men from accessing traditional health services. Studies by city health officials show that two-thirds of men who have sex with men in Quezon City have never had an HIV test.

“This is my first HIV test. I do not know what to expect,” said one young man while filling out registration forms. “I tried to read up on HIV so I would have some background information, but it took me a while to gather the courage to come here.” The young man found the staff supportive and skilled at calming his nerves. People who test positive for HIV receive counselling on antiretroviral medicines and are accompanied by staff through their initial months of HIV treatment, which is free in the Philippines.

Quezon City now operates three Sundown Clinics and in the past few years has significantly increased investments in its HIV programmes. With nearly 3 million residents, Quezon City is the Philippines’ most populous urban centre and has made stopping a burgeoning AIDS epidemic a top priority. Mayor Herbert Bautista has encouraged city residents to know their HIV status, and he has taken an HIV test in public. The city’s effort to scale up HIV testing among men who have sex with men has proven successful, with such tests increasing 30 times. Forty per cent of the city’s HIV tests take place in Sundown Clinics, effectively proving that removing barriers increases access to services.

“Since we have been operating, the perspective has definitely changed,” says Leonel. “Before, we would have a hard time inviting people for testing. Now, most of our clients are walk-ins. People are personally and actively seeking information.” Several other local city governments are starting to adapt the Quezon City model and establish their own clinics.

The Sundown Clinic staff speak proudly of their achievements, but they look forward to closing shop one day. “I pray before sleeping,” says Adel, the only female peer educator at Klinika Bernardo. “I hope that one day there will be no one in need of our services. That’s what I am working for.”

SDG 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development

Early in the AIDS response, in the absence of treatment options and the overwhelming scale of people affected by HIV, it was clear that a purely clinical response to the epidemic was not sufficient. Relatives, faith-based organizations and alliances of people affected by HIV stepped in to do what they could to help people die with dignity, to support the orphans, spouses and dependants left behind and to fight for a new way of doing things. Groups of vastly different people linked by the shared experience of the fear and stigma and horror of HIV and AIDS came together to demand that the response go beyond clinics, hospitals and the formal health service.

Embracing and expanding the concept of partnership was revolutionary, not for AIDS but also in the broader development sphere. Partnerships continue to be central to the AIDS response. Coordination and collaboration across a wide range of partners, including sex workers, scientists and social workers, helps to identify and use expertise more effectively, overcome barriers more quickly and allocate resources more efficiently. Partnerships increase awareness and knowledge and create a critical mass of power and support that help to influence policy-makers and spur stakeholders to take action.

The story of the Sundown Clinic in Quezon City in the Philippines embodies SDG 17—strengthen the means of implementation and revitalize the global partnership for sustainable development. The success of the original clinic and the subsequent addition of two more clinics demonstrate how inclusivity continues to define the AIDS response and provide the inspiration for successful partnerships between a wide diversity of stakeholders.

In the lead-up to IDAHOT (the International Day against Homophobia, Transphobia and Biphobia) 2017, UNAIDS spoke with Kene Esom, the Executive Director of AMSHeR. AMSHeR promotes non-discrimination, particularly discrimination based on sexual orientation and gender identity, and advocates for access to quality health services for lesbian, gay, bisexual and transgender people in Africa.

Question: Tell us about the changes across the African continent since AMSHeR started nine years ago

AMSHeR was established to address discrimination and human rights violations based on sexual orientation and gender identity, the disproportionate vulnerability to HIV of men who have sex with men and the policy and social barriers that hinder access to services for lesbian, gay, bisexual and transgender (LGBT) people in Africa.

African LGBT people are bringing the issues of sexual orientation, gender identity and human rights into regional and global policy and legal spaces and are making the African LGBT experience the basis of policy, service delivery and funding decisions on Africa.

Never before has there been more visibility and interest in LGBT issues and understanding of the experience and needs of African LGBT people and effective representation of African LGBT communities in the global discourse. This is largely because of AMSHeR’s courageous mandate to make African LGBT people the faces and voices of inclusion in Africa and by so doing put LGBT inclusion on the agenda of African states and policy-makers as well as human rights and social justice movements.

Question: What made you focus your recent campaign on engaging with faith leaders?

It is widely accepted that religion and religious leaders have a great influence on political leaders and in African society. The widespread intolerance, discrimination and violence against people based on their real or perceived sexual orientation, gender identity and expression, and lack of access to health services, may be attributed to a highly religious environment that has normalized heterosexuality and patriarchy while demonizing sexual diversity.

Religion-inspired discrimination is very rife, particularly in Africa. The experiences of African LGBT people have been varied, from torture and inhumane treatment in the form of exorcism and conversion therapy, to mob violence incited by religious leaders from the pulpits, to the experiences of religious leaders sitting on national health agencies blocking attempts to provide health and rights services to LGBT people, to religious leaders actively sponsoring discriminatory legislation. 

Religious leaders, because of their respected positions in society, are critical in addressing issues of stigma and discrimination as well as upholding the rights of all people regardless of sexual orientation, and, even more importantly, have emerged as strategically placed in discourses on HIV, sexuality and spirituality.

AMSHeR appreciates the role that religious leaders play, but at times they perpetuate discrimination based on sexual orientation and gender identity, and that is why, since 2015, under our Integrating Spirituality and Sexuality project, we have been working with religious leaders and LGBT people of faith to address these issues.

We have partnered with leaders of faith-based communities to initiate dialogue between institutions and LGBT communities in order to find common ground to integrate spirituality and sexuality. This has been done following lessons learned on how faith-based organizations have been integral in advocating for non-discrimination and stigma against people living with HIV. Faith-based organizations have proved to be allies to many civil society organizations in pushing for non-discrimination and stigma against people living with HIV.

As part of its work, AMSHeR has released a documentary, Queer Voices of Faith, for IDAHOT 2017.

Question: You are a Nigerian working in South Africa for a pan-African organization. What motivates you?

Whether in Nigeria, South Africa, Mozambique or Morocco, I am amazed at the remarkable kindred spirit that connects African societies. I consider myself a pan-Africanist, I believe there is more that connects us than otherwise, despite our diversities, and I celebrate Africa’s diversity and the values that unite us.

AMSHeR has been a perfect vehicle to express my pan-African ideals and promote the quest for social justice across Africa.

Question: What do you see as the future on the continent for LGBT people?

The future of LGBT people in Africa is to strengthen the movement that is now under way in which LGBT people, their leaders and other advocates are steadily seeking to realize their fundamental human rights, including the rights to equality and non‐discrimination, the highest attainable standard of health, freedom of expression, freedom of association and assembly, freedom from unlawful arrest and detention and equal access to justice.

I see a future and it is a bright one. A lot has changed since 2009, when AMSHeR came into operation. We have taken and continue to take incremental steps towards achieving the full inclusion of African LGBT people as equal citizens of Africa. The tide is flowing in one direction and it is in the right direction.

Question: This year’s theme for IDAHOT is family. What does family mean to you?

Family is a bond of love as opposed to biology and all families, in whatever shape or form, should be afforded the same protection and recognition from a legal and ideological perspective. Africa is replete with different expressions of family and we celebrate the role that families play in shaping society. It is also imperative to acknowledge that it is through families that we can reframe respect for diversity and unlearn the prejudice that is at the root of the discrimination that LGBT people face today.

The Martin Ennals Foundation has announced the names of the three finalists for the prestigious global Martin Ennals Award for human rights defenders, which will be awarded in October 2017. One of the three finalists is Karla Avelar, a transgender woman living with HIV from El Salvador who, for more than 20 years, has been defending the human rights of lesbian, gay, bisexual, transgender and intersex (LGBTI) people and advocating for access to health care for people living with HIV.

In 1996, Ms Avelar was one of the founders of the first association of transgender people in El Salvador, and in 2008 she founded the first organization of transgender women living with HIV, COMCAVIS TRANS. The organization works to advance, defend and promote the human rights of LGBTI people, scale up HIV prevention and care and improve access to HIV services for people living with HIV and prisoners.

"On a daily basis, lesbian, gay, bisexual, transgender and intersex people are exposed to death threats, extortion, harassment, physical and verbal violence and discrimination because of our gender identity or sexual orientation,” said Ms Avelar. “This situation makes us vulnerable to HIV."

Ms Avelar, together with COMCAVIS TRANS peer educators, promotes HIV testing and HIV prevention and care among the LGBTI people through outreach activities, such as education and information dissemination in different parts of San Salvador.

Ms Avelar and her team also work on strengthening access to HIV prevention and treatment services for LGBTI prisoners in two penitentiary centres. “We are working on two fronts: with lesbian, gay, bisexual, transgender and intersex people, training them on sexual and reproductive health and HIV prevention, and raising awareness among administrative officials and custodial staff on human rights and zero discrimination,” explained Ms Avelar.

In 2013, the partnership between COMCAVIS TRANS and the penitentiary center of SENSUNTEPEQUE led to the adoption of an agreement, which allows prisoners to have access to condoms each month. COMCAVIS TRANS also supports LGBTI prisoners living with HIV to adhere to their treatment and monitors their access in order to ensure their psychosocial and emotional well-being. 

In El Salvador, LGBTI people continue facing a climate of discrimination and violence, exacerbated by high levels of impunity and limited access to justice. “El Salvador is a country with one of the highest rates of violence in Latin America and, as it is the case throughout the region, the life expectancy of a transgender woman does not exceed 35 years,” said Ms Avelar.

She supports LGBTI people who have suffered human rights violations and acts of violence. Together with her team and the group of volunteers, she advises them and accompanies them to file a complaint. Thanks to the collaboration of other organizations, she makes sure that people in need have open channels to legal and economic assistance. “There are still a lot of barriers,” she says. “However, we are promoting a dialogue with representatives of the national civil police and Office of the National Counsel for the Defense of Human Rights and other authorities to improve the mechanisms to denounce and investigate human rights violations and provide proper and sustained monitoring and evaluation.”

Ms Avelar has also played a significant role advocating for legislation reforms to protect and promote the rights of LGBTI people and address their needs. For example, together with UNAIDS and other national organizations, she participated in a review of an HIV law approved last January. Among other things, the law allows transgender people to receive a better health care free of stigma and discrimination, improve their quality of life and access to health services, education and work, ensuring the respect to their gender identity.

“For all those who know her, Karla Avelar is already the winner of the Martin Ennals Award,” said Celina Miranda, UNAIDS Country Director for El Salvador. “In the midst of all adversity, she is a tireless advocate for human rights, making a difference in the lives of lesbian, gay, bisexual, transgender and intersex people in El Salvador.”

About the Martin Ennals Award

The Martin Ennals Award is an annual prize for human rights defenders. Finalists and the laureate are selected by a jury of 10 of the world’s leading human rights nongovernmental organizations.

UNAIDS is working with partners to reaffirm that the full enjoyment of all human rights and fundamental freedoms for all supports the global response to the AIDS epidemic, including in the areas of prevention, treatment, care and support, and address stigma and discrimination against all people living with, presumed to be living with, at risk of and affected by HIV as a critical element in ending the AIDS epidemic and as outlined in the 2016 United Nations Political Declaration on ending AIDS.