So much progress has been made in the effort to mitigate the spread of HIV/AIDS since the first World AIDS Day in 1988. Stigma surrounding the LGBTQ+ community has lessened across huge swaths of the world, harm-reduction strategies have helped lower rates of infection via intravenous drug use, and effective medication has become more affordable and accessible.
But we should be alarmed that many countries in the Middle East and North Africa, along with Russia, continue to see upticks in infection rates. Nor can we ignore that those same nations still criminalize LGBTQ+ people and same-sex relations, and adhere to draconian attitudes around drug use and sex work. As I write this, Qatar, which prohibits same-sex relations and has stifled dissent, is hosting millions of spectators from around the world for the 2022 World Cup. And just last month, Egypt was the backdrop for high-profile diplomatic gathering COP27, despite a recent detailing torture and abuse of LBTQ+ people at the hands of national police and security forces.
It’s in these places that gay, bisexual, and other men who have sex with men—as well as transgender people, drug users, and sex workers—are most likely to be driven underground, making it harder for health workers to reach them and for them to openly access diagnoses, treatment and care.
The situation is most dire in Africa, where only 22 of 54 African states have legalized homosexuality. In some countries it’s still punishable by imprisonment, while it is punishable by death in four—Mauritania, Nigeria (in states where sharia law is applied), Somalia, and South Sudan.
Yet, further south on the continent, Botswana has surfaced as an inspiring case study in what’s possible when a society moves closer to full equality for LGBTQ+ people. It was earlier this year that the landlocked nation of more than 2 million had become only the third country to surpass the UN’s 95-95-95 goals on HIV—meaning 95% of those living with HIV are aware of their status, 98% of those are receiving treatment, and 95% of cases are virally suppressed.
This remarkable achievement can be attributed to strong leadership and political commitment, a belief in accountability, and a strong health system. But just as vital has been Botswana’s support of civil society in the national response. Same-sex relationships were decriminalized in 2019, which has meant that key affected groups can more easily access care and are less likely to be scapegoated or considered unworthy of public health interventions.
Four decades of living with the HIV/AIDS pandemic has repeatedly reinforced that criminalization drives discrimination, which in turn foments stigma, which ultimately stifles creative and equitable solutions that improve the quality of life for all. We’ve seen it many times before: People living with diseases such as polio, leprosy, and tuberculosis have borne the same burden of stigma, making the eradication of those diseases all the more difficult. This is an especially bitter irony in places like India and Uganda, where laws against homosexuality and same-sex marriage were inherited from the former colonialist masters they’ve spent generations distinguishing themselves from.
However, change is possible. A study published in the journal BMJ Global Health shows that decriminalization of same-sex relations in Angola has helped stem the tide of HIV infections, and that decriminalization of sex work in the Northern Territory of Australia produced similar results. (Singapore’s November 2022 decision to repeal a ban on sex between male partners is promising, though it doesn’t yet extend to the legality of same-sex marriage.) In Europe, Portugal had more cases of HIV infections per capita than any other country on the continent at the beginning of this century. But its decision to decriminalize drug use two decades ago has been a huge contributor to why it now boasts the lowest rate of HIV and Hepatitis C infections in Europe. Switzerland tells a similar story over an even longer span of time.
These are good news stories amid plenty of bad ones. It’s our duty to shine a harsh light on whoever’s furthering misperceptions and stigmas about HIV/AIDS, LGBTQ+ people, drug users and others at risk of HIV, condemn them in the strongest terms, and work with governments to end criminalization of diseases and their risk factors so that everyone, everywhere, can be protected by strong, equitable public health systems.