Antigay Laws Already Having a Negative Effect on Health

Pam Harrison

July 30, 2014

MELBOURNE, Australia — The widespread criminalization of same-sex behavior has negative consequences on groups at high risk for HIV, including men who have sex with men, new research shows.

"Some 76 countries criminalize consensual sex between men," said Glen Milos Santos, PhD, a research scientist at the University of California, San Francisco, during a news conference here at the 20th International AIDS Conference.

Dr. Santos and colleagues analyzed data from a 2012 online global survey of 4020 men who have sex with men to assess the effect of arrest or conviction for same-sex behavior.

Strikingly, "1 in 12 men in our sample reported being arrested or convicted for same-sex behavior," Dr. Santos reported.

The prevalence of arrests and convictions for same-sex behavior varied by region. Sub-Saharan Africa had the highest prevalence, at 24%, followed by Central Asia and Europe, at 18%, the Caribbean, at 15%, and the Middle East and North Africa, at 13%.

Importantly, arrest or conviction for same-sex behavior significantly impaired access to a variety of HIV prevention interventions for men, Dr. Santos noted.

Specifically, rates of access to testing and treatment for sexually transmitted infection, condoms, HIV testing, and mental health services were about 20% lower for men who had been arrested or convicted than for those who had not. And rates of access to medical care services were about 30% lower with an arrest or conviction.

For HIV-infected men with an arrest or conviction, access to HIV treatment was about half that of other HIV-positive men.

"Enforcement of punitive laws for sex between men has a strong negative impact on access to HIV prevention and care services," Dr. Santos concluded. "Criminalization of same-sex behavior needs to be overturned to effectively address HIV and respond to the public health needs of this population."

Nigerian Law

The effect of a law criminalizing same-sex behavior in Nigeria was evaluated by Sheree Schwartz, PhD, from the Johns Hopkins School of Public Health, in Baltimore, Maryland, and colleagues. The law also criminalizes same-sex relationships and the promotion of homosexuality by community-based organizations that support programs for men who have sex with men.

Since the law went into effect in January, fear of accessing healthcare services has increased by about 10% to 15%.

"Obviously, that's a huge concern because access to healthcare is critical to help achieve HIV prevention," Dr. Schwartz observed.

Men who were afraid to talk to a healthcare provider about their same-sex behavior were also less likely to be virologically suppressed at baseline. In addition, they were less likely to initiate antiretroviral therapy during the longitudinal follow-up.

"We see already that the law has had an impact in terms of accessing services, but it has also created an environment in which people who are not comfortable talking to their healthcare providers have poorer health outcomes," Dr. Schwartz concluded.

A program that offers HIV treatment as prevention, also in Nigeria, is being run out of a trusted community venue by the International Centre for Advocacy on Rights to Health, in partnership with the Institute of Human Virology and the Johns Hopkins University Bloomberg School of Public Health.

From March to December 2013, 572 MSM participated in the treatment-as-prevention study, which is an average of 63 men a month, reported Ifeanyi Orazulike, who is national coordinator of sexual minorities against AIDS in Nigeria.

In a month after the enactment of the law, an average of only 15 men participated in the study.

Of 115 men interviewed by the organization, virtually all indicated that they were no longer interested in engaging in HIV intervention programs because of the new law.

The main reasons men cited for their decline in interest were fear of persecution, extortion, and blackmail.

Discrimination in the United States

In the United States, the South has more people living with and dying from HIV and AIDS than any other region, said by Megan McLemore, a senior researcher at Human Rights Watch.

She reported factors contributing to the preponderance of HIV-related morbidity and mortality in the South. In one instance, she explained, police in New Orleans, Louisiana regularly confiscate condoms carried by sex workers, putting them and their clients at risk for HIV.

According to a 2013 report published by Human Rights Watch, New Orleans has only 1 public syringe exchange program that receives no government funding and is open for only 2 hours a week.

"Because state criminal law prohibits possession of syringes for nonmedical use, the exchange operates under a cloud of legal uncertainty," she explained. Volunteers from small underground exchanges risk arrest to deliver clean needles to people who need them.

"Generally, there is good news about the HIV epidemic — deaths are down, new infections are down, and more people are receiving antiretrovirals," McLemore reported at the news conference.

"But we are facing a situation where biomedical advances are outpacing human rights reforms, and HIV infection remains stubbornly high among men who have sex with men, sex workers, transgender persons, prisoners, and people who inject drugs," she noted.

This is not a coincidence, she said. Stigma and discrimination are the direct and indirect results of laws and policies that promote criminal laws that target high-risk groups.

"The Human Rights Watch message today is that behind stigma and discrimination are laws and policies that need to be changed," McLemore explained.

"The evidence is clear that the HIV epidemic will not end until we protect and restore human rights," she added.

The impact antigay laws and policies have on public health parameters, such as access to HIV testing and clinical services for the treatment of sexually transmitted diseases, have long been a concern, said Christopher Beyrer, MD, professor of epidemiology and international health at the Johns Hopkins Center for Global Health in Baltimore, who is president of the International AIDS Society.

"We now have quantitative measures and data to show, indeed, that these laws and policies do have a measurable negative impact on clinical outcomes," he told Medscape Medical News.

"If people are inhibited from getting treatment and viral loads are high, that's a clinical problem for the individual, but it's a transmission problem within these networks," Dr. Beyrer said. "We already know from many studies that a higher proportion of untreated people within these networks is a powerful driver of new infections.

"So these laws and policies now, in a very measurable way, aid and abet HIV transmission and acquisition and really are going to be a rising obstacle to controlling the epidemic."

Dr. Santos, Dr. Schwartz, Mr. Orazulike, and Ms. McLemore have disclosed no relevant financial relationships.

20th International AIDS Conference: Abstracts TUAD0201, TUAD0305LB, TUAD0204, and TUAD0202. Presented July 22, 2014.

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