On May 26, Ugandan President Yoweri Museveni signed the nation’s Anti-Homosexuality Act, also known as the AHA.
Uganda is far from the only nation to criminalize homosexuality — at least 62 other countries, most of them in Africa and the Middle East, also have anti-gay laws on the books. But Uganda’s regulation cracking down on LGBTQ existence is especially draconian. It outlaws same-sex sexual activity but also punishes others who merely tolerate the existence of queer people. According to the law, a person can be punished for even leasing property to a gay person.
This isn’t Uganda’s first attempt to pass such legislation: The nation has had laws forbidding “buggery” (anal sex between men) on the books since British colonial times. In 2009, prodded by support from extremist groups of American evangelical Christians, Uganda’s parliamentary body attempted to pass a law broadening punishable activities to include other forms of gay sex, as well as the “promotion of homosexuality.” Although that law failed, a similar one was passed in 2014. That law was later overturned by the nation’s constitutional court on a technicality; the current law is also being challenged before the court.
Regardless of whether the new law stands, damage has already been done. As Uganda’s government has deliberated over the law, there’s been an uptick in police and civilian harassment and violence against LGBTQ Ugandans, and terrified citizens are trying to flee the country.
When LGBTQ Ugandans suffered a wave of violence after the 2014 law passed, law enforcement set the tone — but ordinary civilians perpetrated much of the abuse, said Jennifer Leaning, a public health and human rights expert at Harvard’s François-Xavier Bagnoud Center for Health and Human Rights, during a public event on Monday. The same dynamic appears to be unfolding now.
But the law also poses threats to those outside the LGBTQ community, including the many Ugandans who support it. Stigmatizing identities has a domino effect on other people: “Everyone is affected when vulnerable people are pushed out of care,” said Asia Russell, executive director of Health GAP, an international HIV equity advocacy organization.
On the face of it, criminalizing homosexuality is immensely dehumanizing and damaging. But the destruction this law can cause runs much deeper, and could set Uganda back on a range of health metrics.
Here’s how that could look.
Uganda’s HIV progress is at risk
One big fear experts have about the AHA is that it will lead to rising rates of HIV and other sexually transmitted infections (STIs) among all Ugandans. HIV is already mired in stigma and misconceptions in the region, and the law will likely drive sexual activity, STI prevention efforts, and care-seeking for HIV and STIs underground.
“If you are worried about being accused of being gay, then you certainly are not going to come in for HIV testing,” said Matthew Kavanagh, a professor of global health at Georgetown University, “even if you’re a heterosexual man.”
In recent years, Uganda had been making steady progress on HIV. The nation was an early adopter of many of the preventive strategies that emerged in the days before HIV medications were available on the continent. Its government hospitals implemented services aimed at preventing transmission from mothers to children in 2000, and the country was a pioneer among African countries in offering HIV testing and education services to the general public. And in the years after HIV treatment rolled out in Uganda in 2004, the country implemented some relatively progressive HIV testing policies.
Between 2010 and 2021, the country’s new HIV infection rate decreased by 39 percent.
In Uganda, as in most of sub-Saharan Africa, most new HIV infections are in women — not in men who have sex with men, as in the US. In 2021, 65 percent of new HIV infections in Uganda were in women and girls, who are most likely to be infected through heterosexual sex, compared with only 19 percent in the US in 2019.
Still, many Ugandans associate HIV risk with gay sex, said Kavanagh. Therefore, merely engaging in HIV prevention, testing, and treatment efforts can implicate someone as being gay and lead to punishment.
Richard Lusimbo, a Ugandan LGBTQ rights activist who leads the Uganda Key Populations Consortium, said during Monday’s event that already, peer sex educators have been jailed for providing HIV preventive services. “All they did was carrying out promotion of health services and providing more information to their peers around condom use, around lubricants,” he said. “Having even lubricant becomes a risk.”
With the consequences so severe, it wouldn’t be a surprise if all people at risk avoided any kind of sexual health care, but especially HIV testing and care services. That poses an enormous threat to Uganda’s progress on HIV.
Already, the AHA has led to so much fear among many people living with HIV that some HIV/AIDS treatment centers in Uganda’s capital are nearly empty, and the HIV treatment medications they normally hand out to patients are piling up, according to reporting from Reuters.
Since the law’s passage, drop-in centers that offer HIV services to members of Uganda’s LGBTQ community have seen a 60 percent drop in service utilization, said Kenneth Mwehonge, who directs Uganda’s Coalition for Health Promotion and Social Development, during Monday’s event.
It’s very worrisome if people living with HIV aren’t getting the medications they need. Modern medical treatment for HIV is extraordinarily effective — it generally makes the virus undetectable, which allows people with HIV to live normal life spans and prevents them from transmitting the infection through sex. But untreated people are at high risk for progressive and life-threatening immune system problems, and are much more likely to transmit the disease through sexual activity.
If the trend of avoiding care persists, it means more HIV will go undiagnosed and untreated, and transmission will likely rise across all populations — not just among gay people.
The law threatens the trust at the heart of provider-patient relationships
By deputizing all of Ugandan society as reporters of homosexual activity, the AHA is likely to raise patient concerns about the safety of seeking medical care, especially if there’s a concern they could be suspected to be gay. That could lead people — LGBTQ and not — to avoid seeing medical providers for a whole range of diseases, both infectious and not.
Under a section of the AHA concerning “promotion of homosexuality,” people can be punished for contributing to the normalization of gay sex acts. Punishments in this case include fines and license revocation. Another section indicates all Ugandans have a “duty to report” those suspected of even intending to have gay sex. This section contains language that protects health care providers from violating confidentiality provisions by reporting a patient.
For these reasons, the law has been widely interpreted to mean that health care providers must call the police on any patient they believe to be gay.
“When you look at the act, it’s very broad and very vague when it talks about promotion,” said Lusimbo, during Monday’s event. “So does providing a service to an LGBTI person qualify as promotion?”
The implication that it does is creating a lot of hesitation among providers who “do not want to be associated or be seen as people who are promoting or engaging in amplifying the voices of the LGBT community,” he said.
When trust in health providers breaks down, it can be lethal to a community’s health, said Kavanagh. “What we know — whether it’s HIV, or Covid, or [mpox], or Ebola — is that trust between the health sector and the population is perhaps the most critical tool in ensuring that the people who are experiencing the highest rates of transmission get diagnosed, get treatments, get a vaccine,” he said. “And what this law is requiring is that health workers actively break that trust. And that is very, very dangerous for public health.”
Indeed, Uganda’s recent success at containing an Ebola outbreak with relative speed relied on community members’ trust in traditional healers, community health workers, and conventional medicine practitioners. Under the AHA, a person with Ebola symptoms might hypothetically avoid seeking care out of fear they’d be suspected of homosexuality because their symptoms resembled acute HIV infection. It’s not only LGBTQ people who would suffer under those circumstances.
Critical foreign aid supporting Uganda’s health and other infrastructure may be withdrawn or redirected
Foreign aid is critical for supporting Uganda’s health system, and important for other parts of its infrastructure — and donors might be pulling back some of that aid now that the AHA has passed. That could result in weaknesses in health care and other systems that harm the whole of Ugandan society.
Uganda is one of the top recipients of foreign aid globally. Aid from foreign governments generally comprises between 6 and 8 percent of the nation’s gross national income, and thousands of nonprofit organizations also operate within the country.
Over the last few months, as Uganda’s political bodies considered the latest version of the AHA in earnest, countries and organizations have begun reconsidering their relationship and their assistance to the country. The World Bank and the United States Agency for International Development are reevaluating their work in Uganda, and a joint statement from several major funders of the nation’s health infrastructure called for the act to be reconsidered.
Programs funded by the President’s Emergency Plan for AIDS Relief, which provides about $400 million in HIV funding to Uganda each year, could become illegal under the new law, said Russell. “There’s a huge concern that PEPFAR strategy becomes promotion of homosexuality under this law,” she said.
Academic institutions that work within the country are also reconsidering how their funds are being used. Louise Ivers, director of Massachusetts General Hospital’s Center for Global Health, wrote in an email to Vox that the organization planned to redirect the millions it spends on its Uganda program away from governmental to nongovernmental institutions.
That means shifting from supporting a public university in southwest Uganda — which helps sustain nurse training and community health work programs — to instead supporting nongovernmental organizations working on humanitarian efforts and education aimed at reducing LGBTQ discrimination in Uganda.
“In many ways just ‘pulling out’ is easy, but instead we are trying to take a careful approach that will both serve the poorest patients (a priority to us as clinicians), while also following through on our values,” Ivers wrote.
Ivers’s concern — and that of many other funders — is to avoid compounding harm to LGBTQ communities by withdrawing critical support not only for HIV care, but for the entire health care system.
It’s not just funding for health services that donors are reconsidering: Kavanagh said there is a “big push” to also review World Bank loans for infrastructure support to the nation. In fact, during the 2014 effort to pass an earlier version of the AHA, the World Bank paused its loans to Uganda.
Reducing support for any public goods in Uganda would likely cause pain for all Ugandans: A weaker health system and bad roads hurt everyone. “The health sector is of interest to the Ugandan government, but other sectors are even more important,” said Kavanagh.
Experts fear a spillover effect to other populations and other countries
Lusimbo fears the AHA will lead to increased persecution not only of LGBTQ people but also of other marginalized groups. In particular, he’s concerned the next step for the law’s proponents is to push for legislation targeting harm reduction programs that provide care to people who inject drugs.
There’s also concern that the AHA will lead Uganda’s neighboring countries to adopt similar attitudes toward LGBTQ people, if not similar legislation. Ingrid Katz, a research scientist at the Center for Global Health at Massachusetts General Hospital, noted that a “family protection bill” in Kenya uses the same language as the AHA. Lusimbo said Ghana and Tanzania are also seeing rising rates of anti-LGBTQ sentiment — “they seem to be having kind of a template that is being followed,” he said.
International pressure is mounting against Uganda, but it could also backfire. Uganda’s president has been defending the law as anti-imperialist: As he explains it, the West is trying to impose its values of LGBTQ tolerance on Uganda.
It’s hard not to note the irony here; after all, American evangelicals helped transform Uganda’s long-simmering homophobia into law. Still, some human rights advocates within the country have asked foreign partners to tread lightly in their opposition to the law — in part to avoid the appearance that resistance is funded by outside interests.
The difficult consequences of any actions make this a challenging time for people who care about public health. Continuing aid appears to condone an egregiously harmful law — but withdrawing aid will also hurt innocent people.
“Governments that espouse hate shouldn’t get funding,” said Kavanagh, and donors who invest in Uganda’s essential social services “have to creatively address this horrific set of policy choices. The economic ramifications, hopefully, will wake Museveni up,” he said.
Although the law is popular among Uganda’s general public, some LGBTQ advocates are clear that they do not want the US government and other funders to take measures that would cause harm to Ugandans more broadly. “We do not believe in sanctions or cutting off aid because at the end of the day, this again has a very negative impact on other Ugandans,” said Lusimbo.
Instead, aid that directly impacts LGBTQ communities or supports the legal work of challenging the AHA before Uganda’s constitutional court is key, he said.
“This is a really delicate time for the outside world to put immense pressure on Uganda,” said Leaning, the human rights expert. Right now, she said, the best help for the nation’s most vulnerable is likely “funding or expertise — done quietly.”