LGBTQ+: a community united by stigma

Abstract

In May, President Yoweri Museveni of Uganda signed a bill into law extending the criminalisation of homosexuality in the country. Uganda's Anti-Homosexuality Act 2023 increases penalties for attempted same-sex conduct to a 10-year sentence and introduces the death penalty for cases of so-called aggravated homosexuality including same-sex sexual relations with people with HIV. The bill added new offences, such as promoting homosexuality, with a prison term of up to 20 years. The law prompted worldwide condemnation, including from US President Joe Biden. The Global Fund to fight AIDS, Tuberculosis and Malaria, PEPFAR, and UNAIDS have said the change in law threatens progress in the country's HIV response, which has been one of the most successful in the African region. An estimated 64 countries criminalise consensual same-sex sexual acts, and 52 employ legal barriers to freedom of expression on LGBTQ+ issues. Any toughening or broadening of such laws is a move in the wrong direction. Criminalisation of same-sex conduct reduces HIV testing uptake and increases HIV burden. Among men who have sex with men (MSM), criminalisation can make getting tested and receiving treatment a high-risk activity. In Nigeria, MSM reported increased fear of seeking health care after criminalisation was expanded in 2014. Compared with countries with the least severe anti-LGBT legislation, those with the most severe had 20% lower ever testing levels, and 70% lower status awareness among MSM. Furthermore, barriers and criminalisation to freedom of expression on LGBTQ+ issues can hinder the work of agencies that offer HIV testing and medication. Prevalence was five times higher in settings where same-sex sexual acts were criminalised and 12 times higher in settings where there had been recent prosecutions. A report by the International Lesbian, Gay, Bisexual, Trans, and Intersex Association on the enforcement of laws criminalising same-sex sexual acts between adults found that carrying HIV-related medication, condoms, and literature on sexual health had been used as a pretext and evidence for prosecuting suspects. The fight against HIV is hampered by laws designed to undermine the human rights of the LGBTQ+ community. In cross-country comparisons, protection against discrimination on the basis of sexual orientation, gender identity, and HIV status was associated with higher rates of HIV status knowledge and viral load suppression among people with HIV. Data from the USA show that state-level support for sexual minorities (eg, recognition of same-sex marriage and laws that protect against discrimination in employment, housing, and public accommodation) were associated with fewer HIV diagnoses, fewer late diagnoses, and lower mortality in MSM. In a recent study in The Lancet HIV, Andrea Wirtz and colleagues, investigated HIV and mortality in transgender women in parts of eastern and southern USA. Risks of HIV seroconversion and death were lower in participants who had sought gender transition than in those who had not, suggesting a positive impact of access to care. Evidence clearly shows that the better the rights situation for all members of the LGBTQ+ community the better the outcomes are for HIV. Beyond Uganda's anti-human-rights legislation, there is a concerning ideological drift worldwide, especially in regard to provision of comprehensive health care for transgender people. So far in 2023, the USA alone has signed into law more than 75 anti-LGBTQ+ bills, including bans to gender-affirming care, the use of bathrooms and similar facilities in accordance with people's gender identity, and school-based laws such as bills banning discussions about sexual orientation, gender identity, and LGBTQ+ people and prohibiting the use of a child's chosen name and pronouns by school staff. HIV risks associated with LGBTQ+ discrimination and stigma showcase the interconnectedness of sexual and gender minorities. Furthermore, many gender minorities are part of sexual minority groups, and are united by challenging heteronormative and binary gender expression. In Wirtz and colleagues' study on transgender women, only a third identified as straight or heterosexual—any limitation of rights that targets transgender people affects the LGBTQ+ community as a whole. This Pride month, we join others in condemning Uganda's legislation alongside any laws that limit human rights of LGBTQ+ people. Since the Stonewall riots the lives of LGBTQ+ people have improved in many regions, but legislation and political rhetoric driven by ideology and moral panic persist. The success of the HIV response and the health and wellbeing of LGBTQ+ people are on the line. Governments must act to protect the human rights of the whole LGBTQ+ community.