“In many countries, HIV prevention programmes are not reaching the people most at risk of infection, such as young people, women and girls, men who have sex with men, sex workers and their clients, injecting drug users, and ethnic and cultural minorities.” From the UNAIDS Press Release accompanying its 2006 AIDS Epidemic Update.
Later in the same document we read this: “The AIDS Epidemic Update underlines how weak HIV surveillance in several regions … often means that people at highest risk – men who have sex with men, sex workers, and injecting drug users – are not adequately reached through HIV prevention and treatment strategies because not enough is known about their particular situations and realities.”
In his opening address at this year’s World AIDS Conference in Toronto, UNAIDS Executive Director, Peter Piot, emphasizing how “we must make the money work,” said, “This means ensuring that the money is working for those who are most vulnerable. By this I mean, among others, men who have sex with men, injecting drug users, sex workers and orphans.”
These comments all drive home the same, dismal fact: though prevention is seen as a key element in HIV programmes, it is UNAIDS’ view that those programmes are, on the whole, not reaching men who have sex with men. And that this group – that’s probably you and me – is indisputably identified as one that is “most vulnerable” or “at highest risk.”
Scrutinise the others who are said to be alongside us in this unenviable predicament and what do you see? You see young people, women and girls, injecting drug users, sex workers and ethnic and cultural minorities.
Clearly we would need to know the specifics of each group’s “particular situations and realities” in order to comment with plausible authority. But – at the risk of being an idiot – we can generalise reliably by noting that in each instance, those listed concerned tend to be marginalized or disempowered in some way. More obviously in the case of men who have sex with men, injecting drug users and sex workers, the level of social ostracisation and stigma is very high indeed in most countries.
So, we have UNAIDS claiming that many of those groups isolated as being “most vulnerable” are, paradoxically and often fatally, excluded from prevention and intervention programmes. We are most vulnerable both to HIV and exclusion from prevention programmes. Clearly, this points, inter alia, to the role and prevalence of stigma.
“We must begin to make real headway in addressing the drivers of this epidemic, especially the low status of women, homophobia, HIV-related stigma, poverty and inequality.” That is Piot, once again, from his opening address in Toronto.
While UNAIDS and many national AIDS programmes (our own included) have, rightly, cited stigma eradication as a key goal and fundamental strategy in HIV prevention and treatment, it appears that very little progress has been made in this area. This is especially true of the stigma attached to the intersection of both HIV and men who have sex with men.
As gay people in South Africa we have, with the help of the Constitution and a handful of black activists and white lawyers, made enormous strides. That is, we have made great progress in having our legal rights recognized. A very carefully conceived programme of test litigation will, by the time you read this, probably have issued in South Africa becoming the 5th country in the world in which marriage between same-sex couples is recognized fully. In the arguments over this “last” right, we have once more achieved huge visibility and audibility. For the past two months, the marriage debate has ensured that “gay rights” have dominated every branch of our media. The wheel has come full circle: as with the media saturation achieved at the time of the very first Test case, the POLMED one, so now with what is the last great demonstration of our constitutional legitimacy, “the gay issue” is unavoidably present in our contemporary popular consciousness.
As you will all know, however, this presence is one that requires great personal and communal fortitude on our part. Popular commentary has been scathingly homophobic. Take the sustained tirades – largely incoherent – of senior journalist John Qwelane. Virulently opposed to the Civil Union Bill, he told his readership that he would “disown” any member of his family if they were gay. Then, as evidence of “something …seriously stinking” in SA, he once more cited the Bill, this time referring to it as “the stabani measure.” In a comment crazed even by Qwelane standards, he suggested that the Constitutional Court decision in favour of same-sex marriage could only have been arrived at if Judges themselves were gay: “I seriously believe that some judges of the Constitutional Court may be gay themselves; otherwise there seems no sensible explanation for them to want to make this country the ‘trahssie’ capital of Africa.”
This is, at one level, laughable vitriol. In implying that the Constitutional Court could only have arrived at its finding if “some” of its members were gay and, therefore, allowed their personal sexual preferences to dictate their legal findings, it might also be in contempt of court.
But the key point is to show how prejudice is mindless and, if engaged in by those with apparent authority, filled with real danger for the well-being of our citizens.
The coincidence of World AIDS Day and the Constitutional Court deadline for legalizing same- sex marriage on 1 December is useful. The run up to the legalisation of same-sex marriage has exposed a vast reservoire of homophobic sentiment in our country. Piot has isolated homophobia as one of the “drivers of this epidemic.” Nationally and internationally, HIV-stigma is also catogorised in this fashion.
This means that men who have sex with men are doubly at risk of stigmatization should they have HIV, and disproportionatelyly at risk of both infection and death in not being adequately reached by prevention and treatment campaigns.
As 2006 – the 25th anniversary of the first diagnosed case of HIV – draws to a close, there are some promising signs in SA. The South African National AIDS Council, SANAC, is being re-structured with Deputy President, Phumzile Mlambo-Ngcuka, in the Chair. Deputy Health Minister, Nozizwe Madlala-Routledge, has come to the fore in official statements about HIV/AIDS, and has said, inter alia, that South Africa’s official stand at the Toronto conference was “an embarrassment.” World Aids Day itself will see the release of a new comprehensive AIDS Plan for SA, one that will include treating 650,000 people with ARVs, distributing 500 million male condoms, promoting “mutual faithfulness” and encouraging children under 15 to abstain from sex.
While the Khomanani programme has been suspended, and what this means in terms of “awareness” literature for World AIDS Day and beyond we can only speculate, Madlala-Routledge has said that the new strategic plan “is focusing a lot” on prevention since “the rate of new infections shows we need a more vibrant and effective prevention strategy.”
Commentators – including myself – have been saying for years that the A,B,C programme is, quite literally, fatally flawed. To have this officially recognized at last is a boon. But, we gay people should be especially vigilant in seeing what - if any – specific attention and provision are made for prevention programmes targeted specifically at gay males.
The Deputy Minister has spoken of poverty, of gender, social and economic inequality as key areas of importance in prevention strategies. But she has not, as far as I know, had anything to say about men who have sex with men. This is a huge oversight, given the sustained and precise mention of this category in UNAIDS and other international literature, research and commentary. Should the new Strategic Plan 2007-2011 make no mention of the issue, we will need to be sure that we do make an issue of it. For now, we can start by noting that it is a fatal irony that, while we are so powerfully present in the public mind at the moment, in terms of our specific needs in this pandemic, we are, it seems, entirely invisible. Lives depend on noting this unfortunate fact.
As the current uproar over same-sex marriage indicates, we are not an unknown quantity in this country. So, this invisibility in official HIV/AIDS commentary and strategy to date, must be a symptom of stigma.
Another, perhaps small, example of this paradoxical blend of exposure and invisibility is to be found in this year’s Sunday Times sponsored Alan Paton award for non-fiction. You’ll know, if only from coverage in Exit, that this was jointly won by Edwin Cameron’s, Witness to AIDS, and Adam Levin’s Aidsafari. That these two very different books should have shared the prize constitutes a bold and emphatic political statement. That the Sunday Times’ own announcement of the award failed to mention that both writers were gay is also – by default – an emphatic statement.
Can we at least say that “everyone” was assumed to know that Justice Cameron is gay? I’m sad to report that my own little vox populi poll, conducted largely amongst young gay males, indicated a big majority that had never heard of this eminent man. Was the Times, perhaps, being “tactful”? Anxiously alert to the huge stigmatization of gay males in Europe and the US at the outbreak of AIDS, did the paper wish not to excite such connections between HIV and gayness here? If so, it was misguided, if only because neither Cameron nor Levin have ever sought to “hide” their gayness. Once more, I’m afraid, we saw this unhappy alliance between exposure and invisibility.
Do we know what the HIV prevalence rate is in the gay male population of SA? I don’t. If we look to SA’s report to UNAIDS in 2005, a report which, as a signatory to the UN Declaration of Commitment on HIV/AIDS, SA was obliged to submit, it seems government doesn’t either. Under the heading on percentage of men who have sex with men who are served by outreach programmes: no data. On condom use amongst this group? No data. Alarming instances of “weak HIV surveillance”?
This gap in our report tells us - in one way at any rate - all we need to know.
If SA’s prevention programmes are, as Madlala-Routledge concedes, failing the country, for gay males they are not failing. They are non existent. Similarly, it seems likely that there is no reliable data on the progress of the epidemic in our sub-culture. UNAIDS 2006 Update quotes data from SA showing that in the 2005 National Household Survey, HALF the respondents infected with HIV believed that they were at no risk of contracting the virus! This alone not only argues for the imperative need for testing, but that we live in cloud cuckoo land. If we are not aware of our positive status, we do not know that we might infect others, nor do we seek treatment (if it is available) until we are symptomatic and when, therefore, ARV treatment might have reduced efficacy. If this applies to the population in general, how much more serious might it be in a sub-culture dubbed “most vulnerable” by UNAIDS?
As we observe World AIDS Day 2006, we should remember Piot’s words from Toronto: “We must spend our energy on fighting this epidemic, not on fighting each other.” The emergence in recent week’s of a possible new structure in our official AIDS political hierarchy, in particular the rapprochement between Madlala-Routledge and the TAC, might show evidence that we can stop fighting each other. But noting these developments, Justice Edwin Cameron has sounded a salutary note of caution. Speaking recently at the University of Cape Town, he observed that Madlala-Routledge and Mlambo-Ngcuka “have what we can at best call a passive mandate to marshal the national response to AIDS. Their conduct is allowed without visible or audible support from above.” Given Minister of Health, Manto Tshabalala-Msimang’s, recent outburst on the ANC website – she claimed that her recent illness “was portrayed as an opportunity to turn others into champions of a campaign to rid our government of the so-called HIV and AIDS denial at the highest level” - it seems the Judge’s caution is well-founded.
On December 1 2006 every South African should pledge him/herself to doing whatever s/he can to marshal our individual, community and national resources to turn back the HIV tide. And as gay people, we must begin to insist that prevention and intervention strategies taking specific, targeted note of our “particular situations and realities” become a prominent part of the country’s HIV/AIDS strategy. Not to do this would be a fatal oversight.