The Voice of Public Health Leadership Globally: Marginalized

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The following is a guest post by Ron MacInnis, Deputy Director for HIV.

RonaldMacInnisBy Ron MacInnis

WASHINGTON, DC — My visit to Uganda last month – and meetings with many dedicated health professionals and HIV advocates – left me with concerns about the direction of the country’s HIV response and about the continued impact of U.S. investments in Uganda that finance a significant portion of that country’s HIV prevention, care, and treatment program. Even as we celebrate a decade of tremendous progress in combating HIV, this progress is threatened by the emergence of a host of problematic and sometimes openly hostile laws and policies, not only in Uganda, but in a wave of cruel and discriminatory legislation pushing like a virus across the globe.

In both Uganda and Nigeria, several pieces of legislation recently adopted or under consideration could transform the legal landscape surrounding HIV—and not for the better. The new “Anti-HIV Bill” pending in Uganda would make “willful transmission of HIV” a punishable offense. The pending “NGO Bill” in Uganda, similar to one before legislators in Nigeria, would restrict the freedom of nongovernmental organizations to engage in public debate, receive grants from global donors, and champion issues of their choice. These measures, together with the Anti-Homosexuality Act adopted earlier this year in Uganda, and the Anti-gay law recently signed in Nigeria, raise disturbing questions. Could a PEPFAR or Global Fund-supported HIV program at the world famous Makerere University hospital or at the University of Lagos legally provide counseling or treatment to someone who is homosexual? Would a Ugandan woman be better protected legally by not seeking to know her HIV status in the maternity ward? Would not knowing her HIV status protect her from being charged in the future with possible “willful HIV transmission” to her newborn child? How can these new measures be reconciled with the billions of dollars the world invests in keeping HIV-positive Ugandans and Nigerians on life-saving antiretroviral treatment?

Uganda and Nigeria are not alone in enacting such legislation. New and unnecessary legislation criminalizing “promotion” of homosexuality has been proposed or adopted in Kyrgyzstan, Gambia, Tanzania, Russia, and elsewhere. In many of these countries, the existing laws already criminalized persons for homosexual acts. These latest and unnecessary laws promote hatred and fear-mongering in countries that are still advancing basic gender equality for women, and only starting to embrace gender and sexual diversity. Sadly, these “anti-gay” laws are popular, although largely political maneuvers and opportunistic acts by politicians who have found themselves a new cause to champion in the name of “morality.” What is most troubling to me is how many public health leaders in each of these countries do not agree with these laws, but find themselves unable to either speak out or mount campaigns to reverse the troubling trend. The voice of public health leadership has been marginalized.

In many of these same countries—Zimbabwe, Russia, Nigeria, and Ethiopia—lawmakers are advancing policies that would also restrict NGOs’ ability to support HIV services and mobilize communities around HIV prevention. The goal of these lawmakers (often the same individuals obsessed with criminalizing homosexuality as harshly as possible) is to keep reins on non-governmental entities that aim to protect and care for sexual minorities and other key populations (such as people who inject drugs or sex workers)—those who are statistically most vulnerable to HIV infection and morbidity. In furthering these bad laws, each of these countries is straining their engagement with the international community to work together in the response to HIV. Donors and global funding mechanisms are continually challenged on how to work in this context.

We all know there is no “one size fits all” approach to ending AIDS. Each country must mount a national response to AIDS in keeping with its own unique mix of policies, public debate, social norms, and political opportunism. Yet, within this diversity, three principles should be held as unassailable in all countries that aim to “end the HIV epidemic”:

(1)    Non-criminalization of HIV transmission and non-criminalization of consensual sex between adults

(2)    Promotion of the free function of NGOs

(3)    Public health programs centered on human rights, with education on (and investment in) programs that mitigate harmful gender norms (homophobia, sexism, misogyny, gender inequality).

Unless these principles become fundamental components of efforts in every country to advance global health partnerships and strengthen health systems, achieving an “AIDS-Free Generation” or “Getting to Zero New Infections” begin to seem like far off possibilities. Public health leaders need to find their voice again, both globally and at country level to make sure bad laws and opportunistic politicians aren’t rolling back the important gains we’ve made in reversing the devastation of HIV and AIDS.


The Health Policy Project (HPP) contributes to improved health outcomes through strengthening the efficiency, effectiveness, and equity of health systems. HPP focuses on the policy aspects of family planning and reproductive health, HIV, and maternal health. We also assist countries to improve health outcomes by addressing barriers due to gender inequalities, socioeconomic status, stigma and discrimination, operational issues, and other factors that prevent people from seeking the health services they need.


Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al. HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS One. 2009; 4(3): e4997.

Beyrer, C., and Baral, SD., (2011), MSM, HIV and the Law: The Case of Gay, Bisexual and other men who have sex with men (MSM), Working Paper for the Third Meeting of the Technical Advisory Group of the Global Commission on HIV and the Law, 7-9 July 2011.

Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. NEJM. 2011; 365(6): 493-505.

Fay H, Baral SD, Trapence G, Motimedi F, Umar E, Iipinge S, et al. Stigma, Health Care Access, and HIV Knowledge Among Men Who Have Sex With Men in Malawi, Namibia, and Botswana. AIDS and Behavior. 2010.

UNAIDS. 2008. Policy Brief: Criminalization of HIV Transmission. UNAIDS and UNDP. Accessible at:

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2 thoughts on “The Voice of Public Health Leadership Globally: Marginalized

  1. Denis LeBlanc

    Thanks to Ron MacInnis for this. As a person living with HIV, I need to be frank; most writers are too diplomatic to say what needs to be said. Country leaders will allow their health officials to be critical – they have been silenced. Many of the leaders of these countries are corrupt and will use key populations as morality scapegoats, to distract the population at home from their own poverty, official corruption and economic or political disaster.

    They legislate against sexual minorities including gays and other key populations such as people who inject drugs or sex workers because they simply do not want to deal with these populations, THEY REALLY WANT GAYS, DRUG USERS AND SEX WORKERS TO BE KILLED OFF BY HIV AND DIE. That is their true HIV prevention program for key populations.

    These countries will not institute full programs for key populations even though they may write down prevention and health programs for key populations in their National plans; but this is a ruse, to get Western money, for as long as it lasts.

    The HIV+ communities have been harping on this for well over 5 years now and the situation for many key populations, particularly in Sub-Saharan Africa keeps getting worse. Thirty years into this pandemic, in one small country for example, Togo, gay men don’t even have reasonable access to free condoms and lube (beyond 8 condoms per year), and Togo is not that bad when compared to other, much larger countries like Nigeria and Uganda.

    Finally, many of these country leaders do not care about an “AIDS-Free Generation” or “Getting to Zero New Infections” — they do not care much about their own populations either – as long as the Western money keeps coming.

  2. Denis LeBlanc

    Correction: Country leaders will not allow their health officials to be critical – they have been silenced.


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