Eighteen months after slamming activists who opened a clinic for lesbian, gay, bisexual, transgender and intersex (LGBTI) people in Kampala, Uganda’s health ministry has decided it was a good idea after all and has begun setting up similar facilities, prompting outrage from the Ministry for Ethics and Integrity and scepticism from some in civil society.
Alex Ario, the acting programme manager of the Ministry of Health’s AIDS Control Programme (ACP), says they are rolling out four specialized clinics for the most at-risk populations (MARPs) in four division of Kampala and several others in major HIV/AIDS hot spots in upcountry towns. The clinics will target men who have sex with men (MSM) and female sex workers (FSW) with health services including HIV testing, counselling and treatment, and screening for other sexually transmitted infections (STIs).
“The clinics will not only be MSM clinics but MARPs clinics, though the focus will be on those MARPs that are most stigmatized, discriminated against and most likely to miss out on intervention services,” Ario told IRIN.
The initiative follows the success of a MARPs STD unit at Mulago National Referral Hospital, which has enrolled some 500 clients for comprehensive HIV treatment.
Gay rights activists opened Uganda's first clinic for LGBTI people in the capital, Kampala, in May 2012 - an act fiercely criticized by the government.
Despite the high prevalence of HIV among MSM and FSW - 13.7 percent and 33 percent respectively, according to the 2008-2009 Crane Survey of high-risk groups in Uganda - the government has not included these groups in its national strategy to fight HIV because homosexual activity and prostitution are illegal.
There remains a strong stigma attached to the LGBTI community; the Anti-Homosexuality Bill, currently before the country’s parliament, seeks more stringent punishments for people engaging in homosexual acts and those perceived to be "promoting" homosexuality.
Even so, the health ministry is moving forward with its MARPs clinics, which are being implemented in phases in order to train healthcare providers, mobilize MARPs, and implement monitoring and evaluation mechanisms.
“They [clinics] will be part of the health delivery system, and I believe nobody will challenge delivery of interventions/services to people that are key in the HIV response,” Ario told IRIN.
“We do not promote what they do, but what they do is our concern because of its public health implications. Therefore, from the public health point of view, we must reach them. As far as health services are concerned, we are not bothered [by] their sexual orientation and the laws. For us, we don’t discriminate in our services. The other aspects of the law will come later."
The US government, which provides support to Uganda’s fight against HIV, has welcomed the initiative.
“We strongly encourage them to ensure that these populations are not stigmatized and are respected under the Ugandan constitution, which guarantees equal rights for all minorities,” Daniel Travis, spokesperson for US Mission Uganda, told IRIN.
But the initiative has prompted outrage from Minister for Ethics and Integrity Simon Lokodo.
“We shall not tolerate these clinics. To open these clinics is a recipe for recognizing these behaviours, which are totally unacceptable. We are not obliged to encourage these acts,” Lokodo told IRIN.
Meanwhile, human rights groups, HIV activists and civil society organizations have expressed scepticism over the clinics. Many argue that care for at-risk populations should take place in regular health facilities.
“The specialized clinics are an innovative stop-gap as the country continues to grapple with community's attitudes towards KPs [key populations]. The provider attitude has a long way to go in accommodating individuals who are different from the majority of the population,” prominent HIV activist Milly Katana told IRIN.
But “the long-term strategy should be to integrate KPs in mainstream clinics... Specialized clinics are expensive to run and their sustainability is questionable... In addition, it is unthinkable that these specialized clinics can be instituted in all parts of the country all at once. The most reasonable thing is to have providers aware that there are individuals who are different and they have the full right to care like the rest of the population.”
Pepe Julian Onziema of Sexual Minorities Uganda (SMUG), a local rights group, echoed these concerns: “It's good to know that the MoH [Ministry of Health] is making this move. It shows that they're taking service provision for all to another level. However, I'm afraid that opening specific clinics to cater for CSW [commercial sex workers] and MSM people will only contribute to further stigma and discrimination.”
He added: “Everyone will know where to find a homosexual, making it easy for homosexual haters to pounce… Clinics should be generally inclusive.”
Minister Lokodo seemed to confirm these suspicions. “We shall arrest these people in these clinics and send them for treatment as culprits,” he said.
Some activists have called for MARPs to be involved in the clinics’ operations.
"We would want sex workers to be involved in the planning of these clinics and also to be used as peers working in the clinics on follow-up of patients, as members of clinic management committees and as part of relevant trainings of staff,” Flavia Kyomukama, director of the Global Coalition on Women and HIV/AIDS in Uganda, told IRIN.
Improving sensitivity and tolerance among healthcare providers and the public will be crucial, activists said.
“I think the key task MoH must be undertaking is the training of caregivers and providing them with tools on sensitivity towards what may seem 'unusual' to them. Carry out awareness drives that are inclusive of health service providers, CSW, MSM, LGBT and [the] general community. This way, non-discrimination is promoted, and people will at least be sensitive enough not to turn anyone away when giving care. Every stakeholder in the fight against HIV/AIDS wins,” said SMUG’s Onziema.