The opening talks at CROI recognise the work of outstanding scientific contributions to the HIV response and also include a leading community activist to give the annual Martin Delaney presentation.
The talks this year were as impressive and important as ever and will become open access webcasts a month after the conference.
Scientific advances in vaccine research
Barney S. Graham, from Morehouse School of Medicine Atlanta, one of the leading scientists in vaccine research, described how years working on an HIV vaccine primed his laboratory to be working on a vaccine against SARS CoV-2 in the first week of January 2021, leading to the development of the Moderna mRNA vaccine within a year. [1]
The dramatic technological advances over the last 20 years can now reduce the timeline for steps previously needed in the trial-and-error approach to vaccine development from decades down to months by using precision vaccine engineering and platform manufacturing. In response to COVID, HIV research and trial networks played a critical role in enabling more than 200,000 people to enrol into SARS vaccine and monoclonal antibody studies.
However, similar to first years of ART for HIV, vaccine access was not equitable, and the majority of deaths averted were in high-income countries. For all the remarkable scientific brilliance, the talk stressed the dual importance of community education programmes to build faith in science, especially when not in a crisis.
Ending paediatric HIV by 2030
Dorothy Mbori-Ngacha, from United Nations Children Fund, spoke on the urgency of ending paediatric HIV, as 130,000 infants become HIV positive every year due to limited access to ART during pregnancy and while breastfeeding and because programmes are still not able to effectively retain all women in care. [2]
Starting from early experiences as a paediatrician in Kenya during the 80s, this talk paid tribute to the thousands of courageous women who participated in research even when there were no treatments. At a time when stigma was still incredibly high, these women wanted to help their children, even though they might not benefit themselves. Steadily, a global research network was able to explain and overcome vertical transmission during pregnancy and breastfeeding, although there is still much to be done.
Treatment and access both steadily improved, with WHO-consolidated guidelines in 2016 recommending universal access to ART, including during pregnancy and for children. Although more than three million paediatric infections have been averted since 2000, roughly 18% of women globally do not have access to ART during and after pregnancy and 130,000 infants became HIV positive during 2022. Some countries still report high rates of disconnection from care when rates of incident infections are still high.
The goals for 2030 need to build on the potential of long-acting drugs for prevention and to include communities in planning access programmes, recognising the importance of choice. These need to be ambitious, not just for HIV but to reduce syphilis, hepatitis B and Chagas. We have done well, but our goal is to end HIV in children is still not over.
LGBTQ+ crisis in Uganda: urgency of international support
The third talk, and the main focus of this HTB report, was given by Frank Mugisha, from Sexual Minorities Uganda, a community organisation that is now banned in Uganda following the hate law passed in 2023. [3, 4]
The Anti-Homosexuality Act (AHA) criminalised LGBTQ+ people, introducing the death penalty for same-sex couples and threatening decades in prison, for supporting anyone who might be LGBTQ+, including for health workers who do not report people to the police. Overnight, thousands of people were evicted from their homes, including by their families, and sacked from their jobs.
Contrary to myths generated to support the AHA, this persecution is the result of foreign involvement, largely from the US, just as the original legislation was a colonial import introduced by the British government in 1950. Although 33/55 African countries still criminalise homosexuality, Uganda’s decision to actively persecute LGBTQ+ citizens with such extreme penalties now threatens social changes that affect the whole country.
As background, almost every tribal language and dialect in Uganda has a much earlier word for homosexuality and this is true in other African countries. In Sierra Leone, the Mende people recognised roles for same-sex couples. In Nigeria, the Nupe people documented same-sex marriages. The Nandi people in Kenya included inter-generational same-sex relationships between warriors and the Asante people in Ghana also recognised diverse gender identities.
However, even in countries with supportive legislation, such as South Africa where equal rights are incorporated into the constitution, homophobic murders still occur. And decriminalisation in Seychelles, Lesotho, Angola and Mozambique hasn’t led to full equality.
Dr Mugisha stressed that Uganda is now different. Even though he grew at a time when talking about sex was a taboo – and talking about sexuality and gender identity was even worse – he didn’t grow up worried that he would be arrested or sent to jail. Children in primary school were taught to not stigmatise people. Uganda developed leading and widely inclusive programmes for HIV prevention that included the President, other leaders, civil society and activists all working together. But where did this go wrong?
While the science to overcome HIV was based on facts, the leadership fighting HIV/AIDS was religious and imported values that targeted anything connected to homosexuality. The President denied that gay Africans even existed and anti-gender and anti-gay religious groups from the US radicalised Ugandans into hate by creating myths and conspiracy theories. These included the same strategies used in Western countries around dangers from assaulting and recruiting children, which promoted gay conversion programmes. This created fear in Ugandans that led to violence, cyber harassment and assaults and for the first time hate speech manifested into violence.
Since 2023 the Anti-Homosexuality Act (AHA) was passed, LGBTQ+ organisations have been shut down for promoting homosexuality. The act includes many of the conditions from the ‘Kill the Gays Bill’ from 2009 that was successfully resisted and never passed.
- It criminalises consensual same-sex sexual acts as ‘aggravated homosexuality’, punishable by death.
- It criminalises health-seeking behaviour and drives people living with HIV away from care.
- It undermines progress made in the HIV response. People will no longer test and many stopped ART a year ago.
- Health workers are liable to 10-year prison sentences for not reporting anyone who ‘might’ be LGBTQ+.
- It criminalises support for LGBTQ+ as ‘promoting homosexuality’ with 20-year prison sentences, including public health workers, other Ugandans and visitors.
- PEPFAR, UNAIDS and other programmes face persecution and imprisonment under this law.
- Although the Ugandan Ministry of Health has said stigma should not occur, reports are widespread. Service delivery has become difficult or impossible. The Ugandan National Council for Science and Technology issued a directive to researchers to report any trial participants violating the AHA.
In the months after the law was passed more than 300 cases of violations, assaults and sexual assaults were documented. [5]
LGBTQ+ people were evicted from their homes, including family homes, and fired from their jobs. Local authorities and police have raided and evicted LGBTQ+ organisations and housing shelters. Cases of aggravated homosexuality and promoting homosexuality have already been brought.
Urgent need for to protect human rights
Activists and advocates are legally challenging the AHA 2023 in the Ugandan High Court and a decision is still expected soon, but even if the verdict is unsuccessful the AHA will still be fought until it is overturned. [6]
The discrimination in the AHA has been challenged outside Uganda, and lead to the World Bank suspending all loans in August 2023, although pressure is still needed to hold the bank to this decision. The US has imposed sanctions on trade with Uganda and PEPFAR has changed policies on funding. Activist pressure has led to travel and visa restrictions on Ugandan dignitaries (a policy that can apparently works). Brave activists continue to documented violations and try to support those who are now isolated and disconnected from care.
The gains made over the years are being reversed. Not just in Africa but in the US and other countries. Women’s rights, reproductive rights, LGBTQ+ and human rights all need to be supported together because we are all under attack. Homophobia and transphobia need to be seen as a global problem. It is homophobia and not homosexuality that that is a foreign import to Africa.
Dr Mugisha called on the importance of scientists in the need to overturn the AHA and on the importance of continued research and data to support progressive policies, including for healthcare: “We need your voices as scientists. Speak up and support us”.
Comment
The anti-LGBTQ+ movement in Uganda is being driven and financed by right-wing religious organisations and extreme evangelicals with conservative ideologies from the US, such as Scott Lively and others. [7]
People fleeing Uganda have no secure or protected options in neighbouring countries. Ghana just passed anti-gay legislation. Suella Braverman as a thankfully brief Home Secretary, stated publicly that LGBTQ+ persecutions should not be accepted as a reason to apply for refugee status in the UK.
Earlier this year Kenya announced that refugee status will no longer be recognised for people who are LGBTQ+, causing hundreds of people to leave the Kakuma refugee camp for Sudan.
How to help
- The immediate call for help includes publicising this crisis. Raising the profile of the current crisis will help attract more support for Ugandans.
- Global activism in Western countries is being co-ordinated by Ugandan activists working with Health GAP in the US. Please contact for details of how to get involved. [8]
- Please sign the global protest led by scientists and researchers against the AHA. [9]
- Please connect to individuals and groups who need financial support. Many individuals no longer have shelter, income or food. Your help can make a big difference. [10]
By Simon Collins, HIV i-Base
References
- Graham BS. Modern Vaccinology: A Legacy of HIV Research. Bernard Fields Lecture.
https://watch.croiwebcasts.org/croi2024/ap/52037 - Mbori-Ngacha D. Reflections on Ending Pediatric HIV: Back to Basics Confront the Unexpected Challenge Assumptions. N’Galy-Mann Lecture.
https://watch.croiwebcasts.org/croi2024/ap/52039 - Mugisha F. Unveiling the Power of Uganda’s LGBTIQ Advocacy in Shaping HIV Response and Health Care Access. CROI 2024. Martin Delaney presentation.
https://watch.croiwebcasts.org/croi2024/ap/52041 (webcast) - Sexual Minorities Uganda
www.smuginternational.org - Uganda report: Increase in LGBTQI+ assaults and human rights violations need urgent activist responses. HTB (October 2023).
https://i-base.info/htb/46384 - Uganda update: LGBT hate law challenged in the courts. HTB (January 2024).
https://i-base.info/htb/47029 - Lively is president of Abiding Truth Ministries and director of Redemption Gate Mission Society, both currently based in Springfield, Mass.
https://www.splcenter.org/fighting-hate/extremist-files/individual/scott-lively - healthgap.org/tag/uganda
- Uganda hate law blocks HIV research: join 300 leading researchers in sign-on protest. HTB (January 2024).
https://i-base.info/htb/47023 - Several small GoFundMe campaigns developed with activist support that guarantees they are genuine and valid.
https://www.gofundme.com/f/support-the-needs-of-six-ugandan-lgbtq-refugees
https://www.gofundme.com/f/assist-lgbtq-refugees-in-the-kakuma-refugee-camp
https://www.gofundme.com/f/support-kevin-with-basic-living-essentials
https://www.gofundme.com/f/help-displaced-lesbian-refugees
https://www.gofundme.com/f/help-pamella-survive-a-desperate-situation
Source : HIV i-Base
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