60 Minutes on US HIV/AIDS intervention in Uganda

Last night, 60 Minutes provided a sympathetic review of the PEPFAR intervention in Uganda. As I have discussed here before, the program has been immensely successful. The broadcast puts real faces on the success (especially the kids) and the problems (extraordinary footage of HIV informing sessions). Near the end of the segment, 60 Minutes interviewed Martin Ssempa but without any mention of the Anti-Homosexuality Bill.

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Bob Simon notes that the spread of HIV is driven by polygamy, “sugar daddies” and sexual networks – all heterosexual issues there. He also documents how US backed drug treatment has brought hope to HIV positive people. I could not help but feel touched by the faces of the children and the pain of the couples who found that one or both of them were HIV positive. The presence of Martin Ssempa without mention of his advocacy for the Anti-Homosexuality Bill is a striking omission in light of the potential for that bill to erode more progress on HIV. The main driver of HIV in Uganda is heterosexual behavior. Ssempa does speak about that, but it certainly seems to me that his recent anti-gay crusade has the potential to undo his good work by making gays the scapegoat for a problem that cannot be solved by the Anti-Homosexuality Bill. I addressed some of these issues in a November, 2009 commentary which I am reprinting after the break.

Adding D to ABC: How a Proposed Ban on Homosexuality in Uganda Will Undo AIDS Progress

Between 2004 and 2008, the United States has provided 1.2 billion dollars to the East African nation of Uganda through the President’s Emergency Plan for AIDS Relief (PEPFAR). Instigated by President George W. Bush, PEPFAR’s results have been striking. According to a 2009 Annals of Internal Medicine research report, an estimated 1.2 million lives have been saved. The AIDS rate has dropped dramatically. PEPFAR funds three components of AIDS education and prevention: Abstinence education, Be faithful in marriage or to one partner, and Condom usage (ABC).

However, a bill proposed in the Ugandan parliament in early October may add a D to this policy and compromise Bush’s good work. The D stands for the death penalty for homosexual offenses, including multiple homosexual acts and engaging in sex while HIV positive.

Introduced by MP David Bahati, the Anti-Homosexuality Bill, 2009 would impose the death penalty on some homosexual behaviors, and maintain life in prison for others. Even touching someone of the same sex could be considered an offense if the intent is sexual. Homosexuality is already illegal in Uganda but this bill cracks down harder on offenders as well as anyone with any relationship to a homosexual. The bill requires persons in authority (pastor, teacher, missionary, physician, parent, etc.) to report any knowledge of any offense covered by the act within 24 hours upon pain of 3 years in jail or a hefty fine. Thus, parents could be expected to turn in same-sex attracted children. Relevant to AIDS relief work, there is no exemption in the bill for professionals. If a patient reveals homosexual behavior in the course of AIDS treatment or education, then those hearing the revelation must report.

As might be expected, the bill is receiving condemnation from human rights groups, including those within the AIDS prevention and treatment community. However, the bill has divided two former collaborators on AIDS policy in Uganda – Martin Ssempa and Edward Green. The story of this divide illustrates the complexity of developing a workable AIDS policy when cultures clash.

Martin Ssempa is a Pentecostal pastor from Kampala and Dr. Edward Green is Director, AIDS Prevention Research Project at Harvard University. They worked together to craft AIDS prevention policy in 2004. At the request of the Uganda AIDS Commission, they and four others authored a paper detailing evidence for what worked in prevention and developed a plan for implementing those strategies in Uganda. In an email, Green explained,

In various forms, the ABC approach has been implemented in Uganda since the mid-1980s. By 2004, there were condom strategies but no fidelity strategies. Ssempa and I (and 4 others) just laid out the evidence of what worked and made plans to include some of that in a package of otherwise ineffective medical services masquerading as AIDS prevention.

Ssempa received a Masters of Arts degree in counseling from Philadelphia Biblical University and boasts on his website that he is “a passionate voice in the global fight against HIV/AIDS.” His DVD on sexual abstinence is promoted by Wait Training, a Colorado-based abstinence education organization. However, he is actively campaigning for the Anti-Homosexuality Bill. Ssempa told me in an email, “I am in total support of the bill and would be most grateful if it did pass.”

According to Harvard’s Green, Ssempa’s support for the bill and the ramifications to AIDS prevention and treatment efforts are deeply troubling. Green said, “The bill sounds dangerous and completely inhumane. As a practical matter, such a bill is unenforceable and would only drive homosexuality underground, terrorize gay men and women and their loved ones, and justify witch hunts.”

AIDS workers on the ground in Uganda agree. In practice, such a law will create ethical conflicts for pastors, health care providers and educators, and heighten stigma for patients. Karen Moul, spokesperson for Catholic Relief Services, a major PEPFAR grantee, told me that if the bill becomes law, it could dramatically inhibit patients presenting for treatment and/or to discuss risky behavior of any kind. “It will only make it harder to get services. The stigma of AIDS is bad enough. Anything that increases stigma will make getting treatment harder. Patients may avoid coming in altogether,” Ms. Moul said.

The bill directly contradicts the approach to primary prevention of AIDS advocated by Dr. Green. Writing in a professional journal, Green summarized the principles in working with stigmatized groups, saying,

Working with marginalized, high-risk groups in any meaningful way involves accessing such people, gaining their trust and developing some level of sympathy for their plight. These groups are often looked down upon, perhaps despised, perhaps more openly in the tradition bound and/or religious societies in the less developed world.

Somehow what seems obvious to Green and Moul is not registering with Ssempa and supporters of the bill. Despite the draconian restrictions and requirements, the bill seems likely to pass due to support from religious leaders like Martin Ssempa. Ssempa told me, “This bill seeks to put Africa and Uganda to be custodians of values and family knowledge as handed down from our fathers and our faith.”

Policy makers in the US and elsewhere will need to confront this impulse. Adding D to ABC in Uganda will not reduce HIV/AIDS and may make matters worse. For the sake of human rights and a working AIDS policy, ABC is enough.


If you want to comment on the 60 Minutes segment, you can do so here.

26 thoughts on “60 Minutes on US HIV/AIDS intervention in Uganda”

  1. And… I should have clarified

    The 2007 numbers are from 34 states (and 5 areas) that require reporting. These are the highest infection rate states, but the total for 2007 was probably 63,000 rather than the 42,000 reported.

    However, the ratios are probably the same.

  2. Or, in rough numbers which are easy to remember:

    half of new transmissions result from gay sex

    a third result from straight sex

    the rest are injection drug related

  3. David,

    It seems in the US that the progression is as I thought in terms of behavior.

    IV drug use-receptive anal intercourse–

    Well, no. Not exactly.

    I think you may be misreading the information. I provided numbers on exposure risk (the likelihood of any particular engagement with an HIV positive person leading to seroconversion).

    If you wish to know the transmission rates in the US, here are the stats for 2007:

    22,472 (53%) male to male

    9,076 (21%) male to female

    4,939 (12%) injection drugs

    4,551 (11%) female to male

    1,260 (3%) both MSM and drugs (exact unknown)

    139 (0.3%) perinatal (mother to child)

    59 (0.1%) other

  4. It seems in the US that the progression is as I thought in terms of behavior.

    IV drug use-receptive anal intercourse–

    The surprise is the receptive vaginal intercourse (next), as I had imagined it was much lower (although still lower by a factor of 5 than the above).

    Thanks for your effort Timothy…

  5. rereading the above… the first half was written before I found the numbers

  6. David,

    The numbers are very different if we are talking the US or Africa. Very VERY different. And we must also consider that the strains of HIV are different on the two continents.

    So “numbers about the rate of transmission” would be hard to tie down. Here are a few statistics I can toss out off the top of my head…

    * Over 90% of HIV infections worldwide are in heterosexuals.

    * In the US, there is about a 50/50 split in new infections between straight and gay.

    * About half of US new infections are among African Americans

    * A 2000 study in Uganda found that rates of male to female and female to male transmission were about the same. However none of the males who were circumcised seroconverted.

    More info can be found in a Seattle Public Heath pamphlet that discusses risks, however it appears to be written from a white male American perspective.

    I found the following grid on Wikipedia

    Estimated per act risk for acquisition of HIV by exposure route (US only)

    Exposure Route – Estimated infections per 10,000 exposures to an infected source

    Blood Transfusion 9,000

    Childbirth (to child) 2,500

    Needle-sharing injection drug use 67

    Receptive anal intercourse* 50

    Percutaneous needle stick 30

    Receptive penile-vaginal intercourse* 10

    Insertive anal intercourse* 6.5

    Insertive penile-vaginal intercourse* 5

    Receptive oral intercourse*§ 1

    Insertive oral intercourse*§ 0.5

    * assuming no condom use

    § source refers to oral intercourse performed on a man

    As for female to female transmission, there have literally only been a few cases in which this could have possibly been the transmission route.

  7. Thanks Timothy…

    The heterosexual transmission from women to men fascinates me…as I would not expect that.

    Do you have any numbers about the rate of transmission:

    female to male, vaginal intercourse

    male to female, vaginal intercourse

    male to female, anal intercourse

    male to male, non-anal intercourse

    male to male, anal intercourse

    female to female.

    I would assume the the numbers are higher for male to female anal intercourse, male to male anal intercourse, male to male non anal intercourse, female to male vaginal intercourse, female to female (these are listed in descending order).

  8. David,

    Forgive me if I get a bit graphic.

    Your assumption is correct. The 50% reduction studies related to men receiving the virus from infected women via heterosexual vaginal intercourse.

    Some nutcase in the US compared infection rates in gay men in the US and found that there was no significant difference between circumcised and uncircumcised. They concluded that “circumcision doesn’t factor into HIV transmission in gay men”. But, stupidly, they made no effort to determine whether or not the gay men engaged in receptive anal sex and it should be pretty obvious that if one is being penetrated, it’s not going to make much difference whether or not they still have foreskin.

    We don’t know whether the circumcision of the insertive party during anal sex has any impact on transmission from the receptive partner to the insertive partner. We do know, however, that there are very very few cases of HIV transmission to the insertive party in the US. VERY few.

    This may be for a number of reasons: 1) HIV may be easier to transmit from a woman to a man in vaginal sex than to an inservite partner in anal sex, perhaps due to presence in either the vaginal or anal cavities. 2) gay men may generally be more conscious of issues of cleanliness prior to anal sex than women are prior to vaginal sex. 3) most Americans men are circumcised and circumcision may play a part.

    We just don’t know.

  9. I am uneasy with how the research findings on the relative protection of circumcision have been disseminated. It breeds confusion on the motive and purpose of the research. The public especially here in Africa is misinterpreting the message from the research to mean one is protected from infection because they are circumcised. It would be better for health policy experts and those formulating and disseminating public health policy to maintain clarity. The ABC formula should be the primary message. Already here in Uganda, one of the study sites for the study, voluntary circumcision is on the up as a result but my concern is that many have jumped onto the bandwagon with a mis-perception that they will not get infected if they engage in unprotected sex which is potentially a tragedy in waiting! The lack of adequate information on the utility of condoms is also worrying.

  10. Thanks for checking in Timothy,

    To clarify:

    1. This 50% number does not differentiate between MSM and MSW….is there a difference?

    Thus, an uncircumcized African man engaging in heterosexual sex may well be at higher risk than a Scandinavian engaging in receptive anal sex, depending on their own personal susceptibility to the virus

    in the former, with the woman as a HIV positive transfering the virus to the African man?

  11. Ugh… two mistakes:

    It should read: “while it is generally true that a condomless anal…”

    And the studies found that circumcision cut seroconversion in half. Thus uncircumcized men are twice as likely to seroconvert (not just 50% more likely)

  12. I would think that IV drug use is the most “effective” way for the virus to spread…

    sodomy ranks somewhere below that…

    penile-vaginal intercourse seems much lower than that.

    That is, in a sense, true. Kind of.

    But while I very much respect your desire to keep groups out of it, that would not be accurate science either.

    It is true that a condomless anal sex recipient (regardless of their gender) is more likely to seroconvert than a male during vaginal sex, there are two groupings that are, in and of themselves high risk.

    1. Uncircumcized men are up to 50% more likely to seroconvert than circumcized men.

    2. Over 90% of black Africans (and about 70% of African Americans) are duffy-negative (have a particular protein on their red blood cells), a characteristic almost unknown in Caucasians. This results in an increased susceptibility to HIV of perhaps 40%. (Some small percentage of Scandinavians appear to be virtually immune)

    Thus, an uncircumcized African man engaging in heterosexual sex may well be at higher risk than a Scandinavian engaging in receptive anal sex, depending on their own personal susceptibility to the virus

    However, that being said, you are quite right that there is a hierarchy of behaviors within groups.

  13. anteros,

    but i get your point… there is a hierarchy of high risk groups. and yes, homosexuals are probably higher up in that hierarchy than heterosexuals.

    Actually, that was not quite my point (identifying groups)…I was trying to identify behaviors.

    Thanks for your answers though…

    Sex and aggression can be linked and have been linked in psychology for about 100 years…Christianity, I believe, seeks to delink aggression from sexuality…

    The aggressive components of sexuality (selfishness, impulsivity, treating others as objects), I believe, correlate with STD’s generally.

    Using lubricants, requires empathy, planning…something that aggression easily overwhelms.

    Aggression mimics passion, but is not love.

  14. also important to include in safer anal sex messages… it’s gotta be water-based lube. no lube or oil-based lube increases risk of infection… that’s even more room for mistakes by those intending to practice safer anal sex.

  15. David Blakeslee:

    I would think that IV drug use is the most “effective” way for the virus to spread…

    sodomy ranks somewhere below that…

    penile-vaginal intercourse seems much lower than that.

    i’m no expert, but I think that sounds reasonable… it kinda corresponds with the risk of direct exposure to bodily fluids. well, if fresh needles were used every time for IV drugs… that would probably be zero risk. sharing needles on the other hand… is kinda like bareback sex… very risky.

    Rather than talking about “most efficient way to spread”…which implies motive…we can talk about high risk behaviors…which implies recklessness.

    If you have more facts, I am interested.

    when comparing recklessness and risks of anal sex versus penile-vaginal intercourse… i found this information very useful – it explains things well.

    sadly, most safer sex messages stop at condom use, which would probably suffice for penile-vaginal intercourse… but safer sex messages for those who practice anal sex should emphasize both condom use and lubrication.

    since , in addition to condom use, more care (lube) is required for safer anal sex, there’s probably more room for accidental “recklessness” (not using lube). i’m not sure that the “correct” or “full” message on safer anal sex is being made sufficiently available to those who need it.

  16. David Blakeslee:

    i dont think IV drug use is very common in Uganda.

    stating the obvious, anal sex is not practiced by all homosexuals, and many heterosexuals practice anal sex – and i’m pretty sure that most instances of anal sex don’t result in HIV infection. homosexuality, or anal sex (Ssempa loves conflating the two) is not the enemy, unprotected sex is.

    but i get your point… there is a hierarchy of high risk groups. and yes, homosexuals are probably higher up in that hierarchy than heterosexuals.

    that’s another reason why homosexuality needs to be decriminalized, and HIV prevention programs need to be extended to cover LGBT Ugandans.

    but that is not the same as Ssempa’s statement, “Homosexuality is the most efficient method of spreading HIV”. if you watch that clip, you will understand that his statement was not driven by “compassion to HIV/AIDS victims” (the reason he was awarded an honorary degree), it was meant to vilify homosexuals as the most efficient disease spreaders. that was his response to the question, why should Ugandans care if two adult men agree to sodomize each other. in his response, he wanted viewers to believe that homosexuality is the main catalyst for the spread of HIV… in the same breath, he mentioned Hepatitis A, B, and C… and then went on his anal licking, rimming and fisting tirade, calling homosexuality “inherently evil”.

    In my opinion (based on what Dr Green had to say, and UNAIDS as well as other credible groups), that kind of vilification, especially of higher risk minority groups, does nothing to help stall the spread of HIV… it does quite the opposite.

  17. anteros

    Unprotected penetrative intercourse with an infected partner, and certain types of exposure to certain body fluids of an infected person… that’s how HIV is transmitted from one person to another.

    I would think that IV drug use is the most “effective” way for the virus to spread…

    sodomy ranks somewhere below that…

    penile-vaginal intercourse seems much lower than that.

    Hence, needle programs, condoms, safe sex talks and abstinence.

    Rather than talking about “most efficient way to spread”…which implies motive…we can talk about high risk behaviors…which implies recklessness.

    If you have more facts, I am interested.

  18. Interesting discourse.

    Cant watch the segment. Bad internet connection.

    I am not claim to be the expert on this. icearc is actually, though he seems not to have responded here. But, I guess he might not want to bring his views on that here.

    Why is Ssempa on the segment?

    Simple. (I guess, to me…)

    1980s, we had an epidemic we dared not speak about.

    1990s, the death and destruction was so severe, that AIDS became an issue of public emergency. Everyone had a relative, friend etc who they knew was dying or dead from HIV/AIDS. Combination of factors turned the epidemic. Rates went low, etc

    2000s, the success in HIV prevention became a political tool to sell Uganda abroad. Pres and Govt sailed on it, internationaly. Uganda became THE sucess story.

    Bush became Pres in US, and, HIV prevention suddenly became no longer science based, but, according to the ideals of Abstinence, and Being Faithful.

    Enter Pastor Ssempa. Abstinence Campaigner. And, being Faithful. Whatever you may say of the man, he is politically very astute. It was during that time that he burnt condoms…. Circumstances remain controversial, since he twists like an eel when you try to pin him down on it. BUT, what is not doubted was that-

    Ssempa was de-campaigning condoms.

    He had lots of political clout, having teemed up with the First Lady. He was the official spokesperson on all issues HIV… And, that was something.

    He was also chief ‘enforcer’, making sure that condoms were not promoted with PEPFAR funds…. And of course he went to the US Congress to tell them why condoms were not part of what worked

    Did I mention that 1990s to 2000s, there was no HIV prevention amongst the ‘sinners’ groups like Homosexuals and Sex Workers? For sex workers, levels were as high as 66% of them….

    Anyway, by late 2000s, people were asking too many questions, Ssempa was becoming more and more defensive, and seems his star was waning with the First Lady…. Bottom line, Sex workers and Homosexual Ugandans were finding some ways into the discussion on HIV prevention.

    PEPFAR funds have been a huge success. Drugs for the poor of poorest, that means life, etc. But, they were very restricted not to target highest vulnerable groups like sex workers, gay men. And, the fact that most of the prevention was given to groups like Ssempa’s (he did get some), which promoted AB, and decampaigned condoms, and never ever mentioing gay men or sex worker sinners…. That was a problem.

    Which is still continuing. though the new era has made the US administration wake up to some of the ‘side effects’

    Did I say I am no expert? Just an interested observer….!

  19. also …as far as fighting HIV/AIDS in the LGBT community goes, South Africa is light years ahead of Uganda.

    Here’s one example

    And another.

    And another.

    So, I guess that mean Uganda could learn something from South Africa, just as South Africa could learn something from Uganda.

  20. David Blakeslee:

    Homosexuality is certainly not the most efficient method of spreading HIV… and that is simply because it’s not a “method of spreading HIV”… neither is heterosexuality.

    Anal sex (sodomy) is not the most efficient method of spreading HIV, simply because it’s not a “method of spreading HIV”… neither is vaginal sex… or oral sex.

    Unprotected penetrative intercourse with an infected partner, and certain types of exposure to certain body fluids of an infected person… that’s how HIV is transmitted from one person to another.

    A person flaunting an honorary degree in any HIV/AIDS related field should be able to draw such important distinctions, rather than misleading the ignorant public with statements such as “Homosexuality is the most efficient method of spreading HIV”.

    Ssempa is just one of millions of Ugandans trying to bring HIV infection rates down… don’t give him too much credit – he doesn’t deserve it. If he had things his way, there would be no condoms in Uganda… a situation that would not help reduce HIV infection rates.

    For many years, South Africa had less than strong (very poor, actually) leadership in its HIV response – former president claiming HIV did not cause AIDS, former health minister withholding and dismissing anti-retrovirals as ineffective and instead suggesting beetroot, garlic etc as treatment. But South Africa has many programs in place, such as loveLife – which is aimed at youth and follows a model very similar to Uganda’s ABC.

  21. I was totally shocked when Rev.Ss came on the show after such a nice ploy. Especially in light of the release a truley honorable religious leader put out yesterday. Apb.Desmond Tutu released his opposition to the genocide bill with a new coalition of 10 African countries etc. So I really couldnt believe ABC did that unless the involved genocidal criminals simply paid for some positive air time?

    I wa s so angry I wrote ABC before the segment was over!

    I truely hope the UN and Abp.Tutu being over the anti genocide dept will be able to charge Rev,Ss, and all the involved Americans with sedition,inciteing and attempted genocide.


    Bp.DDL Rochelle

  22. I was sitting there watching the 60 minutes piece, knowing that Ssempa was coming up, and just hoping that they did not go into the Anti-homosexuality bill. Why, I don’t know. Old fears, maybe…..

  23. The power and credibility of Sempa lies in his years long struggle to attack HIV/AIDS in Uganda by confronting the overwhelming heterosexual contribution…

    It is understandable that 60 minutes who emphasize this…

    I cannot figure out why they would not mention the Anti-homosexuality bill…

    But a deeper question (to me) is…

    Why haven’t people applied Sempa’s appropriate model for heterosexuals in places like South Africa (which has a similar HIV/AIDS rate as Washington DC).


    Is sodomy the most efficient way to spread HIV…or IV drug use?

  24. Thanks for posting this Warren.

    UNAIDS also recognizes the hindrances presented by homophobia and the criminalization of consensual same sex behavior between adults.

    Not only is Ssempa extremely homophobic, but he wants to Ugandans to be as homophobic as he is… in the ABC Nightline segment on the bill, he said he was not concerned that he was whipping up dangerous hatred towards homosexuals, but he was concerned that people weren’t shocked or disgusted (2:00). He also said that gay marriage ought to be punished by life imprisonment (4:15). How are LGBT Ugandans supposed to interpret messages about HIV and extra-marital sex (a big part of the “B” in ABC)?

    Not only is he homophobic, but he is set on getting homosexuality criminalized in a way that would make sex education and sexual health services, including HIV/AIDS programs, not just inaccessible but illegal for LGBT Ugandans.

    I’d been thinking about this earlier today, and posted this comment elsewhere on your blog:

    Ssempa also received an honorary degree from PBU in 2006 for his ministry of compassion to HIV/AIDS victims in his native land.

    That honorary degree really needs to be taken away from Ssempa. We’re talking about a guy, who uses the title “Dr” to boldly make these kind of authoritative statements on national television in his native land:

    “Homosexuality is the most efficient method of spreading HIV” (1:45)

    I find it offensive that such a person should be allowed to pose behind a title that depicts him as an honorable authority on HIV/AIDS in Uganda.

    Take away the honorary degree.

    Here’s more on Ssempa and his fight against HIV/AIDS in Uganda.

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