Recently at PAI, we were presented with the opportunity to partner with a local African civil society organization (CSO) to advance women’s access to reproductive and maternal health. At PAI, our preference is to work with local CSOs, as we strongly believe that long-term policy change and sustained development are more likely to happen with an active, engaged indigenous civil society. Usually when we get a proposal like this, our questions are pretty standard: Does the organization have a strong infrastructure? A proven track record of advocacy and policy change? A commitment to reproductive health and rights? If the answers are “yes,” it’s an easy decision to proceed with a partnership. But this time, we paused.

This particular proposal came from Uganda. It was the first partnership request we’d received since President Yoweri Museveni signed the draconian Anti-Homosexuality Act (AHA) into law and the Ugandan Parliament passed the HIV Prevention and Control Act (HPCA). Both of these bills legalize the state sponsored violation of human rights and have had the support not just of the government, but non-governmental actors as well.

Faced with the prospect of partnering with a Ugandan CSO, we now found ourselves in new territory.   We knew the organization supported reproductive rights, but did that support embrace the full range of sexual and reproductive health and rights (SRHR), including the non-discrimination of lesbian, gay, bisexual, and transgender (LGBT) persons and other disenfranchised minorities? Does the organization support the enactment of these new laws? If yes, how do we reconcile the potential impact we could have on improving one set of rights (reproductive) with the organization’s complete disavowal of another set of rights? And how do we balance our belief in country ownership and sovereignty with these state-sponsored violations of human rights? Our decision making process had just become much more complicated.

No Easy Answers

The questions we’re wrestling with are certainly not unique to PAI. Like most in the international development and SRHR communities, we are deeply troubled by these new Ugandan laws, as well as Nigeria’s Same Sex Marriage Prohibition Act signed into law earlier this year. For those of us in global health, particularly those that focus on SRHR, this new landscape has hit especially close to home. These laws not only contain  blatant human rights violations, but their enactment also threatens to roll back so many of the gains against the HIV/AIDS epidemic we have made in the last decade.

As human rights violations, the horrific nature of these laws speak for themselves. But the potential ramifications for global health and development are equally as damning. In 2012, there were 1.5 million people living with HIV in Uganda and 140,000 new HIV infections. Globally, gay men are up to 13 times more likely to become infected with HIV than the general population. Uganda and Nigeria’s new laws fuel the stigma around HIV and will surely lead to a drop in the number of those seeking needed prevention, care and treatment. Studies have shown that people are much less likely to seek HIV services when they face discrimination, including abuse, imprisonment and/or prosecution. Furthermore, the mandatory testing of pregnant women included in the HPCA puts women at great risk of violence. When women are the first to be tested positive, they are often accused of being the one responsible for bringing HIV into the relationship and are at risk of physical, mental and emotional abuse by their partner. Women who fear violence as a result of getting tested are less likely to seek antenatal or maternity services, putting both themselves and their children at risk.

Caution and Consequences

In addition to the dire public health consequences, these first anti-LGBT  laws—with murmurs of more to come in the Democratic Republic of Congo, Kenya and Ethiopia—have heightened discussion of what, if any, consequences should be imposed, considering the vast amounts of U.S. foreign assistance for health that flow into Nigeria and Uganda each year. One of the reasons for the gains against HIV/AIDS in Uganda and Nigeria has been U.S. investment through the President’s Emergency Plan for AIDS Relief (PEPFAR) and other foreign assistance programs. In 2013, Nigeria received $626 million in global health assistance, making it the single-largest recipient of U.S. health assistance in Africa. Uganda receives the bulk of its health assistance from the United States, with $400 million in 2013. PEPFAR has achieved  tremendous results in the last 10 years, but these anti-LGBT laws are casting a shadow over health investments and spurring conversations about placing conditions on U.S. assistance or cutting it off all together. A recent poll, for instance, showed that 62 percent of Americans approve of cutting financial aid to Uganda.

As an organization working on SRHR, PAI has seen historically how problematic conditions on U.S. assistance can be—and what a chilling effect those conditions can have on improving public health outcomes. For instance, the Global Gag Rule—first imposed 30 years ago—decimated family planning and reproductive health programs across Africa by conditioning the receipt of U.S. financial and technical assistance on an indigenous organization’s agreement to disavow abortion, even if its provision of abortion services, counseling and referral, or advocacy efforts were supported with non-U.S. funds. Although it’s been repealed by the Obama administration, women worldwide still feel its effects today. Likewise, limiting PEPFAR funds to abstinence-only education left young women and men in countries most affected by HIV/AIDS unequipped to protect themselves from infection. Other conditions, like the anti-prostitution pledge requiring indigenous CSOs to have an official policy opposing prostitution as a condition of receiving PEPFAR funds, continue—even though a 2013 Supreme Court decision ruled the requirement unconstitutional when applied to U.S citizens. These conditions keep women and girls from fully achieving their rights.

In the end, we have decided to partner with the Ugandan CSO that approached us. We are comfortable in our choice, but are watching closely to see how the partnership proceeds. History has shown time and time again that government persecution of minority groups and quieting the voice of civil society have negative consequences far beyond the ugly, transitory political imperatives they seek to satisfy.  Likewise, turning a health system into a vehicle for punitive action against innocent people only impedes improving health and wellbeing. As an international community, we must act to ensure the human rights and health of all people. Only by making sure these two things are in place can we achieve sustainable global development and a just world.