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To Stop the Spread of HIV, Address Rights of Marginalized Groups

In 2012, Mwamini K. a sex worker in Dar es Salaam, was raped at gunpoint by a client who got angry when she asked him to use a condom. She did not report the case to the police nor seek medical assistance because she did not trust that she could get the help that she needed, she told me. (Mwamini’s name, like all others here, has been changed.)

Mwamini explained that in 2011, she sought treatment for a sexually transmitted infection at Mwananyamala Hospital. The nurse refused to treat her unless she brought her sexual partner. Mwamini told the nurse that she was a sex worker and did not know who infected her. The hospital turned her away.

The same year, three police officers arrested Mwamini for soliciting clients: “They beat me like a thief. They were saying, ‘What are you doing here? You’re a prostitute, a dog, a pig.’” Mwamini reluctantly went to hospital because she was in serious pain, but told the doctor that she had fallen down the stairs, afraid she would be denied services if she told the truth.

Mwamini’s experience is not unusual. Between May 2012 and April 2013, Human Rights Watch and Wake Up and Step Forward Network (WASO) interviewed over 121 sex workers, people who inject drugs, and lesbian, gay, bisexual, transgender, and intersex people (LGBTI). We asked them about HIV, their experiences seeking health care in government facilities and interaction with law enforcement officers. The result are in a new report, “‘Treat Us Like Human Beings’: Discrimination Against Sex Workers, Sexual and Gender Minorities, and People Who Use Drugs in Tanzania,” released in Dar es Salaam today.

The people we interviewed described abuses by police -- torture, rape, assault, arbitrary arrests, extortion, and refusal to accept complaints when the interviewees were crime victims. They also told us that when they sought care in government health facilities, health workers verbally harassed them, denied services, and violated their right to confidentiality. Requirements to bring their sexual partners or produce Police Form Number 3 (PF3), which public hospitals require before treating assault victims, pose particular obstacles to health care for members of marginalized groups.

Men who have sex with men, transgender people, sex workers, and people who inject drugs belong to what public health specialists call “most at-risk” or “key” populations. While HIV prevalence among the general population has decreased slightly in Tanzania since the 1990s, progress has stagnated. Available data suggest it has increased among key populations. Without reaching all groups, it will impossible for Tanzania to reach its stated goal of “zero new infections.”

Denial of health care and abuses by the police – exacerbated by the fact that Tanzanian law considers them criminals – reinforce stigma and contribute to an environment in which sexual and gender minorities, sex workers, and people who inject drugs become increasingly marginalized and distrustful of the government. That undermines health initiatives that depend on partnership between the government and those most at risk of HIV infection. These abuses also violate national and international law, including the rights to the highest attainable standard of health care, to be free from torture and arbitrary arrest, and to non-discrimination, protected by treaties Tanzania has signed.

Tanzania’s second Strategic Framework on HIV/AIDS calls on the government to reduce stigma and discrimination against most at-risk groups in order to prevent the spread of HIV, as does Zanzibar’s HIV strategy. But our research reveals that the government is not doing so.

Suleiman R., for instance, a Tandika resident who injects heroin, said police arrested him in 2011 and tortured him – striking him with iron bars, and burning him with a clothes iron. Upon release, Suleiman requested a PF3 to get hospital treatment. The police refused, saying, “If we give you a PF3, you will accuse the police in court.”

Saidi W., a gay man in Dar es Salaam, was arrested in 2010 at age 18. Police forced him at gunpoint to call five gay friends, then undressed them, beat them, and took them to Central Police Station. There, they were repeatedly raped by fellow detainees. When Saidi and his friends asked the police for help, the police said, “This is good, this is what you want.”

Sometimes, police behavior may directly contribute to the spread of HIV. In December 2010, police in Tunduma gang-raped Rosemary I., a 12-year-old orphan engaged in sex work. None of the police used condoms. Governments should ensure that children do not engage in sex work, but not by punishing them. Their youth defines them as victims of sexual exploitation under international law -- entitled to protection and assistance by the authorities, not further abuse.

Health workers also perpetuate stigma. Mohammed, a gay man, went to the doctor with an anal STI. Instead of treating him, the doctor told him “What you are doing is a sin before God.” When Sungu Sungu militia members attacked January H., a heroin user, with a panga, a nurse at Temeke Hospital stitched him up without anesthesia. She said he was probably a thief and said: “We are going to sew you without. We could inject you with poison rather than with anesthesia.”

A new National Multi-sectoral Strategic Framework for 2013 to 2017 is soon to come into effect. The Tanzanian AIDS Commission (TACAIDS) says it will include specific strategies to reach key populations. But because the strategies involve reducing discrimination and protecting the rights of key populations, all Tanzanian officials will need to be on board to ensure these strategies are implemented.

If Tanzania is truly committed to addressing the spread of HIV among the most vulnerable, it should address the rights of sex workers, men who have sex with men, transgender people and people who use drugs. President Jakaya Kikwete should publicly condemn violence and discrimination against these groups and call for their protection. Police and health care workers should be trained to protect and treat at-risk groups, and held accountable for doing that, rather than confronting them with hatred and prejudice. And parliament should decriminalize consensual same-sex conduct, consensual adult sex work, and personal drug possession and use. Human rights and public health experts agree that criminalization of these activities poses an obstacle to HIV prevention, care and support.

Tanzanians have a wide range of opinions about sex work, drug use and homosexuality. But ensuring that every Tanzania citizen enjoys their basic rights, including the right to health care and to be free from torture, should not be controversial. From both a human rights and a public health standpoint, it is the right thing to do.

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