Wakiso, Uganda — Infection rates among incarcerated people are more than twice the national average. But behind bars, basic prevention tools are denied.
Livingstone remembers his first and only sexual encounter with a man. It was when he was in prison in 2016, serving one year for insulting a police officer.
Three months into his incarceration, an inmate who had been kind to him asked for sex, says Livingstone, who asked to be identified only by his first name out of fear of persecution. It was the longest he'd ever gone without sex so he agreed.
"I just did it with him. I needed some release," he says, his voice getting hard as he frowns and looks away.
Four months later, Livingstone, who had tested negative for HIV when he was imprisoned seven months earlier, tested positive for the virus that causes AIDS.
He is one of a number of people in Uganda's prisons who have tested positive for HIV. According to government data, HIV rates in Uganda's prisons more than double the national average, despite ongoing efforts to battle spread of the virus in the country. LGBT+ activists and advocates say this is because the government refuses to acknowledge same-sex acts as a mode of HIV transmission in prisons and won't supply preventive measures such as condoms, preexposure prophylaxis, known as PrEP, and post-exposure prophylaxis, called PEP. And with the anti-homosexuality law passed in May 2023 -- upheld by the Constitutional Court nearly a year later after being challenged by activists -- they say the government has been able to double down on its stance, using the law as an excuse to continue to deny preventive treatments.
In all, 12.5% of prison staff and 15% of prisoners are HIV positive, according to a report presented by Parliament's Committee on Defence and Internal Affairs in August 2022, which is yet to be made available to the public. This is more than twice the national adult prevalence rate of 5.8%, according to the latest published data from a Ministry of Health-led survey.
PrEP and PEP are treatments for people at risk of HIV exposure. PEP is more commonly used and is given to people who have been raped and to medical professionals exposed to HIV while working. It's only given to people who have tested HIV negative.
The government is ashamed to admit that same-sex relationships happen in its prisons, says Richard Lusimbo, director general of Uganda Key Populations Consortium, a local nongovernmental organization that advocates for health, human rights and social-economic justice. If it continues to discriminate against men who have sex with men in prison, he says, the fight against new HIV infections will never be successful.
"Until government realizes that, regardless of the laws, everyone has the right to safe, consensual sex -- whether they are in prison or not -- we will never broadly address the issues that expose people to HIV," Lusimbo says.
Health care partners that provide HIV preventive care in Uganda have asked the Ministry of Health to provide treatments to prisoners, Lusimbo says, but to no avail. The government could provide these preventive measures, even under existing laws, he says. He points to Lesotho as an example.
Lesotho is one of two countries in southern Africa that distributes condoms in its prisons, according to the United Nations Office on Drugs and Crime. The country does this despite having ambiguous laws about same-sex acts. The Penal Code Act in 2010 decriminalized same-sex acts, but homosexuality and sodomy are still listed in the Criminal Procedure and Evidence Act as offenses for which arrests can be made without a warrant.
"We can do it too," Lusimbo says.
Sam Ganafa, the executive director of Spectrum, a local organization that provides health services to men who have sex with men, agrees. The government is aware that some prisoners are having sex, he says.
"But because of the unrealistic, discriminative anti-homosexuality law in place, these effective HIV prevention treatments are limited to only those outside of prison," he says.
The government doesn't provide PrEP and PEP to prisoners because that could promote homosexuality, says Frank Baine Mayanja, the Uganda Prisons Service spokesperson. And while same-sex acts do occur between incarcerated people, he does not think that is responsible for the high HIV rates.
People are tested for HIV as they enter prison, says Baine, who goes by his middle name. Those who test positive are given HIV treatment throughout their sentence. But some inmates are locked up during the virus's incubation period, when its presence doesn't show up on tests. This period differs from person to person but is typically around three months.
In 2023, 13% of women and 11% of men in Uganda's prisons had HIV, says Baine, citing unpublished data from the Uganda Prisons Service.
"If the HIV prevalence was a result of homosexuality, as it is being alleged in the media, how come it's high among females?" Baine says.
The prison's medical services team warns prisoners against sharing sharp instruments and having unprotected sex because of the risk of HIV transmission, he says. And the team tells those who are HIV positive to adhere to their antiretroviral therapy.
According to HIV testing data presented at a 2020 conference cohosted by the Center for Disease Control Uganda, more than 50% of new HIV infections in Uganda's prisons occur among people who have been incarcerated for longer than six months. This suggests transmission is likely happening within prison. The presentation also notes that estimated rates of illicit drug use and of men having sex with men are higher in prisons than national estimated rates.
There are multiple risk factors for HIV transmission in prisons, including sharing sharp instruments like razor blades, injection-drug use, tattooing, "homosexual behavior," and sexual assault, according to a 2014 survey presented to Parliament.
According to the survey, around 28% of prisoners, both men and women, agreed that men would use condoms if they were provided. However, 39.5% believed that access to condoms would lead to more sex in prisons.
Nabukalu, who asked to be identified only by her first name for fear of persecution, was in a women's prison for a week over rent default. While she didn't see any incarcerated women having sex with each other, she says she heard rumors of them having sex with male staff. Because of that, prisoners, both men and women, should be provided condoms and other HIV preventive treatments, she says.
Dr. Nelson Musoba, director general of Uganda AIDS Commission, a government agency that coordinates the response to the country's HIV/AIDS epidemic, says preventive measures should be accessible to everyone who thinks they are at risk of contracting HIV, but the treatments are not available in prisons under the government's HIV prevention program.
"It's a complicated issue that we can do nothing about because of the laws in place," he says.
Dr. Stephen Watiti, an HIV activist, says he doesn't advocate for access to HIV preventive treatments in prisons because of the law. Instead, he encourages people in prison to adhere to their antiretroviral treatments to suppress their viral load.
"If they take their medicine very well, chances are high that they will not transmit the HIV virus to their sexual partners in prison," he says.
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Regan, who was incarcerated for three and a half years for having sex with an underage girl, says men having sex with men in Ugandan prisons is more common than the government wants to publicly admit. He was what he calls a "police officer" in the prison, referring to a prefect role that is awarded to inmates for good behavior. Regan walked around the prison dormitory at night to supervise his fellow inmates.
"More than three times I saw inmates make out in the night as I was patrolling," says Regan, who asked to use only his first name for fear of persecution.
He reported inmates having sex to staff, he adds.
"Those reported would have the word homosexual written on their uniform for a month, be beaten, and I heard some [were] raped," he says.
Baine would not comment on Regan's allegation. Sexual activities between prisoners and staff are prohibited, Baine adds.
Livingstone isn't sure how he contracted the virus, because he says he had unprotected sex with a woman he didn't know five days before his arrest.
But whether he contracted the virus in prison or not, he thinks providing condoms and other HIV preventive measures would be an effective way to limit new infections like his.
A lot of sex is transactional in prison, Livingstone says. When he had sex with the man, he wanted release, he says, but he also wanted to show his gratitude. The man had bought him meals he couldn't afford, Livingstone says, like meat and matooke, a dish made from a type of banana with the same name.
"Homosexuality is real in Ugandan prisons," he says.
Nakisanze Segawa is a Global Press Journal reporter based in Kampala, Uganda.
