Sexual minorities, sex workers and people who use drugs who are at a higher risk of HIV than the general population, but in Tanzania, they face widespread police abuse and discrimination in health facilities, according to the new report by Human Rights Watch (HRW) and the Wake Up and Step Forward Coalition (WASO), a local rights group.
The report, “Treat Us Like Human Beings”: Discrimination against Sex Workers, Sexual and Gender Minorities, and People Who Use Drugs in Tanzania, documents abuses against lesbian, gay, bisexual, transgender and intersex (LGBTI) people, men who have sex with men (MSM), sex workers, and drug users. Abuses include denial of health services, violations of confidentiality and denial of freedom of association, as well as verbal harassment, arbitrary arrest, extortion, assault, torture, rape and murder.
"These human rights violations contribute to an environment in which men who have sex with men, transgender people, sex workers and people who inject drugs have become increasingly distrustful of the state," the two organizations said in a joint statement on 18 June. "Their fears undermine public health initiatives that depend on cooperation and partnership between the government and key populations that are most at risk of HIV infection."
The report was conducted between May 2012 and April 2013, with authors interviewing 121 members of high-risk groups, as well as Tanzanian government officials, service providers and academics.
Tanzania's HIV prevalence is 5.8 percent, according to UNAIDS, but high-risk groups have significantly higher rates. In a 2011 survey in one district of the commercial capital, Dar es Salaam, 34 percent of people who injected drugs tested positive for HIV, while separate data from Dar es Salaam showed that female sex workers' HIV prevalence was 31.4 percent. A 2009 review reported an HIV prevalence of 12.4 percent among MSM in Tanzania.
The HRW-WASO report identified dozens of cases in which health workers turned away sex workers, LGBTI people and drug users from health facilities without offering services. Those who sought care were often humiliated instead.
"It's a hard time for us [gays]. We are struggling. We are struggling to get HIV and other health services," Ally Semsella, WASO's chief executive officer, told IRIN by telephone. "The health workers in public health facilities don't want to treat us. It's only some private health facilities that help to attend to our members - but they also, too, fear."
"The doctor examined me and told me it was gonorrhoea, but then refused to treat me. He said, 'You already have sex with men, now you come here to bring us problems. Go away,'" the report quoted one man as saying. "He told me he wouldn't treat me because I'm MSM. I came back home and my mom took me to a private hospital."
Tanzania's HIV policy commits to increasing access to HIV prevention and services for key populations; to build partnerships with NGOs representing these marginalized groups; and to work towards the decriminalization of sex work and same-sex relations. However, activists say these strategies have been carried out half-heartedly.
"If health workers, because of their own prejudices, are turning away transgender people or gays or sex workers or people who use drugs, then they are violating their duties as medical professionals. If police are refusing to accept complaints from some members of society, they are failing to uphold the law," Neela Ghoshal, LGBTI rights researcher at HRW, told IRIN.
Olivia Clement, a Tanzanian activist for the rights of sex workers, told IRIN that sex workers regularly risked abuse at the hands of the police. "They are constantly arrested, harassed, abused, raped, asked for bribes and free sex in order to be released from custody. Those who can't afford to pay bribes end up languishing in bad conditions in prisons," she said.
"A majority of them can't get proper health services due to discrimination," she added. "The health providers should be taught not to discriminate... They have to offer health services to all people irrespective of their background."
WASO's Semsella called on Tanzanian President Jakaya Kikwete to publicly condemn police abuse, discrimination in healthcare, and all other forms of discrimination against sex workers, people who use drugs and LGBTI people.
The report notes that this discrimination reflects attitudes prevalent in the general public.
"Public perceptions of LGBTI people in Tanzania tend to be negative, but a large part of this is based on ignorance and misunderstanding. Many heterosexual Tanzanians don't believe that they know anyone who is gay or transgender or intersex," HRW's Ghoshal said. "And very few LGBTI Tanzanians have the courage to come out of the closet. They are afraid of being disowned by their families, evicted from their homes, expelled from school, fired from their jobs or even arrested."
She added: "The responsibility to end the kind of abuses that we documented does not lie with the society as a whole. That responsibility falls on the shoulders of the government. Discriminatory laws don't help in this regard, and neither does the abusive, appalling way in which police enforce the laws.
“If gay Tanzanians knew they could be themselves without risking being arrested, beaten or raped by the police, more of them would start to speak out, to tell their stories, and more heterosexual Tanzanians would begin to listen."
Homosexuality is punishable by life imprisonment under section 154 of the country's penal code.
Increasingly, public health experts believe decriminalization is key to fighting HIV in high-risk populations such as MSM, people who inject drugs and sex workers. Criminalization drives these groups further underground, limiting their access to sexual health information, prevention and treatment.
"The government’s HIV policy can't succeed if police are driving away the very people the public health programmes most need to reach," Ghoshal said in the statement.