Millie Milton, 52, identifies as a transgender woman and has for more than 18 years. She remembers wearing her mother's veil and clothes from as young as 11 and preferring "female chores" such as sweeping the house.
"My family is very liberated," she said, referencing her mixed ancestry, with an Indian mother and a Nigerian father. She feels comfortable dressing as a woman, believing that this is what best expresses her "as an individual."
According to UNAIDS, new HIV infections among gay men and other men who have sex with men are rising
Advocates are concerned about increasing anti-gay sentiment worldwide
"But where society is concerned, it's a problem."
Milton lives in Guyana, where punitive laws prohibit LGBT people from outwardly being who they are. Homosexual acts are illegal, and men cannot cross-dress for any "improper purpose," the broad definition of which means people who do so still fear arrest or abuse.
Transgender people also struggle to find employment in the small South American country, often resorting to sex work, according to Milton, who is president of Guyana Trans United, the only trans-led organization in the country.
Milton herself found employment in a rum company, she said, but struggled with abuse for decades before finally leaving.
Speaking to CNN at the 22nd International AIDS Conference in Amsterdam this week, she recalled an evening when she walked home through her village and was pelted with bottles by a group of local men. When she reported it to the police, she was told only to let them know if it happened again, she said. On another occasion, she was kicked off a bus for the way she dressed, she said, and used her organization to throw more force at the police this time, eventually taking the driver to court. He pleaded guilty and paid a $70 fine.
"Nobody takes me on the bus anymore," she said.
Too scared to walk and now unable to board buses, Milton mostly travels by taxi, at great cost, including to the health center 11 kilometers (7 miles) away to pick up her antiretroviral drugs.
Milton is HIV-positive and registers for treatment at a clinic farther from home in order to avoid further discrimination in her area.
"It's challenging for me to access treatment," she said. The more obstacles there are, the more likely it is that people will stop taking their treatment altogether.
Milton's organization refuses to let trans people live in fear, instead fighting the barriers that keep them from living the way they want and, for those with HIV, fighting the abuse that stops them from getting treatment to suppress the virus.
Studies have shown that continuously taking antiretroviral drugs can reduce the virus to undetectable levels, but for many LGBT communities -- in Guyana and globally -- access to services is blocked through the homophobia they face.
The issue led Guyana Trans United to call for some emergency help -- from Sir Elton John.
Since 2015, the Elton John AIDS Foundation has been enabling a $10 million fund in partnership with the US President's Emergency Plan for AIDS Relief, known as PEPFAR, to provide grants to organizations that meet the HIV-related needs of LGBT people but that themselves need help. One part of the fund is a rapid response grant that can get money to people in dire need within 72 hours.
Milton reached out on behalf of her organization. At first, it sought money to provide HIV testing and treatment, but the request expanded as she realized that much more needed to change in Guyana. "We need policy changes. We need to sensitize institutions that we get services from," she said. "So we can change our country."
This is the goal of the fund: to support civil society organizations worldwide in changing mindsets and proving that change can happen -- showing governments that it is possible.
"It's the best way to do it, the way we're doing it, and then for the governments to get on board," John told CNN on Tuesday. "We set out templates. ... Governments see they work and come on board with us.
"I don't think there's been a country that we've worked in that it hasn't worked," he said.
The fund has helped LGBT people avoid death threats in Uganda, stop abuse in refugee camps in Malawi, change attitudes among the police in multiple countries and help evicted church clergy find sanctuary.
But there are many more people to help, and today, HIV experts fear that the numbers may only go up.
A global shift to the right
"Our concern at the moment is that there is a shift towards the right," said Shaun Mellors, director of knowledge and influence at the International HIV/AIDS Alliance, who coordinates the Elton John Foundation's rapid response grants. "It's all bubbling up, and it's all increasing at the moment in a really scary way."
South African-born Mellors, 53, is openly gay and living with HIV. He fears that the rise in more conservative mentalities will further increase homophobic mindsets, giving them a louder voice, pushing LGBT people underground and away from HIV services -- both treatment and prevention.
According to UNAIDS, new HIV infections among gay men and other men who have sex with men are rising.
The region where "HIV rates are highest among men who have sex with men is sub-Saharan Africa, the second highest is the Caribbean, and these are both regions with high social intolerance for same-sex behavior," added Chris Beyrer, the Desmond Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health.
"It's impossible to say there is direct causality, but there certainly is a very strong correlation," he said.
A recent report by Human Rights Watch went further and showed a link between crackdowns on LGBT people and HIV rates, finding that attacks, raids and an attitude of open hostility towards LGBT groups in Indonesia by authorities and Islamist militant groups has derailed public health efforts to prevent and curb new infections.
And while the increase in conservative thinking is happening globally, Mellors believes the greatest impact at the moment is in Africa, led by religious groups.
"The fundamentalist religious right has loads of money and is coming in Africa to talk to members of parliament and first ladies and share family values, as in traditional heterosexual family values," he said.
He cites Uganda's anti-homosexuality law, which can sentence homosexuals to life imprisonment, as well as Tanzania, where a change of government in 2017 saw the closure of 30 clinics providing HIV services to known key populations, including LGBT, sex workers and drug users.
"You aren't allowed to do any outreach related to homosexuality. You aren't allowed to distribute lube with your condoms because it's a sign of promoting homosexuality," Mellors said.
Beyrer added the example of Nigeria, where the Same Sex Marriage (Prohibition) Act of 2014 bans same-sex marriage or civil unions, "the public show of same sex amorous relationship" or aiding same-sex marriage and/or gay clubs and societies.
A study of gay men that was ongoing while the new law kicked in found "a substantial increase became virally unsuppressed [meaning the virus was not being controlled by drugs] and lost access to treatment," he said. "There, we could say we had a direct causality."
The study showed a 13% increase in fears of seeking health care and an 8% rise in avoiding health care. "These newly restricted laws were actually making the epidemic for gay men worse in that country," Beyrer said.
He highlighted Mellor's point on traditional family values being asserted "in opposition to liberal values" and the power this can have on the African continent.
"Families are sacred in Africa. ... People rely on their families and kinship networks because they cannot rely on their governments," Beyrer said. "If you are told repeatedly 'these people are undermining the family; they're trying to destroy the African family,' those are fighting words."
The religious influence
"We know it's coming from the US. We know the organizations who are coming to Africa" to build influence, Mellor said, giving examples such as the World Congress of Families, whose themes include "Building Family-Friendly Nations: Making Families Strong Again."
"We do have to find a way of how we're going to counteract this, because it's increasing in size, in wealth and its ability to influence politicians," he said.
Beyrer agreed, naming US pastor Scott Lively as a vocal and influential evangelical Christian funding these causes.
"They feel like America is lost. Marriage equality means they have been defeated, and they have lost the ability to influence American political life," Beyrer said. "Africa is a place they can influence."
Another factor fueling the pushback on liberal movements: modern youth. More connected than ever, adolescents globally are able to explore and connect, resulting in an increasingly liberal generation, he said.
John and his husband, David Furnish, agreed on this point of modern life, which enables LGBT people today to feel less marginalized. "They feel part of the world," John said.
Beyrer, however, fears that the rise of liberal youth and resulting LGBT movements are what's igniting pushback from the religious right. "That dynamic is playing out country after country," he said. "HIV is often at the center of it."
Tackling the trend
Although he thinks things will get worse before they get better in LGBT communities, Beyrer is hopeful that the issues of homophobia and HIV can be tackled indirectly, through community groups and clinics to go around restrictive laws.
Most countries have signed agreements and made international commitments to provide universal access to HIV drugs, he explained. "We can address that and say, 'all means all, and no one should be excluded based on sexual orientation or gender identity,' " he said.
Another argument to be made is on public health, with evidence showing that the epidemic cannot be controlled if the most vulnerable are excluded, he said.
Mellor, on the other hand, hopes to use the rapid response grant he coordinates to help tackle the situation in a smart way, working closely with advocacy organizations to make changes in advance so they are prepared and have emergency plans to protect themselves.
We need to "somehow try and counteract what is happening in far too many of the countries, particularly in East Africa," he said.
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