Evaluating the impact of criminal laws on HIV risk behavior

HIV: California's 2018 criminalization reform and testing among those reporting risk behavior

HIV criminalization laws may discourage HIV testing. We tested whether California's 2018 HIV criminalization law reform increased the likelihood of past-year HIV testing compared to Nevada, which did not reform its HIV criminalization law. We fitted two difference-in-differences logistic regression models: one for all respondents reporting behaviors that increase the chances of getting or transmitting HIV, and one for male respondents reporting these behaviors. All analyses accounted for the complex survey design of BRFSS. HIV criminalization reform was significantly associated with an increased likelihood of past-year HIV testing. After reform, the predicted marginal probability of past-year HIV testing increased by six percentage points. By comparison, probabilities of a past-year HIV test decreased in Nevada. HIV criminalization law reform may increase the likelihood of getting tested by individuals who engage in behaviors that increase the chances of getting or transmitting HIV.

Reshaping the narrative: Tracing the historical trajectory of HIV/AIDS, gay men, and public health in Sweden

The human immunodeficiency virus (HIV) emerged as an endemic health crisis in the United States during the early 1980s. Initially labelled a "gay disease" due to its prevalence among gay men, the spread of HIV led to widespread fear and moral panic, as there was limited medical knowledge on preventing its transmission. While HIV is often associated with Sub-Saharan Africa, this article focuses on Sweden, a pioneering nation that became the first to achieve the remarkable Joint UNAIDS/WHO 90-90-90 continuum in addressing the epidemic. However, despite this significant milestone, the punitive legislation and attitudes prevalent in Sweden have had a counterproductive effect on curbing the virus's spread. Drawing upon a comprehensive triangulation of various data and sources on the evolution of public policy in Sweden, this article argues for the urgent need to reduce stigma surrounding HIV and AIDS. By undertaking further measures to combat stigmatisation, we not only have the potential to prevent the spread of HIV but also significantly enhance the quality of life for individuals living with the virus. An essential step in this journey is to eliminate the legally-enforced mandatory disclosure of one's HIV status, which would mark a tremendous victory for all those affected. With limited evidence to support the effectiveness of criminalisation and penal laws, no longer being viewed as criminals for non-disclosure would be a monumental achievement, positively transforming the lives of people living with HIV and fostering a more inclusive and supportive society.

HIV Criminalization Laws and Enforcement: Assessing the Relationship Between HIV Criminalization at the State Level, Policing at the County Level, and County-level HIV Incidence Rates

The U.S. HIV epidemic disproportionately affects Black and Hispanic communities via ecosocial determinants of excess HIV risk, including HIV criminalization laws and overpolicing. This study used multilevel modeling to test the hypothesis that HIV criminalization laws are associated with higher county HIV incidence, and that this effect is modified by heavier county-level policing. County-level HIV incidence data from 2010 to 2019 were merged with county-level demographic, socioeconomic, and jailed population rate data for counties with stable HIV incidence rates (rates generated from a numerator of at least 12) for > 5 years. Multivariable multilevel (hierarchical) models for count-rate data were fitted, with years nested inside counties, and counties nested within states. An HIV criminalization law was associated with higher countywide HIV incidence rate for the general, Black, and Hispanic populations (aRR = 1.14, 1.30, and 1.32, respectively). This association was modified by an increased county jailed population rate for the general and Black populations.

"We're actually more of a likely ally than an unlikely ally": relationships between syringe services programs and law enforcement

Background

Syringe services programs provide sterile injection supplies and a range of health services (e.g., HIV and HEP-C testing, overdose prevention education, provision of naloxone) to a hard-to-reach population, including people who use drugs, aiming to prevent the transmission of infectious diseases.

Methods

We performed a qualitative needs assessment of existing syringe services programs in the state of Colorado in 2018–2019 to describe—their activities, needs, and barriers. Using a phenomenological approach, we performed semi-structured interviews with key program staff of syringe services programs (n = 11). All interviews were digitally recorded, transcribed, and validated. A data-driven iterative approach was used by researchers to develop a coding scheme to organize the data into major themes found across interviews. Memos were written to synthesize main themes.

Results

Nearly all the syringe program staff discussed their relationships with law enforcement at length. All syringe program staff viewed having a positive relationship with law enforcement as critical to the success of their program. Main factors that influence the quality of relationships between syringe services programs and law enforcement included: (1) alignment in agency culture, (2) support from law enforcement leadership, (3) police officers’ participation and compliance with the Law Enforcement Assisted Diversion (LEAD) program, which provides intensive case management for low-level drug offenders, and (4) implementation of the “Needle-Stick Prevention Law” and Drug Paraphernalia Law Exemption. All syringe program staff expressed a strong desire to have positive relationships with law enforcement and described how a collaborative working relationship was critical to the success of their programs.

Conclusions

Our findings reveal effective strategies to foster relationships between syringe services programs and law enforcement as well as key barriers to address. The need exists for both syringe services programs and law enforcement to devote time and resources to build a strong, positive partnership. Having such positive relationships with law enforcement has positive implications for syringe services program clients, including law enforcement being less likely to ticket persons for having used syringes, and encourage people who use drugs to seek services from syringe services programs, which can then lead them to other resources, such as housing, wound care, and substance use treatment programs.

A Dyadic Analysis of Criminal Justice Involvement and Sexual HIV Risk Behaviors Among Drug-Involved Men in Community Corrections and Their Intimate Partners in New York City: Implications for Prevention, Treatment and Policies

People in community corrections have rates of HIV and sexual risk behaviors that are much higher than the general population. Prior literature suggests that criminal justice involvement is associated with increased sexual risk behaviors, yet these studies focus on incarceration and use one-sided study designs that only collect data from one partner. To address gaps in the literature, this study used the Actor Partner-Interdependence Model with Structural Equation Modeling (SEM), to perform a dyadic analysis estimating individual (actor-only) partner-only, and dyadic patterns (actor-partner) of criminal justice involvement and greater sexual risks in a sample of 227 men on probation and their intimate partners in New York City, United States. Standard errors were bootstrapped with 10,000 replications to reduce bias in the significance tests. Goodness of fit indices suggested adequate or better model fit for all the models. Significant actor-only relationships included associations between exposures to arrest, misdemeanor convictions, time spent in jail or prison, felony convictions, lifetime number of incarceration events, prior conviction for disorderly conduct and increased sexual risk behaviors. Partner only effects included significant associations between male partners conviction for a violent crime and their female partners' sexual risk behaviors. Men's encounters with police and number of prior misdemeanors were associated with their own and intimate partners' sexual risk behaviors. Women's prior arrest was associated with their own and intimate partners' sexual risk behaviors. The results from the present study suggest that men on probation and their intimate partners' criminal justice involvement are associated with increased engagement in sexual risk behaviors. It is necessary to conduct greater research into developing dyadic sexual risk reduction and HIV/STI prevention interventions for people who are involved in the criminal justice system.

Law and mental health: A bridge between individual neurobiology and the collective organization of behaviors

Mental disorders (MD) or mental symptoms (MS) have multifactorial causes. Today we know much more about the variables that cause individual MD\MS, but in our opinion these characterizations, although essential, are not sufficient to account for the complexity in which we live. For example, they do not explain in a coherent and empirically verifiable way how the biological individual relates to the social architecture in which he lives. This article presents a hypothesis that connects social and organizational structures to the emergence of symptoms and mental disorders in the population. It is our belief that some of these structures fundamentally impact the distribution of MD/MS in a population and the medical and psychological communities must consider this impact seriously. Laws aim at directing the behavior of groups of people, whose behavior is strictly interdependent with their neurobiology. Given the ability of laws to direct the behaviors that regulate social interactions, traumatic factors may be considered capable of linking a non-material object (e.g., a law) to a real effect (e.g., MS/MD). We discuss, as a paradigmatic example, the laws that regulate the use of psychotropic substances.

Prosecution of non-disclosure of HIV status: Potential impact on HIV testing and transmission among HIV-negative men who have sex with men

Background

Non-disclosure criminal prosecutions among gay, bisexual and other men who have sex with men (MSM) are increasing, even though transmission risk is low when effective antiretroviral treatment (ART) is used. Reduced HIV testing may reduce the impact of HIV “test and treat” strategies. We aimed to quantify the potential impact of non-disclosure prosecutions on HIV testing and transmission among MSM.

Methods

MSM attending an HIV and primary care clinic in Toronto completed an audio computer-assisted self-interview questionnaire. HIV-negative participants were asked concern over non-disclosure prosecution altered their likelihood of HIV testing. Responses were characterized using cross-tabulations and bivariate logistic regressions. Flow charts modelled how changes in HIV testing behaviour impacted HIV transmission rates controlling for ART use, condom use and HIV status disclosure.

Results

150 HIV-negative MSM were recruited September 2010 to June 2012. 7% (9/124) were less or much less likely to be tested for HIV due to concern over future prosecution. Bivariate regression showed no obvious socio/sexual demographic characteristics associated with decreased willingness of HIV testing to due concern about prosecution. Subsequent models estimated that this 7% reduction in testing could cause an 18.5% increase in community HIV transmission, 73% of which was driven by the failure of HIV-positive but undiagnosed MSM to access care and reduce HIV transmission risk by using ART.

Conclusions

Fear of prosecution over HIV non-disclosure was reported to reduce HIV testing willingness by a minority of HIV-negative MSM in Toronto; however, this reduction has the potential to significantly increase HIV transmission at the community level which has important public health implications.

Association of HIV diagnosis rates and laws criminalizing HIV exposure in the United States

OBJECTIVE

To assess whether state criminal exposure laws are associated with HIV and stage 3 (AIDS) diagnosis rates in the United States.

DESIGN

We assessed the relationship between HIV and stage 3 (AIDS) diagnosis data from the National HIV Surveillance System and the presence of a state criminal exposure law as identified through WestlawNext by using generalized estimating equations.

METHODS

We limited analysis to persons aged at least 13 years with diagnosed HIV infection or AIDS reported to the National HIV Surveillance System of the Centers for Disease Control and Prevention. The primary outcome measures were rates of diagnosis of HIV (2001-2010 in 33 states) and AIDS (1994-2010 in 50 states) per 100 000 individuals per year. In addition to criminal exposure laws, state-level factors evaluated for inclusion in models included income, unemployment, poverty, education, urbanicity, and race/ethnicity.

RESULTS

At the end of the study period, 30 states had laws criminalizing HIV exposure. In bivariate models (P < 0.05), unemployment, poverty, education, urbanicity, and race/ethnicity were associated with HIV and AIDS diagnoses. In final models, proportion of adults with less than a high school education and percentage of the population living in urban areas were significantly associated with HIV and AIDS diagnoses over time; criminal exposure laws were not associated with diagnosis rates.

CONCLUSION

We found no association between HIV or AIDS diagnosis rates and criminal exposure laws across states over time, suggesting that these laws have had no detectable HIV prevention effect.

Criminalization of HIV Exposure: A Review of Empirical Studies in the United States

This review of literature identifies and describes US empirical studies on the criminalization of HIV exposure, examines findings on key questions about these laws, highlights knowledge gaps, and sets a course for future research. Studies published between 1990 and 2014 were identified through key word searches of relevant electronic databases and discussions with experts. Twenty-five empirical studies were identified. Sixteen of these studies used quantitative methods with more than half of these being cross-sectional survey studies. Study samples included male and female HIV-positive persons, HIV-positive and -negative men who have sex with men, public health personnel, and medical providers. Research questions addressed awareness of and attitudes toward HIV exposure laws, potential influences of these laws on seropositive status disclosure for persons living with HIV, HIV testing for HIV-negative persons, safer sex practices for both groups, and associations between HIV exposure laws and HIV-related stigma. Surveys of the laws and studies of enforcement practices were also conducted. Attention should be shifted from examining attitudes about these laws to exploring their potential influence on public health practices and behaviors related to the HIV continuum of care. Studies examining enforcement and prosecution practices are also needed. Adapting a theoretical framework in future research may be useful in better understanding the influence of HIV exposure laws on HIV risk behaviors.

IAPAC Guidelines for Optimizing the HIV Care Continuum for Adults and Adolescents

BACKGROUND

An estimated 50% of people living with HIV (PLHIV) globally are unaware of their status. Among those who know their HIV status, many do not receive antiretroviral therapy (ART) in a timely manner, fail to remain engaged in care, or do not achieve sustained viral suppression. Barriers across the HIV care continuum prevent PLHIV from achieving the therapeutic and preventive effects of ART.

METHODS

A systematic literature search was conducted, and 6132 articles, including randomized controlled trials, observational studies with or without comparators, cross-sectional studies, and descriptive documents, met the inclusion criteria. Of these, 1047 articles were used to generate 36 recommendations to optimize the HIV care continuum for adults and adolescents.

RECOMMENDATIONS

Recommendations are provided for interventions to optimize the HIV care environment; increase HIV testing and linkage to care, treatment coverage, retention in care, and viral suppression; and monitor the HIV care continuum.

Police Encounters Among Needle Exchange Clients in Baltimore: Drug Law Enforcement as a Structural Determinant of Health

OBJECTIVES

We piloted a monitoring mechanism to document police encounters around programs targeting people who inject drugs (PWID), and assessed their demographic predictors at 2 Baltimore, Maryland, needle exchange program (NEP) sites.

METHODS

In a brief survey, 308 clients quantified, characterized, and sited recent police encounters. Multivariate linear regression determined encounter predictors, and we used geocoordinate maps to illustrate clusters.

RESULTS

Within the past 6 months, clients reported a median of 3 stops near NEP sites (interquartile range [IQR] = 0-7.5) and a median of 1 arrest in any location (IQR = 0-2). Three respondents reported police referral to the NEP. Being younger (P = .009), being male (P = .033), and making frequent NEP visits (P = .02) were associated with reported police stops. Among clients reporting arrest or citation for syringe possession, Whites were significantly less likely than non-Whites to report being en route to or from an NEP (P < .001). Reported encounters were clustered around NEPs.

CONCLUSIONS

Systematic surveillance of structural determinants of health for PWID proved feasible when integrated into service activities. Improved monitoring is critical to informing interventions to align policing with public health, especially among groups subject to disproportionate levels of drug law enforcement.

HIV disclosure as practice and public policy

Responses to the largest surveys of HIV-positive people in Ontario show that most either disclose to or do not have partners who are HIV-negative or of unknown status. Non-disclosure strategies and assumptions are reported by relatively small sets of people with some variation according to employment status, sexual orientation, gender, ethnicity, and having had a casual partner. Interviews with 122 people living with HIV show that disclosure is an undertaking fraught with emotional pitfalls complicated by personal histories of having misread cues or having felt deceived leading up to their own sero-conversion, then having to negotiate a stigmatized status with new people. In gay communities, constructions of the self as individual actors in a marketplace of risk co-exist with the sexual etiquette developed throughout the AIDS era of care of the self and other through safer sex. Among heterosexual populations, notions of responsibility show some divergence by gender. The findings of this study suggest that the heightened pressure of criminal sanction on decision-making about disclosure in personal interactions does not address difficulties in HIV transmission and is unlikely to result in enhanced prevention.

Prevalence and public health implications of state laws that criminalize potential HIV exposure in the United States

For the past three decades, legislative approaches to prevent HIV transmission have been used at the national, state, and local levels. One punitive legislative approach has been enactment of laws that criminalize behaviors associated with HIV exposure (HIV-specific criminal laws). In the USA, HIV-specific criminal laws have largely been shaped by state laws. These laws impose criminal penalties on persons who know they have HIV and subsequently engage in certain behaviors, most commonly sexual activity without prior disclosure of HIV-positive serostatus. These laws have been subject to intense public debate. Using public health law research methods, data from the legal database WestlawNext© were analyzed to describe the prevalence and characteristics of laws that criminalize potential HIV exposure in the 50 states (plus the District of Columbia) and to examine the implications of these laws for public health practice. The first state laws were enacted in 1986; as of 2011 a total of 67 laws had been enacted in 33 states. By 1995, nearly two-thirds of all laws had been enacted; by 2000, 85 % of laws had been enacted; and since 2000, an additional 10 laws have been enacted. Twenty-four states require persons who are aware that they have HIV to disclose their status to sexual partners and 14 states require disclosure to needle-sharing partners. Twenty-five states criminalize one or more behaviors that pose a low or negligible risk for HIV transmission. Nearly two-thirds of states in the USA have legislation that criminalizes potential HIV exposure. Many of these laws criminalize behaviors that pose low or negligible risk for HIV transmission. The majority of laws were passed before studies showed that antiretroviral therapy (ART) reduces HIV transmission risk and most laws do not account for HIV prevention measures that reduce transmission risk, such as condom use, ART, or pre-exposure prophylaxis. States with HIV-specific criminal laws are encouraged to use the findings of this paper to re-examine those laws, assess the laws' alignment with current evidence regarding HIV transmission risk, and consider whether the laws are the best vehicle to achieve their intended purposes.

HIV criminal prosecutions and public health: an examination of the empirical research

OBJECTIVES

To review the extant literature on HIV criminal laws, and to determine the impact of these laws on public health practice.

METHODS

The available research on this topic was obtained and reviewed.

RESULTS

The extant literature addressed three main topics: people's awareness of HIV criminal laws; people's perceptions of HIV criminal laws; and the potential effects of HIV criminal laws on people's sexual, HIV-status disclosure and healthcare-seeking practices. Within these categories, the literature demonstrated a high level of awareness of HIV criminal laws, but a poor comprehension of these laws. For perceptions, on the whole, the quantitative research identified support for, while the qualitative literature indicated opposition to, these laws. Lastly, the behavioural effects of HIV criminal laws appear to be complex and non-linear.

CONCLUSIONS

A review of the extant literature from a public health perspective leads to the conclusion that HIV criminal laws undermine public health.

Charges for criminal exposure to HIV and aggravated prostitution filed in the Nashville, Tennessee Prosecutorial Region 2000-2010

This paper examines comprehensive data on arrests for HIV-specific crimes within a single jurisdiction, the Nashville Tennessee prosecutorial region, over 11 years. There were 25 arrests for HIV exposure and 27 for aggravated prostitution. Eleven of the arrests for HIV exposure involved nonsexual behaviors; none alleged transmission. Sixteen of the arrests for HIV exposure involved sexual behavior; three alleged transmission. Aggravated prostitution cases (i.e. prostitution while knowing one has HIV) often involved solicitation of oral sex; none alleged transmission. Maximum sentences for HIV-specific crimes ranged from 5 to 8 years. We conclude that enforcement of US HIV-specific laws is underestimated. Fifty-two arrests over 11 years were recorded in one jurisdiction. Over half of the arrests involved behaviors posing minimal or no HIV transmission risk. Despite concerns about malicious, intentional HIV transmission, no cases alleged malice or intention.

Associations between the legal context of HIV, perceived social capital, and HIV antiretroviral adherence in North America

BACKGROUND

Human rights approaches to manage HIV and efforts to decriminalize HIV exposure/transmission globally offer hope to persons living with HIV (PLWH). However, among vulnerable populations of PLWH, substantial human rights and structural challenges (disadvantage and injustice that results from everyday practices of a well-intentioned liberal society) must be addressed. These challenges span all ecosocial context levels and in North America (Canada and the United States) can include prosecution for HIV nondisclosure and HIV exposure/transmission. Our aims were to: 1) Determine if there were associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital (resources to support one's life chances and overcome life's challenges), and HIV antiretroviral therapy (ART) adherence among PLWH and 2) describe the nature of associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital, and HIV ART adherence among PLWH.

METHODS

We used ecosocial theory and social epidemiology to guide our study. HIV related criminal law data were obtained from published literature. Perceived social capital and HIV ART adherence data were collected from adult PLWH. Correlation and logistic regression were used to identify and characterize observed associations.

RESULTS

Among a sample of adult PLWH (n = 1873), significant positive associations were observed between perceived social capital, HIV disclosure required by law, and self-reported HIV ART adherence. We observed that PLWH who have higher levels of perceived social capital and who live in areas where HIV disclosure is required by law reported better average adherence. In contrast, PLWH who live in areas where HIV transmission/exposure is a crime reported lower 30-day medication adherence. Among our North American participants, being of older age, of White or Hispanic ancestry, and having higher perceived social capital, were significant predictors of better HIV ART adherence.

CONCLUSIONS

Treatment approaches offer clear advantages in controlling HIV and reducing HIV transmission at the population level. These advantages, however, will have limited benefit for adherence to treatments without also addressing the social and structural challenges that allow HIV to continue to spread among society's most vulnerable populations.

Criminalization of HIV transmission and exposure: research and policy agenda

More than half of US jurisdictions have laws criminalizing knowing exposure to or transmission of HIV, yet little evidence supports these laws' effectiveness in reducing HIV incidence. These laws may undermine prevention efforts outlined in the US National HIV/AIDS Strategy, in which the United States has invested substantial federal funds. Future research should include studies of (1) the impact of US HIV exposure laws on public health systems and practices; (2) enforcement of these laws, including arrests, prosecutions, convictions, and sentencing; (3) alternatives to HIV exposure laws; and (4) direct and opportunity costs of enforcement. Policy efforts to mitigate potential negative impacts of these laws could include developing prosecutorial guidelines, modernized statutes, and model public health policies and protocols.

Harmonizing disease prevention and police practice in the implementation of HIV prevention programs: Up-stream strategies from Wilmington, Delaware

Introduction

Improving access to sterile injection equipment is a key component in community-based infectious disease prevention. Implementation of syringe access programs has sometimes been complicated by community opposition and police interference.

Case description

In 2006, the Delaware legislature authorized a pilot syringe exchange program (SEP). A program designed to prevent, monitor, and respond to possible policing and community barriers before they had a chance to effect program implementation and operation. A program designed to prevent, monitor, and respond to these barriers was planned and implemented by a multidisciplinary team of legal practitioners and public health professionals.

Discussion

We report on an integrated intervention to address structural barriers to syringe exchange program utilization. This intervention employs community, police and client education combined with systematic surveillance of and rapid response to police interference to preempt the kinds of structural barriers to implementation observed elsewhere. The intervention addresses community concerns and stresses the benefits of syringe exchange programs to officer occupational safety.

Conclusions

A cohesive effort combining collaboration with and educational outreach to police and community members based on the needs and concerns of these groups as well as SEP clients and potential clients helped establish a supportive street environment for the SEP. Police-driven structural barriers to implementation of public health programs targeting populations engaged in drug use and other illicit behavior can be addressed by up-stream planning, prevention, monitoring and intervention strategies. More research is needed to inform the tailoring of interventions to address police-driven barriers to HIV prevention services, especially among marginalized populations.

Criminalising consensual sexual behaviour in the context of HIV: consequences, evidence, and leadership

This paper provides an overview of the use of the criminal law to regulate sexual behaviour in three areas of critical importance: (1) HIV exposure in otherwise consensual sex, (2) sex work and (3) sexual activity largely affecting sexual minorities. It analyses criminal law pertaining to these three distinct areas together, allowing for a more comprehensive and cohesive understanding of criminalisation and its effects. The paper highlights current evidence of how criminalisation undermines HIV prevention and treatment. It focuses on three specific negative effects of criminalisation: (1) enhancing stigma and discrimination, (2) undermining public health intervention through legal marginalisation and (3) placing people in state custody. The paper also highlights gaps in evidence and the need for strong institutional leadership from UN agencies in ending the criminalisation of consensual sexual activity. This paper serves two goals: (1) highlighting the current state of research and emphasising where key institutions have or have not provided appropriate leadership on these issues and (2) establishing a forward-looking agenda that includes a concerted response to the inappropriate use of the criminal law with respect to sexuality as part of the global response to HIV.

Criminalization of HIV transmission and exposure: in search of rights-based public health alternatives to criminal law

The use of criminal law to address HIV transmission and exposure has been misguided and ineffective. Criminalization of HIV transmission and exposure raises difficult legal questions: what is the appropriate degree of mental culpability to trigger criminal prosecution? Is it appropriate for the law to equate nondisclosure of (known) HIV-positive status to a sexual partner with rape (as the law does in some jurisdictions)? Can it be justified to treat mere nondisclosure of HIV status as equivalent to the intent to cause harm? To what extent will the law recognize circumstances that mitigate harm, risk of harm and mental culpability, such as safer sex practices and low viral load, in mitigating the application of criminal sanctions? Sound guidance on avoiding the misuse of the criminal law in this area has been developed, but unfortunately many criminal laws in this area allow for prosecution even in cases where there is little justification. It is reasonable to expect that the use of these laws contributes to HIV-related stigma and discrimination, particularly when cases are portrayed sensationally in mass media. The harm caused by unjustified prosecutions and convictions and stigma is not counterbalanced by any evidence of public health benefits of this use of criminal law. These laws should urgently be repealed or reformed as part of a shift to strategies centered on human rights.

Dilemma of concepts and strategies for the prevention of spread of HIV in relation to human behavior, law and human rights

The new prevalence data regarding the estimated global number of human immunodeficiency virus positive (HIV+) cases, i.e., including people who are either aware or unaware of their HIV infection in 2010, lead many to wonder why the increase in incidence has reached today's unprecedented level and escalated within such a short time. This, in spite of prevention campaigns in countries affected by HIV/acquired immune deficiency syndrome (AIDS) with their urgent messages aimed at preventing HIV transmission by promoting changes in individual's behavior. This article analyzes the background of the prevention strategies, in particular their political, social and legal concepts in terms of human rights, and reveals traits of human behavior not considered thus far. A radical reappraisal is necessary, at social and legislative levels, as well as options additional to current concepts. When ethical issues come up, they become blamed for outmoded moralistic positions. However, ignoring the reality has led to dire consequences from prioritizing individual human rights over society's collective need to prevent the spread of HIV.

The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs

AIMS

To determine the comparative levels of and associations between policing interference and characteristics of US syringe exchange programs (SEPs).

DESIGN

Cross-sectional.

SETTING

A national survey of US SEPs.

PARTICIPANTS

A total of 111 program managers (representing 59% of all US SEPs).

MEASUREMENTS

Program manager self-report.

FINDINGS

With overall interference profiles ranging from systematic to totally interference-free, 43% of respondents reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients' syringes, 12% at least monthly client arrest en route to or from SEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of SEP, jurisdiction's syringe regulation environment and affiliation with health department were not associated with frequency of police interference. Programs serving predominantly injection drug users (IDUs) of color were 3.56 times more likely to report frequent client arrest en route to or from SEP and 3.92 times more likely to report unauthorized syringe confiscation. Those serving more than three sites were 3.96 times more likely to report client harassment, while stationary operation was protective against uninvited police appearances. The majority (56%) reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation from clients.

CONCLUSIONS

Findings highlight limitations of the impact of legal reforms on aligning police activities with SEP operations. Systematic adverse event surveillance and evidence-based structural interventions are needed to maximize the benefits of public health prevention targeting IDUs and other criminalized populations. SEPs that report no adverse events may represent programs already working in harmony with law enforcement agencies, a priority highlighted in US Centers for Disease Control's new SEP guidelines. The significance of mechanisms translating criminal justice disparities into health disparities is discussed.

An inappropriate tool: criminal law and HIV in Asia

BACKGROUND

Asian countries have applied criminal sanctions widely in areas directly relevant to national HIV programmes and policies, including criminalization of HIV transmission, sex work, homosexuality and drug injection. This criminalization may impede universal access to HIV prevention and treatment services in Asia and undermine vulnerable people's ability to be part of the HIV response.

OBJECTIVE

To review the status of application of criminal law in key HIV-related areas in Asia and analyze its impact.

METHODS

Review of literature and application of human rights norms to analysis of criminal law measures.

RESULTS AND CONCLUSION

Criminal laws in the areas considered here and their enforcement, while intended to reduce HIV transmission, are inappropriate and counterproductive with respect to health and human rights. Governments should remove punitive laws that impede the HIV response and should ensure meaningful participation of people living with HIV, people who use illicit drugs, sex workers and men who have sex with men in combating stigma and discrimination and developing rights-centered approaches to HIV.

Vertical HIV transmission should be excluded from criminal prosecution

Prevention of mother-to-child transmission of HIV (PMTCT) is an important part of global and national responses to HIV and AIDS. In recent years, many countries have adopted laws to criminalise HIV transmission and exposure. Many of these laws are broadly written and have provisions that enable criminal prosecution of vertical transmission in some circumstances. Even if prosecutions have not yet materialised, the use of these laws against HIV-positive pregnant women could compound the stigma already faced by them and have a chilling effect on women's utilisation of prevention of mother-to-child transmission programmes. Although criminal laws targeting HIV transmission have often been proposed and adopted with the intent of protecting women, such laws may disadvantage women instead. Criminal laws on HIV transmission and exposure should be reviewed and revised to ensure that vertical transmission is explicitly excluded as an object of criminal prosecution. Scaling up PMTCT services and ensuring that they are affordable, accessible, welcoming and of good quality is the most effective strategy for reducing vertical transmission of HIV and should be the primary strategy in all countries.

HIV-positive persons' awareness and understanding of their state's criminal HIV disclosure law

Commentary on the potential impact of HIV-specific disclosure laws on persons living with HIV has been critical, plentiful, and enduring. Yet empirical information with which to answer even the most basic questions about these laws, such as whether HIV-positive persons living in a state with a disclosure law are aware of the law, is absent. This study reports on data gathered from a statewide sample of 384 HIV-positive persons living in a state with an HIV disclosure law. Participant awareness and understanding of the law were assessed. Data on the sources from which participants received information on the law and the perceived helpfulness of these sources were also collected. Analyses were conducted to identify associations between participant awareness or understanding of the law and demographic characteristics of participants or information sources encountered. The majority of participants were aware that their state had enacted an HIV-specific disclosure law. Understanding of the law was good, although there was substantial confusion over several provisions. The most prevalent and most helpful sources of information on the law were AIDS-related resources as opposed to mass media. Forty-two percent of the participants learned about the law when first diagnosed with HIV. Sixty-two percent of the participants reported that their case manager had told them about the law.

HIV seropositive status disclosure to prospective sex partners and criminal laws that require it: perspectives of persons living with HIV

Thirty-one HIV-positive persons living in Michigan took part in focus group discussions about Michigan's HIV disclosure law. Discussion themes included perceived responsibility to prevent infection, concern about unwanted secondary disclosure of HIV-positive status, fear of being falsely accused of violating Michigan's HIV disclosure law and perceived vulnerability of HIV-positive persons within the US legal system. Although participants strongly agreed with the ostensible purpose of Michigan's criminal HIV disclosure law, there was considerable concern about the negative impact of the law on persons living with HIV.

Relation between HIV viral load and infectiousness: a model-based analysis

BACKGROUND

A consensus statement released on behalf of the Swiss Federal Commission for HIV/AIDS suggests that people receiving effective antiretroviral therapy-ie, those with undetectable plasma HIV RNA (<40 copies per mL)-are sexually non-infectious. We analysed the implications of this statement at a population level.

METHODS

We used a simple mathematical model to estimate the cumulative risk of HIV transmission from effectively treated HIV-infected patients (HIV RNA <10 copies per mL) over a prolonged period. We investigated the risk of unprotected sexual transmission per act and cumulatively over many exposures, within couples initially discordant for HIV status.

FINDINGS

Assuming that each couple had 100 sexual encounters per year, the cumulative probability of transmission to the serodiscordant partner each year is 0.0022 (uncertainty bounds 0.0008-0.0058) for female-to-male transmission, 0.0043 (0.0016-0.0115) for male-to-female transmission, and 0.043 (0.0159-0.1097) for male-to-male transmission. In a population of 10 000 serodiscordant partnerships, over 10 years the expected number of seroconversions would be 215 (80-564) for female-to-male transmission, 425 (159-1096) for male-to-female transmission, and 3524 (1477-6871) for male-to-male transmission, corresponding to an increase in incidence of four times compared with incidence under current rates of condom use.

INTERPRETATION

Our analyses suggest that the risk of HIV transmission in heterosexual partnerships in the presence of effective treatment is low but non-zero and that the transmission risk in male homosexual partnerships is high over repeated exposures. If the claim of non-infectiousness in effectively treated patients was widely accepted, and condom use subsequently declined, then there is the potential for substantial increases in HIV incidence.

FUNDING

Australian Research Council.

Correlates of sex without serostatus disclosure among a national probability sample of HIV patients

We examined potential correlates of sex without HIV disclosure within a sample of 875 participants from the HIV Cost and Services Utilization Study. Interviews with each participant assessed sexual activities with up to six recent partners, and this study included both respondent and partnership characteristics. Compared with marriage and/or primary same-sex relationships, occasional partnerships and one-time encounters were associated with sex with disclosure, and shorter relationships were more likely to involve sex without disclosure. Knowledge of partner serostatus was also associated with sex without disclosure. Women were less likely to have sex without disclosure than men having sex with men. We found an association between the perceived duty to disclosure to all partners and sex without disclosure, while we found no association in multivariate analyses between outcome expectancies and sex without disclosure.

Conflicting messages: how criminal HIV disclosure laws undermine public health efforts to control the spread of HIV

Twenty-three U.S. states currently have laws that make it a crime for persons who have HIV to engage in various sexual behaviors without, in most cases, disclosing their HIV-positive status to prospective sex partners. As structural interventions aimed at reducing new HIV infections, the laws ideally should complement the HIV prevention efforts of public health professionals. Unfortunately, they do not. This article demonstrates how HIV disclosure laws disregard or discount the effectiveness of universal precautions and safer sex, criminalize activities that are central to harm reduction efforts, and offer, as an implicit alternative to risk reduction and safer sex, a disclosure-based HIV transmission prevention strategy that undermines public health efforts. The article also describes how criminal HIV disclosure laws may work against the efforts of public health leaders to reduce stigmatizing attitudes toward persons living with HIV.

Toward rational criminal HIV exposure laws

This article examines criminal HIV exposure statues that address undisclosed exposure through consensual sexual activity. Twenty-seven U.S. states have adopted some form of HIV exposure statute. Thirteen of these statutes specifically address exposure through sexual activity, while another eleven statutes could be applied to exposure through sexual activity, while another eleven statutes could be applied to exposure through consensual sexual interactions. Although the penalties for breach of these laws are often severe, the risk of actual harm posed by the many of the behaviors prescribed is minimal and in some cases virtually nonexistent. After an overview of the various types of U.S. criminal HIV exposure statutes and discussion of the risk of HIV transmission through the various sexual activities addressed in the laws, the authors highlight the tenuous relationship between proscribed activities and actual risk of virus transmission. The authors address this limitation in the law by offering a framework for the evaluation and construction of HIV exposure statutes that considers not only the intent of the HIV-positive actor but also the risk that his or her conduct poses to others.

“Typhoid Mary” and “HIV Jane”: Responsibility, Agency and Disease Prevention

The construction of disease risks as knowable, calculable and preventable in dominant social science and public health discourses has fostered a certain kind of logic about individual risk and the responsibility for infection. Disease control measures that have developed out of this logic typically fail to recognise the socio-structural roots of many high-risk behaviours that are linked to the spread of infection. Instead, they hold the disease carrier responsible for managing his/her own risk of infection of others, and rely on constraining the agency of the carrier (e.g. by constraining movement, contact or occupation). In occupations associated with a high risk of infection, the idea of responsibility of the actor implicitly raises issues of "professional responsibility". Using the case of "Typhoid Mary" and a hypothetical case of "HIV Jane", this paper explores some of the problems with making sex workers responsible for the prevention of HIV transmission. It argues that for the notion of "responsibility" to make any sense, the HIV-positive person must be in a position to exercise responsibility, and for this they must have agency.

Forensic epidemiology: law at the intersection of public health and criminal investigations

Since at least the mid-1970s, public health and law enforcement officials have conducted joint or parallel investigations of both health problems possibly associated with criminal intent and crimes having particular health dimensions. However, the anthrax and other terrorist attacks of fall 2001 have dramatically underscored the needs that public health and law enforcement officials have for a clear understanding of the goals and methods each discipline uses in investigating such problems, including and especially the potential use of biologic agents as weapons of mass destruction. Recognition of these needs has prompted some experts to call for the application of “forensic epidemiology” to such problems. Even before the attacks of fall 2001, other problems, such as the detection of the West Nile Virus in the United States and concerns that the emergence of this infectious agent was the consequence of a deliberate act, raised novel challenges to the combined interests of public health and criminal investigators.

HIV and the law: integrating law, policy, and social epidemiology

In the foundational piece in this issue of the journal, “Integrating Law and Social Epidemiology,” Burris, Kawachi, and Sarat present a model for understanding the relationship between law and health. This article uses the case of a specific health condition, the human immunodeficiency virus (HIV) infection, as an opportunity to flesh out this schema and to test how the model “fits” the world of the HIV pandemic. In applying the model to this communicable disease, we hope to illustrate the multitude of ways that laws affect the course of the pandemic as well as the course of an individual’s vulnerability or resilience to the disease, and how the complexities of an individual’s life dealing with the virus interface with the world of laws and legal institutions.