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

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.

Housing stability, residential transience, and HIV testing among low-income urban African Americans

The association between housing and HIV has been widely demonstrated, although inquiry into HIV testing has been largely limited to the homeless. This study examines correlates of HIV testing within the past 6 months with housing stability and residential transience (moving two or more times in the past 6 months) among 620 low-income urban African Americans. Unstably housed and transient participants were more likely to participate in high-risk sex behaviors than stably housed participants and non-transient participants, respectively. In multivariate analyses, residential transience was positively associated with recent HIV testing; however, persons unstably housed were not more likely to have recently been tested for HIV despite their increased vulnerability and risk. While structural interventions are necessary to address the HIV disparities related to housing, increased community-based and mobile testing centers may be able to improve access to HIV testing among unstably housed.

Syringe confiscation as an HIV risk factor: the public health implications of arbitrary policing in Tijuana and Ciudad Juarez, Mexico

Female sex workers who inject drugs (FSW-IDUs) face elevated risk for HIV/STIs and constitute a key population for public health prevention. Through direct and indirect pathways including human rights violations, policing practices like syringe confiscation can compound FSW-IDU health risk and facilitate the spread of disease. We studied correlates of experiencing syringe confiscation among FSW-IDUs in northern Mexico, where formal policy allows for syringes to be available over the counter without a prescription, but police practices are often at odds with the law. FSW-IDUs reporting recent syringe sharing and unprotected sex with clients in Tijuana and Ciudad Juarez were administered surveys and HIV/STI testing. Logistic regression was used to identify correlates of syringe confiscation. Among 624 respondent FSW-IDUs, prevalence of syringe confiscation in the last 6 months was 48%. The following factors were positively associated with syringe confiscation: testing positive for HIV (adjusted odds ratio [aOR] = 2.54, 95% confidence interval [CI] = 1.11-5.80), reporting sexual abuse by police (aOR = 12.76, 95% CI = 6.58-24.72), engaging in groin injection (aOR = 1.84, 95% CI = 1.15-2.93), injecting in public (aOR = 1.64; 95% CI = 1.14-2.36), and obtaining syringes from pharmacies (aOR = 1.54; 95% CI = 1.06-2.23). Higher education level was negatively associated with syringe confiscation (aOR = 0.92, 95% CI = 0.87-0.98) as was frequent injection with clients within the last month (aOR = 0.64, 95% CI = 0.44-0.94). This analysis adds to the body of evidence linking unauthorized law enforcement actions targeting high-risk groups with HIV and other adverse health outcomes. Using a public health lens to conceptualize abuse as a structural risk factor, we advocate for multi-prong prevention, systematic monitoring, and evidence-based intervention response to deleterious police practices.

Social deprivation and use of mental health legislation in New Zealand

BACKGROUND

Low socioeconomic status has consistently been associated with poorer health outcomes. Few studies have used ecological analysis to explore relationships between area measures of deprivation and use of mental health legislation.

METHODS

We used an ecological design to explore associations between two area measures of relative deprivation and the two most commonly used sections of New Zealand mental health legislation.

RESULTS

High levels of relative deprivation were positively correlated with use of both acute and long-term community care provisions of mental health legislation with the correlation with long-term care achieving significance (r = .518, p = .016). Low levels of relative deprivation showed negative correlations with use of both provisions. The correlation of -.493 between low levels of relative deprivation and acute care provisions was significant at p = .023. In stepwise regression, the proportion of the population aged 15-64 contributed to the model for section 11, but ethnicity contributed to neither model.

CONCLUSION

Mental health legislation is used disproportionately in areas with high levels of relative deprivation. The results have implications for regional allocation of funding for mental health and social services to support community-based care. Further research is needed to explore other factors that may account for the regional variation.

A review of HIV/AIDS system-level interventions

The escalating HIV/AIDS epidemic worldwide demands that on-going prevention efforts be strengthened, disseminated, and scaled-up. System-level interventions refer to programs aiming to improve the functioning of an agency as well as the delivery of its services to the community. System-level interventions are a promising approach to HIV/AIDS prevention because they focus on (a) improving the agency's ability to adopt evidence-based HIV prevention and care programs; (b) develop and establish policies and procedures that maximize the sustainability of on-going prevention and care efforts; and (c) improve decision-making processes such as incorporating the needs of communities into their tailored services. We reviewed studies focusing on system-level interventions by searching multiple electronic abstracting indices, including PsycInfo, PubMed, and ProQuest. Twenty-three studies out of 624 peer-reviewed studies (published from January 1985 to February 2007) met study criteria. Most of the studies focused on strengthening agency infrastructure, while other studies included collaborative partnerships and technical assistance programs. Our findings suggest that system-level interventions are promising in strengthening HIV/AIDS prevention and treatment efforts. Based on our findings, we propose recommendations for future work in developing and evaluating system-level interventions.

Analysis of social epidemiology research on infectious diseases: historical patterns and future opportunities

BACKGROUND

Despite the many triumphs of biomedical research over infectious diseases, human pathogens continue to impact profoundly populations deprived of social resources. Correspondingly, health researchers have advocated a social determinants approach to the study and prevention of infectious diseases. However, it is unknown whether this call has resulted in an increase in the number of studies examining social determinants of infectious outcomes.

METHODS

Research on social determinants of infectious diseases was systematically quantified by assessing temporal trends in the published literature using MEDLINE, PsycINFO and ISI Web of Science.

RESULTS

Results of the literature review spanning 1966-2005 show that socially related citations increased an annual average of 180.3 for neuropsychiatric conditions, 81.9 for chronic conditions, 44.7 for sexually transmitted diseases and 18.9 for non-sexually transmitted infectious diseases (p<0.0001). Of the 279 publications found to employ the term "social epidemiology", 15 (5.4%) investigated infectious outcomes.

CONCLUSIONS

The results of the literature review suggest a paucity of social research on infectious diseases. There is a need for increased dialogue and collaboration between infectious disease epidemiologists and social epidemiologists.

Why housing?

Housing/lack of housing and HIV are powerfully linked. Housing occupies an important place in the causal chains linking poverty and inequality, and HIV risk and outcomes of infection. The articles in this Special Supplement of AIDS and Behavior confirm the impact of homelessness, and poor or unstable housing, on HIV/AIDS, and challenge scientists to test and policy makers to implement the promise of housing as an innovative response to the epidemic. In order to influence the development of policies on housing to benefit at-risk or HIV-infected persons, however, proponents must justify why this association exists, and how housing can help end the epidemic as well as improve the care and health of persons living with HIV/AIDS. We introduce this supplement with a discussion of the "why" question.

The evolving field of health and human rights: issues and methods

The conference on Health, Law and Human Rights: Exploring the Connections held last fall in Philadelphia was a telling moment in the complex history of a movement — the “health and human rights movement” for want of a better term — inaugurated by the pioneering work of Jonathan Mann, whose memory the Conference honored. The François-Xavier Bagnoud Center for Health and Human Rights — founded by Mann and carrying on his legacy — was pleased to co-sponsor the conference. The conference and this symposium issue containing the main papers provide an excellent opportunity to take stock of that movement by means of a commentary based on the papers. This commentary is made from a resolutely human rights perspective, with the aim of engaging the authors in a dialogue on whether and to what extent each article advances knowledge about the interconnectedness and mutually reinforcing character of health and human rights, which is the lasting legacy of Jonathan Mann.