Criminalization of HIV transmission and exposure: research and policy agenda

Life and love under criminalization: The experiences of people living with HIV in Canada

Based upon qualitative interviews with 54 women and men living with HIV across Ontario, Canada, this paper examines the impact of HIV criminalization on the sexual and romantic relationships of people living with HIV. This research highlights the navigation strategies people living with HIV create and employ to both navigate and protect themselves from the law. Through a thematic and intersectional analysis, this study shows how adoption of these strategies is unequal, with access to navigation strategies varying along lines of gender, race, and sexual orientation. As a result, women and racialized people living with HIV face more difficulties navigating the impact of the law. HIV criminalization in Canada fuels and validates HIV stigma and produces vulnerability both within and outside of the relationships of people living with HIV. This paper seeks to understand HIV criminalization from the perspective of those governed by the law, in hopes of producing knowledge which will contribute to legal reform, inform policy, and support the development of efficacious secondary prevention initiatives.

Criminalization of Human Immunodeficiency Virus in the United States

Human immunodeficiency virus (HIV) criminalization is the prosecution of people with HIV using HIV-specific state statutes, sentence enhancements, and general criminal laws wherein otherwise legal conduct becomes criminalized based on a person's HIV diagnosis. HIV criminal laws perpetuate HIV stigma and discrimination, misrepresent how HIV is transmitted, and are a barrier to HIV prevention and care. Research has found that Black Americans are more likely to be arrested for and convicted of HIV-related offenses. The harm caused by HIV laws on already marginalized communities is long-lasting and severe.

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.

Addressing Ethical Challenges in US-Based HIV Phylogenetic Research

In recent years, phylogenetic analysis of HIV sequence data has been used in research studies to investigate transmission patterns between individuals and groups, including analysis of data from HIV prevention clinical trials, in molecular epidemiology, and in public health surveillance programs. Phylogenetic analysis can provide valuable information to inform HIV prevention efforts, but it also has risks, including stigma and marginalization of groups, or potential identification of HIV transmission between individuals. In response to these concerns, an interdisciplinary working group was assembled to address ethical challenges in US-based HIV phylogenetic research. The working group developed recommendations regarding (1) study design; (2) data security, access, and sharing; (3) legal issues; (4) community engagement; and (5) communication and dissemination. The working group also identified areas for future research and scholarship to promote ethical conduct of HIV phylogenetic research.

Informed consent for HIV phylogenetic research: A case study of urban individuals living with HIV approached for enrollment in an HIV study

INTRODUCTION

Phylogenetic analyses can provide insights on HIV tansmission dynamics. Country and state-level differences in HIV criminalization and disclosure laws and advances in next generation sequencing could impact perceived study risks.

METHODS

We present study opt-out rates and the reasons provided during enrollment for a study conducted in Boston (6/2017-8/2018).

RESULTS

Of 90 patients approached to participate, 45 did not consent to participate. Reasons for not participating included unwillingness to discuss their HIV status, privacy and confidentiality concerns, disinterest, and lack of time.

CONLUSIONS

Given low participation rates and concerns related to HIV disclosure, privacy, and confidentiality, these questions remain (1) should informed consent be required for all phylogenetic analyses, including deidentified and surveillance data? (2) what additional steps can researchers take to protect the privacy of individuals, particularly in contexts where HIV is criminalized or there have been civil/criminal cases investigating HIV transmission? And (3) what role can community members play to minimize the potential risks, particularly for those most marginalized? These questions require input from both researchers and community members living with HIV/AIDS.

Louisiana's Intentional Exposure to HIV Policy: The Social Construction of Target Populations

In 1987, Louisiana became one of the first states to put laws in place to criminalize intentional HIV exposure. Unfortunately, the law does not correlate with science nor does it evidence any effectiveness in reductions in HIV transmissions. In spite of this, it took over 30 years before Louisiana's HIV exposure criminalization law was amended to be more scientifically accurate. There remains little research to determine the impact this policy has on public health efforts to reduce transmissions of HIV. This article will apply the social construction of target populations theory to Louisiana's HIV exposure criminalization law to explore the reasons for the action and inaction that led to the introduction and promotes the continued use of a law that does not demonstrate any effectiveness in actually reducing rates of HIV transmissions.

Mobilizing civil society for the HIV treatment cascade: a global analysis on democracy and its association with people living with HIV who know their status

INTRODUCTION

Civil society organizations (CSOs) play an essential role in the global HIV/AIDS response. Past studies have described the beneficial role of CSOs in meeting the United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, but have not explored how political conditions, which influence the ability of CSOs to organize, have an impact on the cascade. This study explores the relationship between measures of democracy and its association with diagnosis rates among people living with HIV (PLHIV).

METHODS

This study analyses 2016 data derived from the Economist Intelligence Unit's Democracy Index (EIUDI), UNAIDS country estimates for PLHIV and PLHIV who knew their status in 2016, World Bank's 2016 data on nominal gross domestic product (GDP) per capita and country population, HIV Justice Network's 2016 data on HIV criminalization, and country-level estimates for PLHIV, PLHIV who know their status, and expenditure on HIV prevention from other independent sources. An estimated HIV prevalence variable was constructed by dividing the estimated PLHIV population with the total population of a country. Analyses were limited to countries with available data on PLHIV who know their status (n = 111).

RESULTS

Of the 111 countries in the analytic sample, the mean democracy index score was 5.93 (of the 10), median estimated HIV prevalence was 0.20% (IQR 0.10-0.65), median GDP per capita (in thousands, US dollar) was 4.88 (IQR 2.11-13.79), and mean PLHIV who know their status is 67.12%. Preliminary analysis on the five component measures of the EIUDI revealed multicollinearity, and thus the composite democracy index score was used as the measure for democracy. Multivariate linear regression analyses revealed that democracy index scores (β = 2.10, SE = 1.02, p = 0.04) and GDP per capita (in thousands; β = 0.34. SE = 0.11, p < 0.01) were positively associated with diagnosis rates among PLHIV, controlling for country-level expenditure on HIV prevention, HIV criminalization laws and estimated HIV prevalence.

CONCLUSIONS

Results indicate that higher levels of democracy were positively associated with rates of diagnosis among PLHIV. Further analyses following wider implementation of universal testing and treatment is warranted, as well as the need for further research on the mechanisms through which political cultures specifically influence rates of diagnosis among PLHIV.

Sword and Shield: Perceptions of law in empowering and protecting HIV-positive men who have sex with men in Manila, Philippines

Legal protections for people living with HIV (PLHIV) are important for protecting human rights and combatting stigma. While much focus has been on the pernicious impacts of criminalisation of HIV transmission or nondisclosure, little research has accounted for the ways in which perception of protective laws may affect the everyday lives of PLHIV. The Philippines has the fastest growing HIV epidemic in the Asia & Pacific region, with HIV-positive men-who-have-sex-with-men (HIV+ MSM) bearing the majority of cases, and has recently revised their legal protections for PLHIV. We present findings from interviews with 21 HIV+ MSM in Manila, Philippines. Overall, participants viewed legal protections as both empowering and protective. Empowerment was achieved as protections helped participants manage internalised stigma, feel as if they had a weapon to fight discrimination, and perceive a more equitable climate around HIV within broader society. While participants felt as though the law sent positive signals that the government wanted to protect PLHIV, they doubted the actual legal process of bringing suits, leading to harms. Overall, this research presents ways in which legal protections can considered in interventions to empower PLHIV and also identifies opportunities to improve research and advocacy in settings with similarly protective laws.

Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city's HIV/AIDS response.

Monitoring HIV-Related Laws and Policies: Lessons for AIDS and Global Health in Agenda 2030

The National Commitments and Policy Instrument (NCPI) has been used to monitor AIDS-related laws and policies for over 10 years. What can be learnt from this process? Analyses draw on NCPI questionnaires, NCPI responses, the UNAIDS Law Database, survey data and responses to a 2014 survey on the NCPI. The NCPI provides the first and only systematic data on country self-reported national HIV laws and policies. High NCPI reporting rates and survey responses suggest the majority of countries consider the process relevant. Combined civil society and government engagement and reporting is integral to the NCPI. NCPI experience demonstrates its importance in describing the political and legal environment for the HIV response, for programmatic reviews and to stimulate dialogue among stakeholders, but there is a need for updating and in some instances to complement results with more objective quantitative data. We identify five areas that need to be updated in the next iteration of the NCPI and argue that the NCPI approach is relevant to participatory monitoring of targets in the health and other goals of the UN 2030 Agenda for Sustainable Development.

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.

Men Who have Sex with Men Who Believe that Their State has a HIV Criminal Law Report Higher Condomless Anal Sex than Those Who are Unsure of the Law in Their State

We assessed the effects of beliefs about state HIV criminal law on condomless anal sex (CAS < 3 months) among men who have sex with men (MSM) residing in 16 US states (n = 2013; M = 36 years old; 75 % White; 82 % HIV-negative) completing an online survey in 2010 and stratified by residency in a state with any or sex-specific HIV criminal law(s) or where a HIV-related arrest, prosecution, or sentence enhancement (APSE) had occurred. Three-quarters of MSM reported that they were unsure of the law in their state. Men who believed there was a HIV law in their state but lived in states without any or a sex-specific HIV criminal law(s) had higher probabilities of CAS compared to those who were unsure of their state's law; men who believed there was a HIV law in their state and lived in a state where an APSE had occurred had higher probabilities of CAS compared to those who were unsure of their state's law. Correct knowledge of state law was not associated with CAS. Findings suggest that HIV criminal laws have little or counter-productive effects on MSM's risk behavior.

A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings

BACKGROUND

While HIV incidence has stabilized in many settings, increases in health and wellbeing among many people living with HIV/AIDS suggest that the number of HIV-serodiscordant relationships is growing. Given the deficit of reviews addressing social and behavioural characteristics of HIV-serodiscordant couples within high-income settings, our objective was to understand the scope of the published literature, identify evidence gaps, and suggest future research needs.

METHODS

Ten electronic databases were searched. Studies were included if they were reported in English, used primary data, were from the combination antiretroviral (cART) era (>1996), reported on social or behavioural aspects, included any fraction of primary (i.e., stable) relationships, and were conducted in high-income settings. Studies that identified their unit of analysis as either the dyad or individual member of the couple were included. Studies were coded according to a thematic framework.

RESULTS

Included studies (n = 154) clustered into eight themes: risk behaviours (29%), risk management (26%), reproductive issues (12%), relationship quality (9%), serostatus disclosure (7%), adherence to antiretroviral therapy (7%), vulnerability (5%), and social support (3%). The proportion of studies conducted among heterosexual couples, same-sex male couples, and mixed cohorts were 42%, 34%, and 24%, respectively. Most studies (70%) were conducted in the United States, 70% of all studies were quantitative (including interventions), but only one-third were focused on couples (dyads) where both partners are recruited to a study. Over 25% of studies focused on sexual risk among same-sex male couples.

CONCLUSIONS

Future research efforts should focus on the interrelationship of risk management strategies and relationship quality, social determinants of health and wellbeing, HIV testing, vulnerable populations, reproductive issues among same-sex couples, disclosure of serodiscordant status to social networks, dyadic studies, population-based studies, and interventions to support risk management within couples. Additional population-based studies and studies among marginalized groups would be helpful for targeting research and interventions to couples that are most in need. As HIV-positive partners are typically the link to services and research, innovative ways are needed for reaching out to HIV-negative partners. Our review suggests that significantly more research is needed to understand the social and behavioural contexts of HIV-serodiscordant relationships.

Time trends, characteristics, and evidence of scientific advances within the legal complaints for alleged sexual HIV transmission in Spain: 1996-2012

This article quantifies and characterizes existing legal complaints for the sexual transmission of HIV in Spain, describes temporal trends and whether advance of scientific knowledge is reflected in charging decisions, judicial reasoning, and sentences. Sentences and writs dictated by Spanish penal and civil jurisdictions between 1981 and 2012 were obtained through legal databases systematic search. Sixteen sentences and 9 writs belonging to 19 cases were included; 17 judged by penal and two by civil jurisdictions. The first sentence was pronounced in 1996, 3 between 1999 and 2000, 4 between 2001 and 2005, and 18 between 2006 and 2012. In 10 (53%) cases there was effective HIV transmission, there was not in 6 (32%) and in 3 (15%) directionality could not be determined. Of the defendants, 15 (79%) were heterosexual males, 1 of which was an injecting drug user (IDU), 3 were men who have sex with men (MSM), and 1 was a heterosexual woman. In the 10 cases of HIV transmission, the mechanism was heterosexual sex and index cases were males in nine occasions. Disclosure of HIV status, use of condoms and its frequency, and its possible breaks were mentioned in only some sentences/judicial decisions and fewer mentioned the use of antiretroviral treatment. Very few cases referred to plasma viral load (VL), and there are incorrect statements regarding HIV transmissibility. Only one 2012 sentence mentioned VL levels, adherence to ART, CD4 lymphocyte levels, concomitant sexually transmitted infections, and references to pertinent literature. The number of judicial decisions in Spain is increasing and the profile of the plaintiffs, largely heterosexual women, does not reflect the groups most affected by the HIV epidemic, largely IDU and MSM. Most judgments and writs do not reflect HIV scientific and technical advances. It is of utmost importance that these complex processes incorporate the most up-to-date knowledge on the subject.