US: Closing session of CDC's national HIV Prevention conference highlights stigma and HIV-specific criminalisation laws as barriers to improving outcomes in prevention and care

HIV Stigma in Focus at Closing Session of CDC’s National HIV Prevention Conference

HIV-related stigma and its impact on HIV-related health disparities were the topic of the final plenary session at CDC’s National HIV Prevention Conference. The March 21 session examined social and cultural factors that have contributed to stigma as well as efforts to combat the effects of HIV-related stigma on specific populations. Moderator Johanne Morne, director of the New York State Department of Health AIDS Institute, reminded the conference participants that stigma is an historic and continuing theme that must be addressed to improve outcomes along both the HIV prevention and care continuums.

HIV Stigma and What Can Be Done to Combat It

Greg Millett, vice president and director of public policy at amfAR, delivered the keynote address, “Progress: Same or Different? HIV Stigma at 37.” He noted that while many of the most extreme forms of stigma from the early days of the HIV epidemic have dissipated over time, inaccurate beliefs about the HIV risk of casual social contact persist.

Such stigmatizing beliefs are supported by societal factors such as HIV criminalization laws, Mr. Millett said. He pointed to the fact that 29 states still have HIV-specific criminalization laws on the books and while over 800 people have been prosecuted using these laws, none of the prosecutions were for any actual HIV transmission. He highlighted a CDC assessment that found that HIV criminalization laws have no detectable HIV prevention effect given there was no association with HIV diagnosis rates or AIDS diagnoses in states with such laws.

Further, he observed that not only are people with or at risk for HIV too often stigmatized, but the effective tools to prevent HIV such as PrEP are also stigmatized. A recent study found that individuals who experienced a high degree of stigma around their choice to use PrEP were 50% less likely to be on PrEP at their next clinical visit. Additionally, he pointed to syringe services programs (SSPs) that are known to reduce the risk of HIV transmission among people who inject drugs. Yet, stigma related to both HIV and people who use drugs limits public support for SSPs, limiting their expansion in many communities that could benefit from them, he said.

One factor that may enable this enduring stigma, Mr. Millett posited, is Americans’ lack of personal knowledge of people living with HIV. A Kaiser Family Foundation study found that only 45% of Americans say they know someone with HIV. To counter that, he encouraged more people living with HIV to be open about their status since that would contribute to stigma reduction. He also applauded creative efforts from the HIV community to combat stigma. These included public announcements by people living with HIV of their status on social media, anti-stigma campaigns, and even a series of social media videos about living with HIV.

Combatting HIV-related Stigma and Improving Outcomes for Specific Populations

A series of presentations followed, each discussing unique approaches to combating HIV stigma and offering recommendations on how to help reduce it to improve HIV prevention and care outcomes.

  • Daniel Driffin, co-founder of THRIVE SS, discussed building innovative, community-driven solutions to address HIV disparities among African American men living with HIV. Originally founded as a support group in Atlanta, the program has grown to an online platform that engages and offers support to more than 3,500 people across the southeast United States. Among THRIVE SS’s innovations are programs to re-engage and retain men in HIV care, a mental health group, and a photo campaign. Mr. Driffin shared results of a 2018 program participant survey that revealed that 92% of the men surveyed self-reported being virally suppressed. “Black men living with HIV are achieving viral suppression,” Mr. Driffin declared. “I challenge you to no longer say these men are ‘hard to reach.’” His advice for others seeking similar outcomes included: using the lived experiences of people living with HIV to inform HIV care and prevention, re-imagining everything, and supporting community-created approaches.
  • Omar Martinez, assistant professor at Temple University’s School of Social Work, examined HIV-related stigma among sexual and gender minority Latinx individuals. He observed that members of this community often experience stigma related to many aspects of their lives including culture, language, and immigration status, all of which impact their HIV risk. Dr. Martinez profiled several programs that have demonstrated success, including a number that engage non-traditional partners or that address legal and other needs. He advised stakeholders to focus on affirming models of care; to examine immigration status as a social determinant of health; and to continue to invest in the development and replication of “locally-grown” HIV prevention, treatment, and anti-stigma interventions that have proven effective.
  • Gail Wyatt, PhD, professor and director of the UCLA Sexual Health Program, discussed HIV stigma and disparities among African American women, reminding the audience of the importance of the inclusion of women’s perspectives in HIV prevention, care and treatment, and research. She discussed the impact of trauma on women’s health-seeking behaviors and treatment retention. She emphasized that an effective HIV response requires attention to holistic health, including mental health, to improve outcomes for women living with HIV. She also argued that some health care providers need to be re-educated about African American women given that many have biases about Black women that may hinder their delivery of effective health care services.
  • Cecilia Chung, co-director of programs and policy at the Transgender Law Center, shared her personal story as an Asian transgender woman living with HIV and discussed the power of personal storytelling to change hearts. She remarked, “Storytelling can help us get past differences, stigmas, and biases, and humanize individuals.” Being able to confidently tell one’s story affects the listener and also empowers the storyteller as they move forward on their path as a person living with HIV.

Dr. Eugene McCray, Director of CDC’s Division of HIV/AIDS Prevention, closed the session, thanking the participants from across the nation and the more than 500 of them who had shared results of their work with others in sessions, poster presentations, and exhibits during the conference. He noted that CDC was pleased to have been able to share more details of the Ending the HIV Epidemic Plan through several plenary session addresses and in a community engagement session. Implementing that Plan, he observed, will require ongoing dialogue and collaboration. With the powerful tools now available, the insights that data offer, leadership from all sectors, and community-driven and -developed plans, Dr. McCray indicated that he was confident that the nation could achieve the goal of reducing new HIV infections by 90% in ten years.

To view all or part of this plenary session, view CDC’s National Prevention Information Network video of Wednesday’s plenary session on their Facebook page .

Kazakhstan: Women living with HIV submit report to CEDAW, recommending repeal of HIV criminalisation provision in Kazakhstan penal code

Source: EWNA, published on March 11, 2019

For the first time, HIV+ women in Kazakhstan submitted a shadow report to CEDAW 

Today in Geneva, at the pre-sessional working group of the 74th meeting of the UN Committee on the Elimination of All Forms of Discrimination against Women (CEDAW) , representatives of the community of women living with HIV, women who use drugs and sex workers from Kazakhstan presented for the first time a shadow report from civil society on rights situations for women from key groups.

In July 2018, civil society organizations submitted the Shadow Civil Society Report on Discrimination and Violence against Women Living with HIV, Women Using Drugs, Sex Workers and Women from Prisons, to the UN Committee on the Elimination of All Forms of Discrimination against women. The report is based on studies of cases of violation of rights registered by non-governmental organizations in 2015-2017. The full report is available on the EZSS website, in Russian and English .

Here is the text of the oral statement presented by Lyubov Vorontsova, Kazakhstan Union of People Living with HIV (english text below):

“Thank you, Madam Chair.

I am a woman living with HIV from Kazakhstan and I represent the voices of women from my community.

We consider it extremely important to solve the problems of institutionalized discrimination that violates the rights of women and impedes access to health and social services, as well as contribute to social and economic vulnerability.

Women living with HIV have limited access to residential services in existing crisis centers designed to help women affected by violence. In the capital of Kazakhstan, a young girl with a child who was abused by her husband in winter is refused to be placed in an orphanage, since there is such a law and she has HIV. Article 118 of the Criminal Code of Kazakhstan provides for criminal penalties for putting people at risk of HIV infection, which has the opposite effect – this contributes to a higher risk of HIV infection, violence and gender inequality in the family, in the health care system, in society.

According to a study of the Stigma Index, 24.2% of women living with HIV, medical workers forced to terminate a pregnancy (abortion), 34% of women living with HIV never received advice on reproductive opportunities.

We recommend:

  • Revise Article 118. “Infection with Human Immunodeficiency Virus (HIV / AIDS)” of the Criminal Code of the Republic of Kazakhstan dated July 3, 2014 No. 226-V SA-RC to abolish the provision criminalizing the risk of acquiring HIV
  • To set up offices in crisis centers to work with drug addicts and HIV-positive women. Mobilize state efforts to expand the network of crisis centers and other emergency services for women who have experienced domestic violence, and to ensure adequate public funding for these institutions.
  • Introduce changes to the Order of the Minister of Health and Social Development of the Republic of Kazakhstan dated December 21, 2016 No. 1079 “On approval of the standard for providing special social services to victims of domestic violence”, limiting the possibility of women living with HIV in crisis centers.

Women who use drugs report the extreme prevalence of police brutality. Due to stigmatization, pregnant drug-addicted women cannot take advantage of necessary medical services, including drug treatment, antenatal care and post-natal care. Opioid substitution therapy is not available for women when they are hospitalized in any medical institution (including maternity hospitals, tuberculosis dispensaries, etc.).Immediately after childbirth, women are forced to travel independently to the substitution therapy program in order to receive drug support with methadone.

The rights of sex workers by medical personnel are violated, in particular, the humiliation of dignity, the infliction of physical and psychological violence, and the disclosure of HIV-positive status to third parties. For this reason, sex workers refuse timely diagnosis in medical institutions.

We recommend:

  • Develop and adopt a humanization policy for women who use drugs, laws and practices based on respect for human rights, which will protect and eliminate any discrimination and violence against women.
  • Include in the complex of preventive programs to combat HIV and AIDS at the local and national levels, training for police officers to reduce stigma and discrimination against women from vulnerable groups.
  • Actively investigate incidents of violence and any unlawful acts committed by law enforcement officers against sex workers, women who use drugs, and reported by public organizations.
  • Develop mechanisms for ensuring personal security and confidentiality that will allow women to report incidents of violence without fear for their safety.
  • Provide government funding for the provision of free family planning services, in particular contraception for marginalized and vulnerable women.
  • Provide training for medical personnel in providing quality sexual and reproductive health services for women living with HIV, sex workers and women who use drugs.
  • Include a substitution therapy program in the national health care system and drug practice, with further expansion and scaling in Kazakhstan, as well as develop mechanisms for access to treatment of opioid substitution therapy in hospitals (tub dispensary, maternity hospitals and others)

In Kazakhstan, there are no studies and disaggregated data in open sources regarding women prisoners. In the fifth periodic report, the state provides data on legislation that provides access to medical services for female prisoners. But this does not answer the question of whether it meets the needs of female prisoners.

We recommend:

  • Conduct research on the degree of satisfaction with women’s sexual and reproductive health services in places of detention, including data on women living with HIV and drug addicts, characterizing their access to antiretroviral treatment and drug treatment, including opioid substitution therapy. ”

ВПЕРВЫЕ ВИЧ+ ЖЕНЩИНЫ КАЗАХСТАНА ПРЕДСТАВИЛИ ТЕНЕВОЙ ОТЧЕТ В КЛДЖ

Сегодня в Женеве, на предсессионной рабочей группе 74 заседания Комитета ООН по ликвидации всех форм дискриминации в отношении женщин (CEDAW), представительницы сообщества женщин, живущих с ВИЧ, женщин употребляющих наркотики и секс-работниц из Казахстана, впервые представили теневой отчёт от гражданского общества о ситуации с нарушением прав в отношении женщин из ключевых групп.

В июле 2018 г. организациями гражданского общества был подан «Теневой отчет гражданского сообщества о дискриминации и насилии в отношении женщин, живущих с ВИЧ, женщин, употребляющих наркотики, секс — работниц и женщин из мест лишения свободы» в Комитет ООН по ликвидации всех форм дискриминации в отношении женщин. Отчет основан на исследованиях, случаях нарушения прав, зарегистрированных неправительственными организациями в 2015-2017 гг. С полным отчетом можно ознакомиться на сайте ЕЖСС, на русскоми английском языках.

Приводим текст устного заявления, которое представила Любовь Воронцова, Казахстанский Союз Людей, Живущих с ВИЧ (english text below):

«Спасибо, госпожа Председатель.

Я женщина, живущая с ВИЧ из Казахстана, и представляю голоса женщин из своего сообщества.

Мы считаем крайне важным решить проблемы институционализированной дискриминации, которая нарушает права женщин и препятствует доступу к медицинским и социальным услугам, а также способствуют социальной и экономической уязвимости.

Женщины, живущие с ВИЧ, имеют ограниченный доступ к услугам проживания в существующих кризисных центрах, предназначенных для помощи женщинам, пострадавшим от насилия. В столице Казахстана молодая девушка с ребенком, которая зимой подверглась насилию со стороны мужа, получает отказ быть помещенным в приют, поскольку существует такой закон и у нее ВИЧ. Cтатья 118 Уголовного Кодекса Казахстана предусматривает уголовное наказание за постановку в риск заражения ВИЧ, что имеет обратный эффект — это способствует более высокому риску заражения ВИЧ, насилия и гендерного неравенства в семье, в системе здравоохранения, в обществе.

По результатам исследования Индекс Стигмы 24,2% женщин, живущих с ВИЧ, медицинские работники принуждали к прерыванию беременности (аборту), 34% женщин, живущих с ВИЧ, никогда не получали консультацию по репродуктивным возможностям.

Мы рекомендуем:

  • Пересмотреть Статью 118. «Заражение вирусом иммунодефицита человека (ВИЧ/СПИД)» Уголовного кодекса РК от 3 июля 2014 года № 226-V ЗРК, чтобы отменить норму, устанавливающую уголовную ответственность за риск заражения ВИЧ.
  • Создать отделения в кризисных центрах для работы с наркозависимыми и ВИЧ-положительными женщинами. Мобилизовать усилия государства по расширению сети кризисных центров и других служб экстренной помощи женщинам, пережившим домашнее насилие, гарантировать адекватное государственное финансирование для этих учреждений.
  • Внести изменения в Приказ Министра здравоохранения и социального развития Республики Казахстан от 21 декабря 2016 года № 1079 «Об утверждении стандарта оказания специальных социальных услуг жертвам бытового насилия», ограничивающий возможность пребывания в кризисных центрах женщин, живущих с ВИЧ.

Женщины, употребляющие наркотики, сообщают о крайней распространенности жестокости полиции. Из-за стигматизации беременные наркозависимые женщины не могут воспользоваться необходимыми медицинскими услугами, в том числе наркологической, дородовой и послеродовой помощью. Опиоидная заместительная терапия не доступна для женщин при госпитализации в любые медицинские учреждения (включая родильные дома, противотуберкулезные диспансеры и т.д.). Сразу после родов женщины вынуждены самостоятельно добираться до программы заместительной терапии, чтобы получить лекарственную поддержку метадоном.

Нарушаются права секс-работниц со стороны медицинского персонала, в частности, унижение достоинства, причинение физического и психологического насилия, раскрытие ВИЧ-положительного статуса третьим лицам. По этой причине секс-работницы отказываются от своевременной диагностики в медицинских учреждениях

Мы рекомендуем:

  • Разработать и принять политику гуманизации в отношении женщин, употребляющих наркотики, законов и практик, основанных на уважении прав человека, которые обеспечат защиту и исключают любую дискриминацию и насилие в отношении женщин.
  • Включить в комплекс профилактических программ по противодействию ВИЧ и СПИД на местном и национальном уровнях обучающие мероприятия для полицейских о снижении стигмы и дискриминации по отношению к женщинам из уязвимых групп.
  • Активно расследовать случаи насилия и любых незаконных действий, совершенных сотрудниками правоохранительных органов против секс-работниц, женщин, употребляющих наркотики, зарегистрированных и сообщенных общественными организациями.
  • Разработать механизмы обеспечения личной безопасности и конфиденциальности, которые позволят женщинам сообщать о случаях насилия без страха за свою безопасность.
  • Обеспечить государственное финансирование на предоставление бесплатных услуг по планированию семьи, в частности контрацепции для маргинализированных и уязвимых женщин.
  • Обеспечить подготовку медицинского персонала по предоставлению качественных услуг по сексуальному и репродуктивному здоровью для женщин, живущих с ВИЧ, секс-работниц и женщин, употребляющих наркотики.
  • Включить программу заместительной терапии в национальную систему здравоохранения и наркологическую практику, с дальнейшим расширением и масштабированием в Казахстане, а так же разработать механизмы для доступа к лечению опиоидной заместительной терапии в условиях стационаров (тубдиспансер, родильные дома и другие)

В Казахстане отсутствуют исследования и дезагрегированные данные в открытых источниках в отношении женщин-заключенных. В пятом периодическом докладе государство приводит данные о законодательных актах, которые обеспечивают доступ к медицинским услугам для женщин-заключенных. Но, это не отвечает на вопрос о том, удовлетворяет ли это потребности женщин-заключенных.

Мы рекомендуем:

  • Провести исследования о степени удовлетворения услугами по сохранению сексуального и репродуктивного здоровья женщин в местах лишения свободы, включая данные о женщинах, живущих с ВИЧ и наркозависимых, характеризирующие их доступ к антиретровирусному лечению и наркологической помощи, включая опиоидную заместительную терапию.»

US: Five laws categorised as “bad” laws by the Human Rights Campaign in Missouri , including HIV/AIDS criminalisation laws

Missouri ranked in lowest category for LGBTQ protections, nondiscrimination

The Human Rights Campaign recently released their fifth annual State Equality Index — a state-by-state report detailing statewide laws and policies that affect LGBTQ people, assessing how well states are doing to protect LGBTQ individuals from discrimination.

This year, Missouri received the lowest rating, “High Priority to Achieve Basic Equality.” This rating is given to states that focus on raising suport for basic LGBTQ equality laws, such as non-discrimination laws, and for states focusing on municipal protections for LGBTQ people including opposing negative legislation.

Twenty-eight states earned this rating. Seventeen states earned the highest rating, “Working Toward Innovative Equality,” while the remaining five earned “Solidifying Equality” or “Building Equality.”

Karis Agnew, field director for PROMO, Missouri’s statewide LGBTQ advocacy organization, explained that they expected this rating for Missouri.

“It does not surprise me because there are basic protections that LGBTQ people lack in Missouri and those include protection of employment, housing and public accommodations,” Agnew said.

Missouri has a total of six laws that benefit LGBTQ people — hate crime laws, a college and universities non-discrimination law, a sexual orientation non-discrimination policy for state employees, an anti-bullying law specifically for cyberbullying, transgender inclusion in sports, and name and gender updates on identification documents for drivers licenses.

Missouri has five laws that the HRC categorizes as “bad” laws including HIV/AIDS criminalization laws, a state Religious Freedom Restoration Act, and transgender exclusions in state Medicaid coverage.

Missouri lacks all parenting laws such as parental presumption for same-sex couples, second parent adoption, and foster care non-discrimination. Missouri also lacks basic non-discrimination laws for employment, housing, public accommodation, education, adoption, foster care, insurance, credit, and jury selection.

The absence of youth laws in Missouri include anti-bullying laws, protection from conversion therapy, and laws to address LGBTQ youth homelessness. In the health and safety category, Missouri lacks laws including LGBTQ nondiscrimantion protections in Affordable Care Act exchanges, transgender healthcare coverage, and name and gender updates on identification documents for birth certificates.

Alex Padilla, co-president of Spectrum, an LGBTQ group at Missouri State Univerity, explained his fear regarding how few laws Missouri has protecting LGBTQ individuals like himself.

“Whenever I first came out, I was working at a fast food job and I was worried that I could be fired for who I was,” Padilla said.

He explained that he did a quick search online and found that there were no laws protecting him from being harassed or fired because of who he was.

Agnew, who prefers using gender-neutral pronouns, explained that although this rating is low, organizations like PROMO are working hard behind the scenes to make sure Missouri’s laws are progressing.

“When it comes to passing laws that are pro-equality, the thing that we really need the most to be able to do that is make sure that we don’t have bills that are anti-LGBTQ,” Agnew said.

Agnew explained that in 2018 five anti-LGBTQ laws were filed but PROMO worked to ensure zero made it to the governor’s desk to be signed.

“When those are filed, that is our priority, so it is really hard for us to file proactive legislation and pass proactive legislation when we have legislation that is harmful to LGBTQ people that we work so hard to prevent from passing,” Agnew said.

Agnew said a big reason why Missouri is far behind other states in passing pro-LGBTQ legislation is that Missouri legislators are not aware of what it is like to live as an LGBTQ individual.

“I think a lot of our legislators in Missouri honestly don’t know what it’s like to be LGBTQ — the majority of our legislators are not LGBTQ themselves,” Agnew said. “And because of that, I think a lot of them have a lot to learn from their constituents that are.”

Agnew said this year is the 21st year that PROMO has worked to file the Missouri Nondiscrimination Act, which would add protections for sexual orientation and gender identity in places of employment, housing and public accommodations.

“When their constituents aren’t bringing it up they assume it’s not important and not needed,” Agnew said. “The number one thing people can do is engage their elected officials and talk to them about why something like the Missouri Nondiscrimination Act is so important to them.”

Padilla explained how important it is for students to get involved.

“Help us lobby for equality, Padilla said. “Advocating for these things and showing that you are an ally is really helpful to all of Missouri and all of Missouri’s LGBTQ people.”

PROMO is hosting an “Equality Day,” a day of lobbying where people in the community come up to Jefferson City and talk to legislators about the Missouri Nondiscrimination Act on April 10.

Uganda: Mapping of the legal environment shows how the current criminal justice system discriminates against people living with HIV

Published in the Daily Monitor on Febraury 22, 2019

Report shows how laws discriminate against HIV positive people

KAMPALA- Various existing laws criminalise people living with HIV/ Aids, according to a new report released in Kampala on Thursday.

The report is titled: “Draft report on the assessment and mapping of the legal environment on provisions of HIV and TB services to let populations, persons living with HIV and tuberculosis”

“The existing legal framework is not favourable for some categories of the key, vulnerable and priority populations to freely access health services in Uganda. Specifically, the lifestyles sex workers, men who have sex with men, transgender persons and makes them most affected by the existing legal framework in Uganda,” read part of the report

It adds: “The laws criminalise sex work, same sex relationships and drug use. This results into violence, harassment, disappointment of sex workers and their legal recourse to address injustice against them.” “The other law, the HIV and Aids prevention and Control Act although not specifically targeting key vulnerable and priority populations, has implications for both the general affected by HIV in Uganda.”

The report indicates that the HIV and Aids Prevention and Control Act 2014 provides for voluntary HIV testing in Sub Section 9. However, the voluntarism is not considered if a person commits a sexual offense as part of the criminal proceedings and yet Section 8 provides for identity of a person tested with HIV not to be disclosed or released to any person except in accordance with the law and medical standards.

The report was carried out by civil society organisation Center for Health, Human Rights and Development (CEHURD) in conjunction with Aids and Rights Alliance for South Africa (ARASA).

The current criminal justice system is also discriminative as it hands down more deterrent jail terms to those suspects found to be living with HIV than their counterparts that are not.

Reacting to the aforementioned finding, a law professor at Makerere University, Prof. Ben Twinomugisha, explained that sometimes it’s prudent for the prosecution to take an HIV test of a suspect accused of committing a sexual offense for purposes of securing a conviction.

However, he was also quick to say that this compulsory HIV testing will lead to violation of their human rights and that this will drive those infected away instead of going to hospital to get medication.

“But a civil society organisation and I, have since petitioned court challenging Section 43 of the HIV Prevention and Control Act about criminalization of HIV,”  Prof. Twinomugisha said

“Why is it that a person suffering from Hepatitis B, which is more deadly than HIV are not subjected to a test when they commit a crime,” he wondered.

The study was carried out in three districts of Gulu, Mbarara and Tororo.

The study was mainly about the extent to which laws and policies protect and promote the rights of persons living with HIV/ Aids, let populations like sex workers, truck drivers and fishermen can access health care and services.

The HIV prevalence in Uganda stands at 6.2%. In 2016, approximately 1.4 million people were living with HIV and 28,000 Ugandans were estimated to have died of Aids-related illness.

Travel and long-stay restrictions for foreign nationals with HIV have no logical basis and have been deemed a human rights violation by the United Nations

Published in South China Morning Post on February 5, 2019

Visa restrictions for HIV-positive immigrants still in place in dozens of countries

  • Recent leak in Singapore of data of HIV-positive people renewed attention on its curbs on long-term stays by those who have the virus
  • Countries with restrictions include Russia and the United Arab Emirates; there’s no logical basis for them any more, UNAids says

A data leak of Singaporean medical records exposing the HIV-positive status of 14,200 people last month triggered concerns about a backlash for those whose health status was made public in a country that continues to stigmatise the disease.

But the case, involving the records of 8,800 foreign nationals who tested positive for HIV in Singapore, also shines a spotlight on the city state’s restrictive policies towards foreigners with HIV, who face barriers to staying in the country for more than 90 days unless married to a Singaporean national.

The records were leaked by a foreigner in just such a situation, American Mikhy Farrera Brochez, who was deported after serving jail time for drug-related crimes and fraud, including hiding his HIV status. He was able to access the records with help from his boyfriend, a Singaporean doctor.

Singapore is one of only a handful of developed nations that still have laws restricting the long-term stay of foreign nationals with HIV – laws that have been deemed a human rights violation by the United Nations.

“When this [1998] law was brought in there was a lot more fear of unknown issues around disease … but [today] the logic is just not borne out by any scientific or medical basis,” says Eamonn Murphy, UNAids regional director for Asia and the Pacific.

Instead, countries that still have such restrictions in place often do so because of “historical convention, ideology, or even passivity”, Murphy says. He notes that UNAids is renewing its focus on the issue this year, compiling a new report on national restrictions.

UNAids most recent comprehensive report on HIV-related travel and immigration laws in 2015 listed 35 countries with such restrictions.

However, incomplete data published in 2018 by UNAids named at least 18 countries that have policies restricting entry, stay or residence for people living with HIV. Information from many countries were left off the list, and will be updated this year to reflect the true extent. The same report found that 60 countries require testing for residence or other permits, including marriage, not limited to foreigners.

The exact numbers, however, are difficult to pin down, experts say. An independently researched global database counts 49 countries with HIV-related restrictions on long-term stay in 2018, based on information sourced from local embassies and reports from travellers and immigrants. Countries with restrictions include Russia, Singapore, and the United Arab Emirates.

“The data the countries present about themselves in diplomatic settings can be different from the policies that are actually executed,” says American epidemiologist Jessica Keralis, who has researched the public health impacts of such HIV-related restrictions.

For example, countries may not have regulations “on the books”, but employers can revoke visas for HIV-positive employees, or state insurance policy can make it difficult for immigrants to afford treatment, she says.

In other cases, official policy may not be known by regional or local officials and institutions.

These distinctions matter for HIV-positive immigrants, whether white-collar workers, migrant labourers or students, according to David Haerry, who publishes the Global Database on HIV-Specific Travel and Residence Restrictions, which names the 49 countries.

“Oftentimes people [sent abroad for work] don’t know and they fall in the trap: if you don’t know and you have to be tested on the ground, and then you are sent back on health grounds, your company knows,” he says. “It’s a big issue.”

Haerry receives daily emails through the database from people around the world wondering how to travel or relocate safely while living with HIV. In recent years, he’s seen restrictive policies become more of an issue for students looking to study abroad, but who fear the consequences of mandatory HIV testing even in countries where there is no explicit restriction on those who are HIV-positive.

For such situations, “we have no solution”, Haerry says.

Many national restrictions are holdovers from the 1980s, before the disease’s transmission was understood and the antiretroviral therapies and daily medications that can prevent its spread became widely available, according to UNAids’ Murphy. But he has seen progress globally.

A number of countries changed their policies after UNAids launched a 2008 campaign against the 59 governments that had bans at that time. The United States, South Korea and China were among the nations to remove restrictions in 2010, although South Korea retained some related to immigration, while China reportedly has mandatory HIV testing for some visas.

Singapore revised its own regulations in 2015 to allow people living with HIV to enter the country for short-term stays of less than three months, while South Korea in 2017 removed its final restriction, which mandated the testing of foreign teachers.

But conservative cultures, social stigma and inertia have kept some restrictions in play in other nations, experts say. The majority of such restrictions are found in conservative countries; more countries in the Middle East than anywhere else have them.

“The basis of discrimination is misconception and fear, and with HIV these boil down to drug use, men who have sex with men, and all these realities that countries don’t want to face,” says Peter Wiessner, who co-authors the global database. “There’s also xenophobia mixed in.”

That element can have a negative public health impact, according to Keralis.

“It communicates that HIV is a foreign contagion and a foreigners’ problem, and if [citizens] don’t mix with foreigners then they are not at risk,” she says. She notes that, paired with a lack of proper sex education, this can create a dangerous situation.

“There’s no incentive for people to seek more information or modify their behaviours,” she says.

Canada: Workshops find that HIV non-disclosure laws are little known amongst women living with HIV and contribute to social injustices

Published in aidsmap on February 4th, 2019

HIV non-disclosure laws perpetuate social injustices against women in Canada

Krishen Samuel
Published: 05 February 2019
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People living with HIV in Canada can be charged with aggravated sexual assault and be registered as sexual offenders if they do not disclose their HIV status, but many HIV-positive women have little knowledge of this law, according to a recent qualitative study. The law contributes to increased HIV-related stigma, social injustices and vulnerability to violence for women living with HIV, argue Dr Saara Greene and colleagues.

Forty eight women took part in seven arts-based workshops which each took place over a four-day period. Each workshop included an education session regarding the legal implications of non-disclosure, followed by a focus group discussion that allowed women to share thoughts, feelings and concerns regarding the law.

Canada is one of many countries that continues to criminalise non-disclosure of HIV positive status in sexual acts between consenting individuals. Transmission of the virus does not need to occur: a person can be prosecuted for exposure to the virus in the absence of transmission.

In 2012, the Supreme Court of Canada clarified its position on HIV transmission, ruling that people living with HIV are legally required to disclose their status to sexual partners before engaging in sexual activities that pose a ‘realistic possibility of transmission’. According to the Court, two combined factors could be used as a defense against this realistic possibility of transmission: a low plasma viral load (under 1500 copies/ml) and the use of a condom.

Thus, the law does not acknowledge biomedical advances that conclusively show transmission is impossible if the infected individual is virally suppressed (see our factsheet on undetectable viral load and transmission). The ruling leaves room for those engaging in condomless sex with an undetectable viral load to be prosecuted. In Canada, a charge of aggravated sexual assault could carry a maximum sentence of life imprisonment and registration on the sex offender registry.

A more recent 2018 federal directive issued by the attorney general states that a person living with HIV who has maintained a suppressed viral load (under 200 copies/ml of blood) should not be prosecuted, because there is no realistic possibility of transmission. However, this directive only applies in Canada’s three territories and not in the provinces where the vast majority of the population live. Advocates are calling on the provinces to issue similar directives.

The workshops were carried out in 2016 and 2017, in three Canadaian provinces (Ontario, Saskatchewan and British Columbia). The median age of participants was 47 (range: 30-59); the majority of women were Indigenous (60%), with only a small percentage of white women (8%). It was important for minority women to be oversampled as HIV prevalence is nearly three times higher in Indigenous peoples across Canada, with high rates of HIV diagnoses occurring in young Indigenous women. Additionally, 42% of women charged with HIV non-disclosure are Indigenous.

Most women were heterosexual (73%), cisgender (94%) and born in Canada (79%). One-third of women were single, with 29% reporting a common-law relationship.

Analysis of the focus group discussions revealed the following themes:

Confusion and concerns regarding the law

Overall, the education sessions revealed that women were largely unfamiliar with and poorly-informed about laws pertaining to non-disclosure. Questions and concerns were related to legal implications (such as a whether charges could be brought against them for exposure in the absence of transmission or for sexual interactions several years ago). Several women asked what it meant to have a low viral load.

Social and legal injustice

Women felt that the law perpetuates existing injustices in the lives of diagnosed HIV positive women. Thus, factors such as stigma, sexism, racism, colonialism and a lack of education might put those already disadvantaged at a higher risk of being criminalised.

“Like even this isn’t accessible or something understandable for some of my people because we have literacy issues. Some of our people, they left residential school at grade 6 and grade 8…” (Jaqueline, Saskatchewan, speaking about a legal factsheet given to participants)

A contradiction inherent in HIV non-disclosure criminalisation law is that while individuals who are unaware of their HIV status and have a high viral load are more likely to unknowingly infect others, these individuals cannot be prosecuted under Canadian law as intent cannot be proven. The women expressed that the law unjustly targets those who are diagnosed:

“…When I was first diagnosed, I had a higher viral load because I wasn’t being treated. And so actually the silent people who don’t know are more at risk of passing it on. So, who is this [law] even protecting? We are the least likely to pass it on.” (Lori, British Columbia)

As a result of assault laws being used in non-disclosure cases, a common sentiment expressed by women living with HIV was that they were carrying a biological weapon. Thus, HIV stigma was internalised, as a result of the legal system depicting women as capable of inflicting serious harm on their partners:

“…If I was going to go over there and stab [participant] with a knife, that’s aggravated assault. So, they’re taking that knife away and using HIV. I may not have given it to her. So, it’s like the knife never even touched her or the knife wasn’t used. I’m still charged.” (Rachelle, British Columbia)

Sexual surveillance

Participants expressed a sense that they were under surveillance by the criminal justice system when it came to their sex lives. In order to prove innocence, women would need to provide evidence of both a low viral load and condom use, or of disclosure.

The researchers labelled this an ‘intimate injustice’, with HIV-positive women needing to prove their innocence within an inherently unjust and oppressive system. The lengths that women would have to go through to prove this innocence is reflected here:

“So how many people do you have in that room? You have the lawyer that’s witnessing the paper that you’re signing that you’ve disclosed. You have the doctor to say, ‘Yeah, you’re under a viral load’. You’ve got the forensic scientist there getting any evidence. You know, everybody is watching.” (Lilian, British Columbia)

A common question related to undetectability was:

‘So when I look at it, I’m undetectable. So, I cannot transmit HIV to who I’m going to have sex with. So why is it any of their business that I have it when I’m undetectable?’

Another common question was how to prove that a condom was used or that disclosure had occurred after a sexual encounter had taken place. It could come down to a ‘he said, she said’ situation, with the HIV-positive woman needing some form of conclusive proof that she had used a condom or disclosed her status prior to engaging in sexual contact.

“Okay, so say I had a sexual partner. I just met this guy. And my CD4 count is 880. I’m undetectable. But I’ve got to tell him before we get into bed. Do I need to make him sign a document and lock it up and have it witnessed by the neighbor?” (Zainab, Ontario)

Vulnerability to violence

Non-disclosure laws may place women at greater risk for violence. As many as 80% of Canadian women living with HIV have experienced violence in adulthood and the requirement to disclose HIV status to sexual partners could increase the likelihood of intimate partner violence by placing women in a vulnerable position.

Women expressed that they do not always have control over when or how sex occurs with their partners; this negates their agency when it comes to negotiating condom use or disclosing their HIV status.

There was also the question of how disclosure applied in cases of domestic abuse and rape. The law would require women to disclose to abusive partners, placing them at risk of even more violence. The troubling nature of this was expressed in this quote:

“I was raped by three [people] in [Canadian city]. They broke into my home and they held me prisoner for 24 hours and beat me and raped me. And if I had told him I was HIV positive, I would have been dead. I know it. So where does that fit in the picture?” (Julie, British Columbia)

Additionally, the law could be used against HIV-positive women by vindictive partners wishing to ‘punish’ them. Many women had been threatened with charges for non-disclosure by disgruntled partners:

“Could they turn around and even if you’re honest and told them, then … they lied and said, ‘Well, I caught it from her’, or him. And they go to the police and get them charged, just out to be spiteful and mean.” (Catherine, Saskatchewan)

Concerns over violence were particularly salient for Indigenous women:

“When you include the Indigenous community and the numbers and statistics there, like we’re already like 10 times the rate of being gone missing, murdered and, you know, facing violence every day. So, when you throw in … you know, HIV, you know, like it just becomes sometimes not even safe. A lot of people stay in very vulnerable situations because of this law…” (Jaqueline, Saskatchewan)

Conclusion

The researchers conclude that for women living with HIV in Canada, non-disclosure laws can lead to unjust victimisation, perpetuating legal and social injustices. Many of the women did not have the necessary legal knowledge to fully understand the implications of their sexual behaviour to begin with. HIV-related stigma has become legally entrenched and results in women who are anxious about sexual encounters and fearful that they will need to find ways of proving their innocence. Non-disclosure laws may also lead to increased violence against women.

When combined with factors such as sexism, racism, colonialism and violence against women, HIV criminalisation results in continued oppression and thus, advocacy for legal reform is necessary and urgent. The recent federal directive is a step in the right direction but it will still take some time for this to filter down to provincial police and prosecutors.

Reference

Greene S et al. How women living with HIV react and respond to learning about Canadian law that criminalises HIV non-disclosure: ‘how do you prove that you told?’ Culture, Health & Sexuality online ahead of print, 2019. (Abstract).

Webinar: Media Strategy in HIV Criminalization Reform Efforts: After HIV Is Not a Crime III Series (PWN-USA, 2019)

For advocates working on campaigns to repeal or reform HIV criminalization laws in their states, the question about when it is and isn’t a good idea to seek press coverage, how to talk about the campaign to the press, and what options are available for controlling the message are all fundamental strategic questions. Positive Women’s Network-USA Communications Director Jennie Smith-Camejo talks strategy and best practices in this webinar based off the in-person breakout session at HIV Is Not a Crime III Training Academy in 2018 as part of the After HINAC III webinar series.

Webinar: Molecular HIV Surveillance (PWN-USA, 2019)

PWN’s Barb Cardell’s webinar on Molecular HIV Surveillance and its implications for marginalized communities living with HIV, including intersections with HIV criminalization.

US: Robert Suttle reflects on outdated HIV-specific criminalisation laws and the work of advocates to change them all over the US

by 
 
UNDER LOUISIANA LAW, YOU CAN WIND UP WITH A $5,000 FINE AND FIVE YEARS’ JAIL TIME IF SOMEONE COMES IN CONTACT WITH YOUR SPIT — IF YOU’RE HIV POSITIVE. THESE LAWS ARE BASED ON OUTDATED SCIENCE AND MULTIPLE ORGANIZATIONS ARE WORKING TO CHANGE THEM.

Whenever Robert Suttle thinks about his time in jail, his eyes go soft, he lets out a long breath and his lips purse a bit. It’s noticeable that he — after almost a decade — still gets emotional about what put him behind bars.

In 2008, while working as an assistant clerk for the Louisiana Court of Appeals, Suttle went through a bitter breakup that resulted in a tit-for-tat trial, ending in Suttle being sentenced to six months in jail and registering as a sex offender for intentionally exposing a sexual partner to HIV. But there was no transmission of the virus.

And even though Suttle says he disclosed his status to his partner and that the sex was consensual, it didn’t matter much under Louisiana’s HIV exposure law, which states that anyone with HIV or AIDS who has unprotected sex can be tried and charged with a nonviolent felony. Offenders can be sentenced to up to 10 years in prison and must register as a sex offender in some cases.

But Louisiana’s intentional HIV exposure statute, enacted in 1987, revised in 1993 and again in 2011, is out of date and not backed by science. For example, spitting and biting are considered grounds to be charged for criminal exposure to AIDS, even though it’s impossible to transfer the virus through spit and exceedingly rare for HIV to be passed on through biting (and the risk is nonexistent if the skin isn’t broken).  

What’s more, Suttle, who was diagnosed with HIV in 2002, couldn’t pass the virus on anyway. Antiretroviral treatment had made his viral load undetectable, which means the level of HIV in his blood was so low that it would’ve been impossible to transmit.

“I didn’t quite understand how it could come to this,” Suttle says. “It was being gay and HIV positive that led me to … being criminally liable.”

As more people become aware of possible criminal charges — thanks in part to local reporting on alleged offenders — some of those most at-risk are unwilling to get tested. Criminalizing one’s status has created a stigma, advocates say, which in turn can endanger whole communities.

“[People know] that if they test positive, they can get charged or arrested,” says Gina Brown, an HIV and AIDS activist in New Orleans who is HIV positive. “The laws need to change, and people in charge need to get educated.”

Across the nation, HIV transmissions have been steadily declining since the beginning of the decade. At the same time, the demographics of the disease have changed. No longer does HIV primarily affect gay men; today, those who are most at risk also include injection drug users and poor people of color, particularly in the South. Despite that shift, regulations and laws that criminalize one’s HIV status still abound, and they have roots in outdated science that has largely been debunked.

There are currently 26 states with HIV-specific criminalization laws, some of which penalize behavior regardless of whether the virus was actually transmitted. That number was higher in the 1980s and ’90s, when fear of HIV — and myths around how it spread — was rampant. Lawmakers claimed at the time that the statutes were meant to protect the general public. Instead, they have had the opposite effect: Since you can’t be prosecuted if you don’t know your status, there’s an incentive to not getting tested. Studies have also shown that HIV criminalization has little to no effect on deterring people from spreading the virus willingly, and in fact, such laws have only worsened its spread.

Nearly all of the states with the highest rates of new HIV diagnoses — in 2017, Louisiana ranked third — have HIV-specific exposure laws still on the books.

“People don’t know the collateral consequences,” says Suttle, who now works as an assistant director at Sero Project, a nonprofit that fights stigma and discrimination by focusing on HIV criminalization. “These laws hinder people from getting care.”

Suttle says the biggest obstacle is education, especially among people who still view HIV and AIDS as a death sentence.

“Education of the masses cannot be stressed enough. You can talk to anybody, and people honestly think that [people charged under HIV exposure laws] should be fully prosecuted and locked up,” Suttle says, adding that Sero Project has tried to humanize people living with HIV through anti-criminalization campaigns, lobbying and public outreach.

Sero Project is one of only a handful of national organizations — the Elizabeth Taylor AIDS Foundation and the Center for HIV Law and Policy are two others — that have been on the front lines of fighting against HIV criminalization.

This year, Sero Project, in partnership with the Positive Women’s Network, launched a training academy to teach advocates how to organize and repeal state HIV criminalization laws. In South Carolina, Sero Project’s training helped establish a coalition of 50 lawmakers, advocates and nonprofits to try and change the state’s HIV criminalization laws.

“They gave us the tools to do our own work here within our community, and educate people. Now we have more and more people who are interested, because every time we get out and share with the community, we’re getting more people asking about the laws,” says Stacy Jennings, chair of the Positive Women’s Network regional chapter in South Carolina. “It’s sad that [people living with HIV] don’t know [about the laws] because they should know. Every chance we get we’re teaching them.”

As a result of Sero Project’s efforts to get communities educated on local laws, Suttle has seen a sea change in the number of people coming forward to fight the stigma around being HIV positive.

And that’s been helpful in places like Louisiana, where advocates say the need for educating and empowering people to get tested and stay healthy is dire.

“We actually have been able to get into the offices of legislators and tell them why this law is outdated and plain wrong,” says Brown, the AIDS activist. “We have some of the highest rates of HIV transmission in the country, and that won’t get better so long as there are laws that actively make people fearful of getting tested.”

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This is the third installment in NationSwell’s multimedia series “Positive in the South,” which explores the HIV crisis in the Southern U.S., and profiles the people and organizations working to alleviate it.

Published in NationSwell on December 22, 2018

Belarus: Welcoming important developments in the fight against unjust HIV criminalisation

HIV JUSTICE WORLDWIDE along with our partners at The Eurasian Women’s Network on AIDS and Global Network of People Living with HIV (GNP+) welcome this week’s announcement of an amendment to Article 157 of the Criminal Code of the Republic of Belarus, which finally allows consent following disclosure to sexual partner as a defence. Whilst recognizing there is still a long way to go to remove all unjust criminal laws against people living with HIV in Belarus, we congratulate our partners and colleagues in Belarus People PLUS for this achievement!

Today, Parliamentarians of the House of Representatives of the National Assembly of the Republic of Belarus adopted in the second reading three bills, one of which was the law “On introducing amendments to some codes of the Republic of Belarus”. Among other changes, an amendment was adopted to article 157 of the Criminal Code of the Republic of Belarus (one of the most draconian HIV-specific criminal laws in the world), which now allows that people who have warned their partners will no longer be held criminally responsible for potential or perceived HIV exposure or transmission.

Read Yana’s story on GNP+’s website

Until today, Article 157 states that people living with HIV are totally criminally liable for potential or perceived HIV exposure or transmission, even if the so-called injured party had no complaints against their partner, knew about the risks and consented. Prosecutions took place because infectious disease doctors informed police and many people were convicted (read Yana’s story here)

In 2017, 130 criminal cases were initiated under Article 157 of the Criminal Code of the Republic of Belarus, with another 48 in the first half of 2018. Now, it will be possible to revisit those cases.

Anatoly Leshenok, representative of the NGO, People Plus states: “The adopted changes are only the first step in achieving our goal of decriminalising HIV transmission. According to information received from the department for drafting bills, other, more fundamental changes to Article 157 of the Criminal Code of Belarus have not been approved. It is necessary to continue to work with these State structures and with public opinion in order to form a more tolerant attitude towards HIV-positive people. But those changes that have been adopted today –  that’s a success for our team! ”

Anatoly Leshenok. Photo: UNAIDS Country Office in Belarus
Anatoly Leshenok. Photo: UNAIDS Country Office in Belarus

After approval by the Council of the Republic and the President, the amendments will make it possible to revisit previous sentences of the courts, and improve lives of people that were broken previously, as well it provide opportunity now and in the future for people living with HIV in serodiscordant partnerships to plan their lives without worrying if they are criminals every time they have sex.