Transcript HUMAN RIGHTS AND HIV AMONG KEY POPULATIONS IN AFRICA Stefan Baral, MD MPH FRCPC Center for Public Health and Human Rights, Johns Hopkins School.

HUMAN RIGHTS AND HIV
AMONG KEY POPULATIONS
IN AFRICA
Stefan Baral, MD MPH FRCPC
Center for Public Health and Human Rights, Johns Hopkins School of Public Health
Outline

Background
 Link
between Human Rights and HIV
Prerequisites for HIV Prevention Programming
 Case Studies

 Most
At Risk or Key Populations
 Relationship
Between Stigma and Prevention Research
Barriers to Prevention
 Moving Forward

Reproductive Rate


Average number of secondary cases that will
theoretically result from a sentinel case in the absence
of immunity or interventions
R 0= ß x C x D
 R0 -
reproductive rate of an infection
 ß - average probability of transmission per exposure to a
susceptible contact
 C - average number of contacts per unit time
 D - average duration of infectiousness of the infection
Human Rights and HIV

Increased Acquisition and Transmission (ß)



Accessing commodities
 condoms and condom compatible lubricants
 clean needles

Information

Services
Increased Exposure (C)


Barriers to
Eg. Coercion, sexual violence, rape as tool of war
Increased Duration of Contagiousness (D)

Eg. Treatment delays or gaps


Forced detention
Stigma in health care settings
Most At Risk or Key Populations

Specific populations that carry disproportionate
burden of HIV
 Three
Universal Key Affected Populations
 Sex
workers (SW)
 Gay Men and other Men who have sex with Men (MSM)
 People who use drugs (PUD)
 Sentinel
Population for Human Rights Contexts
 Criminalized
in Many Countries
 Significant Social Stigma
 High Risk for HIV
Systematic Review of HIV Prevalence
among Female Sex Workers
Source: Baral, S et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet Infectious Diseases. 2012
Global HIV among MSM
Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012
Combination HIV Prevention Programming
 Behavioural
Interventions
 Increasing condom and lubricant use during sex
 Eg. Peer Education, Risk Reduction Counselling, Adherence Counselling
 Biomedical
Interventions
 Biomedical
interventions aim to decrease transmission
and acquisition risk of sex

Eg. Oral or topical antiviral chemoprophylaxis, Treatment as Prevention
 Structural
Interventions
 Limited
data because of complexity in study design to
characterize efficacy and effectiveness of these
interventions

Eg. Decriminalization, Government-sponsored anti-stigma policy, Mass media
engagement, Gender engagement programs, Community systems strengthening,
Health Sector Interventions
Prerequisites for HIV Prevention Programming

Identification

Must be able to Identify MSM and Sex Workers


Risk Assessment

Must be able to appropriately stratify MSM and Sex Work
according to risk


Willing to Self-Disclose
Asked about risks in a competent and sensitive manner
Follow Up

Must be able to follow up participants to assess adherence
and efficacy of intervention
Safe Environment
 Community Group
 Client trust in health care facility

Case Studies

Combination HIV Prevention and Stigma
 FSW
in Russia, Swaziland
 MSM in Gambia, Malawi
Case Study Russia
Russia
10
9
8
7
6
%
5
HIV Prevalence
4
3
2
1
0
Female Sex Workers
General Population
Source: Decker, Wirtz, Baral, et al., Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. STI, 2012
Client Violence among FSW in Russia
…sometimes I pull on a condom and he pulls it off right
straight away, I pull it on once again and he can give
me a punch for that.
…I say to a client that I don’t practice anal sex and he
replies that he doesn’t need it. When I come to him he
just starts beating me up to make me do what he
wants.
Source: Decker, Wirtz, Baral, et al., Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. STI, 2012
Client Physical Violence & STI/HIV
40%
37%
35%
30%
25%
20%
15%
15%
10%
5%
0%
Client Violence
aOR=3.14, 95% CI 1.09, 8.99
Source: Decker, Wirtz, Baral, et al., Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. STI, 2012
Case Study - Swaziland
90
80
70
HIV Prevalence (%)
60
50
FSW HIV Prevalence
40
Female HIV Prevalence
30
20
10
0
16-20
21-24
25-29
30-40
Age Groups
Source: Central Statistical Office & Macro International, 2008, p. 222
Disclosure of Sex Work in Swaziland
N=313
%
As a result of selling sex Felt afraid to seek healthcare
Experienced legal discrimination
Been refused police protection
Been blackmailed
Verbal and physical harassment
Have been tortured
Have been beaten up
143
152
160
113
198
173
125
44.0
46.8
49.4
34.8
60.9
53.2
38.7
Have been beaten up by
45
21
16
11
9
6
20.8
9.7
7.4
5.1
4.2
2.8
Uniformed Officers (police, miltary, security)
Family Member
Regular Partner
One time client
Regular client, partner
Manager/pimp
Associations of Disclosure of Sex Work

Disclosure of Sex Work to
 Family
Member
 30.3%
 Health
Care Worker
 25.9%

(98/325)
(84/325)
Afraid to Seek Health Care
 OR
3.5 (95% CI 1.3-5.6) disclosed sex work to HCW
 OR 2.0 (95% CI 1.12-3.7) being treated for HIV
Case Study – Gambia
Gambia
12.000%
10.000%
8.000%
% 6.000%
4.000%
2.000%
.000%
MSM HIV Positive
National Prevalance
Gambia, 2012

20 men accused of attempting to commit unnatural
offences
Gambia, 2012
Gambia, 2012
Associations with Disclosure

Disclosure of Sexual Orientation to
 Family
 3.9%
 Health
Member
(8/205)
Care Worker
 15.4%
Variable
Disclosure of
Sexual Orientation
to Family or HCW
(84/205)
Fear
OR
2.61
[95% CI]
[1.08-6.32]
Denial
OR
9.74
[95% CI]
[1.96-48.45]
Case Study - Malawi
Malawi
25
20
%
15
HIV Prevalence
10
5
0
MSM
Men (15+)
Population
Arrests in Malawi, 2010
Interrupting Structural Interventions, April, 2011
Malawi, May, 2011
Associations between fear and experienced discrimination with sexual health
and use of services among MSM in Malawi, Botswana, and Namibia.
Variable
Fear of Seeking Health Care Denied Health Care Services
OR (95% CI)
OR (95% CI)
Blackmailed
OR (95% CI)
Diagnosed with an STI
2.4 (1.4-4.3) *
6.9 (3.0-15.6) **
1.5 (0.8-2.7)
Treated for an STI
2.8 (1.7-4.9) **
7.3 (3.3-16.2) **
1.5 (0.8-2.6)
Received recommendation for
an HIV test
1.9 (1.2-3.0) *
2.2 (0.98-4.8)
1.8 (1.1-2.8) *
1.1 (0.7-1.7)
1.6 (0.7-3.7)
1.0 (0.7-1.6)
2.6 (1.1-6.5) *
3.3 (0.9-12.1)
2.7 (1.1-6.6) *
3.7 (1.6-8.6) *
46.1 (17.3-122.8) **
5.4 (2.2-13.2) **
1.7 (0.9-3.2)
1.2 (0.4-3.6)
0.9 (0.5-1.6)
2.6 (1.6-3.9) **
6.4 (2.5-16.1) **
2.1 (1.4-3.2) *
Ever tested for HIV
Self-Reported Diagnosis of HIV
or AIDS
Self-Reported Treatment for
HIV
HIV positive
Any interaction with health care
Pooled Data from Three Countries
* - p <0.05
** - p <0.01
Source: Fay H, Baral S, Trapence G, Motimedi F, Umar E, et al. Stigma, Health Care Access, and HIV Knowledge Among Men Who Have Sex With Men in Malawi, Namibia, and Botswana. AIDS and Behavior, Dec
2010: 1-10.
Turning the Tide in Malawi?
Case Study Messages

Limited Capacity for HIV Prevention Research if
Populations:
 Live
in fear
 Live hidden
 Have limited access to safe and effective clinical care
Prevention Expenditures for MARPS

Concentrated Epidemics
 MSM
and SW predominant risk groups
 3.3%
of non-treatment expenditures supporting MSM
 2% of non-treatment expenditures support FSW

Generalized Epidemics
 Emerging
evidence of risk among MSM and SW
<
0.1% of non-treatment expenditures supporting MSM and
SW

Many countries have invested 0% of national expenditures for the
prevention needs for MSM and SW
Source: Global HIV Prevention Working Group: Global HIV Prevention: The Access, Funding, and Leadership Gaps. 2009
Anti-Prostitution Loyalty Oath (APLO) aka AntiProstitution Pledge


All international organizations that receive PEPFAR
funding to have a policy that explicitly opposes
prostitution and sex trafficking
Signed by all USG funded programs in 2003
(PEPFAR v1 and also with PEPFAR v2 in 2009) limits
comprehensive surveillance and service provision for
sex workers
 In
combination with criminalization and stigma, the
prostitution pledge has limited the understanding of the
burden of HIV disease among female sex workers
http://www.pepfarwatch.org/the_issues/anti_prostitution_pledge/
Global Fund Investments and Criminalization of SameSex Practices
Countries that Criminalize Consensual Same Sex Practices
• Seven of the ten countries receiving the greatest support
from the Global Fund
• More than half of the 88 countries supported through
PEPFAR
Source: amfAR, JHU. Achieving an AIDS-Free Generation for Gay Men and other MSM, 2011
* - Same-Sex Practices
Criminalized
Conclusions


Stigma, Rights Violations, and HIV are intricately linked
To test combination HIV prevention strategies, stigma must be addressed


And for combination HIV prevention programs to have effectiveness outside of
trial settings, stigma must be addressed
Addressing Stigma

Government and Funders


Implementers (large and small) and Community



Anti-discrimination clauses in all policies, programs, RFP/RFA
Engage media, engage government, engage religious leaders, engage target
community, engage general community. Engage.
Find champions within target communities and in general community and empower them
Academia

All epidemiological research should include an assessment of enacted/perceived stigma


Linking HIV with UI, high numbers of partners, STI no longer contributes to our knowledge of risk
Use the opportunity of epidemiological assessments (size estimations, cohorts, cross-sectional studies,
prevention studies, etc) to collect actionable data

Stigma manifests in different ways in different settings