Global assessment of existing HIV and key population stigma indicators: A data mapping exercise to inform country-level stigma measurement.

BACKGROUND: Stigma is an established barrier to the provision and uptake of HIV prevention, diagnostic, and treatment services. Despite consensus on the importance of addressing stigma, there are currently no country-level summary measures to characterize stigma and track progress in reducing stigma around the globe. This data mapping exercise aimed to assess the potential for existing data to be used to summarize and track stigma, including discrimination, related to HIV status, or key population membership at the country level. METHODS AND FINDINGS: This study assessed existing indicators of stigma related to living with HIV or belonging to 1 of 4 key populations including gay men and other men who have sex with men, sex workers, people who use drugs, and transgender persons. UNAIDS Strategic Information Department led an initial drafting of possible domains, subdomains, and indicators, and a 3-week e-consultation was held to provide feedback. From the e-consultation, 44 indicators were proposed for HIV stigma; 14 for sexual minority stigma (including sexual behavior or orientation) related to men who have sex with men; 12 for sex work stigma; 10 for drug use stigma; and 17 for gender identity stigma related to transgender persons. We conducted a global data mapping exercise to identify and describe the availability and quality of stigma data across countries with the following sources: UNAIDS National Commitments and Policies Instrument (NCPI) database; Multiple Indicator Cluster Surveys (MICS); Demographic and Health Surveys (DHS); People Living with HIV Stigma Index surveys; HIV Key Populations Data Repository; Integrated Biological and Behavioral Surveys (IBBS); and network databases. Data extraction was conducted between August and November 2020. Indicators were evaluated based on the following: if an existing data source could be identified; the number of countries for which data were available for the indicator at present and in the future; variation in the indicator across countries; and considerations of data quality or accuracy. This mapping exercise resulted in the identification of 24 HIV stigma indicators and 10 key population indicators as having potential to be used at present in the creation of valid summary measures of stigma at the country level. These indicators may allow assessment of legal, societal, and behavioral manifestations of stigma across population groups and settings. Study limitations include potential selection bias due to available data sources to the research team and other biases due to the exploratory nature of this data mapping process. CONCLUSIONS: Based on the current state of data available, several indicators have the potential to characterize the level and nature of stigma affecting people living with HIV and key populations across countries and across time. This exercise revealed challenges for an empirical process reliant on existing data to determine how to weight and best combine indicators into indices. However, results for this study can be combined with participatory processes to inform summary measure development and set data collection priorities going forward.

Cross-border COVID-19 spread amidst malaria re-emergence in Venezuela: a human rights analysis.

BACKGROUND: Since 2016 Venezuela has seen a collapse in its economy and public health infrastructure resulting in a humanitarian crisis and massive outward migration. With the emergence of the novel coronavirus SARS-CoV-2 at the end of 2019, the public health emergency within its borders and in neighboring countries has become more severe and as increasing numbers of Venezuelans migrants return home or get stuck along migratory routes, new risks are emerging in the region. RESULTS: Despite clear state obligations to respect, protect and fulfil the rights to health and related economic, social, civil and political rights of its population, in Venezuela, co-occurring malaria and COVID-19 epidemics are propelled by a lack of public investment in health, weak governance, and violations of human rights, especially for certain underserved populations like indigenous groups. COVID-19 has put increased pressure on Venezuelan and regional actors and healthcare systems, as well as international public health agencies, to deal with a domestic and regional public health emergency. CONCLUSIONS: International aid and cooperation for Venezuela to deal with the re-emergence of malaria and the COVID-19 spread, including lifting US-enforced economic sanctions that limit Venezuela's capacity to deal with this crisis, is critical to protecting rights and health in the country and region.

Defining rights-based indicators for HIV epidemic transition.

In a Policy Forum, Joseph Amon and colleagues discuss human rights indicators for tracking progress toward ending the HIV epidemic.

HIV, prisoners, and human rights.

Worldwide, a disproportionate burden of HIV, tuberculosis, and hepatitis is present among current and former prisoners. This problem results from laws, policies, and policing practices that unjustly and discriminatorily detain individuals and fail to ensure continuity of prevention, care, and treatment upon detention, throughout imprisonment, and upon release. These government actions, and the failure to ensure humane prison conditions, constitute violations of human rights to be free of discrimination and cruel and inhuman treatment, to due process of law, and to health. Although interventions to prevent and treat HIV, tuberculosis, hepatitis, and drug dependence have proven successful in prisons and are required by international law, they commonly are not available. Prison health services are often not governed by ministries responsible for national public health programmes, and prison officials are often unwilling to implement effective prevention measures such as needle exchange, condom distribution, and opioid substitution therapy in custodial settings, often based on mistaken ideas about their incompatibility with prison security. In nearly all countries, prisoners face stigma and social marginalisation upon release and frequently are unable to access health and social support services. Reforms in criminal law, policing practices, and justice systems to reduce imprisonment, reforms in the organisation and management of prisons and their health services, and greater investment of resources are needed.

HIV and tuberculosis in prisons in sub-Saharan Africa.

Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.

Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees.

The prison setting presents not only challenges, but also opportunities, for the prevention and treatment of HIV, viral hepatitis, and tuberculosis. We did a comprehensive literature search of data published between 2005 and 2015 to understand the global epidemiology of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and tuberculosis in prisoners. We further modelled the contribution of imprisonment and the potential impact of prevention interventions on HIV transmission in this population. Of the estimated 10·2 million people incarcerated worldwide on any given day in 2014, we estimated that 3·8% have HIV (389 000 living with HIV), 15·1% have HCV (1 546 500), 4·8% have chronic HBV (491 500), and 2·8% have active tuberculosis (286 000). The few studies on incidence suggest that intraprison transmission is generally low, except for large-scale outbreaks. Our model indicates that decreasing the incarceration rate in people who inject drugs and providing opioid agonist therapy could reduce the burden of HIV in this population. The prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who use drugs. The most effective way of controlling these infections in prisoners and the broader community is to reduce the incarceration of people who inject drugs.

Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis.

The burden of HIV/AIDS and other transmissible diseases is higher in prison and jail settings than in the non-incarcerated communities that surround them. In this comprehensive review, we discuss available literature on the topic of clinical management of people infected with HIV, hepatitis B and C viruses, and tuberculosis in incarcerated settings in addition to co-occurrence of one or more of these infections. Methods such as screening practices and provision of treatment during detainment periods are reviewed to identify the effect of community-based treatment when returning inmates into the general population. Where data are available, we describe differences in the provision of medical care in the prison and jail settings of low-income and middle-income countries compared with high-income countries. Structural barriers impede the optimal delivery of clinical care for prisoners, and substance use, mental illness, and infectious disease further complicate the delivery of care. For prison health care to reach the standards of community-based health care, political will and financial investment are required from governmental, medical, and humanitarian organisations worldwide. In this review, we highlight challenges, gaps in knowledge, and priorities for future research to improve health-care in institutions for prisoners.

Utilization of Google enterprise tools to georeference survey data among hard-to-reach groups: strategic application in international settings.

BACKGROUND: As geospatial data have become increasingly integral to health and human rights research, their collection using formal address designations or paper maps has been complicated by numerous factors, including poor cartographic literacy, nomenclature imprecision, and human error. As part of a longitudinal study of people who inject drugs in Tijuana, Mexico, respondents were prompted to georeference specific experiences. RESULTS: At baseline, only about one third of the 737 participants were native to Tijuana, underscoring prevalence of migration/deportation experience. Areas frequented typically represented locations with no street address (e.g. informal encampments). Through web-based cartographic technology and participatory mapping, this study was able to overcome the use of vernacular names and difficulties mapping liminal spaces in generating georeferenced data points that were subsequently analyzed in other research. CONCLUSION: Integrating low-threshold virtual navigation as part of data collection can enhance investigations of mobile populations, informal settlements, and other locations in research into structural production of health at low- or no cost. However, further research into user experience is warranted.

Medical apartheid in Palestine.

The International Convention on the Suppression and Punishment of the Crime of Apartheid (1974) and Article 7 of the Rome Statute of the International Criminal Court (1998) recognise apartheid as a crime against humanity, characterised by a practice of systematic oppression and violations of human rights with the intent of one racial group to maintain domination over another. The term 'medical apartheid', although without a formal definition in international human rights law, has been used similarly to refer to situations of pervasive segregation and discrimination in health care, based upon race, and characterised by stark inequality in health care accessibility, availability, acceptability, and quality. This paper, using a combination of literature review; data on attacks on Palestinian health facilities, workers, and transport; and information from Palestinian and Israeli government authorities on referrals to specialised health care services, examines the ways in which Israeli policies and practices can be understood to constitute a form of 'medical apartheid' that deprives Arab residents of the Palestinian territories the full realisation of their right to health.

Human rights and HIV: rhetoric or determinants?

International donors and UN agencies emphasise the importance of human rights as a key determinant of HIV vulnerability and of access, uptake and retention in HIV prevention and treatment services. Yet, the extent to which HIV researchers are incorporating rights into their research, the specific rights being examined and the frequency of research assessing rights-based approaches, is unknown. METHODS: We examined all articles published in the five highest impact-factor HIV journals: (1) Lancet HIV; (2) AIDS and Behavior; (3) AIDS; (4) Journal of the International AIDS Society (JIAS); and (5) Journal of Acquired Immune Deficiency Syndromes (JAIDS), between 1 January 2017 and 31 December 2022, for reference to 'human right(s)' or 'right(s)'. We analysed articles to assess: (1) what populations were identified in relation to specific human rights concerns; (2) what specific rights were mentioned; (3) whether researchers cited specific legal frameworks; and (4) if and what types of rights-based interventions were examined. RESULTS: Overall, 2.8% (n=224) of the 8080 articles reviewed included a mention of 'human right(s)' or 'right(s)'. Forty-two per cent of these (n=94) were original research articles. The most common key population discussed was men who have sex with men (33 articles), followed by sex workers (21 articles) and transgender people (14 articles). Of the 94 articles, 11 mentioned the right to health and nine referenced reproductive rights. Few articles identified a specific authority-whether in national, regional or international law-for the basis of the rights cited. Fourteen articles discussed rights-based interventions. CONCLUSION: Despite global recognition of the importance of human rights to HIV outcomes, few HIV researchers publishing in the top five cited HIV journals include attention to human rights, or rights-based interventions, in their research. When rights are mentioned, it is often without specificity or recognition of the legal basis for human rights.

Ensuring access to justice: the need for community paralegals to end AIDS by 2030.

INTRODUCTION: The HIV response has long recognized that certain "key populations" such as individuals in detention, adolescent girls and young women, sex workers, people who use drugs, LGBTQ individuals, migrants and others face higher barriers to access to, uptake of, and retention in HIV prevention and treatment services. One approach to addressing these barriers is the training of community paralegals to advocate for the rights of individuals and to address discrimination in health settings. DISCUSSION: Community paralegal programmes have been able to successfully address rights violations that impact access to health services and underlying determinants of health across a range of countries and populations, focusing upon issues such as discrimination and the denial of health services; unlawful detention of outreach workers, sex workers, persons who use drugs and men who have sex with men; and harmful traditional practices and gender-based violence. In addition to resolving specific cases, evaluations of paralegal programmes have found that these programmes increased legal literacy among key populations at risk of HIV and increased understanding of human rights among healthcare providers, resulting in improved access to HIV services. Some evaluations have noted challenges related to the sustainability of paralegal programmes similar to those raised with community health worker programmes more broadly. CONCLUSIONS: To achieve global HIV goals, funding for legal literacy and paralegal programmes should be increased and interventions should be rigorously evaluated. Efforts should target discrimination in access to HIV prevention and treatment and criminalization of key populations, two key barriers to ensuring access to HIV prevention and treatment services.

The impact of social violence on HIV risk for women in Colombia: A concurrent mixed methods study.

Gender, violence, and migration structurally impact health. The Venezuelan humanitarian crisis comprises the largest transnational migration in the history of the Americas. Colombia, a post-conflict country, is the primary recipient of Venezuelans. The Colombian context imposes high levels of violence on women across migration phases. There is little information on the relationship between violence and HIV risk in the region and how it impacts these groups. Evidence on how to approach the HIV response related to Venezuela's humanitarian crisis is lacking. Our study seeks to 1) understand how violence is associated with newly reported HIV/AIDS case rates for women in Colombian municipalities; and 2) describe how social violence impacts HIV risk, treatment, and prevention for Venezuelan migrant and refugee women undergoing transnational migration and resettlement in Colombia. We conducted a concurrent mixed-methods design. We used negative binomial models to explore associations between social violence proxied by Homicide Rates (HR) at the municipality level (n = 84). The also conducted 54 semi-structured interviews with Venezuelan migrant and refugee women and key informants in two Colombian cities to expand and describe contextual vulnerabilities to HIV risk, prevention and care related to violence. We found that newly reported HIV cases in women were 25% higher for every increase of 18 homicides per 100,000, after adjusting for covariates. Upon resettlement, participants cited armed actors' control, lack of government accountability, gender-based violence and stigmatization of HIV as sources of increased HIV risk for VMRW. These factors impose barriers to testing, treatment and care. Social violence in Colombian municipalities is associated with an increase in newly reported HIV/AIDS case rates in women. Violence hinders Venezuelan migrant and refugee women's access and engagement in available HIV prevention and treatment interventions.

No Exit: China's State Surveillance over People Who Use Drugs.

In China, although drug use is an administrative and not criminal offense, individuals detained by public security authorities are subject to coercive or compulsory "treatment," which can include community-based detoxification and rehabilitation and two years of compulsory isolation. Individuals are also entered into a system called the Drug User Internet Dynamic Control and Early Warning System, or simply the Dynamic Control System. The Dynamic Control System, run by the Ministry of Public Security, acts as an extension of China's drug control efforts by monitoring the movement of people in the system and alerting police when individuals, for example, use their identity documents when registering at a hotel, conducting business at a government office or bank, registering a mobile phone, applying for tertiary education, or traveling. This alert typically results in an interrogation and a drug test by police. This paper seeks to summarize, using published government reports, news articles, and academic papers, what is known about the Dynamic Control System, focusing on the procedures of (1) registration; (2) management; and (3) exit. At each step, people subject to the Dynamic Control System face human rights concerns, especially related to the right to privacy, rights to education and work, and right to health.

Human rights in pandemics: criminal and punitive approaches to COVID-19.

In the early years of the HIV epidemic, many countries passed laws criminalising HIV non-disclosure, exposure and/or transmission. These responses, intended to limit transmission and punish those viewed as 'irresponsible', have since been found to undermine effective HIV responses by driving people away from diagnosis and increasing stigma towards those living with HIV. With the emergence of COVID-19, human rights and public health advocates raised concerns that countries might again respond with criminal and punitive approaches. To assess the degree to which countries adopted such strategies, 51 English-language emergency orders from 39 countries, representing seven world regions, were selected from the COVID-19 Law Lab, a database of COVID-19 related laws from over 190 countries. Emergency orders were reviewed to assess the type of restrictions identified, enforcement mechanisms and compliance with principles outlined in the Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights, including legality, legitimate aim, proportionality, non-discrimination, limited duration and subject to review. Approximately half of all orders examined included criminal sanctions related to violations of lockdowns. Few orders fully complied with the legal requirements for the limitation of, or derogation from, human rights obligations in public health emergencies. In future pandemics, policymakers should carefully assess the need for criminal and punitive responses and ensure that emergency orders comply with countries' human rights obligations.

Left behind: persons with disabilities in HIV prevalence research and national strategic plans in east and Southern Africa.

PURPOSE: To assess recent estimates of HIV prevalence and the inclusion of persons with disabilities in the HIV response in sub-Saharan Africa. METHODS: A systematic literature search was conducted of recent HIV prevalence studies among persons with disabilities in sub-Saharan Africa and National Strategic Plans from 18 countries in east and southern Africa were reviewed. Results were compared to a 2014 literature search and a 2009 National Strategic Plans review that used similar methods. RESULTS: Between 2013 and 2018, four published studies were identified with estimates of HIV prevalence among persons with disabilities in sub-Saharan Africa. In each study, HIV prevalence was higher among persons with disabilities than national population estimates. Fourteen of the 18 National Strategic Plans reviewed identified persons with disabilities as a vulnerable or marginalized population and thirteen National Strategic Plans proposed targeted programs for persons with disabilities. Among seven assessed disability inclusion indicators of National Strategic Plans, four showed some improvement, two showed no change, and one regressed compared to the 2009 analysis. CONCLUSIONS: Data on HIV prevalence among persons with disabilities is rare. In addition, inclusion of this population in National Strategic Plans in East and Southern African countries is often lacking specific detail.Implications for rehabilitationHIV prevalence studies in sub-Saharan Africa among persons with disabilities are rare and community studies do not disaggregate by type of disability.Estimates of HIV prevalence among persons with disabilities are greater than national averages.Government National HIV Strategic Plans often mention persons with disabilities as a vulnerable population but less often identify specific interventions or inclusive strategies for prevention or care.The integration of attention to disability in national HIV bio-behavioral surveys would allow increased understanding of HIV vulnerability and prevalence and could increase attention to persons with disabilities as a key population within National Strategic Plans.

People who use drugs, HIV, and human rights.

We reviewed evidence from more than 900 studies and reports on the link between human rights abuses experienced by people who use drugs and vulnerability to HIV infection and access to services. Published work documents widespread abuses of human rights, which increase vulnerability to HIV infection and negatively affect delivery of HIV programmes. These abuses include denial of harm-reduction services, discriminatory access to antiretroviral therapy, abusive law enforcement practices, and coercion in the guise of treatment for drug dependence. Protection of the human rights of people who use drugs therefore is important not only because their rights must be respected, protected, and fulfilled, but also because it is an essential precondition to improving the health of people who use drugs. Rights-based responses to HIV and drug use have had good outcomes where they have been implemented, and they should be replicated in other countries.