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.

Supreme Court v. Necropolitics: The Chaotic Judicialization of COVID-19 in Brazil.

Worldwide, governments have reacted to the COVID-19 pandemic with emergency orders and policies restricting rights to movement, assembly, and education that have impacted daily lives and livelihoods in profound ways. But some leaders, such as President Jair Bolsonaro in Brazil, have resisted taking such steps, denying the seriousness of the pandemic and sabotaging local control measures, thereby compromising population health. Facing one of the world's highest rates of COVID-19 infections and deaths, multiple political actors in Brazil have resorted to judicialization to advance the right to health and other protections in the country. Responding to this litigation has provided the country's Supreme Court an opportunity to assertively confront and counter the executive's necropolitics. In this article, we probe the malleable form and the constitutional basis of the Supreme Court's decisions, assessing their impact on the separation of powers, on the protection of human rights (for example, on those of prisoners, indigenous peoples, and essential workers), and relative to the implementation of evidence-based interventions (for example, lockdowns and vaccination). While the court's actions open up a distinct legal-political field (sometimes called "supremocracy")-oscillating between progressive imperatives, neoliberal valuations, and conservative decisions-the capacity of the judiciary to significantly address systemic violence and to robustly advance human rights remains to be seen.

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.

Right-to-Medicines Litigation and Universal Health Coverage: Institutional Determinants of the Judicialization of Health in Brazil.

Over the past three decades, Brazil has developed a decentralized universal health system and achieved significant advances in key health indicators. At the same time, Brazil's health system has struggled to ensure equitable and quality health services. One response to the broad promises and notable shortcomings has been a sharp rise in right-to-health litigation, most often seeking access to medicines. While much has been written about the characteristics of patient-plaintiffs and the requested medicines in right-to-health litigation in Brazil, little research has examined potential community-level and institutional drivers of judicialization and their role as mechanisms of accountability. To explore these dimensions, we used a mixed-effects analytical model to examine a representative sample of lawsuits for access to medicines filed against the state of Rio Grande do Sul in 2008. We found that the presence of a Public Defender's Office was associated with a sevenfold increase in the likelihood of a municipality having a medicine-requesting lawsuit. This effect was maintained after controlling for a series of municipality characteristics. As low- and middle-income countries seek to achieve universal health coverage within the framework of the Sustainable Development Goals, Brazil's experience may be illustrative of the challenges that health systems will face and the institutional mechanisms that will emerge, advancing accountability and individual patients' interests in response.

Prevalence of trachoma in the Kayes region of Mali eight years after stopping mass drug administration.

BACKGROUND: In 2009, three years after stopping mass treatment with azithromycin, a trachoma impact survey in four health districts in the Kayes region of Mali found a prevalence of trachomatous inflammation-follicular (TF) among children aged 1 to 9 years of >5% and a trachomatous trichiasis (TT) prevalence within the general population (≥1-year-old) of <1%. As a result, the government's national trachoma program expanded trichiasis surgery and related activities required to achieve trachoma elimination. METHODOLOGY/PRINCIPAL FINDINGS: In 2015, to assess progress towards elimination, a follow-up impact survey was conducted in the Kayes, Kéniéba, Nioro and Yélimané health districts. The survey used district level two-stage cluster random sampling methodology with 20 clusters of 30 households in each evaluation unit. Subjects were eligible for examination if they were ≥1 year. TF and TT cases were identified and confirmed by experienced ophthalmologists. In total 14,159 people were enumerated and 11,620 (82%) were examined. TF prevalence (95% confidence interval (CI)) was 0.5% (0.3-1%) in Kayes, 0.8% (0.4-1.7%) in Kéniéba, 0.2% (0-0.9%) in Nioro and 0.3% (0.1-1%) in Yélimané. TT prevalence (95% CI) was 0.04% (0-0.25%) in Kayes, 0.29% (0.11-0.6%) in Kéniéba, 0.04% (0-0.25%) in Nioro and 0.07% (0-0.27%) in Yélimané. CONCLUSIONS/SIGNIFICANCE: Eight years after stopping MDA and intensifying trichiasis surgery outreach campaigns, all four districts reached the TF elimination threshold of <5% and three of four districts reached the TT elimination threshold of <0.1%.

The Judicialization of Health and the Quest for State Accountability: Evidence from 1,262 Lawsuits for Access to Medicines in Southern Brazil.

The impact of increasing numbers of lawsuits for access to medicines in Brazil is hotly debated. Government officials and scholars assert that the "judicialization of health" is driven by urban elites and private interests, and is used primarily to access high-cost drugs. Using a systematic sample of 1,262 lawsuits for access to medicines filed against the southern Brazilian state of Rio Grande do Sul, we assess these claims, offering empirical evidence that counters prevailing myths and affirms the heterogeneity of the judicialization phenomenon. Our findings show that the majority of patient-litigants are in fact poor and older individuals who do not live in major metropolitan areas and who depend on the state to provide their legal representation, and that the majority of medicines requested were already on governmental formularies. Our data challenge arguments that judicialization expands inequities and weakens the universal health care system. Our data also suggest that judicialization may serve as a grassroots instrument for the poor to hold the state accountable. Failing to acknowledge regional differences and attempting to fit all data into one singular narrative may be contributing to a biased interpretation of the nature of judicialization, and limiting the understanding of its drivers, consequences, and implications at local levels.

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.

Between the court and the clinic: lawsuits for medicines and the right to health in Brazil.

BACKGROUND: The Brazilian Constitution states: "Health is the right of all persons and the duty of the State." Yet individuals in Brazil frequently face barriers to health prevention and treatment. One response to these barriers has been a "judicialization" of the right to health, with an increasing number of patients suing the government for access to medicines. OBJECTIVE/METHODS: This study uses a mixed methods approach to identify trends in lawsuits for medicines in the southern state of Rio Grande do Sul (RS) and to characterize patient-plaintiffs. Electronic registries were used to determine the number of health lawsuits filed between 2002 and 2009. In-depth interviews were conducted with thirty patient-plaintiffs, and 1,080 lawsuits for medicines under review between September 1, 2008 and July 31, 2009 were analyzed to assess socio demographic, medical, and legal characteristics of patient-plaintiffs. RESULTS: Between 2002 and 2009, the annual number of health-related lawsuits against the state of RS increased from 1,126 to 17,025. In 2009, 72% of lawsuits sought access to medicines. In-depth interviews revealed that patients are desperate to access medicines for chronic and advanced diseases, and often turn to the courts as a last resort. Among the 1,080 lawsuits examined, patient-plaintiffs were more likely to be older than 45 years (68%), retired or unemployed (71%), and low-income (among those who reported income, 53% (n=350) earned less than the national minimum wage). Fifty-nine percent of all cases were represented by public defenders. Plaintiffs reported 1,615 diseases and requested 2.8 drugs on average (range 1-16). Sixty-five percent of the requested drugs were on government pharmaceutical distribution lists; 78% of the 254 drugs on these lists were requested. In 95% of the cases analyzed, district courts ruled in favor of plaintiffs. Among the 917 cases with a final state high court ruling, 89% were in favor of the plaintiff. In justifying their rulings, judges most frequently cited the government's obligation under the Constitution's provision of a right to health. DISCUSSION: Right-to-health litigation is a widespread practice in southern Brazil. Government pharmaceutical programs are struggling to fulfill their goal of expanded access and rational use of medicines, and poor patients are leveraging public legal assistance and a receptive judiciary to hold the state accountable to their medical needs. "Judicialization" is an alternative pathway for accessing health care, increasingly understood as access to medicines of all kinds. Tracking the health outcomes and budgetary impacts of right to-health court cases could help inform adequate treatment policy and evaluate trends in access.

Acesso de populações migrantes a tratamento antiretroviral no Sul Global / Access to antiretroviral treatment for migrant populations in the Global South / Acceso a tratamiento antirretroviral para las poblaciones migrantes del sur Global

Embora o Direito Internacional dos Direitos Humanos estabeleça o direito à saúde e à não discriminação, poucos países cumpriram com sua obrigação de oferecer tratamento de HIV para não cidadãos - incluindo refugiados, migrantes permanentes em situação irregular e migrantes transitórios. Dois países, África do Sul e Tailândia, ilustram como políticas e práticas governamentais discriminam não cidadãos negando-lhes o tratamento. Na África do Sul, ainda que indivíduos em situação irregular tenham direito a tratamento de saúde gratuito, incluindo a terapia antiretroviral, as instituições públicas de saúde frequentemente negam o tratamento antiretroviral àqueles que não são cidadãos sul-africanos. Na Tailândia, até mesmo entre migrantes regularizados, somente as mulheres grávidas têm direito à terapia antiretroviral. A fim de atender o Direito Internacional dos Direitos Humanos - que garante o fornecimento de um conjunto mínimo de serviços de saúde sem discriminação - os Estados do Sul Global e de todo o mundo devem disponibilizar drogas antiretrovirais e torná-las acessíveis aos migrantes nas mesmas condições que a seus cidadãos.

While international human rights law establishes the right to health and non-discrimination, few countries have realized their obligations to provide HIV treatment to non-citizens-including refugees, long-term migrants with irregular status, and short-term migrants. Two countries, South Africa and Thailand, provide useful illustrations of how government policies and practices discriminate against non-citizens and deny them care. In South Africa, although individuals with irregular status are afforded a right to free health care including antiretroviral therapy (ART), non-South African citizens are frequently denied ART at public health care institutions. In Thailand, even among registered migrants, only pregnant women are entitled to ART. In order to meet international human rights law-which requires the provision of a core minimum of health services without discrimination-states in the Global South and worldwide must make essential ART drugs available and accessible to migrants on the same terms as citizens.

Mientras que el derecho internacional de los derechos humanos establece el derecho a la salud y a la no discriminación, pocos países dan cumplimiento con sus obligaciones de proporcionar tratamiento contra el VIH a los no ciudadanos, incluyendo a los refugiados, los migrantes permanentes en situación irregular y migrantes temporarios. Dos países, Sudáfrica y Tailandia, dan ejemplos útiles de cómo las políticas públicas y sus prácticas discriminan a los no ciudadanos y se les niega atención médica. Aunque en Sudáfrica los individuos con estatus migratorio irregular gozan del derecho a la asistencia sanitaria gratuita, incluyendo el tratamiento antirretroviral (TAR), a los no ciudadanos sudafricanos se les niega frecuentemente el TAR en las instituciones de salud pública. En Tailandia, incluso entre los migrantes regulares, sólo las mujeres embarazadas tienen derecho al TAR. A fin de cumplir con las obligaciones internacionales de derechos humanos -que requieren de la provisión de un mínimo básico de servicios de salud sin discriminación- los estados en el sur global y en todo el mundo deben garantizar la disponibilidad y accesibilidad de los medicamentos esenciales para el TAR para los migrantes en las mismas condiciones que para los ciudadanos.

An outbreak of hepatitis A associated with green onions.

BACKGROUND: In November 2003, a large hepatitis A outbreak was identified among patrons of a single Pennsylvania restaurant. We investigated the cause of the outbreak and factors that contributed to its unprecedented size. METHODS: Demographic and clinical outcome data were collected from patients with laboratory confirmation of hepatitis A, and restaurant workers were tested for hepatitis A. A case-control study was conducted among patrons who dined at the restaurant between October 3 and October 6, 2003. Sequence analysis was performed on a 315-nucleotide region of viral RNA extracted from serum specimens. RESULTS: Of 601 patients identified, 3 died; at least 124 were hospitalized. Of 425 patients who recalled a single dining date at the restaurant, 356 (84 percent) had dined there between October 3 and October 6. Among 240 patients in the case-control study, 218 had eaten mild salsa (91 percent), as compared with 45 of 130 controls (35 percent) (odds ratio, 19.6; 95 percent confidence interval, 11.0 to 34.9) for whom data were available. A total of 98 percent of patients and 58 percent of controls reported having eaten a menu item containing green onions (odds ratio, 33.3; 95 percent confidence interval, 12.8 to 86.2). All restaurant workers were tested, but none were identified who could have been the source of the outbreak. Sequences of hepatitis A virus from all 170 patients who were tested were identical. Mild salsa, which contained green onions grown in Mexico, was prepared in large batches at the restaurant and provided to all patrons. CONCLUSIONS: Green onions that were apparently contaminated before arrival at the restaurant caused this unusually large foodborne outbreak of hepatitis A. The inclusion of contaminated green onions in large batches that were served to all customers contributed to the size of the outbreak.