Human Rights and the Global Fund to Fight AIDS, Tuberculosis and Malaria: How Does a Large Funder of Basic Health Services Meet the Challenge of Rights-Based Programs?

The Global Fund to Fight AIDS, Tuberculosis and Malaria was created to greatly expand access to basic services to address the three diseases in its name. From its beginnings, its governance embodied some human rights principles: civil society is represented on its board, and the country coordination mechanisms that oversee funding requests to the Global Fund include representatives of people affected by the diseases. The Global Fund's core strategies recognize that the health services it supports would not be effective or cost-effective without efforts to reduce human rights-related barriers to access and utilization of health services, particularly those faced by socially marginalized and criminalized persons. Basic human rights elements were written into Global Fund grant agreements, and various technical support measures encouraged the inclusion in funding requests of programs to reduce human rights-related barriers. A five-year initiative to provide intensive technical and financial support for the scaling up of programs to reduce these barriers in 20 countries is ongoing.

HIV and incarceration: prisons and detention.

The high prevalence of HIV infection among prisoners and pre-trial detainees, combined with overcrowding and sub-standard living conditions sometimes amounting to inhuman or degrading treatment in violation of international law, make prisons and other detention centres a high risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return upon their release. We reviewed the evidence regarding HIV prevalence, risk behaviours and transmission in prisons. We also reviewed evidence of the effectiveness of interventions and approaches to reduce the risk behaviours and, consequently, HIV transmission in prisons. A large number of studies report high levels of risk behaviour in prisons, and HIV transmission has been documented. There is a large body of evidence from countries around the world of what prison systems can do to prevent HIV transmission. In particular, condom distribution programmes, accompanied by measures to prevent the occurrence of rape and other forms of non-consensual sex, needle and syringe programmes and opioid substitution therapies, have proven effective at reducing HIV risk behaviours in a wide range of prison environments without resulting in negative consequences for the health of prison staff or prisoners.The introduction of these programmes in prisons is therefore warranted as part of comprehensive programmes to address HIV in prisons, including HIV education, voluntary HIV testing and counselling, and provision of antiretroviral treatment for HIV-positive prisoners. In addition, however, action to reduce overcrowding and improve conditions in detention is urgently needed.

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.

Ten reasons to oppose the criminalization of HIV exposure or transmission.

Recent years have seen a push to apply criminal law to HIV exposure and transmission, often driven by the wish to respond to concerns about the ongoing rapid spread of HIV in many countries. Particularly in Africa, some groups have begun to advocate for criminalization in response to the serious phenomenon of women being infected with HIV through sexual violence or by partners who do not reveal their HIV diagnoses to them. While these issues must be urgently addressed, a closer analysis of the complex issues raised by criminalization of HIV exposure or transmission reveals that criminalization is unlikely to prevent new infections or reduce women's vulnerability to HIV. In fact, it may harm women rather than assist them, and have a negative impact on public health and human rights. This paper is a slightly revised version of a document originally released in December 2008 by a coalition of HIV, women's and human rights organizations. It provides ten reasons why criminalizing HIV exposure or transmission is generally an unjust and ineffective public policy. The obvious exception involves cases where individuals purposely or maliciously transmit HIV with the intent to harm others. In these rare cases, existing criminal laws - rather than new, HIV-specific laws - can and should be used.

Interventions to reduce HIV transmission related to injecting drug use in prison.

The high prevalence of HIV infection and drug dependence among prisoners, combined with the sharing of injecting drug equipment, make prisons a high-risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return on their release. We reviewed the effectiveness of interventions to reduce injecting drug use risk behaviours and, consequently, HIV transmission in prisons. Many studies reported high levels of injecting drug use in prisons, and HIV transmission has been documented. There is increasing evidence of what prison systems can do to prevent HIV transmission related to injecting drug use. In particular, needle and syringe programmes and opioid substitution therapies have proven effective at reducing HIV risk behaviours in a wide range of prison environments, without resulting in negative consequences for the health of prison staff or prisoners. The introduction of these programmes in countries with an existing or emergent epidemic of HIV infection among injecting drug users is therefore warranted, as part of comprehensive programmes to address HIV in prisons.

Panel: rights of people in prison to HIV prevention, treatment and care.

This article contains summaries of the five presentations made during this panel. Ralf Jürgens provides an overview of the issue of needle exchange programs in prisons, and reviews the international experience with such programs. Sandra Ka Hon Chu advances the legal and human rights arguments for establishing needle exchanges in Canadian prisons. Giselle Dias describes the inter-sectoral strategy for HIV/AIDS is prisons being developed by the Prisoners HIV/AIDS Support Action Network (PASAN). Finally, two former prisons turned activists, James Motherall and Greg Simmons, provide their personal perspectives on prevention and treatment behind bars.

Human rights and HIV/AIDS: where are we? and what next?

Issues related to HIV/AIDS and human rights received more attention at AIDS 2008 than ever before at an International AIDS Conference. Nevertheless, in this presentation at one of two sessions devoted to HIV and human rights, Ralf Jürgens warned that despite much rhetoric, real action on HIV/AIDS and human rights remains lacking. He suggested that much needed to change before human rights will be where they need to be--at the centre of the global AIDS struggle. And he proposed a number of concrete activities to get there.

Increasing access to HIV testing and counselling while respecting human rights.

Two days after the World Health Organization (WHO) and UNAIDS released the final version of their Guidance on Provider-initiated Testing and Counselling in Health Facilities (""he Guidelines"), OSI's Public Health Program issued an updated version of its paper on Increasing Access to HIV Testing and Counseling While Respecting Human Rights. Since then, as Ralf Jürgens reports, the paper has served as the basis for a statement and recommendations on scaling up HIV testing and counselling issued by the UNAIDS Reference Group on HIV and Human Rights.3 In addition, it has helped inform guidance currently being developed by WHO and the U.N. Office on Drugs and Crime (UNODC) on HIV testing for prisoners and for people who use drugs.

Prisoners who inject drugs: public health and human rights imperatives.

This article examines the human rights and public health implications of injection drug use in prisons with a specific focus on HIV and hepatitis C (HCV) viruses. The authors argue that prisoners who inject drugs have a right to access harm reduction measures--those that reduce the harmful consequences of drug use without necessarily reducing drug consumption. Moreover, states that fulfill their obligation to provide prisoners with harm reduction measures such as access to bleach, substitution therapy, and sterile injection equipment implement sound public health policy with a positive impact for a population particularly vulnerable to HIV and HCV. Ultimately, this approach benefits not only prisoners but also prison staff and the public, and does not entail lessening of the safety and security of prisons.

Injection drug use, HIV/AIDS and incarceration: evidence from the Vancouver Injection Drug Users Study.

The reliance on law enforcement as the dominant drug policy approach has resulted in record incarceration rates in many countries. Human rights advocates and public health researchers have argued that the risks of HIV transmission resulting from injection drug use within Canadian prisons must be addressed. Despite a decade of advocacy and some progress made, this remains an urgent public health crisis. In light of these concerns, researchers working with the Vancouver Injection Drug Users Study (VIDUS) have undertaken a series of studies specific to injection drug use and HIV/AIDS in prisons. This article summarizes the body of evidence generated via VIDUS, discusses briefly the related human rights implications, and concludes with recommendations for action.

Dublin Declaration on HIV/AIDS in prisons launched.

On 23 February 2004, the Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia was launched. The Declaration focuses on prisons in Europe and Central Asia, but it is also relevant for prisons in other countries, including Canada, which are still far from having adopted a comprehensive approach, based on public health and human rights principles, to HIV/AIDS and hepatitis C in prisons.

Another review of prison-based needle exchange programs published.

In volume 8, issue 1 of the Review, we reported on the publication of a review of prison-based syringe-exchange programs (PSEPs) that concluded that such programs "are feasible and do provide benefit in the reduction of risk behaviour and the transmission of blood-borne infection without any unintended negative consequences." Another, more comprehensive review was recently published, confirming once again that PSEPs have been successful where they have been introduced.

Canadian Human Rights Commission recommends prison needle exchange programs.

In a report released on 28 January 2004, the Canadian Human Rights Commission recommended that the Correctional Service of Canada (CSC) implement a pilot needle exchange program in three or more correctional facilities, at least one of them a women's facility, by June 2004.