Thursday, September 28, 2006

South Africa: Allocation of resources

South Africa has the highest number of people living with HIV in Africa, and rivals only India for the most in the world.

Activists have long pushed for – and had great success – demanding greater access for everyone to antiretroviral drugs in South Africa. But the question is still sometimes raised – how can a scarce resource (antiretroviral drugs) be ethically and most effectively distributed?

As shown by recent reports on the KwaZulu-Natal Province by David P. Wilson, James Kahn, and Sally M. Blower in the Proceedings of the National Academy of Sciences and by Prof Gita Ramjee of the Medical Research Council of South Africa, there are different priorities that could guide allocation strategies.

The article in the PNAS focuses on the urban-rural divide. Using a model that predicted the consequences of three drug allocation strategies in different areas between 2004 and 2008, the researchers argue that the most effective strategy for preventing additional cases of HIV infection would be to prioritize distribution to urban populations. The authors acknowledged the ethical problems in such a strategy, but stated that given an opportunity to treat 500,000 people by 2008, “if the government health policy officials in KwaZulu-Natal wish to apply the utilitarian principle (and minimize the epidemic), our results show that they should allocate all drugs to Durban”.

The biggest problem with the study is that it only looks at preventing infections through 2008. Imagine if we did the same study with a global perspective in 1990 and only looked at infection through 1992. What would our conclusions have been – only to focus programs in Western countries and ignore Asia, Eastern Europe and Africa because they would prevent fewer cases? Didn’t we make that mistake once already?

The Medical Research Council’s study on KwaZulu-Natal focuses on women and revealed alarming HIV prevalence ranging from 38 to 66 percent. The social factors that cause this prevalence are timeless and bridge the urban-rural divide. MRC cites as factors the taboos surrounding sex and promiscuity and the treatment of boys as “demigods…exempt from apology for unfaithfulness”. The existence of AIDS is routinely denied and women are often forced to engage in unprotected sex.

MRC’s research adds complexity to the discussion of allocation strategies. While perhaps treating only people in urban areas would yield fewer infections in the short term, it would do nothing to lower the stigma surrounding AIDS or empower women economically or in their relationships. These social factors stretch across the urban-rural divide and will continue to be a driving force behind AIDS unless tackled directly.

Links to articles:

Voices of HIV/AIDS

The HIV/AIDS Program at Human Rights Watch would like to draw attention to a recent addition to the website: over a dozen stories from courageous individuals intimately involved in the fight against AIDS. Human Rights Watch collaborated with Making Contact to produce a 30 minute program featuring the voices of AIDS activists rarely heard in the mainstream media. All this is available at Human Rights Watch's HIV/AIDS Program webpage.

2006 Awards for Action on HIV/AIDS and Human Rights

Gareth Williams, a leading AIDS activist and voice for the rights of sexual minorities in Jamaica and the English-speaking Caribbean, is the recipient of the 2006 International Award for Action on HIV/AIDS and Human Rights. Stella, a Montréal-based support and information group organized by and for sex workers, is the recipient of the Canadian Award. Both are presented by the Canadian HIV/AIDS Legal Network and Human Rights Watch.

Williams spearheads an emergency support program that provides material care and support for victims of homophobic violence. He also played a key role in encouraging community members to share their stories with researchers for the 2004 Human Rights Watch report, Hated to Death: Homophobia, Violence, and Jamaica’s HIV/AIDS Epidemic: (

Stella serves women, transvestites and transsexuals. The group maintains an ongoing presence in sex work venues, including streets, escort agencies, massage parlours and strip bars.

Until human rights are at the center of AIDS policy and program decision-making, we must continue to thank courageous and tireless advocates for human rights, whose bravery in the face of personal risk, benefits us all. To this end, in 2002, the Canadian HIV/AIDS Legal Network and Human Rights Watch established the Awards for Action on HIV/AIDS and Human Rights to recognize excellence and long-term commitment to work that has a direct impact on HIV/AIDS and human rights issues. An award is presented annually to one Canadian and one international recipient. The 2006 Awards will be presented on September 28th in Gatineau, Quebec (

Wednesday, September 27, 2006

CDC recommends routine testing: Ignores stigma?

The Center for Disease Control and Prevention revised their recommendations on September 22 regarding HIV testing. Now, the CDC urges that all teenagers and most adults receive HIV tests as part of routine medical care. Further, it advocates dropping previous guidelines of pre-test counseling and signed consent forms.

This proposal prioritizes expansive testing over efforts to inform people about high-risk behavior. A study of AIDS cases in 33 U.S. states between 2001 and 2004 showed that over 60 percent of HIV cases are due to male-to-male sexual contact or injection drug use (MMWR 54(45); 1149-1153). The heterosexual partners of MSM and IDUs must also be considered in this statistic. Education and counseling about high-risk behavior is crucial to curbing the epidemic. In the case that people engaged in risky behavior test negative, without counseling there is little motivation to change that behavior or change in risk perception.

Dr. Julie Gerberding, the disease control agency’s director, said, “People with HIV have a right to know that they are infected so they can seek treatment and take steps to protect themselves and their partners.'' But what exactly is the CDC doing to facilitate these steps? People cannot take steps on their own without counseling about their status and guidance through the system. The CDC might take on a leadership role in funding needle exchanges and comprehensive sex education in schools, for example.

The New York Times called the move “a sharp break from the early days of the AIDS epidemic, when the stigma and fear of social ostracism caused many people to avoid being tested”. In fact, stigma around AIDS and sex is still very much alive in the United States. Education policies around abstinence both exemplify and exacerbate this stigma. They affirm the destructive stance that those infected have failed to adhere to moral policies.

HIV Perspectives after 25 years

The Journal of Urban Health recently put together a series entitled “HIV Perspectives after 25 years”. The articles in the issue include:
  • immigration and HIV in New York City
  • integration of HIV prevention activities into the medical care setting
  • conceptual articles about structural intervention
  • the importance of funding prevention as well as vaccine research
  • the devastating effect of HIV/AIDS on children.

The series serves well to show not only how many issues the epidemic affects but also how vast the field of study has become.

While there is no article that explicitly touches on the relationship between human rights and HIV/AIDS, the concept of structural intervention is featured prominently. The articles advocate approaches to public health that alleviate the burden of blame on individuals. Pinning blame on individuals can obstruct the right to health.

The authors state, “[structural interventions] locate the cause of public health problems in contextual or environmental factors that influence risk behavior…rather than in characteristics of the individuals who engage in risk behaviors”.

The authors define four important types of structural interventions in HIV prevention: community mobilization, integration of HIV services, and economic and education interventions.

These articles can be found at:
Journal of Urban Health, Bulletin of the New York Academy of Medicine (2006) Vol. 83, No.1

Report from New York City: the turbulent history of HIV/AIDS education

The HIV/AIDS curriculum of public schools in New York State and New York City has been the subject of important debate for much of the 25 years since the start of the AIDS epidemic – and each twist and turn of the debate has reflected wider debates occurring about AIDS.

Since 1987, the New York State Education Commissioner Regulations have required that every board of education in the state provide education on HIV/AIDS to students K-12. The content of that education has varied, since it’s dependent on the current Chancellor and political context. For example, in 1991 Chancellor Joseph A. Fernandez proposed distribution of free condoms in schools. This was the subject of fierce controversy over the next year and finally passed with fear mongers suggesting that there would be a big increase in sexual behavior.

A decade later, movement in the public school curriculum regarding HIV/AIDS education was initiated by Scott Stringer, then NYS Assembly member (now Manhattan Borough President), who, in 2003, wrote a comprehensive report entitled “Failing Grade: Health Education in NYC Schools” ( In “Failing Grade” Stringer criticizes the vast discrepancy between local mandates for health education and actual practices. The report found that the majority of districts violate New York City’s minimal mandates on health education; often this is simply out of ignorance of the mere existence of regulations.

The need for more sex education is clear—New York City is still the American epicenter of HIV/AIDS (New York City accounts for 15.5 percent of all AIDS cases in the U.S. and more than half of high school students identify as sexually active. The Guttmacher Institute, in a report entitled, “Facts on Sexually Transmitted Infections in the United States” released in August 2006 cited, “although teens and young adults represent only 25% of the sexually active population, 15–24-year-olds account for nearly half of all STI diagnoses each year” (

In November 2005, Chancellor of the NYC Department of Education, Joe Klein, issued a revised curriculum on HIV/AIDS. The new document prioritizes reducing the stigma around people with AIDS, stating as one of its key goals that it will “enable [students] to feel comfortable around people with HIV/AIDS”. To the teachers, it says: “It is important to clarify that it is risk behavior they should avoid, not the people who have AIDS”. It suggests homework to encourage greater parental involvement.

However, it also includes revisions to the health education curriculum that are not necessarily a step in the right direction. The document incorrectly labels abstinence as 100% effective, which does nothing to reduce stigma around sex. The changes include adjustments to the free condom distribution program, instituted in 1991. Now, all parents and guardians have the option of prohibiting their children from the taking advantage of the program: “their children’s identification numbers are placed on a list to ensure that they will not participate”.

This amendment violates the often-stated goal of universal access to prevention that vulnerable teenagers need and will lead only to further delay in effectively addressing HIV/AIDS among adolescents. Plus, really, how hard will it be for a kid whose parents haven’t objected to pick up condoms for a kid whose parents have?

Uganda: Another approach to testing

The debates around HIV testing often focus on the false dichotomy between Voluntary Counseling and Testing (dismissed as the old “failed” approach, despite never having been adequately funded, and working remarkably well in many places with lots of interest but still small overall percentages of populations being tested) and Routine Provider Initiated Counseling and Testing (where patients can, supposedly, opt-out). Routine testing has been promoted even where there are no links to care and support services or to medical treatment.

A recent project in Uganda shows an alternative, more comprehensive, approach. A pilot project conducted by Home-Based AIDS Care combines testing and counseling and, perhaps most notably, takes place in homes. People involved with the Home-Based AIDS Care project overwhelmingly opted to get tested, received counseling whether HIV positive or not, and experienced less stigma from their community. They also were guaranteed access to clinical care and antiretroviral therapy if needed.

The study found that, three months after the diagnosis, there was “substantial increase among positive social events, such as strengthened relationships and community support, and no increase in negative events”. This is likely due to the attention and affirmation that both HIV-positive and -negative individuals in the community received.

Importantly, this technique is considered “operationally feasible” from a financial perspective. This stems in part from targeting entire households which often house several individuals with HIV. Additionally, it promises to be sustainable: as stigma within the community lessens as a result of the counseling, there could be a move towards heightened comfort with methods of protection and earlier testing and treatment.

Uganda is perhaps more able to succeed in these types of programs because they have a long history directly addressing stigma and supporting grassroots initiatives. Other countries in sub-Saharan Africa may have less success, but it is good to see a model of what might be possible.