HIV/AIDS and Human Rights: Conflicts and Synergies Chris Beyrer MD, MPH The Center for Public Health and Human Rights Department of Epidemiology Johns Hopkins Bloomberg School of Public Health
Overview Human Rights and Public Health Case Studies from HIV/AIDS Thailand sex and drugs Brazil building rights into programs Conclusions
Introduction The denial of the basic rights and dignities to human beings in societies undermines responses to health and can make epidemic disease spread worse Abrogation of rights can threaten the health of the public There are real and measurable benefits to health, economies, and societies, when human rights protections form the bases of public health responses Human rights bases can build better public health systems
HIV and Human Rights HIV has emerged as a remarkably sensitive marker of social inequality and vulnerability. HIV has spread most efficiently among those with the least access to health care, education, and prevention and among those most disparaged by mainstream society drug users, sex workers, men who have sex men, prisoners, soldiers, the poor. This has made investing in effective public health programs targeted to those most in need so difficult.
Case Studies from HIV/AIDS Thailand Brazil
100 Figure 3: Government and donor spending on AIDS, 1988-97 90 80 70 60 50 40 30 20 10 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Donors Royal Thai Government Source: WHO, AIDS Division/MOPH, NESDB. Note: Government spending includes only spending out of the AIDS budget and excludes expenditure on health care related to AIDS from the general MOPH budget.
60 Condoms purchased by the AIDS division, 1988-2000 52.8 53 53 50 45 * 47.7 Millions of condoms 40 30 20 18.9 * 20 24.9 25.3 31.5 10 6.7 8.7 11.5 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000* * In addition to these figures, donations of 21 million condoms were received in 1991 and 45 million in 1992, bringing the totals to 40 million in 1991 and 90 million in 1992.
HIV prevalence in 21-year-old army conscripts, by region, 1991-99 14 12 10 Percent 8 6 4 2 0 Nov-91 1992 May-93 Nov-94 1995 1996 1997 1998 19 Central Bangkok Upper North Lower North Northeast Sou
HIV Seroprevalence by RTA Cohort, Upper North, 1991-2001 % HIV + 14 12 10 8 6 4 2 0 1991 1993 1995 1996 1997 1998 2000 2001 Nelson et al., JAIDS 2002; AFRIMS 2001
Distribution of new infections in Thailand by source of infection 100 90 80 Male from sex worker IDU From husband to wife 70 60 50 40 30 20 10 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Figure 1. Photo 1: TDN member participates in a silent protest during the International Conference on the Reduction of Drug-related Harm (Chiang Mai). Source: Thai Drug Users Network, Karyn Kaplan
Figure 4 Photo 4: TDN members protest during the International AIDS Society Conference in Bangkok. Source: Thai Drug Users Network
Brazil Building Human Rights Into Public Health Programs
Figure 1: Growth in targeted interventions for high-risk groups, 1999-2003 Source: Growth in targeted interventions for high-risk groups during AIDS II, 1999-2003 300 267 Number of projects 250 200 150 100 MSM IDU CSW 125 106 138 160 235 234 127 50 17 30 25 30 49 54 57 0 1999 2000 2001 2002 2003
Figure 3: Annual Sales and Unit Prices of Male Condoms in Brazil, 1992-2003 Source: Brazil Ministry of Health 0.80 500 0.70 0.60 0.50 285 320 350 395 407 427 400 300 0.40 216 228 0.30 0.20 0.10 0 158 70 104 3 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 200 100 0 Male condoms sold (right scale) Years Mean price (left scale)
HIV prevalence and risk indicators for high-risk populations in Brazil, 1999-2002 Source: (Ministry of Health/NASCP, 2003), compiled from the following studies: Federal University of Minas Gerais and NASCP (a, b); Federal University of Brasilia and NASCP (c); Opinion polls carried out by IBOPE (d,e). IDU MSM Indicator 1999 a 2001 b 1994-99 2001 d 2002 e HIV prevalence 52% 36.3% 10.8% HCV prevalence 60% 56.4% Condom use 42.1% 62.9% 81% regular partners;95 % casual partners 70% in all anal intercourse in past 6 months Ever HIV tested 52% 66.4% 73% 69% Needle sharing 70% 59.4% Sample size 287 869 1,082 800 1,200
Table 1. HIV Prevalence estimates for adults aged 15-49, in Brazil, year 2000. Gender Prevalence (%) 95% CI Total infxs Low Range High Range Women N=15,426 0.47 0.36, 0.58 Men Est. 0.84 0.65, 1.04 Total 0.65 % 0.51, 0.80 597,000 548,000 647,000
AIDS admissions in the SUS (1996-2001) 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 1996 1997 1998 1999 2000 2001 # of AIDS admissions registered in DATASUS Est. # of patients attended by SUS (year) Est. # of admissions in year maintaining ave. # of admissions for 1996 Est. # of admissions avoided in year
2 1.5 1 0.5 0 1996 1997 1998 1999 2000 2001 Ave. # of admissions/ patients by year
Millions 400 350 300 250 200 150 100 50 0 1996 1997 1998 1999 2000 2001 Estimated cost of admissions avoided in year (US$)
Brazil: Lessons Learned Success in HIV prevention made the universal AIDS treatment rollout feasible A rights-based approach to prevention can help control HIV ARVs can reduce admissions and actually save money if epidemics are limited National AIDS Program in Brazil helped lead to increased access to health care for all citizens Health care is the right of citizens and the responsibility of the state"
Estimated HIV Prevention Coverage for IDU 2004-2005 100 90 80 70 60 50 40 30 20 10 0 2004-05 South & SE Asia Eastern Europe CIS Global Sources: Global Prevention Working Group, USAID, UNAIDS
Photo: Hans Jürgen Burkard
ARV Access IDU (CIS) 2005 90 80 70 60 50 40 30 20 10 0 Belarus Moldova Ukraine % reported HIV cases IDU %IDUs of those on ARVs Making the 3 by 5 Target Work for the Health of Drug Users Kim, WHO, Kim, Jim, 2005
Photo: Hans Jürgen Burkard
Photo: Hans Jürgen Burkard
Source: David Guttenfelder/Associated Press, 2005
Afghan Opium Production (metric tons) 1980-2004 Afghanistan Opium Survey, 2004, UNODC
What will it take to make a difference in this region? Increase access of IDU s to health and social care including a comprehensive package of interventions for HIV prevention and treatment services Promote a non-repressive approach to IDU s based on human rights and public health principles Decrease social marginalization and stigma Source: Spreading the Light of Science, ICRC, 2003
Photo: Dan Bigg
Conclusions The failure of Thailand to respond to IDU spread shows that the denial of basic rights and dignities undermines responses to health and can sustain epidemic spread The success of Brazil in HIV prevention using a rights based approach shows how rights frameworks can inform programs and can save money and lives Public health responses matter more in our globalized world then ever before--so rights based approaches matter more then ever before
Discussion Questions Are there human rights issues making HIV spread worse in your country? Are there rights-based approaches to HIV/AIDS that are improving your country s response?