Protect Vulnerable Populations, Ensure Accountability
July 1, 2010

(New York, July 1, 2010) - The upcoming 18th annual International AIDS Conference should focus on reaching the most vulnerable populations and removing barriers to their treatment, Human Rights Watch said today.

With its theme of "Rights Here Right Now," the conference, which opens in Vienna on July 18, 2010, will bring together more than 25,000 scientists, government leaders, and AIDS activists from around the world to examine the successes and shortcomings of the global AIDS response.

"The conference is about HIV/AIDS and human rights," said Joe Amon, director of health and human rights at Human Rights Watch. "But with 3 million new HIV infections each year, talking about rights won't do the job. We need action and accountability."

Advances in science and medicine will have limited impact without changing the harmful laws and policies that drive people who are at risk away from HIV testing and prevention, and that make it hard for those who need treatment to get it, Human Rights Watch said.

Laws in more than 160 countries criminalize specific groups or behaviors. These include laws targeting sex workers, drug users, men who have sex with men, and HIV exposure or transmission. These laws, as do laws protecting "morality" or "decency," impede HIV outreach and treatment, and also create a risk of selective or arbitrary prosecution, Human Rights Watch said.

"Governments need to end discriminatory laws and misguided and abusive public health and criminal justice policies," Amon said. "These laws fuel stigma and discrimination, increase the risk of HIV, and prevent HIV/AIDS services from reaching the most vulnerable populations."

In particular, governments and international donors need to address the transmission of HIV through drug injection, Human Rights Watch said. Outside of Sub-Saharan Africa, as many as one-third of all new HIV infections occur among people who inject drugs. Within Sub-Saharan Africa, injection drug use is increasing. In some countries, in particular Central and Eastern Europe and East Asia, statistics show that injection drug use is the primary driver of HIV epidemics.

International health and drug-control agencies, including the United Nations Office on Drugs and Crime, UNAIDS, and the World Health Organization, all endorse comprehensive harm reduction - a proven, evidence-based approach - both inside and outside prisons as critical to addressing HIV among people who use drugs. Harm reduction includes opioid substitution therapy with methadone or buprenorphine and needle and syringe exchange. In some countries, comprehensive harm reduction measures have virtually eliminated new HIV transmission due to drug use. Yet these lifesaving measures remain largely unavailable to the vast majority of people who need them, Human Rights Watch said.

"People who use drugs do not forfeit their human rights," Amon said. "All individuals have a human right to obtain lifesaving health services without fear of punishment or discrimination."

Human Rights Watch said that in many countries, drug-control efforts directly interfere with access to HIV services, and that government health ministries and those that work on drug control often pursue contradictory approaches that undermine HIV prevention.

Criminal laws in some countries, such as those concerning possession of drug paraphernalia, may keep many people from carrying sterile syringes or injecting equipment, and cause them to avoid drug treatment or harm reduction services for fear of arrest, Human Rights Watch said. Even without such laws, some drug users avoid harm reduction measures for fear of targeted prosecution for other offenses.

Research published in 2010 found the global investment in harm reduction in low and middle-income countries amounts to about 3 cents per injector per day, an estimated $3 billion less than needed in 2010.

"Vienna is at the doorstep of some of the world's fastest growing HIV epidemics, fueled primarily by injection drug use," Amon said. "Governments attending the conference should pledge to expand access to comprehensive harm reduction services if they are serious about addressing AIDS."

Human Rights Watch called upon delegates to the conference to ensure that policy and legal reform are accompanied by the expansion of services for vulnerable populations not yet reached in the AIDS fight.

"Governments around the world have pledged universal access to HIV prevention, treatment, and care by 2010," Amon said. "2010 is right now. Unless we reach everyone who needs HIV services, the progress that has been made fighting AIDS will be squandered."

Background

Criminalization of HIV transmission / exposure and homosexual conduct
Since 2005, 14 African countries have passed HIV-specific laws that potentially criminalize all sexual behavior among HIV-positive individuals, including those who use condoms, regardless of disclosure and actual risk of transmission. In Africa and elsewhere, laws criminalizing HIV exposure or transmission discourage HIV testing, potentially subjecting those who know their status to criminal penalties, while exempting those who are unaware they are HIV-positive.

According to UNAIDS, these laws may hit women hardest, as they are routinely tested during antenatal care and therefore more likely than men to know their HIV status. Laws criminalizing homosexual conduct provide a basis for state-sponsored violence and harassment, and keep people from seeking HIV-related information or services out of fear of discrimination and abuse.

  • In Zambia, efforts to include men who have sex with men in HIV testing and treatment programs and efforts to introduce condoms and other harm reduction measures in prison are seriously hindered by laws criminalizing consensual homosexual conduct among adults.
  • In Uganda, a proposed law introduced in May would criminalize "attempted transmission" and require mandatory testing of pregnant women and forced disclosure of HIV status. These provisions threaten people living with HIV by exposing them to stigma, discrimination, and physical violence.
  • In Senegal, calls to decriminalize same-sex relations intensified in January 2009 when nine HIV/AIDS advocates were sentenced to five years in prison on charges of "indecent and unnatural acts" and "forming associations of criminals." The ruling had a chilling effect on organizations addressing HIV/AIDS in Senegal, especially those working with men who have sex with men and other marginalized populations.
  • In Kenya, where homosexual conduct is punishable by up to 14 years in prison, violent attacks in 2010 against suspected homosexuals - including at a government health center providing HIV/AIDS services to men who have sex with men - have undermined HIV outreach and services to this vulnerable population.

Compulsory detention of drug users for "treatment"
In many Asian countries, hundreds of thousands of people identified as drug users are detained in locked facilities for months, or even years, without trial or due process, in the name of drug "treatment" or "rehabilitation." The detention of people who use drugs usually takes place without a clinical assessment of whether the person is, in fact, drug-dependent. Inside the centers, they are often denied evidence-based drug treatment and other basic health services and instead are forced to perform arduous physical exercises, military drills, or forced labor. Many face torture and extreme physical cruelty.

  • In Cambodia, people who use drugs are routinely rounded up by police and arbitrarily detained in government-run drug detention centers. Detainees - among them hundreds of children, many housed alongside adults - face torture and extreme physical cruelty, including electric shocks, sexual violence, and beatings with electrical wire. Harsh military drills and forced labor are the mainstays of their "treatment."
  • In China, approximately half a million people are interned at any given time in compulsory drug detention centers, where they can be detained without trial or due process on suspicion of drug use for up to six years. Detainees are routinely beaten, denied access to effective treatment for drug dependency, and subjected to unpaid forced labor.
  • In Vietnam, between 32,000 and 35,000 people who use drugs are locked in drug detention centers for terms as long as four years, without trial or due process. Detainees in these centers are engaged in what the government calls "therapeutic labor" rather than provided evidence-based treatment for drug dependence. They are forced to work long hours for below-market wages, beaten if they fail to meet work quotas, and subject to solitary confinement for violating center rules.
  • Since 2003, thousands of people in Thailand have been coerced into "drug treatment" centers run by security forces. Before "treatment" even begins, people are held for "assessment" for extended periods in prison. In the centers, military drills on the orders of security personnel are a mainstay of "treatment." Thailand's coerced treatment and rehabilitation policy has had long-term consequences for the health and human rights of drug users, as many continue to avoid drug treatment or any government-sponsored health services out of fear of arrest or police action or abuse.

Lack of access to harm reduction services in prison:
Less than 40 countries provide medication-assisted therapy (for example, with methadone or buprenorphine) to prisoners, but they often restrict it to those who have been receiving such treatment prior to incarceration. Only 10 countries provide needle and syringe exchange in prison, despite numerous recommendations from the UN and clear evidence that such programs can work safely and effectively in prisons.

  • In the United States, at least 20 percent of people with HIV have a history of incarceration. One in five incarcerated people is there for drug-related crimes and many others are incarcerated for crimes committed to support a drug habit. Yet most prisoners have no access to comprehensive harm reduction services. Methadone is unavailable to most prisoners, and in many prisons, harsh punishment of drug users denies treatment to those who may need it most. Condoms are considered prohibited contraband in most prisons and jails in the United States.
  • In Ukraine, which has the most severe HIV epidemic in Europe, an estimated 15 percent of prisoners are HIV-positive. Since 2006, Ukraine has taken important steps to increase access to methadone and buprenorphine in the community, but neither is available in prison.
  • In Zambia, poor conditions of confinement and minimal medical care for prisoners expose them to HIV and tuberculosis, including difficult-to-treat and potentially drug resistant strains, threatening the lives and health of inmates and the general public.
  • In Vietnam, nearly 30 percent of the prison population is living with HIV.

Lack of access to palliative care for people living with HIV
The global AIDS community has focused on bringing anti-retroviral treatment to people living with HIV. But a widespread and incorrect perception that palliative care is no longer needed has led to the poor integration of such services into treatment and care programs.

  • Various studies show that many people living with HIV require palliative care because the burden of pain, other symptoms, and psychosocial problems remains high even among those on anti-retroviral treatment, and that such care, when offered simultaneously with treatment, enhances treatment outcomes by improving adherence and retention in care.
  • The World Health Organization estimates that 1 million end-stage AIDS patients face moderate to severe pain but have no access to pain treatment. Much of this suffering could be alleviated by morphine, an effective, safe, and inexpensive medication.

Exclusion of persons with disabilities from HIV/AIDS prevention, care, and treatment
Marginalization and discrimination faced by people with disabilities increases their vulnerability to HIV.

  • According to the World Health Organization, at least 10 percent of the world's population (as many as 660 million people) lives with a disability, with an estimated 80 percent of them in developing countries.
  • A 2004 study by the World Bank and Yale University found that people with disabilities have an HIV infection rate up to three times higher than that of people without disabilities because of their risk of physical abuse, isolation, poverty, and lack of access to services and information.
  • The lack of accessibility to HIV/AIDS treatment facilities and the lack of appropriate prevention education are key obstacles for persons with disabilities. This includes lack of physical accessibility, such as ramps and handrails, as well as communication barriers, such as the limited availability of sign language interpreters and information in Braille, large print, and easy-to-understand formats.
  • According to the UN Education, Scientific and Cultural Organization, only 1 to 2 percent of children with disabilities in developing countries receive basic education, which means they are denied potentially lifesaving information on sexual health.