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Letter to the Office of National AIDS Policy

April 13, 2015

Mr. Douglas Brooks

Director, Office of National AIDS Policy

1600 Pennsylvania Avenue, NW

Washington DC 20500

 

Dear Director Brooks,

We write today, representing 14 organizations to urge the Office of National AIDS Policy (ONAP) to sharpen its focus on HIV among stigmatized and criminalized populations within the United States. Targeted and comprehensive attention is urgently needed to improve health services, including HIV prevention, for lesbian, gay, bisexual and transgender (LGBT) persons, sex workers, people who use illegal and prescription drugs not as prescribed, and people in US jails and prisons.   

Worldwide, the World Health Organization (WHO) estimates that more than 50 percent of new HIV infections are among 5 “key” populations (men who have sex with men, sex workers, transgender people, people in prisons and other closed settings,  people who inject drugs) that are either subject to more intensive scrutiny by law enforcement, criminalized, marginalized, or all of the above.[1] The WHO has also outlined specific guidelines for essential health sector interventions and strategies for improving the legal standing of these populations. In addition, the WHO has described interventions for reducing violence and promoting local and community organization engagement for each of these groups.[2] Similarly, UNAIDS has stated that the criminalization of sex work, drug use and same-sex relationships among consenting adults hinders the delivery of effective HIV interventions, and has called for laws criminalizing same sex relations to be overturned and for the decriminalization of sex work and drug use.[3]

We are sending you this letter and the attached background note to inform the current efforts to revise the National HIV/AIDS Strategy. We encourage the ONAP to closely consult with the WHO and UNAIDS in examining the growing evidence base for these conclusions, and to incorporate similar recommendations into the revised Strategy document.  With this aim, we believe that a task force should be created to examine the impact of criminal laws on vulnerability to HIV infection and access to HIV prevention and treatment programs, and to develop short and long-term recommendations for removing criminal justice related barriers and facilitating positive engagement from law enforcement officials at the local, state and federal levels.

We commend the steps taken by ONAP, CDC, DOJ and other federal agencies to address the issue of statutory criminalization of HIV exposure and we will continue to engage in and contribute to ongoing efforts in that area. However, there are numerous other aspects of criminal justice system that have enormous impact on the HIV epidemic in the US: policing practices that disproportionately impact people of color, target LGBT individuals and use condoms as evidence of prostitution; laws barring syringe exchange and pharmacy-based syringe sales; arrests and incarceration of African-Americans on drug charges at rates that greatly exceed their proportion of the general population among drug offenders (both sellers and users);  inadequate prison re-entry programs and more. Uncomfortable and politically sensitive as it may be, the road to achieving the President’s goal of eliminating HIV runs through the criminal justice system.

Black men are seven times, and black women three times, as likely to be incarcerated than their white counterparts. [4] Many people of color who go to jail or prison come from communities that have been found to be undergoing a generalized HIV epidemic, and these issues are inextricably linked. [5] When one considers the HIV risk, prevalence and treatment outcomes of people who inject drugs, sex workers, transgender women and other LGBT individuals, particularly those of color who are disproportionately subject to arrest and imprisonment, it may be time to re-examine penalties for individual drug possession, prostitution, loitering and other non-violent crimes from the perspective of  public health. Now may be an opportune time for federal agencies leading the fight against HIV to inform and support bipartisan efforts such as the Coalition for Public Safety to reform our nation’s criminal justice system.  As the National Minority AIDS Council and Housing Works concluded:

"Any recommendation to improve outcomes following release from prison or jail must be placed within the larger context of the individual, community and societal harm caused by the large numbers of persons held in US prisons and jails (some 2.4 million men and women). We can never adequately address the overlap of homelessness, incarceration and HIV vulnerability until our nation reforms its criminal justice systems and ‘takes a broader view of public safety that is not produced by punishment alone."[6]  Perhaps most importantly, in keeping with the principle of “nothing about us without us,” the task force should include representatives from each of the key groups whose status and condition will be addressed.

We attach a Background Note that highlights some of the most current research and analysis at the crucial intersection of HIV and criminal justice.  We look forward to your response, and to continued collaboration between our organizations and the Office of National AIDS Policy. Thank you very much for your consideration.

 

Very truly yours,

Megan McLemore, J.D.,L.L.M.

Senior Researcher

Health and Human Rights Division

Human Rights Watch

350 5th Avenue

New York, NY 10118

mclemom@hrw.org

 

Co-signing Organizations:

AIDS Alabama

AIDS United

The Center for Health Law and Policy Innovation, Harvard Law School

The Center for HIV Law and Policy

Drug Policy Alliance

Harm Reduction Coalition

HIPS

HIV Prevention Justice Alliance

National Minority AIDS Council

North Carolina Harm Reduction Coalition

Sisterlove

Southern HIV/AIDS Strategy Initiative

St. James Infirmary

 

cc:

Jonathan Mermin, MD, MPH (CDC)

Allison Nichol (DOJ)

Ronald Valdeserri , MD,MPH (HHS)

 

Background Note

Addressing Stigmatized and Criminalized Populations in the National HIV/AIDS Strategy

 

There are many excellent federal initiatives that currently address the health and HIV prevention needs of many of the populations identified in this letter, including SAMHSA’s Minority AIDS Initiative, CDC’s High-Impact Prevention Program, the SPNS Prison Re-entry Initiatives, and numerous others.  The Affordable Care Act offers substantial opportunities for increasing access to health care for lesbian, gay, bisexual and transgender (LGBT) individuals, prisoners, and members of these “key populations” who are uninsured. However, there is an urgent need for a more targeted and coordinated undertaking. At this critical moment when the US National HIV/AIDS Strategy is under revision, we respectfully urge ONAP and agencies responsible for implementing the Strategy to take steps to ensure that the revised document reflects the prevention, care and service needs of stigmatized and criminalized populations.

Further, we urge the establishment of a task force charged with identifying ways in which the federal and state criminal justice systems act as an impediment to HIV prevention, treatment and access to care. The task force should develop recommendations for how the federal government might promote effective reform at the crucial intersection of criminal justice, HIV and public health. This Background Note highlights some of the current research and analysis at the intersection of HIV and criminal justice and includes some questions that a task force might choose to address. Suggestions for expanding the evidence base related to HIV and stigmatized and criminalized populations are included, but in no way intended to preclude or delay immediate response; in most of these areas the need for coordinated federal action toward reform at the intersection of public health and criminal justice is well documented and long overdue.

 

LGBT Individuals

Gay, bisexual and men who have sex with men are more severely affected by HIV than any other group in the United States. In 2010, young gay and bisexual men (13-24) accounted for 72 percent of new HIV infections among all persons aged 13-24 and 30 percent of all new HIV infections generally.  At the end of 2011, more than half of persons living with an HIV diagnosis in the US were gay or bisexual men, or gay and bisexual men who also inject drugs.[7]

Among all gay and bisexual men, African-American men bear a disproportionate burden of HIV, with infection among young black African-American men increasing 20% between 2008 and 2010. Among gay and bisexual men, Hispanic or Latino men accounted for 22 percent of all new HIV infections in 2010.[8]  

Transgender women are also at high risk of HIV infection, and in 2010, African-American transgender women have the highest percentage of new HIV-positive test results of any group. [9] Misclassified as men who have sex with men in most states until very recently, data are scarce on the true extent of the HIV burden among transgender women. However, data that do exist suggest prevalence in this community as high as 27 percent.[10]

Adult, consensual homosexual sex is no longer a criminal offense in the United States, but LGBT persons are disproportionately represented in every aspect of the criminal justice system. A recent national survey of LGBT persons and people living with HIV conducted by Lambda Legal found that a startling 73 percent had experienced face-to-face contact with police in the last five years. Of these, 1 in 4 reported a form of police misconduct ranging from verbal harassment to sexual assault.[11]  The 2014 report “Roadmap for Change: Federal Policy Recommendations for Addressing the Criminalization of LGBT People and People Living With HIV,” addresses the criminalization of LGBT people as well as the harms they encounter once they enter the criminal justice system, particularly LGBT people of color. These include discriminatory policing practices, harmful conditions for LGBT prisoners and immigrants in detention, and failure to prevent the criminalization of LGBT youth.[12]

LGBT people are overrepresented in the criminal justice system and in the HIV epidemic in this country, and this is not a coincidence: these two disturbing truths are inextricably linked. A 2012 study in the Lancet indicated that in the US, the UK and Canada, previous incarceration is independently associated with HIV infection among black men who have sex with men. [13] The report “Roadmap for Change” highlights numerous ways in which over-involvement in the criminal justice system impedes access to health care for LGBT people, particularly youth and people of color. These include:

  • discriminatory policing such as police practices that associate condom possession with criminal activity, thus deterring condom use among those frequently stopped by police;
  • failure to implement LGBT-inclusive sexual and reproductive health care programs, including lack of HIV prevention, in federal, state, and immigration custody;   
  • inadequate medical care in jail and prison;
  • jail and prison re-entry programs that fail to address the needs of LGBT individuals returning to the community;
  • punitive drug policies that disproportionately affect LGBT persons  who often experience discrimination in access to treatment programs and other health services.[14]

 

These are conditions endemic to our nation’s criminal justice system that increase the likelihood that an LGBT person in the US will become infected with HIV, transmit the virus to someone else, and experience a less healthy treatment outcome.

Questions that could be addressed by an HIV Among Stigmatized and Criminalized Populations Task Force include:

  • How can the National Strategy identify and promote reform of police practices that disproportionately subject LGBT individuals, particularly youth and people of color, to increased scrutiny and differential treatment in the criminal justice system?
  • To what extent can targeted interventions be used to not only reduce HIV infection but build capacity for health related advocacy and peer support among LGBT youth and transgender women?
  • What type of research can further illuminate contact with the criminal justice system as a factor in the significant drop-off between LGBT persons linked to care and those engaged in and retained in care on the national treatment cascade/continuum?
  • How does contact with the criminal justice system impact the availability and accessibility of Pre-exposure Prophylaxis (PrEP) for men who have sex with men, LGBT youth and transgender women?

 

Sex Workers

According to the UNAIDS Guidance Note on HIV and sex work, sex workers include “female, male and transgender adults and young people (over 18 years of age) who receive money or goods in exchange for sexual services, either regularly or occasionally.”[15]  Sex work occurs along a diverse spectrum that includes those who self-identify as sex workers and those who do not. As stated by the US Centers for Disease Control (CDC):

Sex work crosses many socioeconomic groups. Adults who engage in such activities include high-end escorts; people who work in massage parlors and the adult film industry; exotic dancers; state-regulated prostitutes (in Nevada); and street-based men, women, and transgender people who participate in survival sex.[16]

Globally, HIV prevalence among sex workers is estimated to be 12 percent. [17] There is no specific estimate for sex workers in the United States, but the CDC states that “the risk of HIV and other sexually transmitted diseases is high among people who engage in sexual activity for income, employment, or non-monetary items such as food, drugs or shelter.” A 2012 study in New York City among people who exchange sex for money or other goods found that 14 percent of the men and 10 percent of the women were HIV-positive, a dramatically higher figure than the 1.4 percent prevalence in New York City generally. [18] Poverty, increasingly recognized as a primary factor underlying HIV risk, also contributes to lack of access to health services for sex workers generally, as well as for LGBT youth, people of color and transgender women who exchange sex for life necessities.  [19]

In the US, a leading example of a police practice that directly increases vulnerability to HIV infection among sex workers is that of using condoms as evidence of prostitution. This practice ranges from police threatening arrest for possession of condoms to prosecutors introducing condoms as evidence at trial of prostitution, loitering for solicitation and other related charges. Documented to date in in five major US cities, this practice results in reduced willingness to carry condoms on the part of sex workers and those frequently stopped by police on suspicion of sex work, including transgender women and LGBT youth.[20]

We are pleased that the White House Report on 21st Century Policing recently endorsed the recommendation of the Presidential Advisory Commission on HIV/AIDS that the use of condoms as evidence of prostitution be subject to federal oversight and guidance. [21] However addressing use of condoms as evidence of prostitution is a necessary, but not sufficient, step in removing impediments to health care for sex workers related to the criminal justice system. Many sex workers lack health insurance coverage.   In 2013 Human Rights Watch surveyed 169 people who exchange sex for money, drugs or life necessities in New Orleans. Fewer than half reported having health insurance coverage, with 87 percent of Hispanic respondents reporting no health coverage. Among those surveyed who injected drugs, 85 percent had no health insurance. [22]  Sex workers rarely disclose their occupation to health care providers for fear of judgment and discrimination. [23] Further, sex workers around the world have expressed ambivalence and doubt about PrEP outreach efforts, fearing that in legal environments where the rights of sex workers are already undermined, PrEP could be implemented in a way that is coercive and that targets an already stigmatized population.[24]

UNAIDS, WHO, the Global Commission on HIV and the Law and other international health experts have called on countries to take steps toward improving the legal status of sex workers as key to reducing their burden of HIV. As stated by UNAIDS:

With regard to adult sex work that involves no victimization, criminal law should be reviewed with the aim of decriminalizing, then legally regulating occupational health and safety conditions to protect sex workers and their clients, including support for safe sex during work. Criminal law should not impede provision of HIV prevention and care services to sex workers and their clients. [25]

In a special issue released in conjunction with the International AIDS Conference in July 2014, The Lancet Medical Journal published studies indicating that decriminalization of sex work could reduce new HIV infections among sex workers and their clients by 33-46 percent over the next decade.[26] The Lancet series further documented the success of community empowerment approaches to reducing HIV infection among sex workers and their clients, finding that where sex workers take collective ownership of HIV prevention, incidence is “significantly reduced in both sex workers and the general adult population across diverse HIV epidemic scenarios, and that these interventions are cost-effective.”[27] Whether the focus is decriminalization, community empowerment or other approaches, the health and human rights of sex workers must be prioritized in federal efforts to end AIDS. As stated by Dr. Chris Beyrer, the researcher who coordinated the Lancet series and President of the International AIDS Society, “efforts to improve HIV prevention and treatment by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to services and eventual control of the pandemic.”[28] 

 

 

 

Questions that could be addressed by an HIV Among Stigmatized and Criminalized Populations Task Force include:

  • To what extent can targeted interventions be used to not only reduce HIV infection but build capacity for health-related advocacy and peer support among sex workers?
  • How can HIV surveillance data for sex workers be improved?
  • How does the legal status of sex workers impact the availability and accessibility of PrEP for this population?

 People who Use and Inject Drugs

People who inject drugs (PWID) accounted for 8 percent of new HIV infections in the United States in 2010.[29] In the nation’s cities with high HIV prevalence, 1 in 10 persons who inject drugs are living with HIV, with only 63 percent aware of their infection.[30] Racial disparities are stark among injection drug users in relation to HIV, with African-Americans who inject drugs more than twice as likely to be diagnosed with HIV and with AIDS than Caucasian injection drug users. [31] African-Americans are also less likely to access syringes from pharmacies where syringe sale is legal.[32]

In the US, health outcomes for HIV-positive people who inject drugs are very poor. In 2011, injection drug users had the highest death rates from AIDS of any transmission category. [33] In 2012, 33 percent of male IDUs and 26 percent of female IDUs were diagnosed with AIDS at the time of their first positive HIV test, compared to 21 percent of men who have sex with men.[34] Injection drug users also had the lowest percentage of linkage to care within 3 months of diagnosis of any transmission category in 2012.[35]

HIV prevention efforts for PWID have largely focused on the availability of syringe access programs (SAP), well-documented as one of the most effective methods of preventing transmission of HIV and HCV among people who inject drugs.[36] However, politics has trumped science to an alarming extent, with federal funding for local SAPs presently banned by Congress.  In 37 states, syringes have been removed from drug paraphernalia laws, lowering barriers to the operation of syringe access programs, and in 15 states SAPs are explicitly authorized by law.[37] But in many states legal barriers remain in place or exemptions are not well publicized or understood.[38] Every day, volunteers in dozens of US states distribute clean syringes to people who use drugs, and in doing so, risk arrest, particularly in regions such as the US South.[39]

Louisiana, for example, has an incarceration rate that is double the national average. [40] Baton Rouge and New Orleans consistently rank in the top five nationally for new HIV infections and AIDS diagnoses. [41]  People die from AIDS in Louisiana at twice the rate of the national average. [42]  Louisiana has an estimated 45,000 injection drug users. [43] Statewide, nearly half of PWID develop AIDS within six months of an HIV diagnosis, indicating late testing and poor linkage to the health care system. [44] Under state law, syringes may be distributed for “legitimate medical purposes” such as prevention of disease.[45] But possession of a syringe for non-medical use is illegal, creating a cloud of uncertainty that inhibits syringe exchange initiatives.[46] The one public syringe access program in the state operates for only two hours a week in New Orleans, and receives no federal, state or city funding. A CDC HIV Surveillance Survey of injection drug users in New Orleans in 2012 found that 82 percent had never accessed the local syringe program and 65 percent had shared needles in the last year. [47] Yet according to the HIV Plan for 2012-15 published by the state Department of Health and Hospitals, “there is currently no IDU-specific programming provided in the state of Louisiana.”[48]

Retention in HIV treatment is a challenge for people who inject drugs.  A 2011 study showed that brief incarceration (less than 30 days) was “strongly associated” with virologic failure in a study of more than 400 injection drug users in Baltimore. Study participants had all achieved undetectable viral loads and then were tested at intervals for several years. Of those whose viral load increased, incarceration was the factor most clearly associated with inability to maintain their health. Participants who had spent time in jail were twice as likely to lose their undetectable status than those who had not been incarcerated.[49]

In the 2013 report “In Harm’s Way: State Response to Sex Workers, Drug Users and HIV in New Orleans,” Human Rights Watch surveyed nearly 200 people who exchange sex for money, drugs or life necessities.[50] Of those surveyed who inject drugs, 96 percent had spent time in jail or prison. Of participants taking anti-retroviral medications, jail was cited by the majority as a primary interference with the ability to adhere to an HIV medication regimen.

Among our recommendations to the state of Louisiana and the city of New Orleans, Human Rights Watch recommended increased state and city funding for harm reduction activities and formation of a city-wide Working Group on Health Care for People Who Inject Drugs. The goal of the Working Group is to bring together key stakeholders to discuss improved health access and would include law enforcement, public health officials, advocates and people who inject drugs. We also recommended that peer outreach services, shown to be particularly effective in HIV and hepatitis prevention for people who inject drugs, should be expanded.[51] Since publication of our report, city officials have made a contribution of HIV and Hepatitis C test kits to the syringe access program and to local harm reduction groups, and the state is now funding one outreach program to people who inject drugs in the city of Baton Rouge.

At both state and federal levels, the conversation in relation to PWID should not begin and end with the legality of syringe access, as harm reduction information, education and outreach is not illegal in any state. As demonstrated by recent events in Indiana, the injection of pain medications in rural areas that lack access to syringe exchange programs and harm reduction information poses a serious threat to the public health.[52] Indeed, federal efforts should be directed specifically to states where the political climate is not likely to permit syringe exchange to exist or expand in the near future. This reality should be recognized and strategies should be developed for ensuring that harm reduction information, education and services, as well as linkage to treatment and health care services generally, are provided to neglected, stigmatized, and most importantly, criminalized populations.

 

 

 

 

 

 

Questions that could be addressed by an HIV Among Stigmatized and Criminalized Populations Task Force include:

  • What more can be done to promote reform of laws restricting syringe exchange and pharmacy sales at the state level?
  • In states not likely to authorize syringe exchange in the near future, what can be done to ensure that people who  use drugs receive health and harm reduction information, education and outreach?
  • How does the legal status of people who use drugs impact the availability and accessibility of PrEP for this population?

 

Incarcerated Persons

 A 2014 report from the Prison Policy Initiative estimates that in the US, 2.4 million people are held in 1,719 state prisons, 102 federal prisons, 2,259 juvenile correctional facilities, 3,283 local jails and 79 Indian Country jails as well as immigration detention centers, military prisons and prisons in the US territories.[53] In 2010, an estimated 708,000 people were released from federal and state prisons and nearly 12 million cycled through local jails. [54] Human Rights Watch has set forth policy recommendations, grounded in human rights principles, for reforming the US criminal justice system and reducing the large numbers of people in prison.[55] Here, we focus on the fact that many of those subject to arrest and incarceration are members of the “key” populations identified at highest risk for HIV, including people who inject drugs, sex workers, transgender women and LGBT individuals.

The National HIV/AIDS Strategy recognizes the negative consequences of incarceration for both individuals and communities in relation to HIV. With regard to communities, the National HIV/AIDS Strategy stated:

High rates of incarceration within certain communities can be destabilizing. When large numbers of men are incarcerated, the gender imbalance in the communities they leave behind can fuel HIV transmission by increasing the likelihood that the remaining men will have multiple, concurrent relationships with female sex partners. This in turn increases the likelihood that a single male will transmit HIV to multiple female partners.[56]

Imprisonment has been associated with the failure to link people to treatment post-HIV testing, loss to follow up and lack of retention in care.[57] Improving retention along this pathway from testing to viral suppression is the goal of the HIV Care Continuum Initiative, which provides funding for essential re-entry services that have the potential to reduce poverty and homelessness, two factors independently associated with increased HIV risk, and improve linkage to care upon return to the community.[58] The National Minority AIDS Council and Housing Works have recently examined the relationship between large numbers of incarcerated persons in the US, housing instability and HIV and made detailed recommendations for re-entry initiatives that call for removing federal barriers to poverty reduction programs and public housing for previously incarcerated persons. [59]

But the focus on re-entry services should not preclude recognition that the fact of incarceration itself is disruptive to individuals and communities in ways that impede HIV prevention and care. For individuals the negative consequences often begin at arrest, as recent studies indicate that few US jails provide HIV testing nor adequate medical services for people living with HIV. [60] Previous incarceration has been independently associated with increased risk of HIV among black men who have sex with men. [61] Incarceration frequently interrupts the course of anti-retroviral medications. [62] Anne Spaulding MD, MPH of Emory University, one of the nation’s leading experts on HIV in correctional settings has stated, “Of all the life events that knock people out of HIV care, going to jail is one of the biggest disruptors.” [63]

Questions that might be asked by an HIV Among Stigmatized and Criminalized Populations include:

  • How can public health and HIV research inform and contribute to efforts at the federal level to reform the US criminal justice system?
  • What type of research can further illuminate incarceration as a factor in the significant drop-off between those “linked” to care and those “engaged” and “retained” in care on the national treatment cascade/continuum?
  • How could reduction of penalties/decriminalization of individual drug possession and sex work reduce HIV risk and improve health outcomes for these populations?

 

 

Women

Women are not an explicitly criminalized population, but the criminal justice system endangers their health in very specific and problematic ways. Women comprise approximately 20 percent of persons under correctional supervision of some type (prison, jail, probation, parole) and currently women are going to prison at a faster rate than men.[64]

Minority women bear disproportionate burdens of both incarceration and HIV. African-American women are three times, and Hispanic women twice, as likely to be incarcerated than white women.[65] In the United States, one in five new HIV infections occur among women. African-American women are 13 percent of the US population but represent 64 percent of new HIV infections among women. Indeed, African-American and Latina women account for ¾ of new HIV cases among women in the US. [66] The   epidemic among women is most acute in the US South: nearly one in four new HIV diagnoses are among African-American women and in cities such as Baton Rouge the percentage is more than one-third.[67]

The HIV treatment continuum shows a steep drop-off between 88 percent of women living with HIV diagnosed but only 45 percent in treatment and only 32 percent achieving viral suppression.[68] Data from the criminal justice system illuminates factors likely to impede women’s ability to adhere to HIV treatment and achieve healthy outcomes. A higher percentage of women than men are in prison for drug related crimes and a higher percentage of women prisoners have used and injected drugs. [69]  

Violence is a key contributor to HIV risk among women, and women with HIV are more likely to be survivors of domestic violence than their non-positive counterparts.[70] Incarcerated women report recent histories of violence prior to entering jail,  either from a partner, sex customer or other source.[71] In addition, women in the US are more likely than men to be both poor and unstably housed, two factors independently associated with greater HIV risk. [72] Poverty and lack of housing push many women into sex exchange for life necessities which, in a vicious cycle, increases potential for contact with the criminal justice system; a criminal record then decreases potential for employment and housing, and the cycle continues.[73]

Many unique factors increase women’s risk of acquiring and transmitting HIV and interfere with healthy treatment outcomes. In the US, central among these factors is contact with the criminal justice system, particularly for women of color, and it is our hope that the revised National HIV/AIDS Strategy reflects, and attempts to mitigate, this disturbing reality.

 

[1] World Health Organization, Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations, Geneva, July 2014.

[2] Ibid.

[3]UNAIDS, The Gap Report 2014,  pp. 183, 197, 212. Available at http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf  accessed March 17, 2015.

[4] US Centers for Disease Control and Prevention, ” HIV and Incarceration”, http://www.cdc.gov/hiv/risk/other/correctional.html, accessed March 18, 2015.

[5]  P. Denning and E. DiNenno, “Communities in Crisis: Is There a Generalized HIV Epidemic in Impoverished Urban Areas of the US?” US Centers for Disease Control and Prevention, 2014, http://www.cdc.gov/hiv/pdf/statistics_poverty_poster.pdf, accessed March 6, 2015; “Social Determinants of Health Among Adults with Diagnosed HIV Infection in 20 States, the District of Columbia, and Puerto Rico, 2010.” US Centers for Disease Control and Prevention, HIV Surveillance Reports, Supplemental Reports, 2010.

[6] National Minority AIDS Council and Housing Works, Mass Incarceration, Housing Instability and HIV/AIDS: Research Findings and Policy Recommendations, 2013, p. 14.

 

[7] US Centers for Disease Control and Prevention, “HIV Among Gay and Bisexual Men,” http://www.cdc.gov/hiv/risk/gender/msm/facts/index.html, accessed March 17, 2015.

[8] Ibid.

[9]US Centers for Disease Control and Prevention, “HIV Among Transgender People”, http://www.cdc.gov/hiv/risk/transgender/, accessed January 17, 2015.

[10] Ibid.

[11] Lambda Legal, “Protected and Served?” 2015, http://www.lambdalegal.org/protected-and-served, accessed March 19, 2015.

[12]  Hanssens et al, A Roadmap for Change: Federal Policy Recommendations for Addressing the Criminalization of LGBT People and People Living With HIV, 2014, p 5.

[13] G. Millett et al, “Comparisons of Disparities and Risks of HIV Infection in Black Men Who Have Sex with Men in the United States, UK and Canada” The Lancet, 280:9839, July 2012, 341-48.

[14] Roadmap For Change, p. 55.

[15] UNAIDS Guidance Note on HIV and Sex Work, Geneva, 2009, p. 3.

[16] US Centers for Disease Control and Prevention, “HIV Among Sex Workers,” http://www.cdc.gov/hiv/risk/other/sexworkers.html, accessed January 17, 2015.

[17] World Health Organization, Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations, Geneva, July 2014, p. 6.

[18] New York City Department of Health and Mental Hygiene, New York City HIV/AIDS Surveillance Slide Sets, March 2012.

[19] P. Denning and E. DiNenno, “Communities in Crisis: Is There a Generalized HIV Epidemic in Impoverished Urban Areas of the US?” US Centers for Disease Control and Prevention, 2014, http://www.cdc.gov/hiv/pdf/statistics_poverty_poster.pdf, accessed March 6, 2015; “Social Determinants of Health Among Adults with Diagnosed HIV Infection in 20 States, the District of Columbia, and Puerto Rico, 2010.” US Centers for Disease Control and Prevention, HIV Surveillance Reports, Supplemental Reports, 2010.

[20] Human Rights Watch, “Sex Workers at Risk: Condoms as Evidence of Prostitution in Four US Cities,” 2012, https://www.hrw.org/reports/2012/07/19/sex-workers-risk-0 ; Human Rights Watch, “In Harm’s Way; State Response to Sex Workers, Drug Users and HIV in New Orleans, 2013, https://www.hrw.org/reports/2013/12/11/harms-way.

[21] White House Task Force on 21st Century Policing, Interim Report March 2015, p. 27.

[22] Human Rights Watch, “In Harm’s Way.”                                                                  

[23] D. Cohan, et al, “Sex Worker Health: San Francisco Style,” Sexually Transmitted Infections online July 19 2006,  , http://stjamesinfirmary.org/Uploads/Sex%20Work%20SF%20Style.pdf accessed March 9, 2015;  A. Forbes and S.E. Patterson, “Decriminalizing Sex Work Could Reduce HIV Infections, So Why Isn’t Everyone on Board?” Our Bodies Ourselves, August 29, 2014, http://www.ourbodiesourselves.org/health-info/decriminalizing-sex-work-could-reduce-hiv/, accessed March 9, 2015.

[24] Global Network of Sex Work Projects, Global Consultation, http://www.nswp.org/sites/nswp.org/files/PrEP%20Global%20Consultation%20final3.pdf, accessed March 9, 2015.

[25] UNAIDS, International Guidelines on HIV and Human Rights,” Geneva, 2006, p. 30.

[26] K. Shannon et al, “Global Epidemiology of HIV Among Female Sex Workers: Influence of Structural Determinants,” The Lancet, HIV and Sex Workers, July 2014, 13-29.

[27] D. Kerrigan et al, “A Community Empowerment Approach to the HIV Response Among Sex Workers: Effectiveness, Challenges, and Considerations for Implementation and Scale-Up,” The Lancet, HIV and Sex Workers, July 2014, 46-59.

[28] Sarah Boseley, “Decriminalize Sex Work to Control AIDS Pandemic, Scientists Demand,” The Guardian, July 21, 2014, http://www.theguardian.com/society/2014/jul/22/decriminalise-sex-work-co...

[29] US Centers for Disease Control and Prevention, “HIV and People Who Use Drugs,” http://www.cdc.gov/pwud/ accessed March 9, 2015.

[30] US Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, “HIV Infection and HIV-Associated Behaviors Among Persons Who Inject Drugs- 20 Cities, US, 2012” March 20, 2015.

[31] US Centers for Disease Control and Prevention, “HIV Surveillance In Injection Drug Users,” http://www.cdc.gov/hiv/pdf/statistics_surveillance_HIV_injection_drug_users.pdf, accessed March 8, 2015.

[32] E. Costenbader et al, “Racial Differences In Acquisition of Syringes From Pharmacies Under Conditions of Legal But Restricted Sales,” International Journal of Drug Policy, 21:5, September 2010, 425-428.

[33] US Centers for Disease Control and Prevention, HIV Surveillance Report, Supplemental Report, “Monitoring Selected National HIV Prevention and Care Objectives By Using HIV Surveillance Data- US and 6 Dependent Areas- 2012,” http://www.cdc.gov/hiv/pdf/surveillance_Report_vol_19_no_3.pdf, accessed March 8, 2015.

[34] Ibid.

[35] Ibid.

[36] See, e.g. National HIV/AIDS Strategy for the United States, p. 16.

[37] Council of State Governments, “Nevada Newest State to Decriminalize Syringes, “  http://knowledgecenter.csg.org/kc/content/nevada-newest-state-decriminalize-syringes, accessed March 9, 2015.

[38] Robert Wood Johnson Foundation, Public Health Law Research, “Syringe Distribution Laws Map,” current through 2015, http://lawatlas.org/query?dataset=syringe-policies-laws-regulating-non-retail-distribution-of-drug-paraphernalia, accessed March 8, 2015.

[39] T. Castillo, “Southern States Outlaw Syringe Exchanges Used To Prevent Disease,” Alternet, December 6, 2012, http://www.alternet.org/drugs/southern-states-outlaw-syringe-exchanges-used-prevent-disease, accessed March 8, 2015; Human Rights Watch, “In Harm’s Way;” Human Rights Watch, “We Know What To Do: Harm Reduction and Human Rights in North Carolina,” 2011, https://www.hrw.org/news/2011/09/13/we-know-what-do

[40] US Bureau of Justice Statistics, “Prisoners in 2013”; Cindy Chang, “Louisiana is the World’s Prison Capital,” Times-Picayune, May 13, 2012, http://www.nola.com/crime/index.ssf/2012/05/louisiana_is_the_worlds_prison.html, accessed March 8, 2015.

[41] US Centers for Disease Control, “HIV Surveillance Report, Supplemental Report, “Diagnosed HIV Infection Among Adults and Adolescents in Metropolitan Statistical Areas – United States and Puerto Rico, 20111”,  March 2014, http://www.cdc.gov/hiv/pdf/HSSR_MSA_2013_REVISED-PDF04.pdf, accessed March 8, 2015.

[42] Kaiser Family Foundation, “State Health Facts: Estimated Death Rates of Adults and Adolescents with an HIV Diagnosis,” http://kff.org/hivaids/state-indicator/estimated-death-rates-per-100000-of-adults-and-adolescents-with-an-hiv-diagnosis/, accessed March 8, 2015; S. Reif et al, “HIV Diagnoses, Prevalence and Outcomes in Nine Southern States,” Journal of Community Health online, December 19, 2014, https://southernaids.files.wordpress.com/2015/01/hiv-diagnoses-prevalence-and-outcomes-in-nine-southern-states-final.pdf, accessed March 8, 2015.

[43] State of Louisiana, HIV/AIDS Strategy for Prevention, Treatment and Care Services, 2012-2015, p. 21.

[44] Ibid, p. 46.

[45] Louisiana Revised Statutes 40: 1024; Louisiana Administrative Code 46: LIII: 2509.

[46]Louisiana Revised Statutes 40:1033.

[47] Data request, Louisiana Office of Public Health STD/HIV Program, National HIV Behavioral Surveillance IDU 32012, on file with Human Rights Watch.

[48] State of Louisiana, HIV/AIDS Strategy for Prevention, Treatment and Care Services, 2012-2015, p. 47.

[49] R. Westergaard, et al, “Incarceration Predicts Virologic Failure for HIV-Infected Drug Users Receiving Anti-Retroviral Therapy,” Clinical Infectious Disease, 53(7), 2011, 725-31.

[50] Human Rights Watch, “In Harm’s Way.”

[51] US Centers for Disease Control and Prevention, MMWR, “Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis for Persons Who Use Drugs Illicitly: Summary Guidance from the CDC and the US Department of Health and Human Services,” November 9, 2012, 61: 1-40.

[52] J. Zibbell, et al, “Risk Factors for HCV Infection Among Young Adults in Rural New York Who Inject Prescription Opioid Analgesics,” American Journal of Public Health, Vol. 104, No. 11, 2014, 2226-32.

[53] Prison Policy Initiative, “Mass Incarceration,” http://www.prisonpolicy.org/reports/pie.html, accessed March 6, 2015.

[54] US Bureau of Justice Statistics, Correctional Population in the United States 2010, http://www.bjs.gov/content/pub/pdf/cpus10.pdf, accessed March 8, 2015.

[56] National HIV/AIDS Strategy for the United States, p. 13.

[57] AIDS.gov,” Incarceration and HIV”, https://www.aids.gov/federal-resources/policies/incarceration/index.html, accessed March 7, 2015.

[59] National Minority AIDS Council and Housing Works, Mass Incarceration, Housing Instability and HIV/AIDS: Research Findings and Policy Recommendations, 2013.

[60] L. Solomon, et al, “Survey Finds That Many Prisons and Jails Have Room to Improve HIV Testing and Coordination of Post-Release Treatment,” Health Affairs, March, 33:3, 2014.

[61] G. Millett et al, “Comparisons of Disparities and Risks of HIV Infection in Black Men Who Have Sex with Men in the United States, UK and Canada” The Lancet, 280:9839, July 2012, 341-48.

[62] A. Spaulding et al, “Jails, HIV Testing and Linkage to Care Services: An Overview of the EnhanceLink Initiative,” AIDS Behavior online, September 27, 2012, http://abtassociates.com/AbtAssociates/files/d5/d5fccd62-6678-4e8a-82df-9f408236e1e5.pdf, accessed March 8, 2015;  Westergaard, et al, “Incarceration Predicts Virologic Failure for HIV-Infected Drug Users Receiving Anti-Retroviral Therapy,” Clinical Infectious Disease, 53(7), 2011, 725-31.

[63] Woodruff Health Sciences Center, Emory News Center, “HIV/AIDS: Studies Shed Light on Benefits of Enhancing Links to Primary Care and Services in Jail and Beyond,” November 27, 2012.

[64] Bureau of Justice Statistics, “Statistics on Women in the Justice System,” January 2014.

[65] Ibid.

[66] US Centers for Disease Control, “HIV Among Women,” http://www.cdc.gov/hiv/risk/gender/women/, accessed March 26, 2015.

[67] Southern AIDS Strategy Initiative, “HIV Infrastructure Study: Baton Rouge,” April 2014.

[68] Ibid.

[69] US Bureau of Justice Statistics, “Statistics on Women in the Justice System,” January 2014.

[70] Interagency Federal Working Group Report, Addressing the Intersection of HIV/AIDS, Violence Against Women and Girls, and Gender-Related Health Disparities, September 2013.

[71] B. Weir et al, “Violence Against Women with HIV risk and Recent Criminal Justice Involvement,” Violence Against Women, 14:8,August 2008, 944-960.

[72] Interagency Federal Working Group Report.

[73] See, e.g. Human Rights Watch, “In Harm’s Way.” 

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