Sexual Health, HIV/STI and Human Rights Dean’s Lecture March 5 th, 2008 Chris Beyrer MD, MPH The Center for Public Health and Human Rights Johns Hopkins.

Sexual Health, HIV/STI and Human Rights

Dean’s LectureMarch 5th, 2008

Chris Beyrer MD, MPH

The Center for Public Health and Human RightsJohns Hopkins Bloomberg School of Public Health

Core Themes• Human rights abrogation or protection can have

profound impacts on the health of individuals, communities, and populations

• Sexual rights violations are a subset of threats to human dignity. Forced, coerced, and higher risk sexual exposures are highly correlated with adverse sexual and reproductive health outcomes—including STI and HIV

• Responses which address human rights may improve STI prevention and control, and better human rights contexts for those at risk

Outline

I. STI, HIV, and Human Rights

II. Mapping DomainsMigration

Conflict

Trafficking and Sex Work

Special Vulnerabilities—MSM

III. Ways Forward

Human Rights Instruments and Sexual Health 1948 The Universal Declaration of Human Rights

1976 International Covenant on Civil and Political Rights

1976 International Covenant on Economic, Social and Cultural Rights

General Comment 14: Health rights Prevention, treatment, control of epidemic

diseases Focus on realizing rights of women to health throughout the

life span

1981 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW)

Health services to be consistent with the human rights of women:

Autonomy, Privacy, Confidentiality, Informed consent, and Choice

State Responsibilities

Signatory States must not violate these rights

Commit to measurable progress to:RespectProtectFulfill

How do human rights violations increase vulnerability to STI & HIV?

• Increased Exposure– Coercion, sexual violence, rape as tool of war,

population mixing

• Increased Acquisition and Transmission– Treatment delays or gaps, barriers to access,

lack of condoms/contraception

• Increased morbidity and mortality– Barriers to access and to information

Domain IMigrant Populations and STI

Risks

Epidemiology of Migration and HIV/STI

Source: Beyrer B, Baral S, Zenilman J. STDs, HIV/AIDS, and Migrant Populations. Holmes et al. STD 4th Ed. 2008

Burmese Migrants and Barriers to Access in Thailand

Knowledge about Condoms Condom Usage

Thai NationalsBurmese Migrants

Source: Mullany et al, AIDS Care, 2003; Lertpiriyasuwat et al, AIDS, 2003; Leiter et al, Health & Human Rights, 2006

Barriers to information, health care: Language, Legal, Physical, Economic, & Political

PHR/JHU: Thailand’s failure to provide access to services violates Thai law AND undermines national HIV and STD programs

P<0.05

Men Women Men Women

Migration, Residency, and Access

We studied 483 female Sex Workers in Moscow, Russia, in 2004-2005

STD were common Syphilis 15.8% CT 18.4% GC 2.9% HIV 3.1% Any STD 34.6%

Risk Factor: Limited access to health care aOR: 2.1 (95% CI 1.2, 3.5) p = .006

Lack of Moscow residency permit is a barrier to health care access

Source: Stachowiak, et al, SIECUS Rep. 2005

Ecologic Association of Migration and STD in China

Immigration rate STD incidence for 31 provinces and cities

Source: Tucker et al, AIDS, 2005

China has more than 120 million rural-to-urban migrants

Forced Migration: Operation Murambatsvina or “Clear the filth” Porta Farm, Zimbabwe

June 22, 2002 April 6, 2006

Source : © Digital Globe, Inc., Amnesty International 2006

There are no illegal human beings

Archbishop Desmond Tutu

Domain II

STI and Conflict

Conflict and STI Risks

Sexual rights violations are an increasing factor in modern conflict, particularly those that target civilians, ethnic groups

Conflict settings increase risks and present special challenges for service delivery and surveillance

Recent conflicts where rape has been used as tool of war, terror, and ethnic cleansing include

Bosnia, Sierra Leone, Darfur, Burma, Rwanda, DR Congo, and Cote d’Iviore

Estimated fraction of the adult population displaced in Cote d’Ivoire’s armed conflict in 2002

Study AreaEstimated adult population sizein 2001

Estimated % of adult population displaced

Estimated adult population size in April/May 2004

North 552,686 25 414,515

Central 802,325 40 481,395

West 1,075,731 55 484,079

Source: Betsi , N. et al., AIDS Care, 18:4,356-365

Number of health staff before and after Cote d’Ivoire’s 2002 conflict

# of health staff in Central Cote d’Ivoire

# of health staff in North Cote d’Ivoire

# of health staff in West Cote I’voire

Qualification 2001 2004Reduction

(%)2001 2004

Reduction(%)

2001

2004Reduction

(%)

Medical doctor 127 3 124 (98) 38 2 36 (95) 69 6 63 (91)

Nurse 471 67 404 (86) 257 82 175 (68) 310 42 268 (86)

Qualified midwife 184 26 158 (86) 65 9 56 (86) 90 6 84 (93)

Nurses’ aid 42 6 36 (86) 23 5 18 (78) 10 1 9 (90)

Laboratory technologist

88 12 76 (86) 51 10 41 (80) 54 7 47(87)

Total 912 114 798 (88) 108 108 326 (75) 533 62 471(88)

Source: Betsi , N. et al., AIDS Care, 18:4,356-365

Total Number of Cases of STIs Recorded by Health Staff and NGOs

Baseline situation in 2001

Situation in the period betweenApril ’03 – April ‘04

Study Area Total # of STIs# of STIs

per 1,000 adultsTotal # of STIs

Number of STIs per 1,000 adults

Central 9,629 12 6,708 13.9

North 2,697 4.9 2,748 6.6

West 12,310 11.4 20,232 41.8

Total 24,636 10.1 29,688 21.5

Source: Betsi , N. et al., AIDS Care, 18:4,356-365

05

10

15

20

Stu

die

s

1980 1985 1990 1995 2000 2005Year

Lowess smoothed curve with bandwidth 0.3

Figure 1. HIV/AIDS studies initiated, Democratic Republic of Congo, 1982 - 2004

HIV/AIDS Studies Initiated, DRC, 1982-2004

Source: Beyrer , C. et al. Civil conflict and health information: The Case of DR Congo. Public Health & Human Rights: Evidence Based Approaches, 2007

JHU Press, 2007

Conflict and STI

STISTISTISTI•Increased interaction among military and civilians

•Increased levels of commercial or transactional sex

•Decreased availability of reproductive health and other health services

•Decreased utilization of reproductive health and other health services

•Decreased use of means to prevent STI transmission

•Increased population mixing following large internal or regional population movements

•Emergence of norms of sexual predation and violence

•Fragmentation of families

•Increased isolation of communities

•Disruption of sexual networks

•Decreased mobility

Adapted from Mills et al., International Journal of STD & AIDS, Vol 17, 2006

Mobile Obstetric Medics (MOM)

Providing health services in the conflict zones in Eastern Burma

Karen, Karenni, Mon, Shan ethnic teams, Mae Tao Clinic (Dr. Cynthia Maung), Hopkins, UCLA

Cross border MCH program– Family planning, ANC care, attended deliveries,

BEOC, TBA training– Syphilis screening in pregnancy (heat stable rapid test

for whole blood)

Supported by Bill & Melinda Gates Institute for Population and Reproductive Health at Johns Hopkins

Cross-Border Medical Obstetric Medic in Eastern Burma, 2007

Backpack supply teams carrying medical supplies to IDP Communities, Eastern Burma, 2007. The Mobile Obstetric Medic Project

Responses: STI in Conflict

• Innovative delivery: Cross-border into conflict

• Train and empower local health workers

• WHO 2007: Ethical and Safety Recommendations for Researching, Documenting and Monitoring Sexual Violence in Emergencies

– Basic care and support for survivors/victims should be available locally before documentation begins

www.who.int/gender/documents/EthicsSafety_web.pdf

Domain III

Trafficking and Sex Work

Trafficking and Human Rights

Trafficking in persons violates universal human rights to life, liberty, and freedom.

Trafficking of children violates the inherent right of a child to grow up in a protective environment and the right to be free from all forms of abuse and exploitation.

US Dept. of State, 2006

Source : US Department of State, Trafficking in Persons Report, 2006

Trafficking and TVPA

UN estimate is about 4 million persons/year in 2005-2007 were forced, sold, or coerced into trafficked work

Sex trafficking is a small subset of trade in labor and persons

2000: US passes Trafficking Victims Protection

Act

2000-2007: 1,175 victims from 77 countries, 234 last year

Sources States in 2006: El Salvador (62), Mexico (47), Korea (20), Honduras (17)

Source : US Department of State, Trafficking in Persons Report, 2006

The U.S. Anti-Prostitution Pledge: First Amendment Challenges and

Public Health Priorities

Masenior N & Beyrer C. PloS Medicine. Policy Forum. July 2007;4(7):e207

Domain IV

Vulnerable PopulationsMSM

MSM Risk and Rights Contexts

Vulnerability to HIV infection is dramatically increased where sex between men is criminalized

- UNAIDS, 2006

Criminalization and homophobia limit MSM access to HIV prevention, information, commodities, treatment and care - USAID, 2004

Faced with legal or social sanction MSM are excluded, or exclude themselves from sexual health and welfare - UNAIDS, 2006

Structural Discrimination

• 85 UN Member states criminalize sex between consenting adults of the same gender

• More than half of all African States

• 10 States have death penalties for homosexual relations between consenting adults (Pakistan, Saudi Arabia, Iran, Nigeria, Sudan)

Source: International Lesbian and Gay Association, April, 2007

How does Homophobia raise STI and HIV risks?

“Police Assault Metis at Ratna Park for carrying condoms.”

– July 14, 2007

Indian sodomy laws are an active barrier to HIV prevention– The National AIDS Control Organization, NACO, argued the law

creates a public health risk

– "So long as the gay community is forced to go underground, it limits the access to them and makes it difficult to reach them," --Sujatha Rao, NACO

Dignity and Sexual Rights

The Thai Social Order Campaign of 2003

Thai Social Order

Campaign (2003)

…Gay sauna raids

June, 2007 Moscow in protest in response to Moscow’s mayor, Yuri M. Luzhkov, calling gay protests “satanic acts.”

May 2007 Pride March in Moscow. Angry over the demonstration, some young Orthodox Christians began patrols near a chapel that had become a meeting place for homosexuals.

Source: Schwirtz and Yaffa. NYT, July 11, 2007

Clash of Cultures in Russia

Structural Violence:Proportion of STI Prevention Expenditures Targeted at MSM

Source: USAID, 2006

Country, City, or Province

MSM Prevention Expenditure (Thousands)

Total Prevention Expenditure(Thousands)

Share of Prevention Expenditure

Thailand 482.5 12,516 3.9%

Vietnam 220 20,670 2.6%

Ho Chi Minh City 4.2 430 0.05%

Cambodia 190 8,506 2.2%

China 140 n/a n/a

China Province 1 28 21,000 0.13%

China Province 2 0 3,000 0%

Lao People’s Democratic Republic

40 2,694 1.5%

13.0%

51.5%

15.4%

63.0%

00.10.20.30.40.50.60.70.80.9

1

HIV + UnrecognizedInfection

White MSM

African American MSM

p-value <0.001 p-value <0.001

Source: Sifakis F, et al. High HIV Prevalence and Incidence Observed Among African American MSM in Baltimore: The Behavioral Surveillance Research (BESURE) Study. The 13th CROI (abstract V-176).

HIV and Unrecognized Infection among MSMBaltimore (2004-2005)

Responses: Sexual rights and sexual health

• Decriminalization of same sex activity

• Human dignity requires non-discrimination in services, access, funding

• Include MSM risks in national surveillance, in STI assessments—particularly where culturally difficult

HIV, STI and Rights in the US

Impacts of Four Title V, Section 510 Abstinence Education, April 2007

“Abstinence-only sex education programs are not effective in preventing or delaying teenagers from having sexual intercourse”

• Findings from evaluation report commissioned by Congress and conducted by Mathematica Policy Research, Inc.

$176 million

US federal government annual spending for

abstinence -only programs

Consistent with human rights principles?

Autonomy PrivacyConfidentialityInformed consentChoice

Abstinence Only Sexual Health Education

Structural Barriers: Condoms in US Prisons

• CDC has called for condom distribution in US prisons

• HIV rates in California inmates are 8 times higher than general population

• Gov. Schwarzenegger (R) of CA vetoed a 2006 bill with wide voter support allowing condoms in CA prisons: Now allowing “pilot” of condom distribution in one prison

“Mr. Schwarzenegger said he vetoed the bill because it conflicts with state law that makes sexual contact among inmates illegal. That’s self-defeating and a denial of the reality of life behind bars, and the governor seems to know it. His veto statement acknowledged that condom distribution represents a reasonable “public policy, and it is consistent with the need to improve our prison health care system and overall public health.”

This is a denial of right to life, to health, and failure to protect and promote rights

New York Times “Reality and Denial in California Prisons, Oct. 19th, 2007

U.S. and the Right to Health Care

The US does not recognize the fundamental right to health care

The Research Agenda

• What we need to move forward with interventions on the health and rights interface

• Research to assess the benefits of rights-based approaches

• Example: Paul Pronyk and colleagues in South Africa using micro-credit approach – Effect of a structural intervention for the prevention of

intimate partner violence and HIV in rural South Africa: results of a cluster randomized trial.

Lancet 2007

Ways Forward

• Recognize– Human rights contexts of our work

• Partner– With the grassroots, with human rights groups in

country and internationally, with those we seek to serve facing rights violations

• Act– Research, Advocate, and Fund

AcknowledgementsJohns HopkinsStefan BaralNancy KassNicole Franck MaseniorLuke MullanyFrank SifakisAmy TsuiJonathan Zenilman

Open Society InstituteJonathan CohenFrancois Girard Sisonke Msimang

John Fisher ARC IntlShiv Khan Naz

FoundationSunil Pant Blue

DiamondEd Mills Univ. BC