Health Behavior – Larkin Callaghan

1980s Redux? The Troubling Criminalization of HIV

Nick Rhoades, an HIV-positive Iowa man, did exactly what anyone who was privy to a quality sex education program was told to do—he used a condom to protect himself and his partner during a sexual encounter. However, because Rhoades did not disclose his status to this partner, under his state’s law he was arrested, tried, branded a felon, and sentenced to 25 years in prison. He was also required to register as a sex offender, which will follow him for the rest of his life.

One crucial piece of information was buried throughout the process: Rhoades’ partner did not contract HIV through their protected, consensual encounter.

The United States has more criminal laws regarding exposure and transmission of HIV than any other country in the world. Over 125 cases were filed between 2008-2011 alone. By the year 2000, two-thirds of states had HIV-specific laws or had added provisions about HIV to existing laws.

As convictions under these laws mount, health professionals are raising concerns that they could have the perverse effect of setting back efforts to prevent HIV in a way that is reminiscent of the early 1980s.

HIV criminalization laws date back to 1990, when federal legislation aimed to fight the spread of HIV, such as the Ryan White Care Act, required states to punish those who infect others as a requirement for benefitting from government funds.

The laws differ greatly from state to state, so much so that someone committing the same act in two different states could face a felony charge in one, and no repercussions in the other.

For example, in California, to be charged with a felony, a person must know his or her HIV status but not disclosed it and expose someone to the virus via unprotected sex, with the specific intent of infecting the other person. (That last part is tricky, since California also explicitly states that knowing one’s status does not in itself mean one is intending to infect another.) [Note: since this article’s original publication, California lawmakers have voted to reduce the penalty for knowingly potentially exposing someone to HIV from a felony to a misdemeanor.]

The law in Michigan is much harsher. There, failing to disclose HIV-status before having sex with a partner is a felony, regardless of whether or not a condom is used or exposure to the virus or transmission occurs.

Like Michigan, many states’ laws “don’t always account for consent, and very few talk about condom use,” says Professor Leslie Wolf of Georgia State University, who has done extensive research on various HIV laws and policy.

On appeal, Nick Rhoades was given a suspended sentence after serving a year in prison. His sex offender status remains, despite the absence of intent to transmit the virus, as Rhoades’ new representation, Lambda Legal, said was evident by his use of protection.

At least 25 percent of prosecutions in the U.S. even target behavior that has been proven not to lead to the transmission of the virus, actions like spitting and biting, according to the education and advocacy site AIDSMeds, now part of POZ.

For instance, Michigan pursued criminal charges, including terrorism charges, against an HIV-positive man who bit a neighbor during a fight. The state drew on precedent from an earlier Michigan lawsuit that deems HIV-infected blood a harmful biological substance.

The Centers for Disease Control and Prevention specifically notes that HIV cannot be transmitted via saliva, and in regards to biting, specifies, “each of the very small number of cases has included severe trauma with extensive tissue damage and the presence of blood.”

In 2009, a District Court judge in Maine extended the sentence of a woman who was arrested for faking immigration documents simply because she was HIV-positive and pregnant. The judge personally decided to double the federally recommended jail time for her offense because it would keep her in prison until she gave birth—despite before her arrest having arranged healthcare to ensure she would not transmit the virus to her baby.

“On a larger level, HIV criminalization reinforces this idea that someone who is HIV-positive, they’re dirty, they’re bad…all these stereotypes get reinforced,” said Dr. Marguerita Lightfoot, professor of medicine at the University of California, San Francisco and Director of the University’s Center for AIDS Prevention Studies, who has worked extensively on HIV-prevention programs, and directly with a diverse range of people infected with or affected by HIV.

Criminalization also revitalizes not just fear and discrimination, but misinformation, contributing to the thinking that HIV remains a death sentence.

Today, HIV is still a serious diagnosis, but antiretroviral drugs have added decades to the lives of HIV-positive individuals, turning it into a manageable, chronic disease.

Penalizing actions like biting and spitting is reminiscent of the 1980s, when little was known about HIV, and epidemiologic studies recommended no sexual contact at all with an infected individual.

What’s more, HIV is more difficult to contract than is often realized. Epidemiological and biological research has illuminated the disparate difficulty in transmitting HIV, which is highly dependent on the specific behavior and the viral load of the individuals.

For example, if one is on the receiving end of unprotected anal sex from an HIV-positive individual, the risk is significantly higher than if one is an HIV-negative male having unprotected sex with an HIV-positive female. Risk varies if other sexually transmitted infections are present, if the HIV-positive individual was recently infected, if the male partner is circumcised, and a multitude of other factors. These factors are not incorporated into the laws.

As Professor Wolf puts it, the laws “don’t reflect [what we know]. If we’re going to keep them, they have to keep up with what is true.”

The laws also undermine prevention education that emphasizes safe sex by criminalizing individuals after they’ve employed the exact strategies that educators and researchers recommend to prevent HIV transmission, according to Dr. Lightfoot.

Doubts about the efficacy of the laws are born out in numerous studies, one of which in the American Journal of Public Health, which finds that HIV exposure laws do not significantly influence peoples’ decision to disclose an HIV-positive status or change their behavior. The laws may actually deter people from ever even getting tested and knowing their status, contributing to HIV’s spread.

“What’s the benefit of knowing your status if you are going to be prosecuted for engaging in sexual behavior?” said Dr. Lightfoot. “Our current arguments around HIV-testing are that you can get treatment and live a long life. Criminalization overpowers these ideas,” she adds.

Of course, knowing one’s status can decrease the risk of HIV transmission. HIV-positive people can access treatment that lowers viral loads, decreasing the risk of passing the virus on, and they can also take precautions to protect their partners and stem the spread of the disease.

Furthermore, while most agree that someone intentionally transmitting HIV to another should be punished, situations in which someone intentionally exposes and infects another are very rare.

“There’s an assumption that any time a person who is HIV-positive has sex, it’s risky sex,” said Dr. Lightfoot. “When we demonize folks, we lose track that most HIV-positive folks are doing what they can to prevent transmission.”

There are ways the laws could be modified, says Professor Wolf. “What we could do is improve [the laws] so you account for public health messages and do not punish somebody for engaging in safer sex.”

But as they stand now, the laws serve to mainly add fuel to the firestorm of fear around HIV and the spread of the virus itself. “It’s amazing how much bias, misinformation and stigma is still out there,” says Professor Wolf. “It’s amazingly frightening.”

Originally posted at The 2×2 Project.

Making the Cut: Is It Time to Put the Circumcision Debate to Rest?

Circumcision is not a new practice – it is most notably well known as a religious practice in many communities. But its implementation for public health purposes has been controversial. Raising ethical concerns and questions of tractable population health impact, the procedure has gained increasing attention in the past couple of years as it treads on unprecedented ground—surgery for the prevention of infectious disease.

Research in support of circumcision as a protective measure against the spread of HIV and other sexually transmitted diseases is mounting, countering concerns of its potential risks. [Most recently, the American Academy of Pediatrics officially articulated that the health benefits outweigh the risks – though the decision should be left to parents, as those benefits aren’t marked enough to warrant a blanket recommendation.]

The circumcision debate turns largely on biological, behavioral, and relational factors – and these are the elements to keep in mind when thinking of [voluntary male medical] circumcision in the context of HIV. Particularly in developing countries.

Biologically speaking, the foreskin is the ideal environment for bacterial and viral infections to flourish. Heat and lack of oxygen facilitate the growth of pathogens. When the inner foreskin is retracted during heterosexual intercourse, for example, it is exposed to the vaginal secretions of a female partner, which if carrying HIV and other sexually transmitted infections easily fosters transmission. A 2009 study indicated that the greater the size—and therefore surface of—the foreskin, the higher the incidence of HIV in an infected male, underscoring how it can be a breeding ground for the virus.

A recent study conducted by Dr. Ronald Gray of Johns Hopkins University, in which researchers followed Ugandan adult study participants after a circumcision intervention, showed that the subsequent risk of acquiring HIV was reduced for the 40-month follow-up period. In addition, circumcision decreased the viral load of high-risk human papillomavirus—the strains that can cause penile, cervical and anal cancers—in men.

Other studies have shown significant reductions in bacteria after circumcision, which also benefits the female partners of the men. Adverse events or complications appear to be rare in both HIV-positive and HIV-negative men who undergo the procedure, with one study documenting moderate-to-severe complications occurring between 3-4 percent of men regardless of HIV-status.

Behavior change also features prominently in the circumcision debate. Opponents of circumcision express concerns that the procedure may contribute to a perception of immunity against HIV and result in the reduction of condom use. Additionally, there is a question of whether or not it may increase the number of sex partners one has, for the same reason of rationalizing post-surgery invincibility.

Many circumcision interventions studies are not so cut and dry, so to speak. A number contain significant education components, which makes the procedure’s contribution to HIV risk reduction less clear.

One study examined the length of time men who had undergone circumcision waited before engaging in sexual activity. If a man HIV-positive, the risk of infecting a partner is notably higher if he engages in sexual activity before the wound heals, highlighting the importance of the quality of the surgery to minimize healing complications and the importance of concurrent education to delay sexual activity. Since a 2008 study showed that after 30 days, 73% of HIV-positive men had healed wounds, compared to 83% of HIV-negative men (the discrepancy owing to greater time HIV-positive individuals may take for any kind of wound healing), this is of particular importance.

It seems that being married, not single, might diminish concerns about the length of time it takes wounds to heal. There was no statistically significant difference in time waited to engage in sex post-surgery between HIV-positive and HIV-negative men who were married; nearly 28 percent and 29 percent, respectively, engaged before the wound healed, which is the single greatest cause of post-procedure complications. However, among single men, roughly 13 percent of HIV-positive men resumed sex before their wound was fully healed, compared to about 6 percent of HIV-negative men did.

The significant difference between the single HIV-positive men and the single HIV-negative men underscores the potential for altered beliefs about post-circumcision HIV transmission. However, HIV-positive men reported more sexual partners and less consistent condom use than the HIV-negative men throughout the study—itself underscoring the difficulty of risky behavior change. Encouragingly, condom use among HIV-positive men increased over the course of the study.

The relational impacts of circumcision have also been examined. Researchers have assessed the perceptions and opinions of the women in relationships with those who have undergone the surgery. A 2009 study indicated that women whose male partners were circumcised were either more sexually satisfied than they had been previously, or felt no difference. Thirty-nine percent of women indicated more satisfaction, 57 percent noted no change, and less than 3 percent said they were less satisfied than they had been when their partners were uncircumcised. The greater satisfaction, according to the women, was primarily attributed to better hygiene.

These results are important, as one of biggest issues around circumcision is “the sell.” The best way to make that sell, researchers argue, is to have the female partners articulate their preference for and encouragement of circumcision to their male partners. It appears that there may also be a generational difference in the acceptance and uptake of the procedure. Dr. Gray and his colleagues have found that adolescent males disproportionately access circumcision procedures. Even some fathers who encouraged circumcision in their sons refused the procedure themselves.

Precautions are of course essential. Research has shown that it takes practitioners approximately 100 circumcision procedures before they can be considered adept at performing the surgery.

And not all the research being done has produced promising results, specifically for women. While some studies suggest that HIV-discordant couples—HIV-negative woman and HIV-positive man—benefit from circumcision and the procedure prevents infection of the woman, other studies have produced conflicting results.

Biologically, the circumcision seems to benefit primarily men, in preventing the contraction of HIV from an HIV-positive female partner. The same is not necessarily true for HIV-negative women whose male partners are HIV-positive. This biologically higher risk of infection for women is well known among public health researchers. Of course, decreasing the prevalence of HIV-positive men will ultimately, in the long run, help to lower the HIV incidence in women.

Indeed, population health benefits are already emerging. Dr. Gray and colleagues showed earlier this year that in Uganda, 37 percent of the reduction in HIV incidence could be attributed to circumcision, since there was no change in risk behaviors. The impact was not observed in women.

Circumcision seems to make economic sense. The male circumcision procedure costs $30-$60 in adults, and $5-$10 in infants. For each HIV infection avoided due to five to 15 male circumcisions performed, the savings reach well into the billions of dollars with the assumptions of a $150-$900 cost per infection (depending on HIV incidence in a specific region) over the next ten years.

Critics of course remain, and most vocally claim that other strategies, like education and behavior change, are viable solutions that should be championed. Regarding the sustained HIV epidemic and the hopeful strategies of condom use, testing, and treatment, Dr. Gray himself remarked, “I don’t know how to change behavior, I wish I did.”

So while behavior change strategies are perhaps the most important intervention to counter the HIV epidemic, they are not the only effective HIV interventions. The evidence seems to indicate that voluntary circumcision also makes the cut as a contender in the global fight against HIV.

Originally published by The 2×2 Project.