HIV/AIDS – 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.

Retraumatization: The Increased Risk of HIV Transmission among Abuse and Assault Victims

While the transmission of HIV and the causes of HIV-related death are actually more complicated—and even more nuanced—than public discussion would let on, a few presumptions about it remain fairly accurate.

For women who are marginalized in their communities, who are victims of abuse or assault, and who are economically or socially dependent on a spouse, the risk of them contracting HIV or dying from multiple complications from AIDS is simply greater than that of women fortunate enough to not be subjected to these circumstances. Take these scenarios:

The power dynamic in an abusive relationship may prohibit women from being able to protect herself from a partner who refuses to wear a condom
Women in poverty and those who need to rely on a partner for financial support may have greater risk of comorbid infections than women of economic independence. They are less likely to have the health insurance and relationship with a healthcare provider that would support HIV testing and provide the essential—and expensive—HIV medications to ensure a healthy life and lower the risk of co-morbid infections
People without social support, living in fear of what an HIV-positive diagnosis means, or those who have reason to fear stigma around personal behavior when seeking treatment are less likely to know where to access treatment or seek it out because of that fear, stigma and lack of support

Common sense would seem to support these statements. But until recently, the pathways of infection were not always clear, and while the conclusions above seemed certainly reasonable, specific data to support them had been difficult to collect. Two recent studies led by a UCSF-researcher have changed that. One synthesized what is known about PTSD and exposure to trauma among HIV-positive women, and the other explored the root of this relationship.

The results were remarkable. HIV-positive women had between two and six times the rates of childhood and adult physical and sexual abuse, and PTSD. The snapshot of risk behaviors among HIV-positive women was sobering:

	Sample size	Number (%) of participants with each characteristic
Sexual activity
Any sexual activity in the past 6 months	113	61 (54.0%)
With a main partnerMedian number of main partners (if any)	61	43 (70.5%)1 (range 1–2)
With casual partnersMedian number of casual partners (if any)^a	61	23 (37.7%)1 (range 1–25)
Sex with any HIV negative or unknown serostatus partners (if sexually active) in the last 6 months	61	51 (83.6%)
Disclosure of HIV status less than all of the time with these partners	51	29 (56.9%)
Using condoms less than all of the time with these partners	51	31 (60.8%)
Detectable viral load	51	30 (58.8%)
Disclosure of HIV status less than all of the time, and using condoms less than all of the time, and a detectable viral load	51	16 (31.4%)
Substance use (any, recent)
Cigarettes	110	71 (64.5%)
Alcohol	111	50 (45.0%)
Marijuana	111	39 (35.1%)
Crack/cocaine, heroin, and/or methamphetamines	111	45 (40.5%)
IDU^b	112	11 (9.8%)
IDU who share needles	11	5 (45.5%)
IDU who have a detectable viral load	11	6 (54.5%)

There were striking findings in terms of both HIV treatment failure and the impact of the above risk behavior in these women, bringing us the first real data hoping to explain this relationship. Those who suffered from recent trauma had more than four times the odds of anti-retroviral (ART) failure while on treatment than HIV-positive non-victims—and this was seemingly not due to self-reported poor adherence to the medication. One potential explanation offered by the study authors is that abuse and trauma interfere with an individual’s ability to stay on a consistent medication schedule, which is essential for control of the virus. Other studies have confirmed that abuse manifest as control, in which a male partner prevents his HIV-positive female partner from accessing services at a clinic out of fear that the stigma of HIV would be attached to him.

HIV-positive victims of recent trauma also all reported experiencing what the study calls “coerced sex,” and have over three times the odds of un-traumatized women of having sex with HIV-negative or status-unknown individuals. They had greater than four times the odds of inconsistent condom use, potentially exposing those casual partners to the virus. While high-risk sex behavior is always a factor in HIV-transmission, HIV-positive individuals who adhere consistently to HIV treatments are significantly less likely to infect HIV-negative partners during sex. So the lack of treatment adherence among traumatized HIV-positive women combined with the risky sex behavior is a great concern.

Interestingly, these figures were only significant among women who experienced recent trauma, indicating that the ongoing—not merely one occurrence—circumstances of abuse are the key to the relationship between HIV-infection and HIV-related illness and death. This can actually be seen as a snapshot of hope—if we are able to offer abuse, assault, and PTSD victims the appropriate support to heal from the experiences, we may be able to weaken the HIV/trauma relationship.

These studies draw a clear line between victims of assault and trauma and both the spread of HIV within their communities and the increased risk of HIV-related illness and death. But interestingly, the risk goes much deeper than these socioeconomic circumstances. The conversation around HIV transmission is generally split into one of two categories: social and behavioral—risky activity, injection drug use, the prejudicial judgment of sex workers; and medical and clinical—how the virus infiltrates the immune system, takes over cells, and how it is and isn’t suppressed with antiretroviral medications. What isn’t usually discussed is the possible combination of these two categories and how together they create a perfect storm for potential infection.

Recent studies have shown that those individuals suffering from PTSD had significantly higher rates of cytomegalovirus (CMV) in their body. A virus that is found in between 50%-80% of adults in the United States, CMV remains largely undetected—latent, suppressed, unproblematic—in healthy individuals. It’s also seen as a marker of immune health and function, and of the body’s ability to control potential infections. Given that 30% of American women with HIV/AIDS have PTSD (five times the national average), the potential relationship between their HIV-status and even further compromised immune function could lead to a myriad of comorbid infections and premature death. Other research has also shown that additional biological mechanisms may prevent ART-treatment from being as effective as possible, including high cortisol (stress hormone) levels. Not only do these victims have to fight against abuse and assault, they have been left without the essential social support to decrease risky behaviors that may expose others to the virus, and their own bodies are in revolt.

Collecting this kind of information is difficult. It requires consistent and positive communication between women and providers, unobstructed access to medical care and uninterrupted ART treatment, and of course, in this example, most importantly—removal from an abusive environment.

The combination of immunosuppression due to PTSD, the detectable rates of HIV in traumatized women whose viral loads are not suppressed by consistent anti-retroviral treatments, and the concurrent risk behaviors of abused HIV-positive women, all contribute to higher rates of HIV-infection in communities, as well as the potential for co-morbid infections and HIV-related death. Until these women are able to find the essential social and community support, free from abuse and trauma, and until their access to care and preventative measures are fully realized, the relationship between trauma and HIV will only deepen.

Child Mortality – What Are the True Biggest Causes?

A great image from Population Services International‘s most recent issue of their magazine, Impact, from the cover article written by Desmond Chavasse, Ph.D, Vice President, Malaria Control & Child Survival, PSI, about causes of child mortality globally.

One of the purposes of the image, of course, is to show the stark contrast between directed funding for treatment and eradication of certain diseases and the number of children afflicted with these illnesses. How does this impact our understanding of global health and of the marketing around certain hot topic health issues and ways in which donors feel as though they are contributing to a decline in preventable deaths?

When I worked in development for HIV/AIDS organizations, it was fascinating to speak with donors about their reasons for giving and their understanding of the prevalence and incidence (and the general audience grasp of the word incidence, which is the measure of risk of contracting a certain illness or disease within a specified time frame) of HIV. Contrast this with the understanding of malaria, TB, diarrhea, deaths due to childbirth complications (for the mother and the infant), and the gap between perception and reality was startling. In no way do I want to deny the importance of consistent development support for all diseases on a global scale, but I do think there is something lacking in terms of the education around these issues for donors and even some advocates.

Solutions? Come chat with me on Twitter.