Human Rights and HIV in Eastern Europe and the CIS
1. Dudley Tarlton
dudley.tarlton@undp.org
UNDP Europe and the CIS
HIV, Health and Development
Slides from Jeffrey O’Malley and Mandeep Dhaliwal
2. Human Rights & HIV
Outline
• HIV and the Law
• Why Law Matters
• Global Commission on HIV and the Law
• Regional Context
• Trends
• Recommendations
• Case study
3. Human Rights & HIV:
The AIDS Paradox
“Inorder to prevent and
control the spread of HIV, we
must protect and promote the
human rights of those most
vulnerable, typically
marginalized”
4. Key Populations: Burdened and
linked
One-quarter of the 3.7 million people who inject drugs
in EECA are living with HIV
Sex workers, drug users, men who have sex with men,
transgender people, prisoners and migrants exist
everywhere in the world, and are bridge populations
HIV prevention, treatment and care services often fail to
cover them, and are under-funded
Social marginalisation
5. Expenditures for HIV Prevention
MSM: 1.2%
SW: 1% IDU: 2%
Other prevention
services: 96%
Source: UNGASS 2008 Country reporting Data
6. Why the law matters
Structural
change
(enabling
environment)
Source: Cost and Finance Working Group, aids2031 (across 139 countries)
6
7. Why the law matters
Critical enablers such as
the law can contribute
significantly to reducing
HIV incidence for a
relatively low cost
(Investment Framework)
The Lancet 2011; 377:2031-2041in
(DOI:10.1016/S0140-
10. Global Commission on HIV and the Law
“If laws are not able to
express a modern thought
that is humane, a thought
that takes into account
human rights and
eliminates repressive
policies and practices, we
will not see progress in
HIV and development.”
Chair, Global Commission on HIV
and the Law Fernando Henrique
Cardoso
11. 100
Countries reporting
having non-
discrimination
laws/regulations
80 with protection for
this population
Median percentage
Countries reporting
of population NOT having non-
60
reached with discrimination
HIV prevention laws/regulations
services with protection for
this population
(UNGASS indicator 9) 40
20
0
Sex workers Injecting drug Men having
(N=42) users (N=17) sex with men
(N=28)
Source: UNGASS Country Progress Reports 2008
12. Some successes and important lessons
– the legal environment (laws, law enforcement and access to
justice) has a significant impact on access to HIV prevention,
treatment, care and support
–the impact of punitive laws, policies, practices, stigma and
discrimination is often most acutely felt by people living with HIV,
men who have sex with men, transgender people, people who use
drugs
–punitive and discriminatory legal environments limit the capacity of
communities and suppress uptake of essential services
On-going challenges:
–Criminalization of transmission, exposure, MSM and TG, SW,
people who use drugs
–Discrimination
– Lack of ‘healthy’ law enforcement
–Expanding access to justice
–Stigma, discrimination and exclusion of key pops
–Violence – including gender based violence
13. Remove all legal barriers that impede access
to HIV and health commodities and services
for Key Populations
End all forms of violence and harassment
against Key Populations
14. Drug use causes harm, but criminalisation
and punishment are inappropriate, have
failed and exacerbate HIV
Harm reduction – access to clean needles,
drug substitution has proven to be effective;
but criminal law often prevents such
interventions
15. Alter approach towards drug use from a purely
punitive one to one that promotes health and
treatment of users
◦ Immediate closure of compulsory drug detention
centres, replaced by voluntary services for treating drug
dependence
◦ Abolish national registries of drug users and mandatory
testing and forced treatment of drug users
◦ Abolish jailing of users or those who possess drugs for
personal consumption
◦ Review and reform, in partnership with the UN, relevant
portions of the international narcotics conventions
16. Human Rights & HIV
The regional perspective
• HIV and the Law
• Why Law Matters
• Global Commission on HIV and the Law
• Regional Context
• Trends
• Recommendations
• Case study
17. Bottom Line
Eastern Europe and Central Asia is the only
region in the world where HIV prevalence
continues to increase
Only 19 percent of adults in the region
who need ARVs have access to them
18. • Western Europe: Epidemic driven by MSM.
Prevalence rate is low stable.
• Central Europe: Epidemic is also driven by
MSM. Prevalence rates also low.
• Eastern Europe and Central Asia: Different
epidemic profile. Higher prevalence.
Epidemic driven by IDU but sexual
transmission accounts for a growing
proportion of new infections.
19. Predominant mode of transmission of
newly reported HIV cases, 2009*
Sex between men
Heterosexual
Injecting drug use
Data unavailable
10 November 2010
Hidden epidemic: HIV, MSM and transgender people in eastern *Or most recent data
Europe and central Asia
19
19
20.
21. • Highly concentrated
• Stigma, discrimination and social exclusion:
• Legal environment
22. Drug Policies in need of reform
63% of countries in EECA identified drug policy
as a barrier to HIV treatment
Source: Dublin Declaration Report 2010
23. Trends from Europe and Central Asia:
Kyrgyzstan have moved from treating drug dependence as a criminal issue
to a health issue
Ukraine has provided a legal framework for the introduction of OST for
people who use drugs.
Moldova has adopted progressive prison laws and drug policies.
The Russian Federation has also provided social protection rights for the
children of HIV-positive parents.
Countries like Bulgaria, Romania and Slovakia, have, as a condition of EU
accession, revised national laws to better protect the rights of PLHIV and
those vulnerable to it.
Other countries, like Croatia, are also in the process of doing so.
24. Access to Needle/Syringe Programmes among IDU
Central Asia Eastern Europe
33% of IDU 7-15% of IDU
92 needles/year 9 needles/year
Central Asia Eastern Europe
Source: International Harm Reduction Association, 2010
25. Best Practices from the Region:
• Promote drug demand reduction
• De-emphasize the law enforcement approach
• Use health laws to address drug dependence
• Administrative citations for simple possession/use
• Provide needles/syringes in pharmacies
• Drug users are offered the health services the need
26. Case study of a smart drug policy:
• Possession/personal use not criminalised initially
• Law amended to outlaw possession
• But not for small quantities for personal use
• Each case assessed in court individually
• In practice, police and prosecutors don’t prosecute simple possession
The Country?
27. Case study of a smart drug policy:
• Possession/personal use not criminalised initially
• Law amended to outlaw possession
• But not for small quantities for personal use
• Each case assessed in court individually
• In practice, police and prosecutors don’t prosecute simple possession
The Country?
Poland, 1985-1997
Hinweis der Redaktion
Introduce UNDP’s work on HIV.Define the region.
30 years on we know that vulnerability to both HIV and TB infection is fueled by a wide range of human rights violations. People living with HIV around the world continue to suffer stigmatization, discrimination and violations of human rights.In the context of HIV, where human rights are protected and promoted, people are empowered: To access informationTo access non-discriminatory prevention servicesTo access life-saving treatmentTo access care and support…the mainstay of an effective AIDS response
In Eastern Europe & Central Asia, an estimated ¼ of the 3.7 million people who inject drugs in the region are living with HIV Sex workers, drug users, men who have sex with men, transgender people, prisoners and migrants exist everywhere in the world, and are bridge populations (e.g. sex workers + clients, under trial prisoners and spouses, MSM who also have sex with women, sexual partners of drug users etc.) HIV prevention, treatment and care services often fail to cover them, and are under-fundedTheir social marginalisation is compounded by human rights violations and punitive approaches of the law
Global estimates indicate that injecting drug use accounts for between 15-25% of HIV infections worldwide, yet only 2% of all HIV prevention funding is targeted toward people who inject drugs.Recentpolicyguidance as noted in thereports of theCommissionon AIDS in Asia and in thePacific, clearlystatesthat more of ourresourcesmustbedirectedtowhererisk and vulnerabilityisthegreatest. However, thereisstill a major gap betweenpolicy and practice.Thisisespeciallystrikingwhenone compares thistotherecentexperience of the response to H1N1 in the US, wheretheresposnewasprettyimmediate in terms of allocatingresourcestothosemost at risk – i.e.: pregnantwomen, children and healthworkers.
The key question for all of us is “What can we do to change the course of the global HIV epidemic”?Are we going to pursue business as usual, allowing new infections to plateau and slowly increase again, beyond 7,400 a day?Are we going to pursue rapid scale-up of all the public health interventions at our disposal? Or are we also going to pursue structural change – changes to the overall environment that can make prevention and care more effective? Structural change – including to law and law enforcement – is not a panacea or a magic bullet. Nevertheless, it is undoubtedly one of the most effective and under-utilized tools at our disposal. - something about cost efficeinecyCurrent Trends:Coverage of key interventions continues to expand to 2015 as it has in the past few years. As a result some countries achieve universal access for some services but not others and some countries do not achieve universal access by 2015. Across all interventions coverage reaches about two-thirds of universal access targets by 2015 and then remains at those levels after 2015.
The harms of human rights violations in the AIDS response are clear – harms to those who are typically marginalized by stigma, discrimination, homophobia, transphobia, violence and criminalization. These human rights violations harm all of us.The benefits of human rights protection and promotion in the HIV response are clear – protecting and promoting the rights of those most vulnerable - improving their access to essential services - benefits those who are marginalized and excluded and consequently benefits communities and countries – benefits us all.
Unfortunately, there has been an epidemic recently of new legislation to criminalize HIV transmission – which of course criminalizes people who know that they are living with HIV. More than 30 countries have enacted HIV-specific laws that criminalize HIV transmission or exposure. More than two dozen countries have used non-HIV-specific laws to prosecute individuals on similar grounds. In the last few years, 16 countries in Africa have passed laws criminalizing HIV transmission and exposure. Even Germany has charged an individual for HIV transmission. The problem is that often these laws are drafted and applied too broadly and often punish behaviour that is not blameworthy. Besides, it is medically impossible to determine the exact individual source of an HIV infection.When you add this factor to the long-standing criminal and regulatory sanctions against other key populations, a very large percentage of the people we need to empower to slow the spread of HIV are instead being criminalized.
In 2010 UNDP and UNAIDS convened a commission of eminent experts to investigate the ways in which the law has helped or hindered the global response to AIDS. The Commission was made up of heads of state, parliamentarians, jurists and other well known experts. The commission hosted six Regional Dialogues to hear directly from community members, policymakers and law enforcement exactly what their experiences have been with regard to HIV and the law.The dialogue for Eastern Europe and Central Asia was held last May in Moldova, and the findings from that inform much of the rest of my presentation. The final report for the Commission is due this summer and will contain country-specific recommendations.
The legal environment is strongly associated with coverage and uptake of services. As you can see from the data on this slide, protection against discrimination increases HIV service coverage, which almost certainly makes HIV prevention programmes more effective. Poland, fortunately, does have laws prohibiting discrimination based on HIV status. Nonetheless coverage rates for harm reduction services – particularly methadone substitution therapy, and particularly in prisons – remain extremely low.
We now have over 4 million people on life-saving treatment. In one year, from 2007 to 2008, coverage of those in need of treatment went from 33% to 42%. (In our region though, we’re stuck at around 19 percent.) Global infection rates have dropped 17% since 2001. (Though they’re still rising here.)AIDS has demanded the participation of those affected and it has demanded inclusive governance. AIDS has driven down prices of essential medicines and insisted that public health be a consideration in intellectual property law and trade agreements. Success in the AIDS response has been driven by human rights and AIDS has contributed to advancing the human rights agenda. AIDS has made economic, social and cultural rights justifiable before the courts.Despite some remarkable successes in the AIDS , a rising tide of punitive laws, polices, and practices that violate human rights is jeopardizing progress and blocking the achievement of the universal access targets and the MDGs. It is becoming increasingly clear that successes in HIV prevention, treatment and care can only be sustained and scaled up if they are underpinned by legal, regulatory and social environments that advance human rights, gender equality and social justice goals.
First bullet point includes: Repeal laws that prevent access to or possession of relevant HIV prevention commodities – needles/ syringes, condoms etc. Repeal laws and reform practices of police and the judiciary which consider possession of HIV prevention commodities as evidence of intent to commit a crimeSecond bullet point includes:ending police abuse and harassment of NGO workers and membersof Key PopulationsIntroducing effective methods to lodge complaints, prosecute police personnel, and access justiceInvest in training police, public safety officials, judges
Each of these recommended actions are relevant for the Eastern Europe and Central Asia region.
30 years on we know that vulnerability to both HIV and TB infection is fueled by a wide range of human rights violations. People living with HIV around the world continue to suffer stigmatization, discrimination and violations of human rights.In the context of HIV, where human rights are protected and promoted, people are empowered: To access informationTo access non-discriminatory prevention servicesTo access life-saving treatmentTo access care and support…the mainstay of an effective AIDS response
We are skeptical of much of the official data on reported modes of transmission. The high levels of stigma dissuade people from reporting to their doctors exactly how they think they were infected.Worth noting here that the Czech Republic lists sex between men as the most common mode of HIV transmission – and not injecting drug use.
Highly concentrated: Among IDU, sex workers, MSM and prisoners. Stigma, discrimination and social exclusion: HIV associated with behaviours that lead to social marginalisation. Legal environment: Legislative frameworks ok, but policies and practices undermine the rights of PLHIV.
HIV epidemic still fueled by drug useLegislative environments generally supportiveImplementation of existing laws is uneven
Policies and laws that promote drug demand reduction lead to better social and public health outcomes than those aiming for drug supply reduction. The law enforcement approach should be de-emphasized in favour of a public health approach Drug dependence issues should be included in health laws, rather than drug laws.
.
The amendment adopted by the Polish Parliament in December 2011 goes some way toward restoring judicial discretion on drug prosecutions. But experience tells us that whether these legislative changes are implemented in practice is a separate question.
