Photo: Darren J Sylvester/flickr

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AFRICA: Will criminalising HIV transmission work?Countries in sub-Saharan Africa are looking at a new way of preventing HIV infections: criminal charges. But experts argue that applying criminal law to HIV transmission will achieve neither criminal justice nor curb the spread of the virus; rather, it will increase discrimination against people living with HIV, and undermine public health and human rights.

UNAIDS has urged governments to limit criminalisation to cases “where a person knows his or her HIV-positive status, acts with the intention to transmit HIV, and does in fact transmit HIV”. The reality is that intentional and malevolent acts of HIV transmission are rare, so in most instances criminal prosecutions are not appropriately applied.

In Switzerland, a man was sent to jail earlier in 2008 for infecting his girlfriend with HIV, even though he was unaware of his HIV status, and a Texas court recently sentenced a man living with HIV to 35 years in prison for spitting on a police officer, although the chances of the officer being exposed to the virus were negligible.

Laws making HIV transmission an offence are not new to the developed world, but the trend has been growing in African countries, where higher prevalence levels make such laws all the more attractive to policymakers.

“Africa has burst into this whole frenetic spasm of criminalising HIV,” said South African Justice Edwin Cameron, who is also HIV positive, at the International AIDS Conference in Mexico earlier this year.

In Uganda, proposed HIV legislation is not limited to intentional transmission, but also forces HIV-positive people to reveal their status to their sexual partners, and allows medical personnel to reveal someone’s status to their partner.

Most legislative development has taken place in West Africa, where 12 countries recently passed HIV laws. In 2004 participants from 18 countries met at a regional workshop in N’djamena, Chad, to adopt a model law on HIV/AIDS for West and Central Africa.

The law they came up with was far from “model”, according to Richard Pearshouse, director of research and policy at the Canadian HIV/AIDS Legal Network, who maintains that the model law’s broad definition of “wilful transmission” could be used to prosecute HIV-positive women for transmitting the virus to their babies during pregnancy.

People living with HIV have expressed concerns that the growing trend to criminalise HIV infection places legal responsibility for HIV prevention solely on those already living with the virus, and dilutes the message of shared responsibility.

UNAIDS has warned that using criminal law in cases other than intentional transmission could create distrust in relationships with healthcare workers, as people may fear the information will be used against them in a criminal case. Such laws could also “discourage HIV testing, since ignorance of one’s status might be perceived as the best defence in a criminal law suit.”

Some policymakers have called for HIV legislation as a means to protect women from HIV infection, but the irony is that sometimes these laws may result in women being disproportionately prosecuted. Many women find it difficult to negotiate safer sex or to disclose their status to their partner.

What are the alternatives? UNAIDS recommends that instead of applying criminal law to HIV transmission, governments should expand programmes proven to have reduced HIV infection. At the moment, there is no information indicating that using criminal law will work.

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source.www.irinnews.org

GLOBAL: Male circumcision – a gamble for women?

Photo: UNAIDS/P.Virot

Whether women’s HIV risk will be lowered by male circumcision programmes is not certain

MEXICO CITY, 8 August 2008 (PlusNews) – While researchers and advocates at the International AIDS Conference this week urged donors and governments to rapidly scale up male circumcision programmes, others raised concerns about what this would mean for women.

In March 2007, the World Health Organisation and UNAIDS issued recommendations that gave the green light to male circumcision as an HIV prevention strategy, after studies in Kisumu, Kenya and the township of Orange Farm in South Africa showed that it could reduce the risk of infection by up to 60 percent.

But the recommendations also stressed that not enough is known about whether male circumcision reduces sexual transmission of HIV from men to women, making the intervention “highly problematic” according to Marge Berer, editor of the London-based journal Reproductive Health Matters. “From a public health perspective, we are told that 60 percent protection [for circumcised men] is far better than nothing. But is male circumcision good enough for women?” she wondered.

A study of almost 3,000 men between the ages of 18 and 24 in Kenya, compared sexual function between circumcised and uncircumcised men, assessing sexual satisfaction over a two-year period. The researchers found that the circumcised group had no higher rates of sexual dysfunction than the uncircumcised men.

According to John Krieger of the University of Washington, Seattle the men that had been circumcised reported more sexual pleasure post-circumcision, and that they found condoms easier to use.

No one is going to pull out the red carpet for women’s involvement in male circumcision…it is up to women to stop being victimsÂ

In addition, new results from a male circumcision initiative implemented by Population Services International in Zambia suggest that cultural resistance may not pose as serious a barrier as previously thought, and that it is possible to do the procedures safely and effectively in poor settings, using nurses and clinical officers.

Delegates heard that circumcision also lowers the risk of men getting the human papilloma virus (HPV) that causes genital warts, and trichomoniasis, another common sexually transmitted disease.

What about women?

“All I’m hearing [at the conference] is about what it will do for men, the sexual satisfaction of men…but what about the women? What is their involvement?” commented Siphiwe Hlope, a founder of Swazis for Positive Living (SWAPOL), an AIDS support organisation.

Nicolai Lohse a research officer at UNAIDS said mathematical modelling showed women would benefit from male circumcision as long as it did not result in condom use dropping by more than two-thirds. Women’s risk of acquiring HIV would also be reduced if circumcision programmes led to fewer HIV-positive men in the population. The risk to women of HIV acquisition would decline by 2 percent if only 5 percent of men were circumcised, and by 20 percent if half the men in a population were circumcised.

While Berer told delegates on Thursday that the potential benefits of male circumcision were “too large a gamble” for women, many countries in Southern Africa are already in the process of developing national policies on the procedure.

“We have to support these programmes, I don’t think we have a choice. But one would really argue that these programmes have a responsibility to women,” Berer told IRIN/PlusNews.

She called for campaigns expanding male circumcision to involve couples and not to focus solely on men. Women health advocates also had a role to play in drafting national policies. “No one is going to pull out the red carpet for women’s involvement in male circumcision …it is up to women to stop being victims,” Berer added.

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KENYA: Testing from door to door

Photo: Glenna Gordon/IRIN

So far, more than 45,000 people have been tested

TURBO, 17 February 2009 (PlusNews) – Joel Kirwa, a farmer in Rift Valley Province, western Kenya, has never been tested for HIV; he is usually too busy tending his cattle and fields and rarely visits Turbo town, where the nearest voluntary counselling and testing (VCT) centre is located.

Today, however, a health team is going from door to door in his area, offering HIV counselling and testing to every household. “Home testing is very helpful – it is private, so your results and even the fact that you tested are hidden … in the normal VCT centres you can meet people who know you and will talk about you,” he told IRIN/PlusNews.

Kirwa and his wife were both HIV negative, and he proudly displayed the ‘certificate’ the counsellor gave him as proof of his status.

The Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) ran a pilot project in the Rift Valley Province’s Kosirai Division in 2007, testing 19,000 out of 20,000 eligible people. The official programme has been running since August 2008.

“Prior to the start of HCT [home-based counselling and testing], a majority of the HIV patients have been presenting to the clinic late, when their CD4 cell count [a measure of immunity] is low and they are unable to work,” Dr Samson Ndege, the project coordinator, told IRIN/PlusNews.

AMPATH is conducting tests in Turbo, in Uasin Gishu District, and Mautuma, in Lugari District, which have a total population of about 120,000; so far, 45,000 people have been tested, of which 1,483 have been HIV positive.

Anyone over the age of 13 is considered eligible for testing, as well as children under 13 whose mothers are positive; parental consent is required before children can be tested. Personal digital assistants (PDAs) are used for data collection, and coordinates indicating the location of households are marked using a global positioning system.

AMPATH uses community mobilizers, selected by local chiefs, to go from door to door, telling people about the importance of being tested ahead of the counsellor’s visit.

“People have become much more receptive and less suspicious,” said Peter Musili, a nurse and counsellor with AMPATH. “The word of mouth from those previously tested has been very useful.”

Teething problems

Counsellors often have to visit homes more than once. “Many men are normally away from home and may not be found the first time the counsellors visit their homes. It was also difficult to find school-going children at home,” Ndege said.

“We encourage them [counsellors] to make appointments, so that couples can be counselled together during subsequent visits. We have also made arrangements so that visits can be made over the weekend to find children who are day-scholars,” he added.

Photo: Julius Mwelu/IRIN

“Home testing is very helpful – it is private

“Getting couples to test together has been challenging, especially given the high rate of discordance [when only one of them is positive]. Getting those individuals who test positive to go to the clinic has also been difficult – couples who were not tested together may have problems disclosing their status to their partners.”

A recent national survey found that 43.8 percent of HIV-infected married or cohabitating people had an uninfected partner, but more than three-quarters of all respondents who were part of a couple did not know their partner’s HIV status.

Benefits beyond HIV

AMPATH is providing every home in the area with mosquito nets and deworming tablets for children, while counsellors are also collecting data on immunisation and referring parents to health centres where children can be vaccinated.

“We also collect sputum for TB [tuberculosis] tests from individuals who have had coughs for more than two weeks or those who report night sweats and fever,” Ndege said.

Door-to-door testing was successfully piloted in Bushenyi District, in western Uganda, between January 2005 and February 2007, reaching 63 percent of all households. A study on the impact of the programme found that the benefits of home counselling and testing were far-reaching.

“Aside from expanding coverage, door-to-door VCT may significantly improve stigma and disclosure of serostatus, and may also have a prevention effect through improvements in HIV risk behaviour,” the authors concluded.

Kenya traditionally relies on voluntary counselling and testing, in which patients visit VCT centres on their own initiative, but official figures estimate that 63.5 percent of Kenyans have never been tested for HIV.

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SUDAN: Alice Tabu, “At times we wear polythene bags in place of gloves to deliver babies”

LUI, – Southern Sudan’s healthcare system is almost non-existent in many areas after a 21-year war with the north, and health workers are regularly forced to work with minimal medical supplies. Alice Tabu, 24, a midwife at a hospital in Lui in Western Equatoria State, talked to IRIN/PlusNews about the challenges of working in such conditions.

“I have worked as a midwife since 2004. My duties include counselling pregnant mothers coming for antenatal clinic visits, treatment, or to deliver [their babies]. I counsel them on primary healthcare, proper nutrition and about HIV/AIDS.

“Some have no problem at all with the requirement for the HIV test [part of prevention of mother-to-child transmission services] but some are reluctant and will ask for more time to consider, and never return to the clinic.

“I even ask them to bring along their husbands to test together, but the majority of men never accompany their spouses to the clinic or for the HIV test.

“The men say: ‘If I have HIV, it is already in the body and I don’t care; not much can be done to help me out’. I think it is out of ignorance they behave this way.

“Once the HIV results are out, I discuss it with [the mother], explaining what being positive or negative means. But counselling is the easy part; we at the maternity [section] are overworked and facing a big shortage of supplies and, most critically, gloves.

“At times we conduct deliveries without the protection of gloves, when we have none in the maternity ward and the clients don’t carry their own, putting us at risk of contracting HIV.

“At times we wear polythene bags in place of gloves. The last time I had my own gloves was when there was a donation from UNFPA [United Nations Population Fund]. Only last December [2008], I conducted a delivery without gloves.

“It was around midnight when I was on duty alone that a woman went into labour. When I went to examine her she was already pushing, so I went ahead, held the baby in my hands, and also cut the umbilical cord without gloves.

“Even after I checked her hospital card and confirmed she had been screened for HIV, hepatitis B and syphilis, and all found negative, I still had doubts and fear deep inside me. I had an HIV test just to make sure I am free from the virus.

“Next time a mother comes to the labour ward without her own set of gloves, I may not assist, lest I risk losing my life in the event she is HIV positive.”

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source.www.irinnews.org