Sexual Health, HIV/STI
and Human Rights
Dean’s Lecture
March 5th, 2008
Chris Beyrer MD, MPH
The Center for Public Health and Human Rights
Johns 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 Domains
Migration
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:
Respect
Protect
Fulfill
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 I
Migrant Populations and STI
Risks
Epidemiology of Migration and HIV/STI
Association with Migration
Gender Country
Precision
South Africa
Magnitude
OR = 2.4
Odds of HIV infection among migrants to Gold
Mines
Male
Odds of being infected outside of primary
relationship compared to inside
Male
South Africa
OR = 26
p<0.01
95% CI = 1.1 - 5.3
(migrants)
OR = 10
p<0.0001
(nonmigrants)
Odds of being infected outside of primary
relationship for female partners of migrating
men compared to inside
Female
South Africa
Odds of HIV acquisition associated with >14
occupational travel days per month
Male
Kenya
OR = 2.8
95% CI 1.5 - 5.4
Odds of HIV infection for rural to urban migrants
Male
GuineaBissau
aOR = 2.1
95% CI 1.06 - 3.99
Odds of HIV infection for rural women reporting Female
casual sex in urban settings vs only rural settings.
GuineaBissau
aOR = 5.6
95% CI 1.56 - 20.15
Odds of HIV infection among Nepalese migrants
to India compared to non-migrants
Nepal
OR = 4.1
95% CI = 0.51 - 33.5
OR = 2.0
p=0.17
(partner of migrants)
Male
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
1
Knowledge about Condoms
Condom Usage
0.9
Thai Nationals
Burmese Migrants
0.8
0.7
0.6
P<0.05
0.5
0.4
0.3
0.2
0.1
0
Males
Men
Females
Women
Males
Men
Females
Women
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
Source: Mullany et al, AIDS Care, 2003; Lertpiriyasuwat et al, AIDS, 2003;
Leiter et al, Health & Human Rights, 2006
Migration, Residency, and Access
We studied 483 female Sex Workers in Moscow, Russia, in 2004-2005
STD were common




Syphilis
CT
GC
HIV
 Any STD
15.8%
18.4%
2.9%
3.1%
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
China has more than 120 million rural-to-urban migrants
Source: Tucker et al, AIDS, 2005
Forced Migration: Operation Murambatsvina or
“Clear the filth” Porta Farm, Zimbabwe
June 22, 2002
Source : © Digital Globe, Inc., Amnesty International 2006
April 6, 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 Area
Estimated adult
population size
in 2001
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
Estimated % of
adult population
displaced
Estimated adult
population size in
April/May 2004
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
Qualification
2001
2004
Reduction
(%)
2001
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)
912
114
798 (88)
108
108
326 (75)
533
62
471(88)
Total
Source: Betsi , N. et al., AIDS Care, 18:4,356-365
Reduction
(%)
# of health staff in
West Cote I’voire
2004
2001
Reduction
(%)
2004
Total Number of Cases of STIs Recorded by Health
Staff and NGOs
Baseline situation in
2001
Situation in the period between
April ’03 – April ‘04
Total # of STIs
# of STIs
per 1,000 adults
Total # 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
Study Area
Source: Betsi , N. et al., AIDS Care, 18:4,356-365
HIV/AIDS Studies Initiated, DRC, 1982-2004
0
5
Studies
10
15
20
Figure 1. HIV/AIDS studies initiated, Democratic Republic of Congo, 1982 - 2004
1980
1985
1990
1995
Year
Lowess smoothed curve with bandwidth 0.3
Source: Beyrer , C. et al. Civil conflict and health information: The Case of DR Congo.
Public Health & Human Rights: Evidence Based Approaches, 2007
2000
2005
JHU Press, 2007
Conflict and STI
STI
•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
STI
•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 20052007 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 Populations
MSM
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
Clash of
Cultures in
Russia
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
June, 2007 Moscow in protest in response to
Moscow’s mayor, Yuri M. Luzhkov, calling gay
protests “satanic acts.”
Structural Violence:
Proportion of STI Prevention Expenditures Targeted at MSM
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%
Source: USAID, 2006
HIV and Unrecognized Infection among MSM
Baltimore (2004-2005)
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
63.0%
51.5%
13.0%
HIV +
p-value <0.001
White MSM
African American MSM
15.4%
Unrecognized
Infection
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).
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
Abstinence Only Sexual Health Education
Consistent with human rights principles?
Autonomy
Privacy
Confidentiality
Informed consent
Choice
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
Acknowledgements
Johns Hopkins
Stefan Baral
Nancy Kass
Nicole Franck Masenior
Luke Mullany
Frank Sifakis
Amy Tsui
Jonathan Zenilman
Open Society Institute
Jonathan Cohen
Francois Girard
Sisonke Msimang
John Fisher ARC Intl
Shiv Khan Naz
Foundation
Sunil Pant Blue Diamond
Ed Mills
Univ. BC