The Impact of HIV/AIDS criminalization
on awareness, stigma and prevention in
Ontario: A qualitative analysis of
stakeholders’ perspectives
Brittany Greene, BHSc
Jessica Lax-Vanek, BHSc
Karen Chung, BHSc
Sofija Rans, BHSc
Allyson Shorkey, BHSc (c)
Michael G. Wilson, PhD
Conflict of Interest
• We declare that we have no conflicts of interest with
regards to this study
Background
• 1989 to 2009: 104 cases in Canada
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•
•
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65% of cases in the last 6 years
63% of cases resulted in convictions
In only 38% of convictions did transmission actually occur
65% of those charged were males in heterosexual relationships
• “leading some to describe the country as a world leader in HIVrelated criminal prosecutions”
• 1998: prominent case in Canada, R. v. Cuerrier
• established the legal requirement of disclosure when engaging in an
activity posing a “significant risk” of HIV transmission
• Charges have ranged from assault to murder
• Variety of views advocated in the media
(Mykhalovskiy et al, 2010; Mykhalovskiy, 2011)
Methods – Systematic review
• Searches: 11 databases (search terms HIV and criminal*), related article
search using a key paper (Mykhalovskiy, 2011) and reviewed reference list of
an earlier ‘rapid review’ on the topic (OHTN 2011)
• Inclusion criteria: Address HIV criminalization and its impact on or relationship
with prevention, awareness and stigma in high-income countries
• Phase 1
• Search results independently reviewed by two reviewers for inclusion
• Iteratively developed and applied coding framework to map the literature
based type of literature, study design, population, jurisdiction and topics
discussed
• Phase 2 (primary literature only)
• Data extraction (conducted by two independent reviewers)
• Quality appraisal (STROBE for quantitative article and Attree and
Milton’s checklist for the quality appraisal of qualitative research)
Methods – Qualitative study
• Sample
• Developed sample frame of executive directors, front-line workers from
community-based HIV organizations in Ontario, Canada as well as
policy/content experts
• Selected a purposive sample
• Data collection
• Conducted one-on-one telephone interviews with each participant
• Interview guide asked questions about:
• Views and experiences
• Impact (if any) on daily work/organization
• Perceived impact (if any) on HIV awareness, prevention, stigma
• Concerns about future impact
• Data analysis
• Used constant comparative methods to identify emerging themes
• Collectively revised key themes as a team after reviewing all of the transcripts and
coded the data using Nvivo-9
Results – Systematic review
• Phase 1
• Literature included: primary research, policy/advocacy papers,
theory/discussion papers, commentary/editorials and case reports
• Literature focused mainly in Canada (33%) and the United States
(30%)
• Main topics discussed: Stigma (41%), HIV-specific laws (33%),
Significant risk (32%), Justification of laws (32%) and Disclosure
(26%)
• Phase 2
• 16 primary research articles identified (11%)
• 6 quantitative studies
• 9 qualitative studies
• 1 mixed methods
Systematic review – take
home messages
• Positive effects of criminalization are unclear
• Uncertainty surrounding disclosure obligations causes
confusion for PHAs and difficulty in counselling
relationships
• Potential negative public health repercussions of
criminalization include placing sole responsibility on
PHAs and disincentivizing testing
• PHAs are wary of the legal system regarding HIV
criminalization
Results – Qualitative Study
• 14 participants interviewed (data saturation reached)
• Participant information
• Five executive directors
• Five front-line workers
• Four policy/content experts
Key Themes
• Confusion regarding behaviours constituting
“significant risk”
• Negative impact of media
• Impact on disclosure
• Perceived decrease in testing rates
• Negative impact on shared responsibility for safer sex
• Recommendation of guideline development to ensure
optimal use of criminal law
Confusion regarding behaviours
constituting “significant risk”
• “significant risk seems to be this kind of roller coaster that
doesn’t really have any firm grounding”
• “it [significant risk] really depends on the prosecutor, the
judge, the investigators…so it’s a difficult thing to educate
clients on.”
• “look at viral load, look at whether a condom was used or
not…also the importance of making sure that the law is
organic and that it can change.”
• “new prevention technologies that come up and the science
is changing so fast, that the courts need to keep up to it.”
Negative impact of media
• “it [the media] paints a picture of people living with HIV as
being sort of malicious and intend[ing] to hurt others by not
disclosing.”
• “I mean, the question is, how much coverage is there of
other HIV-related issues in the media?”
• “It [the media] just undermines the public education, it
undermines the anti-stigma campaigns, and it gives people a
very one-dimensional view.”
• “I think a lot of our clients see what’s in the media. That
can sometimes be the catalyst for coming and talking to us
about it…Sometimes, that can be the catalyst for further
isolating.”
Impact on disclosure
• “there might be people that more so do not want to disclose
to people because they are afraid…if things happen in the
relationships…they may be…criminally charged.”
• “increase in the stigma that people living with HIV face in
terms of negotiating sex between partners, consenting
partners.”
• “it does not take into account all the complexities that come
along with that [disclosure]”
• “pre-criminalization, post-criminalization, most people are
really really cautious in terms of disclosing and using
protection.”
Perceived decrease in testing
rates
• “They may be concerned that public health will now report
them. There’s a misconception of public health working
with police.”
• “won’t get tested because of fear of what will happen if
somebody finds out if they are HIV positive, and that
further can contribute to the spread of HIV.”
• “if they are positive and they’re not accessing services then
they are putting themselves at risk for their health.”
• “Whereas criminalization might put someone off, it’s
probably a fairly minor reason. So the research into testing
shows that there are quite a few other issues that are likely
higher priority in people’s lives as to testing.”
Negative impact on shared
responsibility for safer sex
• “it [criminalization] creates the illusion in the larger public
that all they need to do is rely on HIV+ people to tell them
that they’re positive and otherwise they may not have to
practice safe sex at all. And if that’s the lesson that’s being
learned…then people are actually raising their risk levels
and possibly raising transmission levels”
• “be the person who is always having to talk about this, to be
the person that has to disclose their status.”
• “you need to see that it is difficult for someone who has
HIV to disclose right up front and everybody has a
responsibility to protect each other.”
Legislative Reform
• “I think the law needs to be clarified, so the people living
with HIV know what their legal obligation is. I think that
the law needs to be interpreted and applied in a way that
takes into account advances in medical science surrounding
HIV and its transmissibility. And I think that police and
prosecutors need to be given some guidance from provincial
attorney general in the way the law should be used.”
• “if there is a role for the law it’s when there is intent around
harm and there is actual transmission of the disease.”
• “I don’t think that the prosecutorial guidelines are going to
make an impact on the frontline with police services and
police officers who are directly dealing with this who don’t
have the education and knowledge and understanding.”
Conclusions
• Further primary research is necessary to understand
the full impact of HIV criminalization laws
• Guidance and clarification is imperative within the
legal system
• Changes at the level of law enforcement and within the
media need also be addressed
• Must ensure that criminalization laws are not
hindering public health initiatives targeting awareness,
prevention and anti-stigma
Acknowledgements and
contact Information
• I would like to thank my co-authors: Brittany Greene, Karen
Chung, Sofija Rans, Allyson Shorkey and Mike Wilson
• We are grateful to the Bachelor of Health Sciences program
at McMaster University for providing funding to attend and
present this work at AIDS 2012.
• Further questions or comments please contact:
• Jessica.lax.vanek@learnlink.mcmaster.ca