Recent proposals to change HIV counseling and testing protocols rest on claims that current laws incorporating informed, written consent are interfering with the testing and treatment that would eliminate racial disparities, and so need to be ?modernized.? But will eliminating virtually all provider-patient communication, and written proof of informed consent, result in earlier, better and sustained access to HIV treatment and medical care, and better outcomes for people of color in this country? The available evidence strongly indicates that the proposed plan is unsupported and unsound. This is so because 1) the plan is not evidence-based, i.e., based on demonstrable evidence that counseling, consent and confidentiality procedures are in fact discouraging patient care; and 2) the evidence strongly suggests that in fact the proposals will worsen racial disparities in access to and initiation and maintenance of, appropriate and life-prolonging treatment. Fortunately, as this report makes clear, the evidence also shows that there are a number of initiatives that likely would make a significant dent in these disparities, and in HIV-related stigma, consequently saving and improving many thousands of lives.
The Kaiser Family Foundation commissioned a racially diverse group study of lower-income women with HIV/AIDS in Philadelphia, Los Angeles, Miami and Savannah to hear directly from them about their lives and the challenges they face in obtaining a full-range of health care services. The specific issues addressed were barriers to receiving care, interactions with the health care system, relationships with providers, challenges unique to women, knowledge level about their illness, effects of HIV/AIDS on other aspects of their lives and the information they need and sources they trust.
Ideas for improving access to quality health care were distilled from the womens insights. First, time of diagnosis is a critical moment to inform, support and connect women with HIV/AIDS services. How women were told about their status affected when and if they sought treatment. Second, gender specific services should be available to women such as mental health support, child care assistance, transportation and access to female providers. Third, women who were connected to local AIDS services organizations, services and networks of information had better health care experiences. Fourth, making Medicaid available to more women with HIV/AIDS and continuing to support ADAP. Fifth, use providers, peers, internet, TV/radio to inform women about HIV/AIDS and especially to reach out to Latinas with HIV/AIDS.
Although not mentioned in the conclusions, a persistent problem for women with HIV is the stigma and prejudice they face from health care professionals who are not HIV specialists. Women still experience denial of services from dentists, gynecologists and general practitioners after disclosing their status. Stigma, and perception of social risk, affects when and whether women disclose their status or pursue and receive care for a multitude of health issues. This study highlights the imperative that all health care professionals be trained and educated about HIV/AIDS issues.
This study compared health indicators, health status, behavioral risks and access barriers among self-identified African American, Hispanic, Asian-Americana and white lesbian/bisexual and heterosexual women in Los Angeles county. Among the racial groups, regardless of sexual orientation, African American, Hispanic and Asian American women had worse health outcomes than white women for example, less access to preventative services. Hispanic and African American women overall had lower life expectancies, higher death rates from heart disease and greater levels of overweight and obesity than white women. The effect of sexual orientation across racial groups, however, is that self-identified lesbians and bisexuals are less likely to receive preventative health services, more likely to be overweight and more likely to engage in risky behavior such as smoking and heavy alcohol consumption than their heterosexual counterparts. The results of the study underscore the importance of considering factors that are not recognized as influential in womens health such as sex, social, cultural and economic power. More studies that capture sexual orientation as a health factor are needed.
Testimony presented at NY State Assembly Health Committee Hearing considering bills, as well as the proposed CDC guidelines, to institute routine testing and to eliminate most pre-test counseling, informed written consent, and post-test counseling of people who test negative on HIV tests. The Center for HIV Law and Policy and Dr. Jeffrey Birnbaum, Director of HEAT (a multidisciplinary adolescent AIDS clinic), addressed three primary points in their testimony:
1) Pending proposals to change NY law on HIV test counseling and proof of consent, particularly without clear plans for linkage to care, may expose providers to liability under a variety of other governing laws and legal/ethical principles;
2) The available evidence indicates that existing racial disparities in HIV care are likely to be exacerbated by elimination of pre-test counseling and proof of informed consent as a predicate to HIV testing;
3) There are multiple models demonstrating the efficacy and feasibility of HIV pre- and post-test counseling and informed, written proof of consent as routine components of HIV testing regimens.
Slide Presentation for Summit on Opportunities for Improving HIV Diagnosis, Prevention, & Access to Care in the U.S., Nov. 29-30, 2006; addressed areas of potential legal liability raised by implementation of September, 2006 CDC Guidelines on HIV testing.
Critics of U.S. penal policies contend that incarceration has exacerbated the HIV epidemic among blacks, who are disproportionately represented in the prison population, accounting for 40% of inmates. This New England Journal of Medicine article examines the facts, perceptions, and some proposed solutions to the HIV epidemic -- and the behaviors and policies that drive it -- occurring behind bars.
As this article discusses, both the World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) have recommended for more than a decade that condoms be made available to prisoners and that measures for clean needles be implemented. Several Western European countries, as well as Canada, Australia, Indonesia, and Iran, have adopted some or all of these harm reduction approaches and have seen no increase in drug use or new cases of HIV infection. The prohibition of condom availability, absence of needle exchange programs, and inadequacy of HIV diagnosis, treatment and programs for reducing high-risk behavior before and after release have resulted in continued rising rates of HIV infection in the U.S. prison system. Theodore M. Hammett of Abt Associates, a Massachusetts-based policy research and consulting firm, is with the Domestic Health, Health Policy, and Clinical Research Division. According to Hammett, adoption of HIV-prevention measures is long overdue. Condoms ought to be widely available in prisonsFrom a public health standpoint, I think theres little question that that should be done. Methadone, also all kinds of drug [abuse] treatment should be much more widely available in correctional settings. As Robert Fullilove of Columbia Universitys Mailman School of Public Health puts it, The issue has never been, do we understand what has to happen to reduce the risks? Its always been, do we have the political will necessary to put what we know is effective into operation?
Over 50 diverse non-profit organizations including the Center for HIV Law and Policy, HIV/AIDS service organizations, reproductive rights advocates, womens and other policy organizations and religious groups together submitted a letter to the members of the State-Foreign Operations Appropriations Conference Committee, asking that they maintain the Senate-approved $461 million funding level for bilateral family planning and reproductive health programs and urging them to also adopt the $40 million contribution for the United Nations Population Fund as recommended by the House of Representatives.
The United States has fallen behind on its efforts to improve global health when adjusted for inflation, current U.S. funding is 41% below FY 1995, yet since that time the number of women of reproductive age in the developing world has increased by approximately 275 million women. These women and men lack access to basic reproductive health care such as contraception (reducing the number of unwanted pregnancies and, therefore, reducing the number of abortions), prenatal and pediatric care, and HIV prevention services and testing.
Given the steep funding reductions that have taken place over the last decade, the minimal but critical increase called for by the Senate is warranted
In a case brought by the Brennan Center for Justice at NYU School of Law, two organizations (AOSI and Pathfinder International) that received funding under the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (the Leadership Act) sued the U.S. Agency for International Development (USAID), among others, seeking to enjoin their narrow reading of the Leadership Act’s provision requiring funded organizations to have a policy expressly opposing prostitution and sex trafficking. In May, 2006, the U.S. District Court for the Southern District of New York ruled that this requirement violated the organizational plaintiff’s First Amendment rights, restricting their privately-funded speech and forcing them to adopt the U.S. government’s views in order to be eligible for funding. The opinion may also be useful to those looking for a source in which to discuss HIV among marginalized groups. The opinion discusses the larger context in which the debate takes place, citing the high rates of HIV among some populations sex workers and the difficulties in reaching this marginalized community.
The Court of Appeals for the Second Circuit remanded in view of proposed new HHS and UNAIDS guidelines to determine whether a preliminary injunction is appropriate. In February 2008, the plaintiffs filed an amended complaint to add Global Health Council and InterAction (international development and public health groups) as plaintiffs; Global Health Council and InterAction then moved for a preliminary injunction on behalf of their members. HHS represented to the court that its July 2007 guidelines will go through a notice and comment process by April 2008, after which the court will assess the constitutionality of the revised guidelines. For copies of pleadings and other information, go to http://www.brennancenter.org/content/resource/aosi_v_usaid/
The Convention on the Elimination of All Forms of Racial Discrimination (“CERD”) is an international treaty designed to protect individuals from discrimination based on race that is both intentional or the result of neutral policies. Particularly relevant to HIV/AIDS issues are: the requirement that state parties take concrete measures in social, economic, cultural, and other fields to ensure the adequate development and protection of certain racial groups or individuals belonging to them for the purpose of guaranteeing them the full and equal enjoyment of human rights and fundamental freedoms (Article 2); and the requirement that state parties undertake to prohibit and eliminate racial discrimination in all its forms and to guarantee the right of everyone to equality before the law in the enjoyment of rights including the right to work and to free choice of employment, the right to housing, the right to public health, medical care, social security, and social services, and the right to education and training (Article 5).
As a treaty, CERD is binding on all parties that ratify it; those who sign but do not ratify it are obligated not to act contrary to the purpose of the convention under Article 18 of the Vienna Convention. State parties must submit periodic reports to the Committee on the Elimination of Racial Discrimination detailing how they are giving effect to CERD. Moreover, under Articles 11-13, if a state party is not giving effect to the provisions of CERD, another state party may bring this to the attention of the Committee, which will collect information from the relevant state parties and, if the dispute cannot be reconciled, will form an ad hoc commission to investigate and issue recommendations. Under Article 14, a state party has the option of allowing the Committee to receive and consider complaints from individuals claiming that the state party has violated their rights under CERD, and the Committee will issue recommendations to the state party accordingly.
The United States has ratified CERD, but has not exercised the option set forth in Article 14.
