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08 luke swenson criminalization

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  • Estimated community plasma HIV-1 RNA concentrations and HIV incidence density, with 95% confidence intervals, among two parallel cohorts of injecting drug users. HIV incidence first estimated in second half of 1996 as enrolment started in May 1996 and repeat HIV tests to assess incidence were available only after six months of follow-up
  • Transcript

    • 1. Criminalization of HIV Non-Disclosure Luke Swenson BC Centre for Excellence in HIV/AIDS YouthCO HIV and Hep C Society
    • 2. Outline
      • General discussion
      • Potential unanticipated consequences of criminalization
      • What is significant risk?
      • Effect of viral load
      • Alternatives to criminalization
    • 3. Criminalization of HIV non-disclosure
      • A number of different charges
        • Assault -> Sexual assault
        • “ Assault” because HIV non-disclosure = fraud according to the law and invalidates consent
      • Can be charged with aggravated sexual assault
        • “ endangers the life of the complainant”
        • Life imprisonment
    • 4. Show me the evidence…
      • Convicting people with HIV of
        • serious crimes,
        • with sentences of up to life in prison, and;
        • publicizing their private health information
      • Should not be taken lightly
      • If our justice system is going to be applying punitive measures against people with HIV…
        • Where ’ s the evidence that it works?
        • Is it a deterrent?
        • Does it decrease transmission?
    • 5. Is the law a deterrent?
      • No evidence that criminal prosecutions are a deterrent to risky behaviour
      • “ Heat of the moment” decisions may not factor in threat of criminal charges
      • No evidence that people in places with non-disclosure laws practice safer sex
        • Burris, Arizona State Law Journal 2007
        • Horvath, AIDS Care 2010
      • Concerns that criminalization deters engagement with health care + public health
        • Mykhalovskiy Soc Sci & Med 2011
    • 6. Wrong targets?
      • The criminal approach only targets people who know they are positive
      • Transmission rates likely much higher in people unaware of their status (PHAC, Estimates of HIV prevalence and incidence in Canada, 2009)
      • A large proportion of infections likely arise from acute infections
        • Unknown serostatus
        • Very high viral load
    • 7. Imprisonment
      • Imprisoning people with HIV may actually lead to more infections
      • Limited harm reduction practices in prison
        • Poor access to condoms, clean needles, rigs
        • Needle sharing (Werb J Pub Health 2008)
      • Poor access and adherence to HAART in prison (Milloy JID 2011)
        • Potentially more infectious
    • 8. Why only HIV?
      • Why is HIV essentially the only health condition that is criminalized in Canada?
        • (3 cases with HBV, HCV, HSV, but no convictions)
      • Human papilloma virus
        • Risk of cervical cancer, other cancers
          • Yet, no charges
      • Influenza – 2000-4000 Canadians die each year
      • Issues with
        • HIV panic and stigma
        • Misinformation/changes in the consequences of living with HIV
        • Misinformation around HIV transmission (significant risk)
    • 9. Misinformation
      • HIV not a death sentence!
      • Currier case: legal decisions from 1997 around HIV were made in a completely different context
      • 1997
        • Only 1 year since HAART first rolled out
        • Limited and toxic treatment options
        • High drug resistance
      • 2011:
        • 25+ antiretroviral agents
        • One-pill QD complete treatment options
        • Declining resistance (Gill CID 2010)
        • Increasing life expectancy, comparable to other chronic conditions (Hogg Lancet 2008)
    • 10. What is significant risk?
      • Cuerrier decision states that charges can be laid if there was a “significant risk” of transmission
      • “ Riskiest” risk of HIV transmission (receptive anal sex with someone with HIV) actually has a relatively low per act risk
        • ~0.5%
        • Receptive vaginal sex even lower risk of ~0.1%
      • Oral sex almost negligible
        • (Division of HIV/AIDS Prevention, National Centre for HIV, STD, and TB Prevention, CDC Atlanta Georgia et al, 2005)
    • 11. Significant risk
      • Consistent condom use is >90% effective at preventing HIV transmission (Pinkerton Soc Sci Med, 1997)
      • Yet the law is still not completely clear about whether even sex with a condom constitutes significant risk
      • Seropositioning?
      • Contradictory advice from public health, primary health providers and the law (Mykhalovskiy Soc Sci & Med 2011)
      • There should be alignment of public health messages and the law
    • 12. Consequences of criminalization
      • Knowing your HIV status now comes with a set of responsibilities punishable by life in prison
      • Potential to deter people from getting tested
        • “ If you don’t know your status, you can’t be charged”
    • 13. Viral load
      • The risk of transmission decreases alongside decreases in viral load
      • People with naturally lower viral loads are less likely to transmit
      • Does unprotected sex with an undetectable viral load count as significant risk?
      • Some cases VL <50 accepted as valid defence. BUT, one case where judge actually said that the accused used undetectability to shirk disclosure -> maximal sentencing (O’Byrne, Sex Res Soc Policy, 2011)
    • 14. Naturally low viral loads associated with reduced transmission Quinn NEJM 2000
    • 15. Estimated community plasma HIV-1 RNA concentrations and HIV incidence density, with 95% confidence intervals, among two parallel cohorts of injecting drug users. Wood E et al. BMJ 2009;338:bmj.b1649 ©2009 by British Medical Journal Publishing Group Community viral load
    • 16. Viral load
      • “ Swiss statement”
        • Vernazza et al. Schweizerische Ärztezeitung / Bulletin des médecins suisses / Bollettino dei medici svizzeri /2008; 89:5
      • An HIV-infected individual without additional STD and on anti-retroviral therapy (ART) with completely suppressed viremia (in the following: “effective ART”) is sexually non-infectious , i.e. he/her cannot pass on the Human Immunodeficiency Virus through sexual contact as long as the following conditions are fulfilled:
        • The HIV-infected individual complies with the anti-retroviral therapy (ART), the effects of which must be evaluated regularly by the treating physician;
        • The viral load (VL) has been non-detectable since at least six months (i.e. viremia is suppressed);
        • There are no additional sexually transmitted diseases (STD) present.
    • 17. HPTN 052 Treatment sharply reduces transmission
      • 1763 serodiscordant couples
      • 96% reduction in infections when positive partner was treated
      • Treatment of HIV prevents its transmission
    • 18. What about disclosure with other positive people
      • It is unclear in the law whether disclosure of one ’ s HIV status is necessary if the partner is also positive
      • Unclear on the risk of “superinfection” (re-infection)
      • But probably quite low
        • NO superinfections in group of 15 gay men followed for ~6 years (Rachinger JID 2011)
        • Only ~16 cases of superinfection ever reported (Smith JID 2005)
        • Significant risk?
    • 19. Alternatives
      • UNAIDS recommends limiting to cases only where there was intentional transmission
      • Rather than criminal prosecutions, other policies could have a more substantive effect on decreasing HIV transmission
      • Universal precautions in healthcare settings
        • Why not universal precautions for sex?
      • Education, counselling on risk reduction, reducing substance use
      • Normalizing discussion about HIV