HIV update - 6th June 2019

HIV criminalisation continues

HIV criminalisation is the application of the criminal law to people living with HIV based on their HIV-positive status. At least 75 countries still have laws that target people living with HIV specifically, or which punish people more harshly because of their HIV status. Such laws typically criminalise non-disclosure of HIV status to a sexual partner, potential or perceived exposure to HIV, or transmission of HIV.

Other countries don’t have HIV-specific laws, but still criminalise people living with HIV. For example, in England & Wales the ‘reckless’ transmission of HIV may be prosecuted under a law dating back from 1861 known as the Offences Against the Person Act.

A global review has found that in the last four years there have been HIV criminalisation cases in at least 49 countries, affecting close to 1000 people. Some countries are much harsher than others, having a disproportionate number of cases of HIV criminalisation than other countries, considering the number of people living with HIV in the country.

By far the worst HIV criminalisation hotspots are Belarus and the Czech Republic.

But also on the list are New Zealand, Canada, Sweden, Russia, Taiwan, Ukraine, Australia, Switzerland – and England & Wales.

The worst region for having laws that specifically target people living with HIV is sub-Saharan Africa, but it seems that not so many arrests or prosecutions actually occur there.

And the report identifies a number of places where unjust laws have been repealed, modernised or withdrawn. They include the Australian state of Victoria, the Democratic Republic of Congo, Belarus (within the last few months), several states in the US, Malawi and Mexico.

For more information on the law in England & Wales, read NAM’s leaflet, ‘Transmission and the law’.         

People living with HIV may have an increased risk of arthritis

Arthritis affects the joints, especially the knees, hips and the small joints in the hands, causing stiffness, pain and inflammation. Osteoarthritis is the most common form of arthritis, affecting approximately 250 million people globally and is related to ageing, with additional risk factors of high blood pressure, diabetes and obesity.

A small US study has reported an increased risk of cartilage damage in the knee associated with HIV infection and antiretroviral therapy. Cartilage is a tissue found throughout the body, covering the surface of joints and acting as a protective cushion. The study aimed to look at changes to the knee cartilage over eight years and was based on ten HIV-positive participants who had been on HIV treatment for at least 12 months with a comparison group of 20 people not living with HIV. The participants were matched for sex, race, age and body size. The baseline tests showed that the group of people living with HIV already had higher markers of damage, including fat pad abnormalities and more fluid around the knees.

Over the eight-year study, people living with HIV experienced greater deterioration to the knee cartilage and increased knee joint inflammation, but there were no significant changes to the structure of the knee. As this was a small study there is a need for further research in a larger group to confirm these findings.

The study highlights the impact of long-term HIV treatment, inflammation and co-morbidities on people living with HIV as they age. It also shows the importance of following general health recommendations, such as losing weight, avoiding joint injuries and getting regular exercise. If you’re concerned about any symptoms from joint pain, please speak to you doctor.

Access to treatment in African countries

Two recent studies highlight significant problems with access to effective antiretroviral medicines in African countries.

In the first, researchers telephoned over 2000 health facilities in South Africa that care for people living with HIV. One in five had a stockout (a complete absence of a specific medication) of at least one drug on the day they were called. Over a third reported stockouts in the previous three months. These included absences of first-line drugs, second-line drugs and dosages for children.

Most stockouts lasted for more than a month. They resulted in people not receiving any HIV treatment, not receiving all their treatment, or being switched to a different regimen, dosage or formulation.

The second study highlights delays in switching to a new combination of antiretroviral drugs after the treatment has stopped working. Current guidelines say that doctors should change people’s medication only after two viral load tests – three months apart – show a viral load above 1000 copies/ml.

This is meant to reduce pressure on healthcare budgets. Although people are offered adherence support while waiting for the second test, this only results in a minority of people getting their viral load down, probably because most already have drug resistance.

The researchers forecast that if African countries switched patients to second-line drugs after a single viral load above 1000 copies/ml (rather than waiting for a second test to confirm the result), people with these high viral loads would have 31% fewer serious illnesses due to HIV and 18% fewer deaths due to HIV.

PrEP use amongst black MSM is stigmatised

Black men who have sex with men (MSM) in the midwest of the United States experience intersectional stigma at multiple levels: interpersonal, community and structural. As a result, they are less likely to use pre-exposure prophylaxis (PrEP), researchers have found.

The qualitative research was conducted against the backdrop of huge inequalities in HIV in the US. Half of black MSM are projected to acquire HIV in their lifetime. Of the 1.1 million who could benefit from PrEP, 45% are black MSM, yet only 11% of those currently using PrEP are black MSM. Focus groups were held with 44 black MSM in Milwaukee, Wisconsin, a city with stark racial disparities.

The results highlight how intersectional stigma contributes to low PrEP uptake for black MSM through mistreatment in healthcare services, racism, homophobia and structural inequalities. PrEP was “known as a gay pill” and therefore seen as a marker of sexuality. The co-occurring identities of HIV status, race, age, disability and sexual orientation collectively deter black MSM from seeking out PrEP as a means of preventing HIV.

Participants said that, as black MSM, they anticipated and experienced stigma from healthcare providers, based on race, sexuality or both, and tended to receive sub-standard healthcare services, which contributed to their hesitancy accessing PrEP. Other factors such as inequality and barriers in accessing health care compared to their white counterparts contributed, as the men cited competing priorities such as poverty, unemployment and racial segregation. Over two-thirds of the participants earned less than $10,000 per year. This resulted in PrEP dropping down black MSM’s priority list.

The researchers note that “An important distinction to make is that it is not an individual’s intersecting identities that contribute to marginalization, but rather the social positions, privileges, power, and oppression (e.g. racism, classism, heterosexism) associated with those identities that contribute to inequalities.”

Significantly, HIV stigma and its consequences were so profound that even being considered at risk for HIV and using PrEP to prevent infection was seen as problematic, as most participants still saw condom use as the “correct” way to gain protection from HIV.

There was an ‘othering’ and stigmatisation of people living with HIV during the discussions. PrEP users were closely linked to men who had become infected with HIV as a result of having condomless sex. MSM who chose not to use condoms, opting for prevention using PrEP, were seen as irresponsible.

For more information on PrEP, read NAM's factsheet.