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National Policy on HIV: An Analysis of How Laws And Policies of a Nation Affect the Spread of the Human Immunodeficiency Virus and related Acquired Immunodeficiency Syndrome

Lauren Kelly Prof. Laurie Edwards Unit 3 March 26, 2014

Kelly 2 Abstract First identified in 1981, the Acquired Immunodeficiency Syndrome, also known as AIDS, became a modern day epidemic for which there is no cure. The disease has made a global impact within the last three decades. Currently there are 33.4 million people globally who have either AIDS or the viral cause, the Human Immunodeficiency Virus. The disease has the most affect in areas of the third world. Of these people living with HIV, 97 percent live in low and middle income countries. Most of those infected reside in the regions of Sub-Saharan Africa, Asia, Latin America and Eastern Europe. The five countries with the highest percentage of the population infect are all in the Sub-Saharan African countries of Swaziland, Botswana, Lesotho, South Africa and Zimbabwe. However, unlike previous epidemics like influenza or polio, HIV and AIDS is a disease that is marked with stigma which has prevented people from around the world from being educated and receiving treatment. Many people associated with HIV are also treated adversely due to cultural and institutional stigmatization. The reason for this is that the high risk groups for HIV are also considered socially undesirable in many cultures. These groups are drug injectors, men who have sex with men, sex workers, transgendered individuals, prisoners, migrants and refugees. HIV is also a disease that is directly related to poverty which is also stigmatized in many nations (AIDS.gov). Since there is currently no cure or vaccine available for HIV and AIDS, the best way to combat the disease is prevention and reduction of transmission. Therefore it is critical that the world governments work towards the reduction of HIV to ensure global health. Introduction One of the most effective ways to prevent the spread of the disease is reducing transmission rates and decreasing the prevalence. This is best done using effective government policy and law on topics such as education, prevention and treatment. This is especially

Kelly 3 important for those in high risk groups that face aversion through stigmatization and therefore become more likely to spread the disease. However, policy and law is mixed with the cultural views in many nations and therefore many countries have laws that punish these groups instead of helping prevent the spread of the disease. This negative laws and policy show as examples for the need to create stigma-free policy, as these laws a directly related with lower prevalence rates. There are also many examples of countries that have successfully used policy and law to combat the transmission of the disease. HIV and the associated AIDS is a disease that is directly related to poverty and therefore countries that have a large number of the population who are in poverty also have high incidence rates (AIDS.gov). Because poverty is a leading cause for many epidemic diseases, using policy and law to help alleviate that healthcare costs for a nations poor is another method to use policy to combat HIV. Using examples from both successful and unsuccessful policy, this paper aims to understand what aspects of policies from around the world aid in the reduction of the prevalence of HIV. A variety of nations, as well as different laws on topics will be analyses to help aid in the understanding of how to use policy to prevent the spread of HIV. Uganda: A Case Study of Effective Political Action Located in Sub-Saharan Africa, Uganda is a country that experienced high rates of infection during the emergence of HIV and AIDS in the 1980s and 90s. Uganda had a significant drop in the prevalence of the disease, mainly due to an effective prevention policy that focused on the promotion of behaviors that were linked to the prevention of HIV (Genuis). Though there is still debate, it remains an example that a countrys policy can affect their incidence rates. Ugandas success relied on the fact that the disease was not dealt with as a sole healthcare issue and instead was political policy. Ugandas response began in the early 1990s and due to the

Kelly 4 quickness at which it approached the issue; it became one of the first success stories for HIV prevention strategies. Ugandas focus was promoting behavioral changes that were linked to a decrease in HIV transmission. The policies focus on faithful relationships and decreasing sexual partners and partnership with local Non-Government Organizations, also known as NGOs, created a decline in transmission rates by the end of the decade (Green). Though some of decline in incidence rats of HIV in Uganda can be contributed to other factors such as increasing awareness, education and risk avoidance, Ugandas dramatic decline was due to a variety of political policy and response. These responses can be summarized into six major elements that occurred chronologically. The first is political support from high levels of government that spanned across different facets of the Ugandan government. The government also established a National AIDS Control Program in 1986 to track the epidemic and then developed a multi-sectorial Uganda AIDS Commission to oversee the national strategy. This response created many difference sections of the Ugandan government to combat that spread of the disease. The second element that occurred was the move towards promotion of behavioral changes of the population (Green). Behavioral changes are linked to reduced transmission rates within Uganda. In study performed in rural Uganda in 2003 to 2004, 926 HIV positive individuals reduced risky sexual behavior by over 70 percent when anti-retroviral therapy was used in conjunction with counseling, testing and provision of condoms. Ugandas focus on behavioral change included media campaigns that focused on decriminalizing the disease, raising awareness and changing the normal behaviors of the population (Bunnell). Uganda also relied on employing the populations patriotic duty to help assist the eradication of the disease (Genuis). The third tool that the government used was religious organizations and leaders, who are a huge

Kelly 5 influence in Africa. They not only provided faith and medical support, they also promoted behaviors that reduced the risk of contracting HIV, such as faithfulness and abstinence (Green). The fourth tool that Uganda employed was a progressive maneuver that encouraged the empowerment of women and aimed to reduce the stigma associated with having HIV or AIDS. This meant that the government began including sexual education and HIV awareness in schools. This also led to the funding of smaller organizations that worked towards womens empowerment and changes in the law, which were linked to the fight against the disease. The fifth and sixth steps that the Ugandan government took towards decreasing the prevalence of HIV were creating the first Confidential Voluntary Counseling and Testing Services (VCT) in Africa and the promotion of condom use (Green). These methods aimed to help reduce the rates of transmission, as well as increasing awareness about the disease and safe sex education. Overall, Ugandas successes lay in their direct response. Their response to the disease aided to the swift reduction of prevalence that was not present anywhere else in Sub-Saharan Africa. Ugandas use of techniques that are directly related to HIV reduction and movement towards reducing the stigmatization of the disease also promoted this reduction in ways that other countries had failed. Therefore, Ugandas approach should be used as an example of successful policy in combating the epidemic.

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HIV prevalence among pregnant women in Uganda. Source: HIV/AIDS surveillance report, STD/AIDS control programme, Ministry of Health, Uganda, June 2001(Green).

Thailand: Reaching Out to Stigmatized Groups Lead to Success and Failure of Prevention Strategies Currently, Thailand has the highest prevalence of HIV in Asia. Over half a million Thais are HIV or AIDS positive and holds a large number of the worlds HIV positive individuals. According to the Joint United Nations Programme on HIV/AIDS, this means that almost two percent of the countrys population is infected with the disease (AIDS.gov). Thailand has had both success and failure through their policy. Thailand has a large population of two of the most stigmatized high risk groups, sex workers and injecting drug users. Thailand had a successful program in reaching out to sex workers (Levine), but its harsh laws for injecting drug users have made them the most vulnerable group to the disease. Though there has been an overall decline in the prevalence Thailand is still at a high risk for the resurgence because of their failures with injecting drug users (Cahill). Thailands policies on sex workers and injecting drug users are an example on how one country can have both success and failure with policy on HIV. Thailands greatest success thus far has been its intervention program for sex workers. Called the 100 Percent Condom Program, it required that all sex workers use condom with

Kelly 7 clients of their services. Despite the fact the prostitution is illegal in Thailand; condoms were provided for free to these brothels. Police also held meetings with the workers and brothel owners to promote condom usage. They also used information from men being treated for sexually transmitted infections at local clinics to disclose the brothel they had used, so that health officials could address and educate those workers. The program was extremely successful and condom use among sex workers reached over ninety percent. Overall the rate of new infections fell by after the implementation of this program (Levine). This programs success shows how reaching out to stigmatized groups without fear of repercussions allowed them to choose HIV prevention strategies that lead to overall better awareness and sexual education throughout the country. This in turn led to a decrease in the prevalence of HIV among one of Thailands vulnerable social groups.

Source: Data from Bureau of Epidemiology, Ministry of Public Health, Thailand original compiled by Sombat Thanprasertsuk, Cheewanan Lertpiriyasuwat and Sanchai Chasombat

In stark contrast to the success with sex workers, injecting drug users have become the largest risk for increasing the epidemic in Thailand. Unlike sex workers, they have been neglected due to laws based on stigma. Thailands no tolerance policy is to blame, as being

Kelly 8 caught possessing or using drugs automatically results in a prison sentence. In Thailand, the rates of incarceration for drug offenses are high and the Thai prisons have very poor HIV prevention and drug treatment programs within prisons (Razak). There is also a crossover of stigmatized groups, as men who have sex with men who also are injecting drug users are very likely to be imprisoned. Though homosexuality is not illegal, there is no protection from discrimination in Thailand. One of the largest issues with injecting drug users in prison is that many have access to drugs where the issue of a lack of clean needles becomes a major factor in the spread of HIV. Sharing needles becomes the only way that an injecting drug user can acquire drugs while in prison. This is an extremely risking behavior when it comes to the spread of HIV (Foy). Another factor in the group of injecting drug users is that Thailand is resistant to use clean needle programs. These programs have been very effective in other nations, such as Australia and Brazil, in reducing the number of new HIV infections. Thailand, instead of using these harm reduction methods, focuses on the harsh war on drugs policy that only increases the number of infections (Cahill). Because of the huge number of injecting drug users within the country, Thailand is in critical need of adopting new methods on dealing with injecting drug users in order to continue their decrease in the prevalence of HIV. These safe needle programs, as well as greater availability of drug treatment programs and a less harsh approach, could potentially decrease the prevalence in this high risk group. Conclusion Though there is no simple solution for decreasing the prevalence of HIV and AIDS, there are several themes in policy and law that can be employed to reduce the spread of HIV within a nation. These themes have been shown to be successful in many nations and adoption is critical in order to decrease the global epidemic. Success stories such as Uganda should be analyzed for

Kelly 9 implementation in other nations, using the themes of education, prevention and behavioral changes. Nations should also reach out to high risk groups for infection, which are usually stigmatized. These outreach programs, like the condom incentive for sex workers in Thailand, have been successful in lower the infection rates in these vulnerable groups. Failures to respond, like the treatment of drug users in Thailand, should also be analyzed to understand why these solutions fail and implement strategies that work. Dialogue needs to take place between nations on what strategies do and do not work if effective policies are to be made. Overall, the solution to HIV and AIDS does not rely on one countries success or failure, but instead on an effective global policy based on evidence to combat the HIV epidemic.

Kelly 10 Works Cited 1. Bunnell, Rebecca, John Paul Ekwaru, Peter Solberg, Nafuna Wamai, Winnie BikaakoKajura, Willy Were, Alex Coutinho, Cheryl Liechty, Elizabeth Madraa, George Rutherford, and Jonathan Mermin. "Changes in Sexual Behavior and Risk of HIV Transmission after Antiretroviral Therapy and Prevention Interventions in Rural Uganda." Aids 20.1 (2006): 85-92. Print. 2. Cahill, Sean. "Syringe Exchange Programs around the World: The Global Context." Gay Men's Health Crisis (2010): n. pag. Web. <http://www.gmhc.org/files/editor/file/gmhc_intl_seps.pdf>. 3. Foy, H.m., C. Kunanusont, J.k. Kreiss, P. Phanuphak, S. Raktham, C-P. Pau, N.l. Young, and S. Rerks-Ngarm. "HIV-1 Subtypes and Male-to-female Transmission in Thailand." The Lancet 345.8957 (1995): 1078-083. Print. 4. Genuis, S. J. "HIV/AIDS Prevention in Uganda: Why Has It Worked?" Postgraduate Medical Journal 81.960 (2005): 615-17. Print. 5. "Global Statistics." AIDS.gov, 6 June 2012. Web. 24 Mar. 2014. <http://aids.gov/hiv-aidsbasics/hiv-aids-101/global-statistics/>. 6. Green, Edward C., Daniel T. Halperin, Vinand Nantulya, and Janice A. Hogle. "Uganda's HIV Prevention Success: The Role of Sexual Behavior Change and the National Response." AIDS and Behavior July (2006): n. pag. Springer Link. Web. 16 Mar. 2014. <http://link.springer.com/article/10.1007%2Fs10461-006-9073-y/fulltext.html>. 7. Levine, Ruth. Case Studies in Global Health: Millions Saved. Sudbury, MA: Jones and Bartlett, 2007. Print. Case 2 Preventing HIV/AIDS and Sexually Transmitted Infections in Thailand.

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Razak, Myat Htoo, Jaroon Jittiwutikarn, Vinai Suriyanon, Tassanai Vongchak, Namtip Srirak, Chris Beyrer, Surinda Kawichai, Sodsai Tovanabutra, Kittipong Rungruengthanakit, Pathom Sawanpanyalert, and David D. Celentano. "HIV Prevalence and Risks Among Injection and Noninjection Drug Users in Northern Thailand: Need for Comprehensive HIV Prevention Programs." JAIDS Journal of Acquired Immune Deficiency Syndromes 33.2 (2003): 259-66. Print.