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health policy

Modelling the scale-down of HIV services in sub-Saharan Africa

19 Sep, 17 | by Leslie Goode, Blogmaster

Search BMJ STI archive, and you will find frequent references to ‘scaling up’, and few – if any – to ‘scaling back’ or ‘scaling down’ (other than Parker/STI).  Who knows if all this may not be about to change, if the US government goes ahead with threats to cut current foreign aid budget ear-marked for HIV by $6.7 billion? How would this affect local HIV programmes?

Walensky & Paltiel  (W&P) model alternative strategies and combinations of strategies for the Republic of South Africa (RSA) and Cote d’Ivoire (CI) to determine which would offer the maximum budgetary return for each year of life lost. Strategies include ‘no new ART’, ‘reduced HIV testing and linking to care’, ‘ART eligibility at a lower CD4 count’, etc.; but all presuppose that commitments to those currently in ART care will be maintained. If scale-back is unavoidable, then it matters how those cuts are implemented; certain combinations of strategies, the authors claim, achieve synergies between strategies such that their combination produces budgetary savings that are greater, per year of life lost, than the total of the two strategies considered separately – for example, ‘late presentation’ and ‘reduced retention’ in RSA. However, ‘no new ART’ turns out to be the strategy that delivers the greatest budgetary savings in an ‘efficient’ manner.

It is hard to gauge the tone of these recommendations – which sound more like a ‘wake-up call’ to the US government than a sober proposal for scale-backs in sub-Saharan countries. Certainly this is not an argument for the long-term cost-effectiveness of any policy for scale-backs, since any short-term savings, they claim, will soon be overtaken by the downstream economic costs of increased HIV transmissions. And even the maximum of savings achievable by these strategies turns out not to exceed 30% of present expenditure. The most efficient alternatives for achieving cuts of 10%-20% will achieve c.$900 and c.$600-900 per every year of life lost in RSA and CI respectively.

In practice, however, it is hard to imagine the necessary cut-backs being achieved in so transparent and rational a manner. At all events, the effect of US cuts to HIV programmes will be presumably be more keenly felt – and will harder to make up for from other (e.g. local) resources – where the proportion of the national HIV budget funded by the US is higher. So, in CI, for example, where 90% of HIV spending comes from international sources, a 10% cut in PEPFAR (President’s Emergency Plan for AIDS Relief) funding would result in a 9% reduction in HIV spending, whereas, in RSA, where most of the funding is self-financed, it would represent a reduction of only 2%. It remains the case, however, that, in absolute terms, that 2% of spending in the RSA is worth $40 million, or double the $20 million saved by the 9% of savings in the CI.

Revised UK NICE Guidelines for HIV testing: why local prevalence based targeting by GPs and hospitals makes sense

11 Jan, 17 | by Leslie Goode, Blogmaster

November 2016 saw the publication of revised UK NICE Guidelines for HIV testing (last updated 2011) – only a few weeks before the appearance of the annual Public Health England Report: HIV in the UK/2016.  The latter highlights the estimated level of still undiagnosed HIV in the UK (which, at 13,500/101,000, places us 3% short of the UNAIDS 90:90:90 target) and the proportion of late diagnoses (approx. two/five thousand).  It also draws attention to the ‘diversity’ of the epidemic, and the relatively poor levels of diagnosis amongst the 16,500 infected non-black African heterosexuals (approx. 1/4, as opposed to 1/7 for MSM or 1/8.5 for black African heterosexuals).

In the light of these findings, we can appreciate the move in the NICE Guidelines, regarding opportunistic testing in primary and secondary care, towards an approach that, first, makes absolutely clear its basis in regional prevalence rather than any other factor, and, second, is more specific – and more demanding – about the occasions when testing is recommended.  We find a new distinction of two levels of high local risk: high (0.2-0.5%) and extremely high (>0.5%).  This determines whether testing should be offered on specified occasions, namely, in primary care, at registration and the performance of any blood test, and, in secondary care, at admission and performance of a blood test (‘high’ prevalence areas); or whether there should be universal opportunistic testing (‘extremely high’ prevalence areas).  As compared with the 2011 guidelines, an insistence on local prevalence as the determining factor replaces the specification of multiple high-risk groups (e.g. MSM or black Africans).

The danger with routine HIV testing is well illustrated by a 2011 study of screening in 29 Paris emergency departments: Wilson d’Almeida & Cremieux/STIs/blogs.  This trial seems to have spectacularly failed to pick up any HIV infections that would not have been detected even without the intervention.  By contrast, what is proposed by the NICE Guidelines is routine testing in areas of extremely high prevalence.  Of course, patients may still refuse testing (Dhairyawan & Orking/STIs) – and appear to do so all the more frequently where they belong to groups, like non-African heterosexuals, that the authors of the 2016 guidelines are so anxious to include (Mohammed & Hughes/STIs).  Nevertheless, the 2014 HINTS study (HIv testing in Non-Traditional Settings) of the acceptability of routine HIV testing has demonstrated encouraging levels of uptake (c.65%) in UK Emergency Departments, Acute Care Units, Primary Care Centres, and dermatology outpatients (Rayment & Sullivan; see also Mohammed & Hughes/STIs).  Conversely, there is evidence, where primary care is concerned, that practitioners may be capable of missing opportunities for testing even where their patients present with indicator conditions for HIV infection (Agusti & Casabona/STIs).

Responding to the new NICE guidelines, a GPs’ representative stresses the existing workload of GPs and the sensitivity of sexual health issues, but broadly welcomes the new emphasis.

 

 

 

UNAIDS 2016 Report: How a ‘life-cycle’ approach can help the world ‘get on the fast track’ to HIV prevention

7 Dec, 16 | by Leslie Goode, Blogmaster

‘Get on the Fast Track: a Life-cycle Approach to HIV’ is the latest UNAIDS report, following on from the UN Assembly’s 2016 declaration of commitment to ‘Fast Track’ goals for ending the HIV/AIDS epidemic. The major theme of the ‘life-cycle’ appears to owe much to the findings of the South African CAPRISA study – above all, the idea of a transmission cycle between younger (25 year-old) women and older (>25 year-old) men.  Broadly, phylogenetic analysis reveals that the prevailing pattern of transmission is as follows.  Younger women appear to get infected through casual relationships with considerably older men, who have, in turn, been infected by their longer-term partners; in time, the younger women grow up and form longer-term relationships – and the cycle is repeated.  The former group – younger (≤25 year-old) women – appear to be more vulnerable to infection than men of the equivalent age due to complex social factors, and have recently seen only c. 6% declines in annual incidence; older (>25 year-old) men have incidence rates that have remained obstinately high despite all recent efforts to reduce them.  These are best explained by poor rates of testing, integration into treatment, and viral suppression making them a potential risk to non-HIV-infected partners.

Diagnosing a problem is one thing; framing the solution quite another.  In case of the younger women, the dominant factors appear to be structural and societal – e.g. gender inequalities.  These are difficult to address without major social and political change.  The authors suggest a number of prevention tools, including sexual education in schools, the introduction of pre-exposure prophylaxis (PrEP), and social transfers.  However, recent trials of PrEP in sub-Saharan Africa do not bode well for this intervention (STI/blogs/’Failed PrEP trial’; STI/blogs/‘Another failed PrEP trial’); while the evidence for the effectiveness of sexuality education and ‘social transfers’ is far from conclusive (School-based Sexuality Programmes/STI/blogs; STI/Galarraga & Sosa-Rubi; STI/Minnis & Padian; STI/Khan & Khan).  However, in the case of the other group – i.e. older men – the obstacles to HIV prevention (poor rates of testing and viral suppression) may be less intractable, and the report proposes a number of very practical measures that could help, including: distribution of self-test kits through female partners attending ante-natal clinics (STI/blogs/’Partner-delivered STI testing’); simplifying ART regimens so individuals have to take just one tablet a day; shifting from CD4 count testing to viral load testing.

The report also has much to say about other phases of the life-cycle, as well as about ‘key populations’ (estimated 45% of new infections).  Regarding the latter, the authors report the stability, or even rise, in new infections amongst sex-workers, drug-users and MSM. They emphasize the negative impact of criminalization of key populations and same-sex relations (73 countries) (see STI/blog/’HIV criminalization’/; STI/blog/’Health workers violate human rights’), the very low levels of domestic funding (on average, only 12% of total spending on MSM prevention), and the relatively young age of many in the ‘key populations’.  The authors recommend ‘comprehensive’ programmes for these populations incorporating access to a range of health care programmes, such as the Red Umbrella programme for sex workers in South African, and the ‘Targeted Strategy Plan’ for the transgender population in Lima, Peru.

 

Criminalizing HIV transmission: Is imprisonment ever the right response?

28 Nov, 16 | by Leslie Goode, Blogmaster

This month sees the publication of a ‘Consensual Statement’  by Australian medical professionals on ‘Sexual Transmission and the Law’.  This draws on a similar Canadian ‘Consensus Statement’  issued in 2014.

The involvement of the law in this area remains a highly controversial matter.  It is easy to assume that UNAIDS policies underlining the public health disbenefits of “overly broad criminalization” largely concern those African nations which have recently adopted draconian legal previsions in response to the HIV crisis (Kpanake & Mullet/STIs; Stackpole-Moore/STIs).  Yet we should not forget that prosecution and imprisonment for transmission of HIV continues to occur in first-world countries as well (e.g. 16 custodial sentences in England over the period 2001-2012 (Phillips & Sukthankar/STIs)).  National jurisdictions differ in respect to whether, in order to be subject to prosecution, the transmission must be intentional or reckless.

Many in sexual health, I suspect, would reject the idea of involving the criminal law in such cases.  Stackpole-Moore/STIs, for example, argues that its use “in order to guide normative behaviour” is irreconcilable with the concern to avoid internalized stigma among at risk populations.  According to S, employing criminal sanctions in this area involves promoting just the kind of social stigma that health policy makers have found so counter-productive in fighting the epidemic.  However, this side-steps the question whether there might ever be a moral argument for legal sanctions regardless of their impact on behaviour.  Phillips & Sukthankar/STIs, in their theoretical examination of traditional justifications for sentencing to imprisonment, recognize the possibility that ‘retributive justice’ could provide some genuine justification for imprisonment for HIV transmission.  This might explain why those African legislators responsible for passing the recent severe previsions, tend, when asked about their motivations, to revert to the argument of retribution – even where that is not the ‘official’ justification (Stackpole-Moore/STIs and Kpanake & Mullet/STIs).

To come at last to the recent Australian and Canadian statements – these discourage, even if they don’t quite exclude, the involvement of the law.  However, they do so not on the grounds of a principled rejection of all justifications for criminalization (such as advocated by Stackpole-Moore/STIs), but on the grounds of the changing reality, and changing perceptions, of HIV.  They specify the risk of per sex-act transmission – in the case of penal-vaginal transmission, rated low (0.4%-1.4%) – and point to the effectiveness and tolerability of treatment.  If HIV is no longer a ‘death-sentence’, then transmitting HIV to a partner can hardly be considered ‘killing’.  Still more conclusively, perhaps, they point to the inadequacy of phylogenetic analysis as forensic evidence, which, they argue, “simply cannot determine beyond reasonable doubt that the reference samples are linked”.

Yet it should be remembered that the first two of these three considerations (unlike the claims of retributive justice) are context-dependent.  Whether or not HIV amounts to a ‘death sentence’ may depend on where you live.  Were the same kind of arguments to be applied in the case of the African countries discussed by S and K&M, they would need to take account of the very different health realities obtaining in those countries.

Where HPV vaccination loses the battle for public support: calculating the health implications for Japan

9 Nov, 16 | by Leslie Goode, Blogmaster

A recent brief contribution to The Lancet-Oncology (Tanaka & Ueda) uses predictions of the probable health outcomes of the suspension of the Japanese HPV vaccination programme to make the case for an urgent reassessment of the current policy.  This intervention is very timely.  The approved age for HPV vaccination for Japanese girls is a window of four years from 13-16 yrs, and the current year (2016-17) constitutes the fourth since the suspension of the programme (June 2013); so the current year is the last opportunity for a return to the initial HPV vaccination policy before the effects of the suspension (for the oldest in the cohort) become irrevocable.   From the following year on (2017-8), the authors argue, every additional year of suspension will exclude an additional age group from the protective effects of HPV vaccination – unless, that is, the eligibility period is extended to include older girls).  With a view to maximizing the impact of this message, they assess the impact of restarting vaccination in 2020 as against restarting in the current year.  They do this on two scenarios depending on whether or not vaccination, when resumed, is given to those who would have missed out in 2013-2017 as well as to those currently eligible.

So how great are these effects?   On the first scenario (no catch-up for missed years), risk of HPV 16/18 infection at 20yrs is estimated for the 2013-6 year groups at around a steady 1.0%, given resumption of vaccination 2020, as against the 0.3-0.4% risk, with resumption in 2016; on the second, that steady 1% risk over the four missed years is replaced by an evenly paced decline from 1.0% to previous levels (0.3-0.4%) over the four-year period.

Of course, it is the long-term health impact of these HPV infections that constitutes the cost of the current Japanese policy, and, were it recognized, the strongest incentive for a resumption of vaccination.  Unfortunately, the full impact is very long term, and hard to quantify.  But some advanced indication of its potential scale is provided by the recent Finish ‘FUTURE’ trial that demonstrated an absence of CIN3 and ICC lesions in vaccinated participants (Paavonen/3/STIs), as well as, more indirectly, the enormous (c.90%) declines in genital wart presentations in Australia (Chow & Fairley/STIs; Ali & Donovan (STIs)) and New  Zealand (Wilson & Baker/STIs).  The benefits foregone by the unvaccinated will also include protection against head and neck – especially oropharyngeal – cancers (Field & Lechner/STIs; King & Sonnenberg/STIs), and against a small, but significant range of anogenital cancers in women (Prevention of anogenital cancers in women/STIs/blogs).  On a more positive note, however, there is some evidence for the benefit of ‘catch-up’ and incomplete vaccination (“Catch-up” and incomplete vaccination/STIs/blogs) as against those who have hitherto put this in doubt (STs/Chesson & Markowitz).

An important lesson of the Japanese experience for everyone concerned with HPV is the importance of public education.  The very poor levels of understanding revealed by a recent systematic review (Patel & Moss/STIs) amongst European adolescents is a timely warning that uninformed attitudes to HPV vaccination are not restricted to the Japanese.

Fresh WHO guidelines on gonorrhoea management + latest US surveillance data on gonorrhoea resistance

13 Oct, 16 | by Leslie Goode, Blogmaster

The emergence in various locations of resistant strains of Neisseria gonorrhoeae (Ng) is narrowing the therapeutic options. The recent (July 2016) WHO Guidelines, revised from 2003, reflect the concern both to treat effectively and steward our remaining defences against the infection in a globally coordinated manner.  They recommend either dual therapy with either single dose 250g intra-muscular ceftriaxone or 400g oral cefixime combined with 1g oral azithromycin (preferred options), or else single therapy with either ceftriaxone, cefixime or 2g spectinomycin).  The choice between these options will depend on local considerations, including Ng susceptibility data.   In the event of treatment failure following WHO-recommended dual therapy, they recommend any of: 500mg ceftraxone, 800mg cefixime, 240mg gentamicin, or 2g spectinomycin, each of them in combination with 2g azithromycin.

Reported surveillance data for a given location will be crucially important, then, for determining at local level the best options for treatment.  Given the global dimension of the threat, however, this data may also be potential evidence for global trends.  Hence the wider interest of the latest (2014) US surveillance data from the Gonococcal Isolate Surveillance Project (GISP)).  Hitherto, the US picture (as in the UK) has been one of steady progression (2006-2011) in prevalence of Ng isolates exhibiting reduced susceptibility (cefixime: MIC ≥0.25 μg/mL; ceftriaxone: MIC ≥0.125 μg/mL), interrupted by a decline in 2013; this is the pattern both for cefixime (0.1%-1.4%-0.4%) and ceftriaxone (0.1%-0.4%-0.1%) (see also Kirkcaldy & Bolan (STIs)).

So where do the latest (2014) data point? As regards cefixime, to a return to the pre-2013 upward trend, it seems, with prevalence rising once again from 0.4% to 0.8%; with ceftriaxone, to the maintenance of the 2013 prevalence level (0.1%).  Presumably, it is the prevalence levels of ceftriaxone that, in the US, constitute the primary focus of concern – since, as in the UK, that is the drug currently recommended, along with azithromycin, for dual therapy.  (See  Town & Hughes (STI) for  an equivalent report of ceftriaxone resistance in the UK).  But the greatest surprise of the 2016 GISP report is the sudden rise of decreased susceptibility to azithromycin: from 0.6% prevalence of reduced resistance strains (MIC ≥2.0 μg/mL) in 2013 to 2.5% in 2014.  The report comments that the recommended dual therapy with azithromycin is unlikely to be a contributor to this trend – though it is possible, they argue, that the small increase in the azithromycin monotherapy by US STD clinics over the last decade could have had some influence on the prevalence of azithromycin resistant strains.  There is evidence of high or rising levels of azithromycin resistance in other locations (Dillon & Thakur (STIs); Bala & Ramesh (STIs)), including, recently, the UK (Chisholm & Fifer/STIs).

Is increasing gonorrhoea resistance in MSM is a result of more treatment, rather than greater sexual activity?

20 Jul, 16 | by Leslie Goode, Blogmaster

Emerging antibiotic resistance to the last-ditch treatment of Neisseria gonorrhoeae compels health policy-makers to balance opposing concerns.  On the one hand, successfully combating spread of the infection requires targeted treatment of core-group individuals.  On the other, a focus on the core-group causes a rebound in core-group incidence, with maximal dissemination of resistance (Chan & McCabe/STIs (C&M); Chan & Fisman/STIs).

Recent public health orthodoxy has tended to favour the more intensive screening of core-group individuals (Ison & Unemo (STI); Giguere & Alary/STIs; Lewis/STIs).  However Fingerhut & Althaus (F&A), in a recent modelling study, seek to shift the balance in the opposite direction.  They claim their model demonstrates that the wide disparity in the spread of resistance spread as between populations of MSM and of HMW (heterosexual men and women) reflects differing levels of treatment rather than differences in sexual behaviour (‘more sexual partners’).

So far as concerns the first part of the claim (‘gonorrhoea spreads faster with more treatment’), F&A’s findings corroborate those of C&M.  However, in coupling this with the claim that gonorrhoea spread is not the result of sexual behaviour (‘gonorrhoea (does not) spread faster with more sexual partners’) they place the balance of responsibility for spread with the prevailing policy of treatment.  This is presumably intended to push policy makers in the direction of a more conservative attitude to targeting testing and screening.

But can F&A really justify this  change of emphasis by differentiating the respective contributions of ‘more treatment’ as against ‘greater sexual activity’ to the difference in resistance between MSM and MSW popultions ?  We are wrong, the authors argue, to assume that ‘more partners’ amongst the MSM population necessarily entails more transmissions (p. 11) – and their model apparently demonstrates this.   A common sense response, however, would be to object that ‘more partners’ presumably implies ‘more sex acts with more partners’ – and that, even if ‘more partners’ does not in itself entail more transmissions, ‘more sex acts with more partners’ might certainly be expected to do so.

Interestingly, Althaus in another paper (see Althaus & Alizon) – admittedly, in connection with heterosexual groups – corroborates our common sense expectation by showing that the number of partners displays, if not a proportional, then at least a linear, relation  to number of sex acts. So can it really be the case that there is not a greater number of transmissions amongst the MSM population, given the greater number of partners? The authors evidently believe not.

Nevertheless, it would be interesting – as well as pertinent, I suspect, to the goals of the study – to have a more satisfying explanation of why, here, as elsewhere, common sense turns out to be wrong.

 

 

 

UK National Health Service (NHS) kicks PrEP into the long grass

18 Jul, 16 | by Leslie Goode, Blogmaster

A recent BMJ editorial condemns the NHS position that it will not consider PrEP for direct NHS funding.  The decision was first communicated in an NHS statement issued in March, then confirmed by a review on 31st May, following reconsideration in response to objections raised by interested groups.  This brought to an end an eighteen-month process of discussion between Department of Health, doctors and patients groups, Public Health England and other stakeholders.  The NHS decision is currently under judicial review – which no doubt explains the timing of the BMJ editorial.

Advocates of PrEP argue that the NHS has powers under the Health and Social Care Act (2012) directly to commission services ‘prioritized for investment’, and that PrEP should qualify for consideration on this basis.  But the conclusion of the NHS is that PrEP does not qualify to be so considered because the Local Authorities Regulations (2013) clearly stipulate that commissioning for sexual health prevention is legally the responsibility of local government.

Technically, then, the argument turns on whether the NHS can commission for PrEP directly, given that PrEP is a form of sexual health prevention. Needless to say, in the eyes of the advocates of PrEP, this is a mere technicality invoked by the NHS in order to shirk its responsibilities.  The NHS statements also include the proposal to work with local government authorities on exploring how they should go about commissioning PrEP services most effectively, and to dedicate £2m to the establishment of local pilots.  The problem here is that local authorities, having lately had £200m shaved off their funding for sexual health services, are presumably not in a hurry to pick up the tab.

So what about the case for PrEP? As regards effectiveness for high-risk MSM populations, PrEP has emerged with flying colours from recent trials, including the UK PROUD  study (PrEP Highly Effective/STIs/blog; PROUD/STIs/blog) and trials with similar populations undertaken in France (IPERGAY) and California (Volk & Hare).  Cost effectiveness, however, is another matter – and here PrEP has failed to make the grade.  Recent studies have shown that in the UK PrEP is not even borderline cost-effective without substantial reductions in the cost of the drugs (Cambiano & Phillips/STIs; PrEP Highly Effective/STIs/blog; PrEP cost effectiveness study). And, of course, even cost-effectiveness is not the same as affordability.  When it is borne in mind how much in the way of demonstrably very cost effective services have recently been rendered unaffordable by government cuts (Unprotected Nation/Report), the case for PrEP in the present climate does not look strong.

Modeling the potential effectiveness of PrEP as against other preventative interventions in addressing MSM HIV

1 Mar, 16 | by Leslie Goode, Blogmaster

 

Despite the known preventative benefits of ART, the incidence of HIV among UK MSM population has remained relatively constant over the last 10 years and looks set to remain so. The UN 90:90:90 target will soon be achieved for this population, yet the goal of eliminating the infection seems no nearer.  Not surprisingly there is an appetite among health professionals for alternative measures – like PrEP.

A recent study (Punyacharoensin & White) claims to be the first to model, on the basis of detailed behavioural and surveillance data, the  impact of seven potential interventions – including PrEP – on HIV incidence in this population.  There is a considerable diversity in the nature of these interventions.  One of them consists in the roll-out of the recent WHO policy of ‘diagnose and treat’: others in the achievement of specific targets, such as yearly HIV testing for a given percentage of MSM: others again in the fulfilment of what seem little more than aspirations, given the absence of any indication of how they might be achieved – such as halving one-time partners or unprotected anal intercourse. The potential impact of each intervention is assessed independently, and then in various combinations with other interventions.

It is evident from the way that the various combinations of interventions are grouped into two sequences that the primary issue for these authors is the potential of PrEP (which happens to be the only genuinely new tool in the box).  The first sequence combines PrEP at varying levels of coverage and effectiveness with the achievement of one-year testing for different proportions of the population, ‘test and treat’, and various levels of risk compensation.  The second sequence goes through much the same process but with PrEP now replaced by a putative 0.5 drop in repeat partnerships.  The main study outcome appears to be the demonstration that introducing PrEP at certain levels of coverage and effectiveness could, in certain combinations, have an impact on incidence (-43.6%) that would be of the same order (-41%) as the achievement (by unspecified means) of a putative 0.5 drop in repeat partnerships.

The biggest problem for the modelers, of course, is the difficulty of predicting the effectiveness of PrEP in a real-life setting.  When empirical evidence of this finally emerges, then the value of this intervention as against traditional interventions will presumably be determined by its relative cost-effectiveness.  In other words, the question to confront health policy makers will be how much of what they would otherwise have spent on traditional interventions should be diverted into PrEP.

In the meantime, if there is key message to emerge from this study, it is that PrEP is worth a try.

Health professionals violate human rights of sex workers in Kenya

10 Feb, 16 | by Leslie Goode, Blogmaster

 

‘Key’ populations – such as sex workers – are now seen as crucial to turning the tide of the HIV epidemic. Given the recognized epidemiological potential of such marginalized groups to act as ‘bridging populations’ into the wider population, much importance has rightly been attached to countering the kind of routine violations of human rights that can effectively exclude such vulnerable populations from participation in health interventions designed to deal most effectively with the causes of the epidemic (UNAIDS Gap Report; UNAIDS (STI/blog). Amidst the talk of public health ‘strategies’, Speaking Out, a recent report based on the personal testimonies of 30 Kenyan sex workers, offers a powerful reminder that the problem of HIV in key populations is a cultural and social challenge before it is a technical one.  It is also a corrective to any strategy that would underestimate, in these days of expanded ART provision, the apparently softer but more complex challenge of cultural interventions to protect human rights. The report offers the results of one of the local community-led research projects supported in eleven countries by the Global Network for People Living with AIDS (GNP+).

At the heart of the problem of violations to the human rights of sex workers is the behaviour of health professionals. Officially, the human rights of such minorities are protected in Kenya by robust constitutional and legislative provisions; in practice, they are routinely flouted by everybody – including health workers. The authors of the report place violations in the following categories. Around HIV diagnosis. An attendee at an ante-natal clinic is HIV tested without her knowledge, and informed of the result in the presence of her current partner, who subsequently separates from her. Breach of confidentiality. On discovering the sex worker status of a positive-diagnosed attendee, a doctor scrolls down to ‘mama’ on the patient’s mobile and summons her mother to the hospital. Discrimination. A health worker who recognizes the status of a women attending with a stab injury announces to colleagues: ‘This is a sex worker who has been stealing other men’s husbands. Just stitch her. If it heals, well and good. If not, so be it’. Denial of services. A sex worker attending a facility following rape, is abused for her status, laughed at for claiming rape, and refused PEP on the grounds that it was not for ‘people like her’.

Such total disregard for the human rights of sex workers is shared by law enforcement officers who refuse to take seriously accusations or rape, refuse protection before the law for human rights violations, summarily arrest, then extort from, and sexually harass, their sex workers, inflict degrading treatment on them while they are in custody, and deny them access to treatment for the duration of their stay.

It is difficult to see how much progress is likely to be made in turning the tide of HIV in this particular ‘key population’ without a wholesale transformation of attitudes. The kind of abuses this study reveals are evidently paralleled in many countries. For example, Ndondo & Dlovu (STIs) and Jose & Nathan (STIs) draw attention, on the basis of qualitative survey evidence, to similar kinds of violations to sex workers’ human rights by law enforcement officers in Zimbabwe and East Timor, respectively. Mayhew & Hawkes (STIs) discuss violations in respect to a number of vulnerable groups including sex workers by both law enforcement officers and health professionals in Pakistan. It would seem that in many countries the UNAIDS strategy of controlling HIV in key bridging populations will encounter stiff cultural challenges.

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