Tag Archives: Canada

Women living with HIV: a matter of safety and respect


Last month the results of a global survey on women living with HIV were published. The survey was designed and conducted by women, and commissioned by the World Health Organisation. Will the findings be acted upon?

In 2014 the World Health Organisation commissioned the largest international survey to date on the sexual and reproductive health and human rights of women living with HIV. The survey was designed, led and conducted by women living with HIV.  Last month the global survey was published: Building A Safe House On Firm Ground.

I live in Canada in a small rural setting, and I have been living with HIV for many years. The survey calls for “safety, support and respect for all women at all times”.  It is my hope that readers examine the survey in its entirety.

A total of 832 women from 94 countries, aged 15-72, with another 113 women in focus groups from 7 countries took part in the survey. Violeta Ross (Bolivia) expressed how “This consultation means for me, the opportunity to learn from one and other. Women living with HIV are the best positioned for the design of sexual and reproductive health policies“.

The single most prominent finding of the survey was how women living with HIV experience high rates of violence, on a continuum throughout the life cycle: 89% of the respondents reported experiencing or fearing gender-based violence, before, during and/or after HIV diagnosis.

Violence was described as physical, psychological and/or financial, with an HIV diagnosis or disclosure acting as a trigger for violence at times. Over 80% of respondents reported experiences of depression, shame and feelings of rejection. Over 75% reported insomnia and difficulty sleeping, self-blame, very low self-esteem, loneliness, body image issues, or anxiety, fear and panic attacks, whether before, or as a direct result of, or after diagnosis.

Poverty ties in with violence, along with gender inequality. Many women with HIV come from diverse backgrounds, such as drug use, sex work, being lesbian or transgender. Women are often in relationships where they do not have the financial means to leave and are reliant on their partners, placing them in an unequal power dynamic and open to further abuse and blackmail.

The survey reveals the way in which the lack of human rights-based approaches to women’s services contributes to mental health issues, lack of satisfying sex lives, and lack of sexual and reproductive rights. All women with HIV have the right to achieving their sexual and reproductive rights as a fundamental part of being human. The survey also highlights the importance of women needing to achieve their own rights in all these areas in order for them adequately to support their children and partners – which women with HIV are very much wanting to do.

The report strongly recommends the meaningful involvement of women living with HIV as active participants in all plans and research which affects them.

As Sophie Strachan of the UNAIDS Dialogue Platform and the Global Coalition of Women and AIDS explained, “The main importance of this consultation is that WHO hear and take up our recommendations, listen to our voices (as experts) to hear the needs of women living with HIV and include peer led support/services in their guidelines. We need gender specific policies to ensure the rights of women in all our diversities are met.”

Gender-based violence against women living with HIV is a world-wide phenomenon. In a Canadian context it takes place on a continuum from polite rejections, discrimination and regular experiences of being stigmatized, to more overt forms of violence including physical assault, threats of violence during disclosure of their HIV status or with partners who use the secret of “shame” of their HIV status to control women and keep them from leaving a relationship.

Women living with HIV in Canada often have children and cannot find adequate child care. So they cannot spend time furthering their education and are therefore trapped in a poverty cycle which is often impossible to break. This further exacerbates the potential for abuse and violence.

Indigenous women in Canada represent a small percentage of the overall population, but are over-represented in the number of women living with HIV in Canada, as are women of colour who have emigrated from other regions of theworld. Women living with HIV in Canada often live in isolation, keeping their HIV status private for fear of backlash from the community and to protect their children from stigma and discrimination.  Living in isolation leads to decisions to not seek treatment, not seek care and support to deal with stress and anxiety, and not take prescribed medication on a regular basis, if at all.

It may come as a surprise to learn that Canada has one of the highest rates of criminalization of HIV for non-disclosure in the world. This needs to be addressed to alleviate fear and silence about HIV. Canada demands that other countries adhere to basic human rights practices, yet at home we do not. Fortunately we have a strong organization, the Canadian HIV/AIDS Legal Network, which lobbies for de-criminalization of HIV and changes in our government’s position on this topic. Criminalization of HIV in fact serves to increase HIV transmission. With the onus on the HIV positive person to disclose their status to sex partners or risk prosecution, individuals assume and expect that everyone living with HIV will disclose, and they rely on this and do not ask questions, do not insist on the use of condoms or any safe sex practices. This causes a false sense of security for people on the dating scene, and indirectly creates a situation where people living with HIV are used as part of screening mechanisms for safe sex practices, with the rationale that a person can rely on prosecution if and when a person does not disclose their status. It places the burden of disclosure on the person living with HIV, and does not emphasize the need for each individual to take responsibility for their own sexual health and well being. Laws will not protect people from contracting HIV, personal responsibity for oneself will.

Two recent court rulings in 2013 and 2014 against women in Canada for non-disclosure of their HIV status highlight how the law lags far behind science in relation to the virtual impossibility of transmitting HIV if one has an undetectable viral load. There is a critical need to decriminalize HIV; there is also a need for everyone to take responsibility for their own sexual health.

Services to support women living with HIV in Canada exist in a splintered fashion and vary from province to province.  In Quebec I have had many conversations with women living with HIV, but there seems to be no clear or definitive answers about why women are so reluctant to engage in services. Service providers do not have the solutions around engaging women in services either. From my own point of view I would like to see more concrete and  practical services which will enable us to learn new job skills to integrate back into the work place.

A human rights focus is needed as much in Canada as it is in the so-called “developing” world. The many components on the continuum of violence towards women living with HIV need to be addressed, including financial inequality, need for adequate housing, job security and human rights-based approaches to employment and care.

There is an obvious need for a national cohesive voice for women living with HIV in Canada. What needs to take place here in Canada, as everywhere, is a serious attempt to practice the meaningful involvement of women living with HIV in the full cycle of all aspects of planning, programme implementation and evaluation. We are the experts, and we alone can identify what our needs are and how they can be addressed. This was clearly demonstrated in the Salamander Trust survey, which has produced the most meaningful and authentic results I have read to date.

World Health Organisation (WHO) guidelines now need to be updated to reflect both the findings of the report, and to reflect recent political and biomedical aspects of the HIV response.

via OpenDemocracy

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HIV Criminalisation, Sex, Risk & Viral Load In The Real World.

Here are two positive developments that move forward the debate about sex, risk, undetectable viral load and the criminalisation of HIV non-disclosure.

2011 marked the thirtieth anniversary of the HIV/AIDS pandemic. Much has been achieved in those three decades, most notably advances in treatment that have changed the face of HIV for those who have access to antiretroviral (ARV) medication from a terminal illness to a chronic yet manageable disease.

But of late there’s been other good news to celebrate. Just last month, for example, researchers from the University of Western Ontario announced that clinical trials are about to begin on a new HIV vaccine they’ve developed. And it does seem that, increasingly, more and more experts are becoming convinced that +ve individuals, appropriately treated with an undetectable viral load are much less likely to pass on the virus than people not on treatment. However, as PositiveLite editor Bob Leahy recently pointed out by how much and in what circumstances is still subject to debate.

The latest people to take the view that +ve individuals on treatment with undetectable viral loads are unlikely to infect their sexual partners are the two organizations that write the HIV treatment guidelines for the UK, the British Association for Sexual Health and HIV  and the British HIV Association. They’ve done this via their newly revised guidelines for the use of post-exposure prophylaxis (PEP).

PEP is an emergency measure aimed at preventing HIV infection after the possible exposure of an HIV negative person to the virus. The new UK guidelines are notable for no longer recommending that PEP be provided in a number of situations where the “source partner” is known to be HIV+ and to have an undetectable viral load. These situations include unprotected vaginal intercourse, unprotected insertive anal intercourse and oral sex. But PEP is still recommended following unprotected receptive anal intercourse.

The guidelines are also notable for not recommending PEP in any situation in which the source partner is thought not to belong to a social group in which HIV prevalence is high, such as gay men or people from high-prevalence countries (such as those in sub-Saharan Africa). The guidelines also clarify that, due to the very low risk of infection, PEP is unnecessary following human bites or contact with a discarded needle.

(Unlike the UK and many other countries in the developed world, Canada has no national guidelines for the use of PEP for non-workplace exposure – such as unprotected sex, a condom breaking during sex, needle sharing or sexual assault –  although some provincial guidelines exist. As a result, PEP for non-workplace exposure is rarely promoted in Canada. On the other hand, PEP after workplace exposures – for example a health care worker who accidentally suffers a needle-stick injury – remains the “standard of care” and is widely used in this country.)

Yet, despite the growing body of evidence that having an undetectable viral load significantly reduces the likelihood of an infected person passing on the virus to an uninfected sexual partner, Canada has witnessed an escalation in the number of people prosecuted for allegedly exposing partners to HIV even if they had an undetectable viral load and/or were using protection such as condoms or engaging in a low risk activity such as oral sex.  Ontario is home to the majority of HIV-related prosecutions in Canada and is also one of the leading jurisdictions in the world when it comes to such prosecutions.

Part of the problem is that the law around HIV disclosure has never been legally defined. Rather, it comes from a 1998 decision of the Supreme Court that HIV+ people have a legal duty to tell a sex partner that they have HIV before they have sex if there’s a “significant risk” that they’ll pass on the virus to that person. This lack of clarity on what constitutes significant risk has meant that the police, Crown attorneys and lower courts have been inconsistent in how they interpret what sex acts, and under what circumstances, pose a significant risk of HIV transmission.

In last month’s Canadian Medical Association Journal, Julio Montaner, one of Canada’s and the world’s leading HIV medical doctors, along with colleagues from the British Columbia Centre for Excellence in HIV/AIDS called for the end of prosecutions for allegedly exposing sexual partners to the virus. “To put the burden on the person infected with HIV that they have to disclose when they may be on treatment or using a condom, or doing both, is really not appropriate,” Montaner told The Vancouver Sun. “Let me be clear, I think that people who behave irresponsibly, they need to be judged accordingly and there are laws to address those issues…but to have a policy that selectively targets HIV is discriminatory and discourages people from seeking out testing and treatment.”

All this will be coming under intense scrutiny next month, when the Supreme Court of Canada is to hear two appeals involving HIV non-disclosure. In both cases, one from Manitoba, the other from Québec, the accused are HIV+ and had consentual sex with their partners without disclosing their HIV status although they used condoms or were on ARV medication that kept the risk of transmission very low. In each case, the accused were acquitted by the provincial Courts of Appeal. However, prosecutors in both cases applied for an appeal before the Supreme Court.

So it was of particular concern that in September 2011, Ontario’s Attorney General indicated his government’s intention to file an application to intervene in the Supreme Court hearing. The government’s intent was to call on the Court to rule that people living with HIV must disclose their status before any sexual activity whatsoever – even in the case where there’s a negligible, effectively zero, risk of HIV transmission – and that not disclosing should be prosecuted as an aggravated sexual assault, which is one of the most serious offences in the Criminal Code.

It was especially troubling that the Ontario Attorney General‘s office took this position at the same time that it was engaged in ongoing discussions regarding the development of prosecutorial guidelines for allegations of HIV non-disclosure.

So it was good news to learn that, just before Christmas 2011, Ontario quietly withdrew its application to intervene before the Supreme Court. The government hasn’t released its reasons for this about-face, although it must be said that the governing Liberal party has just recently been returned to power following a provincial election where they gained a plurality of seats in the provincial parliament. The premier also appointed a new Attorney General who may have been instrumental in deciding against his predecessor’s decision to intervene.

However, the appeal before the Supreme Court will still be going ahead – it starts on February 8, 2012 – at which time the Court will be asked to define “significant risk”. Hopefully, in reaching a decision on the two cases before it, the bench will take into account current medical and scientific research about the risk of transmission and make a decision that’s compatible with scientific, medical, public health and community efforts to prevent the spread of HIV and to provide care, treatment and support for people living with HIV.

You can listen to an excellent debate about the current law – and recommended changes to it – in a podcast of the CBC Radio current affairs program The Current that was broadcast on December 21, 2011. In it Anna Maria Tremonti talks with Tim McCaskell, a long-time AIDS activist and person living with HIV, and Carissima Mathen, an associate professor of law at the University of Ottawa.

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