Daniel Tarantola

History, principles, and practice of health and human rights

Individuals and populations suffer violations of their rights that affect health and wellbeing. Health professionals have a part to play in reduction and prevention of these violations and ensuring that health-related policies and practices promote rights. This needs efforts in terms of advocacy, application of legal standards, and public-health programming. We discuss the changing views of human rights in the context of the HIV/AIDS epidemic and propose further development of the right to health by increased practice, evidence, and action.

Country-specific estimates and models of HIV and AIDS: methods and limitations.

OBJECTIVE This paper presents the methods used to calculate the end of 1997 country-specific estimates of HIV and AIDS produced by the UNAIDS/WHO Working Group on Global HIV/AIDS and STD Surveillance. The objective of this exercise was to improve estimates on HIV/AIDS by using country-specific models of HIV/AIDS epidemics. The paper describes and discusses the processes and obstacles that were encountered in this multi-partner collaboration including national and international experts. METHODS The 1997 estimates required two basic steps. First, point prevalence estimates for 1994 and 1997 were carried out and the starting year of the epidemic was determined for each country. The procedures used to calculate the estimates of prevalence differed according to the assumed type of the epidemic and the available data. The second step involved using these estimates of prevalence over time and the starting date of the epidemic to determine the epidemic curve that best described the spread of HIV in each particular country. A simple epidemiological program (EPIMODEL) was used for the calculation of estimates on incidence and mortality from this epidemic curve. RESULTS Regional models that were used in previous estimation exercises were not able to capture the diversity of HIV epidemics between countries and regions. The result of this first country-specific estimation process yielded higher estimates of HIV infection than previously thought likely, with over 30 million people estimated to be living with HIV/AIDS. The application of survival times that are specific to countries and regions also resulted in higher estimates of mortality, which more accurately describe the impact of the epidemics. At the end of 1997, it was estimated that 11.7 million people worldwide had died as a result of HIV/AIDS since the beginning of the epidemic. CONCLUSION This exercise is an important step in improving understanding of the spread of HIV in different parts of the world. There are, however, shortcomings in the current systems of monitoring the epidemic. Improvements in HIV surveillance systems are needed in many parts of the world. In addition, further research is needed to understand fully the effects of the fertility reduction as a result of HIV, differing sex ratios in HIV infection and other factors influencing the course and measurement of the epidemic.

How Uganda Reversed Its HIV Epidemic

Uganda is one of only two countries in the world that has successfully reversed the course of its HIV epidemic. There remains much controversy about how Ugandas HIV prevalence declined in the 1990s. This article describes the prevention programs and activities that were implemented in Uganda during critical years in its HIV epidemic, 1987 to 1994. Multiple resources were aggregated to fuel HV prevention campaigns at multiple levels to a far greater degree than in neighboring countries. We conclude that the reversed direction of the HIV epidemic in Uganda was the direct result of these interventions and that other countries in the developing world could similarly prevent or reverse the escalation of HIV epidemics with greater availability of HIV prevention resources, and well designed programs that take efforts to a critical breadth and depth of effort.

The Global HIV/AIDS Pandemic

Progress has been achieved in reducing the spread of HIV infection in some developing countries. Certain populations in industrialized countries are also showing a decline in HIV incidence. However the HIV epidemic continues to spread in most developing countries as well as in European countries undergoing political stress and upheaval. Aggravating the issue is the increase of the social economic demographic and health impacts of the epidemic. In developing countries a spread of HIV in young adults adolescents and children is noted; while HIV is found to be increasing in the minority populations of industrialized countries. Heterosexual transmission extensive commercial sex industries the high prevalence of sexually transmitted diseases and injecting drug use provide the potential for explosive epidemics in several countries. Globally the HIV/AIDS pandemic is composed of multiple epidemics in different stages of development that have become increasingly diverse and fragmented each with their own features.

Universal Access to HIV prevention, treatment and care : assessing the inclusion of human rights in international and national strategic plans

Rhetorical acknowledgment of the value of human rights for the AIDS response continues, yet practical application of human rights principles to national efforts appears to be increasingly deficient. We assess the ways in which international and national strategic plans and other core documents take into account the commitments made by countries to uphold human rights in their efforts towards achieving Universal Access. Key documents from the Joint United Nations Programme on HIV and AIDS (UNAIDS), the World Health Organization (WHO), the World Bank, the Global Fund to Fight AIDS, TB and Malaria (GFATM) and the US Presidents Emergency Plan for AIDS Relief (PEPFAR) were reviewed along with 14 national HIV strategic plans chosen for their illustration of the diversity of HIV epidemic patterns, levels of income and geographical location. Whereas human rights concepts overwhelmingly appeared in both international and national strategic documents, their translation into actionable terms or monitoring frameworks was weak, unspecific or absent. Future work should analyse strategic plans, plans of operation, budgets and actual implementation so that full advantage can be taken, not only of the moral and legal value of human rights, but also their instrumental value for achieving Universal Access.

Responding to HIV / AIDS: a historical perspective.

The history of the response to HIV/AIDS has developed in four phases. The first global AIDS strategy by WHO in 1986-87 defined HIV/AIDS in terms of individual risk behaviors. Specification of risk behaviors as a central concern led to risk-reduction programs which were designed to change individual behaviors. As the individual behavior based approach to prevention developed concerns regarding societal behaviors arose. Insights on how to analyze and address the societal basis of vulnerability to HIV/AIDS evolved from two major lines of reasoning and experience: 1) as national and community HIV epidemics matured societal-level risk factor was identified; 2) womens ability to effectuate free and informed choices about their sexual behavior was strongly linked to their roles and status in the society. Public health drew on the human rights framework to analyze societally based vulnerability and to guide efforts at societal transformation. Viewing the contribution of societal factors to vulnerability to HIV/AIDS through a rights perspective disaggregates the societal issues into discrete elements. The most recent phase in the evolving understanding of HIV/AIDS is to see human behavior as a blend of individual characteristics and a societal context defined by human rights.

Placing ethics in the centre: negotiating new spaces for ethical research in conflict situations.

Abstract Issues of power and consent, confidentiality, trust, and benefit, risks to researchers, and potential harm to participants, are all contested when working with different cultures and within environments marked by violence and insecurity. Difficulty resolving these dilemmas may paralyse ethics committees, may fail to give the guidance sought by researchers, and will not help populations who are among the worlds most vulnerable. Even where efforts are made to respond to ethical guidelines and to improve practice, considerable impediments are present in many developing countries, including lack of formal ethical review structures in unstable settings, lack of required skills, limited political and institutional recognition of ethical issues, competing interests, and limitations in clinical and research practice (Elsayed 2004, Macklin 2004). In conflict settings, these limitations are more marked, and the responsibilities of the researcher for ethical practice are greater, but the mechanisms for oversight are weaker. Moreover, the constant focus on vulnerabilities and problems, and the often almost total lack of recognition of strengths and resilience, can further disempower already exploited groups and individuals. The capacity of refugees and communities in conflict to take an active role in the research process is seldom acknowledged, and undermines the potential for more innovative research which can help generate the evidence for better policy and practice.

The Prevalence of Depression Among Men Living With HIV Infection in Vietnam

OBJECTIVES We assessed the prevalence of depression among men living with HIV infection in Vietnam and compared the findings with those from a general population survey of Vietnamese men. METHODS Between November 2007 and April 2008, 584 participants completed a structured questionnaire in Vietnamese that measured self-reported depression. We used the chi2 test to detect differences in prevalence rates within HIV populations and between our respondents and a general Vietnamese male population. RESULTS Respondents had a depression rate of 18.7% over a 1-month period, which was substantially higher than that reported in the Vietnamese male population (0.9%). Rates were highest among men reporting higher levels of stress and more HIV symptoms. Men diagnosed with depression experienced significantly more difficulty than others in accessing medical care. CONCLUSIONS Our results provide the first empirical evidence of depression among men living with HIV in Vietnam and underscore the need to include mental health services in the response to HIV.

Children confronting HIV/AIDS: charting the confluence of rights and health.

From a child rights perspective, HIV/AIDS serves to illuminate how cultural norms and legal precepts facilitate or constrain the protection of the child from HIV infection and from its individual and collective impacts. Recognition of human rights in the design, implementation, and evaluation of governmental policy can point the way toward actions which are not only necessary but, in public health terms, most effective. This article summarizes the three situations -- children infected, affected, and vulnerable -- and three levels of governmental obliations -- to respect, protect, and fulfill rights -- which should be considered when identifying childrens specific needs and rights in the context of HIV/AIDS. The article then proposes a method to analyze systematically the confluence between HIV/AIDS and childrens rights, creating opportunities for a synergy between those involved in HIV/AIDS prevention, care, and research, and others engaged to the promotion and protection of the rights of the child.

Global expansion of HIV infection and AIDS.

The decline of new HIV infections among subgroups in industrialized countries has created a false sense of security; globally, about 13,000 new infections occur each day. In developing countries, limited health care spending bars all but a privileged few from access to new treatment. In the absence of an effective vaccine and intensified prevention, spread of the virus will continue unabated.