Responding to AIDS, Tuberculosis, Malaria, and Emerging Infectious Diseases in Burma: Dilemmas of Policy and Practice

Beyrer and colleagues discuss infectious disease threats in Burma and suggest policy options for responding to them

HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: A systematic review and meta-analysis

Background HIV disproportionately affects gay, bisexual, and other men who have sex with men (MSM) in Africa, where many countries criminalise same-sex behaviour. We assessed changes in the engagement of African MSM with HIV testing and treatment cascade stages over time, and the influence of anti-LGBT legislation and stigma. Methods We systematically searched the peer-reviewed literature to October 10th , 2018 for studies and extracted or derived estimates of HIV testing and/or engagement with the HIV treatment cascade among African MSM from published reports. We derived pooled estimates using inverse-variance random-effects models. We used subgroup and meta-regression analysis to assess associations between testing and status awareness outcomes and study and participant characteristics including the severity of country-level anti-LGBT legislation. Findings Our searches identified 75 independent eligible studies that provided estimates for 44,993 MSM across one or more of five testing and treatment cascade outcomes. HIV testing increased significantly over time overall, with pooled overall proportions of MSM ever tested of 67·3% (95%Confidence interval 62·1-72·3%,N=44) and tested in the past 12 months of 50·1% (42·4-57·8%,N=31) post-2011 – 14% and 18% points higher than pre-2011, respectively. Post-2011, ever testing was highest in Southern(80·0%) and lowest in Northern(34·4%) and Central(56·1%) Africa, with the greatest increase in Western Africa(from 42·4 to 70·9%). Levels of both testing outcomes and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation. Few estimates were available for later stages of the treatment cascade. Available data post61 2011 suggest that the pooled proportion of MSM HIV-positive aware has remained low (18·5%, 12·5-25·3%,N=28) whereas proportions of current ART use were 23·7% (15·5- 33·0%,N=14) among all MSM living with HIV and 53·4% (36·9-69·5%,N=6) among MSM HIV-positive aware. Levels of viral suppression among MSM currently on ART were good (pooled: 75·6%, 64·4-85·5%,N=4), but low among all MSM living with HIV (pooled: 24·7%, 18·8-31·2%,N=4). Interpretation Available data suggests that levels of HIV status awareness among MSM living with HIV in Africa remain low, despite recent improvements in HIV testing; limited data is available on levels of engagement in care, ART use and viral suppression. We found that severe anti LGBT legislation was associated with lower HIV testing and status awareness. Achieving UNAIDS 90-90-90 targets will require substantial improvements

HIV in the USA: priorities for the new administration

President-elect Joe Biden and Vice President-elect Kamala Harris were elected at an extraordinary moment in US history, with the COVID-19 pandemic surging, severe social and economic strain, and a reckoning over racial injustice. COVID-19 has revealed the structural weaknesses of the US health-care system and our millions of uninsured and underinsured people. Health disparities evident in the US HIV epidemic were replicated by COVID-19 with startling speed and severity, disproportionately affecting Black, Latinx, and Indigenous communities, the poor, the unstably housed, the imprisoned, and those at the social margins. Responding to the COVID-19 pandemic is an urgent priority for the new administration. Responding to the HIV epidemic in the USA should be as well

Displacement and disease: The Shan exodus and infectious disease implications for Thailand

Decades of neglect and abuses by the Burmese government have decimated the health of the peoples of Burma, particularly along her eastern frontiers, overwhelmingly populated by ethnic minorities such as the Shan. Vast areas of traditional Shan homelands have been systematically depopulated by the Burmese military regime as part of its counter-insurgency policy, which also employs widespread abuses of civilians by Burmese soldiers, including rape, torture, and extrajudicial executions. These abuses, coupled with Burmese government economic mismanagement which has further entrenched already pervasive poverty in rural Burma, have spawned a humanitarian catastrophe, forcing hundreds of thousands of ethnic Shan villagers to flee their homes for Thailand. In Thailand, they are denied refugee status and its legal protections, living at constant risk for arrest and deportation. Classified as "economic migrants," many are forced to work in exploitative conditions, including in the Thai sex industry, and Shan migrants often lack access to basic health services in Thailand. Available health data on Shan migrants in Thailand already indicates that this population bears a disproportionately high burden of infectious diseases, particularly HIV, tuberculosis, lymphatic filariasis, and some vaccine-preventable illnesses, undermining progress made by Thailand's public health system in controlling such entities. The ongoing failure to address the root political causes of migration and poor health in eastern Burma, coupled with the many barriers to accessing health programs in Thailand by undocumented migrants, particularly the Shan, virtually guarantees Thailand's inability to sustainably control many infectious disease entities, especially along her borders with Burma

HIV Risk among MSM in Senegal: A Qualitative Rapid Assessment of the Impact of Enforcing Laws That Criminalize Same Sex Practices

Men who have sex with men (MSM) are at high risk for HIV in Senegal, with a prevalence of 21.5%. In December 2008, nine male HIV prevention workers were imprisoned for “acts against nature” prohibited by Senegalese law. This qualitative study assessed the impact of these arrests on HIV prevention efforts. A purposive sample of MSM in six regions of Senegal was recruited by network referral. 26 in-depth interviews (IDIs) and 6 focus group discussions (FGDs) were conducted in July–August 2009. 14 key informants were also interviewed. All participants reported pervasive fear and hiding among MSM as a result of the December 2008 arrests and publicity. Service providers suspended HIV prevention work with MSM out of fear for their own safety. Those who continued to provide services noticed a sharp decline in MSM participation. An effective response to the HIV epidemic in Senegal should include active work to decrease enforcement of this law

Medico-Legal Findings, Legal Case Progression, and Outcomes in South African Rape Cases: Retrospective Review

Rachel Jewkes and colleagues examine the processing of rape cases by South African police and courts and show an association between documentation of ano-genital injuries, trials commencing, and convictions in rape cases

Health and Human Rights in Chin State, Western Burma: A Population-Based Assessment Using Multistaged Household Cluster Sampling

Sollom and colleagues report the findings from a household survey study carried out in Western Burma; they report a high prevalence of human rights violations such as forced labor, food theft, forced displacement, beatings, and ethnic persecution

Expert consensus statement on the science of HIV in the context of criminal law

INTRODUCTION: Globally, prosecutions for non-disclosure, exposure or transmission of HIV frequently relate to sexual activity, biting, or spitting. This includes instances in which no harm was intended, HIV transmission did not occur, and HIV transmission was extremely unlikely or not possible. This suggests prosecutions are not always guided by the best available scientific and medical evidence. DISCUSSION: Twenty scientists from regions across the world developed this Expert Consensus Statement to address the use of HIV science by the criminal justice system. A detailed analysis of the best available scientific and medical research data on HIV transmission, treatment effectiveness and forensic phylogenetic evidence was performed and described so it may be better understood in criminal law contexts. Description of the possibility of HIV transmission was limited to acts most often at issue in criminal cases. The possibility of HIV transmission during a single, specific act was positioned along a continuum of risk, noting that the possibility of HIV transmission varies according to a range of intersecting factors including viral load, condom use, and other risk reduction practices. Current evidence suggests the possibility of HIV transmission during a single episode of sex, biting or spitting ranges from no possibility to low possibility. Further research considered the positive health impact of modern antiretroviral therapies that have improved the life expectancy of most people living with HIV to a point similar to their HIV-negative counterparts, transforming HIV infection into a chronic, manageable health condition. Lastly, consideration of the use of scientific evidence in court found that phylogenetic analysis alone cannot prove beyond reasonable doubt that one person infected another although it can be used to exonerate a defendant. CONCLUSIONS: The application of up-to-date scientific evidence in criminal cases has the potential to limit unjust prosecutions and convictions. The authors recommend that caution be exercised when considering prosecution, and encourage governments and those working in legal and judicial systems to pay close attention to the significant advances in HIV science that have occurred over the last three decades to ensure current scientific knowledge informs application of the law in cases related to HIV.publishersversionpublishe