The Centers for Disease Control and Prevention (CDC) defines the goals of its HIV prevention efforts in the United States to be preventing new HIV infections, improving health outcomes for persons living with HIV, reducing HIV-related disparities and health inequities, and continually improving the effectiveness and efficacy of operations. These goals are reflected in the recently updated Strategic Plan of CDC’s Division of HIV/AIDS Prevention and align with national HIV prevention goals. To make progress in reaching these goals, the Division of HIV/AIDS Prevention works with other federal agencies and state, local, and community partners to ensure that the best prevention and treatment methods are being recommended to people living with or at risk for HIV and their providers. In September, CDC took a huge step in this regard by releasing its “Dear Colleague” announcement in which it stated there was effectively no risk of a person with HIV who has an undetectable viral load transmitting the virus to an HIV-negative partner.
The CDC announcement cited three studies involving thousands of couples and many thousands of acts of sex without a condom or pre-exposure prophylaxis (PrEP), in which there were no cases of HIV transmission from an HIV-positive partner who was virally suppressed to an HIV-negative partner. CDC stated that this means people who take antiretroviral therapy (ART) as prescribed and achieve and maintain an undetectable viral load have effectively no risk of transmitting HIV.
As the announcement was released on National Gay Men’s HIV/AIDS Awareness Day, CDC also included some information on how gay and bisexual men (and other men who have sex with men) are disproportionately affected by HIV. In 2015, more than 26,000 gay and bisexual men received an HIV diagnosis, representing two-thirds of all new diagnosis in the United States. Additionally, among gay and bisexual men living with HIV in 2015, only 61% had achieved viral suppression. This means only 61% had effectively no risk of transmitting HIV.
Following the HIV treatment announcement, CDC released a statement on October 15th in recognition of National Latinx AIDS Awareness Day discussing the impact of HIV/AIDS on Hispanic/Latino persons. In 2015, Hispanics/Latinos accounted for about 25% of all HIV diagnoses in the United States, although they made up only 18% of the total population. Among all Hispanics/Latinos living with HIV in 2014, only 58% had a suppressed viral load. This is particularly concerning given that new HIV infections among Latino gay and bisexual men rose by 20% between 2008 and 2014.
CDC encourages both public and private stakeholders to implement interventions to increase retention in HIV treatment and viral suppression, which would reduce the risk of transmitting HIV to effectively zero. These interventions must focus on disproportionately affected communities, especially gay and bisexual men of color, transgender individuals, and Black women. More must be done in order to reduce racial and ethnic disparities in HIV care outcomes.
This blog post was co-authored by Natalie Dobek, a second-year law student at Georgetown Law and a research assistant at the O’Neill Institute.
While some gendered aspects of tuberculosis are beginning to be better understood, there is limited information and focus on addressing certain risk factors and vulnerabilities that impact men and women differently. TB now kills more people than any other infectious disease, and evidence suggests that women may be more vulnerable to forms of extra-pulmonary TB, including genital TB, which is under diagnosed, and also that it is more difficult to diagnose women than men for pulmonary TB, suggesting there may be more undiagnosed cases in women.
Women are at high risk of tuberculosis in some regions. HIV increases the risk of TB infection—women living with HIV are 10 times more likely to develop TB than HIV-negative women. Women who are co-infected with HIV and TB are at extremely high risk of poor health outcomes and mortality and are more likely to die than co-infected men, especially in Africa. These risks are especially concerning for pregnant women in sub-Saharan Africa where TB and high co-infection rates significantly increase risks of maternal mortality and morbidity. Pregnant women living with TB risk having premature babies and their babies are six times more likely to die shortly after birth, than babies of TB-negative women. Pregnant women co-infected with HIV and TB are at extremely high risk of maternal mortality—they are more than twice as likely to die than pregnant women with TB who are HIV-negative.
While co-infection risks have begun to be addressed through programming, including that which facilitates access to linked TB and HIV testing and services, such programmes should be more widely available and there is a need for more data on gender vulnerabilities. For example, some research suggests that men are more vulnerable to pulmonary TB, while other research suggests that it is more difficult to diagnose TB in women due to differences in symptoms and lesion size on the lungs (making TB more difficult to diagnose). Further, there are social and cultural factors present in many developing countries which impose barriers to TB prevention, diagnosis, treatment and care for girls and women, including stigma, discrimination and gender stereotypes which may deter health seeking behavior. If TB services are not provided for free, families may be unable to pay, and if there are limited financial resources, they may be allocated to male family members over females. In some contexts, social determinants of health and TB, such as nutrition, sanitation, education and employment may disproportionately increase risk factors for girls and women. Since malnutrition is a significant risk factor for TB, undernutrition may increase girls’ susceptibility to TB and other poor health outcomes in low resource settings, depending on allocation of scarce resources.
Globally, more men than women have been diagnosed with TB. In some regions, this is closely linked to occupational hazards surrounding mining which is often a predominantly male profession. For example, in Southern Africa, TB is a significant public health threat and extremely high TB rates are in large part attributed to the mining industry. Mine workers in sub-Saharan Africa have some of the highest TB rates in the world—over 867,000 new cases each year are linked to mining. The exceedingly high rates of TB are clearly linked to a many factors, including exposure to silica dust, HIV infection, and poor working and living conditions. While there has been increased advocacy and a number of interventions and efforts to address these conditions and TB within the mining sector, private industry interests often override human rights and public health concerns and too little has been done to ensure occupational hazards are reduced or to ensure workers have access to TB prevention, testing, treatment and support. Additional complexities arise given the number of migrant workers within the sector, who are at heightened risk of TB and, as is the case in many countries in the world, face onerous barriers accessing quality health services.
[photo credit: Nobody Left Behind]
Gender is but one example of an aspect of TB that is inadequately understood and addressed. Other vulnerabilities and TB risk factors include incarceration, migrant status, poverty, sanitation, malnutrition, among others, which must urgently receive attention if we are to reduce new TB infections, deaths, poor health outcomes, drug resistance, and the catastrophic costs of TB. Tuberculosis is a stark example of the extent to which the rights to health and science have not been realised in developing countries and the vast health and social inequities between countries and within them. Perhaps the rapidly increasing tuberculosis rates and ever-increasing cases of drug-resistant TB will be cause for meaningful and effective international, regional and state action to address social inequality and discrimination.
Hanhsi Indy Liu is an SJD candidate at Georgetown University Law Center. Sarah Roache is the director of Global Health Law LL.M. Program and Capacity Building Initiative at the O’Neill Institute for National and Global Health Law. Any questions or comments on this post can be sent to: firstname.lastname@example.org.
Supporters of regulations to reduce consumption of sugary drinks may feel a chilling wind in San Francisco. Just last month, a three-judge panel of the US Ninth Circuit Court of Appeals ruled that the city government’s warning label about the health of sugar-sweetened beverages violates First Amendment protections for commercial speech.
In June 2015, San Francisco passed an ordinance, S.F. Health Code § 4203(a), to mandate a health warning statement on certain sugar-sweetened beverages (“SSB”) advertisements, including billboards and vehicles:
WARNING: Drinking Beverages with added sugars(s) contributes to obesity, diabetes, and tooth decay. This is a message from the City and County of San Francisco.
The ordinance provides details about the form, content, and placement of the warning, including the controversial requirement that it occupy 20 percent of the ad space. The industry, represented by the American Beverage Association, California Retailers Association, and the California State Outdoor Advertising Associations (“associations”) , alleged the content of the warning is misleading and the 20% size requirement places an undue burden on their commercial speech. (See the sample advertisements provided by the industry to the court below)
On 19 September 19, 2017, the United States Court of Appeals, Ninth Circuit, reversed and remanded a previous district court decision which denied the associations’ motion for a preliminary injunction against the implementation of the warning label. The Court of Appeals concluded that the associations are “likely to succeed on the merits of their claims that the ordinance is an “unjustified or unduly burdensome disclosure requirement” in violation of “protected commercial speech.” Therefore, the court held, the district court “abused its discretion in denying the Associations’ motion for a preliminary injunction”.
Perhaps more concerning to public health advocates, the court also found that the required warning statement is not “purely factual and uncontroversial”. The court held that, because the FDA deems sugar “generally recognized as safe” and recognizes that it “can be a part of a healthy dietary pattern when not consumed in excess amounts,” San Francisco’s warning is therefore misleading. The judgment suggests that the warning might survive scrutiny if it used qualified language such as: “overconsumption” of sugar-sweetened beverages “may” contribute to obesity, diabetes, and tooth decay
Furthermore, the appeal court held, the warning is “misleading and, in that sense, untrue,” because it singles out SSB rather than including “all other products with equal or greater amounts of added sugars and calories.” This implies that SSBs are less healthy than other products with added sugars, which is “deceptive in light of the current state of research on this issue.”
Although the ruling could still be appealed, or San Francisco could revise its warning in line with the judgment, this ruling may have a chilling effect on efforts to nudge towards healthier choices through warning labels.
Posted in Non-communicable diseases;
“These woods are where silence has come to lick its wounds.” – Samantha Hunt
In 1994, Ebola, a lethal virus that had been silent for fifteen years, awoke. Two separate outbreaks would shatter this silence, but one of these was unique, the likes of which has not been seen since.
Though the last known Ebola outbreak that affected humans had occurred in 1979 in Sudan, in 1989, Reston virus, a species of Ebolavirus, emerged in laboratory macaques in Virginia that had been imported from the Philippines. The lethal virus caused hemorrhagic fever symptoms in macaques, but was determined to be nonpathogenic to humans. The virus was a new type of Ebola; similar outbreaks would take place in Alice, Texas and again in Reston, Virginia in 1990, and in Sienna, Italy in 1992. The Reston outbreaks would later be dramatized in Richard Preston’s 1995 best-selling book, The Hot Zone, which captures the tension of an Ebola outbreak in a dense urban area, followed by the relief experienced after it was found to be harmless to humans.
The world once again took notice of human cases of Ebola in December 1994, when it reemerged from its fifteen-year slumber in Gabon. As with most mysterious febrile illnesses, the cases of hemorrhagic fever were initially assumed to be yellow fever. The epidemic took place in early December 1994 and was declared over on February 17, 1995; 52 cases were confirmed, 31 died from the virus. The outbreak originated near gold mining encampments near Makoukou, just 75 miles west of the border with Republic of Congo, and 160 miles north of the capitol city of Franceville. The causative virus was identified as Ebola Zaire on December 14, 1994.
However, unbeknownst to investigators in Gabon, the virus had already reemerged elsewhere a month prior. On November 16, 1994, a chimpanzee in the Taï Forest National Park, Côte d’Ivoire was discovered dead by a primate behavior researcher, and was dissected on the spot. The researcher developed dengue-like symptoms on November 24th, and was hospitalized in Abidjan on the 26th after developing further symptoms and not responding to anti-malarials. On December 1, she was evacuated to Switzerland for further treatment and monitoring, and would eventually make a full recovery after 6 weeks of illness.
The cause of infection was determined to be from the handling of the infectious blood and/or tissues from the necropsy of the dead chimpanzee. It was determined to be new species of Ebola, though not until February 1995, months after the Gabon outbreak identification. It was named Ebola Côte d’Ivoire (though its name was changed in 2002 to Ebola Taï Forest to conform with new naming conventions), and it was unlike any Ebolavirus that had been seen prior, or that has been seen since.
First, the infected researcher is the only known case of Ebola Taï Forest, ever. This is especially interesting given the timing of the infection, after a fifteen-year period of Ebola quiescence. The four other known species of Ebola have each had multiple outbreaks, but 1994 Taï Forest was a unique event.
Second, similar to the first outbreak of Ebola in 1976–which had since been discovered to be two separate outbreaks of non-concurrent, differing species of Ebola (Zaire and Sudan)[i]–the Ebola Taï Forest case happened within a month of the Ebola Zaire outbreak in Gabon. This is also interesting in the context of the fifteen-year period of Ebola going undetected.
Third, the Taï Forest outbreak is the first time that a human Ebola case had emerged outside of the central African area known as the Congo River Basin. In fact, prior to 2014 it was the only time Ebola emerged outside of this region; it would be twenty years before Ebola would be discovered in West Africa again, and it would be under much different, catastrophic circumstances. However, the emergence from the Taï Forest is not inconceivable, given the environmental similarities to the tropical rainforests within Ebola’s known zone of endemicity in the Congo River Basin. The possibility exists that Ebola Taï Forest is a viral relic of times long ago, when the rainforests of Côte d’Ivoire and Central Africa were one and the same, stretching from coastal West Africa with the Congo River Basin.
Fourth, the Taï Forest case was the first documented human Ebola infection associated with naturally infected nonhuman primates in Africa. This discovery would shift research toward transmission of Ebola between primates and humans for years to come. Today, epizootic Ebola transmission research is focused mostly on bats, but Ebola is still a significant issue for primates: recent research indicates that up to a third of the world’s chimpanzee and gorilla populations have been wiped out by Ebola.
Finally, the Taï Forest case, though unrecognized as such, is the first Ebola outbreak in what can be viewed as the modern era of Ebola; since 1994, an average of one Ebola outbreak has taken place every year. The questions remain, decades after the Taï Forest outbreak: What has precipitated this frequency of outbreaks, particularly after the fifteen-year lull? Why have we not seen Ebola Taï Forest again? When Ebola emerges again, will we be ready, or will it emerge someplace new?
[i] Cox NJ, McCormick JB, Johnson KM, Kiley MP. Evidence for two subtypes of Ebola virus based on oligonucleotide mapping of RNA. J Infect Dis. 1983;147:272–275.
On October 20, 2017, a team of human rights lawyers and activists were jailed in Dar-es-Salaam, Tanzania – a clear violation of Tanzanian and international human rights obligations.
The initial arrests came on Oct. 17 after a consultation they were holding was raided by the Tanzanian police. Thirteen people were arrested. After authorities initially released all but one of them on bail, all are back in custody today after their bail was revoked.
The group was preparing strategic litigation against the government of Tanzania for violating the right to health of Tanzanians by eliminating and outlawing key programs to fight HIV. These human rights leaders are accused of “promoting homosexuality.” Those arrested include attorney Sibongile Ndashe, executive director of the Initiative for Strategic Litigation in Africa (ISLA), an O’Neill Institute partner organization. Activists from Community Health Education Services and Advocacy, a Tanzanian NGO, are also being held.
The detaining of thirteen attorneys and their clients, including nationals of Tanzania and South Africa, brings recent Tanzania’s targeting of civil society to unprecedented new heights. The detention of human rights attorneys and leading public health and community leaders is not only a severe violation of their rights, but also raises the level of threat to human rights defenders in the country – another step backwards for human rights. If a South African legal organization supporting local clients in litigation could be arrested on spurious charges, what human rights defender in Tanzania is not at risk? It is critical that this action not stand.
We strongly urge the government to release the detainees, discontinue the legal proceedings against them, return passports to the foreign nationals who have been arrested and restore their freedom of movement. The government should also ensure and affirm access to legal representation and support, as ISLA sought to provide, without intimidation. We’ve reached out to our partners to show our support and commitment to challenging this action.
Oscar A. Cabrera
O’Neill Institute for National & Global Health Law
Matthew M. Kavanagh
Director, Global Health Policy & Governance Initiative
O’Neill Institute for National & Global Health Law
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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.