Barcelona 2002: law, ethics, and human rights. Advancing research and access to HIV vaccines: a framework for action

In light of the continuing spread of HIV infection and the devastating impact of the disease on lives, communities, and economies, particularly in the developing world, the investment in new treatments, vaccines, and microbicides has clearly been inadequate. Efforts must be intensified to develop effective HIV vaccines and to ensure that they are accessible to people in all parts of the world. This article is a summary of a paper by Sam Avrett presented at "Putting Third First: Vaccines, Access to Treatments and the Law," a satellite meeting held at Barcelona on 5 July 2002 and organized by the Canadian HIV/AIDS Legal Network, the AIDS Law Project, South Africa, and the Lawyers Collective HIV/AIDS Unit, India. In the article, Avrett calls for immediate action to increase commitment and funding for HIV vaccines, enhance public support and involvement, accelerate vaccine development, and plan for the eventual delivery of the vaccines. The article briefly outlines steps that governments need to take to implement each of these objectives. The article also provides a menu of potential actions for vaccine advocates to consider as they lobby governments.     

Global access to treatment: achievements and challenges

As mentioned in the previous issue, this section of the Review addresses issues related to improving access to adequate and affordable care, treatment, and support everywhere. It replaces the section previously called "Patents and Prices." In this issue, we feature a review of achievements and challenges in recent years in opening global access to HIV/AIDS treatments. The article - one of a series commissioned to mark the tenth anniversary of the Canadian HIV/AIDS Legal Network, discussing past developments and future directions in areas of policy and law related to HIV/AIDS - describes the developments that recast the debate about access to treatment from one focused on patent entitlements to one focused on the right to health and treatment. It analyzes the role of national and international activism, strategically constructed alliances, and principled leadership in achieving this change. And it discusses continuing obstacles to equitable access to HIV/AIDS treatments for the world's population.     

HIV/AIDS and human rights revisited

In their article, Sofia Gruskin and Daniel Tarantola demonstrate how, as the number of people living with HIV and with AIDS continues to grow in nations with different economies, social structures, and legal systems, HIV/AIDS-related human rights issues are not only becoming more apparent, but also increasingly diverse. In the 1980s, the relationship of HIV/AIDS to human rights was only understood as it involved people with HIV or AIDS and the discrimination to which they were subjected. The concerns included mandatory HIV testing; restrictions on international travel; barriers to employment and housing, access to education, medical care, or health insurance; and the many issues raised by named reporting, partner notification, and confidentiality. Almost 20 years into the epidemic, these issues remain serious and most often have not been resolved. In the 1990s, however, there was increased understanding of the importance of human rights as a factor in determining people's vulnerability to HIV infection and their consequent risk of acquiring HIV infection and their chances of accessing appropriate care and support. And most recently, human rights have also come to be understood to be directly relevant to every element of the risk/vulnerability paradigm. Gruskin and Tarantola identify three situations and three levels of governmental obligations that should be considered when identifying the specific needs and related rights of individuals in the context of HIV/AIDS. They conclude that policymakers, program managers, and service providers must become more comfortable using human rights norms and standards to guide and limit government action in all matters affecting the response to HIV/AIDS; and that those involved in HIV/AIDS advocacy must become more familiar with the practicalities of using international human rights law when they strive to hold governments accountable.     

The Global Governance of Communicable Diseases: The Case for Vaccine R&D

Fighting communicable diseases such HIV/AIDS, tuberculosis (TB, and malaria has become a global endeavor, with international health authorities urging the development of effective vaccines for the eradication of these global pandemics. Yet, despite the acknowledged urgency, and given the feasibility of effective vaccine development, public and private research efforts have failed to address a response adequate to the magnitude of the crisis. Members of the academic community suggest bridging this gap by devising research pull mechanisms capable of stimulating private investments, confident that competition-based market devices are more effective than public intervention in shaping scientific breakthroughs. With reference to the economics of innovation, the paper argues that, whilst such an approach would lead to a socially suboptimal production of knowledge, direct public intervention in vaccine R&D activities would represent a far more socially desirable policy option. In recognition of the current financial and political fatigue affecting the international community towards communicable disease control, the paper resorts to the theories of global public goods (GPGs) to provide governments, both in the North and in the South, with a powerful rationale for committing to a cooperative approach for vaccine R&D. The paper encourages the creation of a Global Health Research Fund to manage such exercise and proposes enshrining countries' commitments into an International Health Treaty. The paper ends by providing a number of policy recommendations.     

Barcelona 2002: law, ethics, and human rights. Juggling individual and collective concerns with respect to HIV/AIDS policies

Efforts to prevent the spread of HIV infection sometimes give rise to tensions between individual and collective rights. This article, based on a presentation by Nelson Varas-Díaz (abstract TuOrG1171), explores these tensions in the context of the laws and policies of eight Latin American countries: Costa Rica, Dominican Republic, Ecuador, Guatemala, Honduras, Nicaragua, Panama, and Puerto Rico. The article describes five elements of the response to HIV/AIDS in which tensions between individual and collective rights have surfaced: the participation of people living with HIV/AIDS on national commissions; the ability of HIV-positive persons to access antiretroviral medications; HIV-antibody testing practices; the confidentiality of health information; and the rights and duties of people living with HIV/AIDS. The article concludes that the success of programs designed to prevent the spread of HIV infection depends on the ability of societies and governments to balance the tensions between individual and collective rights.     

Preventing mother-to-child transmission: landmark decision by South African court

On 14 December 2001, the High Court of South Africa delivered its judgment in Treatment Action Campaign et al v Minister of Health et al, ruling that the government was in breach of its constitutional obligations and must promptly develop and implement a comprehensive national program to prevent mother-to-child transmission of HIV, including making antiretroviral drugs available for this purpose. This article summarizes the legal arguments and the outcome of a case that is of global significance in holding governments accountable for their obligations to progressively realize the human right to health.     

Access to treatment as a right to life and health

In some countries in Latin America, in the absence of leadership from governments, activists have had to resort to the courts to obtain access to HIV/AIDS treatments for people with HIV/AIDS. In his presentation to the XIII International AIDS Conference (abstract TuOrE458), Edgar Carrasco, of Acción Ciudadana Contra el Sida (ACCSI), discusses the process that was followed in Venezuela. The presentation describes the very limited access people with HIV/AIDS had to antiretroviral therapies and treatments for opportunistic infections under Venezuela's health and social security systems. It provides details of lawsuits that were launched on behalf of several individuals living with HIV/AIDS, and that resulted in the courts ordering the government to provide treatments for these individuals and, eventually, for all people with HIV/AIDS in Venezuela. The presentation concludes that recourse to the courts is a useful tool for activists and that civil actions launched on behalf of people with HIV/AIDS can serve as an example for people with other chronic diseases.     

HIV-related stigma and discrimination--the epidemic continues

This article is one of a series commissioned to mark the tenth anniversary of the Canadian HIV/AIDS Legal Network, discussing past developments and future directions in areas of policy and law related to HIV/AIDS. It looks at HIV-related stigma and discrimination. The article summarizes the present situation as described in reports from numerous countries throughout the world. It reviews the institutional, non-institutional, and structural dimensions of HIV-related discrimination. It also identifies some essential components of anti-discrimination efforts: legal protection; public, workplace, and health-care programs; community mobilization; and strategizing on the determinants of health.     

An Exploration of Conceptual and Temporal Fallacies in International Health Law and Promotion of Global Public Health Preparedness

In February 2007, Indonesia withheld sharing H5N1 viral samples in order to compel the World Health Organization and Member States to guarantee future access to vaccines for States disproportionately burdened by infectious diseases. This article explores conceptual and temporal fallacies in the International Health Regulations (2005) and the Doha Declaration on the TRIPS Agreement and Public Health, as relates to global public health preparedness. Recommendations include adopting laws to facilitate non-pharmaceutical interventions; securing the rights of affected populations; and fostering inter-State collaborations to promote intra-State public health capacity building.     

Measuring legal implementation of the international guidelines on HIV/AIDS and human rights

With over 36 million people now living with the virus and over 21 million people dying of AIDS in the last two decades, HIV/AIDS is a global health and security problem. These shocking figures eclipse the human toll of many wars, and reveal in themselves that human rights are not being respected, protected, or fulfilled, either through negligent omissions or violations. A human rights approach to the epidemic was advocated early by advocates such as Jonathan Mann, who recognized that infections thrived in conditions of inequality. This approach was crystallized in the International Guidelines on HIV/AIDS and Human Rights that were developed at the Second International Consultation in 1996 convened by UNAIDS and the Office of the High Commissioner for Human Rights. The Guidelines cover three main areas: improving governmental responses in terms of multisectoral responsibility and accountability; widespread law reform and legal support services; and supporting increased private sector and community participation in effective responses to the epidemic. This article focuses on the half of the twelve Guidelines that concern rights that are justiciable and amenable to law reform. It highlights the responsibilities of States Parties to human rights treaties, as they bear the principal burden of the obligations to implement.     

Human rights and HIV/AIDS in the context of 3 by 5: time for new directions?

Over the last decade, the success of the human rights-based approach to HIV/AIDS has been spotty, says Mark Heywood. In this feature article, the author describes the challenges that remain in implementing a human rights approach. He presents an analysis of questions raised by De Cock et al concerning the applicability of the human rights approach. The author argues that human rights advocacy needs to continue, but that new directions are required. The article outlines new directions in the areas of (a) confidentiality and openness, (b) HIV testing, and (c) health systems. The author concludes that the most serious threat to human rights remains the unwillingness of national governments to take all necessary measures to build health services and prevent epidemics.     

Barcelona 2002: law, ethics, and human rights. Using the law to improve access to treatments

The XIII International AIDS Conference in Durban, South Africa in July 2000 focused worldwide attention on the problem of accessing treatments in developing countries. In the interim, thanks to the work of activists - from demonstrations to court cases, and from acts of public courage by people living with HIV/AIDS to ongoing lobbying of politicians and trade negotiators - some very significant developments have occurred. But the reality is that the vast majority of people living with HIV/AIDS still lack access to affordable, quality medicines. This article, a summary of a paper presented at "Putting Third First: Vaccines, Access to Treatments and the Law," a satellite meeting held at Barcelona on 5 July 2002 and organized by the Canadian HIV/AIDS Legal Network, the AIDS Law Project, South Africa, and the Lawyers Collective HIV/AIDS Unit, India, explores three approaches for improving access. In the first part, Richard Elliott provides an overview of the state of the right to health as embodied in international human rights law; comments on the experience to date in litigating claims to the right to health; and identifies potential strategies activists can adopt to advance recognition of the right to health. In the second part, Sharan Parmar and Vivek Divan describe price-control and drug-financing mechanisms used by industrialized countries to increase the affordability of medicines; and discuss how some of these mechanisms could be adapted for use in developing countries. Finally, Jonathan Berger describes the use of litigation in the courts by the Treatment Action Campaign in South Africa.     

Effectiveness of state mandates to maintain local government health services for the poor

State governments have used several types of mandates to assure that local governments fulfill state-defined responsibilities, including public health care for the poor. This article reports the findings of a study of procedural public-participation mandates and financial sanctions imposed by California to hold counties to their obligations to provide indigent health care. An inventory of the laws' implementation in all California counties found noncompliance by some counties, although all counties complied after a state Health Services Department unit was established to monitor the counties and provide them with state aid. Case studies in eight counties identified factors that influenced the effectiveness of the laws in modifying or reversing county proposals to close county hospitals or reduce other health services. Policy guidelines are suggested for states that want to develop mandates to enforce indigent-care responsibilities of local governments.     

Barcelona 2002: law, ethics, and human rights. The need for harm-reduction approaches in Eastern Europe and the former Soviet Union

In a region where HIV is spread primarily by injection drug use, harm-reduction strategies must be the mainstay of prevention efforts. In her plenary presentation to the XIV International Conference on AIDS on 9 July 2002, Kasia Malinowska-Sempruch asserts that if the world does not turn its attention to the emerging and exploding epidemic in Eastern Europe and the former Soviet Union, the region will suffer the same fate as Africa. The presentation explains that while their economies continue to struggle, the countries in the region have seen their public health systems crumble in the face of the twin health crises of injection drug use and HIV infection. The presentation demonstrates how current repressive laws and practices with respect to drug use serve only to fuel the epidemic. It describes harm-reduction approaches (such as needle exchanges and drug-treatment programs) and provides examples of how NGOs in the region have been attempting to implement such approaches, often with little or no support from governments. Finally, the presentation outlines other measures required to respond to the epidemic in the region, including ensuring that people infected with HIV can access care, treatment, and support services.     

Criminal law and HIV/AIDS: strategic considerations

Richard Elliott's paper on criminal law and HIV/AIDS, an edited and updated version of his presentation at "Putting Third First," sets out five guiding principles for criminal law policy and HIV/AIDS; briefly outlines the rationales for criminalization; discusses three strategic legal questions regarding the criminalization of HIV transmission/exposure; and offers a number of recommendations for consideration of those needing to articulate a well-considered perspective on the ethical, legal, human rights, and public health dimensions of the criminalization of HIV transmission/exposure.     

Jamaica: petition for antiretroviral drugs filed

In February 2003, five Jamaican women with HIV/AIDS filed petitions with the Inter-American Commission on Human Rights seeking an order that the government provide them with antiretroviral drugs, in fulfillment of its obligations under the American Convention on Human Rights to respect the right to health and the right to enjoy the benefits of scientific progress.     

Dublin Declaration on HIV/AIDS in prisons launched

On 23 February 2004, the Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia was launched. The Declaration focuses on prisons in Europe and Central Asia, but it is also relevant for prisons in other countries, including Canada, which are still far from having adopted a comprehensive approach, based on public health and human rights principles, to HIV/AIDS and hepatitis C in prisons.     

Culture and interpersonal violence research: paradigm shift to create a full continuum of domestic violence services

This article addresses the importance of culture within the context of domestic violence. It takes the position that to work more effectively with diverse cultural groups, the development of a full continuum of services that includes eliminating the violence and keeping families together is required. The authors believe that intervention models developed in the fields of HIV/AIDS may provide important examples for future work.     

Health, Social Movements, and Rights-based Litigation in South Africa

This article investigates the impact of rights-based litigation on social struggles in the South African health sector. It considers the manner in which individuals and social movements have utilized rights and the legal process in their efforts to dismantle the ill-health/poverty cycle, in the particular context of the struggle for universal access to treatment for HIV/AIDS. Relying on literature concerning the transformative potential of socio-economic rights litigation and on examples from South African case law, the article critically evaluates the gains that have been made and the obstacles that have been encountered in this context. It argues that rights-based litigation presents a powerful tool in the struggle against poverty, but also elaborates on structural and institutional hurdles that continue to inhibit the effectiveness of rights-based strategies in this regard.     

A human rights critique of the United Kingdom's HIV response

The National AIDS Trust (NAT) is the United Kingdom's leading HIV policy and advocacy NGO. NAT is committed to promoting a human rights framework for HIV responses through work with communities, governments, professionals, and the private sector, both within the UK and internationally. In this presentation to the XIII International AIDS Conference (abstract WeOrE524), John Godwin and Saul Walker discuss current human rights issues related to HIV/AIDS in the UK, and NAT's perspective on the International Guidelines on HIV/AIDS and Human Rights as an advocacy tool.