Articles tagged as "Human rights / ethics / law and intellectual property"

Universal Access

Steinbrook R. Message from Toronto--deliver AIDS treatment and prevention. N Engl J Med 2006;355:1081-4. http://content.nejm.org/cgi/content/full/355/11/1081

In this perspective article, Robert Steinbrook looked back on the Toronto AIDS conference arguing that the growth of the pandemic continues to outpace the broad and expanding efforts to control it. Since HAART became available a decade ago, the treatment of HIV infection has been streamlined — for example, from 10 pills daily taken in three doses with food restrictions to as little as 1 pill once a day. Many presentations at the conference showed that treating HIV is feasible in all countries. The best price for a first-line regimen of generic antiretroviral drugs in low-income countries is now about US$130 a year for adults (down from US$285 in April 2004) and less than US$200 a year for children. In 2005, there were an estimated 4.1 million people newly infected with HIV and 2.8 million AIDS-related deaths. The author reviews resource needs and estimates of actual funding, coverage of specific prevention programmes, and includes a chart which compares coverage of antiretroviral treatment by country. Countries with less than 35% of those in need on treatment include Trinidad and Tobago, Burkina Faso, Zambia, Chad, Benin, Cameroon, South Africa, Kenya, Burundi, China, Malawi, and Ethiopia. He then summarises biomedical approaches to prevention currently being evaluated, often in large controlled trials. These include cervical barriers, such as the diaphragm; therapy to suppress herpes simplex virus type 2, the primary cause of genital herpes (a risk factor for acquiring and transmitting HIV); microbicides that could be applied to the vagina or rectum; male circumcision; pre-exposure prophylaxis with antiretroviral drugs; and expanded treatment of infected persons not only for their own health but also to prevent HIV transmission. He then highlights the consensus view that providing antiretroviral therapy to subjects who acquire HIV infection during the course of a study is an indispensable part of the agreement between trial sponsors and trial participants. He suggests that there is disagreement, however, about the obligation to people whose infection is detected when they are screened for trial eligibility, as well as about who should assume the long-term financial costs and manage the complexity of treatment – trial sponsors, the country where the trial is conducted, an international fund, or someone else. Although trial participants are unlikely to need treatment until years after they become infected, they will eventually need it for life.

Editors’ note: UNAIDS is following up on the recommendations of an international consultation on creating effective partnerships for HIV prevention trials in 2005. The whole process, which included three regional consultations, was initiated as a result of the suspension of the tenofovir trials in Cambodia and Cameroon. We are planning three meetings over the coming months to address three specific recommendations: to develop Good Community Practice Guidelines which outline processes, procedures, and minimum requirements for community engagement in HIV prevention research; to identify programmatic and financing approaches for providing care and treatment to people who develop intercurrent infections (or who are screened out at recruitment for HIV prevention trials because they are found to be HIV-positive); and to revise and update the 2000 UNAIDS guidance document on ethical considerations in HIV preventive vaccine research (to be expanded to apply to all HIV prevention trials).

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Legal Structural Determinants

Burris S, Blankenship KM, et al. Addressing the “risk environment” for injection drug users: the mysterious case of the missing Cop. The Milbank Quarterly 2006; 82, 125–56

Ecological models of the determinants of health and the consequent importance of structural interventions have been widely accepted, but using these models in research and practice has been challenging. Examining the role of criminal law enforcement in the “risk environment” of injection drug users (IDUs) provides an opportunity to apply structural thinking to the health problems associated with drug use. Burris and colleagues reviewed international evidence that laws and law enforcement practices influence IDU risk, and conclude that more research is needed at four levels – laws; management of law enforcement agencies; knowledge, attitudes, beliefs, and practices of frontline officers; and attitudes and experiences of IDUs – and that such research can be the basis of interventions within law enforcement to enhance IDU health.

Editors’ note: Research is needed but, pending results, there are already examples from several countries to draw on of local responses meeting an urgent and visible crisis of HIV and IDU, which are advocated and championed by informed, skilled, respected, committed and concerned public health officials, community groups, and pragmatic local law enforcement officials.

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Human Rights and Law

Hogerzeil HV, Samson M, et al. Is access to essential medicines as part of the fulfilment of the right to health enforceable through the courts? Lancet 2006; 368:305-311.http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673606690764.pdf

Most countries in the world have become States parties to one or more international human rights treaties, thus creating an obligation by the State to its people towards the realisation of the right to health, which includes access to essential medicines. But whether such access is enforceable in practice is unknown. Hogerzeil and colleagues did a systematic search to identify completed court cases in low-income and middle-income countries in which individuals or groups had claimed access to essential medicines with reference to the right to health in general, or to specific human rights treaties ratified by the government. They identified and analysed 71 court cases from 12 countries in which access to essential medicines was claimed with reference to the right to health. The authors found that in 59 cases, access to essential medicines as part of the fulfilment of the right to health could indeed be enforced through the courts, particularly in Central and Latin America. Success was mainly linked to constitutional provisions on the right to health, supported by the human rights treaties. Other success factors were a link between the right to health and the right to life, and support by public-interest non-government organisations. Individual cases have generated entitlements across a population group, the right to health was not restricted by limitations in social security coverage, and government policies have successfully been challenged in court. Hogerzeil and colleagues conclude that skilful litigation can help to ensure that governments fulfil their constitutional and international treaty obligations. Such assurances are especially valuable in countries in which social security systems are still being developed. However, redress mechanisms through the courts should be used as a last resort. Rather, policymakers should ensure that human rights standards guide their health policies and programmes from the outset.

Editors’ note: If you are interested in reading more about similar advances achieved in the HIV field, take a look at the excellent publication in the UNAIDS Best Practice Collection entitled "Courting Rights: Case studies in litigating the human rights of people living with HIV".

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Schneider H, Blaauw D, et al. Health Systems and Access to Antiretroviral Drugs for HIV in Southern Africa: Service Delivery and Human Resources Challenges. Reprod Health Matters 2006;14:12-23. http://www.sciencedirect.com/science/journal/09688080

Without strengthened health systems, significant access to antiretroviral therapy in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges to scaling up antiretroviral access in countries with both massive epidemics and weak health systems. The authors draw on their experience in southern Africa and on the WHO framework on health system performance. Whilst acknowledging the still significant gap in financing, the paper focuses on the challenges of reorienting service delivery towards chronic disease care and the human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers are increasingly regarded as key systems constraints to scaling up HIV treatment. Problems, however, go beyond the issue of numbers to include productivity and cultures of service delivery. As more countries receive funds for antiretroviral access programmes, strong national stewardship of these programmes becomes increasingly necessary. The authors propose a set of short- and long-term stewardship tasks, which include resisting the verticalisation of HIV treatment, evaluating community health workers and their potential role in HIV treatment access, undertaking international action on the brain drain, and making greater investments in the national human resource functions of planning, production, remuneration and management.

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