Africa’s HIV transmission laws based on questionable science

Africa’s HIV transmission laws based on questionable science
by Cassandra Willyard, New York
Nature Medicine 13, 890 (2007)
Published online: 31 August 2007

Faced with an AIDS epidemic that kills millions every year, countries in sub-Saharan Africa are contemplating a new prevention strategy: criminal charges.

Uganda, touted as the rare success story in the region, is the latest nation to propose a law that would criminalize knowingly transmitting HIV to another person, the country’s health minister announced in June. Since 2001, Zimbabwe, Lesotho and Swaziland have also adopted similar laws.

Few say the laws do what they’re intended to: reduce the spread of HIV. “They make lawmakers feel good, but they have very limited positive benefits for the public,” says Jonathan Berger, head of policy and research at the Johannesburg-based AIDS Law Project.

Apart from stigmatizing the disease more than it already is, critics warn, the laws ignore the fact that these countries may not have the resources to perform the careful genetic analysis required to distinguish the innocent from the guilty.

Phylogenetic analysis helps pinpoint how closely related two isolates of HIV are. In a criminal case, a virologist would obtain genetic sequences of the virus from both parties involved and compare them to sequences in a database, such as the US National Institutes of Health’s GenBank, or from other infected individuals in the community.

If the viruses appear more closely related to each other than they are to samples taken from the larger population, it increases the likelihood that one person infected the other.

The procedure has its limitations, however. “It doesn’t say anything about the direction of movement. It doesn’t say anything about timing. It doesn’t even really say that the transmission took place between the two people,” says Yusef Azad, director of policy and campaigns at the National AIDS Trust, a UK-based advocacy group. “They both could have been infected by a third party.”

Still, phylogenetics can exonerate the innocent. If the two HIV samples aren’t closely related, it’s unlikely one person could have infected the other. “The greatest power of it is exculpatory,” says Gerald Learn, a microbiologist at the University of Washington. “If I was a defense lawyer, I would insist on it.”

But the procedure is complicated and costly. “Scientists who are not trained in this field couldn’t just read published reports and try to do this on their own without having the proper tools,” says Michael Metzker, assistant professor of molecular genetics at the Baylor College of Medicine in Houston.

Genetic analysis of each HIV sample can require more than 100 sequences, with a price tag between $1 and $5 per sequence—no small sum in a developing country.

A few labs in Uganda are equipped to do the analyses, says Maria Wawer, a professor of population, family and reproductive health at Johns Hopkins University who conducts research in Uganda. “But it is likely to remain too expensive for the foreseeable future,” she says.

Courts in these countries may instead rely on circumstantial evidence, raising the risk of wrongful convictions.

“In the absence of really clear scientific evidence as to who infected whom,” says Azad, “there will too often be an assumption that those categorized as undesirable by society are guilty of infecting other people.”

In 2002, UNAIDS argued against laws that penalize HIV transmission, recommending instead that responsible individuals be prosecuted using standard criminal laws, notes Azad. “Any legislation which singles out HIV for this kind of criminal sanction is breaching international human rights guidelines.”

Australia: Editorial argues epidemiological information should be used to prosecute ‘reckless’ individuals

An editorial in The Age argues that Australia’s HIV Epidemiology Project should be used to track down individuals who are ‘reckless’ so that they can be prosecuted.

This is not only unethical, it is also not scientifically possible given the uncertainties inherent in phylogenetic analysis – the scientific method used when assessing the relationship between HIV genotypes.

A suitable case for treatment. Unsuitable for restriction.
Editorial, The Age
May 14, 2007

The battle against HIV/AIDS in Australia is being waged on shifting territory. In one area there is solid ground: the promise of scientific vigilance to find factors contributing to the rise in infection rates, particularly in Victoria. Elsewhere is a darker, more treacherous landscape: the threat of politically initiated assessments of HIV-positive visitors to Australia and the possibility they could be banned altogether. Both initiatives originate from the Federal Government.

As The Age reports today, the Government’s Health Protection Committee has chosen a team of Victorian scientists to analyse HIV infections over the past three years to determine who or what is responsible for the rise in national infection rates from 656 cases in 2000 to 930 in 2005, an increase of 41 per cent; in this state HIV infection is at its highest level for 20 years: in 2006, 334 cases of HIV were reported to the Department of Human Services, an increase of 17 per cent on the previous year. As part of its investigation, the HIV Epidemiology Project will examine whether genotyping HIV infections – developing a genetic profile of the virus in patients – could help identify groups of individuals transmitting the virus. Three men, including a Melbourne man, Michael John Neal, are before Australian courts on charges of recklessly or deliberately infecting others with HIV.

Although civil-rights groups representing people living with HIV and AIDS have raised ethical concerns over genotyping – previously used only in criminal cases or to determine a virus’ resistance to drugs – the Health Minister, Tony Abbott, who approved the project last month, has said the research is aimed at gathering information on risk groups and not tracking down individuals. This has been supported by the head of the Infectious Disease and Epidemiology Unit at Monash University, Dr Karin Leder, who says risk groups are the focus of the first phase of the project, with any future investigation of individuals dependent on the data received. If, however, this leads to the identification of HIV-positive individuals who, through indiscriminate recklessness are endangering the lives of others, then surely public safety must take precedence over rights to privacy.

The HIV Epidemiology Project should be welcomed. At the very least, it represents a national approach to what is really a national problem, as well as a significant step towards proper research into a condition that knows no boundaries. Any sensible measure that can lead to a reduction in the HIV infection rate cannot be discounted, especially when news of the project comes at the same time as Government funding of almost $10 million over four years for a national HIV-prevention program, including a new media campaign. The project should also, by default, begin to restore confidence in a health system beleaguered by last month’s breakdown in bureaucratic communication at Victoria’s Department of Human Services; this led to the sacking of the state’s chief health officer, Dr Robert Hall, by his minister, Bronwyn Pike, over alleged non-disclosure of three HIV-positive people under police investigation.

A far more sensitive issue, one that stigmatises rather than helps HIV sufferers, is the intention of the Prime Minister, John Howard, to restrict or perhaps ban such infected people from entering the country. Mr Howard has written to his immigration and health ministers seeking advice on the public-health implications of letting HIV-positive people into Australia. This follows Mr Howard’s response last month, when asked about allowing in HIV-positive immigrants, “My initial reaction is no”. Mr Howard also said there could be “humanitarian considerations”.

Some countries, including the United States, Russia and the United Arab Emirates, have absolute bans on HIV sufferers; others, such as Britain and France, are more tolerant. It is difficult to see how Australia could benefit from becoming an HIV exclusion zone without being seen to be unnecessarily discriminatory or alarmist. It would be better for the Government to concentrate on the more effective methods of control through scientific research and public awareness.

Australia: Federal goverment plans HIV genotype database to ‘trace reckless infections’

‘The Age’ reports on the HIV Epidemiology Project which may be used to trace people who criminally transmit HIV.

Full report below:

Plan to genetically trace reckless HIV infections
Julia Medew
April 28, 2007

People who have recklessly or deliberately infected others with HIV could be genetically traced under a project approved by the Federal Government.

Documents obtained by The Age reveal the project will investigate whether genotyping HIV infections — developing a genetic profile of the virus in patients — could identify groups of people or individuals responsible for transmitting the virus.

The approach, believed to be a world first, was approved by Health Minister Tony Abbott earlier this month after several high-profile cases raised concern about how HIV positive people were being managed by health authorities.

Three men, including Melbourne man Michael John Neal, are before Australian courts on charges of recklessly or deliberately infecting others with HIV.

Under the plan, titled HIV Epidemiology Project, a team of scientists will be asked to examine the epidemiology of current HIV infection in Australia, including infections in high-risk groups such as homosexual men, injecting drug users and migrants and refugees gaining entry to the country.

They will also look at the movement of HIV positive people across the nation and behaviour that could be contributing to rising infection rates. HIV infections have surged 41 per cent across Australia from 656 cases in 2000 to 930 in 2005.

Associate Professor Andrew Grulich, head of the HIV Epidemiology and Prevention Program run by the National Centre in HIV Epidemiology and Clinical Research, welcomed news of the project but said any effort to map the transmission of HIV across the nation in recent years would be controversial and extremely difficult.

“(Genotyping) may be of use for investigating particular individuals who are alleged to be behaving irresponsibly but at a population level there is more doubt about whether it would be useful,” he said.

Dr Grulich believed a national approach to genotyping HIV infections would be a world first. It is only used in criminal cases or to determine a virus’ resistance to drugs, he said.

Health Minister Tony Abbott said the project was not designed to target individuals for criminal prosecution, but to help public health education campaigns. “If AIDS is still very much a disease of gays and drug users, there is not much point running a campaign pitched to the general public,” he said.

Jamie Gardiner, a vice-president of Liberty Victoria, said any project designed to point the finger at particular people would undermine the public health approach to HIV that Australia had used since the 1980s.

“It’s hard to imagine that ethics approval would be granted for a project like this. This is a project whose purpose is not about the curing or prevention of illness but one that is being perverted for the pursuit of inappropriate criminal justice objectives,” he said.

Brett Hayhoe, president of People Living with HIV/AIDS Victoria, said “The last thing we need is for an already marginalised community to be marginalised and victimised more.”