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The relationship between the HIV, Disability and the CRPD.

Charlotte McClain-Nhlapo July 26th 2012.

Cross cutting issues HIV like Disability, are not just health

issues- but rather sets of complex constructs with underlying societal inequities and injustices.

The broader social and cultural context of the HIV epidemic and Disability require an understanding of the unique barriers that persons with disabilities and those living with HIV experience.

Stigma and Discrimination Stigma > vulnerability to discrimination.

Discrimination can be both a cause and a consequence of human rights violations.

Requires the removal of socially constructed barriers.

Failure to provide reasonable accommodate is discrimination.

The intersectionality …..

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A symbiotic relationship The HIV and AIDS international human

rights framework and disability is mutually reinforcing and complementary.

The CRPD framework and HIV and AIDS is also synergistic.

Many of the attitudinal barriers are similar.

An inclusive approach Takes into account human rights

principles i.e.• non-discrimination• equality • accessibility • participation

• All contained in CRPD and reflected in all core UN human rights treaties.

Political Declaration on HIV and AIDS (2011)

UN General Assembly recognizes the adoption of the Convention on the Rights of Persons with Disabilities and emphasizes the need “to take into account the rights of persons with disabilities as set forth in the Convention, in particular with regard to health, education, accessibility and information, and in the formulation of our global response to HIV and AIDS.”

Add value of the Rights Based Approach It is a comprehensive approach Seeks to develop inclusive laws, policies

and programming that promote inclusion in all aspects of society.  • That codify equality of access to a

continuum of rights• Protect the most vulnerable• Provide for redress

CRPD as a tool Art. 8 Awareness raising is an important

article in the fight against AIDS for persons with disabilities.

Art. 13 Access to justice in the event that redress is being sought out

Art. 21 Freedom of expression & opinion &access to information

Art 22. Respect for privacy

Developing Legal Frameworks at national level

UNAIDS highlights the importance of protecting the rights of persons affected by and vulnerable to HIV through national legal frameworks.

Three areas of focus: • Empowering communities to have

access to justice.• Ensuring respect for human rights in

the context of law enforcement.• Creating enabling law and policy

frameworks 10

Let’s keep talking about inclusion- Thank you !

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HIV Infection, Disability and Mental Illness

Francine Cournos, M.D.Professor of Clinical Psychiatry (in Epidemiology)

Mailman School of Public HealthColumbia University

fc15@columbia.edu

July 26, 2012

This talk primarily focuses on the five mental illnesses most commonly associated with disability: depression, alcohol use disorder, schizophrenia, bipolar disorder, and drug use disorders.

This talk does not address intellectual disabilities, developmental disorders, or neurological illnesses such as epilepsy.

Mental Disabilities: Focus of This Talk

5 Mental Illnesses Are among the Top 10 Causes of Years Lost to Disability (YLD) Worldwide

WHO, Global Burden of Disease, 2008 Update

Why is Mental Illness Such a Common Cause of Disability?

Mental disorders are relatively common illnesses.

In all regions of the world, neuropsychiatric conditions are the most important causes of disability, accounting for about one third of years lost to disability (YLD) among adults 15 years or older

Mental disorders often begin in childhood--about half have onset before the age of 14--creating the possibly of lives lived for many years with disability.

WHO, Global Burden of Disease, 2008 Update, and other references

Why is Mental Illness Such a Common Cause of Disability?

Mental illnesses cause more severe disability than most medical illnesses. That makes sense: the brain is the central control center for the body.

Severe depression and acute psychosis are classified by WHO as more disabling than AIDS not on antiretroviral drugs, congestive heart failure, tuberculosis and the neurological consequences of malaria.

A person with one mental illness is at increased risk for another mental illness; co-morbidity among mental disorders is very common.

WHO, Global Burden of Disease, 2008 Update, and other references

Why is Mental Illness Such a Common Cause of Disability?

Mental illness is undertreated due to stigma, low priority in global and country level funding; and lack of community care, trained health care workers, psychotropic medications, psychotherapy and rehabilitation.

Many people with mental illness are not in environments that assist them to function well; they may be institutionalized, homeless, ignored and/or become victims of human rights abuses.

WHO, Global Burden of Disease, 2008 Update, and other references

Severely limited HIV prevention services

Drug injection

High rates of unsafe sexual behavior, including those mediated by being high on alcohol or drugs

Increased sex between men in institutional settings

High rates of coerced sex High rates of exchanging sex for essentials (like

food or a place to stay) or drugsMental illness stigma that limits choice of sexual

partners

Many Factors Put People with Mental Disabilities at Risk for HIV Infection

Published studies of HIV infection rates in U.S. and African Psychiatric Hospitals:

• South Africa 27%• Zimbabwe 24%• Uganda 18%• United States 3-23%

High Rates of HIV Infection Are Found Among People Hospitalized for Severe Mental Illness

In Addition, Mental Illnesses Often Precede HIV Infection Among Most At Risk Populations

IDU: High rates of alcohol/substance use disorders and depression

MSM: Elevated rates of alcohol/substance use disorders, depression and anxiety disorders

Sex Workers: Elevated rates of addictive disorders and posttraumatic stress disorder

American Psychiatric Association Practice Guidelines and other reference documents www.psych.org/aids

Worldwide studies reveal that depression and alcohol/substance use disorders are associated with increased morbidity and mortality among people with HIV infection.

Contributing factors include the association of depression and/or alcohol/substance use with

• Failure to access HIV care and treatment• Failure to adhere to antiretroviral treatment (ART) once it has

been started• Prolonged time to viral suppression on ART• Early failure of viral suppression on ART• Possible direct effects on the immune system

Mental Illness Among HIV+ People: Impact on Morbidity/Mortality

The Good News Regarding HIV and People with Mental Disabilities

Treatments for mental illness compare favorably to treatments for medical illness in cost and outcome.

There are well developed guidelines for screening and treating mental illnesses in primary care and HIV care.

People with mental disabilities respond well to HIV prevention strategies and reduce their risk behaviors.

People with psychotic disorders (such as schizophrenia) are as adherent to antiretroviral treatment as the general population.

We will make great progress in upholding human rights by implementing the mental health and HIV services that have been proven to work.

Integration work began in 2007 and is ongoing

From the beginning it was a partnership:• The government of Rwanda • Ndera Neuropsychiatric Hospital • ICAP at Columbia University; PEPFAR funding; CDC• Other stakeholders meeting in technical working group

Accomplishments:• Surveying needs and resources for HIV/MH integration• Beginning implementation at Ndera Neuropsychiatric Hospital • Testing all consenting and capable inpatients at Ndera for HIV

infection, later followed by testing of outpatients

Case Example: Integrating HIV and Mental Health Care in Rwanda

Accomplishments, con’t• As of 2011 >1200 patients tested; among inpatients, HIV+ rate

about 10%; lower rates among outpatients; half of infected inpatients were newly identified

• HIV+ patients were enrolled in HIV care and treatment, usually at Ndera

• Implementation begins at district hospitals• Instruments selected and translated for screening patients in

HIV care for mental illness• Health care providers received training in mental disorders and

use of instruments.• Screening implemented with referral to mental health nurses

for those who screen positive for mental illness

Case Example: Integrating HIV and Mental Health Care in Rwanda

Challenges• Overcoming resource limitations in the areas of available

mental health/health care providers, mentors, psychotropic medications, psychotherapies and alcohol/substance use treatments

• Training clinicians to better distinguish between delirium and mental illness

• Improving research/evaluation to guide implementation efforts and improve adaptation to the Rwandan context.

Case Example: Integrating HIV and Mental Health Care in Rwanda