Source: https://www.hhrjournal.org/2016/11/hiv-hepatitis-c-tb-harm-reduction-and-persons-deprived-of-liberty-what-standards-does-international-human-rights-law-establish-2/
Timestamp: 2019-04-18 11:42:30+00:00

Document:
HIV, hepatitis C virus (HCV), and TB in prisons and other places of detention are serious public health concerns, with prevalence and incidence considerably higher than in the general community because of the overrepresentation of risky behavior, substandard conditions, overcrowding, people who inject drugs, and the wholly inadequate prevention, care, and treatment of these conditions, including the denial of harm reduction services. This is not only a severe public health crisis but also a serious human rights concern. This article works to clarify the standards established by human rights law with regards to HIV, HCV, TB, and harm reduction in prisons by examining international and regional case law, minimum standards on the treatment of prisoners and public health, as well as the work of UN treaty bodies, Special Rapporteurs, and prison monitoring bodies. It is imperative that urgent steps are taken to close the gap between human rights and public health standards on the one hand, and effective implementation in prison settings on the other.
HIV, hepatitis C virus (HCV), and tuberculosis (TB) epidemics are a major public health concern around the world. Although all affect the population at large, they have emerged as an especially severe problem in prisons and other places of detention worldwide. Prison populations have a significantly higher prevalence, and in some contexts a higher incidence, of these diseases than the general public. A recent review of the global epidemiology of HIV, HCV, and TB in prisoners estimated that, of the roughly 10 million people detained worldwide on any given day, 3.8% are living with HIV, 15.1% with HCV, and 2.8% with active TB.1 Throughout this article, the terms ‘prison,’ ‘detention’ and ‘closed settings’ are used interchangeably to refer to all places where people are deprived of their liberty. Similarly, the term ‘prisoner,’ ‘detainee’ and ‘people deprived of their liberty’ are used interchangeably to refer to all persons deprived of their liberty.
Intensifying this risk of infection and related ill health are the substandard conditions in which detainees are frequently held. Overcrowding, poor sanitation, inadequate ventilation and means for maintaining personal hygiene, and lack of access to clean drinking water and nutritional food are common in prisons and contribute to high rates of disease and death. These poor conditions invariably exist within a climate of violence, humiliation, and discrimination that creates barriers to accessing health care services, which are often weak or inadequate to begin with.
Ill health and poor conditions in prisons do not only concern prisoners and prison staff; they are issues of much wider public health concern. Around one-third of people incarcerated worldwide return to their communities every year, and because recidivism is common, especially among people who use drugs, there is a high degree of mobility between prison and community.7 Prison health, therefore, is intimately connected to public health.8 This is not just a public health concern, however, but also a human rights imperative.
Under international human rights law, persons deprived of their liberty retain all fundamental rights and freedoms, apart from those that are unavoidably restricted by the fact of their incarceration.9 Like all persons, therefore, detainees have a right to health.
The highly generalized language used to articulate health rights in human rights treaties does not shed much light on the specific entitlements and obligations to which they give rise. UN treaty bodies, however, have provided useful operational guidance in their work to help understand the contours and content of particular rights. According to the UN Committee on Economic, Social and Cultural Rights (CESCR), for example, the right to health is not a right to be healthy; rather, it is an inclusive right that extends not only to timely and appropriate medical care, but also to the underlying determinants of health, such as access to adequate sanitation facilities, healthy environmental conditions, essential drugs, and health-related education and information.13 This broad understanding of the right to health is important in the context of places of detention.
The right to participation, the basic right of people to have a say in matters that affect their lives, has been described as the right of all rights.76 While the essential role of participation in realizing fundamental human rights has been explicitly recognized in all legally binding human rights treaties, it is particularly important in realizing the right to health. CESCR and the former Special Rapporteur on the right to health have identified participation in all health-related decision-making as an important component of the right to health, as well as one of the underlying determinants of health.77 One of the core obligations of the right to health is the provision for participation in the development, implementation, and review of the national health plan that focuses on issues affecting the most vulnerable and marginalized, as well as in the health policies and interventions flowing from that plan.78 In reality, it may not be possible to ensure everyone’s participation, but the government has an immediate obligation to obtain a representation of views, particularly of those most vulnerable and marginalized.
Importantly, individuals have a right to “active and informed” participation, which relies on institutional arrangements and specific mechanisms to ensure participation at different stages, as well as capacity-building activities to ensure that people have the ability to participate meaningfully and effectively.79 In this context, it is important to note that informed participation relies on the right to health-related education and information.
People retain their human rights during incarceration, including their right to the highest attainable standard of health. There is an enormous gap, however, between public health and human rights standards on the one hand, and effective implementation in custody settings on the other. Data revealing the high prevalence rates inside places of detention compared to those in the broader community, for example, demonstrate that this is particularly the case with regards to HIV, HCV, and TB. Despite their vulnerability to ill health, persons deprived of liberty are much less likely to have access to adequate prevention, care, and treatment of these diseases, including harm reduction services. Additionally, they are often held in substandard conditions that favor the transmission of diseases. This clearly creates an imperative for increased and ongoing attention to HIV, HCV, and TB in places of detention, including a focus on the urgent need to scale up harm reduction in these settings.
Gen Sander, LLM is Human Rights Analyst at Harm Reduction International, London, United Kingdom.
Rick Lines, PhD is Executive Director of Harm Reduction International, London, United Kingdom.
Please address correspondence to the authors c/o Gen Sander, Harm Reduction International, Unit 2C09 Southbank Technopark, 90 London Road, London, SE1 6LN. Email: Gen.Sander@hri.global.
This research was co-funded by the European Commission under the Criminal Justice Programme. The contents of this publication are the sole responsibility of the authors and can in no way be taken to reflect the views of the European Commission.
Copyright © 2016 Sander and Lines. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
K. Dolan, A.L. Wirtz, B. Moazen, et al. “Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees,” The Lancet (July 14 2016).
Joint World Health Organization/Russian Federation International Meeting on Prison Health and Public Health: Moscow Declaration on Prison Health as part of Public Health, Moscow 23-24 October 2003. Available at: http://www.euro.who.int/__data/assets/pdf_file/0007/98971/E94242.pdf?ua=1.
United Nations Office on Drugs and Crime, World Drug Report 2016 (United Nations publication, Sales No. E.16.XI.7); UN Joint Programme on HIV/AIDS (UNAIDS), the GAP report, July 2014. Available at: http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf.
K. Dolan, B. Moazen, A. Noori, et al. “People who inject drugs in prison: HIV prevalence, transmission and prevention,” International Journal of Drug Policy 26 (2015) S12-S15.
See K. Stone, Global state of harm reduction 2016 (London: Harm Reduction International, 2016); and Dolan et al (2016, see note 2).
Dolan et al (2015, see note 7).
See, for example, Moscow Declaration on Prison Health as part of Public Health (2003, see note 3).
UN Human Rights Committee, General Comment No. 21: Article 10 (Humane treatment of persons deprived of their liberty), UN Doc. HRI.GEN.1.Rev.1 (1992), para. 3.
These include the International Covenant on Civil and Political Rights (ICCPR); the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT); the Convention on the Elimination of Discrimination Against Women (CEDAW); the Convention on the Rights of the Child (CRC); the Convention on the Rights of People with Disabilities (CRPD); the European Convention for the Protection of Human Rights and Fundamental Freedoms; The European Convention for the Prevention of Torture and Inhuman and Degrading Treatment or Punishment; the European Social Charter; the African Charter on Human and Peoples’ Rights; and the Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights.
R. Lines, “The right to health of prisoners in international human rights law,” International Journal of Prisoner Health 4(1) (March 2008), p. 11.
A. Grover and J. Gaziyev, “A Contribution by the Special Rapporteur on the Right to Health: Right to Health and Freedom from Torture and Ill-Treatment in Healthcare Settings,” Torture in Healthcare Settings: Reflection on the Special Rapporteur on Torture’s 2013 Thematic Report, Centre for Human Rights and Humanitarian Law Anti Torture Initiative (2013), p. 17. Available at: http://antitorture.org/wp-content/uploads/2014/03/PDF_Torture_in_Healthcare_Publication.pdf.
Committee on Economic, Social and Cultural Rights, General Comment 14: The right to the highest attainable standard of physical and mental health, UN Doc. E/C.12/2000/4 (2000), para. 11. Available at: http://www.ohchr.org/Documents/Issues/Women/WRGS/Health/GC14.pdf.
Lines (2008, see note 13).
Committee on Economic, Social and Cultural Rights (2000, see note 15), para 43(a).
R. Lines, “From equivalence of standards to equivalence of objectives: The entitlements of prisoners to health care standards higher than those outside prisons,” International Journal of Prisoner Health 2(4) (December 2006), pp. 269-280.
Committee on Economic, Social and Cultural Rights (2000, see note 15), para. 37.
A. Grover, UN Special Rapporteur on the Right to the highest attainable standard of physical and mental health, Report of the UN Special Rapporteur on the Right to the highest attainable standard of physical and mental health, UN Doc. A/65/255 (August 6, 2010) para. 60. Available at http://www.ohchr.org/Documents/Issues/Water/ContributionsStigma/others/SPhealthI.pdf.
See Council of Europe, Recommendation (2006)2 of the Committee of Ministers to member states on the European Prison Rules (January 11, 2006), para. 40.3; UN General Assembly, Basic Principles for the Treatment of Prisoners, UN Doc. A/RES/45/111 (14 December 1990), principle 9. Available at http://www.un.org/documents/ga/res/45/a45r111.htm; and UN General Assembly, Revised UN Standard Minimum Rules for the Treatment of Prisoners (the Mandela Rules), UN Doc. A/RES/70/175 (8 January 2016), Rule 24(1). Available at: http://16889-presscdn-0-48.pagely.netdna-cdn.com/wp-content/uploads/1957/06/ENG.pdf.
See, for example, UNODC, WHO, UNAIDS, HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings – A Framework for an Effective National Response (New York, 2006). Available at: https://www.unodc.org/pdf/HIV-AIDS_prisons_July06.pdf; and UNAIDS, Prisons and AIDS (1997). Available at http://data.unaids.org/Publications/IRC-pub05/prisons-pov_en.pdf.
See, for example, UNODC, WHO, UNAIDS, (2006, see note 22); WHO, Guidelines on HIV infection and AIDS in prisons (1993); UN General Assembly (1990, see note 21); Council of Europe, Recommendation 2003/488/EC of 18 June on the prevention and reduction of health-related harm associated with drug dependence, (2003); Council of Europe, EU Action Plan on Drugs 2013-2016, 2013/C 351/01 (November 30, 2013); European Committee for the Prevention of Torture and Inhuman and Degrading Treatment or Punishment, CPT Standards, CPT/Inf(2002) 1 – Rev. 2015. Available at http://www.cpt.coe.int/en/documents/eng-standards.pdf; Gladkiy v. Russia (European Court of Human Rights, Application no. 3242/03, 21 December 2010) para. 84.
See, S. Greer, The Margin of Appreciation: Interpretation and Discretion under the European Convention on Human Rights (Council of Europe Publishing, Human rights files No. 17, 2000). Available at: http://www.echr.coe.int/LibraryDocs/DG2/HRFILES/DG2-EN-HRFILES-17(2000).pdf.
Grover (2010, see note 20) para. 60.
Committee on Economic, Social and Cultural Rights (2000, see note 15).
H. Hogerzeil, “Essential medicines and human rights: what can they learn from each other?” WHO Bulletin (2006). Available at http://www.who.int/bulletin/volumes/84/5/371.pdf.
World Health Organization, “The selection and use of essential medicines,” Report of the WHO Expert Committee 2005 (WHO Technical Report Series, No. 933, 2006).
K. Stone, Global state of harm reduction 2016 (London: Harm Reduction International, 2016).
See H. Stöver and I.I. Michels, “Drug use and opioid substitution treatment for prisoners,” Harm Reduction Journal, 7/17 (2010). Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918585/pdf/1477-7517-7-17.pdf.
UN Human Rights Council, Access to medicine in the context of the right of everyone to the highest attainable standard of physical and mental health, U.N. Doc. A/HRC/RES/12/24 (October 12, 2009).
Grover (2010, see note 20).
Juan Méndez, UN Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Report of UN Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, UN Doc. A/HRC/22/53 (1 February 2013). para. 55.
UN Human Rights Committee, Concluding observations of the seventh periodic report of the Russian Federation, UN Doc. CCPR/C/RUS/CO/7 (31 March 2015) para. 16.
Committee on Economic, Social and Cultural Rights (2000, see note 15) para. 34.
See, for example, Committee on Economic, Social and Cultural Rights (2000, see note 15) para. 11; and Committee on Economic, Social and Cultural Rights, Concluding observations to Ukraine, U.N. Doc. E/C.12/UKR/CO/5 (4 January, 2008).
UN Human Rights Committee, Concluding Observations to Georgia, UN Doc A/57/40 (2002) para. 78(7).
Manfred Nowak, UN Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Report of the UN Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, UN Doc. A/HRC/10/44 (14 January, 2009) para. 71.
Gladkiy (2010, see note 24) para 88.
Barilo v. Ukraine (European Court of Human Rights, Application no. 9607/06, 16 May 2013), para. 68. See also Hummatov v. Azerbaijan (European Court of Human Rights, Application nos. 9852/03 and 13413/04, 29 November 2007), para. 116.
See, for example, the following European Court of Human Rights cases: M.S. v. Russia (Application no. 8589/08, 10 July 2014); Koryak v. Russia (Application no. 24677/10, 13 November 2012); Gladkiy (2010, see note 22); Menchenkov v. Russia (Application no. 35421/05, 7 February 2008); and Khudobin v. Russia (Application no. 59696/00, 26 October 2006).
Khudobin v. Russia (European Court of Human Rights, Application no. 59696/00, 26 October 2006).
See Koryak v. Russia (European Court of Human Rights, Application no. 24677/10, 13 November 2012), para. 108; and A.B. v. Russia (European Court of Human Rights, Application no. 1439/06, 14 October 2010) para. 134.
Kozhokar v. Russia (European Court of Human Rights, Application no. 33099/08, 16 December 2010) para. 115.
Wenner v. Germany (European Court of Human Rights, Application no. 62303/13, 1 September 2016) para. 79.
McGlinchey and Others v. UK (European Court of Human Rights, Application no. 50390/99, 29 July 2003), para 57.
See, UN General Assembly (2016, see note 21), Rule 24; and Council of Europe (2006, see note 21), para. 39.
UNODC, WHO, UNAIDS, (2006, see note 22), para. 48.
UN General Assembly (2016, see note 21), Rule 24 (2).
See, for example, World Medical Association, Declaration of Edinburgh on Prison Conditions and The Spread of TB and Other Communicable Diseases (October 2011).
Committee on Economic, Social and Cultural Rights, (2000, see note 15), para 44(c).
See, Committee on Economic, Social and Cultural Rights, Concluding Observations to Moldova, UN Doc. E/2004/22 (2003) para. 337; and Committee on Economic, Social and Cultural Rights, Concluding Observations to the Russian Federation, UN Doc. E/C.12/RUS/CO/5 (2011) para. 29.
Nowak (2009, see note 42) para. 74.
Human Rights Committee, Concluding observations to Moldova, UN Doc. CCPR/CO/75/MDA (2002) para. 9.
Melnik v. Ukraine (European Court of Human Rights, Application no. 72286/01, 28 March 2006) paras. 104-106.
Staykov v. Bulgaria (European Court of Human Rights, Application no. 49438/99, 12 October 2006), paras. 81-82.
See, for example: World Health Organization, Guidelines on HIV infection and AIDS in prisons, (Geneva: 1993); World Medical Association, Declaration of Edinburgh on Prison Conditions and the Spread of TB and Other Communicable Diseases, Adopted by the 52nd WMA General Assembly, (Edinburgh, Scotland, October 2000), and revised by the 62nd WMA General Assembly (Montevideo, Uruguay, October 2011); The Madrid Recommendation, Health Protection in Prisons as an Essential Part of Public Health, (Spain: World Health Organization, October 2009); UNODC (2006, see note 50); and Council of Europe, Committee of Ministers, Recommendation No. R (98) 7 of the Committee of Ministers to Member States Concerning the Ethical and Organisational Aspects of Health Care in Prison, Adopted by the Committee of Ministers on 8 April 1998.
European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or punishment, 11th General Report on the CPT’s activities, CPT/Inf (2001)16 (3 September 2001) para. 31.
See, for example, UNODC, WHO and UNAIDS (2006, see note 21).
Committee on Economic, Social and Cultural Rights, Concluding Observations on Tajikistan, UN. Doc. E/C.12/TJK/CO/1 (24 November 2006) para. 70; and UN Committee on Economic, Social and Cultural Rights, Concluding Observations on Mauritius, UN. Doc. E/C.12/MUS/CO/4 (10 December 2012) para. 27.
Committee on Economic, Social and Cultural Rights, Concluding Observations on Tajikistan, UN. Doc. E/C.12/TJK/CO/1 (24 November 2006) para. 70.
See, for example, International Guidelines on HIV/AIDS and Human Rights (Geneva: OHCHR and UNAIDS, 2006 Consolidated Version); Principle of medical ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture and other cruel, inhuman or degrading treatment or punishment, (Adopted by the United Nations General Assembly, resolution 37/1994, appendix 1, December 18, 1982); and UNODC, WHO, UNAIDS (2006, see note 23).
See A. Grover, UN Special Rapporteur on the Right to the highest attainable standard of physical and mental health, Report of the UN Special Rapporteur on the Right to the highest attainable standard of physical and mental health, UN Doc. A/64/272, (10 August 2009); and Méndez (2013, see note 37).
See, for example, UN General Assembly (2016, see note 48) Rules, 26, 31 and 32.
European Committee for the Prevention of Torture and Inhuman or Degrading Treatment of Punishment (2001, see note 64) para 31.
Committee on Economic, Social and Cultural Rights, General Comment 4, The right to adequate housing, UN Doc. E/1992/23 (1991) para. 8(d).
UN General Assembly (2016, see note 48) Rules, 13, 14, 18, and 22.
See UN Committee Against Torture, Report of the Committee Against Torture, U.N. Doc. A/53/44 (1998); Manfred Nowak, UN Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, U.N. Doc. A/62/221 (13 August 2007), para. 9.
See the following European Court of Human Rights cases: Benedictov v. Russia (Application No. 106/02, 10 May 2007); and Kalashnikov v. Russia (Application no. 47095/99, 15 July 2002; and Ananyev and Others v. Russia (Application nos 42525/07 and 60800/08, 10 January 2012).
J. Waldron, “Participation: The right of rights,” Proceedings of the Aristotelian Society 98 (1998), pp. 307-337.
See, H. Potts and P. Hunt, Participation and the Right to the Highest Attainable Standard of Health (University of Essex Human Rights Centre, 2008) Foreword; Committee on Economic, Social and Cultural Rights, (2000, see note 13) para. 11.
Committee on Economic, Social and Cultural Rights, (2000, see note 13) para. 43(f).
See Potts and Hunt (2008, see note 78).
See, for example, L. Ferguson and E. Halliday, “Participation and human rights: impact on women’s and children’s health. What does the literature tell us?” in F. Bustreo, P. Hunt, S. Gruskin et al (ed) Women’s and Children’s Health: Evidence of Impact of Human Rights (Geneva: World Health Organization; 2013); Potts and Hunt (2008, see note 76).
UNODC, WHO, and UNAIDS (2006, see note 22), p. 13.
Council of Europe (2006, see note 21).
Grover and Gaziyev (2013, see note 14) p. 6.

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