Stigma and discrimination constitute one of the greatest barriers to dealing effectively with the HIV epidemic, underlying a range of human rights violations and hindering access to prevention, care, treatment and support. There is some existing protection against HIV-based discrimination under international law, but the extent of states' obligations to address such discrimination has not been comprehensively addressed in an international instrument.The United Nations Convention on the Rights of Persons with Disabilities entered into force in May 2008. As countries ratify the convention, they are required to amend national laws and policies to give greater protection to the human rights of people with disabilities, including abolishing disability-based discrimination by the state and protecting persons against such discrimination by others. The Disability Convention addresses many of the issues faced by people living with HIV (PLHIV) but does not explicitly include HIV or AIDS within its open-ended definition of "disability".Therefore, the advent of the Disability Convention prompts us to consider the links between HIV and disability and, specifically, to consider the opportunities it and other legal mechanisms, international or domestic, may afford for advancing the human rights of PLHIV facing human rights infringements. We do so in the belief that the movement for human rights is stronger when constituencies with so many common and overlapping interests are united, and that respectful and strategic collaboration ultimately strengthens both the disability rights and the AIDS movements.In this article, we first examine the links between HIV and disability. We then provide a brief overview of how international human rights law has treated both disability and HIV/AIDS. We note some of the different ways in which national anti-discrimination laws have reflected the links between HIV and disability, illustrated with representative examples from a number of countries. Finally, we offer some conclusions and recommendations about ways forward for collaboration between HIV and disability rights advocates in advancing human rights at the international level, including the use of the new tool that is the Disability Convention. We hope these reflections will promote further discussion across movements, ultimately to the benefit of all persons with disabilities and/or HIV. Stigma and discrimination constitute one of the greatest barriers to dealing effectively with the HIV epidemic, underlying a range of human rights violations and hindering access to prevention, care, treatment and support. Some have called for the creation of a specific international human rights convention to address discrimination and other human rights violations against people living with HIV or AIDS (PLHIV). Others have felt that such an effort is impractical and unnecessary: impractical, because it can take decades to develop and negotiate a treaty through the United Nations, even where there is interest among member states; and unnecessary, because international human rights treaties have already been interpreted as prohibiting discrimination based on health status, including HIV and AIDS, which also means that discrimination that hinders the enjoyment of all other human rights protected by these treaties is also prohibited. Nonetheless, the extent of states' obligations to address discrimination on the grounds of HIV status has not been comprehensively addressed in any international treaty.In December 2006, following intensive, years-long advocacy by disability rights activists, the UN General Assembly adopted the Convention on the Rights of Persons with Disabilities, which entered into force in May 2008 . As counTherefore, the advent of the Disability Convention prompts us to consider the links between HIV and disability and, specifically, to consider the opportunities it and other legal mechanisms, international or domestic, may afford for advancing the human rights of PLHIV as a constituency facing human rights infringements. We do so with the conviction that the movement for human rights is stronger when constituencies with so many common and overlapping interests are united, and that respectful and strategic collaboration ultimately strengthens both the disability rights and the AIDS movements.In this article, we first examine the links between HIV and disability. We then provide a brief overview of how international human rights law has treated both disability and HIV/AIDS. We note some of the different ways in which national anti-discrimination laws have reflected the links between HIV and disability, illustrated with some representative examples from a number of countries. Finally, we offer some conclusions and recommendations about ways forward for collaboration between HIV and disability rights advocates in advancing human rights at the international level, including the use of the new tool, the Disability Convention. We hope these reflections will promote further discussion across movements, ultimately to the benefit of all persons with disabilities and/or HIV.In understanding the links between HIV and (other) disabilities, it is useful first to note how conceptions of disability have developed through several stages:impairment perspective considers disability a health problem or abnormality that is situated in an individual's body or mind. This perspective is best expressed by the medical model which views disability in terms of disease, illness, abnormality and personal tragedy. The medical model assumes that disability is an intrinsic characteristic of individuals with disabilities. This assumption translates into practices that attempt to fix individuals' abnormalities and defects, which are seen as strictly personal conditions.The functional limitations perspective arose from attempts to expand the medical model to include non-medical criteria of disability, especially the social and physical environment. Nonetheless, the notion that impairments are the direct cause of disability remains central to this perspective.The ecological perspective ... sees disability as resulting from the interaction of impairment, activity limitations and participation restrictions in a specific social or physical environment such as work, home or school [...]. There are many variations of the social model, but all portray disability as a social construct created by ability-oriented and ability-dominated environments ... According to the social model, even though impairment has an objective reality that is attached to the body or mind, disability has more to do with society's failure to account for the needs of persons with disabilities. The human rights model is a distinct subgroup of the social model. It understands disability as a social construct. The model is primarily concerned with the individual's inherent dignity as a human being  [The ristics) .Appropriately, this evolution in thinking about disability has, to varying degrees in different jurisdictions, been reflected in the law, such that HIV often falls under the rubric of "disability" for at least some legal purposes -- and in particular, under anti-discrimination laws that can be used to challenge HIV-based discrimination as a form of discrimination based on disability.The need to respond to discrimination in various forms has featured prominently in the growing calls for partnership between HIV activists and disability activists. Although in recent years the disability rights movement has made significant advances, similarly to PLHIV, people with disabilities often encounter stereotyping, discrimination and other infringement of human rights. People with disabilities are among the most marginalized in the world, and the implications of HIV infection for people with disabilities have been largely ignored. Research has identified HIV as a significant but relatively unrecognized problem among people with disabilities worldwide -5. It shSimilarly, people with disabilities, in particular, women and young people, are at greater risk for sexual abuse or assault, elevating their risk of HIV infection ,8. WomenPLHIV also experience disability related to HIV. As it progresses, HIV disease can result in mental and physical conditions that impair ability. In addition, highly active antiretroviral therapy (HAART) and other treatments, while saving and prolonging the lives of PLHIV, can also cause side effects that can be disabling. In such cases, once HIV or its treatment manifests in impairment of some sort, generic legal protection against discrimination on such grounds as "disability" ought certainly to apply. However, as should be apparent from the "social model" understanding of disability, people with HIV who are asymptomatic may experience discrimination regardless of the fact that HIV does not significantly  limit their activities, and it is instead the prejudice of others which causes difficulties , rather than HIV infection itself.Over the past few years, there has been greater research and attention to the links between HIV and disability, growing attention by policy makers and planners, and growing awareness of the importance of ensuring access to such services. More HIV projects with a disability focus are being initiated and more resources are becoming available, although the need continues to far outstrip the response -14. ConsThere has been a progressive improvement in the inclusion of disability in the national AIDS response, starting with minimal involvement at the beginning of 1992 by the National AIDS Coordinating Committee of South Africa (NACOSA), to full participation in the National Strategic Plan on HIV and AIDS and STI 2007-2011 (NSP 2007-2011). The NSP 2007-2011 recognises two important aspects. First, that disabled people are a group vulnerable to infection with HIV and bear the impact of AIDS severely. This recognition should lead to mobilisation of resources for disability and prioritising disabled people in the AIDS response.Second, it recognises the causal relationship between HIV and disability. This raises the need for the disability sector and people living with HIV sector, both represented in the South African National AIDS Council (SANAC), to work collaboratively in developing programmes that respond to the causal relationship. The sectors face similar challenges, such as a struggle for self-representation and the fight for recognition of human rights. In addition, both sectors have to deal with being regarded as welfare cases, objects of medical mystery deserving of pity and ridicule." per se renders a person unable to, for example, hold certain positions. Similarly, the intense stigma surrounding HIV, in part because of its association with sex  and with drug-using behaviour, no doubt has created some hesitancy on the part of disability rights activists taking on HIV/AIDS as an issue of concern.However, discussions between the disability rights movement and HIV activists reveal a gap between HIV activism and disability activism. A major factor leading to the lack of cooperation between the two movements is that both PLHIV and people with disabilities are extremely stigmatized and marginalized. Indeed, suffering from the additional burden of stigma of being seen as "disabled" has no doubt been a concern of PLHIV and AIDS rights advocates. They have often found themselves in the position of seeking to challenge discrimination based on incorrect assumptions that HIV infection In addition, it is not a stretch to recognize that social justice advocates and movements, always struggling to secure resources to address the needs of their constituencies, will understandably be concerned that the possible conflation of HIV and disability could lead to a reduction in hard-won resources for either or both of these sectors. Similarly, in some quarters of the disability rights movement, concern has been raised that recognition of HIV as a disability could lead, under pressure from a relatively well-organized AIDS advocacy constituency, to resources being diverted away from services or advocacy for people with (other) disabilities.reasonable accommodation of disability (discussed below). Seeing commonalities in the stigma and discrimination experienced by both PLHIV and people with disabilities will increase tolerance and better understanding across these (overlapping) communities, and will strengthen both communities' efforts in overcoming stigma and discrimination.However, recently there are more and more calls for greater unity between the disability rights movement and AIDS activists -20. BothFinally, working together in greater numbers will strengthen a common voice for changing public policy in ways that benefit all people, those living with HIV and those living with other disabilities. Cross-disability coalitions highlight that these issues affect an even greater portion of the population, mobilizing greater support and more attention from decision makers. For example, in the context of seeking changes to policies and programmes providing income support to people with disabilities, collaboration between HIV advocates and advocates from other disability groups not only supports exchange of knowledge on the research, policies and models that affect both groups, but also increases the potential and opportunities to inform public policy, since it engages a much broader base of people than if HIV or disability groups are working on issues alone.One such area for collaboration is in international advocacy for the human rights of people living with disabilities and PLHIV, including using the mechanisms of the United Nations to claim and defend human rights. The UN human rights system consists of numerous instruments  and a number of different offices, agencies and mechanisms for trying to ensure that governments live up to their human rights obligations.civil and political rights  and economic, social and cultural rights . They also include treaties that specifically address particular kinds of human rights abuses  and forms of discrimination , and the rights of particular groups, such as women, children, migrant workers -- and now, with the Disability Convention, people with disabilities. .The Universal Declaration of Human Rights sets out key human rights principles that shape the rest of international law on human rights, including the fundamental principle of non-discrimination. Numerous treaties on human rights create legally binding obligations on the governments that have ratified those treaties. Eight "core" human rights treaties are widely ratified by most of the world's countries. These protect Several different mechanisms exist to monitor whether and how countries are living up to their obligations under each of these treaties, and to encourage them in doing so:Office of the UN High Commissioner for Human Rights (OHCHR) is the agency given the lead mandate within the UN system to protect and promote human rights, including working with governments and non-governmental organizations, undertaking investigations and studies, and being a global advocate publicly and within the UN system for human rights.▪ The Human Rights Council consists of representatives from UN member states. It is the top body within the UN for dealing with human rights issues, and reports to the UN General Assembly. It meets regularly over the year, and periodically reviews each country's progress in meeting its human rights obligations through the Universal Periodic Review mechanism.▪ The "special rapporteurs" and "independent experts", who have specific mandates to investigate and monitor the human rights performance of specific countries or to work on specific human rights issues . These are among the "special procedures", as they are called, that can be used to place a human rights concern on the official agenda of UN member states' meetings, particularly at the Human Rights Council, but also at other bodies, such as the UN General Assembly. Special rapporteurs have also been given mandates by other UN bodies and instruments. For example, the 1993 UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities created a mandate for a Special Rapporteur to monitor their implementation [▪ The Human Rights Council can also appoint entation . The Specommittee that consists of independent experts that regularly review countries' progress under the treaties. In some cases, depending on the wording and ratification of one or more Optional Protocols to these treaties, these committees can receive complaints from individuals or groups about specific human rights violations by government, and can issue findings and recommendations to governments to remedy the situation. In the case of the Disability Convention, the treaty itself creates the Committee on the Rights of Persons with Disabilities, to which all states parties to the convention must submit regular reports. The Optional Protocol to the Disability Convention empowers the committee to examine and "judge" complaints, against those states that have ratified the protocol, from individuals and groups of individuals alleging violations of the convention [vis-à-vis a state party on the basis of reliable information indicating "grave or systematic violations" of the convention, although such an inquiry requires the consent of the state party, and any state that ratifies the Optional Protocol may "opt out" of this inquiry procedure.▪ Finally, each of the core human rights treaties is overseen by a nvention . The OptThese different parts of the UN human rights system can be used to protect and promote the human rights of PLHIV and people with disabilities, including the rights recognized and protected by the Disability Convention.There is no one universally accepted definition of "disability" in international human rights law. A number of different definitions are commonly used. While none explicitly recognizes HIV or AIDS as disabilities, a number of them could or have been interpreted as including HIV and AIDS.Consider, for example, the 1993 UN General Assembly declaration setting out the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities, which became the leading instrument within the UN system addressing the human rights of people with disabilities, including through the work of the Special Rapporteur. The Standard Rules also helped inform national legislation in some UN member states. In defining disability, the Standard Rules simply state: "People may be disabled by physical, intellectual, or sensory impairment, medical conditions or mental illness." However,Within the regional human rights systems, the definition of "disability" in the 1999 Inter-American Convention on the Elimination of all Forms of Discrimination against Persons with Disabilities (Article I) is certainly broad enough to encompass HIV/AIDS: "a physical, mental, or sensory impairment, whether permanent or temporary, that limits the capacity to perform one or more essential activities of daily life, and which can be caused or aggravated by the economic and social environment."reasonable accommodation of a disability, which limits or denies any of a person's economic, social or cultural rights set out in the ICESCR. It recognises, in language that could just as easily be applied specifically to the experience of many PLHIV, thatAt the global level, the UN's International Covenant on Economic, Social and Cultural Rights (ICESCR) is one of the core human rights treaties . It does... through neglect, ignorance, prejudice and false assumptions, as well as through exclusion, distinction or separation, persons with disabilities have very often been prevented from exercising their economic, social or cultural rights on an equal basis with persons without disabilities. The effects of disability-based discrimination have been particularly severe in the fields of education, employment, housing, transport, cultural life, and access to public places and services accessibility (including for persons with disabilities and persons living with HIV/AIDS) of health facilities, services and information [Indeed, in General Comment 14, in which the same committee elaborates on the right to the highest attainable standard of health under Article 12 of the ICESCR, it has also explicitly noted that the right to health includes ormation . The comormation .In addition to the ICESCR, the Convention on the Rights of the Child, another of the "core" human rights treaties, expressly prohibits any discrimination in respect of the enjoyment of convention rights on the ground of disability, and explicitly mentions the rights of children with disabilities (in Articles 2 and 23) . Until tIn December 2006, the UN General Assembly adopted the Disability Convention.  The convention does not include a definition of "disability" or "persons with disabilities"; nor does it expressly mention HIV or AIDS.However, reflecting the ecological model of understanding disability, the convention's preamble recognises that "disability is an evolving concept and that disability results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others". Article 1 of the convention further states: "Persons with disabilities include those who have long term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others."Discrimination on the basis of disability is defined in Article 2 of the convention as "any distinction, exclusion or restriction on the basis of disability which has the purpose or effect of impairing or nullifying the recognition, enjoyment or exercise, on an equal basis with others, of all human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field".Before the advent of the Disability Convention, there was no comprehensive treaty in international law addressing the human rights of persons with disabilities. While it is commonly said that the Disability Convention "does not create new rights", it nonetheless represents a major breakthrough in articulating what the existing human rights obligations in international law require of states in order to ensure the equal enjoyment of all human rights by all persons with disabilities. It covers many areas in which persons with disabilities have faced discrimination, including access to justice, participation in political and public life, education, employment, freedom from torture, exploitation and violence, and freedom of movement.The convention identifies areas where adaptations have to be made so that persons with disabilities can exercise their rights and areas where the protection of their rights must be reinforced because those rights have been routinely violated. Under the convention, as is the case with many national laws, discrimination based on disability includes the denial of "reasonable accommodation", defined in Article 2 as:necessary and appropriate modification and adjustments not imposing a disproportionate or undue burden, where needed in a particular case, to ensure to persons with disabilities the enjoyment or exercise on an equal basis with others of all human rights and fundamental freedoms.Reasonable accommodation could, for example, oblige an employer to provide a desk that can accommodate a wheelchair, allow a flexible work schedule for medical purposes, modify instructions or reference manuals, or provide equipment that will enable a person with a visual or hearing impairment do his or her work.non-binding international instruments  that explicitly address discrimination on the basis of HIV. Major international human rights treaties have been interpreted to include HIV as a ground on which discrimination is prohibited.There are several For example, the UN Committee on Economic, Social and Cultural Rights has confirmed that the term "other status" in the ICESCR includes "health status", which in turn includes HIV/AIDS  . In its There is, however, no one international binding document expressly prohibiting discrimination on the basis of HIV or AIDS; the protection is entirely contingent upon this inclusive interpretation. In addition, as these broader human rights treaties are drafted at a level of generality, they do not offer the specific guidance of how the obligations might apply specifically in the context of HIV/AIDS - something that, as noted, the Disability Convention now very importantly elucidates in the context of disability.Such HIV-specific guidance to states regarding their human rights obligations is to be found in the International Guidelines on HIV/AIDS and Human Rights. First issued in 1998 by the Joint United Nations Programme on HIV and AIDS (UNAIDS) and the Office of the UN High Commissioner for Human Rights (OHCHR), and subsequently revised in 2006 to reflect new developments, the stated purpose of the International Guidelines (Paragraph 3) is "to assist States in translating international human rights norms into practical observance in the context of HIV" . The IntThe International Guidelines have been supported repeatedly by UN member states through resolutions adopted at the UN Commission on Human Rights (the predecessor body to the current UN Human Rights Council) -34. In aAt the level of technical experts within the UN system, it is recognized that HIV should be considered to fall within the definition of "disability" for at least the purposes of anti-discrimination law. For example, in its 1996 statement before the UN Commission on Human Rights, UNAIDS recommended that HIV/AIDS should be considered a disability in light of the discrimination that occurs because of HIV/AIDS, and in light of the legal protection needed to guard against that discrimination:"The so-called disabling feature either does not disable at all, but is perceived as disabling; or it may disable somewhat, but could be addressed with reasonable accommodation. The main thing is that there is no justification for differential treatment. The disabilities consequences of asymptomatic HIV is that often people living with HIV, as well as those suspected of being HIV positive, are very often discriminated against because they are wrongly perceived as being unable to perform; they are wrongly perceived as being a threat to public health; or they are perceived as being, or indeed are, a member of some group already suffering discrimination. Thus, if they are not actually disabled by HIV-related conditions, they are often disabled by the discriminatory treatment they receive because of their HIV status. The result is that they are denied the possibility of being productive, self-reliant, full and equal members of society ... Thus, the clinical, social and cultural elements of HIV/AIDS, including the impairment which can result from it and the ignorance, discrimination and stigma which surround it, confirm that it is appropriate to consider HIV/AIDS as a disability for purposes of protection against discrimination."UNAIDS also stated that in order to fully protect the people who face discrimination because of actual or perceived notions regarding their abilities due to their health status, definitions of disability should move beyond functional limitations to cover medical conditions, such as HIV/AIDS .This reflects the recognition that disability is an evolving concept, a foundational premise later articulated in the Disability Convention. More recently, the Handbook for Parliamentarians on HIV and AIDS, updated in 2007 by UNDP, UNAIDS and the Inter-Parliamentary Union, recommended, as one of the components of anti-discrimination legislation, that states provide protection against discrimination on the grounds of disability, widely defined to include AIDS . In Marcholus bolus the more detailed expert commentary accompanying the International Guidelines. In 2001, the UN General Assembly adopted the Declaration of Commitment on HIV/AIDS, in which states committed to enacting, strengthening and enforcing legislation, regulations and other measures to eliminate all forms of discrimination against people living with HIV/AIDS and members of vulnerable groups [Finally, in the UN General Assembly, member states have decried discrimination against PLHIV as contrary to human rights principles, although they have not cited specific treaty provisions, nor have they been willing to explicitly adopt or endorse e groups . They ree groups .There are several ways in which countries have dealt with HIV-based discrimination in national legislation, reflecting different approaches to understanding the relationship between HIV and (other) kinds of disability when it comes to protecting against discrimination.General anti-discrimination laws prohibit discrimination against classes of persons, based upon such factors as race, gender and religion, and sometimes based on such grounds as "health status" and/or "disability" (or sometimes "handicap"). These latter terms could be interpreted as including HIV and/or AIDS. Not many countries explicitly include HIV or AIDS as standalone grounds on which discrimination is prohibited. In some cases, the law may only include (or be interpreted to include) AIDS or opportunistic infections and other health conditions related to HIV infection.HIV-specific laws, which often address a wide range of HIV-related legal issues, and usually include provisions that prohibit discrimination based on HIV status and/or AIDS diagnosis. In some cases, this is the only protection in a country's law against such discrimination. In other cases, the section on discrimination in the country's "AIDS law" may clarify, supplement or reinforce protection already found in other anti-discrimination laws, where these exist and include HIV or AIDS in one way or another, such as under the rubric of protection against discrimination based on disability.Some countries pass per se within this term. For example, in a number of countries , anti-discrimination laws prohibiting discrimination based on disability include asymptomatic HIV infection within the ambit of the term "disability", either by explicit statutory language or as a result of statutory interpretation by courts and tribunals.In some countries where the law prohibits discrimination based on "disability" , HIV-positive status and/or AIDS diagnosis is included In some cases, national anti-discrimination law covers "disability which exists at present, previously existed but no longer exists, or which may exist in the future or which is imputed to a person", and also covers disability which is "suspected or assumed or believed to exist or to have existed" . In manyIn other cases, obtaining legal protection against disability-based discrimination depends on proving in a given instance that a person's ability to perform certain life activities, such as work or education, is limited by some condition. Some laws use broad definitions covering minor disabilities, while others use detailed definitions that limit coverage to people with substantial disabilities. To restrict the scope of protection too much could mean excluding people who suffer from episodic illness or disability . Too narrow an approach could also mean the law fails to address the discrimination that manifests from stereotypes, prejudice and general social stigma, such as that faced by PLHIV and those with other disabilities, or discrimination based on perceived disability - both of which can in themselves be disabling by limiting a person's participation, for example, in the workforce or school. In other words, such an approach would reflect more the "impairment perspective" or the "functional limitations perspective", rather than the more modern "ecological perspective" or "social model" of understanding disability and the barriers to equal enjoyment of human rights for persons with disabilities. In the remainder of this section, we provide some examples of different approaches taken to addressing HIV/AIDS-based discrimination in a number of jurisdictions from different regions.One approach, such as that taken in Australia's federal statute on disability-based discrimination, is to include in the definition of disability broad language referring to disease or illness, such as the following: "the presence in the body of organisms causing disease or illness; or the presence in the body of organisms capable of causing disease or illness" . New ZeaIn other instances, legislation on disability discrimination singles out HIV/AIDS for explicit mention as being included within the ambit of "disability". For example, Hong Kong's Disability Discrimination Ordinance (s. 2) uses the same formulation as Australia's federal statute, but supplements the generic reference to disease or illness with an additional, explicit statement (s. 61(2)) that persons who are HIV positive or have AIDS are protected by the ordinance . SimilarIn other instances, legislation addressing discrimination does not clearly refer to illness or disease, or an agent thereof, in the definition of disability, but nonetheless recognizes a link between health and disability. For example, in 1990, following protest over discrimination against PLHIV, France passed a law prohibiting discrimination on the grounds of "health status or handicap" in the form of a number of amendments to the Penal Code  and the Labour Code, adding these two grounds simultaneously to existing prohibitions on discrimination on such grounds as race, nationality, religion, sexual orientation or marital status . FurtherFor purposes of this Act, "handicap" includes any activity limitation or restriction on participation in social life experienced by a person in his or her environment as a result of a substantial alteration, either ongoing or of a fixed term, of one or more senses or physical, mental, cognitive or psychic functions, of a multiple handicap or of a disabling health problem .The use of the expression, "health status or handicap", in the French statute, and the legislative history relating to HIV, establishes that HIV/AIDS is covered. It is also worth noting this example of an instance in which AIDS activists succeeded in obtaining the expansion of legislative protection against discrimination in a manner that benefits a very broad range of people with other disabilities, with a definition that extends to any medical condition or impairment.In other jurisdictions, anti-discrimination legislation may not explicitly refer to HIV/AIDS, and may not include in the definition any reference to illness or disease or even such a term as "health status", yet courts and tribunals have repeatedly interpreted such terms as "handicap" or "disability" as including HIV and/or AIDS for purposes of protecting against discrimination. For example, none of the anti-discrimination statutes in force in any of Canada's 13 jurisdictions  make explicit reference to HIV. Yet human rights commissions, tribunals and courts at all levels have had little difficulty in finding that such statutes' prohibition on disability-based discrimination includes discrimination based on actual or perceived HIV or AIDS status . The SupWhatever the wording of definitions used in human rights legislation, Canadian courts tend to consider not only the objective basis for certain exclusionary practices , but also the subjective and erroneous perceptions regarding the existence of such limitations. Thus, tribunals and courts have recognized that even though they do not result in functional limitations, various ailments such as congenital physical malformations, asthma, speech impediments, obesity, acne and, more recently, being HIV positive, constitute grounds of discrimination ... Similarly, in the United States, the Americans with Disabilities Act of 1990 (ADA) does not mention HIV or AIDS, or any other disabling conditions directly. Under the ADA, "the term 'disability' means, with respect to an individual (a) a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (b) a record of such an impairment; or (c) being regarded as having such impairment." But the A different approach treats HIV as distinct, although in some ways connected to, disability. We suggest the approach apparent in the examples below arises largely out of a desire to avoid reinforcing a perception that PLHIV are, simply by virtue of their HIV infection, limited in functioning  - in other words, to avoid subjecting PLHIV to the further stigmatization and discrimination attached to disability.per se as a disability:For example, early government policy in South Africa acknowledged the similarities in discrimination experienced by PLHIV and people with disabilities, but drew the line at characterizing HIV infection Integrated National Disability Strategy therefore, they are not included in the definition of disability, except where symptoms, such as prolonged fatigue, interfere with their normal functioning [People who are HIV positive suffer from social discrimination similar to that experienced by people with disabilities. This does not, however, imply that they are necessarily disabled. For the purpose of the ctioning .South Africa is a developing country that has not adopted the approach of enacting an omnibus "AIDS law". Instead it has addressed HIV as relevant in a variety of other existing legal instruments and regimes, including those dealing with discrimination of various forms. In doing so, while government policy recognizes the links between HIV and disability (including recognizing that HIV disease may cause disabilities) , it has For example, the Employment Equity Act in South Africa prohibits "unfair discrimination" in employment on a variety of grounds. It explicitly lists both "disability" and "HIV status" as distinct grounds on which discrimination in employment is prohibited .  distinction being drawn between HIV and disability, in which the former is expressly excluded from the category of the latter. Mauritius, which has been recognized as having one of the world's more progressive omnibus "AIDS laws", has expressly declared that HIV and AIDS are (1) Any person who is HIV-positive or has AIDS shall not be considered as having a disability or incapacity by virtue of any enactment and his status or presumed status shall not be used as a ground to discriminate against that person.(2) Subsection (1) shall not affect the operation of a pension law if that law provides for a benefit accruing to a person according to the degree of disability which entitles him to such benefit .In other jurisdictions, there may be a similarly narrow "functional" approach to recognizing HIV/AIDS as a disability while also providing explicit protection against HIV/AIDS-based discrimination , even where the law contains little in the way of a more general protection against disability-based discrimination. This is the case, for example, in a number of countries previously forming part of the Soviet Union, where there are specific HIV laws which including provisions prohibiting discrimination against people with HIV.In the Russian Federation, for example, there are specific articles that prohibit employment discrimination, denial of medical care and other limitations of rights and interests of people living with HIV, including their and their families' housing rights . HoweverUNAIDS suggests that the inclusion of HIV in national disability laws has been one of the most effective means by which to address discrimination based on HIV status or AIDS , althoug• They address people with HIV, including the full spectrum, from asymptomatic infection to AIDS.• They include people merely perceived as having HIV or AIDS.• They prohibit employers and providers of services from refusing to hire, from refusing to promote, from firing, and from denying services because a person is HIV positive or may become sick in the future or may cause an increase in health care or insurance costs.• They are applicable to a broad range of public and private sector employers and service providers.• They require that a person be qualified for the job and be well enough to perform the job adequately, but also that employers provide reasonable accommodations to facilitate ability to perform .Similarly, as the World Bank has observed: "The most comprehensive laws and policies extend protection to actual, perceived, or suspected HIV status to cover those who are discriminated against due to actual HIV-infection or the perception that they are infected because of proximity to others perceived to be infected  or association with groups stereotypically linked with HIV infection" .In our view, a more nuanced understanding of the links between HIV/AIDS and other forms of disability, and a more modern "social model" of understanding disability, lead to the conclusion that, at least for purposes of anti-discrimination law, HIV and AIDS are legitimately viewed as a "disability" - and that where it exists, protection against discrimination based on disability should extend to protecting against discrimination against PLHIV.This is not to deny that other approaches may also be pursued to achieve this objective, and in some instances, these may even be complementary, thereby enhancing legal protections against HIV/AIDS-related discrimination. But in at least some jurisdictions, a broader understanding of "disability" within or under existing legislation offers a key means of addressing discrimination against PLHIV and should be utilized to maximum benefit.On the international level, a similar conclusion follows with respect to the Disability Convention. Therefore, in the next, concluding section, we return to examining how the convention, the most recent addition to the core human rights treaties, may be used by human rights advocates to strengthen protection against discrimination based on HIV or AIDS status in international law.not to be regarded as having a disability (as argued by the AIDS Law Project as amicus curiae).In one its earliest judgments under South Africa's new post-apartheid constitution, the country's Constitutional Court considered whether South African Airways had violated the constitutional prohibition on "unfair discrimination" by refusing to hire an HIV-positive person as a cabin attendant on the claimed basis that HIV rendered him unable to perform the essential functions of the job. The South African Constitution does not explicitly refer to HIV, but does explicitly refer to disability. In its judgement, the Constitutional Court explicitly declined to address whether the discrimination was based on disability or whether people with HIV ought Nonetheless, in concluding that the employer airline had engaged in unfair discrimination, the court stressed the following underlying point of common relevance to the struggle for equality of both people with HIV and people with (other) disabilities recognized as such:At the heart of the prohibition of unfair discrimination is the recognition that under our Constitution all human beings, regardless of their position in society, must be accorded equal dignity. That dignity is impaired when a person is unfairly discriminated against. The determining factor regarding the unfairness of the discrimination is its impact on the person discriminated against. Relevant considerations in this regard include the position of the victim of the discrimination in society, the purpose sought to be achieved by the discrimination, the extent to which the rights or interests of the victim of the discrimination have been affected and whether the discrimination has impaired the human dignity of the victim .Discrimination based on HIV-positive status and discrimination based on disability, whether or not HIV is perceived or treated legally as a disability, share these basic hallmarks of unfair treatment.In this article, from the perspective that HIV can and should be recognized as a disability for at least some purposes, including anti-discrimination law, we have noted some aspects of the multi-faceted relationship between HIV and other forms of disability, as well as the ways in which international and (some) national laws deal with discrimination related to both HIV and disability. In so doing, we hope to provide a basis for considering the implications, challenges and opportunities of recognizing HIV as a disability, including seeking such an explicit interpretation of the UN's Disability Convention.Through consultation and discussion with AIDS advocates, disability rights advocates, people living with HIV and with other disabilities, and other interested actors, the ultimate goal is to identify and develop potential strategies for achieving better protection and promotion of the rights of people living with HIV and with disabilities. In our view, just as national law on disability-based discrimination should extend to address HIV/AIDS-based discrimination, so too should the provisions of the Disability Convention apply in the context of HIV/AIDS and extend to protect the rights of PLHIV.As noted above, unlike the situation (now) with disability, there is no binding international law instrument dealing explicitly and directly with HIV and human rights. The term, "other status", in at least some international human rights treaties has been interpreted to include HIV. However, this remains at the level of "soft law" interpretations  or recommendations . The extent to which such treaty obligations get reflected in national legislation in ways that extend these human rights to PLHIV is, therefore, heavily dependent on the willingness of domestic legislators or national-level courts and tribunals to adopt such an interpretation.There is no guarantee that protection against discrimination on the ground of "health status", as articulated in international treaties, will be interpreted broadly, so as to include HIV/AIDS, in national legislation and by national courts or tribunals. Therefore, the protection against violations of the rights of PLHIV that is ostensibly afforded by such existing treaties may also depend on the capacity of domestic advocates to make use of the relevant UN human rights mechanisms to press for country-level change to reflect this common interpretation.if HIV and AIDS are understood as disabilities falling under the rubric of the convention. As has already been noted, the term "disability" is not defined in the Disability Convention; it does not, therefore, offer the explicit extension of the protections of international human rights law to PLHIV. However, if it is made clear that the term "disability", in a legally binding international treaty such as the Disability Convention, includes HIV/AIDS, then it will be obligatory for countries that ratify the treaty to ensure that national legislation on the rights of persons with disabilities, including protection against discrimination, extends to protect PLHIV, either explicitly or by interpretation.The Disability Convention offers the prospect of a binding treaty spelling out specific obligations of states parties that would be of benefit to PLHIV - As has been widely recognized, the Disability Convention does not create new rights. However, it does flesh out, in considerably greater detail than has ever been the case, states' obligations under other human rights treaties in the context of disability, making it clear that people with disabilities are entitled to the full enjoyment of those rights set out elsewhere in international law.  This is the chief "added value" of the Disability Convention in the international human rights framework and should not be underestimated. To the extent that this much more detailed treaty is clearly recognized from the outset as applying to HIV/AIDS, then it only strengthens the clear application of international human rights treaties to protect the full enjoyment of a wide range of human rights by PLHIV. As a preliminary list, we therefore suggest a number of possible areas for action by advocates for using the Disability Convention as a new tool for advancing the human rights of PLHIV.First, the Disability Convention (Article 33) obligates states parties to create one or more focal points domestically to be responsible for implementation of the convention. Those focal points should be engaged to think about the HIV-relevant dimensions of the convention, such as in gathering data about HIV-related discrimination, and formulating policy to address disability-related discrimination in a way that includes HIV and AIDS as disabilities.Second, the Disability Convention (Article 38) contemplates the engagement of UN specialized agencies in the implementation of the convention. This provides an opportunity for an agency, such as UNAIDS, to engage with states parties, the Committee of Experts, the OHCHR and even national focal points to ensure attention to the links between HIV and disability are considered in relation to the convention. This could include such initiatives as:• Providing input on questions that the committee should put to states parties for their regular reporting;• Participating in the preparation of a general recommendation on HIV/AIDS and the convention;• Joint efforts by UNAIDS and OHCHR documenting and analyzing disability-based discrimination against PLHIV, as well as the ways in which the infringement of human rights of people with pre-existing disabilities contribute to HIV vulnerability and barriers to care; and• Advising on the development of national law or policy on disability  and law or policy related to HIV/AIDS .Third, the Committee on the Rights of Persons with Disabilities, the committee of independent experts established under the convention (Article 34), will, in the coming years, elaborate on what the Disability Convention requires of states in various areas.  The committee will also review states parties' progress in implementing the convention on a regular cycle (Articles 35-36) and report every two years to the UN General Assembly and the Economic and Social Council (Article 39).It will be important for advocates to ensure that the committee's understanding of the convention is informed by an appreciation of the links between HIV and (other) disabilities. The committee should, for example, develop a "general recommendation" that outlines the application of the convention's provisions in the specific context of HIV/AIDS, making it clear that the convention applies to HIV/AIDS. Similarly, it will be important that the committee, in reviewing states parties' compliance with the convention, be aware of the ways in which the rights of PLHIV are infringed or unfulfilled. PLHIV groups and other AIDS advocates should take advantage of the review process to ensure that the committee receives relevant information about states under review and is equipped and encouraged to raise these HIV/AIDS-related concerns with states parties.Fourth, the states that have ratified the Disability Convention will meet regularly in a "Conference of States Parties" to consider any matters with regard to the implementation of the convention (Article 40) . Such covis-à-vis those states parties that ratify the protocol, to pursue complaints against states regarding deficiencies in implementation of convention obligations. Individuals and groups of individuals  can file complaints with the Committee on the Rights of Persons with Disabilities. Civil society advocates will certainly be turning their efforts to such "litigation" under the Optional Protocol; advocates for the rights of PLHIV in relevant countries should be considering opportunities for using this mechanism to challenge HIV-related discrimination.Finally, under the Optional Protocol to the Disability Convention, there will be the opportunity There is growing recognition of the many links between HIV/AIDS and disability, with implications for direct services, for national programmes and policies on both HIV and disability, and for domestic and international law. The advent of the Disability Convention, with its recognition that disability is "an evolving concept", offers an opportunity for advocates to ensure that the newest addition to the core international human rights treaty becomes an additional tool for strengthening a human rights-based response to HIV/AIDS, both by advancing the rights of people whose pre-existing disability enhances their vulnerability to HIV infection and impedes their access to HIV/AIDS care, and by advancing the rights of people who are living with HIV/AIDS and experience the varying degrees to which the disease and its social reception are disabling. Making common cause between AIDS advocates and disability rights advocates, while being mindful of the similarities and differences in the ways in which HIV infection and other disabilities are experienced and perceived, will strengthen this common struggle for human rights.The authors declare that they have no competing interests.RE undertook research relevant to and drafted or contributed to all parts of the manuscript, as well as revising and editing the entire manuscript. LU undertook research relevant to and drafted or contributed to all parts of the manuscript. EZ contributed research and analysis to the discussion of the links between disability and HIV, and reviewed and commented on the entire manuscript. All the authors were involved in conceiving of the study and read and approved the final manuscript.RE is the executive director of the Canadian HIV/AIDS Legal Network. LU is a senior policy analyst with the Canadian HIV/AIDS Legal Network. EZ is the executive director of the Canadian Working Group on HIV and Rehabilitation.


HIV/AIDS related stigma interferes with the provision of appropriate care and support for people living with HIV/AIDS. Currently, programs to address the stigma approach it as if it occurs in isolation, separate from the co-stigmas related to the various modes of disease transmission including injection drug use (IDU) and commercial sex (CS). In order to develop better programs to address HIV/AIDS related stigma, the inter-relationship (or 'layering') between HIV/AIDS stigma and the co-stigmas needs to be better understood. This paper describes an experimental study for disentangling the layering of HIV/AIDS related stigmas.The study used a factorial survey design. 352 medical students from Guangzhou were presented with four random vignettes each describing a hypothetical male. The vignettes were identical except for the presence of a disease diagnosis  and a co-characteristic , blood transfusion or no co-characteristic). After reading each vignette, participants completed a measure of social distance that assessed the level of stigmatising attitudes.Bivariate and multivariable analyses revealed statistically significant levels of stigma associated with AIDS, IDU, CS and CBD. The layering of stigma was explored using a recently developed technique. Strong interactions between the stigmas of AIDS and the co-characteristics were also found. AIDS was significantly less stigmatising than IDU or CS. Critically, the stigma of AIDS in combination with either the stigmas of IDU or CS was significantly less than the stigma of IDU alone or CS alone.The findings pose several surprising challenges to conventional beliefs about HIV/AIDS related stigma and stigma interventions that have focused exclusively on the disease stigma. Contrary to the belief that having a co-stigma would add to the intensity of stigma attached to people with HIV/AIDS, the findings indicate the presence of an illness might have a moderating effect on the stigma of certain co-characteristics like IDU. The strong interdependence between the stigmas of HIV/AIDS and the co-stigmas of IDU and CS suggest that reducing the co-stigmas should be an integral part of HIV/AIDS stigma intervention within this context. HIV/AIDS has been described as "the most devastating epidemic humanity has even known" . Over 40To reduce HIV/AIDS stigma, one must understand the nature of the stigma, especially in the context of the low success rates reported by existing stigma intervention studies . One reaThe presence of co-stigma has been referred to as 'double stigma', 'triple stigma', or layers of stigmas -14, and Study participants, including physicians, nurses, social workers and psychologists, have been found to respond significantly more harshly towards vignettes describing PLWHA than towards vignettes describing a less value-laden disease such as leukaemia ,23,24. SWhat remains unanswered in these earlier studies, however, is how the stigma of HIV/AIDS is layered with the stigma of a co-characteristic such as IDU. Understanding this is relationship is potentially critical for the development and management of health campaigns and programs targeting stigma reduction, which have thus far focussed on the stigma of HIV/AIDS in isolation from its co-stigmas .Until very recently, one of the impediments to the quantitative analysis of the relationships between stigmas had been the lack of an analytic framework. An approach to the empirical analysis of HIV layering was identified, but it provided no original data to support its use . EssentiFollowing this analytic framework, Figure Model 1 illustrates the stigma of HIV/AIDS and a co-stigma assuming that they are strictly additive. In this case each source of stigma may be addressed independently and is effectively how HIV/AIDS stigma is currently treated. Model 2 illustrates the stigma of HIV/AIDS and a co-stigma assuming that the two sources of stigma completely overlap with one another. Removing the stigma of either one would have no effect on the total level of stigma. The final model portrays a compromise between the two earlier models, and is hypothesised to be the most likely portrayal of the actual relationship between the disease stigma of HIV/AIDS and its co-stigmas. It suggests that the overall stigma is composed of (i) a portion of stigma uniquely associated with being HIV-positive; (ii) a portion that is uniquely associated with the co-stigma, and (iii) a portion that is the shared effect of the two stigmas. In this case an intervention addressing only one source of stigma will only remove that relatively small portion unique to that stigma (i.e. the white portion). To address the total stigma of HIV/AIDS, one would need to deal with both the stigma of HIV/AIDS and the co-stigma.The aim of this study is three fold. It is the first empirical test of the framework proposed by Chan and Reidpath ; and desMedical students were the study population. The choice was driven in part for reasons of convenience, but largely because as future health care providers, their attitudes towards PLWHA have important ramifications for a health care system's capacity to cope with increasing demand determined by the epidemic ,17,22.The study employed an adaptation of a factorial survey design. Vignettes were presented to participants and attitudinal evaluations about each vignette were recorded.Three hundred and sixty second year medical students at a university in Guangzhou were invited to participate. Eight elected not to. The 352 participants were almost evenly split between males and females  had a mean age of 20 .The study was conducted in Guangzhou, Southern China, a region identified as having one of the fastest growing HIV/AIDS epidemics in the world . DespiteGuangzhou is also a fertile location for this study because of China's long history of stigmatisation of behaviours associated with HIV/AIDS transmission including IDU and prostitution. Currently, 73% of all new cases of infection are associated with IDU, while 20% were associated with sexual transmission .The surveys utilised 15 possible vignettes designed to capture the interplay between a disease  and a potentially stigmatised co-characteristic . Adapted from the work of Kelly et al., each vignette was constructed in three parts. Part 1 was a general description of the 'idealised son' that was constant across all 15 vignettes, and created to conform with China's traditional hierarchical principles on the roles and duties occupied by different subjects in relation to the family and the state ,29:Male 'A' was bright and had many talents. He was considered to be a dutiful son to his parents, and a kind, selfless and responsible person by everyone who knew him.When presented on its own without further elaboration, it served as the base condition against which all others could be contrasted. In those vignettes in which Part 2 was included it described 'A"s deteriorating health:Over the past six months, he developed a range of health problems including fatigue, physical decline and recurrent infections. He learned from his doctor that he was seriously ill, and his family and friends were said to have difficulty adjusting to his life-threatening illness.Part 2 ended with a diagnosis of either AIDS or leukaemia:He was diagnosed with [AIDS/leukaemia].Part 3 of the vignette, when it was included, gave additional information about one of the following co-characteristics:Two years ago, he received a blood transfusion as a routine part of a surgical procedure.OROver the past two years, he has sold his blood on a number of occasions;ORFor the past two years, he has occasionally visited commercial sex workers.ORFor the past two years, he has occasionally engaged in injecting drug use for recreational purposes;A vignette was created from each one of the possible 3 × 5 (i.e. disease by co-characteristic) combinations, giving 15 possible vignettes in total.disease factor with three levels , where 'none' represented the base condition of no disease and, consistent with previous studies, leukaemia represented a control disease. There was a second factor of co-characteristics with five levels , where 'none' represented the base condition of no co-characteristic, and blood transfusion represented the control co-characteristic. Given the sample size, there is a restriction on the number of co-stigmatised factors that could be sensibly explored in one study. Whilst homosexuality is a common co-stigmatised factor included in previous studies, in the current study, the co-stigmatised factors were selected on the basis of their significance in terms of HIV transmission in the local epidemic.There were two independent variables. There was the HIV/AIDS knowledge was treated as a covariate because previous studies have shown that misconceptions regarding HIV transmission can lead to avoidance attitudes because of fear of infection from casual contact [ contact -32. HIV/ contact ,33. A scThe other potential covariates included were age and gender.Stigma was operationalised in terms of social distance, a widely used measure of the degree to which a person is willing to share a proximate social space with another -36. The The survey was divided into three sections. The first section collected demographic details. The second section presented a series of three random vignettes, each portraying one of the 15 possible descriptions of the hypothetical person. Following each vignette was the adapted social distance scale. The final section was a measure of HIV/AIDS knowledge.The repeated measurement in this instance, however, was only used as a device to increase the sample size, . There was an implicit trade-off between increasing the number of judgments made about the hypothetical person and the potential redundancy associated with repeated measurement. In order to prevent a set response to each version of the hypothetical person, surveys were individually printed and constructed so that each complete survey elicited responses to three versions of the hypothetical person: one with AIDS, one with leukaemia, and one with no disease. Furthermore, no co-characteristic occurred in any survey more than once. It also meant that in any block of 360 surveys, the presentation was counter-balanced such that no two participants would read descriptions of the same three versions of the hypothetical persons. The 360 possible three-vignette combinations were shuffled using a random number generator prior to distribution.The adaptation and (back) translation of the vignettes went through a series of iterations and the final survey was field tested for readability and sense with 15 medical students.In a single morning, at the conclusion of lectures, research assistants were provided with an opportunity to address concurrent classes of second year medical students, and invite them to participate in a survey on student attitudes. A plain language statement of the research was distributed and it was explained both orally and in the plain language statement that participation was voluntary and the responses were entirely anonymous. Students who did not wish to participate were invited to leave the lecture theatre. However, mindful of the potential for coerced participation through such a public form of non-participation, students were also given alternative forms of non-participation. Specifically, they were informed that they could remain and choose not to submit the survey form or submit a blank form. Separate signed consent was not sought, because it was regarded as culturally inappropriate and would raise unnecessary concerns about anonymity.Research assistants distributed the survey forms serially from a randomly ordered master pile. Students were given 15 minutes to complete the surveys, and encouraged not to look at others' responses. The distribution of vignettes across the 15 possible disease and co-characteristic combinations about 'A' can be found in Additional file All analyses were conducted using of Intercooled Stata version 8.2. In the first instance the scale properties of the social distance scale were examined, and then the bivariate relationship between the independent factors (disease characteristic and co-characteristic), the covariates, and social distance. The effect of the order of the presentation of a vignette on social distance was included as a possible confounding variable. Although the presentation of vignettes was randomised, participants would have been unfamiliar with these particular descriptions, and it was felt that repeated exposure to the task may itself influence the judgements.A multivariable model in which the effects of the independent factors (and interaction effects) were estimated, controlling only for those covariates that were shown to have statistically significant effects on stigma in the bivariate tests. Adjusted cell means (without the model constant) were calculated and the effect of the layering of stigma examined.The multivariable modelling was, conceptually, a straightforward analysis of social distance as a function of (a) the disease characteristic and (b) the co-characteristic. It was slightly complicated by the repeated measurement of social distance within participants – each of whom was asked to respond to three separate vignettes. The clustering of judgements associated with the repeated measurement of social distance within participants was handled using a two-level, maximum likelihood, multilevel regression analysis. In the model, social distance associated with judgements were represented at level one, and participants were represented at level two ,39.The study was approved by the Deakin University Human Research Ethics Committee.The internal reliability of the social distance scale was confirmed using Cronbach's alpha (α =.91) [see Additional file The social distance scale was linearly transformed to lie in the interval 0–100 . Social distance scores occurred over the entire range of the scale, with a mean social distance of 30.4.Bivariate analyses were conducted to examine the relationship between social distance and each of the independent variables and covariates separately, including the order of presentation Table . In virtThe analysis showed the order of presentation to have a statistically significant effect on participants' judgments about social distance. As a percentage of the scale maximum, vignette two was, on average, 4.8% higher on the social distance than vignette one (p = .005), and vignette three was 6% higher (p < .001). That is, social distance increased significantly with the increasing order of presentation. None of the covariates  had a statistically significant effect on social distance.The results were very different for the independent factors, Disease and Co-Characteristic. For the Disease factor, Leukaemia was significantly less stigmatising than no disease, resulting in an average reduction in social distance of 7% (p < .001). In contrast, AIDS was significantly more stigmatising than no disease resulting in an average increase in social distance of 7% (p < .001). As anticipated, having a blood transfusion did not significantly increase social distance above the base category. Likewise, commercial blood donation did not significantly increase social distance (p = .235). In contrast, having engaged in a commercial sex transaction increased social distance by an average of 19% of the scale maximum (p < .001), and having engaged in IDU increased social distance by an average of 25% (p < .001).In the multivariable model of social distance the order of presentation was controlled for. Participants' sex, age, and knowledge of HIV/AIDS, however, were not included as covariates in virtue of their small and statistically non-significant association with social distance in the bivariate models. The focus of the multivariable model was the factors of Disease and Co-characteristic and their interaction effects. Table a priori hypothesis.In the multivariable analysis the two factors and the interaction were statistically significant. The number of tests (i.e. 14) that were conducted raises some issues about Type I errors in multiple comparisons. For reasons discussed by Cook and Farewell (1996), however, this was not regarded as problematic. The core questions revolved around Leukaemia, AIDS, IDU, CS, and their interactions. Most of the effects appeared to fall clearly one way or another. Even using as conservative a correction for multiple comparisons as the Bonferroni adjustment, the only questionable result would be the interaction effect between Leukaemia and CS – for which there was not, in any case, a specific In keeping with the literature, however, the pattern of results suggested that AIDS, IDU, CS, and to a lesser degree CBD, were each highly stigmatising. They increased the social distance score between 9% and 44% of the scale maximum. In contrast, BT in isolation had no statistically significant effect to the level of stigma, confirming its suitability as a control co-characteristic. The pattern of interaction also showed a moderating effect, as anticipated by Reidpath and Chan (2005). Specifically, the stigma associated with the co-occurrence of two highly stigmatised attributes was not simply a summation of the stigma of each; rather, the stigma appeared to lie generally between the stigma of one and the stigma of the sum.In contrast to the bivariate analyses, leukaemia in isolation did not have a statistically significant moderating effect on levels of stigma, however, it had a statistically significant moderating effect on the stigma of IDU, but possibly not on the stigma of CS. In addition, commercial blood donation as a co-characteristic decreased the level of stigma associated with AIDS.Following the approach described by Reidpath and Chan , the layVery different arrangements of layering were observed between AIDS and the various co-characteristics, each of which are discussed in turn. It should be noted, however, that the layering effects are based on estimates with often wide confidence intervals and this limits the extent to which one can interpret the results.Figure 2(1) = 14.02, p < .001. The difference on stigma levels between IDU alone and the combination of the two factors is statistically significant (χ2(1) = 5.22, p = .022). This layering arrangement is also consistent with leukaemia and IDU  = 50.61, p < .001.Chi-square test confirmed that the difference on stigma levels between AIDS alone and the combination of the two factors is statistically significant, χFigure There is no stigma that is uniquely associated with AIDS. It is by reference to Table 2(1) = 3.93, p = .047), but the difference in stigma levels is not statistically significant between AIDS and the two factors combined (χ2(1) = 2.84, p = .092). Similarly, there are no statistically significant difference in the effect on social distance between CS and the two factors combined (χ2(1) = .06, p = .804). This is in sharp contrast with the effects observed in the control disease where the stigma of CS is significantly higher than the stigma of CS and leukaemia combined (χ2(1) = 5.59, p = 0.018).Figure Like the layering arrangement of IDU and AIDS, the middle bar in Figure Figure Unlike the layering arrangements already discussed, the stigma associated with AIDS alone made up 54% of the total stigma in the middle bar, while the 'shared' stigma of the co-characteristic and AIDS makes up 46% of the stigma. There is no stigma that is uniquely associated with CBD. This layering is similar to that of AIDS and the controlled co-characteristic of blood transfusion, where AIDS makes up 69% of the stigma and Blood transfusion 31%.2(1) = 23.62, p < .001), CS (χ2(1) = 4.51, p = .033), CBD (χ2(1) = 20.78, p < .001), and BT (χ2(1) = 9.91, p = .002). Chi-square results also shows that AIDS with BT was significantly more stigmatising than BT alone (χ2(1) = 7.58, p = .006).Previous studies have commonly reported that the stigma attached to people with AIDS and a co-characteristic is significantly more stigmatising than the control disease with the same co-characteristic. Additional chi-square analyses confirmed that this is true for the current dataset. As such, AIDS layered with all four co-characteristics were significantly more stigmatising than leukaemia layered with the same co-characteristics. The results by co-characteristics are as follows: IDU  ,41; and Another challenge to the orthodox understanding of HIV/AIDS stigma is the statistically significant drop in the levels of stigma between an injecting drug user with no disease and an injecting drug user with AIDS  could also be a fruitful line of future inquiry. As with all attitudinal studies, cautions should be made when inferring behaviour from the findings.A final and important issue is with the variability in the data themselves, shown by the wide confidence intervals associated with the parameter estimates. Under these circumstances, particular inferences about the nature of the layering should be regarded as broadly speculative, and indicative of potentially useful, future lines of inquiry.Notwithstanding these limitations, the study presents a potentially useful way of considering the layering of stigmatised characteristics.The findings of this study indicate that, far from being a coherent singular entity, HIV/AIDS related stigma overlaps with a number of co-stigmas associated with the modes of disease transmission. Variations in the ways different co-stigmas overlapped with HIV/AIDS stigma were examined, with each having different implications for stigma interventions. The most important was the extent to which the co-stigmas of IDU and CS were layered upon the disease stigma of HIV/AIDS suggesting that the co-stigmas should be taken into account in the development and implementation of HIV/AIDS stigma interventions. Although more work is needed, the research methods used in the current study provided a way that would hopefully contribute to a better means of analysing the nature of stigma as it relates to different HIV/AIDS epidemics.Acquired Immune Deficiency Syndrome (AIDS)Blood Transfusion (BT)Commercial blood donation (CBD)Commercial sex (CS)Human immunodeficiency virus (HIV)Injecting drug use (IDU)People living with HIV/AIDS (PLWHA)The author(s) declare that they have no competing interests.DR contributed to the initial conception of the study, contributed to the study design and statistical analysis. KYC conceived of the study and was principally responsible for the study design, statistical analysis and the drafting of the manuscript. KLZ and YY worked on the cultural adaptability of the survey and data collection. All authors have provided feedbacks on the drafts and approved the final manuscript.The pre-publication history for this paper can be accessed here:Scale Items.Click here for fileThe distribution of vignettes across the 15 possible disease and co-characteristic combinations about person 'A'.Click here for fileReliability of the adapted social distance scale based on results of the first vignette read by participants.Click here for file


The prevalence of penicillin-nonsusceptible pneumococci is sharply divided between France (43%) and Germany (7%). These differences may be explained on different levels: antibiotic- prescribing practices for respiratory tract infections; patient-demand factors and health-belief differences; social determinants, including differing child-care practices; and differences in regulatory practices. Understanding these determinants is crucial for the success of possible interventions. Finally, we emphasize the overarching importance of a sociocultural approach to preventing antibiotic resistance in the community. Streptococcus pneumoniae varies tremendously between different countries and continents  are roughly equivalent, which allowed us to assume that at least in terms of general health indicators both countries could be judged to be comparable . We reviA computer-based literature review was undertaken with the MEDLINE database from 1980 to the present. While references were sought by using specific subject headings related to differences in the prevalence of antibiotic-resistant pneumococci between Germany and France and reasons for the observed disparity , the paucity of relevant retrievals prompted us to repeat the search by using keywords specific for each of the questions asked. This extended search included articles about differences in economic and sociocultural determinants . Additional references were identified from the references cited in these reports and personal files. Papers in English, German, and French were reviewed. Antibiotic use on a national level was expressed as defined daily doses (DDD) of different antibiotic agents per 1,000 inhabitants per day, one DDD being the standard daily dose of an antibiotic agent for 1 day’s treatment .S. pneumoniae collected from patients of all ages throughout Europe in 1998, 93% (n=168) were susceptible to penicillin (MIC <0.06 mg/L) in Germany, whereas only 47% of French isolates (n=167) remained fully penicillin-susceptible . A . A 12). A pan-European survey showed marked differences in the rate of nonprescription of antibiotics at the first consultation for respiratory tract infections  20). In. In20). S. pneumoniae in the oropharyngeal flora. When finally prescribed, penicillin agents are usually given in higher doses to German patients than French patients. In a European study, 30% of German adult patients received >3g per day of amoxicillin for lower respiratory tract infections, whereas French patients received considerably lower antibiotic dosages .,29.12,29Based on these health-belief factors, most German physicians follow a less aggressive, watchful-waiting approach in the case of non–life-threatening infections. In particular, German physicians agree that antibiotics are not first-line drugs for the treatment of uncomplicated respiratory tract infections. Indicative of the general attitude is this statement by a German general practitioner: “We never give antibiotics for a common cold ….On the first visit we would only give aspirin. After five days we would do a blood sedimentation and listen to the lungs. Then we might give antibiotics” .In France, physicians have repeatedly reported that unrealistic patient expectations, patient pressure to prescribe antibiotics, and insufficient time to educate patients about the inefficacy of antibiotics for upper respiratory tract infections are the major reasons why antibiotics are prescribed for these self-limiting diseases ,29,36,37However, French physicians may overestimate the extent to which patient satisfaction depends only on receiving an antibiotic prescription; therefore practitioners should be convinced that the primary determinant of patient satisfaction is not prescribing antibiotics but rather, effective communication about the patient’s illness . For insSocial factors also influence antibiotic use and resistance rates in France and Germany. This influence can be best illustrated by otitis media, the leading reason for excessive antimicrobial use in French children . AttendaIn France, a long tradition of early childhood education exists in the public sector. Known as “écoles maternelles,” nearly 100% of 3- to 5-year-olds attend these publicly funded pre-schools; about 35% of 2-year-olds also attend . In contBecause of the transmission of antibiotic-resistant pneumococci among infants in nurseries in France, a panel of national experts recommended encouraging alternatives that could delay placement in day-care centers until children are 18 months old . HoweverBy contrast with Germany, another important risk factor for otitis media and pneumococcal infection in infants  is highlAntibiotic prescriptions are affected through reimbursement policies and the structure of the pharmaceutical market. The average level of retail prices for pharmaceutical products is very low in France. For example, if the price in France is 100, the level would be 162 in the United Kingdom and 175 in Germany . AnotherHistorically, the French drug economy has largely been regulated by product price control and has been structured as a low-price, high-quantity system, whereas Germany has tended more towards a high-price, low-quantity system ,57. The Most importantly, health authorities in Germany have more regulatory power by allocating collective expenditure caps and, therefore, have a broader impact on drug use than that exerted by similar agencies in France. In 1993, the introduction of capped physician budgets and a system of reference pricing in Germany led to a switch in prescribing preferences and an incentive for German physicians to avoid expensive products priced above the reference price, such as oral broad-spectrum cephalosporins . ConsequIn France, the introduction of national prescription guidelines  for upper respiratory tract infections in 1994 did not decrease the overall volume of outpatient antibiotic use and had only a modest economic impact. However, prescription patterns have changed in line with those guidelines and led to a decrease in the use of fluoroquinolones and oral cephalosporins and to a substantial increase in macrolide use for acute bronchitis and pharyngitis .Several alternative explanations for the observed differences in antibiotic resistance rates can be made. First, variation in antibiotic use may be caused by differences in the frequency of respiratory tract infections. However, the rate of antibiotic consumption in France implies a rate of bacterial respiratory illness that is at least 5 times higher than the reported rates in the literature ; therefoThis report represents a unique attempt to combine different data sources to give a more complete picture of sociocultural and economic forces influencing the ecology of antibiotic use and pneumococcal resistance in two large European countries. The published literature regarding the prevalence of antibiotic-resistant pneumococci provides convincing evidence that France and Germany have sharply different rate. The reasons for the observed resistance gap are multifactorial and include substantial differences in physicians’ and patients’ attitudes towards antibiotics; sociocultural and economic factors; and disparities in regulatory practices. Studies are remarkably consistent in documenting the high frequency with which antibiotics are used in France for upper respiratory tract infections without appropriate microbiologic rationale. Unfortunately, despite the widespread publication of recommendations over the last decade and some modest modifications in the pattern of antibiotic utilization , the wilIn Germany, low prevalence of pneumococcal resistance coincides with less antibiotic consumption, selection of narrow-spectrum antibiotics, higher dosing of amino-penicillins, and possibly, better treatment compliance . Thus, lHaemophilus influenzae type B meningitis in some countries, particularly in Asia, may be due at least partially to extensive antibiotic use. However, no recently published, representative surveillance data exist about illness and death from complications of common respiratory tract infectious in France or Germany. Future international studies about the use of outpatient antibiotics (An interesting question remains about whether differences in national antibiotic-prescribing patterns affect the rates of illness and death from complications of respiratory tract infections. A recent study  showed, ibiotics  should iibiotics .Finally, we argue that effects exerted at the macro-level by the cultural and socioeconomic environment contribute substantially to the observed differences in prescribing practices and related antibiotic resistance rates. Consequently, failure to understand the sociocultural and economic perspectives of antibiotic consumption and resistance will lead to inadequate conclusions about the chances of success for possible interventions. More research to inform decision-makers on the determinants of the variation in antibiotic use and resistance patterns is urgently needed.


Methionine (MET)-dependent cell lines require MET to proliferate, and homocysteine (HCY) does not act as a substitute for this requirement. From six O6-methylguanine-DNA methyltransferase (MGMT)-efficient (mer+) cell lines tested, two medulloblastomas (Daoy and D-341) and a lung non-small-cell adenocarcinoma with metastatic potential (H-1623) were most sensitive to MET deprivation, while two glioblastomas  and a small-cell lung carcinoma H-1944 were moderately to weakly dependent. Regardless of the degree of MET dependence, all of these lines down-regulated their MGMT activity within 48-72 h of transfer from MET+HCY- to MET-HCY+ media, long before the eradication of the culture. Reduction of MGMT activity was due to a decline of both MGMT mRNA and protein levels. However, the reduction was not related to the methylation status of the MGMT promoter at the SmaI site or the HpaII sites in the body of the gene; such sites have been shown to be associated in MGMT regulation and in defining the mer phenotype. MET-dependent, mer+ tumour cells cultured in MET-HCY+ were more sensitive to BCNU (IC50 = 5-10 microM) than those cultured in MET+HCY-(IC50 = 45-90 microM), while MET-independent or mer- cell lines were unaffected. This indicates that reduction of MGMT, imposed by the absence of MET, renders mer+ tumour cells more susceptible to alkylating agents. The relatively selective suppression of MGMT activity in mer+ MET-dependent tumour cells, in combination with the inability of such cells to proliferate in the absence of MET, may lead to the development of more effective treatment strategies for mer+ MET-dependent tumours.


In general, the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) population has begun to experience the benefits of highly active antiretroviral therapy (HAART); unfortunately, these benefits have not extended equally to Blacks in the United States, possibly due to differences in patient comorbidities and demographics. These differences include rates of hepatitis B and C infection, substance use, and socioeconomic status. To investigate the impact of these factors, we compared hospital mortality and length of stay (LOS) between Blacks and Whites with HIV/AIDS while adjusting for differences in these key characteristics.The 1996–2006 National Hospital Discharge Surveys were used to identify HIV/AIDS patients admitted to US hospitals. Survey weights were incorporated to provide national estimates. Patients < 18 years of age, those who left against medical advice, those with an unknown discharge disposition and those with a LOS < 1 day were excluded. Patients were stratified into subgroups by race (Black or White). Two multivariable logistic regression models were constructed with race as the independent variable and outcomes  as the dependent variables. Factors that were significantly different between Blacks and Whites at baseline via bivariable statistical tests were included as covariates.P < 0.001), opportunistic infections  and cocaine use . Conversely, fewer Blacks were co-infected with hepatitis C virus . Hepatitis B virus was relatively infrequent (3% for both groups). Crude mortality rates were similar for both cohorts (5%); however, a greater proportion of Blacks had a LOS > 10 days . Black race, in the presence of comorbidities, was correlated with a higher odds of LOS > 10 days , but was not significantly correlated with a higher odds of mortality .In the general US population, there are approximately 5 times fewer Blacks than Whites. In the present study, 1.5 million HIV/AIDS hospital discharges were identified and Blacks were 6 times more likely to be hospitalized than Whites. Notably, Blacks had higher rates of substance use (30% vs. 24%; Black race is a predictor of LOS > 10 days, but not mortality, among HIV/AIDS patients admitted to US hospitals. It is possible that racial disparities in hospital outcomes may be closing with time. Human Immunodeficiency Virus (HIV) has had a devastating impact on the United States, and the effects are far reaching. Each year in the United States, HIV infects over 56,000 people and claims upwards of 14,000 lives . DespiteMany Blacks may first seek care late in the course of their disease, after they have already become symptomatic with an opportunistic infection (OI) ,11. BecaThe presence of these comorbidities may worsen the overall health outcomes of those patients with advanced HIV/AIDS disease even when equivalent therapy is provided -22. SubsHospital discharge data were extracted from the 1996–2006 NHDS, a series of annual national surveys conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) . The NHDMycobacterium Avium, pneumocystosis, progressive multifocal leukoencephalopathy, Salmonella, Toxoplasmosis gondii, and tuberculosis ). Simple logistic regression analysis revealed the following variables (P < 0.001) to be associated with LOS > 10 days: race, survey year, age, gender, insurance status, presence of OI, HBV, HCV, and cocaine use. All variables from the regression analysis were subsequently entered in the multivariable model as covariates. Multivariable analysis identified Black race as an independent predictor for LOS > 10 days . Simple logistic regression analysis revealed the following variables (Figure This study compared health outcomes for Black and White HIV/AIDS patients across the United States in the HAART era. Despite the many successes that have resulted from combating the disease over the past decade, published data suggest that Blacks continue to experience a disproportionate burden of HIV infection. Not only are Blacks overrepresented in the total number of people living with the disease, they continue to experience the highest rates of new infections and AIDS-related deaths . In the Although HAART is clearly an effective treatment for HIV, the clinical benefits of therapy may not extend equally to patients who are diagnosed with advanced stages of infections ,5. Thus,in vitro and in experimental animal models to enhance viral replication and interfere with the body's ability to defend itself naturally against infection. This may hasten disease progression and the development of AIDS-defining conditions, even among patients who are adherent to antiretroviral therapy [Baseline rates of substance use were higher among Blacks than Whites. The rate of cocaine use for Blacks was almost three times that of Whites; interestingly, regression analysis revealed cocaine use was 'protective' for mortality, perhaps because cocaine use was also associated with younger age. Nevertheless, studies suggest illicit drug use may have a negative impact on the treatment and course of HIV/AIDS infection ,40. Conc therapy -43. Howe therapy . Of the  therapy -25.Beyond the HIV/AIDS population, other racial disparities exist for Blacks; they tend to have higher rates of HBV and HCV compared to Whites ,25,44. FLikewise, the national impact of race disparities among individuals with concomitant STIs is not well-characterized . The incwidened in the HAART era [A surprising, but fortunate finding from this study is the possibility that racial disparities in hospital outcomes may be closing with time. This possible reduction in racial disparities in outcome has been demonstrated elsewhere ,37,54,55AART era . AccordiAART era . The invAART era ,57. The This study shares the limitations of all retrospective cohort studies. In addition, the analysis was limited by the lack of available clinical variables, including medication information, time of HIV diagnosis, and objective clinical markers of disease progression. Therefore, we could not assess the relationships between quality of care indicators and patient outcomes. Additionally, management of acute HBV, HCV, and STIs may not require hospitalization. These data are also limited by proxies for racism and discrimination that are known predictors of racially-biased outcomes. These variables are important when describing disparities and could have at least partly explained the racial variations and/or non-variations found in this study. The data source lacks information regarding patients of Hispanic descent; therefore, we were unable to draw conclusions about health disparities for this minority group that is also facing a disproportionate burden of HIV . AnotherThis study characterized the rates of comorbid conditions, hospital mortality and LOS, and evaluated trends in health outcomes among Black and White HIV/AIDS patients over a decade. Some disparities may still persist despite the availability of effective interventions to reduce morbidity and mortality. This national assessment of hospital discharges demonstrates that Black race may be predictive of longer LOS, but not mortality. In addition, disparities in health outcomes may be decreasing with time. Further research efforts are warranted to recognize and clarify the complexities facing the Black HIV/AIDS population in order to reduce health disparities.HAART: highly active antiretroviral therapy; HIV: Human Immunodeficiency Virus; AIDS: Acquired Immunodeficiency Syndrome; LOS: length of hospital stay; CI: confidence interval; OR: odds ratio; L-R likelihood ratio; OI: opportunistic infection; STI: sexually transmitted infection.The authors declare that they have no competing interests.CUO had full access to the data in the study and assisted with the study design, study concepts, data analysis and interpretation, and drafting of the manuscript. CRF directed and supervised all aspects of the study from its conception to the finalization of the manuscript. JMH assisted in drafting the manuscript. JS assisted in the statistical analysis and interpretation of data, as well as critical revision of the manuscript for important intellectual content. All authors assisted with critical revision of the manuscript for important intellectual content, and have approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/9/127/prepub