Know Your Epidemic - Part B

International and regional commitments signed by the Lebanese government:

This section will provide an overview of certain treaties and conventions that are ratified by the Lebanese government. These conventions be limited to those that are related to either women/girls or children/youth.

1. Women

The Convention on the elimination of all forms of violence against women (CEDAW) was adopted in 1979 by the UN general assembly. It addresses discrimination against women as and defines it as “…..any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women, irrespective of their marital status, on a basis of equality of men and women, of human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field.” This treaty defines such discrimination in 30 articles and defines a national agenda to end discrimination against women. Lebanon ratified it on 16 Apr 1997 (United Nations, 2009).

Even though the Lebanese constitution doesn’t explicitly state the equality of women and men, it does acknowledge “absolute” equality of all citizens before the law in Articles 7 and 12. It also acknowledges political equlity to all citizens above the age of 21 as stated in Article 21. Public and personal liberties including freedom to belief, education and speech are all protected rights in the Lebanese constitution (Lebanese Constitution).

Other treaties and conventions related to women ratified by the Lebanese government are;

· The convention on the political rights of women (1953), ratified in 1955

· UNESCO’s convention related to nondiscrimination in education (1960), ratified in 1964

· The convention on women workers in night shifts (1948), ratified in 1962 and later on amended by convention number 171 (1962)

· The convention on salary equality (1951), ratified in 1977

· The convention on employment of women in underground work (1937), ratified in 1946

· The convention on non-discrimination in employment and professions (1958), ratified in 1977

· The convention on employment policy (1964), ratified in 1977

The ratification and inclusion of such treaties into legislations have facilitated women in Lebanon to achieve major milestones such as; political rights to vote and participate in political processes (1953), equality for inheritance for non-Muslim denominations (1959), women’s right to chose their citizenship (1965), freedom of movement (1974), elimination of the provisions punishing contraception (1983), Unification of the retirement age for men and women under the social security law (1987), recognition of the qualifications of women to testify in the Land Registry (1993), recognition of women to be involved in business without their husband’s permission (1994), the right of a female employee in the diplomatic sector who married a foreigner to pursue her duties (1994), and the qualifications of married women regarding insurance contracts (1995) (Committee on the elimination of discrimnation against women, 2004).

Treaties and conventions related to women that are not ratified by the Lebanese government;

· The convention on white slave trading and the exploitation of others through prostitution (1949)

o The complementary convention (1956)

· The conventions on the citizenship of married women (1957)

· The convention on the consent to marriage, minimum age and registration of marriage (1962)

· The convention of a paid teaching license (1973)

· ILO’s Convention on farmers (1975)

· The convention on the development of human resources (1975)

· The convention on workers and family providers (1981)

· The convention 103 on maternal leave

It should be noted that such treaties and conventions that are not ratified by the Lebanese government as well as the reservations made on the CEDAW pertain mainly to personal status, marriage mechanisms and citizenship. This is due to the fact that such matters are still mostly dealt according to sectarian laws and religious courts. The unification of such laws and regulations is a possible pathway to assure that all women are protected from violations of their human rights (Committee on the elimination of discrimnation against women, 2004).

2. Youth

The united nation’s convention on the rights of the child is one of the main treaties related to children and youth. The guiding principles of the convention stress on the rights of youth to non-discrimination, life, survival and development, and participation. Hence, putting forth a couple of the most important concepts i.e. participation. Lebanon ratified the convention in 1991 with reservations on article 2, 3 and 12.

Other youth related conventions that are signed by the Lebanese government;

· International Convention on Civil and Political Rights (1966), ratified in 1972

· International Convention on Economic, Social and Cultural Rights (1966), ratified in 1972

It is notable to mention that the Lebanese government undertook noteworthy steps in promoting the efforts targeting youth through the establishment of the Higher Council for Childhood, publication on the legal situation of children in Lebanon, establishment of the Parliamentary Committee for the Protection of Childhood, the National Committee for the Disabled and others. Such endeavourers are important to promote the proper environment for children and youth.

Yet on the other hand, the reality doesn’t reflect such intentions where monitoring of the situation of children and possible violations is not comprehensive throughout the country. Moreover, there are laws that exist which still are inconsistent with the articles of the convention of the child and other treaties that have been ratified by Lebanon (Commitee on the Rights of the Child, 1996).

Existing policies on HIV and universal access in your community:

1. Universal access and education;

When it comes to education and awareness on sexual and reproductive health and rights, there is a major block-out in many of the educational curricula and media venues. Schools and universities are reluctant to address such issues with openness and transparency and usually revert to – mostly in school based curricula and faith based educational institutions – absenteeism-only education. Still, we need to acknowledge the recent efforts that were taken to introduce reproductive health education into national curricula as a substitute of sexual health education. Even though issues of sexuality and related health topics are still not fully and directly discussed, this can be considered as window to advocate for a more direct and clear curricula later on.

Media venues do not encourage or adopt promotional ads or segments that target such issues. Despite that there have been a significant activity on local activity to address issues of sexuality and sexual activity in contrast to previous strict mainstreamed conservative values, such efforts are still minimalistic and are countered with vigorous response from other media outlets that deem such endeavors are immoral and should be banned.

2. Universal access and prevention:

When talking about prevention, it would help to dissect the issue to the policies and challenges related to the availability of services and the accessibility of different populations to such services.

Services such as VCT centers, condom availability through free distribution or those purchased from the pharmacy as well as certain – though limited – awareness and capacity building interventions are available in the community and are mostly provided by civil society organization that form a network headed by the National Aids Program (a governmental-led institution). Such services receive little and limited media coverage and promotion making them difficult to be marketed and reached.

Accessibility to such services remains a very problematic issue. With high stigmatization, reverting to these services or showing interest in them might be regarded by many as a sign that such a person is HIV-positive. This constitutes very limiting factors that hinder many from accessing such services. Condom purchase also follows similar trends.

3. Universal access and treatment:

The National Aids Program’s (NAP) policy towards treatment is that all identified individuals who are HIV-Positive are eligible to free access to treatment including ART when needed. This implies to Lebanese citizens as well as to Palestinians refugees residing in Lebanon. Foreign individuals who reside in Lebanon might need to revert to their countries’ embassy if treatment was not provided by NAP (yet NAP claims that all residing individuals have the right to access free treatment).

Still, the treatment coverage rate is estimated at 26% by the UNAIDS and many benefactors of the treatment program argue that many of the drugs might at times be “out of stock”.

Country network involved in the HIV/AIDS response:

In Lebanon, the HIV/AIDS response is headed by the National AIDS Program and collaborates with the different civil society organizations to form a network that collectively targets the response in the country. NAP is semi-governmental institute which started as joint program of the WHO and the Lebanese Ministry of Public Health. The program is still to date a joint program though it has surpassed its initial due date to be disjoint from the WHO. This current status gives NAP a unique position where it can advocate and introduce concepts that otherwise might be strongly disapproved and banned from implementation or circulation.

Lebanon Score Card:

My issue of interest is the inclusion of sexual health educational materials in the academic curricula and mainstreamed media. For this issue, the following scores are reported:

Accountable parties:

1. Governmental agencies;

Many governmental agencies can be involved in this issue such as the Ministry of Social Affairs, the Ministry of Health, the Ministry of Education and Higher Education, Ministry of Youth and Sports and the National AIDS Program.

2. Civil society;

There are many grass root organizations that can collaborate on this issue. Community based organization that focus on advocating for awareness and prevention as well as faith based organization are integral parties. Similar international agencies may also be fundamental parts in addressing this issue.

Bibliography

Commitee on the Rights of the Child. (1996). Concluding observations of the Committee on the Rights of the Child: Lebanon.

Committee on the elimination of discrimnation against women. (2004). Considerations of reports submitted by State parties under Article 18 of the Convention on the Elimination of All Forms of Discrimination against Women: Initial report of state parties, Lebanon. United Nation.

Lebanese Constitution. (n.d.). Art. 9, 12, 21, 2, & 10.

United Nations. (2009). Convention on the Eliminationof all forms of Discrimination Against Women. Retrieved April 27, 2010, from United Nations Division for the Advancement of Women: http://www.un.org/womenwatch/daw/cedaw/

Problem Tree

Click for the pdf file

Gosh...This is coming after such trouble. :)

So, there are so many issues to tackle here. But I'm quite interested in the fact that there aren't much lobbying from the civil society for introducing sexual and reproductive health in school curricula. Having such a curricula can pave the way to elevating the issue of providing universal access to information and education on a national level.
When it comes to limited time and resources, I would believe that targeting teachers and educators with workshops to sensitize the issue of sexual and reproductive health can be on importance in the long way to lobby for sexual education programs.

Addiction and Criminalization

(Translation = An Addict but not a Criminal)

Criminalization of drug users have detrimental effects on the HIV/AIDS response in the populations of injecting drug users. Criminalization efforts have proved to drive targeted populations underground and deter efforts needed to effectively lower their risk levels. Criminalized behaviours are less likely to be reported and those who practice such behaviors are also less likely to seek services based on their behavioral risks.
In Lebanon, organizations of the civil society (mainly Oum el Nour and SKOUN) have been quite active in lobbying for non-criminalizing regulations towards drug users. Such lobbying efforts were successful in changing the penal codes such that arrested users are referred to treatment and rehabilitation centers. The new regulations fall short were they fail to recognize an addict, a non-addict drug user, small-time dealers and large dealers. This is important since drug dealers are criminalized. Thus, the system is still cracked and IDU can be easily charged with drug dealing and trading. The lobbying is far from over.

Part A: Country Epidemic Information

Country Epidemic Information

People living with HIV
PLHIV are estimated at 380 000 [280 000 – 510 000] according to UNAIDS reports in 2007 (Melhem, 2009) in the MENA region. In Lebanon, the current number of PLHIV is reported to be 3 000 [1 700 – 7 200] (UNAIDS, 2008). This figure is probably an under-report of the true figure of PLHIV and the confidence interval is very wide to provide a concrete profile. Either way, along with annual incidence, we might estimate a number along the higher 4 000.

Incident Cases
Incident cases are estimated at 40 000 [20 000 – 66 000] in the MENA region according to UNAIDS reports in 2007 (Melhem, 2009).The Lebanese National AIDS Program reported 92 incident case in 2007 (NAP, 2007).

Deaths associated with AIDS
Number of associated deaths is estimated at 27 000 [20 000 – 35 000] in the MENA region according to UNAIDS reports in 2007 (Melhem, 2009). In Lebanon, it is estimated to be <200>[<100 citation="t" id="2604149"> (UNAIDS, 2008).

Social profile of PLHIV
The 2008 Lebanon UNGASS report doesn’t present any figures or numbers on the social profile of PLHIV. However, it does state that PLHIV within the age group of 15-49 is estimated at 0.1% that is to say that 69.8% of PLHIV are within the age group of 15 – 49 years while 30.2% are 50 years of age and above. The 2008 UNGASS report as well the 2008 Epidemiological Fact Sheet on HIV and AIDS 2008 – Lebanon report do not report any HIV case to children less than 15 years of age (UNAIDS, 2008).

The NAP provides the following age groups break down; 14.9% of reported cases are lower than 31 years, 52.1% are between 31 and 50 years old, 27.9% above 50 years, while 5.1% are not specified. The cases are also distributed between 81.7% for male cases and 17.9% for females, 0.4% is not specified. NAP also reported that those cases that have not proceeded to symptomatic AIDS status constitute 42%, those who did constitute 40.9% while 17.1% of the cases had unspecified status (NAP, 2007).

ART coverage
PLHIV receiving ART was estimated at <500 citation="t" id="2604156">(UNAIDS, 2008). Yet, UNAIDS identified 940 [550 – 2 300] PLHIV in need for ART in that same year to establish a 26% [11% - 45%] treatment coverage for both sexes. The 2008 UNGASS reports different figures. It reports the total number of people in need for ART to be 432 while 246 of these individuals received treatment to establish a 56% coverage rate for both sexes.
In Lebanon, all individuals who are in need of ART have to go through the Ministry of Public Health (MOPH) by applying for the MOPH Drug Center. UNAIDS reported 9 children under the age of 15 receiving ART (UNAIDS, 2008), though no pediatric HIV case was reported in the UNGASS 2008 report of any other documentation.

Young women living with HIV
It is estimated to be 0.1% of females 15-24 years of age. That adds up to 190 cases of young females living with HIV in Lebanon in the year of 2007 (UNAIDS, 2008).

Dynamics of transmission
The main mode of transmission is unprotected sexual activity which accounts for 70% of the incident cases. Other modes of transmission include the transfer of contaminated blood content (6.4%), use of contaminated syringes for drug injection (5.7%), mother-to-infant (2.2%) as well as accidents resulting from the use of infected utensils (2.1%) (NAP, 2007).

Missing information
In Lebanon, there is a huge bulk of information missing. I would most probably state the lack of reliable figures in the UNGASS reporting, need for consistent size estimation in order to define the type of the epidemic, the experience of the Palestinian refugees living within the under-privileged and excluded conditions of the refugee camps as well as lack of continuous reporting and registry of the epidemic by the National AIDS Program to the public.

Social Inequalities

High Risk Groups
There is lack of a defined assessment of HIV prevalence in the country. Hence, it becomes to challenging to identify high risk groups. NAP accounts 11.65% of the HIV transmission to occur in people identified as homosexual or bisexual (the method of identification is not specified), 6.75% due to transfer of contaminated blood, 5.82% within the intravenous drug users population and 2.78% through vertical transmission (mother-to-child) (NAP, 2007).

In the light of these points, it would of interest to prevalence rates in possible population which might be considered vulnerable due to certain socio-economical factors. Of these populations are; Palestinian refugees, refugees of other nationalities (Iraqi, Sudanese…), Domestic workers and non-registered immigrants (Egyptians, Syrian…), women and girls, youth and youth coming from possible vulnerable populations (double standard), sex workers, prisoners and incarcerated individuals, as well as rural populations.

Social, economic, political and historical factors that affect the life choices and behaviors of people from vulnerable groups

1) Refugees;

i. Palestinian refugees;
Following the 1948 Arab-Israeli conflict, 750 000 Palestinian lost their homes and land and were forced to exile outside Palestine. Currently, Palestinian refugees are estimated around 400 000 individuals (almost 10% of the Lebanese populations) gathered in 12 official gathering/camps across Lebanon. Unlike those in Syria and Jordan, Palestinian refugees in Lebanon are not considered formal citizens of another state and thus can’t claim the same rights as other foreigners. In fact they are not allowed to work in almost 20 different professions and are denied some basic social and civil rights such as access to public social services, limited access to public health or educational services, estate possession…. UNRWA is the sole provider of education, health and relief and social services (UNRWA).
The current number and concentration of the Palestinian refugees along with lack of support from the Lebanese government and the denial of their rights, overwhelms the efforts and resources of the UNRWA and descends this population in a perilous circle of debt and poverty.

ii. Other Refugees;
Although Lebanon has not ratified the 1951 UN convention or the 1967 protocol relating to the status of refugees, the 1962 law concerning the entry and exit of foreigners “whose life or freedom is in danger for political reasons” may request political asylum in Lebanon. Yet, there has not been any mechanism, regulation or infrastructure put in place to process the claims for asylum. In that sense, people who enter illegally to Lebanon to seek asylum or those who do enter legally but overstay their visas as illegal immigrants who face fines, imprisonment or even deportation. (HRW, 2007)

Spiegel argues that it’s a misconception to presume that HIV rates are higher in refugees gatherings than in the host community. It is rather it is context specific. He states that issues of mobility and accessibility between the different populations, interaction, as well as exposure to violence govern the nature of HIV transmission in these populations (Spiegel, 2004). In Lebanon, due to the high interaction between the refugees and host community, mobility and lack of external acts of violence (yet the camps are always in a low security status), the dynamics that Spiegel has demonstrated to might lower HIV transmission are not in effect; and thus giving way to epidemic transmission similar to that in poor-resources settings

2) Foreign workers;

i. Domestic workers;
Jureidini presents his argument in women migrant domestic workers in Lebanon by the following statement: “Abuses of foreign domestic workers is not unique in Lebanon, but are astonishingly prevalent …”. He traces such abuses to the lack of a clear mechanism to translate international conventions to local language and systems as well as the lack of awareness among the law enforcement bodies (Jureidini, 2002).

ii. Foreign workers;
Foreign workers from Syria, Egypt, Sudan and other regional countries face major obstacles when it comes to securing self-sustaining and respectable job opportunities. Lower-priced and easier-to-manage (Young, 2000), such workers are usually faced with lower SES and other violations to their social and civil rights.

The continuous violations of the rights of foreign workers provide opportunities for such populations to be denied proper access to health services or affording such services when they are accessible.

iii. Rural population; in a highly centralized system, populations that exist in rural areas of the country experience lower accessibility to empowerment information, awareness and service provision.

Youth and risk of HIV
Studies have documented the low utilization rate of health services by young people in the Arab region (De Jong, Jawad, Mortagy, & Shepard, 2005). There are different factors that underley such a phenomena such as the stigma relating using certain health service which can be linked to sexual activity, a morally wrong behavior (such as going to the dermatologist or the gynecologist in some cases). Other factors is concerned with the high fees of such services, lack of free support health services, the youth being mostly uninsured (the culture of insurance is usually preserved for the more well-to-do individuals) and most importantly the lack of awareness needed to utilize such services.

Gender inequality
Recent movements in the civil society and by organizations such as KAFA (www.kafa.org.lb) have called to progress in the reporting to forms of violence against women as well as social segregation. Although a moderate country, Lebanon does provide space for suppression of women in private settings such as the case in domestic violence or in a more institutional manner by denying her right to pass her nationality to her children. The latter case have seen much progress and Lebanon has reach a stage where it is expected to annul that violation and produce a more legal guarantee to endure that the women have full rights as men in their nationality and that of their children.
Still, there remains a need to have a legal guarantee that can protect women from domestic violence and sensitize the law enforcement and the community about the need to “break the silence”. Until then, it remains a challenge to estimate the prevalence of gender-based violence.
Women who reside in a community that doesn’t provide their full protection from violations of human rights are less likely not be properly empowered to maintain their bodily rights and pursuit a safe sexual health.

Criminalization of drug use
The 1947 law (amended in 1998) stopped viewing a drug user as a “criminal” but rather a “sick” person in need of help and is to be referred to treatment. Yet in light of scarcity of resources, certain cases end up in incarceration.

On the other hand, the law criminalizes the selling, trading and third party facilitation of such drugs (classified into categories) with imprisonement from 3 months to 3 years and a fine of 2 – 5 million Lebanese pound (1 300 – 3 300 USD). It makes no distinction between the amount seized and the kind of trade being done (consumer, small-time dealer or drug-lords) (SKOUN).

Criminalization of commercial sex work
Commercial sex work is technically legal under certain conditions. Permits, brothel establishments are possible under certain circumstances. Yet the government had stopped issued permits for years now and all forms of prostitutions is punished by imprisonment from one month to one year. It is notable to mention that though the sex workers are punished, their customers are not.

Yet, women from Eastern Europe (Russia, Ukraine, Belarus, Moldova…) are contracted under “artist visa” to work as dancers, waitresses and models at “super nightclubs”. The contracts are signed at the General Security Office where the officials “inform her not to engage in commercial sex work” and request her to take periodical HIV/AIDS test (which is quite preposterous since that only shows that they are aware of her true working conditions). There are “…approximately 5,000 artist visas are issued every year and there are 2,500 artists in the country at any given time”, which raises concerns on issues of human trafficking (KAFA, 2008).

Criminalization of HIV transmission
There are identified law that criminalize HIV transmission in Lebanon.

Criminalization of Homosexuality
Homosexuality is criminalized in the country under the penal code law “534”. The law does not specifically targets homosexuals but rather any form of “un-natural” sexual intercourse. Under the efforts of the civil society organizations for personal liberties over the last decade, currently the law enforcements do not actively use the law to persecute or criminalize identified homosexuals (HELEM).

Stigma and discrimination against sexual minorities
Being a non-secular country, Lebanon experiences stigma fueled by the unyielding religious views of Christianity and Islam that views homosexuality as a sin. Almost most of the moral views in the Lebanese societies are based on the adoption of the teachings of either Christian scripture or the Islamic sharia’a.

References

CAS. (2006). National Survey of Household Living Conditions 2004-2005. Beirut: Central Administration of Statistics.

De Jong, J., Jawad, R., Mortagy, I., & Shepard, B. (2005). The sexual and reproductive health of young people in the Arab countries and Iran. Reproductive Health Matters , 13 (25), 49-59.

HELEM. (n.d.). HELEM. Retrieved March 14, 2010, from HELEM: www.helem.net

HRW. (2007). Rot Here or Die There: Bleak choices for Iragi refugees. Human Rights Watch.

Jureidini, R. (2002). International Migration Papers: Women Migrant Domestic Workers in Lebanon. Interntional Labour Office, International Migration Program. Geneva: Interntional Labour Office.

KAFA. (2008). Shadow Report on Article 6th to 40th CEDAW Session. Beirut: KAFA.

Melhem, N. (2009, February 11). PhD, Associate Professor, AUB. Concepts of Immunology for Public Health Professionals/HIV - EPHD300 . Beirut, Beirut, Lebanon: AUB.

MOPH. (2008). 2008 UNGASS Progress Report. Beirut: MOPH.

NAP. (2007). National AIDS Program. Retrieved 03 14, 2010, from Ministry of Public Health: www.cms1.omsar.gov.lb

SKOUN. (n.d.). Drugs in Lebanon. Retrieved March 14, 2010, from SKOUN: http://www.skoun.org/drugs3.html

Spiegel, P. B. (2004). HIV/AIDS among Conflict-affect and Displaced Populations: Dispelling Myths and Taking Action. Disasters , 28 (3), 322-339.

UNAIDS. (2008). Country Profile. Retrieved March 13, 2010, from UNAIDS: http://www.unaids.org/en/CountryResponses/Countries/lebanon.asp

UNAIDS. (2008). Epidemiolocical Fact Sheet on HIV and AIDS: Core data on epidemiology and response, Lebanon 2008 Updates. UNAIDS, WHO, UNICEF. Switzerland: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance.

UNRWA. (n.d.). UNRWA-Lebaon. Retrieved March 14, 2010, from UNRWA: http://www.unrwa.org/etemplate.php?id=65

Young, M. (2000). Migrant Workers in Lebanon. Beirut: Lebanese NGO Forum.