Medicine, Faculty of
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BMC Public Health. 2020 Aug 10;20(1):1220
British Columbia Centre for Excellence in HIV/AIDS
British Columbia Centre on Substance Use
The Author(s).
Ng, Cara
Chayama, Koharu L.
Krüsi, Andrea
Small, Will
Knight, Rod E.
Background: While previous research has identified how criminalization of HIV non-disclosure can have deleterious effects on those living with HIV, the perspectives of people who use drugs – a population disproportionately affected by HIV– should be more meaningfully considered in these discussions. Methods: Using constant comparative techniques, data from 60 interviews with men and women living with and without HIV and who use drugs in Vancouver were analyzed to explore their perceptions about Canada’s HIV non-disclosure legal framework. Results: Participants’ perspectives on the framework involved three themes: understandings of HIV risk; HIV-related stigma; and their own experiences with HIV. While several participants favored the punitive character of the legal framework, these arguments were premised on misinformed and stigmatized assumptions regarding HIV. Conclusions: The paper concludes by discussing the challenges and opportunities for resisting HIV stigma and misconceptions about HIV within the context of personal accounts that, at times, support criminalization of non-disclosure.
RESEARCH ARTICLE Open AccessPerspectives of HIV-positive and -negativepeople who use drugs regarding thecriminalization of HIV non-disclosure inCanada: a qualitative studyCara Ng1, Koharu Loulou Chayama1,2, Andrea Krüsi2,3, Will Small1,4 and Rod Knight1,2*AbstractBackground: While previous research has identified how criminalization of HIV non-disclosure can have deleteriouseffects on those living with HIV, the perspectives of people who use drugs – a population disproportionatelyaffected by HIV– should be more meaningfully considered in these discussions.Methods: Using constant comparative techniques, data from 60 interviews with men and women living with andwithout HIV and who use drugs in Vancouver were analyzed to explore their perceptions about Canada’s HIV non-disclosure legal framework.Results: Participants’ perspectives on the framework involved three themes: understandings of HIV risk; HIV-relatedstigma; and their own experiences with HIV. While several participants favored the punitive character of the legalframework, these arguments were premised on misinformed and stigmatized assumptions regarding HIV.Conclusions: The paper concludes by discussing the challenges and opportunities for resisting HIV stigma andmisconceptions about HIV within the context of personal accounts that, at times, support criminalization of non-disclosure.Keywords: People who use drugs, Criminalization, HIV, Non-disclosure, StigmaBackgroundWithin and across many global settings, the non-disclosureof human immunodeficiency viruses (HIV) during sexualencounters remains a criminalized act. Specifically, 68countries in the world, including Canada, criminalize the“non-disclosure, exposure or transmission” of HIV, while33 other countries have applied different criminal provi-sions in similar instances [1]. In 2017, Canada ranked ashaving the third largest number of recorded prosecutionsfor alleged HIV non-disclosure globally [1–4]. Within theCanadian legal framework, HIV non-disclosure can resultin charges of aggravated sexual assault or attempted mur-der. There have been approximately 184 people who havefaced charges related to non-disclosure between 1989 and2016 in this country, with the majority occurring since2004 [5]. The legal framework for prosecuting HIV non-disclosure was first established in the precedent-setting R v.Cuerrier 1998 decision in which the Supreme Court ofCanada ruled that people living with HIV are legally re-quired to disclose their HIV positive status in cases of “sig-nificant risk of serious bodily harm”, regardless of whethertransmission had occurred [6].© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.* Correspondence: bccsu-rk@bccsu.ubc.ca1British Columbia Centre on Substance Use, 4th Floor, 1045 Howe Street,Vancouver, B.C V6Z 2A9, Canada2Department of Medicine, University of British Columbia, Vancouver, CanadaFull list of author information is available at the end of the articleNg et al. BMC Public Health (2020) 20:1220 https://doi.org/10.1186/s12889-020-09291-3In the early 2010s, the Supreme Court was revisitingthe meaning of “significant risk”, with arguments sug-gesting this terminology can lead to ambiguity andtherefore contribute to the legal framework being dif-ferentially and unevenly applied [7, 8]. Indeed, manycriticisms have arisen in terms of how the legalframework is unfairly applied, including how chargestend to be concentrated among racialized people [9,10] as well as how it is not uniformly applied acrossvarious levels of the judicial system (e.g., across differ-ent civil and/or provincial jurisdictions). In a 2012 de-cision during two cases of appeal (R v. Mabior and Rv. DC), the Supreme Court ruled that individuals liv-ing with HIV must disclose their HIV positive statusin sexual situations where “a realistic possibility ofHIV transmission” occurred [11].Unfortunately, from a medical perspective, the judicialapplication of this current legal framework ruling – a“realistic possibility” of transmission – does not suffi-ciently or consistently account for the current ‘interven-tion landscape’ of HIV treatment and prevention [1, 12–14]. It is now widely accepted that “undetectable viralloads are untransmittable” (i.e., U=U) [15] – a consensusthat is firmly established, including through data pub-lished in 2016 from two large-scale clinical trials (PARTNERS and HPTN-052) [12, 13, 16]. Within some rulingsunder the “realistic possibility” framework, people whoare HIV-positive can be protected from criminalization,but the burden of proof that a “realistic possibility” oftransmission did not occur is high and rests entirely onthe person living with HIV to demonstrate and provethat they met the standards of risk. Specifically, thisframework has been interpreted by subsequent judicialrulings to require people living with HIV to be able toprove that they fulfilled two requirements during sexualencounters in which they did not disclose their HIV sta-tus in order to avoid being convicted: first, that they hadlow or suppressed viral loads at the time of the sexualencounter; and, second, that they also used a condom.As such, despite the reality that many people livingwith HIV have undetectable viral loads and transmis-sion is no longer empirically possible when viral loadsare low, under the current application of the legalframework, even those who have undetectable viralloads can be charged with serious criminal offences andbe sentenced to significant time in prison if they cannotprove that they had an undetectable viral load and thatthey used a condom at the time of the encounter inwhich disclosure did not occur [14, 17, 18]. In late2018, the federal government issued new prosecutorialguidelines to address the “over criminalization” of HIVnon-disclosure however these guidelines are not bind-ing outside the Yukon, Northwest Territories, andNunavut [19].The Criminalization of HIVWhile the legal framework around HIV non-disclosure isostensibly deployed to ‘govern’ and prevent HIV transmis-sion, human rights activists and people living with HIV havedrawn attention to the ways this legal framework both failsto prevent HIV transmission and increases overall harm –and, that harms are unequally experienced by socially vul-nerable and disadvantaged populations. For example, as isthe case with the criminalization of drug use, research haspointed to the ways the criminalization of non-disclosureleads to the uneven application of criminal charges amongIndigenous and Black people, as well as among LGBTQ andpoor communities living with HIV [10, 20, 21].Previous research has also identified how laws and pol-icies that criminalize HIV can serve as structural driversof HIV stigmatization [14, 22]. These include, for ex-ample, studies that have identified how Canada’s legalframework may negatively impact trust and confidential-ity within patient-clinician encounters, as well as how itcan reduce access to regular testing for those who donot know their status and affect retention within theHIV cascade of care for those living with HIV [22, 23].There have been studies that have focused attention onthe ways legal frameworks increase overall harm forthose living with HIV (e.g., stigma, prejudice) whiledoing little to prevent HIV transmission [24, 25]. Othershave also argued that instead of focusing on the sharedresponsibility that those living without HIV – includingcommunities and society more broadly – have in termsof preventing HIV transmission, the criminalization ofnon-disclosure emphasizes individualized notions of re-sponsibility of HIV prevention. This leaves the onus ofHIV prevention left exclusively upon those living withHIV [21, 26], thereby contradicting decades of publichealth HIV prevention messaging.Everyday understandings about HIV non-disclosureAmidst concerns about the various effects of thecriminalization of HIV non-disclosure, including the un-intended effects of stigma and other correspondingnegative health and social outcomes, in the Canadiancontext, surprisingly little is known about how the legalframework is actually understood, perceived and experi-enced by individuals in a society ‘governed’ by theseframeworks. There have been a few important studiesregarding the ways in which the criminalization of non-disclosure impacts upon marginalized groups in Canada.These studies have focused on the ways people livingwith HIV from a range of social locations (e.g., peoplewho use drugs, refugee and immigrant women, cis andtrans women) understand non-disclosure legal frame-works and negotiate it within the context of their ownlives and sexual relationships [27–29]. In a recent article,Knight et al. [14] explored the impacts of HIVNg et al. BMC Public Health (2020) 20:1220 Page 2 of 13criminalization legal frameworks on the perspectivesof and experiences with HIV risk among 85 HIV-negative men and/or men who were unaware of theirserostatus. In that study, the authors identified twonarratives, including narratives of “justification” and“interrogation” in relation to existing legal frameworksaround HIV criminalization. Within the interrogationnarrative, the authors identified how participantstended to problematize the acceptability of criminaliz-ing HIV non-disclosure because they felt that theframework created unjust barriers to HIV testing up-take (for those unaware of their status) and HIVtreatment and care (for those living with HIV).Within the justification narrative, the authors notedthat HIV literacy was often very low, including refer-ences to HIV as a “death sentence”. Those who ad-vanced the justification narrative also tended tosuggest that the legal framework provides both pun-ishment and deterrence, which were perceived tosupersede considerations about barriers to care forboth HIV-positive and -negative individuals.While examples of research in this area clearlyexist, authors of this article are not aware of anyqualitative studies regarding the perspectives of bothpeople living with and without HIV who use illicitdrugs on the non-disclosure legal framework in theCanadian setting. Furthermore, people who injectdrugs have poor access to HIV prevention, treatment,and care due to the continued criminalization of druguse and ongoing stigma against people who use drugs[30, 31]. Of all new HIV diagnoses in BC in 2016,7.1% occurred among people who inject drugs(PWID) – despite only comprising approximately 1%of the population [32]. Given that this population en-counters a variety of social and structural barriers toaccessing health care, and are also vulnerable to con-tracting HIV due to repressive anti-drug policies thatenhance HIV susceptibility and present barriers tocare [33–36], understanding these perspectives is crit-ical to closing health inequities.While previous research has been helpful in identi-fying the impacts that HIV non-disclosure legalframeworks have on people living with HIV (e.g. in-creased violence and stigma), more information abouthow these frameworks influence the experiences andperspectives of both people living with and withoutHIV in the Canadian context are needed. This know-ledge gap remains salient for people who use drugs.Therefore, the objective of this study was to examinethe perspectives of people who use drugs about theHIV non-disclosure legal framework. To do so, theinsights of 30 men and 30 women living with andwithout HIV who use drugs living in Vancouver,Canada were explored.MethodsStudy settingData collection activities were based in Metro Vancouverin the province of British Columbia (BC), Canada. Theregion’s total population in 2016 was 2,463,431 [37]. Inline with historical trends in BC, men continue to havehigher rates of HIV transmission than women. Whilethe BC Centre for Disease Control reports that 7.1% ofall new HIV diagnoses in BC occurred among PWID,this population has also recently experienced decliningrates of the disease (e.g., 66 cases in 2008 compared to16 cases in 2016), likely reflecting the success of recentexpansion and sustained prevention efforts with thispopulation [32]. For example, a “seek and treat” pilotprogram was launched in Vancouver and Northern BCin 2010, in order to expand access to HIV testing andtreatment for BC residents [38]. Among PWID, 70.6% ofnew diagnoses were among men, and the greatest num-ber of new infections occurred among those between 30and 59 years of age [39] (94.1%). In BC, Indigenouspeople are also disproportionately affected by HIV; in2015, they comprised 7.9% of new diagnoses in the prov-ince, while representing only 5% of the total population.Indigenous men comprised 4.5% of new diagnoses in theprovince among men, while Indigenous women com-prised 27% of new diagnoses in the province amongwomen [39]. Further, Indigenous populations in BCcomprised 13% of opioid-related deaths in the province,despite making up only 3.4% of the population [40].Recruitment and data collectionParticipants were recruited between February and Sep-tember of 2017. HIV-negative PWID were recruitedthrough the Vancouver Injection Drug Users Study(VIDUS) and HIV-positive PWID were recruitedthrough the AIDS Care Cohort to Evaluate access toSurvival Services (ACCESS) study. These cohorts requireparticipants to be 18 years of age or older, provide writ-ten informed consent, and have used illicit (ACCESS) orinjection (VIDUS) drugs prior to their enrolment [3, 4].ACCESS and VIDUS participants have been recruitedthrough community outreach, and both studies maintainfollow-up rates of ≥85%. At baseline and semi-annualfollow-up visits, participants complete questionnaires ad-ministered by a trained interviewer or nurse, and providea blood sample for HIV and Hepatitis C virus (HCV)testing (VIDUS) or ongoing clinical monitoring of HIVdisease progression (ACCESS).Stratified purposeful sampling [41] was used to delib-erately select participants from a variety of backgroundsand ‘profiles’ (e.g., by gender identity, ethno-culturalidentity) and to identify those who may experience vari-ous vulnerabilities (e.g., previous or current injectiondrug use) with regards to HIV and HIV non-disclosureNg et al. BMC Public Health (2020) 20:1220 Page 3 of 13legal frameworks [42, 43]. It is important to note that thesampling distribution in terms of ethno-cultural and racialidentity does not match the distribution of the generalpopulation in BC. For instance, while Indigenous peoplecomprise 5.9% of the population in BC, in the study sam-ple, they represent over half of participants (~ 51.67%)[37]. Their ‘over-representation’ in the sample likely re-flects the co-existing issues of inequality (e.g., poverty, ra-cism, colonization) faced by Indigenous communities inBC and Canada.ACCESS and VIDUS frontline research staffapproached individuals who were eligible and met thesampling framework to participate in qualitative inter-views during their semi-annual or other follow-up visitsto the field office. Eligibility criteria included being par-ticipants in VIDUS or ACCESS. Participants wereflagged in the cohort database so that when they arrivedat the field office for their visits, they would beapproached by the front desk person and asked if theywere interested in participating in the study. Researchand nursing staff also determined eligibility by trackingand ‘flagging’ potential interviewees on the main ornursing questionnaire (i.e., if participants were found tomeet the eligibility requirements through the questionsposed in these questionnaires, they would be approachedto do an interview). Participants were told that there wasa study about the experiences of accessing HIV pro-grams and services for people using drugs. At this point,prospective participants who expressed interest in par-ticipating in the study were referred to a member of theteam who provided them with further information aboutthe interview, confirmed their eligibility, and invitedthose who were eligible to participate in the study subse-quent to providing written informed consent. Partici-pants received a CAD$30 honorarium to compensatethem for their participation. Ethics approval was ob-tained from the University of British Columbia’s Behav-ioural Research Ethics Board (#H16–00325).Interviews were conducted within the research officesin Vancouver’s Downtown Eastside. Interviews lasted 30to 60min in duration and were audio-recorded. Duringeach interview, participants were asked to share whatthey knew about the legal framework surrounding HIVnon-disclosure in Canada. All participants were providedwith some additional background information by theinterviewer based on a script provided in the interviewguide. Participants were also asked the opportunity toask questions of clarification regarding Canada’s HIVnon-disclosure legal framework. They were then invitedto discuss how their understandings of HIV and HIVrisk might relate to the broader context of Canada’scurrent legal framework pertaining to HIV non-disclosure. It is important to point out that while the in-terviews may have provided an educational componentfor the participants about the HIV non-disclosure legalframework for those who did not already know about it,this was not the intention. In order to remain as neutralas possible, the interview guide provided a script thatwas factual in nature regarding the HIV non-disclosurelegal framework. All of the interviewers were experi-enced in interviewing and used open-ended questionswhile avoiding leading questions. See Table 1 for thequestions and probes interviewers used to guide the dis-cussion during interviews.AnalysisAudio recordings of the interviews were transcribed andaccuracy checked by a third party and subsequentlyuploaded to NVivo12. This research is framed within amodified grounded theory methodology [44]. Co-authors(of whom one, RK, was involved in the interviewingprocess) read and re- read transcripts, employing con-stant comparative techniques [45, 46] to inductively de-rive themes relevant to the study. Constant comparativetechniques were appropriate for this study since it wasimportant for the themes to be directly constituted andinformed by the patterns and contradictions thatemerged from the qualitative data in the interviews. Spe-cifically, the individual transcripts were compared andcontrasted to identify patterns, and shared and divergentunderstandings were identified. Next, an open-codingapproach was used in which coding was first organizedinto ‘trees’ to group the codes thematically. The emer-gent thematic codes focused on capturing the micro-(e.g., previous experiences), meso- (e.g., interpersonalrelations) and macro (e.g., socio-cultural) factors [47]that shape participants’ opinions and behaviours relatedto the criminalization of HIV non-disclosure, with aspecific focus on how understandings of HIV risk influ-ence each participant’s perspectives regarding the legalframework.Consistency of coding (inter-coder reliability) wasassessed by team members and any discrepancies werediscussed and resolved at research team meetings. Dis-crepancies between codes and coders were resolvedthrough discussion and raw data was re-visited asneeded during data meetings. Analytic memos were keptthroughout the coding to document the analysis processas it developed and key decisions, and these were dis-cussed throughout the analysis of the data, writing ofthis article, and drafting of this report. “Verification”strategies were also used to establish rigor in the ap-proach to validate decisions about the analysis, includingthe emphasis of responsiveness and openness of all au-thors to the data in adjusting or revising the codes andpresentation of each thematic to result in a consensus-driven representation of the findings.Ng et al. BMC Public Health (2020) 20:1220 Page 4 of 13The data analysis was guided by two overarching analyt-ical questions, which were arrived at during the final stagesof organizing data and data analysis: 1) How are partici-pants’ perspectives on the criminalization of HIV non-disclosure shaped by understandings of societal stigma? 2)How are perspectives about the criminalization of HIV non-disclosure shaped by understandings of HIV and HIV riskin an era where “Undetectable = Untransmittable”? As thisprocess unfolded, a final set of codes to identify the broadthemes that emerged across the data set was established. Indoing so, a thematic analysis was conducted with both aninductive analytic approach to develop initial coding schemaand general themes, as well as deductive approaches inwhich findings were used to compare and contrast the exist-ing literature pertaining to the perspectives and experiencesof the non-disclosure legal frameworks [48, 49].FindingsIn total, 60 participants (30 men; 30 women), whoranged in age from 33 to 73, were recruited to partici-pate in in-depth, semi-structured interviews. Table 2provides further information on the socio-demographiccharacteristics of the sample.Overview of findingsDuring the interviews, participants’ perspectives were soli-cited on the legal framework that criminalizes HIV non-disclosure in Canada. During these discussions, some ofthe participants were more familiar than others with thespecifics of the Canadian legal framework. However, al-most all of the participants were aware that there could belegal implications for people living with HIV who do notdisclose their status during sexual encounters. Below, find-ings in light of three interrelated themes are presentedthat emerged from the analysis of how participants dis-cussed their perceptions of and experiences with thecurrent legal framework as follows: (1) understandings ofHIV risk; (2) stigmatized beliefs about people living withHIV; and (3) personal experiences with HIV and HIV risk.Each quotation is preceded by a short description of eachparticipant’s socio-demographic profile and followed by aresearcher-assigned numeric code.1) ‘They have no right to play God with your life’:Understandings of HIV risk and an evolving HIVintervention ‘landscape’Table 1 Questions and probes on the topic of the criminalization of HIV non-disclosurePERSPECTIVES ON HIV CRIMINALIZATIONIn Canada, we have a law that criminalizes HIV+ individuals who do not disclose theirHIV + status to sexual partners unless they use a condom AND have a ‘low’ viral load.During this section, I am not asking about what you have done in the past, butam interested in understanding your opinions on this issue.Have you come across any information related to this law?▪ Were you aware of this law?▪ What do you think about this law?▪ Where did you hear this information?▪ Can you tell me about any accounts of HIV non-disclosure that might stand out in your memory?In Canada HIV non-disclosure has most often been prosecuted as aggravated sexual as-sault. Aggravated sexual assault carries a sentence of jail time up to a maximum of lifeimprisonment and registration on the Sexual Offender Registry. This is one of the mostserious crimes in the Canadian Criminal Code. In Canada, over 150 people have beenprosecuted for HIV non-disclosure to date, even where no transmission has taken placeand where in many cases the risk of transmission was considered to be very small. Whatare your initial thoughts on how HIV is treated in Canada in these sorts ofcircumstances?▪ Tell me about your overall thoughts about this law.▪ How do you think this law influences people living withHIV?▪ Do you think that this law is unfair for certain groups ofpeople?▪ Do you think everyone is able to disclose their HIV statuswhen they are going to have sex?Table 2 Socio-demographic characteristics of study participants(n) (%)Living with HIVYes 30 50%No 30 50%EthnicityIndigenous/First Nations/Metis 31 ~ 51.67%White 25 ~ 41.67%Black/Caribbean/African 3 5%Unspecified 1 ~ 1.67%Gender identitiesWoman 30 50%Man 30 50%Age30–39 7 ~ 11.67%40–49 24 40%50–59 21 35%60–69 5 ~ 8.33%70+ 2 ~ 3.33%Unspecified 1 ~ 1.67%Sexual OrientationGay 4 ~ 6.67%Straight 46 ~ 77%Two-Spirit 2 ~ 3.33%Bisexual 3 5%Other 2 ~ 3.33%Unspecified 3 5%“gender identities” categories are inclusive of both cisgender andtransgender identitiesNg et al. BMC Public Health (2020) 20:1220 Page 5 of 13Participants were asked about how the risk of HIVtransmission features within how they think about Cana-da’s HIV non-disclosure legal framework. As inter-viewers initiated these discussions, many of the HIV-negative participants told interviewers that they believedan HIV diagnosis would result in either the rapid declineof health or even death (e.g., progression to Acquiredimmunodeficiency syndrome, i.e., AIDS) and was there-fore, in their view, analogous to physical assault or mur-der. For example, two participants explained:I mean, you can die from that [HIV]. And if theother person doesn’t know about it, then it’s like amurder charge kind of thing, you know what I mean?(HIV-Negative, Woman, White; 0030)They didn’t ask you to give them that disease to them.I think they should all be thrown in jail. (HIV-Nega-tive, Woman, Indigenous/First Nations; 0028)As interview discussion about HIV risk continued,participants described how they viewed the act of aperson living with HIV not disclosing their status asfeaturing morally questionable behaviour – thoughthe act of not disclosing was invariably underscoredby concerns about risk of transmission, regardless ofwhether or not one is undetectable. For example,when asked if participants felt the legal frameworksshould still apply to situations in which individualshad “low to no risk” of transmission, participants’ re-sponses tended to emphasize that concerns about riskalways needed to feature within their assessments ofthe legal frameworks:If they’re undetectable and they still have the virus,it can still be a risk factor. Yeah, but still they putthe other person at risk without disclosing. Theydidn’t care whether they got it or not. They’re onlythinking about their own sexual needs. (HIV-Nega-tive, Man, Indigenous/First Nations; 0012)I don’t think there’s very much difference. It’s still …it’s still irresponsible for the person who’s got HIV,you know … I know if I had it, I would be respon-sible and tell them, you know. Anybody that’saround me, like regardless of … what people think ofme, it’s just the responsible thing to do, right?Because … it’s not something that I would want tocatch. (HIV-Negative, Man, Indigenous/First Na-tions; 0023)Respondent: You should be going down for murder,I feel. You want to fucking fuck with someone’s life,then you’ve just murdered them. [ … .]Interviewer: And you can’t even get it in cases where– you know how we talked about like undetectable?Respondent: Yeah.Interviewer: So even if it’s really low to no risk?Respondent: Well, still, though. You didn’t tell them!They have no right to play God with your life. (HIV-Negative, Woman, Indigenous/First Nations; 0011)During these discussions, interviewers were frequentlystruck with how participants – particularly those not liv-ing with HIV – tended to express support for HIV non-disclosure legal frameworks based on misguided under-standings of HIV ‘risk’ in the context of highly effectiveand available treatment in British Columbia.Among those living with HIV, a very different under-standing of HIV risk tended to emerge. For example,most participants living with HIV described that theywere aware that when viral loads are undetectable, trans-mission is not possible. Nevertheless, some of those liv-ing with HIV continued to emphasize that they feltdisclosing their HIV status to sex partners was some-thing that one ought to do, regardless of the risks in-volved. These participants described that they wanted todisclose to partners so they could align more closelywith virtues they valued, including honesty and compas-sion – something they described as being particularlyimportant when a current or prospective romantic and/or sex partner was involved.Among some participants living with HIV, however,significant misconceptions about HIV risk continued toemerge in the interviews, particularly during discussionsabout how one can be charged and sentenced to longterms in prison for not disclosing, including in situationsin which an individual has a suppressed viral load butdid not use a condom:Well, I think it’s imperative that people know [evenin cases where transmission is low], because youknow, whether you’re going to get lucky that night,it’s their livelihood [health]. So, I mean, you changetheir lives if you … and you should respect that, be-cause you know what happened to you, yourself,right? (HIV-Positive, Man, White; 0033)They should get a lot more than that.... you’re givingsomebody life, ruin somebody’s life. (HIV-Positive,Woman, White; 0049).Well, I think it’s [being charged with aggravated sex-ual assault for not disclosing when undetectable] aNg et al. BMC Public Health (2020) 20:1220 Page 6 of 13good idea, because you’re basically playing withsomebody else’s life. Because it’s a life. You have thisdisease for life, you know. (HIV-Positive, Woman,Indigenous/First Nations; 0045)Participants’ perspectives about HIV risk and the legalframeworks tended to largely stem from a ‘pre-Anti-retroviral’ era that disavowed the current realities of theintervention ‘landscape’. As such, these perspectiveswere frequently underpinned by a misguided premisethat there is always risk for transmission, including whenindividuals with HIV have low viral loads (less than 200copies per milliliter of blood), which is not consistentwith current understandings.2) ‘They’re too ashamed of telling anybody’: Stigmaand HIV non-disclosureAt times, including when participants referred to howone’s life would be “ruined” or “played with” for thosewho acquire HIV, interviewers were left wondering howparticipants’ concerns relate to the health and/or socialconsequences of HIV acquisition. To better understandthese perspectives, participants were asked about howHIV disclosures occur in “real world” settings. Almostall of the participants described how one’s HIV-positivestatus could make it too difficult to disclose within sex-ual encounters, and this was invariably based on the so-cial implications (e.g., rejection) one may experience as aresult of disclosing. For example, participants frequentlydescribed how the fear of sexual or social rejection couldpresent real-world barriers for people living with HIVfrom being able to disclose their status to sex partners:I think with HIV, when you factor in that socialstigma, like why should someone have to say like,‘Oh, I’m HIV-positive,’ on the chance that person’sgoing to react really negatively or harshly?” (HIV-Negative, Woman, White; 0021)I don’t think a lot of them do [disclose] becausethey’re afraid, you know. Like they’re afraid that theymight lose their partners or whatnot. (HIV-Positive,Man, Indigenous/First Nations; 0043)As such, a subset of participants began to interrogatehow one’s ‘decision’ not to disclose their HIV-positivestatus was deeply linked to features of social context thatstigmatize HIV. Within these discussions, interviewerswere often struck with how calls for ‘personal responsi-bility’ and the need to disclose ran counter to partici-pants’ understandings and concerns about the profoundstigma that actively limits – or, in many cases, prevents– the ability to disclose. For example, one participantdescribed how, despite emphasizing that feelings ofshame and fears of social repercussions represent criticalbarriers to disclosure, she felt those living with HIVshould nevertheless be ‘responsible’ and disclose theirstatus:One of the ways that it’s [HIV] contracted a lot, be-cause they’re [people living with HIV] too ashamedof telling anybody that they’re positive and not beingresponsible enough to say, “Hey, I’m HIV positive.Maybe we should … take some responsible steps”,you know. (HIV-Negative, Woman, White; 005)Despite the widespread acknowledgement among partic-ipants that stigma limited how disclosure can occur, itbecame clear that many of the participants felt that ne-gotiations about safer sex were, in ‘practice’, almost en-tirely the responsibility of individuals living with HIV.Within these discussions, some participants emphasizedthat concerns about stigmatization needed to be recon-ciled alongside the values they placed both on the auton-omy and privacy of people living with HIV and the valuethey placed on protecting the health of ‘self’ and ‘others’.Nevertheless, as these discussions unfolded, participantstended not to describe how those living without HIVmay also have responsibilities around safer sex practices,instead often returning to the need to compel those liv-ing with HIV to disclose their HIV status via mandatoryand coercive enforcement mechanisms, i.e., legal frame-works. Here, participants tended to suggest that con-cerns about autonomy or privacy for people living withHIV – concerns all participants emphasized needed tobe taken seriously – should be overruled in order to pro-tect the health and well-being of those not living withHIV. One participant not living with HIV described thecomplexities involved in navigating between personal au-tonomy and the health and wellbeing of the broadercommunity:I feel like the ability to choose when [someone is go-ing] to disclose is important, and stigmatized factsabout themselves and medical history is very import-ant to protect. But also, that those kinds of consider-ations of autonomy and privacy stop being personalwhen they start affecting other people. And it’s justwhen and where it switches from the one to theother. (HIV-Negative, Woman, White; 0021)Some of the participants living with HIV described howthe stigma associated with HIV reinforced how they inter-acted with sex partners, with many describing how thefear of both being criminally charged and socially and/orromantically rejected shaped situations that made themfeel unsafe. One participant living with HIV describedNg et al. BMC Public Health (2020) 20:1220 Page 7 of 13how past experiences of rejection from romantic partnersresulted in him deciding to disclose his HIV status at thebeginning of a romantic relationship in order to preventfuture feelings of heartbreak should he become attachedand then rejected again:When you like someone that much you’re gonna say“Oh, oh my God, I’ll lose them if I say I’m positive,I’ll probably lose them, right.” But if you tell them inthe beginning at least it hurt less cause you’re not at-tached with the person yet. (HIV-Positive, Man,White; 0048)While all of the participants in the study felt HIV stigmarepresented a key barrier to those who are tasked withdisclosing their HIV-positive status, two participants liv-ing with HIV argued that HIV stigma ‘no longer mat-tered’ to them, partially due to the evolving socialcontext surrounding HIV. For example, two participantsdescribed:I’m pretty confident in who I am, right? So it doesn’tbother me what people think, so I tell people that Ihave HIV like pretty well right away... And the life-style I live, HIV is … it’s so common right? It’s got nostigma attached to it at all, right? You know? (HIV-Positive, Man, White; 0034)Well, you know, before it [HIV stigma] might havebeen more of a problem, right? But nowadays, I don’tthink it is, you know, because the education is morethere. People were ashamed back then, even when Ifirst got it. But now it’s, you know, it’s so open, youknow. Like the HIV is so open now, you know. It’snot a shameful thing. (HIV-Positive, Woman, Indi-genous/First Nations; 0045)Despite emphasizing that the negative effects of HIVstigma were from a previous era, these participantsnevertheless expressed support for the legal frameworksthat criminalize HIV non-disclosure. For these partici-pants, a dissonance began to emerge in which the ‘pro-gress’ made with regards to HIV treatment wasundermined by the extent to which they continued toview HIV as an ‘exceptional’ infectious disease that, as aresult, required a legal framework to ‘govern’ HIV riskand transmission. These discussions were often highlypersonal and revealed important histories about howthose living with HIV connected their previous experi-ences with HIV and HIV risk to their understandings ofthe HIV non-disclosure legal frameworks. As such, asthe interviews progressed, the stories of those living withHIV continued to emerge and inform their perceptionsabout the HIV non-disclosure legal framework.3) ‘That’s what happened to me’: Personal experienceswith HIV and HIV riskA number of participants expressed varying degrees ofsupport for the criminalization of HIV non-disclosurebased both on their own personal experiences with HIV,as well as based on stories about HIV non-disclosure cir-culating among their peers and via the media. As partici-pants provided examples that they had heard about, theytended not to know the individuals involved in the stor-ies directly. Nevertheless, participants described howthese situations featured purported acts of non-disclosure that were committed with the clear intentionof a person living with HIV to purposefully harm, i.e., in-fect, others by exposing them to HIV:I heard of a couple of other girls down here that weregoing out and having sex with men, and they knewthey had HIV and they intentionally... I think they’restill out there somewhere. And were spreading it,and they should be put down [euthanized] … That’sa serial killer. [Mm-hmm] a serial killer. And yeah,those people should be extinguished. (HIV-Negative,Man, Indigenous/First Nations; 0025)You know, there was one guy that went around … . Idon’t know if it was in the States or in Canada, but– I think it was in Canada, but he exposed, what, 30girls, or so? And oh, man, it was crazy. Fuck, he justwent out, and he knew he had it. And they wereafter him, a manhunt on him. And they finally gothim. (HIV-Negative, Man, White; 0026)As such, participants tended to buttress a ‘pro-criminalization’ stance on HIV non-disclosure based onsomewhat sensationalized accounts and stories. For ex-ample, as participants reflected on the stories they hadheard about, some tended to construct narratives thatfeatured people living with HIV as inherently ‘bad’ and‘to be feared’ because they could easily and withoutwarning choose to purposefully transmit the virus. Whilethis concern tended to be put forth by those living with-out HIV, several of those living with HIV reflected onhow these perceptions of the reprehensible ‘other’ ranup against their own experiences and observations ofothers living with HIV:I think the law should be you should have to be openno matter what. [ … ] If somebody wants to give youHIV they can give you HIV and you’re not gonna donothing about it. They want to stab you with a rigfull of their blood what can you do? It’s a pretty easyway to transmit it. But, like in social living as op-posed to all these other transmittable diseases likeNg et al. BMC Public Health (2020) 20:1220 Page 8 of 13other STDs right, it of course is a very low risk withHIV now. But people actually people know that nowand they’re being high risk because of that and thatworries me too. (HIV-Positive, Man, White; 0056)Many of the participants reflected on how they felt theylikely acquired HIV from a partner who did not disclosetheir positive status, though all of the participants re-ported that they were unsure and unaware of the specificencounter that may have resulted in their own acquisi-tion of HIV – experiences that occurred up to 20 yearspreviously. A sub-set of the participants living with HIVdescribed how they would have liked their previous sex-ual partners to have disclosed their HIV-positive statusbecause they could have either declined to have sex orused precautions (e.g., condoms). For example, one par-ticipant reflected on how her own experience acquiringHIV features within how she thinks about HIV risk andthe application of the legal framework surrounding HIVnon-disclosure:Where no transmission takes place, it’s kind of a lit-tle harsh. But it depends on the situation. They still… whether transmission took place or not, you stilldidn’t tell them. You took their choice away … . Andthat’s not right in my mind. It’s really not right. Like,if I’m ever intimate with anybody, I tell them rightaway. I’ve got HIV. Now you deal with it. It’s yourchoice. It’s in your court. Because, like I said, I wasperturbed when nobody told me. (HIV-Positive,Woman, undisclosed ethnicity; 0038)As the interviews came to an end, some participants liv-ing with HIV pointed out a conundrum or dilemma ofsorts, which functions as a catch-22, that they had iden-tified based on their own experiences living with HIV.Specifically, these participants identified how the legalframework in Canada is implicated in increasing HIVstigmatization broadly and, as a result and at the sametime, (re) produces a set of social conditions that makesdisclosure extremely difficult and unsafe (e.g., due tofears of violence). As such, several participants pointedout how they felt the law itself is inherently paradoxicaland counterproductive, particularly within the pursuit of“governing” HIV disclosure. For example, one partici-pant living with HIV described how the criminalizationof HIV non-disclosure is, in itself, a stigmatizing act.Here, the participant described how the law seems to bepremised on concerns that those living with HIV wouldpurposefully transmit concurrently frames people livingwith HIV as being inherently ‘bad’ people:I think [the legal framework] makes people withHIV look really bad. Like, you know, it makes themlook like they don’t give a shit about nothing. Like Iwouldn’t want to hurt somebody. I don’t know whypeople would want to hurt somebody. I don’t evenknow how people do it. I mean, like if I would haveknown that, that person could have got charged, youknow, like that I slept with that time. Like I mean, Iprobably would have like. I probably would havesaid, “No, don’t charge him.” I mean, that would becrazy. (HIV-Positive, Man, Indigenous/First Nations;0044)DiscussionThe findings reveal several important insights withregards to PWUD’s perspectives and experiences regard-ing legal frameworks surrounding HIV non-disclosure inCanada. First, participants tended to characterize thebenefits of the legal framework with regards to misin-formed understandings of HIV risk, as well as based onstigmatized beliefs about people living with HIV. Assuch, participants who described favoring the legalframework tended to premise their rationale based onmisinformed and stigmatized assumptions about HIVand HIV risk. Others described how their own personalexperiences with HIV and HIV non-disclosure informedhow they thought about the legal framework, includinghow they either justified or interrogated the legalframework.Many of the participants in the study described howthey felt the legal frameworks could serve an importantrole in compelling those living with HIV to disclose theirstatus with sexual partners. Within these examples, sev-eral participants described how they felt the interests ofthose living without HIV may need to ‘supersede’ the in-terests of those living with HIV (e.g., privacy, safety).While a few participants living with HIV understoodthat “Undetectable = Untransmittable”, they neverthelesstended to express support about the need to discloseone’s HIV status, frequently suggesting that the legalframeworks should be founded on the need to upholdand govern a set of social conditions in which those liv-ing with HIV could do no harm to others. As the inter-views progressed, interviewers were frequently struckwith how concerns about ‘doing no harm’ ran parallel tothe very reasons and justifications participants livingwith HIV used in their conscientious efforts to avoidtransmitting the virus.While relational values are important to consider, inlight of a criminalization legal framework that presumesthat the sexual behaviours of people living with HIVneed “governing”, it is important to further unpack thedrivers of this perceived responsibility to disclose evenwhen transmission is deemed “impossible”. HIV excep-tionalism is an important lens in understanding whysome study participants who live with HIV may have feltNg et al. BMC Public Health (2020) 20:1220 Page 9 of 13compelled to disclose their status – particularly among asample of people who have likely viewed and experiencedHIV and HIV risk through an ‘exceptionalist’ lens, includ-ing during critical periods of their life course (e.g., HIV ac-quisition events; experiences living in a neighbourhoodwith very high HIV prevalence). Originally coined in 1991,HIV exceptionalism refers to the idea that HIV requires aresponse above and beyond “normal” public health inter-ventions and should be treated differently in policy and lawcompared to other diseases, including those that are sexu-ally transmitted and/or lethal [50, 51]. HIV exceptionalismcontinues to be reinforced by the criminalization of HIVnon-disclosure and may partially explain participants’ per-ceived duty to disclose their seropositive status regardlessof transmission risk. It is perhaps less likely that partici-pants would have perceived the same level of duty to dis-close other health conditions (e.g., Human Papillomavirus,Hepatitis C) to their sexual partners, illustrating the weightthat HIV exceptionalism continues to carry in relation toother diseases, despite the immense progress that has beenmade with regard to medical treatments and prophylactics.Similar to previous research a few of the authors ofthis article have conducted with other populations (e.g.,young men) [14], participants in the current studytended to rationalize their support for the legal frame-work based on both misinformed assumptions and stig-matized beliefs about HIV that do not account for thecurrent HIV intervention landscape. Unlike previous re-search undertaken by the authors, however, participantsin the current study seemed less likely to emphasize theevolving intervention landscape (e.g., “U=U”) in their ac-counts, even after participants were asked about howundetectable/untransmittable viral loads ought to featurein considerations about the legal framework. As such,justifications of the highly criminalized legal frameworktended to suggest that it would be effective at controllingHIV transmission, with little to no concern about effect-ive treatment or prevention strategies. Furthermore, sev-eral participants advanced support for the frameworkbased on media depictions of highly sensationalized ac-counts of HIV non-disclosure. Yet, several participantsliving with HIV also provided support for the frameworkbased on their own personal experiences and the beliefthat, had the legal framework existed when they were in-fected with HIV in previous decades (i.e., prior to 1989),they would never have contracted the virus. Indeed,these arguments tended to assume that the overall effectof the legal framework would be effectively protective ofpublic health, a claim that runs counter to the growingbody of evidence that indicates that criminalization ofHIV non-disclosure increases overall harm. As such,these findings underscore the extent to which the legalframework both reflects and contributes to widespreadmisunderstandings and stigmatized beliefs about HIV.Hopefully, future changes to the HIV non-disclosurelegal framework (e.g., provincial and federal prosecutor-ial guidelines, potential legislative reforms) will be ad-vanced to both reflect the scientific consensus of HIVtreatment and prevention [1], while also providing op-portunities to address stigmatizing beliefs and misin-formed assumptions about HIV. Fortunately, sinceempirical social scientific research was last conductedexamining the perspectives of people navigating HIVrisk in the context of the legal framework in their every-day lives [14], the Government of Canada has made newchanges to directives and guidelines around prosecutingcases of HIV non-disclosure [19]. The new directivesstate that the federal government will no longer be pros-ecuting people living with HIV who have maintained asuppressed viral load. Though the new guidelines onlyapply to the Northwest Territories, Nunavut, and Yukon– territories in which judicial policy falls under federaljurisdiction – it is widely hoped that the provinces willfollow suit with similar prosecutorial guidelines [19]. Re-cently, BC also made revisions to its own prosecutorialguidelines regarding non-disclosure, with the CrownCounsel being instructed to carefully balance the inter-ests of the general public and the individual and sexualautonomy of victims while also ensuring that personsliving with HIV are not subject to criminalization orstigmatization solely based on their illness [52]. Whilemany advocates view these guidelines as an improve-ment from the current legal framework, many alsobelieve it does not go far enough due to the fact thatit does not clearly rule out the possibility of prosecut-ing those who have used a condom but do not havea suppressed viral load [53]. Nevertheless, it is hope-ful that these new prosecutorial guidelines may havesome effect in reducing HIV-related stigma, inaddition to drawing attention to the ways individualswith HIV can achieve suppressed – and thereforeuntransmittable – viral loads.Despite years of effective treatment therapies and edu-cational efforts [54, 55], the findings underscore the ex-tent to which HIV-related stigma continues to persistand undermine discourses of justice as well as publichealth objectives. Just as some of those living with HIVidentified within their own narratives, it is extremelyconcerning that the criminalization of HIV non-disclosure is actively exacerbating stigma and perpetuat-ing discriminatory attitudes and norms towards peopleliving with HIV [23, 56] – including some of those thatwere identified in the current study. Nevertheless, HIVcriminalization is only a partial explanation for the pres-ence of HIV-related stigma in participant descriptions.The continued stigma towards people living with HIVsuggests that the fear and anxieties produced throughpublic discourse during the height of the HIV epidemicNg et al. BMC Public Health (2020) 20:1220 Page 10 of 13in the 1980s and 90s [57, 58] remains deeply entrenchedin public consciousness and memory to this day. Fur-ther, since marginalized populations are overrepresentedamong those living with HIV, it is also reasonable toinfer that HIV-related stigma serves partly as a proxy forsocietal attitudes towards these communities.Despite positive changes to prosecutorial guidelines is-sued by the federal government, important questionsaround equity and justice still remain given that the HIVcriminalization legal framework continues to apply tothose with detectable viral loads. Baylis et al. argue thatthe greatest “burdens of pandemic” are often shoulderedby the poorest and the most socially marginalized com-munities which, in itself, generates ethical issues [59].The study population represents people who use drugs, agroup among those disproportionately affected by HIV.The criminalization of drugs has reinforced themarginalization of people who use drugs, particularlythose who are poor and racialized, while also discouragingthem from accessing harm reduction and other healthcare services. Repressive anti-drug policies and practiceshave increased vulnerability to HIV among people whouse drugs and discouraged their engagement in the HIVcare continuum [36]. Studies continue to find that peopleliving with HIV who use drugs are less likely to receiveantiretroviral therapy [60]. Further, they are less likely tohave suppressed viral loads while on treatment than otherpopulations [61, 62]. By extension, while thecriminalization of non-disclosure – in its ostensible at-tempt to protect ‘public health’ – has already been shownto be unfairly and selectively applied to poor, Indigenous,and Black communities [10, 20], it is highly concerningthat any application of this framework will continue todisproportionately impact PWUD, thereby serving as asignificant structural driver of inequity.The three themes identified in this study point to theneed for public health campaigns and programs to in-crease stigma reduction efforts and education about “U=U”. Reducing stigma could also entail correcting widelyheld assumptions about the disease by educating healthcare providers and the general public about the advancesin biomedical technologies that have allowed manypeople living with HIV to achieve and sustain undetect-able viral loads. Anti-stigma messages could alsoemphasize the significant role of socio-structural vulner-abilities that influence disease acquisition and transmis-sion (e.g., poverty, housing insecurity, lack of access toharm reduction services, drug prohibition) instead of fo-cusing on individual solutions and blame. Future publichealth campaigns and programs should be mindful ofcreating universal messaging that aims to reduce stigmafor all people living with HIV to avoid reinforcement ofstigma against those who have not achieved viralsuppression.To the knowledge of the authors, this is the first quali-tative study to explore the perspectives of both peopleliving with and without HIV who use illicit drugs on thecriminalization of HIV non-disclosure in Canada. Whilethe participant sample may be limited because it mostlyrepresents the perspectives of people living within asmall geographical area of the country and living in pov-erty, this study offers in-depth insights into the ways inwhich broader policies, structures, and norms shape atti-tudes and perceptions about the HIV legal frameworkamong a population underrepresented in literature.Nevertheless, the participants in this study included a di-verse group from other social categories such as gender,ethnicity, and sero-status. Despite this, this study is sub-ject to several important limitations. The potential amp-lification of response biases (e.g., social desirability bias)may have also influenced the sorts of responses partici-pants felt appropriate in the context of an interview. Pre-vious research has shown that HIV-related stigma isoften compounded by other mutually constituting stig-mas based on sexuality, gender, race, class, drug use andemployment in sex work – something authors were un-able to further explore given limitations with the currentstudy design. Future research should seek to explorethese co-occurring stigmas with an intersectional lens inorder to further identify complex barriers that hinder ac-cess to justice for people living with HIV. Furthermore,the scope of the findings may have been impacted bythe sociodemographic features of the participant sam-ple (e.g., age, sexual identity, and behaviour). Whilegay, bisexual, and men who have sex with men(MSM) account for a disproportionate number ofHIV diagnoses in BC [32], they accounted for only asmall percentage of those interviewed. Interviewing ahigher number of people from these groups may havegenerated other insights regarding the HIV non-disclosure legal framework [10]. The range of per-spectives presented by the data may have been limitedby the number of participants (n = 60) that were in-vited to be part of the study. The study was designedto include 60 participants as it was believed this sam-ple size would generate sufficient data and permit adiverse range of participants to be included in thestudy sample. However, the authors recognize thatthere are multiple perspectives on what constitutesdata ‘saturation’ and that 60 participants may nothave accounted fully for the variations at the intersec-tions of ethno-racial identity, gender, class, sexualidentity and so forth. Finally, future research in thisarea should include ‘natural experiments’ focused onthe shifting frameworks in this area, including re-search involving people living with and without HIVand who live in regions affected by the federal gov-ernment’s new prosecutorial guidelines.Ng et al. BMC Public Health (2020) 20:1220 Page 11 of 13ConclusionsUnderstandings around HIV criminalization among par-ticipants in this study were significantly shaped by mis-guided understandings of how HIV is transmitted in thepost-antiretroviral era, ongoing stigma towards peopleliving with HIV, and personal experiences of contractingthe disease or anecdotal ‘evidence’. While recent changesto federal prosecutorial guidelines surrounding the legalframework in Canada presents promising opportunitiesto address HIV stigma and the negative effects of crim-inalizing HIV non-disclosure, further reforms across thecountry’s judicial systems are needed to address thelong-lasting effects on the underlying cultural and socialconditions that cultivate discriminatory understandingsof HIV risk and people living with HIV.AbbreviationsHIV: Human immunodeficiency viruses; U=U: Undetectable viral loads areuntransmittable; PWID: People who inject drugs; BC: British Columbia;VIDUS: Vancouver injection drug users study; ACCESS: AIDS care cohort toevaluate access to survival services; AIDS: Acquired immunodeficiencysyndromeAcknowledgmentsThe authors would like to thank the participants for their involvement in thisstudy. They would also like to thank the Canadian Institutes of HealthResearch and the National Institutes of Health for funding this study.Authors’ contributionsCN and RK analyzed and interpreted the coding runs related to participantperspectives on the criminalization of HIV non-disclosure. CN and RK wrotethe initial draft and worked on subsequent drafts of the manuscript. CN andRK read and approved the final draft of the manuscript. KC read throughlater drafts and contributed writing to the Discussions section; she also rec-ommended changes to other parts of the manuscript. AK and WS readthrough later drafts and recommended changes to data interpretation, aswell as changes to the Introduction, review of existing literature, Methods,and Discussions sections. All authors have read and approved of thismanuscript.FundingThis study was funded by the Canadian Institutes of Health Research (ref#R711348), the United States National Institutes of Health (ref# 20R11908), andthe Michael Smith Foundation for Health Research (ref # n/a). While thesefunding bodies funded the positions of those who worked on this study,they had no role in the design of the study and collection, analysis,interpretation of data, or writing of the manuscript.Availability of data and materialsThe data in these findings are presented in this manuscript in support ofthemes as anonymized participant quotations. Due to the inability tosufficiently anonymize large qualitative datasets, further data cannot bemade publicly available as per study approval by the research ethics boardof Providence Health Care and the University of British Columbia.Ethics approval and consent to participateEligible participants provided written informed consent prior to taking partin the interview. Ethics approval for this study, along with the accompanyingconsent document, was obtained from the University of British Columbia’sBehavioural Research Ethics Board (#H16–00325).Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Author details1British Columbia Centre on Substance Use, 4th Floor, 1045 Howe Street,Vancouver, B.C V6Z 2A9, Canada. 2Department of Medicine, University ofBritish Columbia, Vancouver, Canada. 3Centre for Gender and Sexual HealthEquity, Vancouver, Canada. 4Faculty of Health Sciences, Simon FraserUniversity, Burnaby, Canada.Received: 20 August 2019 Accepted: 23 July 2020References1. Barre-Sinoussi F, Abdool Karim SS, Albert J, Bekker LG, Beyrer C, Cahn P,et al. Expert consensus statement on the science of HIV in the context ofcriminal law. J Int AIDS Soc. 2018;21(7):e25161.2. Picard A. Countries, including Canada, are prosecuting people with HIVbecause they misunderstand science, leading researchers say The Globeand Mail 2018 [cited 2019 May 31]. Available from: https://www.theglobeandmail.com/canada/article-countries-including-canada-are-prosecuting-people-with-hiv-because/.3. Network HJ. Unpublished data. 2018.4. Criminalization CCtRH. Developing a community consensus statement onending unjust prosecutions for HIV non-disclosure. 2017.5. Smith J. Wilson-Raybould raises criminalization of HIV non-disclosure withcounterparts The National Post 2017 [cited 2019 May 31]. Available from:https://nationalpost.com/pmn/news-pmn/canada-news-pmn/wilson-raybould-raises-criminalization-of-hiv-non-disclosure-with-counterparts.6. R. v. Cuerrier. Supreme Court of Canada; 1998.7. Mykhalovskiy E. The problem of "significant risk": exploring the public healthimpact of criminalizing HIV non-disclosure. Soc Sci Med. 2011;73(5):668–75.8. Symington A. Criminalization confusion and concerns: The decade since theCuerrier decision. Can HIV AIDS Policy Law Rev. 2009;14(1):5–10.9. Mykhalovskiy E, Betteridge G. Who? What? Where? When? And with whatconsequences? An analysis of criminal cases of HIV non-disclosure inCanada. Can J Law Soc. 2013;27(01):31–53.10. HIV/AIDS. JUNPo. Ending overly broad criminalisation of HIV non-disclosure,exposure and transmission: critical scientific, medical and legalconsiderations. United Nations; 2013.11. R v. Mabior. Supreme Court of Canada; 2012.12. Loutfy MTM, Baril J-G, Montaner JSG, Kaul R, Hankins C. Canadian consensusstatement on HIV and its transmission in the context of criminal law. Can JInfect Dis Med Microbiol. 2014;25(3):6.13. Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, et al.Sexual activity without condoms and risk of HIV transmission inSerodifferent couples when the HIV-positive partner is using suppressiveantiretroviral therapy. JAMA. 2016;316(2):171–81.14. Knight R, Krusi A, Carson A, Fast D, Shannon K, Shoveller J. Criminalization ofHIV non-disclosure: narratives from young men living in Vancouver, Canada.PLoS One. 2018;13(7):e0201110.15. Siedner MJ, Triant V. Undetectable = Untransmittable and your health: thepersonal benefits of early and continuous therapy for HIV infection. J InfectDis. 2019;219(2):173–6.16. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC,Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1transmission. N Engl J Med. 2016;375(9):830–9.17. CATIE. Criminalization of HIV non-disclosure. Available from: https://www.catie.ca/en/hiv-canada/8/8-3#:~:text=However%2C%20the%20criminalization%20of%20non,sexual%20transmission%20of%20the%20virus. [cited 2019 May 31].18. Canadian HIV/AIDS Legal Network. The Criminalization of HIV Non-Disclosure in Canada: Current status and the need for change. 2019.Available from: http://www.aidslaw.ca/site/the-criminalization-of-hiv-non-disclosure-in-canada-report/?lang=en. [cited 31 May 2019].19. Brown D. Justice Department issues new guidelines on prosecution fornon-disclosure of HIV status CBC News 2018 [cited 2018 May 31]. Availablefrom: https://www.cbc.ca/news/canada/toronto/canada-prosecutions-hiv-non-closures-cases-1.4929292.20. Shimeless H, Bailey R. African and Caribbean Council on HIV/AIDS inOntario. Ontario: 20th Annual Conference of the Canadian Association forHIV Research; 2011.21. Wilson C. The impact of the criminalization of HIV non-disclosure on thehealth and human rights of “black” communities. Health Tomorrow:Interdisciplinarity Internationality. 2013;1(1):109–143.Ng et al. BMC Public Health (2020) 20:1220 Page 12 of 1322. O'Byrne P, Bryan A, Woodyatt C. Nondisclosure prosecutions and HIVprevention: results from an Ottawa-based gay men's sex survey. J AssocNurses AIDS Care. 2013;24(1):81–7.23. Arreola S, Santos G-M, Beck J, Sundararaj M, Wilson PA, Hebert P, et al.Sexual stigma, Criminalization, investment, and access to HIV servicesamong men who have sex with men worldwide. AIDS Behav. 2014;19(2):227–34.24. Adam BD, Elliott R, Corriveau P, English K. Impacts of Criminalization on theeveryday lives of people living with HIV in Canada. Sex Res Soc Policy. 2013;11(1):39–49.25. Harsono DGC, O’Keefe E, Lazzarini Z. Criminalization of HIV Exposure: AReview of Empirical Studies in the United States. AIDS Behavior. 2017;21(1):27–50.26. Mykhalovskiy E BJ, Sanders C, Jones M. The public health implications ofcriminalizing HIV non-disclosure, exposure and transmission: Report of aninternational workshop.; 2014.27. Patterson S, Kaida A, Ogilvie G, Hogg R, Nicholson V, Dobrer S, et al.Awareness and understanding of HIV non-disclosure case law amongpeople living with HIV who use illicit drugs in a Canadian setting. Int J DrugPolicy. 2017;43:113–21.28. Krüsi A, Czyzewski K, Magagula P. Through our eyes. MedicineAnthropology Theory | An open-access journal in the anthropology ofhealth, illness, and medicine. 2017;4(3).29. Krusi A, Ranville F, Gurney L, Lyons T, Shoveller J, Shannon K. Positivesexuality: HIV disclosure, gender, violence and the law-a qualitative study.PLoS One. 2018;13(8):e0202776.30. World Health Organization. People Who Inject Drugs. Available from:https://www.who.int/hiv/topics/idu/about/en/. [cited 2019 May 31].31. AVERT. People who inject drugs, HIV and AIDS [updated October 10, 2019.32. Control. BCfD. HIV in British Columbia: Annual Surveillance Report 2016.2018.33. Neale J, Tompkins C, Sheard L. Barriers to accessing generic health andsocial care services: a qualitative study of injecting drug users. Health SocCare Community. 2008;16(2):147–54.34. Lang K, Neil J, Wright J, Dell CA, Berenbaum S, El-Aneed A. Qualitativeinvestigation of barriers to accessing care by people who inject drugs inSaskatoon, Canada: perspectives of service providers. Subst Abuse Treat PrevPolicy. 2013;8(35):1–11.35. Matsuzaki M, Vu QM, Gwadz M, Delaney JAC, Kuo I, Trejo MEP, et al.Perceived access and barriers to care among illicit drug users andhazardous drinkers: findings from the seek, test, treat, and retain dataharmonization initiative (STTR). BMC Public Health. 2018;18(1):366.36. UNAids. Prevention Gap Report. 2016.37. Canada S. Census of population. 2016.38. Olding M, Enns B, Panagiotoglou D, Shoveller J, Harrigan PR, Barrios R, et al.A historical review of HIV prevention and care initiatives in British Columbia,Canada: 1996-2015. J Int AIDS Soc. 2017;20(1):21941.39. Control BCfD. HIV in British Columbia: annual surveillance report 2015. 2017.40. Bramham D. More needed to redress the tragic fact that Indigenous peopleare disproportionately victims of opioid crisis Vancouver Sun. 2019.Available from: https://vancouversun.com/opinion/columnists/daphne-bramham-more-needed-to-redress-the-tragic-fact-that-indigenous-people-are-disproportionately-victims-of-opioid-crisis. [cited 2019 May 1].41. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K.Purposeful sampling for qualitative data collection and analysis in mixedmethod implementation research. Admin Pol Ment Health. 2015;42(5):533–44.42. Creswell J, Klassen AC, Plano Clark VL, Smith KC. Best practices for mixedmethods research in health sciences. Office Behav Soc Sci Res. 2011;2011:1–39.43. Patton. Designing qualitative studies. In: Qualitative research and evaluationmethods. 3rd ed. Thousand Oaks, CA: Sage; 2002. p. 230–47.44. Constructing CK, Theory G. 2nd edition ed. Thousand Oaks, CA: Sage; 2014.45. Boeije H. A purposeful approach to the constant comparative method inthe analysis of qualitative interviews. Qual Quant. 2002;36(4):391–409.46. Hallberg LRM. The “core category” of grounded theory: making constantcomparisons. Int J Qual Stud Health Well Being. 2009;1(3):141–8.47. Kapiri L, Norheim OF, Martin DK. Priority setting at the micro-, meso, andmacro- levels in Canada, Norway and Uganda. Health Policy. 2007;82(1):78–94.48. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.2006;3(2):77–101.49. Clarke V, Braun V. Thematic analysis. J Posit Psychol. 2016;12(3):297–8.50. Oppenheimer GM, Bayer R. The rise and fall of AIDS exceptionalism. VirtualMentor. 2009;11(12):988–92.51. Smith JH, Whiteside A. The history of AIDS exceptionalism. J Int AIDS Soc.2010;13:47.52. Crown Counsel Policy Manual, (2019).53. New Policy for BC Prosecutors Still Harms People Living with HIV [pressrelease]. April 23, 2019.54. Taylor D. In Your Face: AIDS posters confront stigma CATIE. 2014.55. Davis J. Evolution of an epidemic: 25 years of HIV/AIDS media campaigns inthe US. The Henry J Kaiser Family Foundation; 2006 June 2006.56. Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: aconceptual framework and implications for action. Soc Sci Med. 2003;57(1):13–24.57. Persson A, Newman C. Making monsters: heterosexuality, crime and race inrecent Western media coverage of HIV. Sociol Health Illn. 2008;30(4):632–46.58. Squire C. Body talk: the material and discursive regulation of sexuality,madness and reproduction. In: Ussher J, editor. AIDS Panic. London:Routledge; 1997.59. Baylis F, Kenny NP, Sherwin S. A relational account of public health ethics.Public Health Ethics. 2008;1(3):196–209.60. Westergaard RP, Ambrose BK, Mehta SH, Kirk GD. Provider and clinic-levelcorrelates of deferring antiretroviral therapy for people who inject drugs: asurvey of North American HIV providers. J Int AIDS Soc. 2012;15(1):10.61. Lourenco L, Colley G, Nosyk B, Shopin D, Montaner JS, Lima VD, et al. Highlevels of heterogeneity in the HIV cascade of care across differentpopulation subgroups in British Columbia, Canada. PLoS One. 2014;9(12):e115277.62. Martin L, Houston S, Yasui Y, Wild TC, Saunders LD. Rates of initial virologicalsuppression and subsequent virological failure after initiating highly activeantiretroviral therapy: the impact of aboriginal ethnicity and injection druguse. Curr HIV Res. 2010;8(8):649–658.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Ng et al. BMC Public Health (2020) 20:1220 Page 13 of 13
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Vancouver : University of British Columbia Library
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Attribution 4.0 International (CC BY 4.0)
Faculty
People who use drugs
Criminalization
HIV
Non-disclosure
Stigma
Perspectives of HIV-positive and -negative people who use drugs regarding the criminalization of HIV non-disclosure in Canada: a qualitative study
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