Many countries use similar strategies in prevention campaigns, but despite that the spread of HIV is unabated. The basic messages of the current liberal prevention strategies aim to promote changes in individual behaviour so as to prevent HIV transmission. The strategies avoid any kind of regulation, prescription and controls, and trust solely on the readiness of the sexually active part of the general population, and in particular the “at-risk populations” to cooperate with those messages. However, only a small number of people have cooperated. The increase in the incidence of HIV over the past decade in the countries listed discloses the failures of the current prevention strategies. With respect to the goal of trying to influence those people prone to high-risk sexual lifestyles, and the injecting drug users, the prevention strategies have not had a meaningful effect in the long term. This is also reflected in the increase of other STIs such as hepatitis C, syphilis, and the human papilloma virus, which are worse when there is co-infection with HIV. The liberal prevention strategies turned out to be inadequate for the goal, and must be adjusted to real life situations to counteract their misuse. Meanwhile there are ample evidence-based measures which must be implemented into concerted efforts by complementing the current strategies with respect to a person-to-person bound infection. Medical care policies have to consider the non-adherence behaviour of those in need.
In its HIV/AIDS surveillance report for Europe in 2010, the European Centre for Disease and Prevention Control (ECDC) states: “HIV infection remains major public health importance in Europe, with evidence of continuing transmission in Europe. Overall there is no clear indication of a decline in the number of cases being diagnosed each year and HIV continues to be concentrated in key populations at higher risk (e.g., people who inject drugs and their sexual partners; men who have sex with men and migrants)” [
For the USA, the “CDC estimates that 1,144,500 persons aged 13 years and older are living with HIV infection, including 180,900 (15.8%) who are unaware of their infection…” and “Gay, bisexual, and other men who have sex with men (MSM), (…) are most seriously affected by HIV” [
The latest reports from France [
In the broadest sense, these developments reflect the reinvigorating trends of increasing high-risk sexual attitudes in those subgroups2. The “Global epidemiology of HIV infection in men who have sex with men” underscores the impact of this group in the as yet uncurbed spread of HIV [
There are almost overlooked issues, e.g., 1) the youth in the USA [
“Despite great progress in tackling the HIV epidemic worldwide in the past two decades, there is one population in which the epidemic continues to grow in countries of all incomes: men who have sex with men (MSM)” [
How could this happen? At first it is important to note that MSM are not a cohesive group in themselves because of differences in, for example, ethnic background, education, awareness of the adverse consequences once infected by HIV, and furthermore the homeless people. Comments from recent scientific papers aim at “…reinvigorated trends engaging into increasing risk behaviour…” which reflect a deliberate intention of engaging in such high risk attitudes and thereby oppose the correct prevention messages.
“Estimates of risk behaviours and the incidence of HIV among MSM before and after the introduction and expansion of ART suggest that the population-level protective benefits of ART (TASP strategy, Chapter 4.3.) may be attenuated by a number of factors, most notably, continuing or increasing frequency of condom-less anal intercourse and incidence of other sexually transmitted infections (STIs)” [
“Homosexual men continue to report increasing levels of UAI. HIV prevalence is high in this group, with many infections remaining undiagnosed. The high level of risky behaviour in HIV positive men, regardless of whether they are diagnosed, is of public health concern, in an era when HIV prevalence, antiretroviral resistance, and STI incidence are increasing” [
“In the last decade, major shifts toward increasing HIV risk behaviour have been reported in behavioural surveillance studies of MSM (…)”, and “These trends have been followed by increasing rates of sexually transmitted infections…” [
Furthermore, in European countries, as well as in the US, it’s not the HIV alone that bothers public health; other STIs have to be considered too in this context, whether as a single-agent infection or co-infections with HIV such as Hepatitis C. The ECDC has acknowledged that in the European Union and the European Economic Area (EU/EEA) “…men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmitted infections (STI)” [
The latest report on the global burden of HCV claims that 2% to 3% of the world’s population is infected, i.e., 142 to 213 million people; this amounts to approximately six times the number of people living with HIV, but no HCV related prevention campaigns exist [
Like HIV and HBV, the basic sources of transmission for HCV are blood-borne. These include transmission via sexual practices (classifying it as a STI), but there are differences in the efficiency of transmission by heterosexual activity―“…an extremely infrequent event” [
The adverse effects of the HIV infection itself in the final stage of AIDS are well documented. However, for people bearing HIV/HCV co-infections the conditions worsen [
HBV also causes blood-borne infections and shares modes of transmission with HIV and HCV although these vary depending on the geographic area [
An effective vaccine exists, and therefore screening for HBV should be offered to the people most at risk [
Because there are high rates of syphilis in MSM [
Regarding the HPV there is growing concern for MSM [
Only a few studies address the impact of genital shedding of herpes viruses contributing as a cofactor for HIV-1 transmission [
The paradigm behind the current behavioural intervention concepts of the HIV prevention strategies applied in numerous countries since the late 1980s is largely based on “social learning strategies” in context with the New Public Health (NPH) [
Such concepts mismatch the mode of HIV transmission with that of a community acquired infection such as influenza.
Programme and decision makers have classified the HIV infection (primarily a STI) into an exceptional status, although it is comparable with HBV and (several years later) HCV infection, example given due to shared routes of transmission, and seriousness of disease in the long-term prognosis, but without any exceptionalism for HBV and HCV. By defining the HIV infection as “exceptional”, those populations most at-risk and already infected by HIV in turn were stigmatized in a manner that amounted to a kind of social dislocation.
The social aftermaths are obvious: instead of focusing on HIV positive individuals and those at-risk to integrate them into community-based networks thus being able to provide them help with precise information on their particular risky behaviours, emphasis of the prevention campaigns has targeted the general population, the vast majority of whom are uninfected. Almost as a consequence in particular the most at risk people and those already HIV infected of the different groups addressed here, were marginalised and developed their own networks (which may overlap). In view of MSM networks in the context of the increasing prevalence of HIV infected MSM concentrated epidemics may develop in these particular at-risk communities with a critical threshold of HIV-infected people, thereby increasing the odds for an acceleration of the spread of HIV within such networks, such as “…linked clusters…” [
The designers of prevention campaigns didn’t seriously consider a crucial issue: “Preventive interventions with positive individuals are likely to have a greater impact on the epidemic, for an equivalent input of cost, time, resources, than preventative interventions focused on negative individuals. A change in the risky behaviour of an HIV positive person will, on average, and in almost all affected populations, have a much bigger impact on the spread of the virus than an equivalent change in the behaviour of an HIV negative person” [
However, far too many of the at-risk-prone people were, and still are, not poised to implement the correct messages of the prevention campaigns to change their behaviour regarding sexual partnerships respectively sex for fun and drug use to prevent the transmission of HIV. Far too many of these people are not willing to cooperate, but instead they intentionally continue in high-risk behaviour practices such as unprotected vaginal and in particular MSM―anal intercourse (UAI) resp. Such kind of behaviour cannot be attributed to any kind of discrimination resp., stigmatization. The anatomical structure of the GALT should be considered when comparing different HIV transmission rates when practising UAI during vaginal sex vs. anal intercourse [
Region | Year | Estimated adults and children living with HIV* | Adult (15 - 49) prevalence (%) | HIV prevalence among MSM** |
---|---|---|---|---|
East Asia | 2000 | 320,000 | <0.1 | no data given |
2012 | 880,000 | <0.1 | ||
North America | 2000 | 940,000 | 0.5 | USA, 20 cities, 2011: 18%a Canada, cities, 2011: 11% - 23%b |
2012 | 1,300,000 | 0.5 | ||
Western and Central Europe | 2000 | 570,000 | 0.2 | |
2012 | 860,000 | 0.2 | <1% to >5; in certain countries >10%c |
*Source: UNAIDS Report on the Global AIDS Epidemic―2013. HIV Estimates with Uncertainty Bounds, 1990-2012. *Uncertainity Bounds Have Been Omitted Here. http://www.unaids.org/en/dataanalysis/knowyourepidemic/epidemiologypublications/ **More data [
The mono-thematic straightened concepts regarding the prevention of the HIV infection try to influence individual behaviour by targeting complex emotionally based behavioural patterns with cognitive level based messages according to the rules of logic. Contrary to reason it was anticipated that intellectually based messages targeting the cognitive level would be effective in achieving a long-lasting control on intimate behaviour. Programme and decision makers have neglected reality in that 1) the real behaviour in discussion is based on a very emotional level; and 2) superposed by, for example, ethnicity, education, psychological distress, and culturally coined and traded behaviour right up to modern risky lifestyles. Decision makers have further neglected the complexity of situations. For example, with respect to the great variety of people, ranging from loners up to those people who have self-organised into real and virtual sexual networks, i.e., they have organised themselves. Such networks may boost group dynamics thereby fostering social interaction and promoting their own norms, example given by peer pressure. Furthermore, those “learning concepts” have failed in the context of responsibility for partners and the community, and to include those people who are not able to understand the messages.
Could behavioural intervention strategies have long-term influence on people driven by their sexual urge and in particular the most at-risk population responsible for the increasing HIV incidence in Europe, North America and elsewhere [
The basic statements, “Current prevention efforts have been unable to contain or reduce HIV transmission in this population” [
According to UNAIDS, prevention strategies of a different kind seem to work to some degree in various countries, [
The Global Health Sector Strategy on HIV/AIDS 2011-2015 presented by the WHO provides an improved strategy of prevention by implementing “…four strategic directions, each composed of core elements” [
The liberal prevention strategies rely on people who are willing and able to behave responsibly, in the sense of self-discipline which has to be de rigueur for all concerned. But decision makers have denied the realty of the extreme idiosyncrasies of human behaviour. The statement of the ECDC regarding the increase of STI and HIV clearly marks the failure of the current prevention strategy wherever it has been applied: “The increase of risky behaviour was reported to be associated with treatment optimism and cART fatigue, as well as improved quality of life of HIV-infected MSM. Negotiated safety trends such as strategic positioning, serosorting, and withdrawal are increasingly reported, but these are not necessarily effective risk reduction strategies. This trend poses new challenges for HIV and STI prevention, requiring an evolution of interventions to remain effective” [
These liberal concepts are not linked to any personal constraints or official sanctions.
As a consequence the people who continue to spread HIV are essentially shielded by anonymity, for example, there is no-name reporting, no partner-notification if someone is HIV positive. The review of the ECDC on the lack of “partner notification” in many countries of the EU shows the negligence of those responsible for Public Health matters [
Those responsible have failed to realise the complexity of the behaviour in particular of those most at risk people, example given, counteracting the messages of the prevention campaigns which are the prerequisites in the proper sense of a conditio sine qua non [
The liberal tenets of the current prevention strategies are inadequate to curb the spread of HIV by subpopulations willing to undertake high-risk prone sexual behaviour. This kind of strategy equals an experiment that has never before been tried, and is done without the concept of a controlled study at such a scale [
The assumptions have turned out to be fundamental misconceptions for such a task and have failed in their stated goals. Decisions makers responsible for enacting these strategies by focusing only on liberal attitudes have failed to reveal faults. By contrast, they maintain the defaults and so continue to provide protection for the misuse of liberal tenets and prolonging the ongoing spread of HIV in general.
The programme and decision makers of the current prevention campaigns have focused primarily on the interests of the individual but have neglected the interests of the societies which have to pay for individual failure. Improved prevention concepts have to consider concepts balancing between the entitlements of people at risk and already affected by HIV, resp., and those of society.
We suggest combining different measures known thus far for a comprehensive, multisectoral strategy, and having in mind the reality of human behaviour and the diversity of the target groups. 1) The programme-makers responsible for shaping new prevention strategies must acknowledge the reality of human behaviour, i.e., not only follow liberal strategies promoting and relying on an individual’s own responsibility thereby tolerating the spread of HIV; this was the wrong directive. 2) The only chance seems to balance new strategies: including the rules of an open society and more restrictive measures based on unprecedented concepts. Different elements for a new comprehensive prevention strategy must be combined following a rational background [
A public health initiative is required to alert the general population, and to encourage people at risk to ask for an HIV test. Such campaigns should clarify to the public that ART/HAART is not a cure, as many believe, and may have side effects. Designers of such programmes should implement the messages outlined by del Rio [
The “exceptionalism” of the HIV infection has to be reversed and HIV should be handled the same way as for Hepatitis B and Hepatitis C: “AIDS is not an exceptional disease” [
・ The TASP Approach and More Using cART
New hope for curbing the ongoing spread of HIV came with the “Treatment as Prevention” strategy [TASP]. People diagnosed HIV-positive can be offered a cART. Beyond the benefit of improving their health condition, there is an agreement that cART can reduce the viral load of HIV in blood [VL] thereby decreasing HIV infectiousness [
The new guidelines published by the WHO, to treat HIV infected people earlier in the course of HIV infection [
・ The “Antiretroviral Pre-Exposure Prophylaxis…” (PrEP)
The strategy is to provide PrEP treatment as “…a new prevention intervention in which HIV-uninfected people take a daily dose of antiretroviral medication to lower their chances of acquiring HIV” [
・ The Post-Exposure Prophylaxis (PEP)
For several years this strategy was propagated for occupational settings (example given, needle stick dependent situations for health care workers) and HIV-negative people after “risky sex”.
・ Help for IDU
A study about IDU in Bangkok and Thailand looks promising in reducing the sexual transmission of HIV [
These people contribute considerably to its transmission. How can they be found [
The US Preventive Services Task Force (USPSTF) recommends a HIV testing in “…adolescents and adults aged 15 to 65 years. Younger adolescents and older adults at increased risk…” and “…pregnant women…” [
A vital necessity in adapting HIV testing policies is seen in the P.R. China [
But will this work on a liberal modality thereby sheltering the inconsiderate behaviour of the subsets of “at risk” people, allowing them to continue in their vested interests? The experience so far should encourage reconsideration of a more “aggressive” strategy, as considered by several authors. This is a consequence of the non-compliant attitude of those actors contributing to the ongoing spread of HIV [
A community-based approach, forwarding a comprehensive prevention and treatment strategy, has been established in the P.R. China. It uses the “Network of community physicians connected with residents” and covers a broad spectrum of severe infectious diseases (SIDs), such as tuberculosis, hepatitis and HIV/AIDS [
Health care providers need to cooperate so as to offer all index patients “…structured intervention (such as motivational interviewing or counselling) when attending their sexual health clinic…” [
Despite the basic good news that intensifying HIV testing can help reduce HIV incidence in the group of MSM/UK [
General points of view: the current prevention strategies are grounded on liberal concepts throughout. They haven’t provided effective allocated directives/functions for enforcing sustainable changes in individual behaviour, in particular for the most affected target groups. The interconnection of no-name reporting of an HIV-positive test, no mandatory duty to disclose his/her HIV-positive status to partner/s [
The UNAIDS initiative on the “Decriminalization” of HIV transmission in different countries outlines the different measures, and jurisdiction in case of HIV transmission.
More specifically, political decision makers have not thoughtfully considered real life issues. Instead their decisions tolerate the assaults made by means of HIV infection, and the lethal consequences, thereby neglecting duties to the communities they are committed to by virtue of legislation.
The strategy of decriminalization suggests that normally a penalty has to be imposed, only because a person is infected and intentionally transmits HIV to a partner. From the outset, such a criminal law would not penalise unlawful acts, but rather the bodily constitution of a person, which would breach the link between criminal law and unlawful acts. The German criminal system is based on the idea that a penalty shall only be imposed on the grounds of an unlawful act. Nevertheless these unlawful acts can be related to the persons’ physical constitution, such as the case with diseases.
In such a case, the principle applies that any violation is prohibited if the violation is committed by an unlawful act. Thus, somebody with a serious illness transgresses the generally tolerated risk area if they intentionally or negligently infect other people. Admittedly, it is often difficult to establish that the act of a certain person has caused the transmission and thus that a crime has been committed. Additionally the confidence into a good ending which for example can be based on the habituation effect of risky behaviour can lead to the fact that at least intention can be precluded.
As a consequence, many legal systems have established a new category of criminal offence. These offences still do not penalise a person’s physical condition, but a person’s unlawful act. Yet, the offences do not require harm (death, injury, etc.) to have arisen; so that the person’s mental elements of the offence can comprise the harmful act. One might describe these offences as penalising the imperilment, not just the actual impairment of a certain legally protected right. As a result, the procedural problems of having to prove causation and intention in relation to a particular harm do not arise. Concerning the dogmatics of criminal law, in such legal systems one can perceive a coexistence of offences that require a harm to be inflicted and those that do not. This might only be of subsidiary importance. This means that the latter will only apply if it cannot be established that the classical offences of homicide and assault have been committed. In the jurisdictions that do not know strict liability torts, only the traditional statutory offences for the protection of life and physical integrity apply. What does “decriminalization” mean in different legal systems? For those legal systems that acknowledge imperilment as an element of an offence, the abolition of these offences would cause the traditional offences of homicide and assault to be applied for those acts again. The unlawful acts are not therefore legalized, but the standard of proving a crime to have been committed will rise to its former level. If the decriminalization was implemented further, so as to exempt criminal liability for intentionally or negligently transferring HIV within these traditional offences, the legislators would be obliged to give good reasons why certain acts that lead to criminally penalized injuries can no longer be punished. In Germany’s legal system, this is out of question. There can be no explanation for penalizing, for example, negligently causing physical injury while driving as a traffic offence, when the negligent transmission of the HIV virus remains unpunished. Neither could this be dogmatically justified or reconciled with the ordinary law or constitution. Consideration is given in the UK of “the ongoing controversy regarding the prosecution (…) of people living with HIV who do not disclose their HIV positive status to sexual partners” [
“Specific attention should be paid to: travel restrictions, employment, homophobia, sex work, drug control laws and criminalization of HIV transmission. A public-health approach to managing behaviours that put people at risk of HIV acquisition should be promoted as an alternate to criminalization. Sentencing alternatives to incarceration should be promoted as good public health practice” ([
The crucial point is: UNAIDS is requested to explain adjusting the HIV infection of another person as, for example, grievous bodily harm/bodily injury/whether intentional or not which in view of a decriminalization would infringe and ignore, resp., constitutional rights in certain countries at least [
“General criminological theory offers at least three main mechanisms through which criminal law is thought to have its effects…” [
Therefore, any kind of “decriminalization” of HIV transmission is unappropriated.
Chinese Criminal Law (short CCL) never speaks directly of HIV, but provides for two different kinds of norms that aim at reducing direct or indirect HIV transmission.
CCL Section 360 tries to curb the intentional spread of serious sexually transmitted decease (STD), with the term clearly including HIV when interpreted in accordance with the Administrative Provision Concerning the Prevention from Sexual Decease (性病防治管理办法) Section 2. However, direct intentional transmission of HIV through sexual intercourse is only a crime when it is part of prostitution. What is punished is not the actual spread of HIV, but the danger of spreading it. The prosecution does not therefore need to provide evidence of a specific means of infection. If a person knows that he/she is HIV positive and engages in unsafe sex practices without informing his/her partner, transmission has to occur, otherwise CCL Section 234 I (infliction of bodily harm) is not applicable, since legal provisions do not punish a mere attempt. If one person notifies the other before engaging in unprotected sex, intentional harm will be denied by the procurator, regardless of whether harm was inflicted or not4.
Unintentional transmission of HIV due to improper handling of blood donations is punishable under CCL Sections 333, 334 concerning illegal selling, or providing blood and related products. Despite these provisions being part of CCL since 1997, isolated instances of patients being infected with HIV still occur in the health care sector5.
Since evidence of a causal relationship between unprotected sex and HIV infection may prove rather hard to find in individual cases, and since criminal justice institutions sometimes refuse to enforce arrest warrants when suspects are known to be HIV carriers6, some provinces have tried to introduce new provisions7 that allow for administrative sanctions against HIV related offenders and thus apply much more lenient rules of evidence, and avoiding criminal trial. It is thus obvious that at least some institutions within China are in favour of legal sanctioning of some forms of spreading HIV. However, due to the very clear decriminalization policy in criminal law, any sanctions have to choose the framework of administrative law.
5.3. A short overview for HIV transmission and the law in England and Wales, see [
“The key fact about HIV is that it is a non-equilibrium infectious agent” [
・ The messages of the liberal prevention strategies have to be geared in such a way that people at risk clearly see their potential to improve/change actual behavior. The messages must pay particular attention to immigrants.
・ In addition, specific prevention messages for high-risk people have to be developed in order to encourage personal responsibility.
・ It is important to have implementation of control measures such as individually based partner notification if one partner tested HIV positive. Therefore, real and virtual community settings should be the appropriate targets. This needs to be attached to requirements.
・ However, depending on an unwarrantable and ongoing increase of the prevalence of HIV positive people, the no-name reporting of HIV positive test results has to be replaced by a real name reporting as an inevitable measure. By means of an individually tailored counseling, this measure should only be used for a back tracing, thereby enabling the number of people unaware of their HIV infection to be reduced.
・ With respect to the increasing percentages of HIV co-infections with other STI, a routine testing for STI must become a standard, in particular in MSM settings.
・ The Treatment as Prevention (TASP) concept and the pre-exposure prophylaxis (PrEP) have to be adjusted for individual patients. Intensive counseling is needed to reduce misuse of the drugs with respect to their behavior.
・ A routine testing must become a necessary measure because of the manifest non-cooperative behavior of too many at-risk people with the prevention issues. There should be some measures similar to those proposed by the US Task Force Service, the UK, or a “…universal testing…” [
We appreciate the cooperation of Prof. Dr. jur. Arndt Sinn for his critical review of the Chapter 5.1.; Centre for European and International Criminal Law Studies (ZEIS), University of Osnabrueck, Osnabrueck 49076, Germany.
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Human Immunodeficiency Virus (HIV) 1/2: the transmission among humans happens mainly by sexual activities of diverse varieties and injecting drug use. HIV is a retrovirus that mainly infects cells of the human immune system, e.g., certain CD4+ T cells which are named T-helper cells because of their function in organizing the adaptive immune response. After infection of the cells and reverse transcription of its RNA genome into a double stranded DNA copy, this cDNA becomes integrated into the cellular genome. The Acute Retroviral Syndrome (ARS) weeks after infection does not show up in all infected people. Years after the infection with/without non- specific symptoms, the final stage of AIDS develops. AIDS stands for Acquired Immune Deficiency Syndrome, i.e., it is not a disease entity. From the time of the primary infection the immune system gets weakened; a surrogate marker for that is the concentration of CD4+ T cells in the blood. The CD4+ T cell count declines from around 1000 per µl blood (in healthy persons) down to below 100 per µl and even less if the HIV infected patient remains untreated with antiretroviral drugs (Antiretroviral Therapy/ART). The concentration of HIV RNA/ml blood plasma (the viral load/VL) increases over the course of time. Because the immune system is weakened, the patients progressively suffer from, e.g., infectious diseases, new infections from the outside and the opportunistic infections (OI) already inside the body. OI established in the body are kept in check by the individual’s immune system as long as it works.
The Hepatitis C Virus causes systemic infection in humans. Its infection mainly causes the liver disease Hepatitis C. However, the hepatocytes are not only the target cells because there are extrahepatic diseases, e.g., mixed cryoglobulinemia, which is believed to be causally associated with an HCV infection. The official nomenclature lists six genotypes and numerous geno-subtypes within. Genotypes must be taken into account regarding the disease progression and the standard of care treatment. By making use of the new generation of Direct Acting Antivirals (DAA) a real cure looks promising. The HCV gets transmitted through infected blood, e.g., by injecting drug users using needles and/or syringes contaminated with infected blood, or engaging in unprotected sexual intercourse with an infected partner, whereby the odds of transmitting an infection are high for anal intercourse and (very!) low for vaginal intercourse. Depending on various conditions, the onset of an acute disease develops in approximately 20% of infected people, i.e., about 80% with persistent viremia do not show clinical symptoms for years up to decades and may be infectious for other people. During this time of chronic infection a chronic liver disease may develop culminating in liver end-stage disease and liver cancer (HCC) in low percentages per year.
Syphilis is listed as a sexually transmitted infection (STI) caused by the bacteria Treponema pallidum. It is predominantly transmitted by all kinds of unprotected sexual practices. The sores occurring after infection are present mostly in genital areas and extragenital areas likewise. They constitute the main infectious sources. In addition, mother-to-child transmission can happen in utero. Because T. pallidum can be present in the blood, blood donations have to be tested for this agent with licensed test kits.
Human papilloma viruses (HPV) are DNA viruses. More than 100 genotypes are known. Because they are easily transmitted by smear infections via lesions of the skin and mucous membranes of the mouth and the genital tract, HPV show high prevalence in the human population. In particular, this is to be seen in the context of HIV and the sexual routes of transmission. Clinical manifestations range from benign warts to malign tumors, e.g., cervical cancer, depending on the genotype.
ART, antiretroviral therapy; CCL, Chinese Criminal Law; CDC, Centre of Disease and Prevention Control/USA; CRF, Circulating Recombinant Form; ECDC, European Centre of Disease and Prevention Control; EEA, European Economic Area; EU, European Union; ECHR, European Court of Human Rights; GALT, gut associated lymphoid tissue; HAART, highly active antiretroviral therapy; MDR, multi drug resistance; MSM, men-sex- with-men; STI, sexual transmitted infections; TASP, treatment as prevention; TDR, transmitted drug resistance; UAI, unprotected anal intercourse.