1. HUMAN RIGHTS AND HEALTH EQUITY: IMPLICATIONS FOR ADVOCACY, ACTION, AND GOVERNANCE
Session 3.
How to Apply the Human Rights-Based Approach in Analysing Health Issues
Case Study and Group Work
Sherine Shawky (SRC)
Laila El-Zeini (SRC)
2 November 2014

2. 5. Presentation of Group Work Summary
Session Overview
1. Case Study: Basic Information
2. Case Study: Points for Discussion
3. Preparation for Group Work
4. Group Work
5. Presentation of Group Work Summary
This is another option for an Overview slide.
Monday, November 3, 2014

3. 1. Case Study: Epidemiology of Hepatitis C
Sunday, November 2, 2014

4. Hepatitis C
Hepatitis is an inflammation of the liver caused by hepatitis C virus (HCV)
HCV was first identified in 1989 as the primary agent for post-transfusion non-A, non-B hepatitis
HCV is a positive single-stranded RNA virus of the Flavivirdae family with six major genotypes identified to date and several subtypes
Sunday, November 2, 2014

5. Global Distribution of HCV Seroprevalence
Hepatitis C is a Pandemic
>185million live with HCV
~350,000 die each year from HCV
World health Organization (2014). Guidelines For The Screening, Care And Treatment Of Persons With Hepatitis Infection April 2014
Sunday, November 2, 2014

6. Global Distribution of HCV Genotypes
The wide genetic diversity of HCV has an important implications to clinical manifestations and treatment success
World health Organization (2014). Guidelines For The Screening, Care And Treatment Of Persons With Hepatitis Infection April 2014
Sunday, November 2, 2014

7. Modes of Transmission Blood-born infection is the main route
Sexual transmission in persons with high risk behaviors is not common
Mother-to-child transmission is not common
Intra-nasal inhalation of drugs is not common
Sunday, November 2, 2014

8. Vulnerable Populations
Population at risk
Comment
Persons who inject drugs
Unsterile equipment to inject drugs or contaminated drug solutions
Patients in healthcare facilities with inadequate infection control practices
Unsafe injection practices and procedures as dental care, renal dialysis, tissue grafts and unscreened transfusion of blood & blood products
Children born to mothers infected with HCV
4–8% among mothers without HIV infection
17-25% among mothers with HIV infection
People with sexual partners who are HCV-infected
No/low risk of sexual transmission among HIV-uninfected couples. Sexual transmission is strongly linked to pre-existing HIV infection
People with HIV infection
Unprotected sex among HIV infection cases, in particular MSM
People who have used intranasal drugs
Non-injecting drug use (e.g. through sharing of inhalation equipment for cocaine)
People who have had tattoos, piercings, nail trimming, scarification
Unsterile equipment
Excessive alcohol users
Accelerate the disease progression and increase risk of HCC
Transfusion of blood and blood products
Organ or tissue grafts
Hemodialysis, peritoneal dialysis
Injecting medicines/drugs with infected needles
Tattooing, body piercing, nail trimming, scarification, circumcision
Sunday, November 2, 2014

9. Clinical Course of HCV Co-infections: Hepatitis B Virus (HBV) HIV/AIDS
Chronic HCV Infection
80-90% are asymptomatic and have no physical findings
Acute HCV Infection
Asymptomatic, mild flu-like symptoms
15-45% recover spontaneously within 6 months
Incubation Period
55-85%
HCV
Infection
2weeks-2months
of Acute HCV
Extra-hepatic manifestations
Diabetes
Thyroiditis
Cryoglobulinaemia
Glomerulonephritis
SjÖgren sydrome
Skin disorders
Cognitive disfunction, depression
Immunologic disorders
Auto-antibodies as rheumatoid factor, antinuclear antibodies
Co-infections:
Hepatitis B Virus (HBV)
HIV/AIDS
Tuberculosis
Schistosomiasis
Sunday, November 2, 2014

10. Natural History of the Disease
Chronic HCV Infection
Mild
Sever
Cirrhosis A
Cirrhosis B
Cirrhosis C
HCC
10-15%
50-60%
15-30%
2-4% per year
2-4% per year 10 20 30 40 50
Years of Infection
Sunday, November 2, 2014

11. Measures for Controlling HCV Infection Spread
Prevention:
In the absence of a vaccine, prevention of HCV infection depends upon reducing the risk of exposure to the virus
Screening for HCV infection:
Screening is necessary to detect the “health carriers” who harbor the infection but are asymptomatic with no physical signs and can spread the infection unperceived
Care of patients with HCV:
Careful medical examination prior to therapy
Liver biopsy or non-invasive methods to assess the stage of disease and identify patients with advanced disease for priority treatment before onset of decompensated cirrhosis
Treatment of co-infections and other diseases
Sunday, November 2, 2014

12. Evolution in Treatment of Hepatitis C
52 weeks course
24 weeks course
12 weeks course
24 weeks course
12 weeks course
Pegylated Interferon alpha (PEG-INF) +
Ribavirin
(RBV)
Peg INF+ RBV +
Sofosbuvir
(SOVALDI)
Sofosbuvir
(SOVALDI) +
Other new drugs
Standard Interferon (INF)
Sofosbuvir
(SOVALDI) OR
Cure rate= ~20%
Cure rate= ~50%
Cure rate= ~90%
Cure rate=~99%
Challenges to treatment include:
High cost of treatment
The need for sophisticated laboratory tests
The need for well trained clinicians
The side effects due to the high toxicity of some of the medicines
The resistance to treatment
Sunday, November 2, 2014

13. HCV and Inequities Low- and middle income countries:
Unsafe injection practices and procedures
Unscreened blood
Unsafe injecting drug practices
Unavailability of treatment
Inability to afford healthcare and treatment
Lack of health insurance or social insurance
Gender:
Males: reluctant to express suffering, free life, increased risk of injecting drugs, unsafe sex,
Females: reluctant to seek healthcare, cannot negotiate safe sex
Occupational exposure:
Healthcare professionals
Policy agents and army soldiers
Geographic location
Rural and remote areas were healthcare services are lacking
Traditions
Unsafe female genital cutting
Unsafe male circumcision
Unsafe tattooing, piercing, scarification
Informal healthcare providers (barber shops, dayas, etc.)
Stigma towards disease status and risk behaviors
Sunday, November 2, 2014

14. 2. Case Study HCV Infection: Points for Discussion
Sunday, November 2, 2014

15. Human Rights Approach to Control HCV Infection in Egypt
Let’s discuss
Right to protect oneself against health threats
Right not to be infected
Right to healthcare
Right to medication
Right to Health
Cross-cutting ethics
Cross-cutting norms
Right to life
Right to information
Right to privacy
Right to security, education and work
Freedom from tortures or cruel human treatment
Right to freedom from harmful traditional practices
Right to bodily integrity
Right to marry and found a family
May be other rights?
Health-related Rights
Sunday, November 2, 2014

16. Cross-cutting Ethic Respect Autonomy
Respect, dignity, informed consent
Beneficence
Maximize possible benefits
Minimize physical & social harm
Confidentiality
Privacy
International approval
State approval
Justice
Fair practice to societies
Fair practice to individuals
Horizontal equity
Vertical equity
Sunday, November 2, 2014

17. Cross-cutting Norms Non-discrimination
Equality, non- stigmatizing actions
Agreement on the measures and satisfaction with how involved they feel in decision making
Participation
Accountability
Transparency of information
Freedom from tortures or cruel human treatment
Effective remedies
Sunday, November 2, 2014

18. Hepatitis C: unresolved Issues
Let’s discuss
How can the poor and rural residence be protected against exposure to infection (unsafe medical practices) and to non-affordability of treatment?
How can we protect screening and diagnostic results from being used to dismiss people from work and education?
How can we protect the right of HCV infected cases to access other healthcare services?
How can we help HCV infected cases to get married and found a family?
How can we prevent improve the image of HCV patients notably those connected to injecting drug use and HIV/AIDS?
How can we obligations of state and non-state actors; the legal framework; trade and property rights?
How can we protect the community right from the spread of infection?
How can we protect the state from serious violations of regulations and monopolies?
How can the uneducated and those with low health awareness levels contribute to healthcare decision making?
How can we gain the community support to HCV prevention and treatment?
Sunday, November 2, 2014

19. 3. Group Work: Human Rights and Specific Health Issues
Sunday, November 2, 2014

20. Guidelines for Group Work
Select a health issue Discuss relevant dimensions of equity and the right to health (both determinants and health care) Discuss relationship with other human rights Summarize how the human rights-based approach can contribute to addressing the chosen issue
Sunday, November 2, 2014

21. 4. Group Work: Human Rights and Specific Health Issues Presentations
Sunday, November 2, 2014

22. References
World health Organization (2014). Guidelines For The Screening, Care And Treatment Of Persons With Hepatitis Infection April WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. Available at
Egypt Ministry of Health and population (2008). Egypt National Control strategy for Viral Hepatitis. Available at
El-Zayadi et al. (2000). Current Status of Hepatitis C in Egypt, Second Edition. Cairo Liver Center, Cairo, Egypt
El-Zanaty, Fatma and Ann Way, Egypt Demographic and Health Survey Cairo, Egypt: Ministry of Health , El Zanaty and Associates and Macro International. Evidence Based Population Policy (EPDI), Population Status in Egypt: 15. IDSC and UNFPA, Cairo, Egypt. Available at
Sunday, November 2, 2014