HIV and key populations: providing care where it is most needed
As a virus, HIV does not discriminate. But when combined with social and economic factors affecting health such as gender, sexual orientation, and poverty, HIV becomes a virus that manifests much more strongly in some groups over others. In public health language, these are our key populations- the groups of people who experience a heightened risk of being infected with HIV due to one of more of those factors.
Key populations include sex workers, men who have sex with men (MSM), people who inject drugs (PWID), and transgender persons.
Taking a look at data from several sub-Saharan African countries, we can see that HIV prevalence among key populations stand significantly higher than that of the general population. In Niger, where prevalence is 0.5% in the general population, sex workers’ prevalence is 17.3%. In Burundi, the difference is 1.3% and 26.5%. Sub-Saharan Africa’s HIV epidemic is a generalized one, but new infections are increasingly being driven by key populations. Even in countries where HIV incidence is falling or stabilizing, incidence continues to rise among key populations.
Why are key populations more at risk in the first place?
Consider the fact that many countries enforce laws criminalizing certain sexual behaviors, drug use, and perceived atypical sexual orientation. Prostitution, a line of work often driven by poverty and/or coercion, is criminalized in 116 countries. Homosexuality is criminalized in 78 countries and carries the death penalty in seven. Such laws only serve to reinforce discrimination against individuals who are already socially marginalized and denied access to health services including HIV prevention and care. After all, access to healthcare is a fundamental human right, and we are not fully addressing the HIV epidemic if we do not consider these barriers to access and how discriminatory laws drive people away from life-saving care.
When criminalization and discrimination against key populations are combined with existing high-risk behaviors such as unprotected sexual intercourse and use of unsterilized needles to inject drugs, HIV infections rise. And when we add gender to the mix, we have another layer of disparity. Women and girls are disproportionately affected by HIV due to sexual violence, forced and/or early marriage, and factors related to poverty. In fact, HIV prevalence among young women is twice that of young men in every country in sub-Saharan Africa.
Imagine a young woman living below the poverty line in her country. Now imagine that this young woman is a sex worker. Forced or financially persuaded into having unprotected sex with her clients, she faces an increased risk of being infected with HIV. It becomes easy to understand just how difficult it can be for her to step into a clinic for HIV services when we consider the challenges she experiences on a day to day basis by virtue of her gender, age, and involvement in sex work.
When developing and implementing improvement programs, we public health professionals must ask the right questions and apply those answers into our work. We need to be asking if our programs benefit the people who need it the most, if our facilities are welcoming to all people seeking care, and if the clients we serve are treated with dignity and provided with the excellent care they deserve.
- WHO consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations (http://www.who.int/hiv/pub/guidelines/keypopulations/en/)
- UNAIDS Gap Report (http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_...)