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Tackling HIV/AIDS Among Key Populations: Essential to Achieving an AIDS-Free Generation

August 2013

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has embarked on a historic effort to ensure an AIDS-free generation.1 This visionary initiative aligns with broader international efforts that aim to lay the foundation for the eventual end of HIV/AIDS.2

However, ending the AIDS epidemic will not be possible without greatly increased efforts to reduce new infections and prevent AIDS-related deaths among key populations at highest risk of HIV acquisition and transmission. This issue brief focuses on four such populations -- sex workers, people who inject drugs, men who have sex with men (MSM), and transgender individuals -- and demonstrates why equitable attention to the HIV-related needs of these groups is essential to future progress on AIDS and why current efforts are failing to get the job done. In light of growing evidence that antiretroviral therapy dramatically reduces the risk of HIV transmission,3,4 ensuring access to competent HIV testing and treatment services is a particular priority for these key populations and for the broader AIDS response.

Key Populations and Their Sex Partners Account for a High Proportion of New HIV Infections
Key Populations and Their Sex Partners Account for a High Proportion of New HIV Infections

Key Populations Are Severely and Disproportionately Affected by HIV in All Parts of the World

It has long been believed that key populations represent a modest share of the epidemic globally and that the prevalence of HIV among key populations is largely confined to countries with low-level or concentrated epidemics. Recently, however, epidemiological studies have determined that key populations represent a major share of the global HIV epidemic.

Throughout the world, including sub-Saharan Africa, HIV prevalence is substantially higher among key populations. Compared to the general population, for example, HIV prevalence is 22 times higher among people who inject drugs.5 In low- and middle-income countries, MSM and female sex workers (compared to all women of reproductive age) are 19 and 13.5 times more likely to have HIV, respectively, than the background population.6,7 A review of available evidence from 15 countries found that over 19 percent of transgender women were living with HIV.8

Key populations and their sex partners account for as much as 51 percent of new infections in Nigeria,9 33 percent in Kenya,10 27.5 percent in Mozambique,11 80 percent in Morocco,12 47 percent in the Dominican Republic,13 and 65 percent in Peru.14 MSM alone account for more than 33 percent of new infections in China,15 and projections indicate that MSM could make up half or more of all new infections in Asia by 2020.16 As studies documenting modes of HIV transmission in various settings have generally failed to take into account the role of transgender populations, it is not possible to estimate the share of new infections among this group.


The Epidemic's Burden on Key Populations Is Growing

Encouragingly, the overall rate of new HIV infections appears to be in decline. However, epidemics among key populations continue to grow. In part, this stems from increased biological and behavioral HIV acquisition and transmission risks among populations such as MSM. Evidence strongly suggests that people who inject drugs will access services if they are provided, but policy and program failures have impeded service scale-up, contributing to continued high rates of new HIV infections and AIDS-related deaths.

In addition, many members of key populations are members of dense, high HIV-prevalence social and sexual networks that facilitate the continued spread of HIV. The sustained growth of HIV epidemics among key populations is also engendered by structural factors such as stigma, discrimination, and punitive laws that intensify the marginalization these groups experience and deter them from seeking the services they need. In South Africa, where the overall epidemic is slowing somewhat, experts project that HIV prevalence among MSM will continue to rise.17 This pattern is in line with that experienced in the U.S., where new infections among MSM have increased even as rates of heterosexual transmission have declined.18 Unless effective strategies are put in place to mitigate the HIV burden in key populations, the global epidemic will worsen over time, preventing the world from realizing the dream of an AIDS-free generation.

HIV Prevention and Treatment Efforts Neglect Key Populations

Although PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other donors have taken steps to strengthen their HIV programs for key populations, these groups are often underrepresented in national AIDS programs. Moreover, programs focused on key populations are generally the first to be cut when budget reductions are needed.19-21 HIV prevention coverage is low for these groups,22 and HIV treatment programs often fail to reach key populations due to discrimination by health workers and legitimate fears that accessing health care will result in being reported to hostile law enforcement officials.23

Discriminatory laws and policies often contribute to, and reinforce, the suboptimal reach of HIV services. Globally, 40 percent of countries criminalize same-sex sexual relations and many countries treat drug use primarily as a criminal offense rather than a public health issue.24 Additionally, the U.S. government's prostitution pledge, only recently overturned, has hindered many HIV service providers from working with sex workers.

These statutes have contributed to poor coverage of HIV programs. Among those living with HIV, people who inject drugs are least likely to obtain antiretroviral therapy. In Russia, for example, less than one percent of HIV-positive people who inject drugs are receiving antiretroviral therapy.25

Effectively addressing the HIV-related needs of key populations will require new resources for HIV programs specifically developed for these groups; diplomatic efforts to encourage the repeal, or limited enforcement, of discriminatory laws and policies; and focused clinical skills and sensitivity training for health and social service workers to enable them to effectively serve marginalized populations. In sub-Saharan Africa, for example, every country has laws in place that criminalize at least one key population.26 The current legal prohibition on the use of federal funds to support needle and syringe exchange programs seriously inhibits U.S. efforts to address HIV among people who inject drugs domestically and globally.27

We Know How to Prevent and Treat HIV in Key Populations

Evidence-based strategies are available to substantially reduce the number of new HIV infections and AIDS-related deaths among key populations.

  • Sex Workers: Condom promotion efforts have been most successful among sex workers, with high condom uptake in this population helping avert new infections.22 Sex workers also need culturally appropriate access to HIV testing, linkage to care, timely initiation of antiretroviral therapy, and support services to enhance retention in care and treatment adherence.
  • People Who Inject Drugs: Countries that have implemented a harm reduction approach -- which combines needle and syringe exchange, drug treatment, including methadone maintenance therapy, HIV treatment, and comprehensive health services -- have witnessed dramatic declines in new drug-related infections, with some countries approaching the elimination of transmission among people who inject drugs.22
  • Men Who Have Sex With Men: Immediate implementation of available prevention tools would reduce new infections among MSM by more than 40 percent.28 Due to the comparatively high per-act probability of HIV transmission during anal intercourse, biomedical strategies to reduce the physiological likelihood of HIV transmission among MSM will likely be needed to reverse the epidemic in this population. After San Francisco introduced a major citywide effort to reach MSM with HIV testing and active linkage to universal treatment services, a 40 percent decline in community viral load was associated with a 45 percent reduction in new infections.29
  • Transgender Individuals: Although the evidence base is limited on HIV prevention for transgender individuals -- underscoring the critical importance of additional transgender-focused research -- it is clear that HIV prevention works for this population. Drawing from available practice, experts at the University of California-San Francisco have identified the best methods for transgender-focused HIV prevention.30 The World Health Organization has issued guidelines for HIV prevention programming for transgender people and an even more comprehensive guidance document is forthcoming.31


In spite of an aggregate decline in HIV incidence worldwide, a growing body of epidemiological evidence shows that key populations continue to bear a disproportionately high burden of HIV infection in both low- and high-prevalence countries. With HIV/AIDS concentrated among these populations, efforts to achieve an AIDS-free generation will not succeed unless much greater attention and adequate resources are directed to address their HIV-related needs.


  1. PEPFAR (2012). Blueprint for Creating an AIDS-Free Generation.
  2. UNAIDS (2011). UNAIDS World AIDS Day Report 2011.
  3. Cohen MS et al (2011). Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New Eng J Med 365:493-505.
  4. Tanser F, Bärninghausen T, Grapsa E, Zaidi J, Newell M (2013). High Coverage of ART Associated with Decline in Risk of HIV Acquisition in Rural KwaZulu-Natal, South Africa. Science 339:966-971.
  5. UNAIDS (2012). Report on the global AIDS epidemic.
  6. Baral S et al. (2007). Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000-2006: A Systematic Review. PLoS Med 4:e339.
  7. Baral S et al. (2012). Burden of HIV among female sex workers in lowincome and middle-income countries: a systematic review and metaanalysis. Lancet Infect Dis doi:10.1016/S1473-3099(12)70066-X.
  8. Baral S et al. (2012). Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis doi:10.1016/S1473-3099(12)70315-8.
  9. UNAIDS, World Bank (2010). New HIV infections by modes of transmission in West Africa: a multi-country analysis.
  10. World Bank, UNAIDS (2009). Kenya: HIV Prevention Response and Modes of Transmission Analysis.
  11. World Bank, UNAIDS (2010). Analysis of Modes of HIV Transmission and National Response to HIV and AIDS.
  12. Moroccan Ministry of Health et al. (2010). HIV Modes of Transmission Analysis in Morocco.
  13. UNAIDS et al. (2010). HIV Modes of Transmission Model: Analysis of the distribution of new HIV infections in the Dominican Republic and recommendations for prevention.
  14. Pan American Health Organization (2009). Modos de Transmisión del VIH en América Latina.
  15. UNAIDS et al. (2012). Country snapshot: China -- Men who have sex with men.
  16. amfAR/Treat Asia (2010). HIV/AIDS in Asia Overview.
  17. Baral S et al. (2011). HIV Risk and Associations of HIV infection among men who have sex with men in Peri-Uran Cape Town, South Africa. BMC Pub Health 11:766.
  18. Hall HI et al. (2008). Estimation of HIV Incidence in the United States. JAMA 300:520-529.
  19. Makofane K et al. (2013). Men who have sex with men inadequately addressed in African AIDS National Strategic Plans. Glob Pub Health 8:129-143.
  20. amfAR (2011). Achieving an AIDS-Free Generation for Gay Men and Other MSM.
  21. amfAR (2012). Achieving an AIDS-Free Generation for Gay Men and Other MSM in Southern Africa.
  22. UNAIDS Global Report (2012).
  23. amfAR (2010). The Shifting Global Health Landscape: Implications for HIV/AIDS and Vulnerable Populations.
  24. Itaborahy LP (2012). State Sponsored Homophobia: A world survey of laws criminalizing same-sex sexual acts between consenting adults. International Lesbian, Gay, Bisexual, Trans and Intersex Association.
  25. Mathers BM et al. (2010). HIV prevention, treatment and care services for people who inject drugs: a systematic review of global, regional and national coverage. Lancet 375:1014-28.
  26. Baral S, Phaswana-Mafuya N (2012). Rewiring the narrative of the epidemiology of HIV in sub-Saharan Africa. SAHARA J. 9:127-130.
  27. amfAR (2013). Federal Funding for Syringe Services Programs: Saving Money, Promoting Public Safety, and Improving Public Health.
  28. Beyrer C et al. (2012). A call to action for comprehensive HIV services for men who have sex with men. Lancet 380:424-38.
  29. Das M et al. (2010). Decreases in Community Viral Load Are Accompanied by Reductions in New HIV Infections in San Francisco. PLoS ONE 5:e11068.
  30. UCSF Center of Excellence for Transgender Health. 8 Best Practices for HIV Prevention among Trans People. (Accessed on March 26, 2013.)
  31. WHO (2011). Prevention and Treatment of HIV and Other Sexually Transmitted Infections Among Men Who Have Sex with Men and Transgender People: Recommendations for a Public Health Approach.

This article was provided by amfAR, The Foundation for AIDS Research. Visit amfAR's website to find out more about their activities and publications.
See Also
More News and Reports on U.S. Global HIV/AIDS Relief (PEPFAR)

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