Feature story

HIV prevention among key populations

22 November 2016

Since 2010, the annual global number of new HIV infections among adults (15 years and older) has remained static, at an estimated 1.9 million. Members of key populations, including sex workers, people who inject drugs, transgender people, prisoners and gay men and other men who have sex with men, and their sexual partners accounted for 45% of all new HIV infections in 2015.

In some countries and regions, infection rates among key populations are extremely high—HIV prevalence among sex workers varies between 50% and 70% in several countries in southern Africa. One study from Zimbabwe found HIV prevalence rates of 27% for male inmates, 39% for female inmates and 60% for sex workers, with 9.6% of these getting newly infected between 2009-2014. New infections among gay men and other men who have sex with men have been increasing in all regions in recent years. Across countries, key populations are between 10 and 50 times in greater risk of HIV infection compared to other adults.  

Criminalization and stigmatization of same-sex relationships, sex work and drug possession and use, and discrimination, including in the health sector, are preventing key populations from accessing HIV prevention services. Effective government support and community-based and implemented HIV prevention and treatment programmes that provide tailored services for each group are currently too few and too small to result in a significant reduction in new infections.

In order to achieve the target of reducing new HIV infections among key populations by 75% by 2020, a large-scale increase of programmes and the creation of an enabling social and legal environment are needed.

We must reduce new HIV infections among key populations

The global number of new HIV infections among adults has remained static, at an estimated 1.9 million, since 2010, threatening further progress towards the end of the AIDS epidemic.

New HIV infections among gay men and other men who have sex with men are rising globally, and there has been no apparent reductions of new infections among sex workers, transgender people, people who use drugs or prisoners. Studies conducted in southern Africa have found HIV prevalence 10–20 times higher among sex workers than among adults in the general population, with rates of HIV infection reaching 50% of all sex workers tested, and HIV prevalence reaching 86% in one study in Zimbabwe. A synthesis of studies including more than 11 000 transgender people worldwide estimates HIV prevalence to be 19.1%.

Key populations remain among the most vulnerable to HIV. Analysis of the data available to UNAIDS suggests that more than 90% of new HIV infections in central Asia, Europe, North America, the Middle East and North Africa in 2014 were among people from key populations and their sexual partners, who accounted for 45% of new HIV infections worldwide in 2015.

Reinvigorating HIV prevention among key populations requires domestic and international investments to provide key populations with tools, such as condoms and lubricants, pre-exposure prophylaxis and sterile needles and syringes, and testing and treatment. However, the design and delivery of such HIV combination prevention services is often limited by a reluctance to invest in the health of key populations and to reach out to them.

In many countries, key populations are pushed to the fringes of society by stigma and the criminalization of same-sex relationships, drug use and sex work. Marginalization, including discrimination in the health sector, limits access to effective HIV services. There is an urgent need to ensure that key populations are fully included in AIDS responses and that services are made available to them.

Guidelines and tools have been developed for and with the participation of key populations in order to strengthen community empowerment and improve the delivery of combination prevention services by community-led civil society organizations, governments and development partners.

The available evidence shows that when services are made available within an environment free of stigma and discrimination and involving key population communities, new HIV infections have declined significantly. For example, street youth in St Petersburg had a 73% decrease in HIV seroprevalence from 2006 to 2012, primarily due to decreased initiation of injection drug use. This marked reduction in the HIV epidemic among street youth occurred after implementation of extensive support programs and socio-economic improvements.

The replication of such successes and the scale-up of combination prevention programmes in all cities and sites where key populations live and work, implemented by countries and community organization networks, will help prevention efforts get back on track to achieving the target of reducing new HIV infections by 75% by 2020.