Stefan Baral
Claire E Holland
Kate Shannon
Carmen Logie
Paul Semugoma
Bhekie Sithole
Erin Papworth
Fatou Drame
Chris Beyrer
Publication Date
August 15, 2014

Key Populations Program, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health

"Structural determinants are especially important in mediating HIV risk among key populations, including men who have sex with men, people who inject drugs, sex workers of all genders, and transgender women. The objective of this systematic review was to synthesize the evidence characterizing the community-level determinants that potentiate or mitigate HIV-related outcomes for key populations."

Using a literature review, researchers identified community- and social-level determinants of HIV transmission associated with prevalent HIV infections and HIV-related outcomes among men who have sex with men (MSM), transgender women, female sex workers (FSW), and people who inject drugs (PWID). "Adverse community determinants that emerged in the review as significantly associated with HIV infection or HIV risk/protective behaviors included (1) lack of access to safe and competent HIV prevention, treatment, and care services; (2) insufficient key population–specific health promotion, such as encouraging condom use with sex-positive messaging; and (3) the reinforcement of stigma and discrimination. Significant beneficial community determinants included social network characteristics such as the provision of social support, reinforcement of protective social norms, and measures of social capital, including social cohesion, participation, and inclusion." The article is from the JAIDS: Journal of Acquired Immune Deficiency Syndromes supplement addressing clinicians and public health scientists in the field of HIV prevention and treatment who might value information on health communication. (Footnotes removed by the editor.)

In more detail, by key population:
Men Who Have Sex With Men - Reduced utilisation of health and HIV services by MSM, due to actual or perceived discrimination, may limit knowledge of the risks and access to prevention methods. "Statistically significant community and social associations with beneficial HIV-related outcomes include having a confidant, believing in collective efficacy, participating in a public event, being out as an MSM, and knowing other MSM in one's city." However, due to abuse, social isolation and lack of social support, shaming, expulsion from school, and exclusion from employment, "sexual and gender minorities are more likely to be homeless or to engage in survival or commercial sex work."

In Southern Africa, Uganda, Malawi, Botswana, and Namibia, there was a strong association between experiencing discrimination on the basis of sexuality and fear of health care services. Tailored, community-based programmes led by MSM have "yielded greater feelings of connection, social support, and self-esteem among community members...In Cameroon, men who were living with HIV were more likely to have obtained health services, thanks mainly to a dynamic community-based organization in the study city that provides HIV prevention, care, and treatment specifically for the lesbian, gay, bisexual, and transgender population (adjusted odds ratio, 4.9; 95% confidence interval, 1.6 to 14.6). In Senegal, a pilot community-driven MSM cohort study demonstrated the value, in terms of retention and psychosocial community support, of interventions conducted jointly by the community and research team."

Criminalisation is reported to have far-reaching effects on individuals, organisations, and communities, including increased violence, lack of police protection from violence, denial of organisational registration by governments, individual arrests and detention, and threats to clinics, including criminalisation of outreach efforts. "Currently, in sub-Saharan Africa, there are 38 countries, and in the Caribbean, there are 10 countries that criminalize same-sex practices." This limits testing and treatment availability and research participation.

Transgender Populations - HIV prevalence among transgender women in 10 low- and middle-income countries is 21.6%, "which is more than 40 times higher than the rates of HIV infection among other adults across 15 countries." Social and structural factors limit access to HIV information and services, as well as economic opportunities. "The denial of care and government-sponsored brutality limit the provision and uptake of HIV prevention, treatment, and care services for transgender women....Across the continent [of Africa], transgender women are often treated as a subcategory of MSM, resulting in the incorrect assumptions that their needs are identical to those of other MSM." Though there is a reported dearth of information on trans populations, groups are emerging for support and research - including Transrespect versus Transphobia Worldwide (TvT) and Gender DynamiX in South Africa. "Better approaches to researching transgender communities have been recommended, including sampling frameworks that focus on transgender women rather than male-identified MSM, and 2-step gender identity assessment."

Female Sex Workers - "A recent review and meta-analyses found FSW to be 13.5 times more likely to be living with HIV than the general population of women of reproductive age in low- and middle-income settings...," due, in part, to sex-worker-related stigma that limits service access for testing, care, and treatment. Denial of antiretroviral therapy (ART) and health worker discrimination are reported, including in sub-Saharan Africa. Gender-related structural inequities result in lower access to education and employment as well as reduced ability to negotiate condom use.

"Peer support and engagement, including peer outreach and education, can promote HIV prevention by shifting norms concerning condom use and sexual risk. Adapted health services designed to provide tailored medical care for FSW, often integrated into antenatal or general health services to avoid stigma and community exposure, have proved to be effective settings to engage women who sell sex in the first step of the HIV continuum of care.98,99 Measures of collective efficacy and social cohesion (eg, mutual trust and support between workers) have been linked independently and through venue-level policy supports to increased condom use in a number of settings. At a community level, social participation and collective action, as part of a broader process of organizing sex workers and community empowerment, can significantly reduce HIV risks among FSW -notable examples include the Sonagachi and Avahan models [see Related Summaries below] in India. Community empowerment has also helped to reduce HIV risks by lowering levels of violence against FSW."

People Who Inject Drugs - Though fewer studies are available, the review found the following: "a community network providing emotional support helped to decrease the odds of HIV infection among males who inject drugs in India, and greater social support was associated with a decrease in inconsistent condom use among FSWs who inject drugs in China." Data from population-based studies in Ukraine was used in mathematical models "to demonstrate that reductions in beatings by the police could reduce HIV incidence -principally by reducing needle sharing among communities of PWID afraid to use needle and syringe exchanges for the fear of police abuses."

Though criminalised, treatment of PWID through the basic package of HIV prevention and care services recommended by the World Health Organization can, as reported here, keep "HIV incidence rates in this population are very low - well under 1/100 person-years." Effective services are listed as needle and syringe exchange, opioid substitution therapy, and ART for PWID living with HIV infection. Strong community engagement and support is suggested as the way to address the problem, demonstrated through evidence of the converse: "where they are actively being suppressed, as in Russia in 2014, HIV burdens increase rapidly among PWID."

The results of the review suggest that "if HIV services are offered to key populations in ways consistent with human dignity, safety, and good clinical and public health practices, uptake improves, and HIV spread can be markedly reduced."  The studies accessed reinforce the importance of the "continued measurement of community-level determinants of HIV risks and of the innovation in tools to effectively address these risks as components of the next generation of the HIV response....With advances in ART-based prevention and treatment strategies, the 'what' of the tools needed to end the HIV pandemic has been defined. However, the 'how' remains an open question - especially for key populations, given the limited population-level information on the effectiveness of HIV prevention, treatment, and care programs."


JAIDS: Journal of Acquired Immune Deficiency Syndromes, August 15 2014 - Volume 66 - p. S237-S240, accessed July 22 2014. Image credit: AVERT website