April 2011

The Foundation
for AIDS Research FACT SHEET
Reaching Key Populations: A Critical Priority
to Controlling the AIDS Epidemic
In most countries HIV is a disease that discriminates, dispropor-
tionately affecting society’s most vulnerable. Even in generalized
epidemics in which a significant share of the wider population is
Increasing Coverage of High Risk Groups Would
living with HIV/AIDS, people in vulnerable communities often have Have a Major Impact on the AIDS Epidemic
considerably higher rates of HIV infection.
Modeling recently conducted by the World Bank suggests the extent
Despite the urgent need for scaled-up HIV prevention services for to which increasing access and coverage for such high-risk groups as
populations at highest risk and the availability of an expanding vari- men who have sex with men (MSM) and injecting drug users (IDUs)
ety of prevention strategies, the world has largely ignored the plight would have a significant impact on the trajectory of the HIV epidemic
of these individuals. This reality is deeply concerning in part because overall. Among the report’s finding:
the lack of attention to HIV prevention among these populations also
• Existing preventive interventions as well as treatment of
undermines the overall response to the epidemic. Reaching vulner-
HIV-postive MSM would lead to overall declines in HIV.
able populations with effective HIV prevention and treatment is
critical to bringing the AIDS epidemic under control. • Where a significant share of new HIV infections are among IDUs,
major impacts among the general population could be seen if
Populations at Highest Risk Are at the Center coverage of needle exchange and drug substitution therapy
of the Global AIDS Pandemic (e.g., methadone, buprenorphine) is increased.

Addressing HIV among high-risk groups is crucial for a number of These findings suggest that increasing coverage and access for
reasons: high-risk groups are also essential components of the overall
response to HIV.
• Significantly higher risk of becoming infected. According
to conservative estimates, sex workers are roughly eight times
more likely to be infected with HIV than other adults, MSM are Thailand: Projections of the Number of New HIV Infections with
15 times more likely, and IDUs are 32.5 times more likely.1 These Implementation of Four Intervention Scenarios for MSM (2008-2015)5
disproportionate risks are apparent not only in concentrated or
low-prevalence epidemics, but also in generalized epidemics in
sub-Saharan Africa, where sex workers2 and MSM3 are at least
Number of new infections (thousands)

four times more likely than other adults to be living with HIV.

• A substantial share of new HIV infections. Vulnerable

populations are heavily affected in concentrated epidemics
outside sub-Saharan Africa. Yet even within Africa, these groups
account for a notable share of new infections. In countries
such as Mozambique and Kenya, sex workers, MSM, and IDUs
together represent between one-quarter and one-third of all new
HIV infections.4 Globally, sustained progress in reducing rates
of new infections will not be possible without implementing
effective HIV prevention strategies for populations at highest risk.

• Major risks of transmission to other groups. In addition to Null Current 100% MSM 100% MSM
coverage interventions interventions and
the considerable health risks experienced by these populations, 60% IDU
their high HIV prevalence also affects broader efforts to bring

amfAR Public Policy Office 1150 17th Street, NW • Suite 406 • Washington, DC 20036 • T: +1 202.331.8600 F: +1 202.331.8606 www.amfar.org
 national epidemics under control. In West Africa, it is estimated that
13-29 percent of men may have paid for sex in the last 12 months,6
resulting in substantial risks of HIV exposure to the female sex
partners of these men. A considerable percentage of MSM also
have sex with women.7 And in Eastern Europe and Central Asia,
where epidemics have historically been overwhelmingly rooted
in intravenous drug use, a growing share of new infections are
among the sex partners of HIV-positive drug users.8 In particular,
female partners of IDUs are at a heightened risk because many are
unaware of their partners’ drug use or unwilling to acknowledge it,
a situation that jeopardizes personal and child health.9
Effective Strategies to Lower New Infections
Among Key Populations
• HIV prevention for sex workers. Focused prevention services
for sex workers help bring national epidemics under control. As
a result of condom promotion efforts, HIV prevalence among sex
workers in Thailand declined from 33.2 percent in 1994 to 5.3
percent in 2007.10 After the Avahan Indian AIDS initiative, launched
by the Bill & Melinda Gates Foundation, brought HIV prevention
and other services to scale for sex workers in India, HIV prevalence
among sex workers declined from 10.3 percent in 2003 to 4.9
percent in 2006.11 As a result of prevention efforts in Ethiopia,
condom use among sex workers increased from 5.3 percent in
1989 to 91.6 percent in 2005.12
• HIV prevention for MSM. Successful recent trials of pre-exposure
prophylaxis among MSM in six countries demonstrated both
substantial motivation among MSM for HIV prevention services and
excellent rates of retention in prevention research.13 Although the
number of annual new HIV infections among gay men appears to
be increasing in the U.S., incidence is falling in some areas as HIV
testing, earlier initiation and broader coverage of AIDS treatment,
and targeted prevention services are scaled to reach more of the
population at risk.14
• HIV prevention for IDUs. Harm reduction for drug users involves
a package of interventions, including access to sterile injecting
equipment and to drug substitution therapy (e.g., methadone,
buprenorphine). In New York City, increased access to harm
reduction services was associated with a nearly 80 percent drop in
new HIV infections among drug users from 1990 to 2002.15 In the
Netherlands, Switzerland, and other countries that once had large
epidemics among IDUs, HIV transmission from injecting drug use
has been virtually eliminated as a result of scaled-up prevention
services.16
Addressing HIV Among Vulnerable Populations
Is a Critical Component of Global Health
Without supporting programs that address the HIV epidemic among
at-risk communities, efforts to improve global health will inevitably fall
short. But it is crucial to support programs that can be effective.
• Increase investments in service channels specifically designed
for vulnerable populations. Due to official discrimination and
hostility from health workers, many vulnerable groups avoid
seeking health services. According to an international survey in
2010, 56 percent of people living with or affected by HIV reported
experiencing negative attitudes from health workers due to their
membership in a stigmatized group, with one in four saying they
were afraid to seek services due to the risk of experiencing social
disapproval or active discrimination.17 Because mainstream health
services do not effectively serve vulnerable populations, the U.S.
government should actively work to support delivery of evidence-
based HIV prevention services through community-based channels
that vulnerable populations trust.
• Build the capacity of health systems to address the needs
of vulnerable populations. While increasing investments in
channels expressly designed for most-at-risk populations, the
U.S. government should support long-term efforts to increase the
competence of health systems to provide appropriate services to
key populations. In particular, U.S. funding should support trainings
for health workers to increase their understanding of the health
needs of vulnerable groups, build awareness of evidence-based
approaches, and address misinformation and negative social
attitudes that may impede the effectiveness of mainstream health
services.
• Assess the appropriate mix between NGO and government
providers with respect to services for vulnerable populations.
U.S. funding should support country-specific assessments of
the ability of government-run health facilities to meet the needs
of vulnerable populations. Due to the diversity of vulnerable
populations, the optimal approach will typically involve a robust
mix of non-discriminatory, culturally appropriate services operated
by governments as well as tailored services conceptualized and
delivered by communities themselves. Depending on particular
country settings, the optimal balance between government
and community services will be influenced by the capacities of
governments and communities, the depth of service needs, legal
frameworks, the attitudes and abilities of health workers, and the
desires of vulnerable populations.

References
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Priority HIV/AIDS Interventions in the Health Sector, 2009; epidemiology, biologic markers, respondent-driven sampling, Final%20PE.pdf).
UNAIDS. Global Report on the AIDS Epidemic, 2008. and supervised-injection facilities. Curr Opin HIV AIDS. 14. Das M, et al. Success of Test and Treat in San Francisco?
2. WHO, et al. (2009) 2009;4:308-313. Reduced Time to Virologic Suppression, Decreased
3. Desmond Tutu HIV Foundation, et al. Men Who Have Sex with 9. Reference Group of HIV and Injecting Drug Users, United Community Viral Load, and Fewer New HIV Infections, 2004
Men: An Introductory Guide for Health Workers in Africa, 2009. Nations. Women who inject drugs: A review of their risks, to 2009. Poster presented as part of the 18th Conference
4. UNAIDS. Global Report on the AIDS Epidemic, 2010. experiences and needs, 2010. on Retroviruses and Opportunistic Infections, Boston,
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Global HIV Epidemics Among Men Who Have Sex with Men Ministry of Public Health. UNGASS Country Report—Thailand, 15. Des Jarlais DC, et al. HIV incidence among injection drug users
(MSM): Epidemiology, Prevention, Access to Care, Costs, and 2008. in New York City, 1990 to 2002: Use of serologic test algorithm
Human Rights. World Bank, 2011. 11. National AIDS Control Organization, Government of India. to assess expansion of HIV prevention services. Am J Pub
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response synthesis: Implication for prevention. World Bank, 12. Federal Democratic Republic of Ethiopia. Universal Access 16. UNAIDS. AIDS Epidemic Update, 2009.
2008. Country Review—Aide Memoire, 2010. 17. NGO Delegation to the UNAIDS Board. Stigma and
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men who have sex with men in Ventiane Capital, Lao People’s (Accessed on March 17, 2011, at http://www.iprexnews. 2010. Available at http://unaidspcbngo.org/wp-content/
Democratic Republic. AIDS. 2007;23:409-414. com/studyresults/pdfembargo/englishversion/iPrEx%20 uploads/2010/05/2010_NGO_Report_Final_website.pdf.