Legal empowerment is key to ending AIDS

When the global HIV pandemic began more than 40 years ago, HIV was a death sentence. Thanks to the work of scientists, people living with HIV, other key populations at higher risk of acquiring HIV, their allies and communities, we now have medicines that can transform HIV into a chronic, manageable condition and prevention options like pre-exposure prophylaxis (PrEP) that halt transmission altogether.

Despite these advances, progress toward ending AIDS has stalled and PrEP coverage remains alarmingly low.

Why? Persistent inequities in the global AIDS response.

Compounding, intersecting crises like COVID-19, conflict and climate emergencies have disrupted services, leading to backsliding and increased competition for resources and attention. This new reality, coupled with entrenched inequities and discrimination against people living with HIV and other key populations are impeding access.

As available resources for the HIV response shrink, the world needs investments and strategies that are evidence- and rights-based, and resources that target the deeply-rooted inequities prolonging the pandemic. The way forward must unequivocally center the voices and advance the leadership of people living with HIV, other key populations and those most affected by HIV to work with governments and partners to remove the inequities that increase risk and prevent access to lifesaving tools and services.

Decriminalization is essential and a key step on the path to equality. Ending HIV-related criminalization not only addresses inequities head-on but is also a force multiplier that enables and improves the efficacy of HIV response by broadening access to the services and support that people need.

It’s scientifically proven to work. People living with HIV and other key populations fare better when their human rights are respected. Countries with non-discrimination in law have higher knowledge of HIV status and viral suppression rates, and HIV transmission rates drop sharply when personal drug use and possession are decriminalized.

Removing harmful laws also creates much-needed space for HIV responses to function. Advocacy organizations, which are often trusted providers of services to key populations, can become targets of violence and subjected to laws, policies and practices that impede their ability to operate. But when key populations and advocacy organizations are actively involved and engaged with governments, the effects can be dramatic, as seen during the COVID-19 pandemic.

When the COVID-19 lockdowns began, many people living with HIV had only a month’s worth of medicine on hand, and trips to clinics or pharmacies to restock carried the risk of contracting the then-novel coronavirus. In response, countries instituted multi-month dispensing so patients could maintain an extended supply of medicine and avoid potentially dangerous excursions. Advocacy organization were key to driving this in Chile, where activists filed petitions through the courts to ensure nationwide implementation and monitored stock-outs of antiretroviral drugs at pharmacies.

When led by key populations, decriminalization efforts can address the root causes of why progress has stalled. No one can better reveal the gaps and develop solutions than the very people the system is currently failing to serve, and tools like government-led participatory legal environment assessments help countries meaningfully engage and empower local communities.

The results can be profound. Following a 2019 legal environment assessment in Zimbabwe, people living with HIV and key populations drove forward recommendations that ultimately led to the repeal of a law criminalizing HIV transmission in the country. In 2022, Zimbabwe announced it had already exceeded the global 2025 targets for knowledge of status, PLHIV on treatment and viral suppression.

Accelerating these kinds of efforts is crucial, but action has been slow. To help create the political will needed to drive faster action, the United Nations Development Programme (UNDP) convened the independent Global Commission on HIV and the Law to provide clear and actionable recommendations on decriminalization. Since they were published in 2012, UNDP, working closely with government, civil society and UN partners, has supported implementation of these recommendations in 90 countries.

This includes assisting countries to repeal punitive laws that marginalize people and increase their risk and vulnerability. UNDP has supported governments to work with people living with HIV, other key populations and advocacy organizations to carry out more than 50 legal environment assessments, reviews and audits to better understand the impact of punitive laws and levers for change. This process helped drive progress in many countries in the past few years, like changes in Moldova that allow women living with HIV to adopt children and have in-vitro fertilization in certain circumstances — a tremendous leap forward for equity.

More needs to be done, which is why UNDP has launched a new partnership with the United States President’s Emergency Plan for AIDS Relief (PEPFAR) that aims to scale key population-led approaches to counter punitive and discriminatory laws and HIV-related criminalization while investing in their leadership and capacity. This new partnership is committed to working with partners to support countries and key populations in their efforts to overcome structural barriers, advocating for the health, wellbeing and equality of key populations.

To end AIDS for good, we must address the harmful laws and policies standing in the way of progress. If discriminatory laws and policies are in place, inequality will continue to harm health and well-being and stand in the way of progress.

We have the science and tools to end this pandemic. Let’s end HIV-related criminalization and support the empowerment and leadership of key populations and follow their lead to the end of the AIDS pandemic before another 40 years passes.

Mandeep Dhaliwal is the director of the HIV and Health Group for the United Nations Development Programme.