Key vulnerable populations

The population groups considered in this section are clearly not mutually exclusive. This requires that we understand and take account of the multiple factors, such as gender, age, sexuality, ethnicity and socio-economic status, that shape people's lives in ways that influence their vulnerability to HIV.

People living with HIV
The impact of HIV is felt most strongly, and understood most profoundly, by those living with the disease. The meaningful involvement of PLHIV and affected communities makes a powerful contribution to the HIV response by empowering people living with HIV to draw on their lived experiences. In turn this contributes to reducing stigma and discrimination and increasing the effectiveness and appropriateness of programmes.

Women and girls and men and boys
Programmes need to recognise and respond to the variety of ways in which gender inequities expose women and girls to the risk of HIV infection, undermine women's access to information, services and programmes, and entrench the subordination of women. In many cultures, unequal power in sexual relationships undermines the capacity of women and girls to exercise control over their sexual choices. One of the most serious manifestations of this inequity is gender-based violence, which can expose women to HIV infection, and fear of which can prevent them from protecting themselves against infection. Legislation often restricts the right of women to own or inherit property, entrenching their economic dependence on men, and limiting their capacity to refuse sex or negotiate condom use. A gendered approach to HIV requires advocating for a legislative and policy environment that promotes the rights of women and girls, in order to shift the dynamics that underscore women's subordinate position in society and sexual relationships.

To reduce the spread and minimise the impact of HIV, inequities between men and women must be reduced. This must necessarily involve men and boys as well as women and girls. Given the power men often have in society, communities, families and sexual relationships, there is a growing recognition of the need for programmes for men and boys that challenge gender roles and norms, enabling them to change their attitudes and behaviours that affect the vulnerability of women and girls. There is also a need to address the ways in which gender roles and norms undermine men's ability to access health programmes, including sexual health, HIV prevention and treatment, care and support.

Children and young people
Young people continue to make up a significant proportion of new infections each year, with 38 per cent of PLHIV worldwide now under the age of 25. We need to recognise and meet the needs of the growing population of young people living with HIV. Sub-populations of young people are particularly vulnerable to infection, including young women, young men who have sex with men, young people who inject drugs, and sexually exploited children. Many young people do not know how to protect themselves from HIV, and there are significant social and cultural barriers that impede the widespread availability of appropriate sexual health and HIV education for young people.

There is also a clear cycle of vulnerability in relation to orphans and children affected by HIV/AIDS. An estimated 14 million children worldwide have lost one or both parents to AIDS. A holistic response, including care in the community, is needed to address their needs, and this in turn can reduce their vulnerability to HIV infection.

Older people
Older people are both infected and affected by HIV, but far too often their specific needs are overlooked. Data on infection rates among people over 50 are inadequate, yet the data that are available indicate rising infection rates among older people. With the expanding availability of ARVs, more people will be living with HIV and their needs are likely to change as they grow older. In high-prevalence countries in particular, older people are often the primary carers for their adult children who have HIV and/or children orphaned or made vulnerable by their parents' ill health or untimely death. Age-, gender- and HIV/AIDS-related stigma plays a role in older men and women being overlooked in programming.

Men who have sex with men (MSM), including gay men
Sex between men has been the predominant mode of transmission in some countries. However, it is also a factor in all HIV epidemics, though it is often statistically hidden and officially denied. In recent decades there have been significant advances in decriminalising sex between men in many countries. Nonetheless, laws that criminalise or otherwise stigmatise or discriminate against MSM are contrary to human rights law and continue to drive the spread of HIV by alienating such men from access to prevention, treatment, care and support programmes. Programmes need to be appropriate for and enable MSM to protect themselves from HIV infection and respond to discrimination. Advocacy efforts need to be directed to law reform and addressing the social stigmatisation that increases the vulnerability of MSM.

Generally, the term ‘men who have sex with men (MSM)' is used throughout the Code to include gay men. However, it is important to note that the needs and experiences of gay men and men who have sex with men but who may not identify as gay are different and require responses that are appropriate to those differing needs and experiences.

Sex workers and their clients
The stigma associated with sex work in many countries around the world creates significant barriers to sexual health and HIV prevention efforts among sex workers and their clients. While sex work has been decriminalised in some countries, it remains illegal in many more. Even where knowledge about safe sex practices is high among sex workers, the prevailing power dynamics, entrenched by gender, legal and social inequities, make it difficult to put that knowledge into practice. With this in mind, programmes, services and advocacy efforts need to be appropriate for sex workers and their clients. Strategies are required to promote an environment which supports access to treatment for HIV and other sexually transmitted infections (STIs). Supporting sex workers, including through collective action, empowers them to negotiate transactions, and address the health and social contexts that increase their vulnerability to HIV infection.

People who inject drugs
HIV transmission through injecting drug use accounts for approximately 10 per cent of HIV infections globally and is a dominant factor driving HIV infection rates in many countries. Injecting drug use is a major factor in epidemics in Asia, North America, Western Europe, parts of Latin America, and in the Middle East and Northern Africa. In some Eastern European countries, especially the countries of the former Soviet Union, injecting drug use is driving an epidemic among young people.

The illegality and stigma associated with injecting drug use invariably lead to discrimination against people who use drugs and create barriers to accessing services. Failure to protect the human rights of people who inject drugs makes them afraid to access health and related support services, leading to negative health outcomes and undermining HIV prevention efforts. A comprehensive range of services and programmes is needed in order to respond effectively to the harms associated with injecting drug use, including education programmes that reduce the risk of HIV infection among those who inject drugs (as well as those that deter people from drug use), access to clean needles and syringes, drug treatment programmes, and appropriate health care services. Concerted efforts must be made to ensure support for, and availability of, the full complement of services and programmes that reach and involve people who inject drugs.

Transgender people
Transgender people face stigma and discrimination, which exacerbate their HIV risk. There are few transgender-sensitive HIV programmes. Social marginalisation can result in the denial of health, education, employment and housing opportunities. Access to treatment, care and support is often limited due to fear of a person's transgender status being revealed, lack of knowledge about the health care needs of transgender people, and discrimination.

Prisoners
Correctional facilities, such as adult gaols and juvenile detention centres, are commonly characterised by concentrated populations of people living with HIV/AIDS, where injecting drug use, tattooing and consensual and forced sex commonly occur, in an environment where there is limited and often no access to the means of preventing the spread of HIV or to education programmes on HIV prevention. This has significant consequences not only for prisoners themselves but also for the families and communities to whom they return, often after relatively short terms of imprisonment. Attempts to reduce drug use by mandatory drug screening have often had counter-productive results. Programmes need to address the specific risks of HIV infection in prisons and meet the often complex health needs of prisoners, including those living with HIV/AIDS.

Mobile populations: internally displaced people, refugees, migrant and mobile workers
The spread of HIV across communities, countries and continents is testimony to linkages between population movement and the growing epidemic. There is increasing recognition that the mobility of people, whether displaced by conflict or natural disasters, or to access work, can create particular kinds of vulnerability to HIV/AIDS and its consequences. People move, voluntarily and involuntarily; temporarily, seasonally and permanently. 

Mobility increases vulnerability to HIV/AIDS, both for those who are mobile and for their partners back home. Migrant and mobile workers are often more vulnerable to HIV infection because of isolation resulting from stigma and discrimination and differences in language and culture; separation from regular sexual partners; lack of support and friendship; and lack of access to health and social services. Where these factors are combined with lack of legal protection, vulnerability to HIV infection is further increased. Effective responses to the vulnerability of mobile populations must include cross-border and regional responses, involving partners in source, transit and destination countries; culturally and linguistically appropriate outreach programmes; and advocacy efforts to protect and promote the human rights of, and where necessary improve the legal status of, migrant and mobile workers.

At the end of 2001, over 70 different countries were experiencing an emergency situation of some kind, resulting in over 50 million people being affected worldwide. The conditions that arise in emergencies such as armed conflict and natural disasters - social instability, poverty, displacement of populations, gender-based violence - are also the conditions that favour the spread of HIV infection. There is increasing recognition that humanitarian programmes need to both integrate HIV-specific responses, such as making condoms available, and adapt interventions to better address the underlying causes of vulnerability to HIV and its consequences in emergency settings