Earlier this year, we had the privilege of working with the Elton John AIDS Foundation to help refresh its grant making strategy. The new strategy builds on twenty years of experience to focus even more clearly than before on reaching the most vulnerable and marginalized populations, such as commercial sex workers, men who have sex with men, injecting drug users alocand transgendered men and women.
The need to reach these groups is unarguable. They often face a significantly heightened risk of infection with HIV, and those that are already HIV-positive can suffer disproportionately, due to a toxic combination of poverty, discrimination and poorly-adapted services. In a world that is seeking zero new infections and zero deaths, reaching these “most-at-risk populations” (MARPs) is essential.
We already know a lot about what needs to be done. Groups such as the WHO, amfAR, the International Harm Reduction Alliance, and the Global Forum on Men who have Sex with Men and HIV, among many others have done great work in documenting more than 20 years of effective approaches, and a rich evidence base is available. Despite this, efforts focused on MARPs are woefully under-resourced, especially in the highest-burden countries. UNGASS reports that in countries with generalized epidemics, less than 1% of funding is devoted to MARPs. National HIV-prevention budgets are often heavily skewed away from MARPs, while the proportion of Global Fund resources focused on these populations has fallen from almost a third in 2007 to around 14% last year. Philanthropic funding for MARPs follows a similar pattern.
There are three interrelated reasons for this:
- Basic data on MARPs are often unavailable, rendering the scale and nature of the problem invisible to policymakers. For example, despite small-scale studies suggesting that transgendered women are between three and nine times more likely to be HIV-positive then men who have sex with men, simple indicators such the HIV prevalence rate are not systematically measured and reported.
- Ingrained discrimination on the part of policymakers and service providers reduces MARPs’ access to services and often means that services that are available are poorly-adapted. Witness, for example, the lack of harm reduction programs in high-burden locations such as Russia, despite the fact that robust evidence has been available for more than a decade that such programs have a measurable impact on a country's HIV burden.
- The needs of MARPs are often more complex than those of other populations. People may exhibit multiple risk behaviors (e.g., commercial sex workers that also inject drugs), and high levels of social marginalization may mean that a coordinated, multi-agency response is needed.
This presents the AIDS community with a challenge—science alone will not solve these problems. What is called for is rather the slow, messy work of highlighting needs, persuading power brokers of the need to act, and coordinating localized responses. That's an uncomfortable place for actors used to wielding big budgets on regional and global programs. But, if we are to realize the vision of zero deaths and zero new infections, it is a challenge to which we must rise.