In every region of the world, there are key populations who are particularly vulnerable to HIV infection. One of the key populations is transgender women, who are at 34 times greater risk of acquiring HIV than other adults.

Discrimination, abuse, harassment and violence are distressingly common experiences for transgender people. They often face, from a young age, stigma, discrimination and social rejection in their homes and communities for expressing their gender identity. Such discrimination, violence and criminalization prevent transgender people from getting the HIV services they need to stay healthy.

Transgender women who also are involved in sex work are even more likely to be subjected to such treatment, as shown in a study from the Dominican Republic.

The prevalence of discriminatory attitudes towards people living with HIV varies widely. Across nearly all regions, there are countries where large proportions of adults continue to hold discriminatory attitudes towards people living with HIV.

In 52 of 58 countries with recent population-based survey data, more than 25% of people aged 15 to 49 years reported holding discriminatory attitudes towards people living with HIV, and more than 50% held discriminatory attitudes in 36 of 58 countries.

Discriminatory experiences within health-care settings can be especially common and pernicious. Country data reported to UNAIDS show that the proportions of people belonging to key populations who avoid health-care services due to stigma and/or discrimination remain disconcertingly high. Across all key populations, at least one in three reporting countries stated that more than 10% of respondents avoided health care, including three in four countries for people who inject drugs.

Removing laws that harm, such as laws on sex work, same-sex sexual relations, the use or possession of drugs for personal use and the non-disclosure, exposure or transmission of HIV, is one way of overcoming stigma and discrimination and hence increasing the uptake of services by key populations.

Sexual activity often starts during adolescence. Many countries have age of consent laws in relation to sexual activity that are inconsistent with minimum age laws for accessing sexual and reproductive health information and services without parental permission. This means that adolescents may legally have sex before they can legally access any information or services relating to safer sex practices or contraception, leaving them at greater risk of HIV, other sexually transmitted infections (STIs) and unwanted pregnancy.

The removal of laws that require parental permission to access services for sexual and reproductive health and HIV prevention, testing and treatment has been shown to improve health-seeking behaviours. That effect is even stronger when schools can provide age-appropriate comprehensive sexuality education to young people so they can protect themselves from HIV, STIs, unwanted pregnancy and gender-based and sexual violence.

Forty countries reported to UNAIDS in 2021 that they have laws requiring parental/guardian consent for adolescents to access hormonal or long-lasting contraceptives, 108 reported that this consent is required for an HIV test, 43 for HIV self-testing, 92 for HIV treatment and 22 for PrEP. Among these countries, some provide exceptions based on demonstrated maturity: 10 for hormonal or long-lasting contraceptives, 15 for HIV testing, eight for self-testing and nine for HIV treatment. The age cut-off of parental consent laws varied by service. The majority of countries that reported having requirements for parental/guardian consent had an age cut-off of 18 years, with exceptions in a few countries where adolescents as young as 14 years could access a service without parental/guardian consent, which varied by service. 

Globally, the testing and treatment targets for 2020 were almost reached among adult women (15 years and older) living with HIV. Men living with HIV, however, are consistently faring worse than women across the HIV testing and treatment continuum. Compared to women living with HIV, there are 740 000 more men living with HIV who do not know their HIV status, 1.3 million more men who are not on treatment and 920 000 more men who are not virally suppressed.

While gender norms that prize male strength and stoicism may partly explain why many men delay seeking care, other factors are also at play. Primary health-care services in eastern and southern Africa place a great deal of focus on women of reproductive age, and reproductive, maternal and child health services offer ideal entry points for HIV services; similar entry points for men are not commonplace. Interventions to reach and include men more successfully in HIV testing and treatment services are increasing—including through workplace-based interventions and greater use of self-testing approaches, and by providing services at outpatient departments—but a more finely-tuned understanding of why men's use of HIV services continues to lag can help shape additional ways to close this gap.

The UNAIDS Key Populations Atlas is an online tool that provides a range of information about members of key populations—sex workers, gay men and other men who have sex with men, people who inject drugs, transgender people and prisoners—worldwide, together with information about people living with HIV.

Information about gay men and other men who have sex with men has been expanded with the inclusion of 11 new indicators from the EMIS and LAMIS projects. Under funding from the European Commission, EMIS-2017 collected data from gay men and other men who have sex with men in 50 countries between October 2017 and January 2018. LAMIS is the Latin American version of EMIS and finished data collection across 18 additional countries in May 2018.

The 11 new indicators shown in the Key Population Atlas—on syphilis, symptomatic syphilis, gonorrhoea, symptomatic gonorrhoea, chlamydia, symptomatic chlamydia, sexually transmitted infections testing, syphilis partner notification, gonorrhoea partner notification and hepatitis A and B vaccination—were chosen because of their high relevance to the communities.

Community-led and community-based infrastructure is essential for addressing the inequalities that drive pandemics such as the AIDS and COVID-19 pandemics, as well as for ensuring the continuity of health services and protecting the rights and livelihoods of the most vulnerable. The EMIS and LAMIS findings will be important for informing civil society organizations working on sexual health, HIV prevention and sexual minority rights and for policymakers, non-community prevention planners, epidemiologists and modellers.

“To leave no one behind, we need people-centred data collection that spotlights the inequalities that are hampering access to services. It is critical to understand who are the most affected and unable to access services. This will enable the European Commission, European Union Member States and civil society and community organization alike to address the specific needs of gay men and other men who have sex with men,” said Jantine Jacobi, the UNAIDS representative to the European Union.

Civil society and community-based organizations, especially those led by key populations, can complement traditional health systems’ pandemic responses, but this requires that they be treated as full partners—involved in governing, designing, planning and budgeting pandemic responses––with the technical and financial support to do so effectively.

The findings of the new indicators will help to increase the role of partnerships and communities across each country and will serve as the basis for decision-making and policy planning. For example, in Ireland, the EMIS-2017 National Report acknowledges that, “there has been an increase in HIV and STI testing compared to previous surveys and this is in some part due to the positive interventions carried out by stakeholders and the MSM [men who have sex with men] community in response to findings from previous surveys. Some of these positive interventions in relation to HIV testing can also be attributed to the increased availability of community testing.”