Addressing HIV-related inequalities: the new frontier in the HIV response

December 1, 2022


Elizabeth Kemigisha

Post-doctoral Research Scientist


World AIDS day serves to remind us about the toll of HIV- those who have died, the sick and affected and gives us an opportunity to reflect on what we need to do to make things better. This year’s theme, “Equalize”, is carefully selected to help  various actors to refocus their attention on inequalities for better results. “Equalize” is a clarion call to address the inequalities holding back progress in ending AIDS. For a while now, it has been well-known and understood how HIV-related inequalities are driving pandemics. Indeed, the Global AIDS Strategy, the five-year road map to guide the global HIV response, highlights and gives prominence to the issue of inequalities and why they need to be addressed. As the HIV epidemic evolves, so should the response.

In practical terms, what does “addressing HIV-related inequalities” or “Equalize” mean? There are differences in risk of exposure to HIV perpetuated by societal norms, unfavorable laws, gendered biases, stigma and discrimination, place of residence, socio-economic status, and access to services. The inequalities along these lines permeate communities within the local, national as well as regional contexts. Currently, the toolbox for cost-effective interventions against HIV is richer with wider options. The continued support by Global Fund, PEPFAR, and other funders, as well as commitments from national governments, have ensured that lack of essential drugs and supplies are not the main drivers of inequalities but rather reaching those at risk.   Within the framework of the national HIV response and the local context, appropriate interventions need to be identified to mitigate and remove the inequalities whose continued existence facilitates  HIV transmission and or limit access to information and services. The “equalize” call envisages a situation whereby if we continue doing business as usual, we are unlikely to achieve our goals in the context of reducing global financing, economic crises, and other emerging health priorities such as the COVID-19 pandemic. We need to deliberate and identify local gaps and drivers of the epidemic, identify cost-effective approaches and tools and implement them while continually evaluating, and adjusting the response. To facilitate this process, UNAIDS, with support from APHRC and the University of Southern California (Institute on Inequalities in Global Health) is developing an HIV-related inequalities framework and toolkit to support countries in understanding, identifying, and responding to various HIV-related inequalities wherever they occur. 

Identifying and acting on HIV-related inequalities will not be straightforward  for various reasons:

  1. Data availability
  2. Financial and human resources
  3. Willingness to act- political will and leadership

Data: Often, HIV-related inequalities are not obvious based on official data, which might hide the differences in indicators at local, regional, and national levels. Presenting disaggregated data by various potential inequalities parameters are important, but this is not always done or possible. There is a need for deliberate in-depth dive-deep analyses of existing service, program and survey data to look for inequalities. For this to happen, there is a need for data analysis capacity, financial resources to collect new data, and the use of non-traditional data, including qualitative data. Access to publicly funded data from programs or research should be encouraged to increase the use and understanding of the nuances that are often hidden. As an illustration of how new data need to be generated and analyzed to inform programming, APHRC, with funding from the Bill and Melinda Foundation (BMGF), is evaluating the impact of DREAMS interventions against HIV amongst adolescent girls and young women (AGYW) in informal settlements in Nairobi and Kisumu. These two geographies are known to have a higher burden of HIV, while AGYW are also known to be the subpopulation with most new HIV infections. Learning from this impact evaluation will provide information on whether intended beneficiaries are receiving the intervention, the quality and quantity of intervention reaching them and whether there is a change in terms of HIV incidence as well as the risk of transmission. The learning will directly inform actions and responses to the call to “Equalize.”

Resources: Identifying and responding to HIV-related inequalities may call for additional human, financial and other resources. Countries and funders need to be prepared to invest more  in addressing identified inequalities which, if left unattended, might sustain the pandemic. On the other hand, additional resources might not be needed but reallocating, using innovative approaches and leveraging health systems synergies that other programs like the Expanded Program for Immunisation (EPI) have harnessed to sustain childhood immunization for a long period, can come to bear. 

Political will: It is imperative to appreciate that many HIV-related inequalities are driven by factors beyond an individual’s capacity to act for change. Such deterrents to equitable access to HIV prevention and care services may include legal instruments that criminalize certain behaviors, such as commercial sex work, gay sex, injecting drug use,adolescent access to contraception among others, further widening the gap to reach out to the most at-risk population. Societal norms are also powerful drivers of inequalities manifesting as differential treatment of individuals based on gender, such as access to education, forced marriages and gender-based violence. These often need political will for action. Coupled with the need for extra financing, inequalities whose effective action requires political actions may prove tough to address and yet might bring the most benefit when leadership is on board. 

Working towards achieving the 95-95-95 targets by 2030 requires collective action to “equalize” to end the AIDS pandemic. We need sustained action, find innovative ways to identify and address inequalities including structural and entrenched drivers as well leveraging the potential of strong health systems to deliver services to the most-at-risk sub-populations. Actors in the HIV response should rethink their strategies and ensure wider involvement to address inequalities in HIV prevention and treatment.