House of Commons - International Development

Select Committee on International Development Second Report

3 Marginalised groups

12. According to much of the evidence we received, four groups, which UNAIDS terms the "four key populations" — sex workers, men who have sex with men, injecting drug users and prisoners — are 'driving' epidemics. The DFID submission notes:

"Responding to the needs of marginalised groups is not only important in itself, it is often key to halting emerging epidemics, which usually start with concentrations of HIV prevalence in certain groups. These concentrated epidemics … can then spread beyond these contained groups to the wider population. Once HIV moves beyond marginalised groups, countries may face a mixed-, generalised- and ultimately hyper-epidemic where HIV can spread exponentially as can be seen in many southern African countries."[34]

13. While such evidence underlines the importance of reaching these groups, we are concerned that, as UNAIDS told us, national and multilateral programmes often do not succeed in doing so.[35] In oral evidence, UNAIDS gave the example of countries in western Africa where 95% of people are infected through paid sex although only 5% of the national AIDS budget targets sex workers.[36]This view was supported by evidence from the International Planned Parenthood Federation (IPPF):

"In many settings HIV is concentrated within specific populations … and is not generalised across the population. Despite this, resources to combat the HIV epidemic are frequently used in programmes aimed at the general population."[37]

Human rights of marginalised groups

14. There is significant social stigma attached to HIV/AIDS and this often overlaps with stigma towards, and at times official denial of, marginalised groups. IHAA told us that "marginalisation, discrimination, stigma and invisibility fuel HIV infections for these groups which makes them much more vulnerable … [and unable] to access services".[38] In effect, marginalised groups are therefore doubly vulnerable to the impact of HIV/AIDS. The UNAIDS 2006 Report says:

"Ending the AIDS pandemic will depend largely on changing the social norms, attitudes and behaviours that contribute to its expansion. Action against AIDS-related stigma and discrimination must be supported by top leadership and at every level of society, and must address women's empowerment, homophobia, attitudes towards sex workers and injecting drug users."[39]

15. Of the 126 countries who contributed national reports to UNAIDS in 2006, over half acknowledged the existence of policies that interfere with the accessibility and effectiveness of HIV prevention and care measures, such as laws criminalising consensual sex between men or which drive the sex industry underground, and policies limiting or prohibiting condom and needle access in prisons. According to a FCO-funded study conducted by Naz Foundation International (NFI) on policies in South Asia:

"Prevalent social attitudes and beliefs often inform governmental policies for combating HIV/AIDS. Therefore, while the health ministries of South Asian countries advocate work with MSM [men who have sex with men] to reduce the spread of HIV, the home ministries often persist with promoting laws that criminalise homosexual behaviour."[40]

16. Against this background, tackling HIV effectively emerges not simply as a question of prevention and treatment but also of human rights. As the Secretary of State for International Development said at the UN in June, "We need to recognise that tackling AIDS is not only about money. It's also about culture and social attitudes."[41] The DFID submission expands on this point:

"There are… both human rights and public health rationales for countries facing emerging epidemics to take immediate action to reduce vulnerability to HIV in marginalised groups... Reaching these groups is vital to halting emerging epidemics; it is also their human right to receive the AIDS services they need."[42]

17. The evidence from IPPF, NFI and IHAA emphasises the importance of developing HIV prevention and care strategies "within a human rights framework".[43] This is often termed a 'rights-based approach' or an approach which emphasises non-discrimination and attention to vulnerability and empowerment. Evidence from IHAA referred to the case of Cambodia, where community-based advocacy groups took a rights-based approach to persuade the Government that not only did marginalised groups exist but that they were key to an effective national response to the epidemic.[44]

18. We believe that programmes which address the drivers of epidemics, rather than generalised programmes, will be most successful in combating the spread of HIV/AIDS. Social and legal barriers to effective prevention and treatment programmes for key groups need to be addressed in some countries to ensure successful implementation of national HIV/AIDS strategies. We support such a rights-based approach and recommend that DFID ensure that all national programmes it supports address stigma and discrimination to prevent further marginalisation of those at highest risk of infection. We recommend that, as well as continuing to make these points bilaterally and internationally, DFID make specific efforts to encourage the repeal of restrictive policies, at both domestic and international level, that impede effective services.

Advocacy in international forums

19. The UN high-level meeting in New York this year was an opportunity to put the rights and needs of marginalised groups at the heart of the international community's response to HIV/AIDS.[45] In the event, negotiations did not deliver such a message and the declaration emerging from the meeting remains largely silent on this point. In that context, the evidence from IHAA highlighted an opportunity for the UK:

"The international community at the UN is not at a point of agreement around an international declaration, for instance, or a new convention on the rights of sexual minorities, but what I think the good offices of the British Government could do is work with countries on a bilateral basis to generate greater community interest and political will aimed at securing greater recognition of the special needs of sexual minorities in the international community and the UN in particular."[46]

In specific terms, IHAA made the case for a UK Special Representative to look at these issues, modelled on the UK Special Representative for Climate Change, and for a UN Special Rapporteur on HIV/AIDS and Human Rights.[47] The international community will need to keep under review the scope for, and value in, more bilateral and multilateral institutions to deal with HIV/AIDS advocacy.

20. A series of initiatives will be necessary to maintain momentum towards achieving the challenging targets for tackling HIV/AIDS. DFID should remain open-minded about this and should keep under review the case for further bilateral and multilateral representatives to push for progress in neglected areas of HIV/AIDS advocacy.

Better policy-making through engagement with marginalised groups

21. Some of the evidence we received points to pitfalls in designing and implementing targeted programmes. World Vision's evidence notes that "In most cases, the risks faced by marginalized groups are compounded by virtue of the fact that they belong to more than one 'risk group'".[48] According to IPPF, this overlapping "has implications for how services and information are designed, in that they need to reflect this complexity. Categorising of individuals… [can lead to] stigma and discrimination — where 'groups' become identified as 'vectors for transmission' rather than as individuals".[49]

22. DFID and NGOs provided examples of how support for involvement of marginalised groups in policy formulation could produce policies that better reflect the complexity of the groups, and the overlaps between the groups, being targeted.[50] This is an encouraging start. We recommend that DFID ensure that key populations are involved in policy formulation consistently across the range of programmes that DFID designs, implements and funds. We also recommend that DFID ensure that its partners, whether NGOs or national governments, support the involvement of people living with HIV and AIDS and marginalised groups in guiding governments and NGOs in their policy-making and in providing the right services.

34 Memorandum submitted by DFID, para 15 Back

35 UNAIDS, 2006 Report, pp 14-15 Back

36 Q 8 [Dr Anindya Chatterjee] Back

37 Memorandum submitted by International Planned Parenthood Federation, para 4.2 Back

38 Q 5 [Mr Joseph O'Reilly] Back

39 UNAIDS, 2006 Report Back

40 NFI, From the Front Line, www.nfi.net Back

41 Memorandum submitted by DFID, para 28 Back

42 Memorandum submitted by DFID, para 16 Back

43 Memorandum submitted by International Planned Parenthood Federation, para 2 Back

44 Q 11 [Mr Joseph O'Reilly] Back

45 UN General Assembly Special Session on HIV/AIDS, June 2006, http://www.un.org/ga/aidsmeeting2006 Back