O'Neill Institute | January 24, 2024
Introduction
The HIV Language Compendium is a curated compilation of internationally agreed upon language that provides precedents for the use, proper interpretation and significance of concepts and terms crucial for an evidence-based and rights-affirming response to HIV.
Having been developed in 2021 during the UN HLM, the Compendium has now been expanded to include additional concepts. The section that follows below provides all added concepts together with the context-specific definitions for greater clarity.
Our aim is to provide a more user-friendly compendium that strengthens the capacity of civil society and key populations to understand and challenge regressive language that may be adopted in political declarations
Access to Health Products
Access to Health Products is a human right, intrinsically linked with the right to health. Under the right to health framework, health products must be available, accessible, acceptable, and of good quality. This right covers small molecule drugs, biologics, vaccines, diagnostics, and other types of health tools such as gene- and cell-therapies. While some precedents mention access to “essential medicines,” this right includes health products beyond those formally recognized in the World Health Organization (WHO) list of essential medicines. It also covers access across diseases, including HIV, malaria, tuberculosis, other infectious diseases, and noncommunicable diseases. The right to access covers products indicated for preventive and prophylaxis healthcare. Access to health products must be guaranteed during and also in the absence of emergencies.
Access to HIV treatments and other health products continues to be disturbingly uneven in many places, with poorer health outcomes for women and girls, children, minorities, indigenous populations, persons living in poverty, queer people, persons with disability, migrants, stateless persons, and others experiencing marginalization. Improving access to health products could save millions of lives every year. Intellectual property is often recognized as a critical legal barrier impeding the generic manufacture of health products, leading to lack of access and excessive pricing.
The Doha Declaration on the TRIPS Agreement and Public Health and several other subsequent precedents have recognized that the TRIPS agreement should be interpreted and implemented in a manner supportive of the right to protect public health, in particular to promote access to health products for all. Many of the precedents reflected under the term access to health products reaffirm the right to protect public health over intellectual property rights, including by making full use of the flexibilities under the TRIPS agreement and other international commitments. Nevertheless, these recognitions should only be considered as a baseline and not a ceiling.
Other policy interventions required under a right to health framework to ensure access to health products include facilitating technology transfer, enhancing local and regional manufacturing capabilities, ring fencing domestic resource allocation, and exploring and implementing alternative incentives for encouraging research and development. An increasing number of precedents are recognizing the need for these policy interventions to protect the right to health, and they are reflected in this Language Compendium under the access to health products term and also under alternative R&D models, local and regional manufacture, and technology transfer.
Bodily Autonomy and Integrity
Bodily Integrity and Autonomy refers to the human right that everyone should enjoy to take self-determined decisions over their own body. Stated otherwise, bodily integrity and autonomy is the human right that all individuals have to determine their own fate without undue policing or patronizing control over their own bodies. While bodily integrity and selfdetermination is itself a human right, it is also central to the enjoyment of other human rights principles such as gender equality and human dignity. However, bodily integrity and autonomy is often prevented by legal, social, religious, and institutional norms that prevent personal decisions over someone’s own body. Examples of these norms include “marry your rapist” laws that allow perpetrators to escape punishment if they marry their victims, denying autonomy experienced by survivors of rape. Some of these legal, social, religious, and institutional norms directly or indirectly threaten physical and mental health, or even life. These legal, social, religious, and institutional norms can significantly restrict health outcomes in fields such as sexual and reproductive rights.
Precedents reflected in the Language Compendium have recognized the resolution between bodily integrity and autonomy, and the right to health. They have recognized, for instance, that sexual and reproductive freedom, and the right to be free from interference, such as the right to be free from torture, nonconsensual medical treatment and experimentation, are intrinsically related to the human right to health. Precedents have also recognized that failure to uphold bodily autonomy results in profound losses for individual women and girls.
Combination Prevention
Combination Prevention are rights-, evidence-, and community-based programs that promote a combination of biomedical, behavioral, and structural interventions designed to meet the HIV prevention needs of specific people and communities. Combination prevention has the potential to reduce HIV infections through activities with a greater sustained impact. Examples of combination prevention programs include the focus on educating and training vulnerable groups to counsel and advocate for policy change while at the same time ensuring integrated preventative healthcare services and products. Combination prevention requires evidence-based, stakeholder driven, rights- based and inclusive programs with accountability mechanisms. While applicable for HIV, combination prevention approaches can also be used for other diseases.
Internationally agreed commitments reflected in the Language Compendium have recognized the need to increase national leadership, resource allocation, and other measures for proven HIV combination prevention, “including condom promotion and distribution, preexposure prophylaxis, postexposure prophylaxis, voluntary male medical circumcision, harm reduction, in accordance with national legislation, sexual and reproductive healthcare services, including screening and treatment of sexually transmitted infections, enabling legal and policy environments, full access to comprehensive information and education, in and out of school.”
Precedents recognizing the need to tailor HIV combination prevention approaches to meet the diverse needs of key populations have also been adopted, as reflected in the Language Compendium. International commitments to ensure by 2025 that 95 percent of people at risk of HIV infection have access to and use appropriate, prioritized, person-centered, and effective combination prevention options also exist.
Comprehensive Sexuality Education
Comprehensive Sexuality Education gives young people accurate, age-appropriate information about sexuality and their sexual and reproductive health, which is critical for their health and survival. Comprehensive sexuality education equips and empowers young people to protect themselves from HIV and other sexually transmitted diseases. Comprehensive sexuality education programs should be based on an established curriculum; scientifically accurate; tailored for different ages; comprehensive; and should be differentiated from sex education. Given the intersectionality of HIV risk factors and barriers to its prevention and treatment, there is growing recognition that comprehensive sexuality education practices must address the needs of young people & key populations and structural drivers of sexual and reproductive health. This can be achieved by ensuring culturally appropriate, community driven engagement which is tailored for a sub-group. Topics covered by comprehensive sexuality education include families and relationships; respect, consent and bodily autonomy; anatomy, puberty and menstruation; contraception and pregnancy; sexually transmitted infections, including HIV; and others.
Evidence consistently shows that high-quality sexuality education delivers positive health outcomes, with lifelong impacts. Young people are more likely to delay the onset of sexual activity – and when they do have sex, to practice safer sex – when they are better informed about their sexuality, sexual health and their rights. Yet research shows that the majority of adolescents lack the knowledge required to make decisions about their sexual and reproductive health responsibly, leaving them vulnerable to coercion, HIV infection, and unintended pregnancy.
International agreements reflected in the Language Compendium include commitments to address this gap by “accelerating efforts to scale up scientifically accurate, age-appropriate comprehensive education, relevant to cultural contexts, that provides adolescent girls and boys and young women and men, in and out of school, consistent with their evolving capacities, with information on sexual and reproductive health and HIV prevention, gender equality and women’s empowerment, human rights, physical, psychological and pubertal development and power in relationships between women and men.” Precedents in the Language Compendium also recognize that comprehensive sexuality education helps “build self-esteem and informed decision making, communication and risk reduction skills and develop respectful relationships,” enabling young people and others at risk “to protect themselves from HIV infection.”
Digital Health
Digital Health refers to the use of information and communication technologies in healthcare. Digital health includes a broad range of technologies, such as wearable devices, mobile health, telehealth, health information technologies, and telemedicine. Digital health technologies are used in a wide range of applications, from applications in general wellness to applications as medical devices. Digital health technologies include technologies intended for use as medical products, in a medical product, as companion diagnostic, or as a peripheral to medical products.
Harnessing information and communication technologies in healthcare has the potential to lower costs relating to clinic visits, travel, or unpaid sick leave. Assistive digital technologies can contribute to the fulfillment of the right to health for instance by persons with disabilities and by elders, particularly if these technologies are designed in consultation with them. Digital tools could also facilitate improved analysis of epidemiological trends, resource allocation, disease forecasting, development of novel products, monitoring, among several other possible advantages. Digital health, however, also represents several risks. Digital tools could be used, for instance, to perpetuate racism, sexism, ableism or discrimination based on sexual orientation or gender identity. Digital health tools could also be used for arbitrary and unlawful interference with the right to privacy.
Recognizing this, precedents reflected in the Language Compendium have affirmed that the same right that people have offline must also be protected online, including the right to privacy.
Gender Equality
Gender Equality is a human right. Gender equality means that women are entitled to live with dignity and freedom from fear. Gender has been identified as a critical component of HIV related programs. Evidence indicates that the patriarchal societal structure has created deep gender divides. This gender divide is then strongly associated with HIV infections and status. This can manifest as, for instance, gendered violence leading to higher risk to acquire HIV or disclosure of HIV status leading to violence and persistent violence can lead to poor adherence to antiretroviral treatment. People capable of giving birth that also have HIV status and overlapping vulnerabilities can have higher propensity to face discrimination from healthcare workers.
Addressing vulnerabilities driven by gender requires an understanding of their added risks and clear articulation of the need for gender-centric legislations and policies. International resolutions and other documents reflected in the Language Compendium highlight the need for those legislations and policies. These precedents urge States “to prevent and respond to gender-related killing of women and girls,” in accordance with their commitments and obligations under international law. International precedents have also underlined intersectionalities that create overlapping vulnerabilities for women that, for instance, have HIV status or are migrant workers.
Alternative Research and Development (R&D) Models
Industry often argues that intellectual property monopolies and reliance on high prices are necessary to incentivize the research and development of novel health products.
Some governments and other stakeholders often echo these claims. These arguments are typically raised to justify research and development models where the resulting health products, including technologies for the diagnostics, prevention and treatment of HIV, are unavailable or inaccessible to many of those who need them. Contrary to these claims, however, alternative research and development incentives models have been explored and implemented to encourage the development of health products.
Alternative R&D Models is a broad term used in the Language Compendium to refer to all alternative models for encouraging research and development that depart from a reliance on exclusive intellectual property rights and high prices. These alternative R&D models include models based on the principle of delinking funding of R&D from product prices.
Local and Regional Manufacturing
Industry often argues that intellectual property monopolies and reliance on high prices are necessary to incentivize the research and development of novel health products.
Some governments and other stakeholders often echo these claims. These arguments are typically raised to justify research and development models where the resulting health products, including technologies for the diagnostics, prevention and treatment of HIV, are unavailable or inaccessible to many of those who need them. Contrary to these claims, however, alternative research and development incentives models have been explored and implemented to encourage the development of health products.
Alternative R&D Models is a broad term used in the Language Compendium to refer to all alternative models for encouraging research and development that depart from a reliance on exclusive intellectual property rights and high prices. These alternative R&D models include models based on the principle of delinking funding of R&D from product prices.
Local and Regional Manufacturing
Local and Regional Manufacturing broadly refers to the manufacture of health products at the local or regional levels, particularly in low- and middle-income countries. Health products encompass a wide range of health products including small-molecule drugs, biologics, vaccines, diagnostics, and cell- and gene-therapies. Enhancing local and regional manufacturing capacity is increasingly being recognized as necessary to ensure equitable access to health products. Enhancing local and regional manufacturing can also increase health system resilience and reduce dependence from foreign industry and political powers. Local capabilities can be enhanced with interventions that include public, private, and philanthropic manufacturers.
Strengthening the capacity to manufacture health products locally or regionally often requires building physical infrastructures, increasing technical skills, improving regulatory environments, public procurement, non-exclusive intellectual property licensing, and open sharing of knowledge. The occurrence of these types of interventions is driven by legal and policy frameworks, as well as political will for instance to increase domestic investments and other national efforts. Long term and sustainable local and regional manufacturing capability can be created by strengthening research and development capabilities.
Several initiatives are underway to strengthen local and regional capacities to manufacture health products, many of them motivated by global inequitable distribution during the COVID-19 pandemic. As reflected in the Language Compendium, several international precedents have called for support to these and other initiatives to strengthen local and regional manufacturing.
Gender Identity and Expression
Gender Identity refers to each person’s internal and individual experience of gender. People have their own sense and right to decide whether they want to be a woman, a man, both, neither, or anywhere along the gender spectrum. Gender identity may be the same or different from birth-assigned sex. Gender identity refers to how a person publicly expresses or presents their gender. Gender can be expressed through behavior and outward appearance, including dress, hair, make-up, body language, and voice. Pronouns are common ways of expressing gender. Gender Expression is separate and independent from sexual orientation and sex assigned at birth.
While globally there is an increasing acceptance of the fact that gender exists on a spectrum instead of a binary choice between man or woman, there are still many laws and policies lacking inclusive language with respect to gender-diverse populations. This perpetuates stigma and violence, predisposing gender-diverse populations to poor health outcomes and human rights violations. Failure to recognize gender-diversity populations is detrimental to control of HIV because there is a lack of sensitivity towards the needs and demands of key populations and vulnerable groups. Societal stigma leads to impoverishment and increases vulnerability. This in turn increases the propensity to be exposed to sexual violence and deprives access to healthcare and preventative services because of discriminatory treatment by the healthcare providers.
Reports by the Special Rapporteur on the Right to Health reflected in the Language Compendium recognize that to achieve a comprehensive health response to violence it is necessary to adopt “an inclusive and non-binary approach to gender and gender-based violence.” Laws, policies, programs, and services addressing gender-based violence should be “inclusive of all persons, with or without disabilities, children and adults, and should include cisgender, transgender, non-binary, queer and intersex people.”
Publicly Funded Research
Publicly Funded Research covers precedents recognizing that public and philanthropic entities make significant contributions to the development of novel health products. Public and philanthropic contributions represent a significant portion of the funds that support research and development for new health products. According to several accounts, the United States invested tens of billions of dollars to develop, produce, and
purchase messenger RNA (mRNA) vaccines. Moreover, seventy percent of tuberculosis research and development funding in 2021 came from public entities, with the United States National Institutes of Health (NIH) providing the largest single allocation at 354 million dollars. Public and philanthropic funding is considerable in other areas, like gene therapies. Public and philanthropic funders, however, often fail to contractually require their grantees to openly share knowledge and distribute their products equitably across the globe.
States are beginning to acknowledge these failures. Although weak, some commitments to facilitate equitable access to technologies supported by public institutions have already been adopted in precedents reflected in the Language Compendium. These commitments are only a baseline. Future international commitments and national funding policies must ensure that publicly funded research include contractual safeguards requiring affordable pricing, intellectual property licensing, and sharing of
Gender Norms and Stereotypes
Gender Norms and Stereotyping refers to the practice of ascribing specific attributes, characteristics, or roles to an individual by reason only of their membership in the social group of women or men. Specific clothes, jobs, and parenting roles, for example, are often associated with the gender identities of ‘man’ and ‘woman.’ As social constructs, these norms and stereotypes are defined and enforced by cultures, communities, and institutions, and are often used to justify discrimination against those that do not adhere to them. Gender norms and stereotyping can lead to the violation of human rights and fundamental freedoms.
Given that HIV is mainly tied to sexual health and behavior, gender norms greatly contribute to barriers to prevention, testing and treatment. For instance, in many cultures it is assumed that women will abstain from sex before marriage. Under that assumption, those seeking preventive care or testing after intercourse may be turned away or harassed because they do not adhere to this gender norm. Similarly, to encourage male HIV testing, some governments prioritize the care of pregnant people who are accompanied by male partners. Pregnant people with HIV status who do not have this gender-stereotypical lifestyle may forgo appointments, may be refused health services, or may go through labor without medical supervision. Social constructs like these can vary drastically, making key population and community leadership central to effective responses.
Internationally agreed resolutions and other precedents reflected in the Language Compendium have urged States to change “gender stereotypes and negative social norms.” Other precedents have called for prioritizing “investments into gender- transformative, community-led interventions, especially those shown to reduce both HIV and violence against women and girls.”
Harm Reduction
Harm Reduction refers to the laws, policies, and practices that seek to reduce harm associated with a particular – relatively risky behavior. Harm reduction entails substitution of a high-risk behavior with a relatively less risky behavior. This requires a comprehensive set of policies to tackle a public health challenge which might be banned or criminalized. For instance, some countries have implemented syringe exchange programs to incentivize people who inject drugs to use a new needle every time. These programs reduce chances of acquiring infections like HIV, Hepatitis B, and Hepatitis C from the use of old needles and thereby typically improve health outcomes. Other such policies include opioid substitution therapy, safe injection sites and free distribution of naloxone.
Criminalization of HIV and certain behaviors such as drug use is one of the major impediments to the implementation of harm reduction. Criminal punishment, or even the fear of facing criminal punishment, makes these policies less accessible and thereby less effective.
Effective harm reduction laws, policies, and practices are rooted in human rights as it protects individual autonomy, curtails discrimination and provides equal access to healthcare. Despite the widespread evidence of positive impact of harm reduction policies, many countries continue to fail to invest in harm reduction, retraining and sensitization of healthcare providers, and lack of community involvement while promulgating and implementing harm reduction policies.
States have recently adopted several international commitments relating to harm reduction, as reflected in the Language Compendium. These include commitments to increase national leadership and resource allocation towards harm reduction policy interventions.
Human Rights
Human Rights are rights inherent to everyone regardless of nationality, sex, national or ethnic origin, color, religion, language, or any other status. Human rights are obligations binding under international law. They range from the most fundamental – the right to life to those that make life worth living, such as the rights to food, education, work, health, and liberty.
Most precedents reflected in the Language Compendium involve or have relation to human rights. The human right section of the Language Compendium should be read in combination with several other terms, including access to health products, bodily autonomy and integrity, digital health, gender equality, gender identity and expression, key and vulnerable populations, reproductive rights, sexual rights, among others.
Intersectionality
Intersectionality refers to the recognition of the ways in which social identities overlap and, in some circumstances, can create compounding experiences of discrimination and oppression. All identities are intersectional. Race, ethnicity, gender, sexual orientation, and other traits inform the way people view themselves and are treated
in society. Intersectionality is also a key consideration in the HIV response because it can compound vulnerabilities to the HIV pandemic, or conversely, give people access to multiple sources of support. For example, gender nonconforming people who inject drugs may need more specific and intensive interventions than cisgender people who inject drugs because they face multiple types of stigma and discrimination.
In practice, accounting for intersectionality may take the following forms: conducting surveys of key populations to see what supplementary supports are needed, adding gender affirmation and racial equity modules to trainings for law enforcement and healthcare providers, providing both male and female condoms, and investing in peer outreach and education networks to engage criminalized populations. Intersectionality should be a vital consideration in both the crafting and enforcements of HIV laws and policies.
As reflected in the Language Compendium, several international documents have acknowledged that “individuals can hold multiple identities across different spectrums” and that individual experiences of these identities are “interconnected.” “Importantly, the complex intersections between the structural barriers which affect key populations and their gender, disability, education, race, religion and socio-economic status cannot be ignored.” Moreover, the Special Rapporteur on the Right to Health has called for an “intersectional and rights-based approach to violence that addresses the root causes of such violence, including the binary conceptualization of gender and heteronormative norms, and patriarchal, racist, ableist and capitalist oppression and determinants of health in law and practice, is urgently needed.”
Key and Vulnerable Populations
Certain populations are at greater risk of acquiring HIV and others are more vulnerable to HIV. Those populations that are at greater risk of acquiring HIV and are more vulnerable to HIV are referred to in the Language Compendium as Key and Vulnerable Populations. Many of these communities have intersecting identities, and their behaviors and identities are criminalized, discriminated against, and stigmatized. This makes them more at risk of and vulnerable to HIV. When living with HIV, people in these communities are also more likely to remain undetected, be denied healthcare, lose housing, unemployment, and be subject to further criminalization.
Recognizing that certain populations are at greater risk of acquiring HIV and are more vulnerable to HIV has several legal, policy, and practical implications. Biomedical, social and legal responses to HIV need to serve and uplift key and vulnerable populations. Uplifting these communities is crucial for improving equitable health outcomes, protecting their human rights and responding effectively to HIV. This has been substantiated in several international precedents. Precedents reflected in the Language Compendium recognized the need for tailoring HIV combination prevention approaches “to meet the diverse needs of key populations, including among sex workers, men who have sex with men, people who inject drugs, transgender people, people in prisons and other closed settings and all people living with HIV.” Language reflected in international documents also highlight the need to eliminate stigma and discrimination in healthcare settings, ensure access to combination prevention, treatment, care and support for people living with, at risk of and affected by HIV, prevent deprivation in terms of social determinants of health, liberty, autonomy and more.
Key Population and Community Leadership
People living with HIV should be placed at the center of HIV responses, represented in decision making bodies, and influence decisions that affect their lives. People living with HIV should also have access to technical support for community mobilization, strengthened organizational capacities, and leadership development. Community Leadership refers to the fact that communities should be placed at the center of responses and exercise this type of leadership. Key populations for instance must play a significant role in designing, implementing and evaluating HIV services which in turn provides the opportunity to make HIV services more people-centered. It further encourages co-creation of innovative HIV services tailored towards addressing the needs of Key Populations. Caution should be made to avoid tokenistic involvement of key populations in HIV service delivery as this diminishes authentic key population-led services delivery.
With or without official recognition, communities have often led their own responses to counter neglect, discrimination and criminalization with mutual aid strategies of community prevention, treatment and care in substitution for denied or inadequate health sector provided services as well as through advocacy and organized resistance against the laws, policies and practices which abridge their sexual and reproductive rights. Community leadership has always been and will always remain indispensable to effective responses to HIV, related and sexual and reproductive health challenges, and the drive towards universal health coverage.
Several international agreements recognizing the need to place communities at the center of HIV responses already exists and are reflected in the Language Compendium.
Negative Legal Determinants
Negative Legal Determinants refers to the recognition that laws and regulations can negatively affect health outcomes, including for people living with HIV status. This recognition is supported by an increasing body of evidence documenting the negative effects of laws, regulations, and policies on health outcomes including by impeding access to healthcare, frustrating community response and further stigmatizing the marginalized groups. The term negative legal determinants is a broad term and includes laws, regulations, policies, practices, among other legal determinants. These can be enacted by national governments, regionally, or through sources of international law. Negative legal determinants include laws that criminalize, punish, or discriminate against people living with HIV or other health conditions.
Populations that are key and vulnerable to HIV are stigmatized and subjected to discriminatory treatment because of societal reasons but also through their interaction with legal systems. Despite the evidence on the impacts of such policies, stigmatization and discrimination including through criminalization of sex work, homosexuality, and injection of drugs continues to exists.
Positive Legal Determinants
Positive Legal Determinants refers to the recognition that laws and regulations can positively affect health outcomes, including for people living with HIV status. This recognition is supported by an increasing body of evidence documenting that positive effects that law, regulations, and policies can have on health outcomes including by facilitating access to healthcare, empowering community response, and protecting marginalized and vulnerable groups. The term positive legal determinants is broad and includes laws, regulations, policies, practices, among other legal determinants. These can be enacted by national governments, regionally, or through sources of international law. Positive legal determinants include laws consisting of inclusive legal policies and institutional reforms which have the capability to ensure justice along with equitable health outcomes. Law and policy can enable great strides in the fight against HIV/ AIDS. When decision-makers recognize, support, and decriminalize key programs and populations, they allow community-led and justice-oriented responses to flourish.
Inclusive policy stances ensure that there is less fear leading to better testing rates and adherence to antiviral therapy and hence better health outcomes. Furthermore, these policies ensure that the rights of the marginalized are not infringed and when they are there is greater space for redressal. Positive legal determinants like these can benefit entire jurisdictions by improving access to health services, enforcing the human right to health, and building community capacity.
Reproductive Rights
All individuals have a human right to control decisions regarding contraception, abortion, sterilization, and childbirth. Reproductive Rights refer to that freedom. As a threat to sexual and reproductive health, the HIV pandemic is shaped by the comprehensiveness and enforcement of reproductive rights. Integration of sexual and reproductive services with HIV preventative and curative services is key to every stage of the global HIV response. This integration is especially important for key and vulnerable populations with intersectional disadvantages, which includes women who inject drugs, who are exposed to partner violence, and who are deprived of housing.
Reproductive rights mandate the integration of abortion-related care, consistent condom use, promoting pre-exposure prophylaxis, access to information and care to reduce vertical transmission like access to antiretroviral during pregnancy, Caesarean section, and limited breastfeeding with voluntary HIV testing and counselling. This integration is essential to ensure that every individual has the ability to make independent, informed, and confidential choices about one’s sexual and reproductive health. To achieve this, the entire reproductive health and HIV ecosystems have to cooperate with one another achieving harmony between a sensitive and synergized health sector with gender-sensitive and rights-based political climate. Communities must come together to ensure that the needs of the key and vulnerable populations are met.
Precedents in the Language Compendium call for the repeal of discriminatory laws and policies that increase women and girls’ vulnerability to HIV and to address violations of their sexual and reproductive health and rights. The Language Compendium also reflect precedents recognizing that sexual and gender-based violence, including intimate partner violence, the unequal socio-economic status of women, structural barriers to women’s economic empowerment and insufficient protection of the sexual and reproductive health and reproductive rights compromise the ability of women and girls to protect themselves from HIV infection and aggravate the pandemic. These precedents also call for increasing national leadership, resource allocation, and other measures to enhance, among others, sexual and reproductive healthcare services.
Sex Characteristics
Sex Characteristics are physical traits, such as reproductive organs and hormonal patterns, as opposed to gender identity and expression or sexual orientation. Individual sex characteristics often do not conform to those of ‘male’ or ‘female’ – such as those of intersex and epicene people. People with sex characteristics that do not conform to binaries are at risk of being excluded from sex-specific HIV policies and programs. Accounting for diverse sex characteristics is key towards universal access to quality sexual and reproductive health.
For example, penile condoms may be unusable for people who have undergone genderaffirming surgeries, so distributing them will have a limited impact on HIV prevention. Intersex people may also require services and resources that are not included in traditional AIDS responses; these can be addressed by adding to trainings for healthcare providers and creating intersex-specific HIV support groups, among other measures. Including people with diverse sex characteristics contributes to advancing a universal, right-based HIV response.
Sexual Orientation
Sexual tendency towards another person is called Sexual Orientation. Sexual orientation could be to the opposite sex, the same sex, or both. No one shall be discriminated against on the basis of sexual orientation. Under the international human rights framework, sexual orientation is an integral concept of sex; a state is obliged to respect, protect, and fulfill any rights enjoyed by people without distinction of any sex and sexual orientation. However, in some countries, cultural, societal, and institutional discrimination based upon sexual orientation remains ubiquitous. Of these, sexual orientation is often the root of verbal and physical violence. Sexual orientation may constitute the cause of criminal charges, torture, or ill-treatment, forcing people of non-traditional sexual orientation to seek asylum and deprive them of the right to return home. Some extreme cases also show the practice of conversion therapy intending to “cure” sexual orientation. Law and policy distinguishing between individuals on the basis of sexual orientation could adversely label their identity and further exacerbate the conundrum facing them.
Sexual Rights
Sexual Rights are a subset of human rights that implicate gender and sexuality. Sexual rights include protections against violence and discrimination in sexual situations and based on sexual orientation, as well as access to reproductive health information, preventive care, and treatment. Violations to sexual rights can be direct, such as through sexual assault and harassment, or indirect, like in the form of anti-LGBTQIA+ laws that enable stigma and discrimination. Both the experience and anticipation of these abuses can lead to mental illness, physical disability, incarceration, and social ostracization, among other effects. These effects derived from the violation of sexual rights can be uniquely traumatizing and consequential.
Sexual rights are fundamental to asserting and maintaining reproductive health. Respectively, these can influence risks of HIV exposure, willingness to undergo HIV testing, and ability to seek out and adhere to quality HIV treatment. Unless and until people can be assured their sexual rights are protected, HIV programs and policies may be unable to fully support them.
Societal Enablers
Right-based HIV responses are driven by structural factors, including political commitments and advocacy, laws, policies, practices, community mobilization, stigma reduction, local responses to change the risk environment, among other factors. These are referred to here as the Societal Enablers – they enhance the effectiveness of HIV programs by removing impediments to service availability, access and uptake at the societal level. The UNAIDS Strategic Framework 2020-2025 further provides for societal enablers as: a) Societies with supportive legal environments and access to justice; b) Gender equal societies; c) Societies free from stigma and discrimination; and d) Coaction across development sectors to reduce exclusion and poverty. Social enablers may take the form of any top-down or socially imposed influence on sexual and reproductive health, such as positive legal determinants and social norms like gender equality. Since they can greatly affect the health and well-being of entire populations, societal enablers can and should be leveraged in the global fight against HIV. Many barriers to HIV testing and treatment are societal, so structural measures must be taken to counter them.
Other societal enablers are more nuanced and intersectional. Sexism and homophobia, for instance, can manifest in a range of factors like violence, microaggressions, and lack of representation in HIV programs. In response, societal enablers like community grants and awareness campaigns should be employed to support disenfranchised groups and combat social stigma. Societal enablers are most effective when they are tailored to specific countries, communities, and key populations. If they are overly broad or impractical to implement in a given context, societal enablers may have little-to-no impact on people’s sexual and reproductive health. Community leadership is therefore fundamental to developing laws and policies that respond to people’s lived experiences of specific social barriers.
Stigma and Discrimination
Stigma refers to negative stereotypes or assumptions about people. When stigma translates into actions that exclude, disenfranchise, or harm people is called Discrimination. For example, the stigma that people who inject drugs are unreliable could translate to the discriminatory action of unjustifying terminating their employment. Many types of stigma are rooted in and propagated by cultural and social norms, like rigid gender norms and stereotypes. Discrimination can be codified into laws and policies, like the criminalization of sex work and the LGBTQIA+ community. Together, stigma and discrimination may lead to violence, humiliation, trauma, denial of life-saving care, social ostracization, and incarceration, among other consequences.
Key populations are especially affected by stigma and discrimination. The expectation of discrimination can be a deterrent for people seeking HIV information or testing, engaging with support groups or systems, and sharing sensitive but crucial information with healthcare providers. Even those able to access and afford support may face stigma and discrimination, since key populations are often refused care or so poorly treated that they never return.
Community-based interventions are also hampered by these obstacles. In criminalized settings, for example, it can be difficult to find trustworthy, confidential resources or engage people who expect their human rights will be violated. But key population leadership is crucial to rightsbased responses to stigma and discrimination – not only do they vary drastically by community they also manifest in lived experiences and require carefully tailored responses.
Universal Health Coverage
Universal Health Coverage refers to the ambition of communities and countries in which everyone can access quality healthcare without great financial burden. All United Nations Member States have expressed support for universal health coverage, even if their political commitments vary in scope and nature. Universal Health Coverage has also been recognized as a first step in realizing the human right of everyone to the highest attainable standard of health.
Universal Health Coverage is critical to the HIV response. Some of the greatest drivers of the HIV pandemic involve the inaccessibility and unaffordability of medical care for key and vulnerable populations. These include the costs of pre-exposure prophylaxis, condoms, and antiretroviral therapy; legal and discriminatory barriers, like being refused care; and a lack of health information that addresses key populations’ unique risk factors and needs. With inclusive and duly enforced Universal Health Coverage, these barriers would be mitigated if not eliminated entirely.