A UNAIDS analysis published in the journal BMJ Global Health found that countries that discriminate on the basis of sexuality, sex work and drug use had consistently lower HIV diagnosis rates and fewer people achieving an undetectable viral load compared to those with laws that support human rights.

Matthew Kavanagh, PhD, of the Department of International Health at Georgetown University, and colleagues conducted a cross-sectional analysis of UNAIDS data released in July 2020. The UNAIDS 90-90-90 goals for 2020 call for 90% of people living with HIV to know their status, 90% of them to be on treatment and 90% of those to have an undetectable viral load. But UNAIDS announced last year that very few countries had reached these targets. New York City was the only place in the United States to achieve these goals.

The researchers looked at 90-90-90 data and cross-referenced it with each country’s policies related to same-sex relationships, drug use, sex work and, in a fourth category, all three. Countries where such laws had changed substantially were dropped from the analysis. Then they looked at progress to 90-90-90 in countries with laws that protect people from such discrimination as well as protect people from gender-based violence.

When it came to knowing one’s status, people living with HIV in countries that criminalized same-sex relationships or sexual behavior were 11% less likely to know they were living with HIV, people who lived in countries that criminalized sex work were 10% less likely to know their status and people in countries that criminalized drug use were 14% less likely to know their status. When the researchers controlled for HIV prevalence and government health care spending, only same-sex criminalization laws were still associated with lower HIV diagnosis rates. The other kinds of discrimination were still linked to lower diagnosis, but the association was no longer statistically significant.

Similarly, people in countries that discriminated based on sexuality, sex work or drug use were less likely to achieve an undetectable viral load, with rates of viral suppression being 8%, 6% and 15% lower, respectively.

By contrast, people who lived in countries with nondiscrimination protections were 10% more likely to know their status and 11% more likely to achieve viral suppression. What’s more, people in countries that prosecute gender-based violence were 16% more likely to both know their status and have an undetectable viral load.

The study didn’t look at the impact of misogynistic, transphobic, racist or xenophobic policies on viral suppression. Nor did it look at laws specifically criminalizing HIV status. Because it looked internationally, it did not study differences in viral suppression between states that have more discriminatory policies versus states with more inclusive policies. And while the associations seemed strong, the study couldn’t determine whether the laws caused the changes in HIV diagnoses or viral suppression.

“This study finds little support for the argument that criminalizing behavior among marginalized people in a pandemic results in positive outcomes,” wrote Kavanagh and colleagues. “This is an important point of departure for future analyses in the era not just of HIV but the COVID-19 pandemic, tuberculosis and many other contexts."

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