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The first presentation I attended at the 20th International AIDS Conference going on this week in Melbourne, Australia, was on “hard to reach” populations. Three presenters discussed their research and programs with prisoners in the United States, people who use drugs and their sexual partners in Vietnam, and HIV patients who had stopped taking antiretroviral medicine in Mozambique. The presentations were polished and the data was compelling but I couldn’t help but feel like I was missing something fundamental: why are these populations “hard to reach”?
Prisoners by definition are pretty easy to reach. They usually can’t go very far. Similarly, drug users in Vietnam cycle in and out of forced labor camps, and the police don’t seem to have any problem finding them. The presentation on HIV patients in Mozambique was even more curious. Patients that stopped coming to the clinic were defined as “hard to reach.” But when the researchers went into the community, they quickly found more than three of four of these patients.
Although I was jet-lagged, it seemed to me that by labeling these folks “hard to reach,” we were essentially blaming them for our failure to provide appropriate HIV prevention and treatment services.
In two decades of work on HIV and human rights, Human Rights Watch has documented the experiences of individuals living with HIV around the world as they confront discrimination in healthcare settings, employment, and housing, and face violence in their homes and communities. We have documented the consequences of rape, violence, and arbitrary arrests on vulnerable groups like drug users, gay and bisexual men, sex workers, and prisoners. Our research has shown how these injustices, often based in laws and policies, facilitate HIV transmission and reduce access to lifesaving treatment.
We have found that it is not the individuals at risk of HIV infection who are hard to reach. It’s the politicians and policymakers who adopt ideological rather than evidence-based programs.
But HIV researchers too seem to be hard to reach at times, failing to investigate political determinants of health, and the impact of laws, policies, and enforcement on HIV vulnerability and access to care.
The development of an explicit political epidemiology – the impact of politics and political determinants (laws, policies, and enforcement) on health behaviors and outcomes – would highlight, for example, how high levels of police harassment and abuse, discriminatory laws and practices, and policies that deny prevention services increase vulnerability to HIV infection, impede access to treatment, and increase AIDS morbidity and mortality. It would also improve our understanding of how human rights abuses impact health outcomes.
This approach would no longer blame prisoners, drug users, and HIV patients for hiding in plain sight. Instead, it would increase pressure on policymakers to ensure that access to evidence-based HIV prevention and treatment is available to all.