1. 1 Regional Workshop on HIV/AIDS and Vulnerable Populations Elizabeth Ninan AIDS Campaign Team for Africa, World Bank 11-13 March 2009

2. 2 Vulnerability to HIV and AIDS Largely created by a set of interrelated social, economic, cultural and legal factors. Fueled by societal roles and expectations, including cultural perceptions of sexuality and gender norms, economic status, working environment and geographic location.

3. 3 Vulnerability to HIV and AIDS “Most-at-risk-populations” (MARPs) are populations with an elevated risk or vulnerability to HIV/AIDS in some form of risky behavior, occupation or lifestyle such as sex workers, LGBT, prisoners, IDUs, truck drivers, military, long-distance mobile workers, miners, fishermen, IDPs, refugees Vulnerability of certain population groups stemming from demographic, economic and social factors such as women, youth, orphans and other vulnerable children (OVC) and people with disabilities

4. 4 Are there Commonalities between these Vulnerable Groups? Generally higher HIV prevalence amongst these groups and higher risk behaviour Marginalized and criminalized Stigma and discrimination, human rights abuses (reduced access, utilization of services) Subjected to violence Socio-economic, social, legal and policy constraints Political economy where governements not willing to invest in vulnerable groups either using domestic or external recources Limited public health response and access to services Lack of reliable epidemiological data and information available services Research and programs tend to be small scale pilots

5. 5 HIV PREVALENCE AND TRANSMISSION SOURCES, 2005 Infections from sex work, clients, soldiers, truckers Infections from general population 93% 7% 50% 14%

6. 6 HIV PREVALENCE AND TRANSMISSION SOURCES, 2005 Adult male infections from sex work Adult male infections from general population 2% 78% 24% 76%

7. 7 AFRICA MSM HIV PREVALENCE, 2009 General Adult Prevalence 2007 Nigeria, 2006, 13.4% Nigeria, 2007, 13.5% Malawi, 2008, 21% Cape Town, South Africa, 2007, 13.2% Zanzibar, 2007, 12.3% Mali, 2007, 37% Senegal, 2005, 22% Senegal, 2007, 22% Egypt, 2006, 1% Egypt, 2008, 6.2% Sudan, 2005, 9.3% Sudan, 2008, 7.8% Mombassa, 2007, 25% Nairobi, 2008, 37% Mauritania, 2007, 19.1% Cote D’Ivoire, 2006, 25% Soweto, South Africa, 2008, 29% Oelrichs, 2009 Zambia, 2006, 33% Namibia, 2008, 12% Ghana, 2006, 25% Botswana, 2008, 20% Uganda, 2008, 15%

8. 8 AFRICA MSM HIV PREVALENCE Oelrichs, 2009 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Senegal Mali Nigeria South Africa Egypt Sudan Kenya Zanzibar Malawi Mauritania Ghana MSM General Population

9. 9 Sexual Minorities A sexual minority is a group whose sexual identity, orientation or practices differ from the majority of the surrounding society (lesbians, gay, bisexual, transgender) identityorientationpractices Sexual minorties are part of every society but the extent of disclosure varies 20% of MSM men report ever having sex with women; 16% of MSM also report being married – higher in African context (UNAIDS, 2008)

10. 10 Sexual Minorities Only 12% of MSM in Africa have access to HIV services -UNGASS 2008 Little is known about what types of interventions work in terms of access to prevention, treatment, care and support for MSMs 85 UN States criminalize sex between consenting males,10 of the 85 have death penalities

11. 11 HIV PREVALENCE AND INCIDENCE AMONG FSW AND MSM IN MOMBASA, KENYA

12. 12 Sex Workers Sex work: the exchange of money or goods for sexual services, either regularly or occasionally, where the sex worker may or may not consciously define such activity as income-generating’ (UNFPA, 2002). Widespread view that occasional engagement in transactional sex, or sexual barter, constitutes ‘sex work’. Sex work may be formal or informal.

13. 13 Sex Workers Several programs have been effective such as Thailand (100% condom usage) and Senegal (STI syndromic management): few programs target clients Lack of negotiating power and threat of violence given they are often outside protection of the law Human trafficking- 600,000 to 800,000 (80% women). West African countries, Egypt, and South Africa are the primary countries

14. 14 Prisoners

15. 15 Prisoners Roughly 668,000 prisoners in Africa HIV prevalence significantly higher among prisoners (between 6 to 50 times) compared to national averages Overcrowded premises where unsafe injecting drug use and unprotected sex are common Sexual violence in prison Lack of prevention and treatment services for prisoners (condoms, lubricants, clean needles/syringes, and/or bleach)

16. 16 HIV/AIDS in SSAfrican Prisons

17. 17 UN Agency Technical Division of Labour for Focus Vulnerable Groups Sexual minorities – UNDP Sex workers- UNFPA Prison community- UNODC Policy, monitoring and coordination- UNAIDS Support to strategic, prioritized and costed National Plans, capacity development, impact alleviation- World Bank

18. 18 World Bank Support Lending: US$1.6 billion to 35 countries and 5 regional initiatives through the MAPs Assessments: - Rapid Analysis of HIV Epidemiological and Response Data on Vulnerable Populations in the Great Lakes Region of Africa, GLIA, 2008 - Gender assessments in 5 African countries - Prisons and HIV/AIDS, 2005, UNODC, WHO - Disability Study in 3 African countries, forthcoming Consultations: - Africa Regional Youth Consultation on HIV/AIDS and RH, 2007- UNFPA, UNICEF - Prisons and HIV/AIDS, 2005, UNODC, WHO - Vulnerable Groups workshop on MSMs, Senegal 2006, UNDP Toolkits - OVC, Disability

19. 19 Africa Region HIV/AIDS Agenda for Action (2007-2011) Pillar 1: Focus the response, through evidence-based and prioritized HIV/AIDS strategies Objective: Support countries to better understand their own epidemics, what works in the specific situations they face and how best to assist vulnerable groups

20. 20 Priorities Strengthen seroprevalence (surveillance surveys) and behavioral studies Improve evidence base of effective interventions and how to bring them to scale- more operations research and impact evaluation on interventions, standard monitoring indicators Track resources invested in national strategies directed at these groups

21. 21 Priorities Responsible advocacy and community strategies, particularly on humans rights Increased information exchanges between networks and assocaitions Legal and policy reforms, particularly promoting human rights Develop tools, norms, standards and good practices

22. 22 Acknowledgements Elizabeth Lule, ACTafrica, World Bank David Wilson, GHAP, World Bank Richard Seifman, ACTafrica, World Bank

23. 23 THANK YOU