Law, Criminalisation and HIV in the World: Have countries that criminalise achieved more or less successful AIDS pandemic response?

Abstract How does the use of criminal law affect disease-fighting efforts, particularly in a pandemic? This longstanding question for governments around the world is felt acutely in the context of the COVID-19 and HIV pandemics. Many countries have laws and policies that criminalise behaviours, making same-sex relationships, illicit drug use, and sex work illegal. Meanwhile, some countries have enshrined gender- and rights-protective institutions in law. Under the global AIDS strategy of the last five years, national AIDS response efforts in countries have focused on reaching people living with HIV with testing and antiretroviral treatment to suppress the HIV virus, preventing mortality and HIV transmission. At the end of this 5-year push, this article provides an ecological analysis of whether those countries with criminalising legal environments achieved more or less success. In countries where same-sex relationships were fully criminalised, the portion of people living with HIV who knew their status was 11% lower and viral suppression rates were 8% lower. Under sex-work criminalization, the rate of people living with HIV who knew their status was 10% lower and viral suppression 6% lower. Drug use criminalisation was associated with 14% lower knowledge of status and viral. On the other hand in countries with laws advancing non-discrimination, human rights institutions, and gender-based violence response, HIV services indicators were significantly better. This ecological evidence on the relationships between the legal environment and successful HIV response provides support for a strategy that includes a focus on law reform to achieve goals missed in 2020. Summary Box Countries around the world, across economic and geographic boundaries, have taken different approaches to the application of criminal law to same-sex sex, sex work, and drug use—with most taking a partially or fully criminalising legal approach in one or more of these areas. In tackling the AIDS pandemic, globally agreed goals for 2020 focused on ensuring most people living with HIV were aware of their HIV status and had suppressed the HIV virus through effective antiretroviral treatment. The AIDS response in countries that criminalised was less successful than those that did not—achieving significantly lower levels of HIV status knowledge and HIV viral suppression. Countries with clear laws advancing non-discrimination, human rights institutions, and gender-based violence response had better knowledge of HIV status and viral suppression rates. This analysis suggests a new global AIDS strategy that includes a focus on law reform may hold promise in achieving goals that were missed in 2020.