Generalised versus Concentrated Epidemics 

“the factors driving HIV are still not fully understood[1].” For that reason an either or approach is not the answer to effectively turn the tide.  Targeted responses to both generalised and concentrated populations, informed by data as well as an understanding of the role of gender inequalities and human rights in both populations is important.   

Recent debates have brought into question the focus of current HIV efforts; and whether the most effective strategy was a focus on generalized or concentrated epidemics.  A concentrated HIV epidemic is one where HIV has spread rapidly in one or more defined subpopulations but is not well-established in the general population. A generalized epidemic is one where most new infections are from heterosexual contact in the general population.  According to UNAIDS, in a concentrated epidemic there is still the opportunity to focus HIV prevention, treatment, care and support efforts on those populations which are most affected, while recognizing that no subpopulation is fully self-contained.   

However, “the global HIV epidemic is by no means over. At the end of 2007, an estimated 33.2 million people were living with HIV.  Some 2.5 million people became newly infected that year, and 2.1 million died of AIDS. AIDS remains the leading cause of death in Africa.  Worldwide, HIV is still largely driven by heterosexual transmission. The majority of new infections in sub-Saharan Africa occur through heterosexual transmission, with a number of generalized epidemics outside of Africa, such as in Haiti and Papua New Guinea”[2]. 

At the same time, it is also correct to say that in many regions of the world, including Europe, Asia, Latin America and West Africa, most countries are experiencing concentrated epidemics.  This means that a one-size-fits-all response to HIV is not the solution.  Absent from all the debates though are the role of gender inequalities and human rights within responses to both generalised and concentrated populations.   In most situations, the combination of social vulnerabilities, and biological and behavioural factors place sex workers and their clients; injecting drug users; men who have sex with men; and incarcerated people (prisoners) at differentially higher risk of acquiring and/or transmitting HIV. 

Members of other populations, such as people with sexually transmitted infections, mobile or migrant workers who endure long periods of spousal or partner separation, uniformed services personnel and ethnic or cultural minorities may also be likely to be exposed to HIV.  These communities are often driven underground both because of existing stigma against them, as well as because of the stigma associated with HIV infection: a double jeopardy that efficiently identifies and infects the weakest members of society. The need to have targeted interventions focused on concentrated populations is confirmed by data showing that very few countries have protections in place against discrimination for sex workers, men who have sex with men and injecting drug users. In half of all reporting countries there are laws or policies which actually impede access by the most-at-risk populations to HIV prevention, treatment, care and support[3].  There are several important issues to consider: 

• Heterosexual transmission continues to drive the epidemic among sex workers, their clients, and their clients' partners. In addition, prisoners, injecting drug users, as well as men who have sex with men, may also engage in heterosexual relationships. The need for both a generalized and concentrated approach cannot therefore be disputed.
  
• Gender based vulnerability does not only affect women. Culturally rooted peer pressure among men to reflect a certain image of virility often leads to risky behaviours such as having multiple partners or being reluctant to have safe sex. In addition, men having sex with men are one of the most stigmatised and vulnerable groups in relation to HIV/AIDS.  
  
• The burden of care concerns especially older women, very young women and adolescent girls as young adults become sick or die from HIV/AIDS-related illnesses. One of the consequences is that young women and girls are forced to forfeit opportunities for education or employment. Also, many income earning opportunities for these women are highly exploitative, such as domestic work or commercial sexual activity. As a result, gender inequalities become further entrenched and the spread of HIV/AIDS is accelerated.  Prevention approaches need to be sensitive to these realities. 
  
•  The combination of stigma and violence, is part of the gendered reality confronted by sex workers.
  
• The complex relationship of risk-vulnerability-impact needs to be at the heart of gender sensitive responses to both concentrated and generalised populations.  Risk is determined by individual behaviour and situations such as having multiple sexual partners, having unprotected sex, sharing needles when injecting drugs or being under the influence of alcohol when having sex or having an untreated sexually transmitted infection.  Vulnerability stands for an individual's or community's inability to control their risk of infection due to factors that are beyond the individual's control. Such factors could be poverty, illiteracy, gender, living in a rural area, being a refugee, etc.  Impact is about the long-term changes that HIV/AIDS causes at an individual, a community or a society level. HIV/AIDS not only impacts on the physical and mental health of individuals and populations, but a full blown epidemic also changes socio-cultural structures and traditions and impacts on economies and many different sectors[4].  

Moving forward, 

•  It is not an either or approach.  What is needed to effectively turn the tide is to have targeted responses to both generalised and concentrated populations, informed by data.  A shift from a health-led response to a comprehensive response is required, which involves many sectors and many different actors. The HIV/AIDS epidemic can only be effectively fought by a combination of both HIV/AIDS specific interventions and by mainstreaming efforts. It is crucial to use a gender and culturally sensitive and appropriate approach when responding to the epidemic.
  
• Decision makers at national and local levels need to collect and use evidence to inform HIV prevention and treatment programmes, as it relates to both concentrated and generalised populations, in particular its relationship to gender inequality. 
  
• Underlying drivers of concentrated epidemics include gender inequality, stigma and discrimination, and human rights violations. These drivers need to be addressed through a range of measures including: training and community awareness raising, especially involving policy makers, law enforcement and health care and other service providers. Also legal and policy reform is needed to help remove barriers to accessing HIV prevention, treatment, care and support, including access to essential commodities and services for HIV prevention and care.    

July 2008     

Women Won’t Wait seeks to accelerate effective responses to the linkages of violence against all women and girls and the spread of HIV by tracking and, where necessary, calling for changes in the policies, programming and funding streams of national governments and international multilateral and bilateral donor and technical agencies. For more information about the Women Won’t Wait campaign, please contact: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it  

International Members of the “Women Won’t Wait – End HIV and Violence Against Women. Now.” campaign:Action Aid; African Women’s Development and Communications Network (FEMNET); Association for Women’s Rights in Development (AWID); Center for Women’s Global Leadership (CWGL); Center for Health and Gender Equity (CHANGE); Fundación para Estudio e Investigación de la Mujer (FEIM); GESTOS-Soropositividade, Comunicação & Gênero; International Community of Women Living with HIV&AIDS Southern Africa (ICW-Southern Africa); International Women’s AIDS Caucus; International Women’s Health Coalition (IWHC); Latin American and Caribbean Women’s Health Network; Open Society Initiative for Southern Africa (OSISA); Program on International Health and Human Rights, Harvard School of Public Health; SANGRAM; VAMP; and Women and Law in Southern Africa (WLSA).