The NCPI data draw attention to the widespread existence of laws and policies that constitute structural barriers to effective HIV responses for key populations around the world. For people who use drugs, the barriers are fairly similar across different national settings with most reported barriers constituting impediments to accessing harm reduction services. For men who have sex with men a diverse range of obstacles exist across different countries including mandatory HIV testing and barriers to accessing condoms. For sex workers, wide-ranging regulatory barriers were cited including restrictions on who can engage in sex work and where sex work can be carried out. The NCPI also highlights “protective” laws and policies designed to promote an effective HIV response for key populations, as well as conflicts which exist in policy frameworks.
UNAIDS has underscored the importance of legal and policy environments which respect human rights to ensure an effective HIV response. The UNAIDS five-year strategy includes “advancing human rights and gender equality” as one of the three pillars necessary for stopping the HIV epidemic (alongside the pillars of prevention and treatment) [42
The 2010 report of the UN Special Rapporteur on the Right to Health focuses on criminalization of same-sex relationships, sex work and HIV transmission. Framing his arguments within the obligations under the right to the highest attainable standard of health, he notes that “criminalization impacts detrimentally on health outcomes for individuals, even if the laws around these practices are not enforced, or enforced infrequently” [43
]. He recommends decriminalization and the introduction of appropriate monitoring and accountability mechanisms to protect against violations and the provision of avenues for redress if required [43
To comprehensively address structural barriers to HIV requires attention to a multitude of elements but the salience of the legal and policy environment for the lives of people who use drugs, men who have sex with men and sex workers is without question. This analysis was, however, limited by the data available in the NCPI, which covers some aspects of laws, policies and human rights but is by no means comprehensive. It also does not shed light on the degree to which reported laws are actually implemented and does not assure that what is reported is actually in place.
Laws and policies about which the NCPI does not collect information, but which are collected by other reliable sources, such as HIV-related travel restrictions and the criminalization of HIV transmission also pose enormous barriers for these and other key populations [44
]. Recognition of the harms inherent in all of these laws, and the potential positive role that a supportive legal environment can play, suggests the need for legal reform to ensure an enabling legal and policy environment within which HIV services can be delivered more effectively and efficiently used by the populations who need them.
Several methodological issues are suggested for further research. In particular, work is needed to make the associations clearer between data on the legal and policy environment and HIV outcomes. Teasing apart how the legal and policy environment might constitute structural barriers or interventions is particularly complicated where there are conflicts between the laws and policies in place. There is a long and complex causal pathway to determining HIV outcomes; attributing them solely to the presence or absence of a specific law or policy would be simplistic. Yet, there is no denying that law plays a significant role in the ability to access HIV-related information and services.
In addition to theoretical advances, efforts are being made to develop analytical methods to assess the possible connections between legal and policy environments and HIV-related outcomes, with the aim not to determine statistical associations but to highlight general trends [46
]. This work raises a host of issues for consideration including how to assess the content of law, as well as, importantly, its implementation. Although classical experimental study designs might be appropriate for evaluating some interventions to address structural barriers, practical and ethical reasons have precluded their use in instances such as legal reform [18
]. Grounded within the human rights imperative for ensuring a supportive legal and policy environment, innovations in analytical methodology are required to better understand the mechanisms through which legal and policy interventions operate to affect HIV-related outcomes. Qualitative studies can also play an important role in addressing research gaps in this area.