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

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 ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was funded by a grant from UNAIDS and USAID. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: no human subjects were involved, only secondary data analysis. All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data are available online at www.HIVPolicyLab.org and https://aidsinfo.unaids.org/