Reducing inequalities and social exclusion that affect HIV and health status

26 Oct - 10 Nov 2015
Go back to HIV, Health and Development Strategy of the United Nations Development Programme (2016-2021)

The defining call of the 2030 Agenda is ‘to leave no one behind’ and to reduce inequalities within and between countries – it is, in large measure, an ‘Agenda for Equality and Non-Discrimination’. The 2030 Agenda reinforces the UN system’s existing mandate on human rights, including the principles of equality and non-discrimination.

Inequalities are not only related to income and wealth. Other kinds of inequalities include, inter alia, inequalities in opportunities and outcomes in relation to education, health, food security, employment, housing, health services and economic resources.

Evidence shows that disparities in health outcomes tend to mirror inequities in broader society. This illustrates the interdependence of health and development. Gender inequalities, for example, including unequal power relations and discriminatory gender-based norms, stereotypes and practices, are a strong driver of poor health outcomes for women and adolescent girls with adolescent girls being at alarmingly high risk of acquiring HIV.

Many drivers of social exclusion, such as stigma, discrimination, criminalization and marginalization, limit access to HIV, health and other basic services and increase health risks for the most vulnerable people, such as men who have sex with men, transgender people and sex workers. The data is stark: Key populations in the context of HIV - including men who have sex with men, sex workers, people who inject drugs and transgender people – and their partners are at high risk for HIV and account for between 40% and 50% of all new HIV infections worldwide.

Cities and urban areas bear a large share of the HIV burden, particularly in Africa and Asia. Cities are places where the risk of HIV may be heightened for some populations, especially young men, poor women and girls and those marginalized by ethnic, gender and sexual differences.

Related resources:

 - Strategy Note on reducing inequalities and social exclusion that affect HIV and health status

 - Gender, HIV and health

 - Key populations

 

Proposed Guiding Questions

  • In the context of HIV and health, who is being left behind and why? What are the main challenges and gaps? What are the opportunities for addressing these gaps?
  • What contribution can UNDP make in this area?
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Comments (14)

Saripalli Suryanarayana • from India

Our concerns to day are about Cancers, HIV, Diabetics, Thyroid affecting the women health.We are also worried about children born with defects because the mother carried these abnormalities unknowingly.As we discuss in HIFA, or Malaria community etc, we are well aware of many types of virus and bacteria affecting the communities apart from the hereditary problems coming out of Genes.

We are developing the DNA sequencing which will eliminate certain problems coming to children out of the 22 or 23 pairs of chromosomes.

The urban as well the rural people need education, not just write or read about social economic and a lesson on public health.Progressively we need technicians and engineers to assist the microbiologists, doctors and virologists.

Let us start such institutes progressively in next 3 years, in each country, and in each province of that country.

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Shirley (not verified)
  • In the context of HIV and health, who is being left behind and why? 
  • Besides the key populations that are globally recognized, it is important to focus on other vulnerable populations, depending on the country/regional epidemic. Adolescents and youth, migrants and mobile populations, people who use drugs (not just injecting drugs), women, and indigenous and afro-descendant populations. Often these populations face challenges because they are not part of the recognized key populations, so it is more difficult to mobilize funding for them, or to ensure that the health and HIV services address their specific needs. 
  • What contribution can UNDP make in this area?
  • UNDP can support civil society and governments to address key populations' and other key populations' needs, reduce stigma and discrimination, reduce barriers to access health services. There is also a need to generate more research on these populations. UNDP can help build the capacity of community-based, national and regional organizations/networks to play a stronger role in the response. 
  • UNDP has been instrumental in the LAC region's adoption of stigma and discrimination targets. It can ensure that at country level, relevant stakeholders work on an action plan to make sure progress is made in the next five years in the relevant areas - especially legal reform, discrimination in health settings, access to justice. 
Saripalli Suryanarayana • from India

Third party monitoring,creating local NGO to assist and develop proper assistance in education of the deprived communities encouraging the availabulity and distribution of generic medicines.Creating the system of PPP  and set a mechanism for their earnings. 

Yunah Bvumbwe (not verified)

there is a pressing need to address power relations  between men and women. Culturally men have too much unfettered power over women about their sexual life.women and girls often find themselves in compromising  situations  when it comes to  safe sex as well as consent, they are too scared to negotiate for protected sex which always leave them vulnerable.  In my country ,statistics always highlight that women and girls are the most vulnerable to HIV and AIDS  , new infections among adolescent girls and young women are frightening. 

If boys are socialized at an early stage to treat their female counterparts  as equal to themselves, we won't see them in the future exercising  power over females. 

Leaving no one behind  includes focusing on those people who by nature have been failing to let their voices heard.

Barbara Rogers • from United Kingdom

I am saddened that HIV would be considered in relation to women with nothing but token references to sexual and reproductive health. I note that you have worked with UNFPA but only on an HIV programme! Until women have full access to good pregnancy and maternity care, and a real choice about when or whether to have children, the reference to including women will be merely tokenist. You include gender-based violence (yes, that's important) but exclude any discussion of integrating HIV with a real campaign to promote reproductive health and choice. Shame on you.

   I suggest you sit down with UNFPA and WHO, and put your money where your mouth is about supporting women's health. UNFPA is very poorly funded compared to other agencies and is expected to do all of this on its own.

Ernest Rukangira (not verified)

The impact of AIDS on individuals, families and communities, particularly in Africa, is devastating. In some settings, AIDS has been reported to be a contributor to   the reduction of quality of health and  the increase of poverty at family level.

HIV therapies are complex, expensive and extremely demanding on the patient. The human costs for people living with HIV are high. Many cannot work, and others can still suffer ill-informed prejudice and discrimination. Children with HIV have an especially difficult time – as well as the effects on their own health they may face losing one or both of their parents prematurely.

Preventing poor sexual health depends on everyone having the information, skills and services that they need. Skilled professionals in health, education, social care and voluntary services play vital roles in HIV and STI prevention and raise awareness of sexual health and help people to get the information and services they need.

Some Governments tend to deny the problem of HIV/IAID for various reasons:  economic, social and cultural. Successful HIV prevention is about enabling individuals, couples and communities to be open about sexuality matters, including debate and education about  sexual behaviour and cultural norms associated with it. Stigma and discrimination towards People Living With HIV (PLWH) and vulnerable groups present major barriers to eradicate the epidemic.

Cultural concepts and beliefs, discrimination and stigma promote the denial of HIV/AIDS and contribute to hiding the disease which can hamper access to information, services, care and support.

Fear of stigma and discrimination can discourage people from getting tested and, when they know they have HIV, from disclosing their status or accessing treatment and care.

HIV/AID could have been eradicated if there were no stigma and discrimination in many countries. The public and HIV/AID patients should be educated to understand that HIV/AIs is a disease like many other diseases.

The impact of poverty on someone living with HIV is particularly detrimental. Poverty can worsen an HIV positive person’s health, as they are unable to afford the nutritional food, appropriate housing or heating they need to remain well when living with a compromised immune system.

It can also make adherence to treatment more difficult - when people struggle to provide the basics in life for their families, looking after themselves and taking their treatment become a lower priority.

This is fundamental to achieving success in other areas; knowledge is essential to prevention and testing, to planning and delivering health, social care and support services and to ending the stigma and discrimination that people living with HIV still face.

In Europe and North America, the epidemic continues to disproportionately affect minority ethnic communities in urban areas

In developed and developing countries, poverty affect  marginalised groups such as  people with no education, landless people, ethnic minorities, ex-offenders, drug misusers,  trafficked women, sex workers, orphans, single mothers, etc. These groups live in poor urban areas mainly urban slums.

There is an also new phenomenon of sex corruption in urban areas especially in relation to access to employment, health, education, government positions and other services.

 Vulnerable and neglected groups, mainly the poor, women and girls,  orphans and vulnerable children, and the illiterate are  the ones trapped by their cultural believes are the ones who are left behind because they have no support and encouragement to take the steps to  be tested HIV/AIDS and do not know what to in cased they are tested positive. Some groups need targeted sexual health information and HIV/STI prevention because they are at higher risk, are particularly vulnerable or have particular access requirements. These include stigma, discrimination, poverty and social exclusion, language, access problems, low awareness and concerns about confidentiality. Other vulnerable, minority and neglected groups include: 

  • Migrants ,black and minority ethnic groups in large cities of developed countries
  • Trafficked women and girls
  • Women affected  by or at risk of FGM
  • Gay and bisexual men
  • injecting drug misusers
  • Sex workers
  • People in prisons and youth offending establishments

 These include stigma, discrimination, poverty and social exclusion, language, access problems, low awareness and concerns about confidentiality.

 We know that women and men face different risks and barriers in relation to the AIDS epidemic and in accessing services. Gender inequalities mean that women and girls cannot always decide if, when, how and with whom they have sex, or when to access basic services.  Multiple partners, women’s roles, women‘s economic status can significantly increase the risks of HIV infection.

In Africa, there are little or no protections against discrimination in employment, housing, and other areas based on sexual orientation and gender identity.

The potential consequences – job loss, lack of access to healthcare, homelessness – can push individuals into risky behaviours that greatly increase their HIV risk and severely limit their ability to obtain adequate care once infected.

The solutions to tackle HIV/AIDS should not be only women being able to refuse sex, and men using condoms and making condoms available to everyone. It is all about the level of education, poverty, cultural barriers and irresponsible behaviour and attitudes toward sex. The donor community and government should focus on these elements.

Female genital mutilation

Female genital mutilation (FGM) – sometimes known as female circumcision – should be made illegal, unacceptable, and a violation of the human rights of the young girls (usually aged between four and ten) who suffer it.

All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons should be made illegal.

Wherever there are people from cultures with a tradition of FGM there is a need to raise the awareness and skills of health, education and social services professionals. Local services need to support community initiatives aimed at stopping this practice.

Health professionals’ contribution to the eradication of female genital mutilation (FGM) needs to include appropriate child protection measures (as the practice is traditionally performed on girls between the ages of 4 and 10).

 

UNDP and partners’ role:

More research needs to be carried to generate detailed knowledge of the epidemic – including the drivers, risks, trends and connections with other health conditions. Research findings should be made available in local languages  in the countries, communities and families affected

Provide the capacity building to Governments in collecting reliable data and evidence about the status of HIV/AIDS and services. Better collection, monitoring and use of data are needed to improve outcomes. The data should  be regularly published to warn to the public  about the threats caused by the disease and to learn about what is being done to tackle the problem. Collate available evidence, assess what works and make clear recommendations on future approaches.

UNDP and its partners should promote measures and opportunities to reduce drug prices and increase access to more affordable and sustainable treatment over the long term.

Promoting strong national political leadership: This has demonstrated to be an effective strategy to reduce the level of HIV/AIDS. Case studies and measures of success should be documented and disseminated to enable the exchange of experience about  HIV prevention programmes, treatment, care and support.

UNDP should help the Governments to develop national strategies and action plans as UNDP has done so in other areas such as the environment. This will help the Governments to effectively allocate resources to most people at risk or affected, define the indicators and outcomes to be achieved in short, medium and long term.

 Supporting training of the media and social movements about HIV/AIDs reporting, women’s rights, counselling and advocacy is essential.

 Ensure Poverty Reduction Strategy Papers and other national development plans should reflect AIDS plans in relation to neglected targeted groups.

 Ensure equitable access to safe, affordable, essential drugs and commodities for all in need by working with drug manufacturers and combating fake and ineffective drugs

 Promoting the implementation of education programmes that help young people, both those in and out of school, to have safe and healthy sexual relationships, free from stereotyping, violence and exploitation

 Work in partnership with Food Services and Agencies to fight against malnutrition, hunger and fighting against food insecurity. Promote Research on local and neglected foods that contribute to increasing the human  immune system. Agriculture policies, programmes and plans should integrate the outcomes in relation to fighting HIV/AIDS.

 Ensure that all staff working in sexual health and HIV are properly trained and supported so they can deliver respectful and non-discriminatory care

 Ensure there is positive and accurate coverage about HIV in the media, with the focus on evidence, improving information on behaviour and attitudes, need assessment for people affected by HIV/AID.

 Training and education is provided for frontline staff in key public services, such as health, social care, police and education, so that people living with HIV no longer experience stigma and discrimination when accessing such services

 Supporting the development and implementation of community programmes reaching priority most-at-risk populations (including men who have sex with men, young people, refugees, domestic workers). Promote programmes that eradicate HIV-related stigma and discrimination and ensure that people living with HIV are aware of and access their rights.

 Support the Prison Services in preventing the spread of HIV/AIDSs in prison, offering information and treatment of substance misusers.

 In targeting these groups commissioners and providers need to work together to overcome the common barriers to accessing information and prevention services.

There is a range of service and health promotion initiatives that can help, including staff training on discrimination, outreach health promotion and targeting hard to reach or stigmatised groups.  Everyone providing sexual health information and HIV prevention needs better access to up to date information.

 In urban areas, exploit the wide range of media available for providing information on sexual health, especially in urban areas: social media, TV and Radio. Undertake research and recognise relevant factors, such as alcohol use, drug misuse, homelessness, sex related corruption, social exclusion and life in urban slums

 Support the Civil society working with LGBT to make people more aware of the benefits of testing and of where testing, treatment and care are available.

 Increase antenatal HIV testing to reduce mother-to-infant HIV infections.

 Address the causes that heighten the vulnerability of women and girls to trafficking and HIV

 Identify service delivery and operational lessons from the work that has been done, and any factors that help them to be successful.

 Organise public awareness campaigns  aimed at breaking the culture of silence on  GBV and HIV/AIDs while raising awareness of gender inequality, human rights, and the importance of women’s participation in public life.

 Provide funding to Community Based Organisations (CBOs) which directly work or HIV/AID patients at community level. Many CBOs are small, under-funded groups formed in response to the essential needs of their families and members’ communities.

 Make mandatory to Health Services to report annually on numbers of people with HIV and AIDS and review what services are in place or planned.

National HIV/AIDS Strategy to explicitly include gay and bisexual men and transgender people in its plan to reduce infections, increase access to care, and reduce disparities

Undertake the review of the implementation of the Abuja Declaration on HIV/AIDS, Tuberculosis, and Other Related Infectious Disease:

 http://www.un.org/ga/aids/pdf/abuja_declaration.pdf

Research priorities

  • What are the needs of  minority and  targeted groups ( mentioned above)
  • What is the impact of ethnicity, culture, deprivation, and other socio-economic factors in sexual health
  • The impact of costs of treatment, HIV drug affordability and completion of treatment
  • Why some groups do not access services or not engaged in sexual and reproductive health interventions
  • What are available formal and informal routes for women and girls to seek redress and report the risks to  gBV and HIV/AIDs and how these routes are effective or ineffective in helping women and girls?
  • What are the barriers women and girls are facing in asserting their rights and seeking protection against GBV and HIV/AIDs?
  • What support is needed to empower and assist women to enable them to assert their rights
  •  What appropriate and effective service delivery arrangements that have contributed to the success in fighting HIV/AIDs
  •  What types of governance structures, legal, institutional mechanisms and practices guide successful  GBV and HIV/AIDs Service Delivery management at the community level?
  •  What HIV/AIDs service delivery models that can be replicated in different countries taking into account the country’s social, cultural, economic, legal and political context?

 

 Ernest Rukangira

Conserve Africa Foundation

1st Floor, 57 The Market Square

London N9 0TZ

Web: http://www.conserveafrica.org.uk/

Ernest Rukangira (not verified)

Dear All,

Thank you very much for your excellent contributions and knowledge exchange about this important topic.

 

In addition to my contribution, to illustrate the problem of GBV, I have attached a research proposal about  “Research, capacity building and awareness raising

in responding to GBV: Exploring the level of efficiency and effectiveness of Gender-Based Domestic Violence Service Delivery in South Sudan.”

 

I understand  that this is not a forum for fundraising. However, if the Moderator allows, I would very much appreciate if any funder could support the attached  proposal.

 

Yours sincerely

 

Ernest

 

=--=-=

Ernest Rukangira

Conserve Africa Foundation

1st Floor, 57 The Market Square

London N9 0TZ

Tel/Fax: +44(0)2088036161

E-mail: ernest.rukangira@conserveafrica.org.uk

Web: http://www.conserveafrica.org.uk/

Rachel Albone (not verified)

I welcome the priority of the Inclusion of key populations and other excluded  groups in the UNDP strategy note. People aged 50 and over are consistently left behind in the HIV response and lack equitable access to HIV and broader health services and support. UNAIDS has recognised that responding to the needs of people aged 50 and over has been a significant gap in the response. Epidemic monitoring and data collection has tended to focus on people aged 15-49, excluding people who fall outside this age bracket. As a result very few national or regional strategies and responses have included people aged 50 and over. The work undertaken by UNAIDS over recent years to start to close this data gap and to highlight and address the challenges faced by people living with HIV in their older age in ‘HIV and Aging: a special supplement to the UNAIDS report on the global AIDS epidemic 2013’ and ‘The Gap Report’ has marked a crucial step forwards.

 

The adoption of the Sustainable Development Goals also provides a key opportunity to address the needs of people across the lifecourse, including in older age, with a global goal on health to ‘Ensure healthy lives and promote well-being for all at all ages’.

 

HIV and Ageing

 

  • HIV has pronounced impacts on people in older age but they are largely unrecognised and little understood
  • There is a significant and increasing number of people aged 50 and over living with HIV:
  1. 5.5 million people aged 50 and over are living with HIV globally[i], up from 4.2 million in 2014[ii]
  2. Estimate that 9 million people 50 and over will be living with HIV in sub-Saharan Africa by 2040[iii]
  3. 120,000 people aged 50 and over acquire HIV each year[iv]
  • Millions of older people are caring for family members affected by HIV. UNICEF data shows grandparents care for 40-60% of children orphaned as a result of AIDS in east and southern Africa.[v] The World Bank made similar findings - 81% of double orphans in Zimbabwe[vi]

 

People in older age, whether at risk of infection, living with HIV or in their role as carers, must be included in the HIV response. In line with international targets, all people, irrespective of age, must be reached with services that achieve:

  1. a reduction in new infections
  2. increased access to testing and ART, resulting in viral suppression
  3. zero discrimination
  4. the mitigation of the impact of HIV on their psychosocial and socio-economic wellbeing

 

I also welcome the priority of Promoting gender equality and eliminating gender-based violence in the UNDP strategy note. Women in older age experience multiple and intersecting forms of discrimination. Gender-based and other inequality can accumulate over a life time and be exacerbated in older age. This can have devastating effects for women in older age unless specifically addressed.  Women living with HIV in older age face discrimination on the basis of their age, sex, HIV status and level of income security. http://www.helpage.org/what-we-do/hiv-and-aids/age-sex-and-hiv-older-womens-stories/

 

With violence against women recognised as a key factor influencing women’s health it is crucial that the current gaps in understanding of when and how women experience violence across the lifecourse are filled. For example, current data tools and surveys that address violence against women are restricted to women between the ages of 15 and 49 meaning there is limited understanding of violence against women in older age.

 

Sexual and reproductive health and rights is another area where women in older age are frequently neglected because of a focus on women of reproductive age, yet SRHR needs remain throughout a woman’s lifecourse.  

[i] UNAIDS 2015 UNAIDS 2016-2021 Strategy: On the fast track to end AIDS

[ii] UNAIDS 2014 The Gap Report

[iii] Jan AC Hontelez, Sake J de Vlas, Rob Baltussen, Marie-Louise Newell, Roel Bakker, Frank Tanser, Mark Lurie, and Till Bärnighausen. The impact of antiretroviral therapy on the age composition of the HIV epidemic in sub-Saharan Africa. AIDS 2012. in press

[iv] See i

ivUNICEF, State of the world’s children 2007: women and children, the double dividend of gender equality

[vi] Beegle K et al, Orphanhood and the Living Arrangements of Children in Sub-Saharan Africa 2009

 

 

 

 

Kingsley (not verified)

The subject of inequalities and social exclusion is such an important one. Our current case study find some key challenges in the access of care especially of the key populations. One of the great limitations of PLHIV is their access to social support and empowerment programmes. The recommendations of most interviewed was about gaining some economic indepence as the majority have lost their jobs due to one, their condition as PLHIV and also as Key population. The call for some form of entrepreneural support or startup capitals would go along way in ensuring their sustainable access to the needed care. I don't know if that is out the mandate of UNDP as I find assisting persons in that light establishing their economic freedom would be key to addressing their inequalities and social exclusion most especially for person in the economically challenged sub-saharan Africa where "poorman has no friend".

Kingsley (not verified)

The subject of inequalities and social exclusion is such an important one. Our current case study find some key challenges in the access of care especially of the key populations. One of the great limitations of PLHIV is their access to social support and empowerment programmes. The recommendations of most interviewed was about gaining some economic indepence as the majority have lost their jobs due to one, their condition as PLHIV and also as Key population. The call for some form of entrepreneural support or startup capitals would go along way in ensuring their sustainable access to the needed care. I don't know if that is out the mandate of UNDP as I find assisting persons in that light establishing their economic freedom would be key to addressing their inequalities and social exclusion most especially for person in the economically challenged sub-saharan Africa where "poorman has no friend".

Kingsley (not verified)

The subject of inequalities and social exclusion is such an important one. Our current case study find some key challenges in the access of care especially of the key populations. One of the great limitations of PLHIV is their access to social support and empowerment programmes. The recommendations of most interviewed was about gaining some economic indepence as the majority have lost their jobs due to one, their condition as PLHIV and also as Key population. The call for some form of entrepreneural support or startup capitals would go along way in ensuring their sustainable access to the needed care. I don't know if that is out the mandate of UNDP as I find assisting persons in that light establishing their economic freedom would be key to addressing their inequalities and social exclusion most especially for person in the economically challenged sub-saharan Africa where "poorman has no friend".

rhon reynolds (not verified)

This is one of UNDP's strenght and comparative advantage in the fight agaist HIV. I think this sectioned could be strengthened with the specific inclusion of men and boys in combatting gender inequality. Specifically the strategy should detail how UNDP will  work to involve men and boys in programmes to stop gender-based violence. Men need support in recognising and overcoming the ways that traditional norms of masculinity place themselves and their partners at risk. 

While we agree that violence and the criminalisation of key populations make them increasingly vulnerable to HIV, I would have liked to have seen the specific mention of how the application of criminal laws against people living with HIV for non-disclosure, exposure and transmission being addressed. 

The section that refers to the inclusion of key populations and other excluded groups fails to mention that key populations are people living with HIV, this section would be bolstered by a specific mention of how UNDP would engage PLHIV networks, CSOs in upholding and defending rights of KP.

Priya Kanayson (not verified)

The NCD alliance supports Priority 1.1, to promote gender equality and eliminate gender-based violence, as an important component of this new strategy. The need for gender-sensitive and responsive health systems is particularly important in developing countries, where many women are unable to seek care owing to the lack of female caregivers, stigma, social and cultural norms. Lack of access to and availability of quality, affordable essential medicines, vaccines, and technologies further exacerbates the problem. 

 Women and children in LMICs often bear a triple burden of poor health related to reproductive and maternal health, communicable diseases, and non-communicable diseases. Increasing exposure to NCD risk factors affects not only women’s health, but also increases the vulnerability of future generations to ill-health. For example, excessive consumption of alcohol, a behaviour that often develops in adolescence and a leading risk factor for NCDs, is also a factor in violence against women and girls, which can manifest in health issues such as HIV and other chronic conditions. Moreover, alcohol has been identified as a leading risk factor for death and disability globally, accounting for 3.8% of death and 4.6% of DALYs lost in 2004 alone.

Universal health coverage is a means to reducing inequality and social exclusion as it relates to health systems and services, as it focuses greater attention on coverage of quality services, health equity, and financial risk protection. 

Josefina Valencia Toledano (not verified)

By making a count of the groups who have faced bigger exclusion in the response around HIV, lesbians and bisexual women are one of the most excluded. This situation responds to various reasons related to discrimination and misogyny. Prejudices about sexuality between women, have come to generate the false belief that sex between women is not considered as such and therefore is not seen as an activity with potential risks for HIV transmission. However, the diversity of sexual practices among these populations shows otherwise, as well as the multiple ways to have sex between women, identity is a definition that does not necessarily correspond nor should corresponder to sexual practices; i.e. some lesbians and bisexuals for different reasons and at different times of their life cycle, have sex with men. Closed and biased conceptions about the practices of these women has caused: lack of research and information about the level of risk . There is not enough biomedical information; diagnostics; or safety protocols to reduce risks.  In any case, lesbians and bisexuals are ignored and ignore the possible consequences of having unprotected sex, or the consequences of not attending regular medical reviews. All of this seriously impacts the health of lesbian and bisexual women, because the lack of information  increases the risk and vulnerability. Moreover, many of the women attending health services that reveal their sexual orientation, far from receiving care related to the specific needs of their sexuality, usually face discrimination or do not receive timely and adequate information, which often generates that lesbians do not attend regular consultation to take timely diagnosis on sexual health care. 

Al hacer un recuento de las poblaciones que han enfrentado mayor exclusión en las acciones de respuesta en torno al VIH se encuentran las lesbianas y las mujeres bisexuales. Dicha situación responde a diversos motivos vinculados a la discriminación  y la misoginia. Los prejuicios  sobre la sexualidad entre mujeres, han llegado a generar la falsa creencia de que el sexo entre mujeres no es considerado como tal y por lo tanto no se concibe como una actividad con potenciales riesgos para la transmisión del VIH. Sin embargo, la diversidad de prácticas sexuales entre estas poblaciones muestra lo contrario, pues además de las múltiples manifestaciones que tiene el sexo entre mujeres, la identidad es una definición que no necesariamente corresponde -ni tendría que corresponder- a las prácticas sexuales; es decir las lesbianas y las bisexuales por diversas razones y en distintos momentos de su ciclo vital, tienen relaciones sexuales con hombres. Las concepciones cerradas y sesgadas sobre las prácticas de estas mujeres ha provocado que no se desarrolle suficiente investigación, ni se sistematice información en torno al nivel de riesgo que existe. No hay suficiente información biomédica; generación de diagnósticos sobre la materia; ni protocolos de seguridad para reducir los riesgos. En todo caso, se omiten e ignoran las posibles consecuencias de tener prácticas sexuales sin protección o las consecuencias de no asistir a consultas de revisión regulares. Todo lo anterior  impacta seriamente la salud de las lesbianas y mujeres bisexuales, pues la falta de información y difusión de conocimientos incrementa el riesgo y la vulnerabilidad  y deriva. Por otro lado, muchas de las mujeres que acuden a servicios de salud y revelan su orientación sexual lejos de recibir una atención que atienda las necesidades específicas que de su sexualidad derivan, enfrentan discriminación o no reciben información oportuna, ni adecuada, lo que con frecuencia genera que las lesbianas no acudan a consultas regulares que permitan tener diagnósticos oportunos en materia de atención a la salud sexual. Finalmente no debemos ignorar que por diversas razones, entre ellas la violencia hacia las mujeres, el VIH ha incrementado su incidencia en ellas y que por esta razón el tema en cuestión debe estar presente en las investigaciones y acciones de respuesta y prevención del VIH.