Decriminalization – a prerequisite to ending Aids and TB

Every person has the right to live a full life with dignity. Yet across Southern Africa, a region that has achieved some of the world’s most remarkable gains against HIV, punitive criminal laws are undermining that principle. 

Laws criminalising sex work, same-sex relationships, drug use, and HIV transmission are driving people away from the very health services that could save their lives.

As we mark Zero Discrimination Day on 1 March and look ahead to World TB Day on 25 March, this month offers a critical moment to confront a truth we can no longer avoid: the same laws that fuel the HIV epidemic also fuel tuberculosis. Both diseases thrive where criminalisation drives people underground and into denial and ignorance.

At the South African AIDS Conference in 2023, we met with former sex workers who now form part of the advocacy group, SWEAT, calling for the decriminalisation of sex work. Many relayed their stories of abuse, from both clients and the police. However, it wasn’t just the lack of police protection that made them more vulnerable to abuse but with it came a lack of access to health protection. 

Their stories are not unique. They are proof that punitive laws are, in practice, driving people away from lifesaving health services.

This is not rhetoric. It is epidemiology.

They further described their relief at institutions such as WITS RHI and OUT among others, who had created spaces for them to access condoms, HIV prevention medication, testing and treatment without the fear of humiliation, scorn and stigma. Unfortunately, with the funding cuts of 2025, some of these clinics no longer exist. Today, many are dependent on the grassroot community-based organisations to provide these much-needed services. 

Eswatini has the highest HIV prevalence of any country in the world – over 27% of its population is living with the virus. Yet HIV prevalence among sex workers in Eswatini stands at 60.5%, among the highest recorded anywhere on the continent. 

In Lesotho and South Africa, key populations — including sex workers, gay men and other men who have sex with men, transgender people, and people who use drugs — bear a disproportionate burden of new infections. These are not coincidences of biology. They are the predictable consequences of criminalisation.

When sex work is criminalised, sex workers power equation with clients change totally and they cannot negotiate safer working  conditions. They cannot report violence to police without risking arrest. 

They avoid health facilities where stigma and legal exposure await them. When same-sex relationships are criminalised, gay men and transgender people are pushed underground, unable to access targeted prevention services, too afraid of disclosure to test for HIV or initiate treatment. 

When drug use is criminalised without pathways to harm reduction, people who inject drugs share equipment and avoid health systems. When people living with HIV face the prospect of criminal prosecution for transmission or exposure, they defer testing, delay treatment, and remain silent, fuelling the very spread the law claims to prevent.

Criminalisation does not protect communities. It fractures them.

As March also marks World TB Day on the 25th, this is a moment to name an uncomfortable truth: the same structural failures that sustain the HIV epidemic also sustain tuberculosis. 

In South Africa alone, more than half of all notified TB patients – 54% – are co-infected with HIV, and the incidence of new TB among people living with HIV remains the highest in Africa, exceeding 50% in parts of southern Africa. TB is the leading cause of death among people living with HIV globally, and the populations most exposed to both diseases are precisely those most criminalised. 

Sex workers, people who use drugs, and incarcerated people face overlapping TB and HIV risks, compounded by the same barrier: fear of a health system that works with the law against them, not for them. 

Social determinants such as poverty, inequality, and stigma, continue to be major barriers to eliminating TB, but law is the lever governments can pull today. We cannot “End TB” and “End AIDS” as separate siloed missions. We must end the conditions that make both diseases lethal for the most marginalised.

The findings from the 2024 HIV Stigma Index 2.0 report show that “more than half (54.6%) of those living with the virus have experienced the feeling of shame or guilt about their HIV positive status at some point in their lives”. 

Internalised stigma can lead to feelings of shame, fear of disclosure, isolation, and despair. Overall, internalised stigma was higher amongst key populations: 65% of people who were using drugs experienced feeling shame or guilt about their status, followed by 60.3% of transgender people, 57.7% among men who have sex with men (MSM), and lastly 56.3% among sex workers.

South Africa’s Constitutional Court has long enshrined the right to dignity, equality, and bodily autonomy. Its Cabinet has proposed the repeal of laws criminalising sex work, a step UNAids has strongly welcomed. South Africa’s progressive legal architecture stands as a model for the region.

But progressive laws on paper mean nothing if their implementation remains punitive in practice, or if our neighbours are left behind. Lesotho has made important strides, with a new Labour Act banning employment discrimination against LGBTQI+ people and people living with HIV.

 But same-sex relations remain criminalised in both Lesotho and Eswatini, and across the region, HIV exposure and transmission laws continue to be weaponised in ways wholly out of step with the science.

The urgency of this moment is reflected in the newly launched Global AIDS Strategy 2026–2031, which focuses global efforts to end AIDS as a public health threat by 2030 and sustain the HIV response beyond it.

The strategy makes a decisive shift, from a predominantly intervention-centred approach to a people-centred one, and is explicit that legal and social barriers, including criminalisation, must be dismantled if the world is to reach its goals. Governments in this sub-region are encouraged to read it, adopt it, and act on it. 

UNAids is unequivocal: ending the criminalisation of key populations is not a peripheral human rights concern. It is central to the science of epidemic control. Research across sub-Saharan Africa confirms that countries which criminalise same-sex relationships have measurably worse HIV outcomes, lower rates of testing, lower viral suppression, higher rates of transmission. The single intervention that would make the greatest difference to the HIV and TB trajectories of Lesotho, Eswatini and South Africa is not a new drug or a new technology. It is legal reform.

These three countries; South Africa, Eswatini and Lesotho have defied expectations before. The scale-up of antiretroviral therapy across southern Africa is one of the great public health achievements of this century. Eswatini and Lesotho have achieved the 95-95-95 treatment targets.

South Africa has committed to a 5.9% annual increase in health expenditure, with ring-fenced allocations for HIV and tuberculosis. These are hard-won gains, and we must protect them.

But progress built on foundations that exclude the most marginalised will not hold. On this Zero Discrimination Day, and as we approach World TB Day on 25 March, the path forward is clear.

Governments, with the support of UNAids, civil society, and affected communities, have the opportunity to accelerate transformative legal reform: decriminalising sex work, repealing laws that criminalise same-sex relationships, replacing HIV-specific criminal statutes with evidence-based public health frameworks, and investing in harm reduction for people who use drugs. This is work we must do together, governments, implementers, advocates, and communities standing visibly alongside those most affected by criminalisation.

To end AIDS and TB, we must work in partnership to end the laws that perpetuate both.

Alankar Malviya is the UNAids director for South Africa, Lesotho and Eswatini

UNAids leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. For more information, visit unaids.org.