Pathfinder international is publishing a timely report on “HIV Prevention Among Vulnerable Populations”. The choice of words here and in particular the use of vulnerability rather than group at risk is of importance.

The introduction of the report recalls that “in the first decade of the AIDS epidemic, the term “at risk group” was applied to those social groups in which the first cases of the disease were diagnosed – MSM, SW and IDU.” As a consequence members of these groups where dehumanised, cast out and labelled as a social danger.

Later in the early 90s, the term “at risk group” was replaced by “risk behaviour” when it became clear that not all members of the “at risk group” where dangerous or more susceptible to be infected or to infect others but that it was the behaviour of some in the group that was risky.

But the report notes that the concept of risk behaviour also has its limitations, “with its focus on the responsibility and protection of individuals, the concept does not take into account the sociocultural construction of risk. e.g., what in their environment drives people to take risks, (e.g., hiding their sexuality or drug use, getting paid more for sex without a condom, the power inequities in social and interpersonal relationships).”

This is where the concept of vulnerability comes in. First introduced by Jonatahn Mann and Daniel Tarantola in 1996 in their book AIDS in the World: Global Dimensions, Social Roots and Responses Vol 2, vulnerability to HIV reflects an Individual’s or community‘s ability to control their risk of HIV infection. In this regard, several factors can enhance people’s vulnerability such as poverty, gender inequality, cultural norms, personal knowledge, conflicts, and natural disasters.

Understanding and integrating the concept of vulnerability in prevention interventions would dramatically affect how they are conducted. For example, if a female sex worker doesn’t know if she will have food today to feed her children, or if she can make significantly more money, she will agree to sex without a condom even if she knows she may get HIV. Telling a sex worker that (s)he MUST use a condom, the focus of many behavioural interventions based on “healthy behaviour”, is of little impact in these circumstances and doomed to failure.

Effective HIV prevention programmes need to address the context in which the people they target live. In the previous example of a sex worker this include the social and legal perception of prostitution, the stigma and discrimination attached to the work, the marginalisation from community and civil society, the personal situation that lead to prostitution.

This report is of particular importance when the last AIDS conference has been focussed on groups at risk and in a way is going one step backward. There is a danger that the sudden interest in the groups at risk ignores or confounds risks and vulnerability. This is particularly important and relevant in societies where the “at risk group” such as MSM can’t cluster together individuals but where the members of the group move across several other social groups without a clear identity that identify them “at risk”.

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