This study operationalizes the rights-based approach (RBA) to HIV through a five-dimensional analytical framework synthesized from international human rights law, public health scholarship, and UNAIDS technical guidance. The RBA framework recognizes that effective HIV responses require addressing structural determinants of vulnerability, ensuring meaningful participation of affected communities, and protecting human dignity alongside achieving biomedical outcomes (28–30).

The five interdependent dimensions are:

India, Nepal, Pakistan, and Sri Lanka were selected through purposive sampling based on four criteria. First, all four countries experience concentrated HIV epidemics with prevalence exceeding 5% among at least one key population group, enabling examination of interventions targeting most-affected communities. Second, shared colonial legal heritage has resulted in similar criminalization patterns, particularly regarding same-sex conduct, providing comparable baseline legal frameworks. Third, divergent trajectories in contemporary legal reform—ranging from India’s decriminalization of same-sex conduct to Sri Lanka’s retention of colonial-era statutes—offer variation in the independent variable of interest. Fourth, collective representation of approximately 80% of South Asia’s HIV burden ensures regional relevance and policy impact (29, 30, 40–42).

The review covered materials published and available between 2010 and 2024, reflecting the most active phase of rights-based and decriminalization reforms in the region. Where official policy or legal documents were not publicly accessible, information was cross-verified using secondary institutional sources and peer-reviewed publications to ensure completeness and accuracy. Data collection employed a systematic and multi-source approach to ensure comprehensiveness and reliability. Legal and policy documents included national constitutions, penal codes, HIV-specific legislation, national strategic plans, and related regulatory frameworks, accessed through government websites, legal databases, and policy repositories. Programmatic data were drawn from National AIDS Control Organization reports, UNAIDS country profiles and Global AIDS Monitoring reports, Global Fund grant documents and implementation letters, and WHO HIV country profiles. Published research comprised peer-reviewed articles identified through structured searches of PubMed, Scopus, and regional databases using terms combining “HIV,” “law,” “discrimination,” “key populations,” and country names, supplemented by grey literature from international organizations. Community perspectives were incorporated through published reports, advocacy documents, and policy submissions by leading regional CSOs, including Naz Foundation (India), Blue Diamond Society (Nepal), Naz Male Health Alliance (Pakistan), and Equal Ground (Sri Lanka) (35, 43–45).

The present study employed a narrative comparative review design, which allows for the integration of heterogeneous evidence—legal texts, policy frameworks, programmatic reports, and community perspectives—within a unified analytical lens. This approach is particularly suited to exploring complex, intersectional, and context-dependent relationships between law, ethics, and HIV governance that may not be fully captured through quantitative synthesis. It also contributes to theory development by linking policy evolution with rights-based and ethical frameworks across diverse socio-legal settings in South Asia.

Analysis followed a structured comparative case study methodology. Document review and thematic coding were conducted using NVivo 12 software, with legal texts, policy documents, and research literature coded against the five RBA dimensions using both deductive codes derived from the conceptual framework and inductive codes emerging from the data. Cross-country comparison employed a constant comparative method to identify patterns, divergences, and causal relationships across dimensions and countries. Data triangulation verified findings by comparing information across source types, with particular attention to identifying consistencies and discrepancies between official policy documents and community organization assessments. The analysis culminated in development of a comparative assessment matrix (Table 1) summarizing key findings across all dimensions and countries, and a conceptual pathway diagram (Figures 1, 2) illustrating theorized relationships between RBA implementation and HIV outcomes (5, 36–39).

The RBA framework is visualized in two conceptual diagrams.

The comparative analysis reveals significant heterogeneity in rights-based HIV policy implementation across South Asia, with countries demonstrating varied progress across the five analytical dimensions. India and Nepal exhibit partial advancement in legal decriminalization and constitutional protections, while Pakistan and Sri Lanka maintain more restrictive legal frameworks despite pockets of progressive legislation. All four countries demonstrate persistent gaps in enforcement mechanisms, funding allocation for community participation, and service accessibility for criminalized populations (46, 47).

Cross-cutting patterns emerge across the region. First, colonial-era legal frameworks continue to influence contemporary HIV policy environments, with Section 377 derivatives and vagrancy laws serving as primary instruments of criminalization. Second, civil society organizations function as de facto service providers filling state capacity gaps, yet operate under increasing legal and financial constraints. Third, urban–rural disparities in service access reflect broader health system inequalities, with key populations in remote areas facing compounded marginalization. Fourth, women within key population groups—female sex workers, women who inject drugs, and transgender women—experience intersectional discrimination that compounds HIV vulnerability.

Comparative assessment of rights-based HIV policy dimensions in South Asia shown in Table 1.

India’s Navtej Singh Johar judgment decriminalized same-sex conduct in 2018, affirming privacy and dignity rights (14). However, sex work and drug use remain criminalized under separate statutes, producing a patchwork legal environment hindering universal service access (48). Nepal’s constitution enshrines non-discrimination for sexual and gender minorities, supplemented by judicial recognition of third gender and same-sex marriage in principle, yet lacks comprehensive implementing legislation (16, 49). Pakistan’s Transgender Persons Act offers broad protections but coexists with criminalization of MSM, sex workers, and PWID under penal and Hudood statutes, limiting its practical impact (50, 51). Sri Lanka’s colonial-era penal provisions continue unaltered, creating a hostile environment that deters service uptake despite robust general population services (52, 53).

India’s HIV/AIDS Act of 2017 prohibits discrimination but lacks robust enforcement mechanisms and omits explicit SOGI protections, undermining its efficacy (8, 54). Nepal’s constitutional guarantees remain largely aspirational without dedicated statutes or enforcement bodies (55, 56). Pakistan’s transgender law mandates non-discrimination for transgender persons, but legislative contestation and limited resources for oversight weaken its enforcement (50, 51). Sri Lanka lacks targeted legal protections, relying on ad hoc court rulings to address HIV-related discrimination (57, 58).

India’s decentralized ART network and emerging PrEP programs offer a model for integration, yet rural and gender-diverse populations face discrimination and policing barriers at harm reduction sites (55, 59). Nepal’s NGO-led mobile testing expands outreach but sustainability hinges on continued donor support (60, 61). Pakistan’s donor-reliant services and absence of PrEP perpetuate low coverage and retention, while Sri Lanka’s centralized, stigma-prone system excludes nocturnal and mobile key populations (62–64).

CSOs are critical service providers across the region; however, legal restrictions on foreign funding (India’s FCRA), donor dependence (Nepal, Pakistan), and lack of state support (Sri Lanka) curtail their scale and influence (61, 65–68). Evidence shows that properly resourced community-led responses outperform top-down models in achieving cascade targets among key populations (15, 69).

The analysis corroborates international evidence that decriminalization of same-sex conduct, sex work, and drug use is associated with significant improvements in HIV service uptake and outcomes (111–113). India’s 2018 repeal of Section 377 led to an 11% increase in testing among MSM within 2 years, reflecting enhanced community trust and reduced fear of arrest (14, 114). Nepal’s constitutional protections and judicial recognition of third gender status correspond with near-universal ART coverage among transgender individuals in urban centers (15, 115). Conversely, Pakistan’s mixed legal landscape—progressive transgender law amidst criminalization of other key populations—yields uneven outcomes: high uptake among transgender persons in pilot sites but low overall cascade performance (10, 116). Sri Lanka’s continued criminalization of LGBTI and sex work populations correlates with service avoidance and unreported transmission clusters despite robust general population services (18, 63).

A consistent theme is the gap between legal reform and practical enforcement. Laws without implementation mechanisms risk creating illusory protections that undermine community confidence. In India, the HIV/AIDS Act (2017) legally prohibits discrimination but lacks designated enforcement bodies and suffers from low awareness among healthcare workers, limiting its impact (8, 54). Pakistan’s Transgender Persons Act mandates anti-discrimination safeguards yet faces regulatory vacuums and budgetary shortfalls for the National Commission for Transgender Persons, curtailing its operational capacity (50, 51). Nepal’s stalled Gender and Sexual Minorities Rights Act exemplifies how progressive constitutional language can stagnate without legislative follow-through (55). Addressing this gap requires not only law reform but also strengthened institutions, capacity building for rights commissions, and dedicated funding for enforcement and monitoring (117, 118).

Stigma within healthcare remains a potent barrier despite legal protections. Studies in India and Sri Lanka document high levels of provider prejudice toward sex workers, PWID, and transgender individuals, leading to delayed presentation and poor retention (13, 119, 120). Training programs reduce discriminatory attitudes by up to 60% when combined with institutional accountability measures, yet most countries lack mandatory, standardized non-discrimination curricula for health cadres (84, 121). Structural stigma also manifests in service location and design—centralized hospital-based ART services in Sri Lanka and Pakistan exclude rural and mobile populations, while harm reduction programs in India are subject to police raids, deterring PWID from accessing needle-syringe exchange and OST (59, 62, 122, 123). Health system transformation must prioritize culture change through leadership engagement, inclusive policies, and routine monitoring of stigma indicators alongside clinical outcomes (124, 125).

Civil society organizations (CSOs) have been the linchpin of effective HIV responses, especially in reaching marginalized groups. Peer-led outreach by the Durbar Mahila Samanwaya Committee in India and Blue Diamond Society in Nepal has achieved high testing and retention rates among female sex workers and transgender persons, respectively (15, 61, 126). However, CSOs often operate under restrictive legal frameworks and with inadequate funding; Pakistan allocates only 5% of its HIV budget to community services, undermining scale-up potential (16, 66). Evidence indicates that every 10% increase in community-led service funding correlates with a 5% improvement in cascade outcomes among key populations (127). Institutionalizing community participation requires formal governance mechanisms—reserved seats on national AIDS boards, budgetary earmarks, and co-creation of program strategies—to ensure that affected populations shape the services designed for them (69, 107).

South Asia’s experience underscores that legal change is necessary but not sufficient; it must be accompanied by robust implementation, stigma reduction, service redesign, and community empowerment to realize full public health benefits. The causal pathway from rights-based governance to epidemic control is evidenced by regional correlations between RBA score (aggregated dimension ratings) and 95-95-95 achievements: higher RBA scores align with stronger cascade performance (128, 129). This framework offers a model for other regions, such as Eastern Europe and Central Asia, where punitive laws and service gaps mirror South Asian challenges (130, 131).

The four strategic pillars—legal reform, health system transformation, funding equity, and regional collaboration—offer synergistic opportunities. Modeling from decriminalization in Portugal and harm reduction in Ukraine suggests that integrating these pillars can reduce HIV incidence by 30%–45% over a decade (132, 133). Policymakers should prioritize intersecting interventions, such as combining decriminalization pilots with community-led service expansion and anti-stigma training, to maximize impact and generate politically salient successes early in the reform process (134).

This study’s strength lies in its comprehensive, comparative approach, integrating legal analysis, policy review, program data, and community perspectives across four diverse national contexts. Employing a structured RBA framework ensures consistency and facilitates actionable insights. Limitations include reliance on secondary sources, variable data quality across countries, and limited disaggregation of outcome data for key populations. Future research should incorporate primary qualitative studies with affected individuals and service providers to deepen understanding of implementation barriers and facilitators (135, 136).

While legal reforms such as decriminalization, anti-discrimination statutes, and constitutional protections are critical milestones in advancing the rights of people living with HIV (PLHIV), they cannot by themselves guarantee meaningful change. Evidence from national and regional contexts demonstrates that statutory protections often coexist with coercive practices such as mandatory HIV testing, travel restrictions, and punitive disclosure requirements. These measures, although frequently justified in the name of protecting public health, can in practice undermine autonomy, confidentiality, and equitable access to care, thereby reinforcing stigma rather than alleviating it (137, 138).

A rights-based approach therefore requires more than the enactment of laws; it demands the integration of public health ethics into policy design and implementation. Ethical principles of justice, non-maleficence, autonomy, and solidarity provide the normative foundation to ensure that legal reforms advance health equity. For example, laws that prohibit discrimination must be accompanied by provider training, community engagement, and mechanisms of accountability to prevent violations in healthcare settings. Similarly, protections for key populations must be enforced through supportive rather than punitive health systems that build trust with marginalized communities.

By aligning legal frameworks with ethical imperatives, governments can move beyond symbolic compliance toward reforms that tangibly reduce stigma, expand access, and improve health outcomes. This balance between the structural guarantees of law and the lived realities of ethical practice is central to achieving sustainable progress in HIV prevention and care.