If you’re a person living with HIV or a member of the LGBTQ community, how would you rate your quality of life on a scale of 1 to 5? How would you rate your city? In essence, that’s what a new global report has tried to measure for 50 cities and municipalities participating in the international HIV initiative called Fast-Track Cities. The report assessed various health factors, including those related to HIV, that affect LGBTQ people in those 50 cities.

The results? A summary of the report’s key takeaways offers these six insights:

  • On average, LGBTQ quality of life was rated 3.2 on a 1 to 5 scale across 50 cities—midway between “poor” and “excellent.”

  • HIV services were better rated than other forms of health services, and nonprofits scored better than other local actors on LGBTQ community engagement.

  • Access to LGBTQ inclusive health care services received mediocre scores, with mental health care and gender-affirming care particularly lacking.

  • Even in cities and municipalities with LGBTQ legal protections, most key informants raised discrimination and criminal justice issues as a concern.

  • Across regions, African cities report the worst average quality of life score (2.7), followed by cities in the Americas (3.2), Europe (3.3) and Asia-Pacific (3.6).

  • All cities and municipalities have areas that need improvement, with no city or municipality achieving overall “excellent” scores on LGBTQ health issues.

Titled LGBTI+ Health Equity: A Global Report of 50 Fast-Track Cities, the report was funded with help of ViiV Healthcare and produced by the International Association of Providers of AIDS Care (IAPAC), which spearheads the Fast-Track Cities initiative to end the epidemics of HIV, tuberculosis (TB) and viral hepatitis (hep B and C) by 2030. The report was released August 18 to coincide with Copenhagen 2021 WorldPride.

“The link between LGBTI+ health equity and our work at IAPAC is perhaps obvious given the longstanding and staggering disparities that LGBTI+ individuals face with respect to HIV,” writes IAPAC president and CEO José M. Zuniga, PhD, MPH, in the report’s introductory letter. (You can watch Zuniga in the video at the top of this article; it’s also available on IAPAC’s YouTube channel.)

The cover of the 2021 LGBTQ health report

The cover of the 2021 LGBTQ health reportIAPAC.org

“While HIV continues to be a critical issue in LGBTI+ health,” Zuniga continues in the letter, “we cannot allow that to be the only LGBTI+ health topic that is studied, discussed, funded and actioned. Fundamentally, LGBTI+ health equity is about stigma, discrimination, and injustice, but also about resilience. The history of conditions facing LGBTI+ communities has led to myriad health inequities—including physical, mental, and behavioral—that are all interwoven.…

“The bottom line is that we cannot adequately address HIV and other health conditions without including LGBTI+ populations, and we cannot adequately serve LGBTI+ populations unless we understand the diversity and complexity of these communities and their needs.”

To that end, the report and survey aim to understand and improve the health equity of LGBTQ individuals in Fast-Track Cities.

One aspect of the report measures a number of social determinants of health, rating them on a scale of 1 (not a problem) to 4 (serious problem). Topics include housing access (a 3.2 rating), employment access (2.9), criminal justice for people of color (2.8) and discrimination based on gender identity (3), sexual orientation (2.7) and HIV (2.4).

In its executive summary, the report notes, in part:

[M]any cities lacked data beyond HIV among sexual minority men and transgender women, and some other conditions with respect to sexual minority men only. These results indicate a dire need for disaggregated data on LGBTI+ health, particularly at the local level, where interventions are implemented.


HIV-related services received by far the best rating when looking at access to care for LGBTI+ individuals, scoring a 3.8 on a 1 to 5 scale. Primary care was next, with a score of 3.1, followed by mental health care at 2.8, and gender-affirming care at 2.7. These trends were relatively consistent across the study’s four regions and reaffirm the status of HIV care providers as leaders in LGBTI+ health equity, but also highlight the need for more focus on mental health and services for transgender individuals.

The report offers 10 recommendations to address health inequities:

  1. Prioritize the elimination of inequities within LGBTI+ communities. These include those affecting racial and ethnic minorities, immigrants, low-income individuals, and people with disabilities, as well as needs specific to transgender and nonbinary people.

  2. Address underlying socioeconomic factors.

  3. Improve inclusive data collection.
  4. Address criminal justice disparities.
  5. Ensure LGBTQ nondiscrimination.
  6. Engage LGBTQ communities.

  7. Recognize gender minorities and their health needs.

  8. Improve health systems.

  9. Foster multisectoral collaboration between local, national and international entities.

  10. Support HIV service providers and LGBTQ care leaders.

The Fast-Track Cities initiative was launched on World AIDS Day, December 1, 2014, in Paris as a collaborative effort between IAPAC, UNAIDS and UN-Habitat. More than 350 organizations worldwide have signed the resulting Paris Declaration on Fast-Track Cities.

For a complete list of global cities and their data, go to the Fast-Track Cities Global Web Portal.

In related news, see “How Did 12 U.S. Cities Do in Reaching their 90-90-90 HIV Goals?” from December 2020, “NYC Is the First U.S. Fast-Track City to Meet the 90-90-90 HIV Goals” from December 2019 and “Podcast Series Tells Unique Stories of ‘Fast-Track Cities’ Fighting HIV.”