A client receives their antiretroviral treatment (ART) through home delivery in Togo.
Photo credit: Raymond Varvatos Avosseh for FHI 360
Key Populations (KP) include sex workers, gay men and other men who have sex with men, transgender people, people who inject drugs, and people in prisons and other enclosed settings. Globally, key populations are disproportionately affected by HIV. In 2021, key populations and their sexual partners accounted for 70 percent of new HIV infections. They have inequitable access to safe, effective, and quality HIV services and face disproportionate levels of stigma, discrimination, violence, human rights violations, and criminalization. Significant barriers, such as police harassment, societal discrimination, and insufficient community-based services prevent them from getting the care they need. USAID supports countries as they work to address these barriers and move toward the UNAIDS 10-10-10 Social Enabler Targets.
Differentiating Services and Supporting a Comprehensive Package of Services
Health equity for key populations can be best addressed by differentiating prevention, testing, care, and treatment services and integrating services (including mental health, STI, family planning, TB, and other services) to ensure that barriers to service access are addressed.
USAID engages hard to reach populations and provides client-centered services through KP community-led programming. Key populations are provided prevention, HIV testing, prevention, and treatment services through differentiated service delivery models, providing services in ways key populations can be served without discrimination. To build access to services, USAID supports drop-in centers, online and personalized outreach and case management, and alternative pick-up points, such as one-stop-shops that provide community-based treatment initiation and refills in addition to testing and other services. USAID programming integrates interventions to prevent and respond to violence, address stigma and discrimination, foster enabling policies, promote legal literacy, and support health care worker sensitization and the provision of competent care.
USAID has developed a comprehensive package of services and approaches through a range of early interventions and works with local partners and governments to deliver services. The comprehensive package comes from the WHO global key population guidelines, which serve as the standard for all international HIV implementation and guide national government policy and planning.
Comprehensive Package of Services for Key Populations:
- Health Interventions
- Condom and lubricant programming
- Harm reduction interventions
- Behavioral interventions
- HIV testing services
- HIV treatment and care + pre-exposure prophylaxis (PrEP)
- Prevention and management of viral Hep, TB, and mental health conditions
- Sexual and reproductive health interventions
- Structural Interventions
- Supportive legislation, policy, and funding
- Addressing stigma and discrimination
- Community empowerment
- Addressing violence
- Ensuring the safety and security of HIV implementers
USAID promotes HIV prevention through interpersonal communications, provision of condoms and lubricants, and promotion, initiation, and dispensation of PrEP. Testing approaches, including social network testing, index testing, self-testing, and risk network testing, complement traditional peer outreach models and lead to improved case identification of HIV-positive key populations as well as improved identification of key population members at significant ongoing risk for HIV, who are offered PrEP and other prevention.
To support HIV treatment and care for key populations, USAID built access to multi-month dispensing for both PrEP and antiretroviral treatment (ART) and dispensed these through clinics, drop-in centers, pharmacies, home delivery and other convenient pick up points, while also referring and supporting clients who get their care from ART sites. USAID key population programs have scaled treatment, care, and viral load services through clinical and community sites in order to increase access to these essential and lifesaving services, and have also scaled online and virtual approaches for engaging, linking, and retaining clients (and their social networks) into care. In addition to other differentiated models, these “Going Online” efforts to expand online and virtual channels to accelerate HIV support and epidemic control have been critical during COVID-19.
In all aspects of programming, USAID recognizes the need to achieve complete coverage of key populations and focuses on routine and surveillance data for targeting and informing performance.
Supporting Health Systems through Integration
USAID programs have supported decentralized drug distribution to allow distribution of HIV self test kits, PrEP, and HIV treatment medication through private pharmacies, automatic dispensing units, and in the mail. These innovative approaches, in partnership with the Ministries of Health and private sector pharmacies in countries where these activities are implemented, have resulted in improvements in expanding HIV service options beyond traditional clinical settings, and help people access HIV testing and stay on treatment.
Sustainability and Local Partners
Within each country with USAID key population programming, a sustainable national response is the goal of USAID’s work. There are many opportunities to leverage the high-quality work funded by PEPFAR to enhance the quality of services in-country. USAID will continue to promote program alignment, identify metrics for program monitoring, and support innovations that can be scaled to support quality programs.
As USAID shifts funding to directly support local partners and prioritize funding KP-led organizations, core to the USAID mandate is the participation of key population community leaders in the implementation and monitoring of HIV services. In the future, USAID will continue to strengthen the long-term sustainability of key population services and community leadership through a focus on sustainable financing methods like social contracting and integration within national systems.
In support of PEPFAR and UNAIDS’ 95-95-95 goals, USAID implements and monitors progress of key population programming across the full cascade of HIV services.
Linkage to Treatment in FY22:
- Approximately 100,000 members of key populations learned of their HIV-positive status through USAID support;
- Nearly 97,000 (>95 percent) members of key populations were linked to treatment including more than 75,000 new clients who were linked to treatment (75 percent) within USAID programs; and
- Today USAID supports community treatment initiation for key populations in 34 countries.
Scaling PrEP in FY22
- More than 225,000 HIV-negative members of key populations initiated PrEP through USAID support, and for every new PrEP initiation per quarter an equal or greater number continued PrEP (>80,000 in Q4).
- PEPFAR Solutions Platform- Key Populations
- Differentiated and simplified pre-exposure prophylaxis for HIV prevention: update to WHO implementation guidance, July 2022 UNAIDS: Key Population Trusted Access Platforms
- PEPFAR Key Populations Investment Fund Fact Sheet
- KPIF West Africa: Building the capacity of nascent Key Population organizations to drive the HIV response
- Innovate, Implement, Integrate: Virtual interventions in response to HIV, sexually transmitted infections and viral hepatitis (unaids.org)
- QuickRes Technical Guide: A Global Online Reservation and Case Management App for HIV Programs
- EpiC: Long-Term HIV Treatment Adherence for Key Populations
- EpiC Spotlight on PreP
- EpiC Index Testing and Risk Network Referral Training Package
- EpiC Project Blog
- LINKAGES: Violence Prevention and Response Series
- LINKAGES: Reaching the Third 95: Viral Load Suppression among Key Population Individuals Living with HIV