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Key Populations: Achieving Equitable Access To End HIV

USAID's investments in key populations help 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.

Key Populations (KP) include sex workers, 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. “According to UNAIDS, in 2022, the relative risk of acquiring HIV was 14 times higher for people who inject drugs, 23 times higher for gay men and other men who have sex with men, 9 times higher for sex workers and 20 times higher for transgender women than in the wider population globally.” Key populations 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 KPs 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.

Our Approach and Results

Health equity for key populations can be addressed by differentiating prevention, testing, care, and treatment services and integrating services (including mental health, STI, family planning, TB, and other services) into existing KP HIV services to ensure that barriers to service access are addressed.

USAID reaches key populations who would otherwise lack access to HIV and other health services by providing service choice through a range of client-centered services through KP community-led programming, private sector health options and KP competent public health facilities. Key populations are provided prevention, HIV testing, and treatment services through differentiated service delivery models, providing services in ways key populations can be served without discrimination. To increase access to services, USAID supports drop-in centers and one-stop-shops that provide community-based treatment initiation and refills in addition to testing and other services, online and personalized peer-based outreach and case management, mobile services and alternative pick-up points, such as pharmacy pick up for HIV treatment, PrEP and HIV self testing kits. USAID programming for KPs helps 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  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. The comprehensive package includes:

  • Health Interventions

    • Condom and lubricant programming

    • Harm reduction interventions

    • Behavioral interventions

    • HIV testing services, including HIV self-testing

    • HIV treatment and care 

    • Pre-exposure prophylaxis (PrEP) and post exposure prophylaxis (PEP)

    • 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 increased 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 were especially critical during the COVID-19 pandemic.

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, while maintaining data security.

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, engaging key population community leaders in the implementation and monitoring of HIV services promotes local, sustainable solutions. 

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 inclusion of community-led services within national health and social insurance schemes.

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.

  • In 2023, USAID and partners supported more than 1.8 million people within key populations to avert HIV infection through HIV prevention services and supportive interventions.

  • USAID supported more than 283,000 people within key populations to start PrEP in 2023, reducing their risk of contracting HIV. Together, key populations and AGYW constitute more than half of all USAID-supported people who started on PrEP.

  • In 2023, USAID supported more than 300,000 people within key populations, in 42 countries, to receive life-saving HIV medication. 

  • USAID supports implementing partners to address key populations’ comprehensive health needs—moving beyond single diseases to support the whole person within KP-focused and KP-friendly settings. 

Resources

Visit our HIV and AIDS Resource Page