Key Populations: Achieving Equitable Access To End AIDS

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A client receives their antiretroviral treatment (ART) through home delivery in Togo
A client receives their antiretroviral treatment (ART) through home delivery in Togo.
Photo credit: Raymond Varvatos Avosseh for FHI 360


The HIV response underscores the importance of working with Key Populations (KP) 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, these populations are particularly vulnerable and disproportionately affected by HIV due to risk behaviors, marginalization, and structural factors such as stigma, discrimination, violence, human right violations, and criminalization, all which contribute to a lack of access to health services. In 2020, key populations and their sexual partners accounted for 65 percent of new HIV infections globally.

The new UNAIDS Global AIDS Strategy (2021–2026) seeks to reduce the inequalities that drive the AIDS epidemic and put people at the center to get the world on-track to end AIDS as a public health threat by 2030. For the majority of key populations and other priority populations, including millions of people living with HIV who are unaware of their HIV status or lack access to treatment, the benefits of scientific advances and HIV-related social and legal protection remain beyond reach. Recognizing this, one of four pillars of current PEPFAR guidance is to focus on equity across the PEPFAR enterprise and use an equity lens to ensure services are tailored for those not yet fully experiencing the benefits of HIV epidemic control, including key populations, children, adolescent girls and young women, and other priority populations.

USAID Impact

Supporting a Comprehensive Package of Services

USAID engages hard to reach populations and provides client-centered services through community-led programming. Today across 47 countries, USAID’s key populations programs offer differentiated services to access HIV testing, prevention, and care services that allow for choice, personal care and the provision of services in locations where key populations are treated with dignity and the integrated services they require. It is a shared goal with our implementing partners that these services should be sustainable as well as competent, reinforced by national policies, domestic financing and rights based accountability that reinforces the importance of community monitoring and service delivery. Among the approaches that increase access to health services are service points managed directly by the community, but linked into the public health system (drop in centers/ one stop shops), online and personalized outreach, and alternative pick-up points, such as community-based testing, PrEP and treatment initiation, and refills.

Among the structural interventions that USAID seeks to scale is community led violence prevention and response to address norms of violence, stigma and discrimination, fostering enabling policies, offering mental health and psycosocial support services, promoting legal literacy for KP beneficiaires, and supporting health care worker competency training. USAID/OHA also collaborates with the Democracy, Human Rights, and Governance Bureau to support additional structural interventions, such as helping KP beneficiaries know their rights, informing governments of the impact of harmful policies on health services, and strengthening the capacity of KP community structuctures and organizations. In the midst of COVID-19-related disruptions to individual lives and services, USAID has worked closely with implementing partners to adapt programming and share solutions for ensuring continuity of vital services for key populations. USAID and partners have also worked with various donors to meet additional emergency needs of KP beneficiaires due to economic challenges of COVID, as so many KP beneficiaries lack familial support.

USAID promotes a comprehensive package of services and approaches through a range of early interventions. The comprehensive package follows 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 and counselling
    • HIV treatment and care + 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, and
    • Mental health services.

There is tailoring of the specific services a person requires and the way they are delivered based on relative risk and need. 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 who are otherwise hard to reach. 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, and through private pharmacies 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 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. These “Going Online” efforts to expand online and virtual channels to accelerate HIV support and epidemic control have been critical during COVID-19.

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, ensure communities are funded and capacitated to lead the work and systems ( including funding for human rights based programming), and ensure services are in place to correct disruptions. USAID will continue to promote program alignment, identify metrics for program monitoring, and support innovations that can be scaled to support quality programs. To this end, USAID collaborates with other donors to advance key populations programming.

As USAID shifts funding to directly support local partners, core to the USAID mandate is the participation of key population community leaders in the implementation and monitoring of HIV services.

2021 Achievements

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.

Prevention and Testing in FY20:

  • Over one million members of key populations accessed testing services;
  • More than 330,000 members of key populations accessed HIV self-testing; and
  • Over 64,000 members of key populations on PrEP.

Linkage to Treatment in FY21:

  • More than 100,000 members of key populations learned of their HIV-positive status through USAID support;
  • More than 100,000 (97%) members of key populations were linked to treatment (independent of the PEPFAR agency supporting the ART site), including 72,795 new clients who were linked to treatment (65%) within USAID programs; and
  • Today USAID supports community treatment initiation for key populations in 37 countries.

Adherence and Viral Load Suppression in FY20 (a priority and focus of KP programming):

  • The number of key population clients on treatment continues to grow, with 218,081 accessing care and treatment services and 98% continuing on treatment from FY21 Q3 to Q4; and,
  • Of those clients on treatment within USAID programs, 115,619 have accessed viral load testing services and 95% of those tested are virally suppressed.

Structural Interventions in FY20:

  • USAID promoted structural interventions in 17 countries, policy efforts in ten countries, and capacity strengthening of community-based organizations (CBOs) in 23 countries; and,
  • USAID provided small grants to 16 local KP-led organizations across seven countries. These grants funded KP safe spaces, strengthened violence prevention and response mechanisms, stigma reduction training for healthcare workers, legal literacy workshops, law enforcement sensitization on KP, and livelihood support and economic strengthening.

Additional Resources

Last updated: May 12, 2022

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