Key Populations: Targeted Approaches Toward an AIDS-Free Generation

Photo of condoms

Targeted Condom and Lubricant Distribution, Vietnam
Cameron Wolf/USAID


Key populations (also referred to as most-at-risk populations) are people who inject drugs, gay men and other men who have sex with men (MSM), transgender persons and sex workers. They are disproportionately infected with HIV compared to the general population. There is no way toward an AIDS-free future without targeting approaches toward these highly marginalized and often hard to reach populations. The overall HIV prevalence among female sex workers in sub-Saharan Africa is about 14 times the overall HIV prevalence among the general population of women ages 15 to 49. The relative global burden among MSM compared to men in the general population shows a 19-fold difference. Rates among transgender persons and injecting drug users also are disproportionately high. Coverage rates of effective interventions among these key populations are extremely low, while stigma and discrimination – including gender-based violence – is high. Key populations, their partners and clients of sex workers face alarmingly low access to services as persistent societal barriers stand in the way. The implementation and scale-up of comprehensive prevention and treatment interventions are needed to address the burden of HIV faced by key populations. Without this, we cannot effectively turn the tide on HIV.


The U.S. Agency for International Development (USAID), through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), has supported HIV and AIDS research, policy, prevention, care and treatment services for key populations at the country, regional and global levels.  These efforts have been focused on countries with concentrated and low- level epidemics (i.e., Ghana, Cambodia, Dominican Republic and Ukraine) as well as within generalized high-prevalence settings (i.e., Cameroon, Kenya, Haiti and Swaziland). 

Photo of HIV counselor

HIV Counselor, Papua New Guinea
Cameron Wolf/USAID

Early efforts by USAID supported the design of the first behavioral and integrated biologic surveys, which set the course for key population evaluation for the past 20 years.  These efforts informed programming, and USAID developed “packages” of services and approaches for key populations through a range of early interventions in Asia, Latin America, Eastern Europe and later Africa. These packages spread and influenced what is now referred to as the comprehensive package of services for key populations promoted by PEPFAR, the World Health Organization (WHO) and UNAIDS. The comprehensive package comes from evidence-based guidelines designed to ensure that national public health officials, managers of HIV and sexually transmitted infection (STI) programs, key population communities and health workers have standards from which to tailor their local response and ensures other donors, including USAID and the Global Fund to Fight AIDS, Tuberculosis and Malaria, offer complementary support.

Key components of a comprehensive package of services:

Photo of transgender outreach worker wearing a condom dress.

Transgender Outreach Worker in Condom Dress, Thailand
Cameron Wolf/USAID

  • Empowering peer-led outreach (including targeted behavior and social norm change approaches)
  • Community-based services in safe spaces (including drop-in centers)
  • Interventions to address gender-based violence
  • Provision of condoms and lubricant
  • STI testing and treatment
  • HIV testing and counseling
  • Clinical care and antiretroviral treatment
  • Community-based care and support for resilience

This recommended package is most effective when implemented with structural interventions and community mobilization approaches. A sustained key population response is one where services are of high quality and can be accessed by sex workers, MSM, transgender persons and people who inject drugs. It is one where sustained responses are driven through the community, organizations, groups and networks to ensure that the rights of key populations, including those living with HIV and AIDS, are respected.


In Ghana, MSM and sex workers, both male and female, are highly stigmatized and vulnerable to verbal and physical abuse. Laws against sexual solicitation and male-to-male sex further contribute to risk of violence and abuse among key populations.  Documented attacks range from rape, unlawful arrest, extortion, hate crimes and, in a few cases, murder. Threats to personal safety clearly inhibit access to HIV and other health care-related services.  In response, USAID Ghana implemented an integrated protection network into its community-based HIV prevention, referral and care activities. The network, known as “M-Friends, M-Watchers,” is built around a rapid response system to address rights violations against key populations. In each locality, individuals in positions of power who are considered potential allies are trained as “M-Friends.” They include lawyers, police, district assembly members and health care workers. “M-Watchers” are lead peer educators (either MSM or sex workers) who are trained to identify and report abuses (within 2 hours of when they are first notified).  The system also works with the local federation of female lawyers. They provide legal literacy and train and deploy lawyers in all 10 regions of the country to provide legal aid to MSM and sex workers. In many cases these populations need an understanding of their rights as citizens and the knowledge that they are supported. This contributes to the collective response to defend their rights as a community. This is one component of the complementary package of HIV and AIDS services used to enable key populations to take action and access services in Ghana.

Photo of a man holding a condom and wearing a shirt say that says 'safe sex'.

Promotional Materials, Thailand
Cameron Wolf/USAID


The implementation and scale-up of available, targeted interventions for key populations are important steps toward gaining better control over the spread and impact of HIV and AIDS.


Last updated: February 02, 2016

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