“We FSW [female sex workers], we do not have time, we work at night and sleep during the day. If you find us at the community, we will accept the test – we only go to the clinic when we test HIV positive. Many FSW will never accept to go the clinic. If we can get ARVs in the community that would be great.” – Amon, FSW, Abidjan, Cote d’Ivoire
Providing HIV services in a way that reflects the preferences of various groups of people with similar needs puts clients at the center, uses health system resources more efficiently and dramatically improves outcomes.
In the USAID- and PEPFAR-supported LINKAGES project, we have found that differentiated service delivery for key populations – groups that include men who have sex with men, sex workers, people who inject drugs, and transgender people – increases the number of people reached, tested, initiated on treatment and retained in care.
In the past two years, emphasis has been placed on differentiated service delivery for antiretroviral therapy (ART) among key populations with good success. Case studies are featured in Differentiated Care for Antiretroviral Therapy for Key Populations: Case Examples from the LINKAGES Project.
But achieving the full impact of differentiated care demands a broader view. It is crucially important for the HIV services community to broaden application to encompass the prevention side of the cascade of HIV services for key populations. Within the LINKAGES project, this means reaching beneficiaries where they live and work – through venue-based outreaches, mobile clinics, drop-in centers and linkage to public facilities for testing.
Differentiated care in Cote d’Ivoire resulted in a more than 1000 percent increase in the number of individuals who received HIV testing services through community-based venues versus seven clinics between October 2016 and September 2017 (30,675 in community locations compared to 2,361 at the clinics). This success continued into the first quarter of 2018 (12,596 compared to 613).
The foundation for implementing differentiated service delivery for key populations involves strategic location of services; addressing a wider range of health and social needs; ensuring confidentiality and anonymity; community involvement, including defined and paid roles for peers; extending clinic operating hours; flexible times and locations of service provision; nonjudgmental and friendly services; event-driven services; and increasing mobile services.
Detailed guidance on planning and implementing differentiated care is provided in A Synopsis of Differentiated Care for ART Program Managers. Topics include reconfiguration of client flow systems, defining client categories based on needed care, and case studies with specific adherence support schedules.
Using the differentiated service approach for key populations, particularly for prevention, increases those who are aware of their status and supports them in leading HIV responses among their communities. But implementation needs to be scaled up.
We need to invest in more drop-in centers to bring HIV testing to key population communities. We need to consult and engage key population members to find out where the best places are to provide services and what modalities will work best for them. And, finally, in some settings, regulatory barriers to legitimizing lay and peer providers as part of health care need to be overcome.
We know that differentiated care is a game changer for reaching key populations and retaining them in care. The challenge is how to help stakeholders and others understand the crucial importance of a comprehensive approach to implementation by including the prevention side of the cascade.