This blog post was originally published here on IAS.
HIV programmes are experiencing severe disruptions as a result of COVID-19. However, we must ensure continuity of treatment and support for viral suppression among people living with HIV, continue identifying undiagnosed individuals and initiating them on treatment, and help the vulnerable avoid acquiring HIV.
Key populations – men who have sex with men, people who use drugs, sex workers and transgender people – are particularly vulnerable to HIV service interruptions and additional harm during the COVID-19 pandemic. Stigma, discrimination, violence and other human rights violations routinely experienced by key populations will likely worsen, as will unemployment, housing instability and food insecurity. This will compound the obstacles key populations face in accessing services, perhaps making it more likely they will be denied assistance when they seek care. Other important services, like opioid substitution and gender-affirming hormone therapies, may be deprioritized as non-essential. Collectively, these experiences will have far-reaching consequences on mental health, exacerbated by physical distancing, and undermine HIV responses.
We urgently require rights-based, evidence-informed and community-led solutions that maintain or increase key populations’ access to HIV services while minimizing potential exposure to COVID-19 and promoting individuals’ safety. These must support physical distancing and decongestion of health facilities – in ways that respond to realities of key populations. Through the USAID- and PEPFAR-supported LINKAGES project, working in more than 30 countries, we have learned a lot about reaching key populations with HIV services.
We offer five ways to preserve key population-focused HIV services and promote the safety and well-being of staff and clients during the pandemic.
- Decentralize services to access points preferred by key populations. Advancing decentralized distribution of ART and other medications is critical for ensuring uninterrupted access to HIV services and reducing contact with clinics. Optimizing decentralization strategies requires that distribution points are accessible and safe for key populations. In Kenya and Malawi, LINKAGES found that making ART available in community-led drop-in centres (DICs) resulted in immediate improvements in treatment initiation and retention among men who have sex with men and female sex workers. DICs must be supported to achieve government accreditation to provide ART. Other strategies include peer navigators delivering ART at homes and hotspots. In Eswatini, LINKAGES identified drop-off locations where men who have sex with men and female sex workers can pick up condoms, lubricants and HIV self-test kits.
- Scale up multi-month dispensing (MMD) and community refills of ART, PrEP and other medications. For ART, establish three- and six-month MMD options, if stocks allow, to eliminate clinic visits. Where stocks are limited, prioritize clients who should be offered MMD, ensuring that key populations are given the same considerations as non-stigmatized clients. In Kenya and Malawi, our teams use a tool to monitor clinical service needs of key populations on ART to ensure that clients are scheduled for visits for MMD of ART and viral load testing. The LINKAGES Eswatini team adopted peer-led, community-based ART and PrEP refills for stable (three-month MMD) and non-stable and newly diagnosed (one-month supply) key population clients. MMD should also ensure an uninterrupted supply of condoms, lubricants and family planning commodities at key population-friendly community distribution points.
- Maximize online service delivery options. Harnessing online platforms to reach key populations has long been part of LINKAGES’ programming. In the era of COVID-19, this is essential for maintaining core HIV services and supporting community engagement during physical distancing. Online platforms can help: maintain contact with beneficiaries and reach new clients using social media and messenger apps; support people living with HIV through virtual case management; and screen and consult clients using telemedicine. Our programmes in 10 countries are shifting many of these services online with the Online Reservation App for HIV outreach, referral and case management. Programmes are beginning to use virtual platforms to provide technical assistance to clinical and community partners. In Indonesia, for example, staff are facilitating WhatsApp discussions to offer technical assistance to public health providers.
- Address the health and safety needs of implementers and beneficiaries. Preventing and responding to violence should be central in HIV programmes, and risks posed to key populations by the COVID-19 pandemic require that we double down on these efforts. Train healthcare workers on how to deal with the increased risk of violence (including intimate partner violence) key populations may face during the pandemic, and providing support online or by phone. When services are closed, offer people who inject drugs extra supplies, including syringes and harm reduction equipment for safer smoking, snorting and injecting. Help transgender clients limit disruptions to gender-affirming treatments, including hormone replacement therapy. This may help these individuals stay safe and HIV negative or adherent to treatment. Consider the health and safety of implementers. Assist staff in assessing their risk and decide together on the level of risk workers will be asked to take on. Help them secure authorization to move around and provide services, and determine how they will be supported if they are arrested during lockdowns or exposed to COVID-19 during outreach. Make mental health support available and encourage use of these services.
- Monitor the impact of COVID-19 on programmes and make data-driven course corrections. Use strategic information systems to monitor the effect of the pandemic on services across the cascade. You will soon begin to see what parts of the cascade and what key populations are most affected. You can look for trends to understand what solutions are most effective. Track the impact of COVID-19 on broader structural issues that will likely affect service delivery outcomes, including: funding for key population-focused programmes; human rights violations; violence; denial of services; and the need for mental health, nutrition and other services.
Scaling up these measures now can help safeguard the hard-fought gains of the global HIV response. If these solutions are sustained beyond the pandemic, they may also serve to modernize key population programming and position it to be more effective in our new reality.