Rose Wilcher, Knowledge Management Director, LINKAGES & EpiC, FHI 360
Hally Mahler, Project Director, LINKAGES & EpiC, FHI 360
Tisha Wheeler, Key Populations and Rights Branch Chief, Office of HIV/AIDS, USAID
From 2014 to 2021, Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) was USAID’s flagship project designed to scale a community-led response to the HIV epidemic among key populations (KPs) — men who have sex with men, female sex workers, people who inject drugs, and transgender individuals. LINKAGES was funded primarily through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and led by FHI 360 with partners Pact, IntraHealth, and the University of North Carolina. In addition, through the LINKAGES Advisory Board, the project received strategic guidance from global KP constituency groups. LINKAGES was implemented in 40 countries and brought innovation and client-centered care to unprecedented numbers of KP individuals.
Over the life of project, LINKAGES tested more than 2.5 million individuals for HIV. Nearly 99,000 people were newly diagnosed with HIV through the project, and more than 66,000 were initiated on life-saving antiretroviral therapy (ART). The story behind these numbers lies with the project’s community partners. LINKAGES worked with more than 200 local partners, 60 of which were KP-led, civil society organizations (CSOs). Through these partnerships, LINKAGES demonstrated what these CSOs already knew — community leadership works.
A cornerstone of KP programming that the LINKAGES project formalized and scaled was the engagement and leadership of KP community members as peer outreach workers, peer educators, peer navigators, and lay health providers. In Cote d’Ivoire, for example, LINKAGES trained more than 250 peer educators and peer navigators, all of whom were later certified by the government to provide HIV testing in their communities. In many places, these peers also provided first-line support to victims of violence, assisted with HIV self-testing, and championed pre-exposure prophylaxis (PrEP).
Community-led ART and PrEP services
In many countries, local CSO partners established community service sites or drop-in centers (DICs) where KP members could galvanize human rights efforts, provide social support in stigmatized environments, and access services. To promote sustainability, LINKAGES sought to highlight the success of this community model in reaching KPs. As a result, many of these DICs received the necessary government accreditation to expand their clinical offerings to include ART services, diagnosis and treatment of sexually transmitted infections, and PrEP. By the end of the project in Kenya, 44% of men who have sex with men and 45% of female sex workers preferred to be linked to treatment at the DICs, as opposed to government-run health facilities, and were accessing ART there. In Thailand, LINKAGES’ KP-led partners accounted for 58% of all PrEP uptake in Thailand between 2014 and 2020.
LINKAGES began providing HIV services virtually in 2017 to promote more inclusive, convenient, and client-centered services. Through its Going Online portfolio, LINKAGES pioneered the use of differentiated online outreach approaches, including social network outreach, social influencer outreach, and online targeted advertising; introduced the Online Reservation and Case Management App (ORA); and implemented LINK, a routine electronic client feedback system for HIV services. These approaches led to increases in HIV case finding and contributed to treatment retention and PrEP continuation, especially during the COVID-19 pandemic. With 35 countries now implementing Going Online approaches, these virtual services will continue to be important features of community-led HIV service delivery programs going forward.
The Tangerine Clinic became the first transgender health center in Thailand — and a model for differentiated, trans-competent service delivery. Established in 2016 by LINKAGES’ partner Thai Red Cross, the Tangerine Clinic offers integrated HIV services as part of a comprehensive health care package for trans people that also included hormone-level monitoring, mental health support and referral, and legal and human rights support and referral. Clinic staff — many of whom are transgender lay providers — have provided technical assistance for replication of all or part of this model in Vietnam, Burma, and Laos.
LINKAGES strengthened the capacity of peer outreach workers and clinical providers at DICs to assess violence exposure among KP members and provide appropriate support and referrals when violence was disclosed. The project established effective crisis response teams — led by community members themselves — and systems for reporting and responding to incidents of violence perpetrated against KP individuals. The project improved the safety and security of KP program implementers and demonstrated that it is possible to reduce the perpetration of stigma and discrimination against KPs by health care providers and police officers, even in settings where KPs are criminalized.
Throughout the project, LINKAGES worked with its local partners to use program data to advocate for policy changes that increase KPs’ access to HIV services. Through this collaborative, data-driven advocacy, LINKAGES contributed to policy changes that favored KPs in 23 countries. In three countries, LINKAGES data were successfully used by advocates in legal cases to support decriminalization of KPs.
LINKAGES was committed to strengthening the capacity of its local partners and successfully supported the transition of several to direct U.S. Government funding by the end of the project. CSOs reported receiving more than US $8.7 million in additional funding from donors other than USAID to continue programs for KPs. In Thailand, LINKAGES’ successful implementation of a KP-led service delivery model led to Thai government financing of former LINKAGES partners for ongoing implementation of the model. In other places, such as the Democratic Republic of the Congo, LINKAGES supported the formation of KP-led organizations focused on service delivery to their communities.
Strategic information and new evidence
LINKAGES used an evidenced-based approach to guide interventions for KPs. Working closely with its local partners, LINKAGES used quantitative and qualitative data from programmatic mapping, Priorities for Local AIDS Control Efforts (PLACE) studies, rapid coverage surveys, Integrated Biological and Behavioral Surveillance surveys, and routine program data to determine population needs, measure the effect of the interventions, and continuously refine program approaches. LINKAGES institutionalized custom indicators that complemented the standard PEPFAR indicators to enhance tracking of service uptake along the continuum of care. LINKAGES also set standards for and scaled the use of unique identifier codes that were accepted as safe and confidential by KP communities in several countries and developed individual level, sustainable software-based data management systems using the DHIS2 tracker. LINKAGES was committed to sharing the knowledge it generated from its data-driven implementation experience, contributing more than 50 articles and two KP-themed journal supplements to the peer-reviewed literature.
LINKAGES transitions to EpiC
In April 2019, the USAID- and PEPFAR-funded Meeting Targets and Maintaining Epidemic Control (EpiC) project, led by FHI 360 and partners, was launched. Over the first year of the project, most of LINKAGES’ country programs were transitioned to EpiC, under which KP programs continue to grow and innovate. As the LINKAGES project now officially comes to an end, we want to express our deepest gratitude to all of the project’s partners and collaborators for their contributions and for laying the foundation for continued progress in addressing the epidemic among KPs.
Photo Credit: LINKAGES Angola