Meghan DiCarlo, Senior Technical Advisor, FHI 360/EpiC

Leading scientists, thought leaders, program innovators, and community advocates will gather July 30–August 2 at AIDS 2020—the 24th International AIDS Conference—in Montreal to discuss the latest scientific discoveries, programmatic innovations, and policy priorities for HIV prevention, testing, care, and treatment. What better time to reinvigorate the HIV response—more than two years into the COVID-19 pandemic—and recommit to the global 95-95-95 targets set forth by the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Accelerating progress toward epidemic control is especially important for members of key populations—men who have sex with men, sex workers, transgender people, people who inject drugs, and people in prisons and other closed settings—who shoulder a disproportionate burden of HIV. Globally, over half of estimated new HIV infections occur among key population members and their sexual partners.

Reaching epidemic control will, for many countries, increasingly require intensified programming and targeted resource allocation to meet the needs of these groups. However, insufficient funds in amount and the way they are spent contributes to the systematic marginalization of key populations from services.

UNAIDS has recently highlighted the urgent need to take action to end the inequalities, including those faced by key populations, which have only been exacerbated by the COVID-19 pandemic.

To address inequalities and improve health outcomes among key populations, funders and programs must increase investments in four key areas, including trusted access to services; differentiated service delivery; removal of legal, political, and discriminatory barriers; and integration of services.

Build a trusted access platform

Key population programs must be built on the foundation of a trusted access platform, a coordinated, client-centered, community- and clinic-based effort that works to establish trust, reaches underserved key populations, and encourages use to improve health and well-being. Many facility-based models fall short of addressing inequities and thus fail to reach those in most need. Trusted platforms may involve providing services directly through key population organizations or communities; increasing agency through solidarity and community mobilization; supporting community-led monitoring; and increasing provider competencies to provide respectful services.

Scale up differentiated service delivery models tailored to the needs of key populations

DSD models are client-centered approaches that adapt, simplify, and tailor HIV services to better meet client needs and reduce unnecessary health care system burden. Frequently, DSD models for key populations involve peers, often as educators, counselors, mobilizers, navigators, or simply as network members, to leverage expert community knowledge, build trust, and increase uptake of community-based services. However, a lack of funding for community-led demand generation for such services and lack of financial investment to adequately provide community-based services constrain DSD scale-up. A lack of policy support for some DSD models limits more widespread access.

Prioritize structural interventions

Structural interventions seek to change aspects of the legal, political, socioeconomic, and built environment that shape lives and impact health. Evidence from across sub-Saharan Africa demonstrates that key structural elements including discriminatory and punitive laws, human rights violations, and stigma increase HIV risk and hinder uptake of services among key populations. Although critical for an effective HIV response, these interventions consistently lack sufficient political and financial investment.

Integrate health services

While dollars for service integration may be sufficient, funds for key population programming are often siloed into specific health areas, such as HIV, thus limiting programs’ ability to comprehensively address all needs such as mental health, gender-affirming care, harm reduction, and gender-based violence. Service integration allows programs to be more responsive to the needs of key population members and also provides potential cost savings and efficiencies.

These four elements entail upfront and ongoing costs not always present in facility-based models. Investment in these elements is lacking because information on costs is insufficient and because these components are often viewed as “extras,” not necessities. Costing studies of key population programs frequently neglect to assess all amounts needed to provide effective services for key populations and systematically underestimate total and unitary costs.

More accurate cost data, as well as more data on the benefits of comprehensive programs, are needed.  A commentary on a recent costing study from the USAID Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project suggest that adequate funding for these four program elements can yield benefits in program performance. Despite this and other evidence, the lack of data on the true costs of these elements and the costs of failing to provide them prevents sufficient investment in these critical elements.

As nations strive to reach the 2030 UNAIDS goals, donors, governments, and implementers should reconsider the true, but often hidden, costs in future health care dollars and, in lives, if they fail to invest in community-based and community-driven key population programs that address structural inequities. We must consider not only dollars wasted but also costs of perpetuating inequities and missing those who must be reached in the last mile of HIV epidemic control.

Featured Image: EpiC partner Engage Men’s Health (EMH) peer outreach team has been working with Wembley Shelter in Johannesburg for almost a year. In that time, a safe space for MSM has been established. A park home has been allocated as an MSM dormitory. EMH has trained social workers on issues faced by the broader community and how to provide sensitive and competent services. In addition, the aim of the project is to provide not only health services but also skills development and mental health programs for vulnerable young MSM and LGBT people (David Penney/EpiC).