In 2014, USAID awarded FHI 360 the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project, a global cooperative agreement funded by PEPFAR and dedicated to addressing the HIV epidemic among key populations — men who have sex with men, sex workers, transgender people, and people who inject drugs. Over the past seven years, LINKAGES transformed how the needs of key populations are addressed in global and local responses to the HIV epidemic. The key-populations-focused programming launched in many countries through LINKAGES now continues under the Meeting Targets and Maintaining Epidemic Control (EpiC) project. As LINKAGES officially comes to an end, we are taking stock of what the project has meant for people, policies, partners, and programming.
This blog is the first in a three-part series dedicated to recognizing and celebrating the achievements of the LINKAGES project around the world. Here we share highlights — with links to technical resources and reports providing more detail — of the work in Africa.
LINKAGES Angola directly engaged key populations in creating and implementing their own solutions to address challenges with antiretroviral therapy (ART) adherence and HIV testing. Additionally, the project helped train female sex worker peer educators to provide HIV testing and counseling. The implementation of the enhanced peer outreach approach and online outreach were successful in reaching and identifying men who have sex with men living with HIV. The project’s contributions to Angola’s national guidance on legal rights pertaining to gender and sexual orientation increased access to HIV services for key populations.
The LINKAGES Botswana team supported the Government of Botswana in introducing pre-exposure prophylaxis (PrEP) and initiating more than 500 key population individuals on PrEP in the final year. The project also successfully introduced the enhanced peer outreach approach, index testing, and peer navigation, which led to substantial increases in case finding and ART linkage rates. At the policy level, the project contributed data used in the legal case that led to the Botswana High Court’s decision to decriminalize homosexuality in June 2019.
In Burundi, LINKAGES created three drop-in centers for female sex workers that provided HIV testing, sexually transmitted infection diagnosis, and ART services. The project also helped strengthen an existing drop-in center to serve men who have sex with men and transgender people. The Burundi team found case-finding success through index testing, the enhanced peer outreach approach, and HIV self-testing, with a 90 percent linkage-to-ART rate over the life of the project and 97 percent the last year.
LINKAGES Cote d’Ivoire successfully implemented index testing and the enhanced peer outreach approach with men who have sex with men and female sex workers, leading the government to adopt these case-finding strategies as national approaches. LINKAGES Cote d’Ivoire also equipped health care providers and police officers to help reduce stigma and discrimination as well as prevent and respond to sexual and gender-based violence.
Democratic Republic of the Congo
LINKAGES DRC introduced differentiated HIV testing modalities including index testing, HIV self-testing, and the enhanced peer outreach approach, enabling the project to newly diagnose nearly 8,000 people living with HIV. The DRC team secured approval from the government to introduce ART initiation and refills at key-population-friendly community ART distribution points, and led the introduction of pre-exposure prophylaxis (PrEP) for key populations in the country. As part of local partner capacity development efforts, LINKAGES DRC helped establish two key-population-led organizations — one for female sex workers and one for men who have sex with men.
In Eswatini, LINKAGES prioritized working with law enforcement as a way to mitigate structural barriers to better HIV outcomes among key populations. The project developed and implemented trainings for the Royal Swaziland Police Service (RSPS) that helped educate police commanders on why members of key populations are at such high risk of HIV infection and the importance of upholding their human rights. The project demonstrated that it is possible to forge effective partnerships between the police and key populations, even in settings where sex work and same-sex relationships are criminalized. These efforts complemented the project’s service delivery efforts, including community-based delivery of PrEP.
LINKAGES Kenya developed several key population program monitoring tools that were later adopted by the Ministry of Health, including unique identifier codes and the people living with HIV tracker. They engaged county health management teams in ensuring drop-in centers met accreditation criteria to provide ART, which led to improved treatment initiation and retention among men who have sex with men and female sex workers. The Kenya team was a pioneer in building the capacity of civil society organization implementing partners and preparing them to receive direct funding.
LINKAGES Lesotho advocated for greater recognition of the needs of key populations in national HIV policies and guidelines and provided the national HIV program with quality key population program data. The project supported the establishment of a Key Population Technical Working Group and informed the development of a national HIV service package. LINKAGES introduced several innovations to improve case finding, including a risk assessment screening tool to assist in segmenting and prioritizing key populations for HIV services based on their level of risk.
LINKAGES Liberia introduced several strategic actions to increase treatment initiation and adherence, ultimately achieving a 97 percent overall ART initiation rate among the newly diagnosed. Additionally, LINKAGES contributed to an increase in national viral load testing coverage and improved viral load suppression rates across project districts. The project created an effective structure for gender-based violence response for key populations, and led efforts to reduce violence and stigma toward them in government-run health care facilities
In Malawi, LINKAGES’ suite of services was adopted as the country’s standard key population service package and integrated into the national HIV prevention strategy. Over the life of project, the LINKAGES Malawi team newly diagnosed more than 7,200 individuals living with HIV and initiated nearly 90 percent on treatment. One of the most significant achievements was negotiating the provision of ART at local partner-run drop-in centers. LINKAGES Malawi also developed the capacity of peer outreach workers and clinical providers at drop-in centers to assess violence exposure and provide appropriate support and referrals when disclosed.
LINKAGES Mali demonstrated that strategies such as enhanced peer outreach approach, risk segmentation, index testing, risk network referral, peer navigation, and online outreach offered ways to engage previously unreached key population individuals and link them to high-quality HIV services. The team also increased viral load monitoring of people living with HIV by introducing dried blood spot samples for viral load testing and strengthening collaboration among staff at community, government health facility, and national referral laboratory levels. The project introduced the use of unique identifier codes to improve client tracking and support.
Photo Credit: LINKAGES Angola