Written by Chris Akolo, Technical Director, LINKAGES

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Today marks the 19^th World AIDS Day – a global call for unity in working toward epidemic control, support for people living with HIV, and commemoration of the more than 35 million people who have died of HIV- or AIDS-related illness since the virus was first identified in 1984.

I began work as an HIV physician in 1999 and have spent the past 18 years implementing HIV prevention, care, and treatment programs in resource-limited settings. For the past three years, I’ve served as technical director of the USAID– and PEPFAR-funded LINKAGES project, the largest global project dedicated to addressing the epidemic among key populations (KPs) including men who have sex with men, people who inject drugs, sex workers, and transgender people.

Since we first set out in 2014, the LINKAGES project has been through three major phases: (1) start-up; (2) rapid acceleration; and (3) stabilization at scale. We are now forging ahead in this third phase, providing support and technical assistance to improve HIV programming for KPs in 30 countries across Africa, Asia, and the Caribbean.  Using a common core Key Population Implementation Guide, which is oriented around the HIV cascade, our support in these countries consists of a range of activities designed to identify, reach, and help KP members learn their HIV status and enable those who are HIV-positive to access care and remain adherent to treatment. Getting to this phase has not been easy, and I have learned a lot along the way. On this World AIDS Day, I share some of the most important lessons I’ve learned during my time with the project:

• Key population members themselves must be at the forefront of programming. We are most successful when KP members are directly involved in the design and implementation of services. In all of the countries where we work, we engage KPs as peer educators and outreach workers to identify others in their communities and connect them to HIV testing and other related services. We employ them as peer navigators to support others living with HIV to access and adhere to treatment. And, we undertake institutional capacity building with KP-led community-based organizations for long-term sustainability.
• Data for decision-making is key. LINKAGES has developed robust strategic information systems with custom indicators that allow us to understand – in a timely manner and with great specificity – where we are having success and where we need to adjust our programmatic approaches at different points along the cascade. We have built the capacity of country teams and implementing partners in data analysis, interpretation and use, and instituted frequent data review meetings at country level. This culture of data use has allowed us to fine-tune our programming to each country context and accelerate progress toward aggressive program targets.
• We must constantly innovate. Sometimes the data tell us we are falling short and, when that happens, we must be quick to try new solutions. For example, when we were having trouble reaching HIV testing and case finding targets in a few countries, we introduced the Enhanced Peer Outreach Approach (EPOA) to engage previously unidentified and particularly high risk KP members with HIV prevention and testing. We saw immediate improvements with this approach, which is now being scaled up in other LINKAGES countries.
• We must modernize key population programming. As new biomedical interventions are introduced – like HIV self-testing and pre-exposure prophylaxis (PrEP) – we work to ensure that KPs have access to them. LINKAGES is introducing HIV self-testing in three countries and implementing PrEP demonstration projects in two others, with plans underway to expand to three more. We also employ cutting-edge information and communications technology (ICT) solutions in our programming – leveraging social media, conducting “virtual mapping” to enumerate online spaces commonly used by KPs, introducing online appointment booking, and partnering with ICT companies like Grindr to expand our reach and impact.
• We cannot underestimate the context of violence, stigma, and discrimination in which we work. Our efforts to improve uptake of HIV testing services and link those who are positive to treatment will have limited success if we are not also addressing the structural determinants of KPs’ vulnerability to HIV. LINKAGES is dedicated to integrating violence prevention and response in our programming. Nineteen countries have implemented at least one violence prevention and response activity, with two more set to begin implementation by the end of this year. These activities have already identified more than 1,200 cases of violence, brought new KPs to HIV services, increased the provision of post-exposure prophylaxis and emergency contraception to victims of sexual violence, changed attitudes among police and other common perpetrators of violence, and helped victims of violence understand and demand their rights. In order to address stigma within health care settings, we have developed a training package with health care providers in more than 10 countries on providing KP-competent services. LINKAGES has also developed SMS², a text message-based system for monitoring and providing real-time feedback on the quality of health services provided to KPs.

As we look to a fast-approaching new year, we will carry forward these lessons from the past and renew our call to place key populations at the forefront of global efforts to reach epidemic control and achieve UNAID’s 90-90-90 targets by 2020.