In an era of limited resources, HIV prevention, care and treatment efforts need to focus on the smartest investments. This means investing in programs that can have the greatest impact in halting HIV transmission and turning back the epidemic. From a public health perspective, the effective use of resources requires focusing on key populations who have the highest level of HIV infection and tackling the barriers that discourage and prevent them from accessing health systems and services. These populations are broadly defined as sex workers, men who have sex with men, transgender persons and persons who inject drugs.
As the world gathers at the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia, July 20–25, 2014, we have an excellent opportunity to share how investing in evidence-based strategies can change the trajectory of the epidemic once and for all.
We know what works to prevent HIV acquisition and transmission among key populations and how to link these groups to HIV treatment and retain them over time. Yet, in reality, sex workers, men who have sex with men, transgender persons and persons who inject drugs are often unable to find and access respectful and high-quality HIV services. Limited systems capacity, stigma and discrimination, violence, discriminatory laws, harmful gender and other social norms, exclusion from meaningful input into programs and lack of government support to scale up and sustain current donor-supported services for key populations remain persistent obstacles.
Programs for key populations are especially weak and fragmented in sub-Saharan Africa, where the focus has primarily been on curbing the epidemic among the general population. Recent efforts to provide HIV services for key populations in the region have encountered new barriers. State-sponsored attacks and deeply discriminatory laws prohibiting same-sex relations in Nigeria and Uganda further exacerbate the many challenges already facing key populations in accessing HIV prevention and care.
Turning the tide
The good news is that some countries, such as Ghana, Senegal and South Africa, are addressing human rights violations at the community and systems levels with a measurable impact. They have done this by including key populations in their national strategic plans and budgets, by conducting routine HIV surveillance to understand the burden of HIV in these populations, and by providing HIV prevention and treatment at scale using dedicated community providers who are drawn largely from key populations themselves and health care workers who are passionate about providing quality care. The result: Key populations are increasingly empowered to hold their governments accountable for delivering sustainable services that address their needs.
We can do much more. A number of proven strategies can help ensure key populations are reached with effective interventions, including:
- Identifying target populations and locales and comprehensively assessing risk. We can develop better methods and metrics to map sub-networks of key populations, their HIV risk and their access to services. We also must assess the impact of gender norms on access to services, social cohesion, police violence and other community and structural factors that influence risk.
- Diagnosing “leaks” and revealing barriers within the HIV services cascade. Use of the proven cascade framework, an easy-to-understand analytic approach to address gaps in the HIV prevention-care-treatment continuum, will help identify opportunities to improve services to stop the spread of HIV — from HIV testing through care and treatment. It is a powerful tool for advocacy, consensus-building and planning that can help transform how governments view, value and invest in HIV services for key populations.
- Scaling up “what works” to ensure the most strategic use of resources and access to newly emerging technologies. Innovative, cost-efficient approaches help to make tailored comprehensive service packages easily available. HIV mobile health technologies (mHealth) to improve tracking and retention and create new prevention technology and point-of-care diagnostics are good investments, and all need to be tested, disseminated and brought to scale.
- Strengthening key population organizations to address structural barriers. Key populations can be supported in organizing to advocate for changes in the actions of law enforcement and court personnel, health care workers, and policymakers. Highly effective key population organizations can be trained to mentor counterparts with less capacity, enabling organizations serving key populations to deliver high-quality HIV services.
- Ensuring key population interventions are sustainable over the long term. Government buy-in and financial support toward HIV services for key populations are essential. It goes without saying that both political will and financial resources are necessary to assure we have optimal impact on HIV infection in key populations.
AIDS 2014 provides yet another opportunity to share what we know works in HIV prevention, care and treatment. Let’s not waste this chance to focus on the people who are most in need and on the strategies that can create cost-effective and lasting impact.