A little more than a month after World AIDS Day 2019, COVID-19 started to impact our HIV programs in Asia as countries like Cambodia, Thailand and Vietnam began quarantine. Community testing ground to a halt. People living with HIV worried about access to their medications. HIV pre-exposure prophylaxis (PrEP) enrollment slowed. COVID-19 testing diverted laboratories from HIV services. By March 2020, the rest of the world was equally impacted. FHI 360’s HIV programs were determined to continue serving people, but there were deep concerns. We were not alone, of course; the global HIV community was facing COVID-19 together. But with so much uncertainty, we wondered: Would COVID-19 substantially set back hard-won gains toward epidemic control? Did we have the tools in hand, or could we develop the tools, to weather this crisis?
Tagged: key populations
I have three long-haired boys, and wherever we go in Cambodia, people are confused, certain they are girls. We are constantly asked, “Why?” The answer is simple: They like having long hair. My boys’ push against traditional gender expressions is perhaps acceptable only because Cambodians have come to expect odd behavior from foreigners.
Yet, it is a different matter for a Cambodian transgender individual with long hair. Transgender individuals in this setting face many acute challenges, and their unconventional appearance is only one of them.
Transgender individuals in Cambodia carry a high burden of HIV. According to a study conducted by FHI 360 in select urban centers of the country, transgender individuals have an HIV prevalence of 4.15 percent (compared to 0.6 percent for the general population). Despite this striking percentage, they have historically been left out of HIV prevention and care programs. When they were included, they were incorrectly targeted as men who have sex with men. This means that there were no distinct behavior change communications or services for this group.
At approximately 18 percent, the prevalence of HIV in Botswana’s general population is one of the highest in the world. As a result, national HIV prevention efforts have focused more intensively on the general population than on other populations. Little is known about key populations, such as female sex workers and men who have sex with men, whose behaviors are both stigmatized and illegal in Botswana.
In 2012, the Botswana Ministry of Health used an integrated behavioral and biological surveillance survey to estimate population sizes and prevalence of HIV and sexually transmitted infections (STIs) among female sex workers and men who have sex with men. The study was historic. For the first time, it showed the HIV and STI burden among these two key populations and raised awareness about how they might have contributed to the generalized HIV epidemic.
The survey, carried out with technical assistance from FHI 360 through the Preventive Technologies Agreement (funded by the U.S. Agency for International Development), uncovered a population of more than 4,000 female sex workers in the three districts where the survey was conducted. Among these female sex workers, HIV prevalence was 61.9 percent, and the prevalence of gonorrhea and chlamydia were both higher than 10 percent. The female sex workers had a mean of more than seven partners per week, and condom failure, which includes condom breakage and being paid or forced not to use condoms, was common.
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.