December 21, 2021

Key Populations: Achieving Equitable Access to End AIDS

A client receives their antiretroviral treatment (ART) through home delivery in Togo.Photo credit: Raymond Varvatos Avosseh for FHI 360


Key Populations (KP) include sex workers, gay men and other men who have sex with men, transgender people, people who inject drugs, and people in prisons and other enclosed settings. Globally, these populations are particularly vulnerable and disproportionately affected by HIV due to certain risk behaviors, marginalization, and structural factors such as stigma, discrimination, violence, human right violations, and criminalization–all which contribute to a lack of access to health services. In 2020, key populations and their sexual partners accounted for 62% of new HIV infections globally.

Key populations are often difficult to reach for critical testing, care, and treatment services. They face a higher risk of acquiring HIV and have higher risk for onward transmission and yet their access to services is limited. Globally, their rates of accessing safe, effective, and quality HIV services are extremely low, while stigma and discrimination, including gender-based violence, are high compared to the general population. Significant barriers, such as police harassment, societal discrimination, and insufficient community-based services prevent them from getting the care they need.

USAID Impact

Supporting a Comprehensive Package of Services

USAID engages hard to reach populations and provides client-centered services through community- led programming. Key populations are provided HIV testing, prevention, and care services through differentiated service delivery models, providing services in locations where key populations can be served without discrimination. Key populations face disproportionate structural barriers that impact their ability to access quality HIV services. To build access to services, USAID supports drop-in centers, online and personalized outreach, and alternative pick-up points, such as one-stop-shops that provide community-based treatment initiation and refills in addition to testing services. USAID programming integrates interventions to prevent and respond to violence, address stigma and discrimination, foster enabling policies, promote legal literacy, and support health care worker sensitization and the provision of competent care. In the midst of COVID-19 related disruptions to service, USAID has worked closely with implementing partners to adapt programming and share solutions for ensuring continuity of vital services for key populations.

USAID has developed a comprehensive package of services and approaches through a range of early interventions. The comprehensive package comes from the WHO global key population guidelines, which serve as the standard for all international HIV implementation and guide national government policy and planning.

Comprehensive Package of Services for Key Populations:

  • Health Interventions
    • Condom and lubricant programming
    • Harm reduction interventions
    • Behavioral interventions
    • HIV testing and counselling
    • HIV treatment and care + PreP
    • Prevention and management of viral Hep, TB, and mental health conditions
    • Sexual and reproductive health interventions
  • Structural Interventions
    • Supportive legislation, policy, and funding
    • Addressing stigma and discrimination
    • Community empowerment
    • Addressing violence

USAID promotes HIV prevention through interpersonal communications, provision of condoms and lubricants, and promotion, initiation, and dispensation of PrEP. Testing approaches, including social network testing, index testing, self-testing, and risk network testing, complement traditional peer outreach models and lead to improved case identification of HIV-positive key populations who are otherwise hard to reach. To support HIV treatment and care for key populations, USAID built access to multi-month dispensing for both PrEP and antiretroviral treatment (ART) and dispensed these through clinics or drop-in centers while also referring and supporting clients who get their care from ART sites. USAID key population programs have scaled treatment, care, and viral load services through clinical sites in order to increase access to these essential and lifesaving services, and have also scaled online and virtual approaches for engaging, linking, and retaining clients (and their social networks) into care. These “Going Online” efforts to expand online and virtual channels to accelerate HIV support and epidemic control have been critical during COVID-19.

Within each country with USAID key population programming, a sustainable national response is the goal of USAID’s work. There are many opportunities to leverage the high-quality work funded by PEPFAR to enhance the quality of services in-country. USAID will continue to promote program alignment, identify metrics for program monitoring, and support innovations that can be scaled to support quality programs.

As USAID shifts funding to directly support local partners, core to the USAID mandate is the participation of key population community leaders in the implementation and monitoring of HIV services.

2020 Achievements

In support of PEPFAR and UNAIDS’ 95-95-95 goals, USAID implements and monitors progress of key population programming across the full cascade of HIV services.

Prevention and Testing in FY20:

  • USAID reached over 1.4 million members of key populations with HIV prevention services.
  • Despite COVID-related disruptions, 1.1 million members of key populations accessed testing services.
  • USAID provided PrEP to over 66,000 eligible key population clients who tested negative. The number of KP clients on PreP has more than doubled since FY 2019, and will continue to grow as more countries scale up PreP services.

Linkage to Treatment in FY20:

  • USAID identified 102,000 HIV-positive members of key populations.
  • 66,671 new clients were linked to treatment (65%) within USAID programs and a total of 88% were linked to treatment independent of the PEPFAR agency supporting the ART site.
  • Treatment initiation doubled from 2019 to 2020, and today USAID supports community treatment initiation for key populations in 33 countries.

Adherence and Viral Load Suppression in FY20 (a priority and focus of KP programming):

  • The number of key population clients on treatment continues to grow, with 142,267 accessing care and treatment services and 99% percent continuing on treatment from FY20 Q3 to Q4.
  • Of those clients on treatment within USAID programs, 55,206 have accessed viral load testing services and 93% of those tested are virally suppressed.

Structural Interventions in FY20:

  • In FY20, as key population clinical services were scaled up, fourteen local partners received direct USAID funding to implement key population programs.
  • USAID promoted structural interventions in 17 countries, policy efforts in ten countries, and capacity strengthening of community-based organizations (CBOs) in 21 countries.
  • Across seven countries, USAID prioritized funding for KP-led CBOS who have never received direct USG funding; 16 KP-led CBOs received substantial USG funding to implement structural interventions such as mitigation of KP/HIV-related stigma, discrimination, and violence in health care settings and promotion of legal literacy for KPs.