Twenty-One Years of Progress: The Evolution of HIV Programming for those at the Highest Risk

Over the last 21 years, USAID has made significant shifts in how we work with key populations, or those who are at significantly higher risk of contracting HIV. That includes gay men and other men who have sex with men, female sex workers, people who inject drugs, transgender people, and people in prisons and other closed settings.

In 2021, people within key populations and their partners accounted for 70% of new HIV infections. They continue to face inequalities that affect access to safe, effective, and quality HIV services and experience disproportionate levels of stigma, discrimination, violence, human rights violations, and criminalization. These barriers prevent key populations from accessing the HIV care they need. 

Three USAID experts share their insights on how working for key populations has evolved, and their hopes for future programming that will resolve the remaining gaps to end HIV as a public health threat by 2030. 

USAID’s early work with key populations

Prior to the start of the President’s Emergency Plan for AIDS Relief (PEPFAR), USAID supported distribution of condoms through regional programs as a prevention measure against sexually transmitted infections. Progress was measured by the total number of people reached, with little or no disaggregation of who the recipients were, and what their health outcome was. 

“When we first started working on key populations programming, all we could offer individual members of key populations were condoms and sometimes a referral for treatment of opportunistic infections if they were HIV-positive and getting sick. Our programming was very prevention-focused out of necessity,” said Clancy Broxton, branch chief for Key Populations and Rights in USAID’s Office of HIV/AIDS. 

Following the release of the first PEPFAR indicator guide in 2006, USAID, with PEPFAR support, began to measure indicators at the community level in HIV programs. This targeted data collection effort allowed USAID to parse out data, and identify individuals reached and key populations at higher risk of contracting HIV. 

Transitioning from prevention services to a clinical response 

Antiretroviral therapy (ART), the first treatment regimen approved to help people with HIV live longer, healthier lives, became available through PEPFAR in 2003. In 2014, LINKAGES, a global USAID project that focused on providing HIV services for key populations, including ART, began.

“Beginning in the mid-2000s, we were slowly able to start adding more and more clinical services to USAID programming with key populations. ART became more widely available and we were able to start offering those services in KP-competent ways,” added Broxton, using the abbreviation for key populations. 

LINKAGES was one of the first USAID programs to improve comprehensive HIV prevention, care, and treatment services to reduce HIV transmission among key populations. Today, this work continues under the Meeting Targets and Maintaining Epidemic Control (EpiC) project, which promotes the management of national HIV programs by improving HIV case finding, prevention efforts, treatment programming, and viral load suppression.

A comprehensive approach to working with key populations 

From 2013 to 2017, USAID contributed to global guidance reports for collaborative interventions, which included outlines for comprehensive HIV programming for sex workers, men who have sex with men, transgender people, and people who inject drugs. The guidance recognizes that effective treatment for HIV requires early intervention and a package of services and approaches that include not just health, but psychosocial, structural, human rights, and rights-based approaches, and collaboration with local partners and governments to deliver services. This package now serves as the standard for all international HIV policies and programs. 

In 2019, USAID celebrated reaching one million members of key populations with HIV services, ahead of PEPFAR’s release of the 2020 Key Populations Investment Fund. 

“USAID’s continued support has increased the number of civil society organizations receiving direct funding over time, and there is more work to be done,” said Judy Chen, the deputy branch chief of the Key Populations and Rights Branch.

What’s next?

As USAID celebrates over 20 years of working with key populations, our goal is to sustain the gains made and accelerate progress to end the HIV epidemic. Using new approaches and health innovations —such as telehealth appointments, online case management, and peer connectivity through social media to make it easier for people to access HIV services—USAID helps reach people with services that are convenient and discrete.

“USAID’s innovations in reaching key populations have been instrumental in successful programming.  We continually learn from the lived realities of key populations leaders themselves, since they know best on how to reach and serve their communities,” said Kent Klindera, senior technical advisor on Key Populations in USAID’s Office of HIV/AIDS

In 2023, USAID and our partners supported more than 300,000 people within key populations to receive life-saving HIV medications, and more than 1.8 million to avert HIV infection through supportive interventions and HIV prevention services.

Looking ahead, meeting people where they are, finding HIV cases earlier and linking to treatment, strengthening community-led and community-based approaches, and working with communities will continue to lead to significant progress to achieve equitable access to safe, effective, and quality HIV services for key populations.

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ABOUT THE AUTHOR: Jenna Pellegrino is a Communications Program Analyst in the Office of HIV/AIDS.