A call for differentiated approaches to delivering HIV services to key populations

Abstract

Introduction: Key populations (KPs) are disproportionally affected by HIV and have low rates of access to HIV testing and treatment services compared to the broader population. WHO promotes the use of differentiated approaches for reaching and recruiting KP into the HIV services continuum. These approaches may help increase access to KPs who are often criminalized or stigmatized. By catering to the specific needs of each KP individual, differentiated approaches may increase service acceptability, quality and coverage, reduce costs and support KP members in leading the HIV response among their communities.Discussion: WHO recommends the implementation of community-based and lay provider administered HIV testing services. Together, these approaches reduce barriers and costs associated with other testing strategies, allow greater ownership in HIV programmes for KP members and reach more people than do facility-based services. Despite this evidence availability and support for them is limited.Peer-driven interventions have been shown to be effective in engaging, recruiting and supporting clients. Some programmes employ HIV-positive or non-PLHIV “peer navigators” and other staff to provide case management, enrolment and/or re-enrolment in care and treatment services. However, a better understanding of the impact, cost effectiveness and potential burden on peer volunteers is required.Task shifting and non-facility-based service locations for antiretroviral therapy (ART) initiation and maintenance and antiretroviral (ARV) distribution are recommended in both the consolidated HIV treatment and KP guidelines of WHO. These approaches are accepted in generalized epidemics and for the general population where successful models exist; however, few organizations provide or initiate ART at KP community-based services.Conclusions: The application of a differentiated service approach for KP could increase the number of people who know their status and receive effective and sustained prevention and treatment for HIV. However, while community-based and lay provider testing are effective and affordable, they are not implemented to scale. Furthermore regulatory barriers to legitimizing lay and peer providers as part of healthcare delivery systems need to be overcome in many settings. WHO recommendations on task shifting and decentralization of ART treatment and care are often not applied to KP settings.

Research priorities to inform “Treat All” policy implementation for people living with HIV in sub‐Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA)

“…For example, men are a particularly important group for tailored testing strategies, as they are less likely to be tested for HIV until they become ill . A number of models show promise for optimizing uptake of HIV testing and screening, including home‐ and community‐based testing, index partner testing, the integration of HIV testing into multi‐disease community‐level health campaigns, the use of lay cadres to expand testing and linkage to care, and self‐testing . Research approaches: Cluster randomized controlled trials (RCTs), rigorous programme evaluations, mixed methods studies on optimal timing of and barriers to repeat testing, and discrete choice experiments on preferences related to testing location (home or community based) and modalities (e.g. integration of HIV testing into other health services) will aid in identifying effective strategies that improve early diagnosis and linkage to care, particularly for underserved groups.…”

“… Context: Differentiated care strategies are essential for meeting the needs of underserved groups and key populations who do not access routine services and/or require additional support to achieve optimal HIV outcomes . It is estimated that about 15% of patients on first‐line ART do not achieve viral suppression within 12 months , with children and adolescents more likely to have elevated viral loads .…”

Princess PrEP program: the first key population-led model to deliver pre-exposure prophylaxis to key populations by key populations in Thailand

“…Clients who were stable on ART could select to receive ART maintenance by trained KP community health workers at the community health centres according to the differentiated service delivery model. 13 A prevention package was offered to all HIV-negative clients and included condoms, lubricants, PrEP and postexposure prophylaxis (PEP). PrEP was offered to every HIVnegative client who was at risk of HIV infection as mutually assessed by the client and KP community health workers based on any one of the following risks: inconsistent condom use, multiple partners, partners with unsuppressed viral load, STIs, PEP use, drug or substance use and needle sharing in the past 6 months.…”

Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study

“…As the number of people on ART in low-income countries increases, the challenges of delivering lifelong treatment become harder to tackle and require innovative solutions to ensure efficient services, without compromising on quality. Given that approximately one third of patients initiated on ART are documented as lost to follow-up (LTFU) within two years [4,5], national HIV programmes are building strategies to ensure that more patients remain in care [6][7][8].…”