Adequate funding of comprehensive community‐based programs for key populations needed now more than ever to reach and sustain HIV targets

Abstract

Introduction Globally, over half of the estimated new HIV infections now occur among key populations, including men who have sex with men, sex workers, people who inject drugs, transgender individuals, and people in prisons and other closed settings, and their sexual partners. Reaching epidemic control will, for many countries, increasingly require intensified programming and targeted resource allocation to meet the needs of key populations and their sexual partners. However, insufficient funding, both in terms of overall amounts and the way the funding is spent, contributes to the systematic marginalization of key populations from needed HIV services. Discussion The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently highlighted the urgent need to take action to end inequalities, including those faced by key populations, which have only been exacerbated by the COVID‐19 pandemic. To address these inequalities and improve health outcomes, key population programs must expand the use of a trusted access platform, scale up differentiated service delivery models tailored to the needs of key populations, rollout structural interventions and ensure service integration. These critical program elements are often considered “extras,” not necessities, and consequently costing studies of key population programs systematically underestimate the total and unitary costs of services for key populations. Findings from a recent costing study from the LINKAGES project suggest that adequate funding for these four program elements can yield benefits in program performance. Despite this and other evidence, the lack of data on the true costs of these elements and the costs of failing to provide them prevents sufficient investment in these critical elements. Conclusions As nations strive to reach the 2030 UNAIDS goals, donors, governments and implementers should reconsider the true, but often hidden costs in future healthcare dollars and in lives if they fail to invest in the community‐based and community‐driven key population programs that address structural inequities. Supporting these efforts contributes to closing the remaining gaps in the 95‐95‐95 goals. The financial and opportunity cost of perpetuating inequities and missing those who must be reached in the last mile of HIV epidemic control must be considered.

Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi

“…Our assessment of clinical service unit costs by LINKAGES program area shows that above-service program management and data monitoring and non-clinical services delivered to KPs alongside clinical services––deemed to be essential by experts––made up large components of service costs [ 4 ]. Program management and data monitoring accounted for between 27–42% (Kenya) and 31–32% (Malawi) of mean unit costs for the seven clinical services.…”

“…The only other costing study of a comprehensive HIV program for KPs that we are aware of is the costing study of the Avahan program in India [ 4 , 10 ]. Cost analysis of the Avahan program also considered non-clinical service elements including interventions to reach and engage FSW, MSM, and TGW.…”

“…Forty years since the first cases of AIDS were reported, KPs continue to be marginalized and criminalized in many countries, HIV prevention services for KPs continue to be inaccessible to many, and providing HIV testing and treatment services to KPs living with HIV remains a challenge even in countries with high performing HIV programs [1]. To achieve HIV epidemic control, countries around the world, including in sub-Saharan Africa, will need to significantly scale up effective HIV services for KPs [2][3][4].…”

“…Moreover, pre-service delivery activities, including population mapping and size estimation, are integral to the effective delivery of KP HIV services [16][17][18]. Critically, these non-clinical features are viewed as core elements of comprehensive HIV services for KPs and not as optional extras [4].…”

Costs and cost drivers of comprehensive sexual reproductive health services to female sex workers in Kenya

“…However, the lack of a standard unit cost of KP interventions also presents a signi cant challenge as national programs and individual organizations lack data upon which to build a case (11). The few studies that have estimated the costs of KP programs have focused on facility service delivery and not included costs associated with size estimation, community engagement, peer education, and interventions to reduce stigma, discrimination, and violence (13). Furthermore, to the best of our knowledge, no studies have included the costs of non-HIV clinical services (such as contraception), which are critical for KP sexual and reproductive health, and which should be layered into KP HIV programs.…”