LINKAGES puts key population HIV programming on the map at IAS 2017

Written by Tiffany Lillie, LINKAGES Senior Technical Advisor; Hally Mahler, LINKAGES Director; and Chris Akolo, Director of Global Health, Population, & Nutrition, FHI 360


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Hally Mahler leads one of two satellite sessions hosted by LINKAGES at IAS 2017.

LINKAGES had a significant presence at the 9th International AIDS Society (IAS) Conference on HIV Science (IAS 2017), held July 23-26 in Paris. The project hosted two satellite sessions on key populations (KPs), an oral abstract on peer navigation in Cameroon, and 12 poster exhibitions from Angola, Botswana, Burundi, Kenya, and Thailand. During the conference, LINKAGES also participated in multiple stigma and discrimination sessions hosted by IAS and the “Me and My Healthcare Provider Initiative,” a global campaign focused on the broader needs of KPs affected by HIV that celebrates the many doctors, nurses, receptionists, pharmacists, and other frontline health providers who deliver quality HIV prevention and care to their KP patients every day.

UNAIDS offered these global statistics: “In 2016, more than two-thirds (70 percent) of people living with HIV now know their HIV status. Of the people who know their status, 77 percent were accessing treatment, and of the people accessing treatment, 82 percent were virally suppressed.”

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Giuseppe Cristino (LINKAGES Angola) presents a poster on HIV risk assessment.

While the numbers are promising, UNAIDS also noted that those most at risk for HIV – namely KPs – are still being left behind, and integrated health services will be necessary moving forward to reach 90-90-90 targets. This idea was a key takeaway from IAS 2017, with increased attention being placed on the need to deliver quality and responsive HIV services to KPs – including men who have sex with men, people who inject drugs, sex workers, and transgender people.

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Chris Akolo addresses a group of KP health workers during a special session.

Globally, 44 percent of new HIV infections are among KP members and their sexual partners. In sub-Saharan Africa (SSA), that figure remains at 25 percent. In regions outside of SSA, a staggering 80 percent of new HIV infections are among these groups. So, what innovative service delivery models were showcased at IAS 2017 to improve HIV programming for KPs worldwide? The LINKAGES team notes seven key takeaways:

  1. Pre-exposure prophylaxis (PrEP), the use of anti-HIV medication to keep HIV-negative people from being infected, is being scaled up at a tremendous rate around the world. In the United States, Europe, Africa, and certain parts of Asia, PrEP on demand is increasingly popular. In order to prevent HIV from spreading, health organizations must take bold action to move forward with PrEP.
  2. Undetectable = Untransmissible. The evidence is clear. A large study was conducted in Australia, Brazil, and Thailand that examined transmission risk among HIV serodiscordant MSM couples. After years of follow-up, not a single linked HIV transmission within any of the participating couples was found. This groundbreaking research supports the hypothesis that undetectable viral load prevents HIV transmission in MSM. MSM-specific programs are beginning to use this data to help encourage HIV treatment with sex-positive messaging.
  3. Innovations in information and communications technology (ICT) are forging ahead quickly, particularly with online appointment systems that allow at-risk populations to maintain confidentiality while seeking HIV testing or treatment services. Initial success with LINKAGES’ own SMS2, a mobile system that allows peer outreach workers to send text messages to KPs to ask about HIV service satisfaction, proves that ICT is an essential component of HIV programs.
  4. HIV self-testing is here and ready for prime time. Several studies, including LINKAGES Thailand work, have revealed that people like to have a variety of choices in how they access self-testing. Presentations on mail order, central pickup locations, and peer-mediated testing were given at IAS 2017.
  5. Stigma and discrimination are real barriers to achieving an HIV and AIDS-free generation, but there are no easy answers. Stefan Baral, Associate Professor of Epidemiology at Johns Hopkins Bloomberg School of Public Health, presented research on this topic. After an intensive training package in stigma reduction for KP clients and health providers, clients became more willing to seek health services but their experiences of discrimination within the health system did not diminish.
  6. Differentiated care and service delivery is promising for HIV programming for KPs. Providing options to individuals grants them autonomy and allows them to choose how and when they access services. IAS released a supplement on differentiated care and HIV, which prominently features KPs.
  7. Finally, demonstration projects are no longer necessary. The previously mentioned innovations, channels, and topics of discussion at IAS 2017 have proven successful in improving health outcomes. What comes next? Health organizations and other key stakeholders must take these innovations in HIV science and bring them to scale where they are needed most.
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Lusia Ang, Stella Chege, and Neo Monnapula were recognized as HIV health provider champions. Photo courtesy of IAS 2017.

Three ways to turn science into practice to reduce HIV among key populations

Written by Rose Wilcher, Director, Research Utilization, FHI 360, and Hally Mahler, Project Director, LINKAGES

This blog post was originally featured on FHI 360’s Degrees.


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Photo: Jessica Scranton, FHI 360

Next week, leading scientists and cutting-edge thinkers will gather at the International AIDS Society’s 9th IAS Conference on HIV Science in Paris to discuss the latest scientific discoveries in HIV prevention, care and treatment. These discoveries hold the potential to accelerate progress toward the global 90-90-90 targets set forth by the Joint United Nations Programme on HIV/AIDS (UNAIDS). And, they are especially important for key populations — including men who have sex with men, sex workers, transgender people and people who inject drugs — who shoulder a disproportionate burden of HIV. UNAIDS estimates that 45% percent of all new HIV infections among adults worldwide occur among these key populations and their sex partners. Reaching these groups with new technologies and approaches is essential to ending the epidemic.

The headway on display at IAS will, we hope, leave us feeling optimistic. However, science cannot have impact unless it is applied in policy and programs. We are working to translate evidence of what works into widespread practice for key populations through the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project, which is funded by the U.S. Agency for International Development (USAID) and the U.S. President’s Emergency Fund for AIDS Relief (PEPFAR). But progress is slower than it should be, largely because the issues that drive the spread of HIV in key population communities — unrelenting stigma, discrimination, violence and, in many cases, criminalization — also mean that these groups are often the last to benefit from scientific discoveries.

To ensure that new technologies and emerging evidence-based practices reach those who want and need them most, we should do three things.

We need more community-led demand for the latest evidence-based innovations. Even the most compelling evidence does not put itself into practice, especially for the benefit of the most marginalized. When members of key populations demand access to innovations that could make a difference in their lives, that is often the needed catalyst to move research to practice. Organizations led by key populations are chronically underfunded and undervalued, but their voice and engagement are critical to ensuring that evidence-based practices reach them in a way that is safe, appropriate and responsive to their needs.

For example, great strides have been made in recent years using pre-exposure prophylaxis (PrEP) as a new HIV prevention option, and it is sure to be a hot topic at the IAS conference. But, PrEP implementation, particularly for key populations, is complex and moving slowly. The International Treatment Preparedness Coalition (ITPC), a LINKAGES partner, recently convened a global think tank meeting with stakeholders representing the communities that are most affected by HIV to discuss how best to increase access to PrEP. “This was the first time that people from different communities from across the globe sat together in one room to discuss how to demand PrEP on their own terms,” said Solange Baptiste, executive director of ITPC. The discussions at that meeting are informing an upcoming global policy brief and an activist toolkit on PrEP that can accelerate implementation.

We must create an environment that enables the delivery and uptake of evidence-based interventions among those who need them most. Even when the latest prevention, care and treatment options and services are available, stigma, violence and discrimination from health care providers, family members, police, and partners hinder access to services. In many of the countries where LINKAGES works, including Botswana, Cameroon, the Dominican Republic, Kenya, Malawi and Suriname, we are systematically integrating violence prevention and response into HIV programming for key populations. We are working to mitigate stigma in health care facilities through the introduction of a text-message-based quality assurance tool that gathers information about key populations’ experiences of stigma and discrimination at health facilities and assesses overall client satisfaction with the care they received.

But, work to dismantle stigma and address violence against key populations, including through policy and legal reforms, always needs more attention. We will miss opportunities for the science to have maximum impact if the environment in which the science needs to be applied is not also progressing.

We need to accompany these efforts with the generation of more evidence through implementation science. Such investments will build collective knowledge about how to introduce proven interventions in real-world contexts, thereby speeding up the pace of replication and implementation at scale.

At the IAS conference, LINKAGES and colleagues from USAID, the U.S. Centers for Disease Control and Prevention (CDC) and amfAR will convene a satellite session that will present findings from implementation science studies focused on key populations that were conducted in Brazil, Peru, Senegal, South Africa and Thailand. Taken together, these studies contribute important new evidence about how to enhance uptake of and retention in services for key populations, across the HIV prevention, care and treatment cascade. They also illustrate how valuable implementation science is to ensuring that proven interventions achieve results through widespread implementation.

The evidence base on HIV and key populations has grown tremendously in the past several years, and more will come to the fore at the IAS conference. We will be participating with an eye toward how we can move the science into practice so that it benefits as many people as possible, as quickly as possible. The science holds much promise; we cannot let implementation lag.

Commission on the Status of Women & Transgender Women

Written by Beyonce Karungi, Executive Director, Transgender Equality Uganda

The Commission on the Status of Women (CSW) is the largest international gathering of governments and civil society dedicated to developing an agenda that promotes progress for women and girls. Each year, the UN brings together women and girls from all over the world to discuss issues that affect women from all spheres of life. Despite the sense of total inclusion, transgender women and girls are often underrepresented in this crucial space. Consequently, the transgender community faces a challenge in raising and addressing the issues specific to them.

The CSW recently emphasized inclusion of transgender people in its sustainable development goals. The discussion surrounding trans inclusion was unprecedented and a major credit to the UN organizers. Hopefully, this discussion continues to provide an ongoing dialogue that will work toward the improvement of the status of all women – including trans women – around the world.

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Beyonce Karungi presenting at a sex worker panel during CSW

I was one of the few transgender women present at the latest CSW. While there, I participated in many forums including development of the UN Women’s Strategic Plan development (2018-2021) at the UN headquarters. We lobbied UN women to include the transgender community in the strategic plan by connecting us with country offices and registering us to participate not only in trans-specific events but also in the main CSW discussions that typically include all women and girls.

At CSW, I also participated in a sex worker session focused on the conditions faced by this key population. Internationally, policy discourse has shifted in many ways to defend sex work as real work. Still, efforts to criminalize clients are unaligned with what sex workers need in order to be able to thrive as workers.

I was also involved in the Lesbian Bisexual Transgender Intersex (LBTI) women’s session. LBTI women are not explicitly mentioned as a vulnerable group in many spaces. This cultural stance and attitude is in large part internalized by LBTI people, which creates a strong obstacle to self-identification. The stigma surrounding LBTI women makes them a socially invisible community within general society. The result is that, with a few exceptions, the most vocal leadership of LBTI women’s rights has traditionally been men.

CSW participants discussed many issues, including peace and security for women and human rights defenders, sexual and reproductive health and rights, maternal health, gender-based violence, and family planning. Transgender women and girls continue to be excluded from the economic, political, and social sectors, which limits their access to education, health services, and employment.

While one of the main goals of the CSW is to empower all women and girls, transgender women remain unfairly marginalized.

The CSW needs to ensure that transgender people are represented and that data collection is supported so we can begin to advance the livelihood and well-being of transgender women everywhere. It is within the power of the CSW to include all women in discussions on women’s status in the world, and doing so will increase the awareness and importance of transgender inclusion, health, and rights.