Differentiated Care for Key Populations, Part III: Haiti

Written by LINKAGES Haiti staff.

Differentiated antiretroviral therapy (ART) delivery, a part of differentiated care, aims to improve retention and viral suppression by optimizing drug and care delivery. Models fall into four categories: health care worker-managed groups, client-managed groups, facility-based individual, and out-of-facility individual. The case studies presented in this four-part series come from the USAID– and PEPFAR-supported LINKAGES project in Botswana, Haiti, Kenya, and Malawi. They are examples of the out-of-facility individual model, sometimes referred to as the community model, and can be found in Differentiated Care for Antiretroviral Therapy for Key Populations: Case Examples from the LINKAGES Project.

Through its implementing partners, LINKAGES Haiti delivers differentiated care for men who have sex with men (MSM) and female sex workers (FSWs). The goal of LINKAGES is to improve access to and uptake of HIV prevention, testing, and care and treatment services for these key populations (KPs). In Haiti, following the Ministry of Health’s adoption of the World Health Organization’s recommendation for Test and Start — an approach where people are started on ART immediately after being diagnosed with HIV — LINKAGES has scaled up access to ART among MSM and FSWs by integrating ART delivery within 10 existing KP-focused service delivery sites from October 2016 to June 2017. A multidisciplinary health care team is available at the site level (medical doctors, nurses, lab technicians, psychologist, pharmacist, and social workers). This team is trained not only in HIV counseling, care, and treatment, but also on provision of KP-friendly services to ensure that KPs are able to access services without fear of stigma and discrimination. Safe spaces were also added in the sites that did not previously have a safe space for KPs to conduct social activities and meetings.haitiFIG3

Three of the sites are operated by Fondation SEROvie, a KP-led organization that provides HIV prevention and testing services, along with critical community engagement and empowerment activities. Before the introduction of ART services at these sites, MSM who tested positive at a SEROvie center or at a mobile testing drive were referred to other public and private ART sites. After the addition of ART services at SEROvie sites, the ART initiation rate among MSM improved from less than 18 percent to over 70 percent and even reached 94 percent in one quarter (Figure 3). The increased ART initiation rate among MSM is due to the availability of ART at SEROvie, thus removing the need for referral and links to care and treatment at other health facilities.

Six other sites are operated by FOSREF, an organization that provides services for FSWs. Before ART service was added to these sites, HIV-positive FSWs were referred to other public and private clinics for ART, and the percentage of FSWs initiated on treatment was less than 17 percent. After the addition of ART services at the FOSREF sites, the ART initiation rate has been consistently 45 percent and climbed to over 78 percent in the past three quarters (Figure 4).

haitiFIG4In addition to ART provision at these centers, the ten sites offer community antiretroviral distribution to HIV-positive FSWs and MSM to reinforce patient retention in treatment and care. Dr. Rachid Dorsainvil, an HIV technical advisor with FHI 360, explains, “In Haiti, two models of differentiated care are used across the LINKAGES network: community drug distribution and multi-month scripting. Both models have contributed to the improvements in links to care and treatment observed for both MSM and FSWs in Haiti last year.”

As part of these two models, at SEROvie and FOSREF peer navigators are responsible for delivering the ART, and clients can receive an antiretroviral supply for two to three months, depending on their adherence level. This strategy is used primarily by HIV-positive patients who cannot come regularly to pick up their antiretroviral treatment because of the distance or their busy schedules.

Rafael Reynold, a MSM and a beneficiary of SEROvie’s HIV-related services, works as a chef in a restaurant. He recounts the difference community distribution and multi-month scripting have made for him: “I was diagnosed HIV positive two years ago during a mobile testing activity that was conducted in my neighborhood by a SEROvie clinical team. I was initiated on ART at the SEROvie clinic located in Port-au-Prince. As I never missed an appointment and had my viral load suppressed, I have benefitted [from a] three-month antiretroviral supply. I don’t have to stress about going every month [for an] appointment, as I work seven days a week in the restaurant. So, being able to experience the community drug distribution has really improved my life.”


Speed, scale, and quality: How LINKAGES implemented evidence-based key population programming in 19 countries in its first 12 months

Written by Meghan DiCarlo, Deputy Director – Program Acceleration, LINKAGES, and Lirica Nishimoto, Program Officer, LINKAGES

Caribbean acceleration

Caribbean Regional Acceleration Workshop 2017

When the USAID– and PEPFAR-supported LINKAGES project first started in June 2014, we expected a handful of countries to buy in to the global mechanism dedicated to meeting the HIV prevention, care, and treatment needs of key populations (KPs).  However, almost immediately, the demand exceeded our expectations. USAID missions in seven countries bought in to LINKAGES in the first six months, and in just over a year, LINKAGES was working in 19 countries! The exponential growth of the program across Africa, Latin America and the Caribbean, and Southeast Asia required us to re-evaluate how we could successfully deliver high-quality KP programming across such a large swath of countries, with more being added by the day.  We did not want to have disjointed country programs of varying quality. We wanted each program to be delivered efficiently and tailored to local context, but grounded in the critical, evidence-based elements of KP programming. As a global mechanism, we had a unique opportunity and an obligation to support countries to scale up quality KP programming that would achieve results.

Our answer was the program acceleration (acceleration) initiative, which was launched in December 2015. The goal of this initiative is to accelerate and strengthen service delivery for KPs at scale by providing training, capacity development, mentoring, and knowledge exchange to in-country LINKAGES staff, local implementing partners, and staff from ministries of health. One of the first steps we took under the acceleration initiative was to develop a common core KP program and guide to serve as the initiative’s foundation. The common core includes information on seven key program areas based on global guidance:

  • Engage key populations in population size estimation, mapping, and program planning
  • Key population empowerment and engagement in programs
  • Structural interventions
  • Peer outreach
  • Clinical services
  • Program management
  • Monitoring and data use

Next, we trained a core group of expert technical assistance providers and country implementers on the common core program and set up frequent, rapid, and targeted technical assistance to support countries in implementing high-quality KP programming.

Botswana acceleration

LINKAGES Botswana presents on the coupon system at the 2017 Africa Region Acceleration Workshop.

It has been almost two years since the acceleration initiative was established. Implemented in 17 countries to date, the initiative has been successfully supporting local staff and partners to deliver a comprehensive package of health services at speed, scale (within and across countries), and according to standards (a common core program).

We have documented the achievements and lessons from acceleration in two new resources. For more on how to rapidly deliver and scale up quality KP programming, see Accelerating the Implementation and Scale-up of Comprehensive Programs for HIV Prevention, Diagnosis, Treatment, and Care for Key Populations and Acceleration Country Success Stories.

Addressing violence in HIV programs for key populations: Opportunities for integration

In commemoration of the 16 Days of Activism Against Gender-Based Violence campaign, LINKAGES’ new infographic explores how HIV programs for key populations can address violence. The infographic highlights the global prevalence of HIV and violence among key populations, the impact of violence on HIV among key populations across the cascade, and six recommendations to integrate violence prevention and response into HIV programs for key populations. We hope it will be useful to those designing or implementing HIV programs for key populations as well as those who seek to advocate for greater integration between violence and HIV services.



Using a gender lens to increase impact of HIV programming for key populations: the LINKAGES Gender Strategy

Written by Giuliana Morales, Senior Technical Officer, Research Utilization, FHI 360, and Aubrey Weber, Technical Officer, Research Utilization, FHI 360


LINKAGES, CHAMP, and CBOs participate in a small group discussion on strategies to improve the implementation of the minimum package of gender-based violence services for key populations in Bamenda, Douala, and Yaoundé, Cameroon. Photograph by Christian Tanyi.

Key populations (KPs) – including men who have sex with men (MSM), people who inject drugs (PWID), sex workers, and transgender (trans) people – often suffer from rigid and harmful gender norms. They underlie much of the stigma, discrimination, and violence faced by KP groups worldwide, inhibiting their ability to access HIV prevention, care, and treatment services. For example, in Kenya, women who inject drugs often face more stigma, discrimination, and violence than their male counterparts but may  be left out of PWID programming altogether due to the gendered expectation that PWID are male.gender strategy

While KP programming has rarely employed gender integration on a systematic level, gender integration has been shown to improve and sustain HIV outcomes. To address this missed opportunity, the USAID– and PEPFAR-funded LINKAGES project developed a Gender Strategy that describes the benefits of gender integration and provides specific actions and tools to integrate gender in HIV programming for KPs. Based on the mandate of the LINKAGES project and in accordance with PEPFAR guidance, LINKAGES focuses its gender integration efforts in three areas:

Designing and implementing activities that reach all members of KPs and challenge harmful gender norms at the root of stigma, discrimination, and violence against KPs

A gender analysis is the first step in the process of gender integration. As gender analyses have not been traditionally conducted with KPs, LINKAGES developed a Gender Analysis Toolkit, using learning from analyses conducted in Cameroon and Kenya. As the briefs from both countries show, a gender analysis can help programs answer important questions such as: Are all members of KPs being considered in your programming? What harmful gender-related beliefs may contribute to HIV risk, a lack of service uptake, stigma, discrimination, or violence against KPs? How do harms caused by gender norms link KPs and the issues they face to those of the broader population, and are there opportunities for combined efforts? The answers help in the design and implementation of gender accommodating and transformative HIV programming (the programming types most likely to result in lasting change).

Promoting the inclusion of trans people in KP programming

Trans women are 49 times more likely to be living with HIV than the general population, yet they have historically been ignored in HIV programming. Many of the reasons for this exclusion are gender-related; therefore, LINKAGES’ gender strategy emphasizes the need for increased understanding of and improved HIV programming for trans people. To support advocacy efforts for more trans-competent programming, LINKAGES developed Rights in Action: Transgender Health and HIV, a brief that includes information on the importance of working with trans people, the way that transphobia ultimately leads to HIV acquisition, and the many opportunities for intervention that address both current health needs and the underlying causes of the epidemic.

Preventing and responding to gender-based violence and other forms of violence against KPsresourcelist

Violence against KPs is widespread and can often be traced back to rigid beliefs about acceptable gender expression and sexual behavior for men and women. Global evidence shows that violence is both a cause and consequence of HIV: violence can increase HIV risk, decrease testing uptake and disclosure, and decrease adherence to antiretroviral treatment among KPs while living with HIV can increase KPs’ vulnerability to violence. To achieve lasting results in the fight against HIV, LINKAGES developed and is rolling out practical guidelines for integrating violence prevention and response into HIV programs. The LINKAGES Gender Strategy also provides information on international resources that can be accessed when violence occurs or safety threats intensify.

Addressing the HIV epidemic against KPs is necessary to achieving 90-90-90 goals, and incorporating a gender lens into KP programs will increase the impact of investments made in this vital programming area.