Key Populations

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Too often, people most affected by the diseases are the same people who don’t have access to health care. Factors such as stigma, discrimination and criminalization are among the barriers that prevent them from accessing health services.

To solve this problem, Global Fund partners must tailor services to the specific needs of these populations, as well as invest in programs that address the underlying barriers to services. The best way to do this is to involve key populations in the design, implementation and monitoring of those health services, as well as in policy decisions that affect them.

Who are key populations?

Key populations experience both increased impact from one of the diseases and decreased access to services. Widespread stigma and discrimination, state and non-state violence and harassment, restrictive laws and policies, and criminalization of behaviors or practices put key populations at heightened risks and undermine their access to services.

“The Global Fund has empowered communities. The implication of trusting and directly supporting communities to run a program as sub-recipients is huge. 'Owning the epidemic' has been taken literally, with positive response. We plan, strategize, and invent at a community level to ensure that we achieve our targets and impact our communities.”
Peninah Mwangi, Country Coordinating Mechanism member and Director of the Bar Hostess Empowerment and Support Programme representing sex workers in Kenya

HIV

In the context of HIV, key populations include:

  • Men who have sex with men
  • Transgender people, especially transgender women
  • Sex workers
  • People who inject drugs
  • People living with HIV
  • People in prison and detention

TB

In the context of TB, miners are reported to have greater incidence of TB than any other working population in the world, and TB incidence among migrant miners is 10 times higher than in the communities from which they originate.

The latest effort to estimate the global total number of TB cases among prisoners and detainees was based on 25 countries and it found there are about 300,000 TB cases among prisoners and detainees around the world annually.

According to UNAIDS, there are 37 million people living with HIV around the world and 1.2 million of them are co-infected with TB, annually accounting for 11 percent of all TB cases.

WHO estimates at least 1 million children become ill with TB each year, representing about 10 percent of all TB cases.

The Global Fund also recognizes vulnerable populations – those who have increased vulnerabilities in a particular context but may not fit the criteria highlighted above, such as adolescent girls and young women, people with disabilities among others.

Investing for impact: Focus on key populations

The Global Fund Strategy 2017-2022 prioritizes investment in evidenced-based programs for key populations, in removing barriers to health services and in providing support to secure their meaningful engagement. In addition, the Global Fund asks countries to prioritize programs for key and vulnerable populations in their funding requests, as well as through domestic commitments, based on country income context.

For HIV, the Global Fund is the most prominent external funder of key population programs across many regions. It remains the largest single financier of harm reduction programs for people who inject drugs globally from all sources.

For TB, the Global Fund focuses on countries with highest proportion of key populations, including people living with TB/HIV co-infection, migrants, refugees and displaced people, miners, prisoners, children in contact with TB cases and people who inject drugs.

For malaria, the Global Fund supports a comprehensive approach that combines education, prevention, diagnosis and treatment, especially for children under 5 and pregnant women in malaria endemic zones. It also puts a particular focus on an innovative regional approach to reach populations who have difficulties in accessing care, such as undocumented migrants in the Greater Mekong region, who are at risk for drug-resistant malaria.

Engaging key populations

The Global Fund’s response to key populations across the three diseases has evolved over time. Today, focus on key populations is integrated across the core business of the organization.

We know we have greater impact on the three disease when key populations are engaged in the design and delivery of health services. To enable key populations to play this important role, the Global Fund supports efforts to strengthen social networks and organizations that are led by members of key population communities and represent the needs of these communities.

Key populations should be engaged in the process at every stage of the funding cycle. This includes:

  • Governance
  • Design
  • Implementation
  • Monitoring

Governance

At the global level, there is a seat on our Board representing communities living with and those affected by the diseases, including key populations. In each country, we require the Country Coordinating Mechanism to include people who represent those affected by the three diseases.

“When you reflect on my past from using drugs in the streets and you compare it to my current position as a key populations representative at the Global Fund platforms I feel like I have gone from zero to hero because when I was on the streets I was hopeless but now I am member of the CCM voicing the issues of people who use drugs.”
Maziabi Salum, former drug user, Tanzania

Design

Key populations should meaningfully contribute to the design and development of programs/services. This includes engagement during the development of national disease plans, development of a funding request to the Global Fund, as well as during grant-making stages.

However, health governance systems are often not prepared to interact with key populations from marginalized, stigmatized, criminalized and disempowered communities. Equally, key population communities may lack capacity and readiness to engage – lacking adequate technical expertise to understand data and programs, for example. These are among the challenges to meaningfully engage key populations.

To address this, the Global Fund invests in enabling networks and organizations of key populations to impart knowledge and expertise, as well as facilitate mutual learnings. Read more. We also make sure that our policies protect identities when necessary to avoid consequences as a result of coming forward.

Designing targeted programs for key populations requires a granular level of data on disease burden, population size, access to services and specific barriers, so the Global Fund invests in strengthening strategic information and data systems.

“It is not just the financial support that is important to us. Community systems strengthening activities were enhanced through Global Fund grants and contributed to building community leadership and capacity to support a sustainable response to HIV.”
Anton Basenko, Senior Program Officer for the Alliance for Public Health in Ukraine

Implementation

Services for key populations are frequently best delivered by those who understand the specific needs of their communities. Evidence has shown, for example, young men who have sex with men are effective peer educators to raise awareness on sexual health, including HIV. Similarly, in settings where TB is prevalent among migrant populations, peer educators who have in-depth knowledge about cultures, practices and needs are best positioned to raise awareness on TB, generate demand for screening, and provide referrals to health facilities.

Close collaborations with government, bilateral, multilateral and community partners also play a key role in ensuring the delivery of high-quality, evidence-based programs for key populations and to address human rights and gender-related barriers to services across the three diseases.

Monitoring

Because of lived experience and direct interactions with service structures, key populations need to be provided with an opportunity to share feedback on quality of services. Firsthand knowledge and insight of key populations are critical to ensuring that programs deliver impact.

“Ending the epidemics today is not only a biomedical and financial challenge, but it is also a social, political, and human rights issue. Having the Global Fund in Belize has meant that the voices of key populations are being taken into account.”
EriKa Castellanos, Executive Director of the Collaborative Network for Persons Living with HIV (CNET+) in Belize

Published 20 July 2018