Key Populations

The Global Fund / John Rae

Too often, people most affected by HIV, tuberculosis and malaria 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 overcome these barriers, Global Fund partners tailor services to the specific needs of these populations, as well as invest in programs that address the underlying causes of discrimination. 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 or more 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

These populations are socially marginalized, often criminalized and face a range of human rights abuses that increase their vulnerability to HIV.

The Global Fund / Vincent Becker

Vernon and Zama benefit from services for people who inject drugs at Durban’s TB/HIV Care Center in South Africa. But more needs to be done – harm reduction programs are among the key interventions least accepted, further stigmatizing those who rely on them.

“We are the same women,” Delgerzaya M. (left) says about the sex workers with whom she works. “I understand their challenges better than others.” Delgerzaya M. and Usukhbayar D. are former sex workers who now introduce sex workers to the HIV prevention training and resources offered by the Global Fund-supported NGO “Perfect Ladiesin Ulaanbaatar, Mongolia.

The Global Fund / Kevin Keen

TB

Prisoners and incarcerated populations, people living with HIV, migrants, refugees and indigenous populations are all groups that are highly vulnerable to TB, as well as experiencing significant marginalization, decreased access to quality services, and human rights violations.

Miners in Southern Africa, for example, are reported to have greater incidence of TB than any other working population in the world, and TB incidence among migrant miners there is 10 times higher than in the communities from which they originate.

The level of TB in prisons has been reported to be up to 100 times higher than that of the general population, according to the World Health Organization, and cases of TB in prisons may account for up to 25% of a country’s TB burden.

Among other populations, according to UNAIDS, of 10 million people globally who developed TB 2017, 9% of them were co-infected with HIV. At least 1 million children become ill with TB each year, representing about 10% of all TB cases, according to the World Health Organization.

Malaria

The concept of “key populations” in the context of malaria is relatively new and not yet as well defined as for HIV and TB. However, there are groups that meet the criteria for key populations. Refugees, migrants, internally displaced people and indigenous populations in malaria-endemic areas are often at greater risk of transmission, usually have decreased access to care and services, and are also often marginalized.

The Global Fund / John Rae

The Global Fund also recognizes vulnerable populations – those who have increased vulnerabilities in a particular context, but may not fit the criteria highlighted above. These include adolescent girls and young women, and 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 leading external funder of key population programs across many regions. It remains the largest single financier globally of harm reduction programs for people who inject drugs.

For TB, the Global Fund focuses on countries with the 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 diseases 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 and 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. We also make sure that our policies protect identities when necessary to avoid negative consequences 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, 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 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, Global Action for Trans* Equality

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Published 13 September 2019