Key Populations

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.

HIV

In the context of HIV, key populations include:

• Men who have sex with men
• Trans and gender diverse people
• Sex workers
• People who use and/or inject drugs
• People living with HIV
• People in prison and other closed settings

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

TB

Prisoners and incarcerated populations, people living with HIV, migrants, refugees, miners and people who work in poorly ventilated conditions, 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, people living with HIV are 19 times more likely to develop active TB disease than people without HIV, according to the World Health Organization. At least 1 million children become ill with TB each year, representing about 10% of all TB cases, according to the 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, pregnant women, children under 5, 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.

Investing For Impact: Focus on Key Populations

The Global Fund Strategy 2023-2028 emphasizes the importance of supporting and including key populations in every stage of the fight against HIV, TB and malaria. From service planning, implementation and monitoring to advocacy and the provision of expert technical support, members of key populations are essential stakeholders and partners. We work with them to remove barriers to and increase their engagement in all Global Fund-related processes.

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.

Leadership and Engagement of 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, and organizations led by 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 key populations and those affected by the three diseases.

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 and abide by our key principle of “do no harm”.

Designing programs tailored to the needs of 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.

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 the quality of services through community-led monitoring. Firsthand knowledge and insight of key populations are critical to ensuring that programs deliver impact.