Treating key and mobile populations as people, not public health problems

key pops
SHARE staff

Of no surprise to those in the HIV field, the epidemic continues to be fueled by stigma, none more evident than among key and mobile populations, such as people who inject drugs and sex workers. Speakers at the Southern African HIV Clinicians Society conference shared their experiences in working with these groups and challenged participants to view them as people – and not merely a public health problem.  

People who inject drugs are incredibly vulnerable to HIV infection and other chronic blood-born infections, such as hepatitis C. The stigmatization of people who inject drugs can reduce them to “nuisances” within their communities and in the eyes of healthcare providers and authorities. Dr. Andrew Scheibe of the University of Cape Town and TB/HIV Care Association warns that criminalizing a substance essentially criminalizes the user, and for people who inject drugs, spending time incarcerated is one of the strongest predictors of long-term abuse of injectable drugs. Stigma pushes people away from their homes and communities, leaving them with low self-esteem. Policymakers sometimes make programming decisions based on morality rather than science, Dr. Scheibe said. This includes the closure of programs which provide sterile injecting equipment and information on safe injecting. South Africa is part of the global injectable drug trafficking network, Dr. Scheibe noted, and we need to acknowledge the data and provide empathetic harm reduction interventions. He shared several personal stories of clients supported by the Step Up Project, a demonstration project providing a package of essential HIV and other wellness services recommended by the World Health Organization to people who inject drugs.

Another key population critical to ultimate control of the HIV epidemic is sex workers. Naomi Hill from Wits Reproductive Health and HIV Institute (Wits RHI) shared approaches and results from a collaborative project providing prevention and treatment services to sex workers. With support from South Africa’s Department of Health, the Networking HIV and AIDS Community of Southern Africa (NACOSA), and USAID, as well as a range of sub-partners providing specific areas of expertise, the project employs microplanning, which decentralizes outreach management and planning to grassroots workers and allows them to make programmatic decisions to best reach the sex workers. The project uses geo-spatial hotspot mapping as well as site and individual risk assessments to guide its service provision. Site assessments provide information on peak days, relevant community issues, and population size, while individual risk assessments enable the project to focus on those at greatest risk based on factors such as healthcare access, condom use, substance use, how many clients a sex worker has, and how long he or she has been a sex worker. The project addresses both sides of the HIV cascade of care: those who test HIV-positive as well as those who test HIV-negative. It engages sex workers in pre-exposure prophylaxis (PrEP) for HIV prevention, creating demand by improving messaging (that PrEP is a safe and viable option), offering the service at pap smear campaigns, engaging PrEP ambassadors/hotspot champions, and conducting virtual marketing. The project’s PrEP retention and adherence interventions include intensified tracking and tracing, additional support during the first four months after initiation (the highest drop-off period), and improved messaging on potential side effects. Just over 10% of sex workers tested through the project are diagnosed with HIV. Of these, 71% have been linked to care and 44% are currently on antiretroviral therapy (ART). PrEP enrollment among HIV-negative sex workers has varied from 18-30%.

Thandeka Khoza, also from Wits RHI, shared the organization’s work with Unitaid in the provision of HIV self-testing in South Africa, with men as a key target, as well as adolescent girls and young women and key populations (including sex workers, men who have sex with men, people who inject drugs, and transgender people). Self-testing is a supplementary strategy to achieve the first “90” (90% of all people living with HIV should know their status) and is particularly appropriate to reach key and under-tested populations which may face challenges with accessing traditional healthcare. The oral test kit used provides results in 20 minutes and includes a barcode for tracking and tracing. Clients are provided with a call line, user app for information, and tailored educational materials. Peer educators follow up with clients telephonically and assist in linking HIV-positive clients to care. The project is assessing acceptability, willingness to pay for the test, and usability in various locations and populations, and has found low levels of social harm from self-testing. Approaches in reaching men with self-testing include peer referral, voluntary medical male circumcision (VMMC) services, sporting events, virtual platforms, partner delivery, and community-based distribution. The project hopes to ultimately use its data to inform the National Department of Health on the most effective implementation model by assessing which distribution models work best for which population, how to measure impact against national targets, how to achieve the best linkage to care, the cost-effectiveness of each model, and how to address social harm concerns.

Key and mobile populations remain an essential part of the effort to end AIDS and prevent new infections. People who inject drugs, sex workers, men, and other groups still do not have open access to a full range of HIV prevention, treatment and care services due to stigma, criminalization, and other factors. We need to stop treating others as public health problems, the speakers emphasized, and treat them as people who need our support regardless of our opinions on their behavior. Despite large-scale inaction, or worse, counter-productive policies, it is exciting to learn more about sound evidence-informed programming that is improving the lives of people at higher risk of HIV infection and further contributing to the evidence base for interventions founded on science rather than morality. 

criminalization, key populations, Southern African HIV Clinicians Society, SAHCS Conference 2018, stigma and discrimination, people who inject drugs (PWID), sex workers, mobile populations, access to health services, VMMC, voluntary medical male circumcision (VMMC), pre-exposure prophylaxis (PrEP), PrEP, co-infections, HIV-HCV co-infection, hepatitis C, harm reduction