“Nothing about us without us”: controlling the epidemic among key populations in Africa

As some countries in Africa are on the verge of reaching epidemic control – meaning there are fewer HIV diagnoses than deaths of people living with HIV – progress among key populations remain largely unknown, participants at the INTEREST 2022 conference in Kampala heard last week. In 2020, key populations and their sexual partners accounted for 39% of new HIV infections in sub-Saharan Africa. However, only eight countries had data on the prevalence of injecting drug users, while only two had data on transgender people.

Key populations in Africa – including sex workers, men who have sex with men (MSM), transgender people, injecting drug users and prisoners – are highly vulnerable to HIV due to risky behaviors , marginalization, stigma, discrimination, violence and human rights violations and criminalization. In 2021, estimated HIV prevalence was 31% among sex workers in Eastern and Southern Africa, 28% among transgender people, 19% among people who inject drugs, 13% among gay men and other men who have sex sex with men, and 11% among prisoners.

The few studies that have been done show huge gaps in the HIV care cascade for key populations – fewer people know their HIV status, are on treatment and are virally suppressed than in the general population.

Dr. Chris Akolo of FHI 360 said countries need to dedicate more resources to mapping and understanding the size of key populations to ensure adequate programming. He also shared that scaling up HIV testing approaches such as index testing, social media testing and self-testing was particularly crucial for new key populations not always reached by testing approaches. traditional.

Additionally, strengthening STI testing services, using peer navigators to support HIV treatment enrollment and continuity, and optimizing differentiated service delivery models for oral PrEP, are essential to achieve and maintain epidemic control.

Dr Akolo explained that a community PrEP program in South Africa for men who have sex with men recruited 84% of new PrEP users through community outreach strategies, of which only 16% started. in a clinical setting. He said taking PrEP to key populations was key to getting better coverage.

To improve viral suppression among key populations, he suggested promoting U=U messages and implementing decentralized drug distribution – including delivery to clients’ homes, a private clinic or a pharmacy of the client’s choice. , as well as automated distribution, where a package of ARV refills is made available in secure automated lockers. To improve viral load testing, he called for online appointment booking, collection of samples from private clinics and pharmacies, and virtual adherence counseling.

The conference learned that these strategies need to be led by key populations and culturally competent organizations. He encouraged HIV service providers in Africa to move to online spaces to expand reach and connect with key populations.

Dr Akolo added that working towards the 10-10-10 targets would help control the epidemic among key populations. The UNAIDS 10-10-10 targets state that by 2025, less than 10% of countries should have punitive legal and policy environments that deny or limit access to services, less than 10% of people living with HIV and key populations will experience stigma and discrimination. , and less than 10% of women, girls, people living with HIV and key populations will experience gender inequality and violence.

African countries must also invest in preventing violence, protecting key populations and health providers from homophobic violence, and training and sensitizing health workers to reduce stigma.

Earlier, Dr Laura Nyblade of RTI International spoke to the conference about how stigma undermines access to healthcare and health outcomes for clients. She described some of the processes of stigma in health care settings:

• distinguish and label differences, for example having special days, times or places for people living with HIV and key populations
• associate negative attributes with key populations, e.g.., “people who use drugs have bad morals(quote from a clinician in Tanzania)
• separating ‘us’ from ‘them’, for example, “I tend to run away from them. I’m not even close to them. [men with feminine mannerisms] either to have a conversation or whatever. I just hate them. (quote from a clinician in Ghana)
• discrimination; for example, “A friend who was [admitted to] one of the facilities died because the aunt who also works at the facility told her colleagues in the ward that he was an MSM…so nurses and doctors should not deal with [him]. The nurses and doctors also abandoned my friend and he died. (quote from MSM in Ghana)

She also shared an example of intersectional stigma, where the person was simultaneously affected by stigma towards MSM, gender nonconformity and HIV.

“My friend when he went to [health facility name] the nurse told me ‘you are one of those people’: one of those people means that you are gay. “As soon as I saw you, I knew it. Your mannerism, when I saw you, I saw you were one of them, and I know very well that you bring HIV to the hospital.'”

Stigma in health care settings has also presented itself in stigmatizing language such as ‘HIV infected’, ‘AIDS infected’ and ‘AIDS patient’. She encouraged healthcare workers to use people-centred language, such as “person living with HIV”.

In conclusion, Dr Nyblade recommended mainstreaming stigma and discrimination reduction into all national HIV programs and strategies, while Dr Akolo stressed the need to address discriminatory laws that continue to impact key populations and create an enabling environment for improved access to services.

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