A decade and beyond: learnings from HIV programming with underserved and marginalized key populations in Kenya.

INTRODUCTION: Key populations (KP) continue to account for high HIV incidence globally. Still, prioritization of KP in the national HIV prevention response remains insufficient, leading to their suboptimal access to HIV programmes. This commentary aims to share Kenya's challenges and successes in achieving 2020 global HIV targets and scaling up the KP programme in the last decade. DISCUSSION: The KP programme in Kenya has scaled up in the last decade with the inclusion of female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), transgender people and people in prisons as priority populations in the national HIV response. KP coverage based on official size estimates for FSW is 73%, for MSM is 82%, for PWID through needle syringe programme (NSP) is 71%, and through opioid substitution therapy (OST) is 26% and for transgender people is 5%. The service outcomes for KP have been relatively strong in prevention with high condom use at last paid sex for FSW (92%) and use of sterile equipment among PWID (88%), though condom use at last sex with a non-regular partner among MSM (78%) is still low. The KP programme has not met care continuum targets for all subpopulations with low case findings. The national KP programme led by the Ministry of Health has scaled up the programme through (a) strategic partnerships with KP-led and competent organizations, researchers and donors; (b) development of policy guidance and programme standards; (c) continuous sensitization and advocacy to garner support; (d) development of national reporting systems, among others. However, the programme is still struggling with uncertain size estimates; lack of updated bio-behavioural survey data; inadequate scale-up of interventions among transgender people and people in prison settings; gaps in reaching adolescent and young KP, and effectively addressing structural barriers like violence and stigma. CONCLUSIONS: To reach the ambitious global HIV targets, sufficient coverage of KP with quality HIV programmes is critical. Despite scaling up the KP programme, Kenya has not yet achieved the 2020 global HIV targets and needs more efforts to scale-up quality programmes for KP who are underserved in the HIV response.

Design, implementation, and monitoring of HIV service packages for people who inject drugs: An assessment of programs supported by the Global Fund in 46 countries.

BACKGROUND: People who inject drugs (PWID) are at higher risk of acquiring and transmitting HIV, accounting for an estimated 10% of HIV new infections globally. The World Health Organization (WHO) and other international agencies have clearly outlined the comprehensive package of services that should be available for PWID. METHODS: This paper summarizes the data and findings from the PWID service packages assessed in 15 countries across different regions. It also provides data on the design of PWID programs in a further 30 countries that identified PWID as a key population in their national HIV strategic documents. A mixed-method approach was used, including desk reviews, key informant interviews, site observations and group interviews with implementers and PWID focus groups. RESULTS: Design of service packages varied considerably between countries while many matched the WHO Comprehensive Package. Only 85% countries (39/46) included needle-syringe exchange programs (NSEP) and 76% included opioid agonist therapy (OAT). Only 17% countries included overdose management in their package design. Across the 46 countries assessed, the average coverage with defined prevention package was 40% among countries for which coverage figures could be derived. CONCLUSIONS: Despite some examples of client-based, high-quality services in challenging environments, few countries, which rely primarily on external donor support, are reaching the necessary coverage levels across the full range of PWID HIV prevention, testing and care services. Transition from donor to domestic funding to fund this element of the HIV responses in many countries presents a compelling case to prevent PWID from being further left behind.

Are monitoring and evaluation systems adequate to report the programmatic coverage of HIV services among key populations in countries?

There was no global guidance or agreement regarding when a country has an adequate system to report on the service packages among human immunodeficiency virus (HIV) key populations. This article describes an approach to categorizing the system in a country for reporting the service package among HIV key populations. The approach consists of four dimensions, namely the epidemiological significance, comprehensiveness of the service packages, geographic coverage of services, and adequacy of the monitoring system. The proposed categorization approach utilizes available information and can inform the improvement of the service delivery and monitoring systems among HIV key populations.