Given the hard work of communities, government, academics and implementing partners, there have been significant decreases in HIV incidence over the last decade in countries across sub-Saharan Africa including Malawi. Targeted scale-up of HIV testing and antiretroviral-based prevention and treatment programs has increased the coverage of lifesaving services across the country. However, new infections haven’t slowed as much as had been expected based on projections from mathematical models. And this disconnect may be due to essential HIV services still being largely out of reach for populations that have historically been marginalized from the HIV response.
For key populations — including female sex workers, gay men and other men who have sex with men, and transgender women — a lack of friendly services combined with structural barriers such as stigma, discrimination and punitive legal policies have contributed to a high and sustained incidence of HIV, even in 2022. Our new study, published in Open Forum Infectious Diseases, examined one project’s attempts to help address some of these issues.
Reaching key populations
Differentiated HIV prevention and treatment approaches that operate adjacent to existing health systems can facilitate access for key populations to access HIV prevention, diagnostic and treatment interventions. In Malawi, with support from USAID and PEPFAR, the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project partnered with organizations led by and friendly to key populations to deliver a package of differentiated HIV services from 2015-2019. Achievements under LINKAGES included:
- The establishment of safe spaces through drop-in centers where people could access antiretroviral therapy, post-exposure prophylaxis and screening for sexually transmitted infections, family planning and gender-based violence;
- Community-based HIV services and testing through routine mobile outreach;
- Scale-up of peer-led HIV testing approaches including index testing and risk network referral testing for female sex workers;
- An enhanced peer outreach approach, a coupon-based referral network approach that incorporates performance-based incentives to access hard-to-reach key population networks using peer mobilizers.
In our study, we aimed to determine how differentiated HIV testing approaches implemented under LINKAGES were more or less effective in engaging key populations across the HIV prevention and treatment cascades. A key advance of this work was our ability to link individuals across multiple touch points over time using a web-based DHIS2 tracker database, which facilitated the merging of records across multiple routine data collection forms. We used these merged records to assemble an analytic cohort comprising up to 2 years of prospective follow-up for all participants diagnosed with HIV through the program.
A total of 18,397 individuals were included in the analyses, of whom 10,627 (58%) were female sex workers, 2,219 (12%) were men who have sex with men, and 4,970 (27%) were clients of female sex workers. Community-based peer testing through mobile outreach was the most common entry point into the program for all populations with the exception of female sex workers, who were more likely to access services through the drop-in centers. Intensive HIV testing approaches including index testing and the enhanced peer outreach approach identified a high proportion of persons living with HIV despite reaching few individuals overall.
Approaches also impacted ART initiation differently for persons living with HIV. For example, female sex workers who tested positive through risk network referral testing were more likely to initiate ART within 30 days compared to those who tested positive through clinic-based testing (adjusted risk ratio, 1.50; 95% confidence interval, 1.23-1.82). For men who have sex with men, those who tested positive through a drop-in center and those who tested positive through index testing were more likely to initiate ART within 30 days compared to those who tested positive in clinic (drop-in center testing: aRR, 1.82; 95% CI, 1.19-2.78; index testing: aRR, 1.45; 95% CI, 1.06- 2.00). Clinic-based testing appeared to be the most successful for initiating clients of female sex workers on ART; clients who were diagnosed through mobile outreach and through the drop-in center were less likely to initiate ART when compared to those who were diagnosed in clinic (community-based peer testing: aRR, 0.63; 95% CI, 0.45-0.88; drop-in center: aRR, 0.65; 95% CI, 0.43-0.99).
Adapting strategies to close “last mile” gaps
The results of our study suggest the potential of differentiated HIV testing and outreach services in improving ART initiation among key populations in Malawi. However, for these interventions to achieve their potential, these services should be empirically tailored to the distinct needs of each key population. 2030 is less than 8 years away — and the goal remains to have achieved zero new infections by then. In parts of Malawi, where the UNAIDS 95-95-95 targets for HIV diagnosis, linkage to treatment and viral suppression are within reach, differentiated approaches tailored to the needs of those who remain underserved and at risk of HIV can help accelerate efforts to close “last mile” gaps. Ultimately, achieving zero new infections by 2030 in Malawi and its neighbors suggests the need to adapt treatment strategies given persistent individual and structural barriers to treatment for key populations living with HIV.