Introduction
HIV, viral hepatitis and STI epidemics, particularly among key populations, continue to be fuelled by laws and policies criminalizing sex work; drug use or possession; diverse forms of gender expression and sexuality; stigma and discrimination; gender discrimination; violence; lack of community empowerment and other violations of human rights. These sociostructural factors limit access to health services, constrain how these services are delivered and diminish their effectiveness.
“Critical enablers1”, as used in this guideline, means strategies, activities and approaches that aim to improve the accessibility, acceptability, uptake, equitable coverage, effectiveness and efficiency of HIV, viral hepatitis and STI services. Enablers operate at many levels – individual, community, institutional, societal and national, regional and global. They are crucial to developing strategies and implementing comprehensive HIV, viral hepatitis and STI programmes and services for key populations in all epidemic contexts.
The health sector has an important role to play, but successful implementation of critical enablers requires collaboration across different sectors, such as health, justice, housing, education, welfare and labour. It also requires multiple partners from government, civil society, religious institutions and the private sector. Full and meaningful involvement of key population-led organizations is crucial.
Special considerations for adolescents and young people
The barriers and critical enablers outlined in this chapter apply to both adults and adolescents in key populations. For adolescents from key populations, these factors may be further exacerbated by their rapid physical and mental development and complex psychosocial, familial, and social, educational and economic vulnerabilities. Also, adolescents from key populations experience sociostructural barriers to services, notably policy and legal barriers related to age of consent. Children of key populations can experience stigma and discrimination, and hence face the same difficulties in access to services. Health care providers may be prosecuted for providing services to adolescents without parental/guardian consent, further reducing access to services.
Key populations’ experience, values and preferences related to structural barriers and critical enablers
Qualitative research conducted by the global key population-led networks for the development of this guideline (for a detailed report, please see Web Annex B) found that all key populations reported criminalization, stigma and discrimination as persistent barriers to accessing health services and remaining in treatment, as well as being driving factors in perpetuating vulnerability, human rights abuses and poor health outcomes. Participants from the trans and gender diverse people’s network additionally emphasized structural barriers to legal gender recognition.
The criminalization of drug use or possession, sex work, same-sex relations and gender expression deter members of key populations from accessing services due to fears of legal repercussions. It was also noted how criminalization perpetuates the exclusion of key population-led and rights-based health programming from funding mechanisms and state health responses. Participants in the qualitative study additionally noted that law enforcement using the possession of condoms and injecting equipment as so-called evidence of sex work and drug use or possession further hinders the use of evidence-based prevention services and commodities.
Stigma and discrimination, exacerbated by criminalization, also remain a salient barrier to accessing services and remaining in treatment for key populations. Participants across key population groups emphasized the pervasive problem of provider-based stigma and discrimination, including judgemental attitudes, breaches of confidentiality, denial of treatment, violence and abuse – even in contexts where legal protections exist.
To improve key populations’ access to, and retention in, HIV, STI and viral hepatitis services, and to promote their health and human rights in general, participants stressed the need for legal and policy reform, community-led responses, community empowerment and capacity-building, and anti-violence initiatives.
Community empowerment was emphasized across all key population-led networks participating in the qualitative research project. Participants discussed the importance of key population-led responses, including peer outreach and other peer-based services, awareness-raising, advocacy, drop-in-centres, capacity-building and resource mobilization to ensure sustainable, community-led programming. These initiatives were seen both as a means to improve access to services, as well as an essential measure for addressing structural barriers undermining key populations’ health and human rights.
In addition, participants noted the importance of sensitizing health care staff, law enforcement, NGO workers and the broader community. Key population-led sensitization training was perceived as an effective intervention to decrease stigma and discrimination and improve the acceptability of health services. Participants also recommended anti-violence interventions as enabling interventions.
Participants felt that because violence can be common (largely due to the effects of criminalization that require systemic solutions), violence prevention interventions need to be incorporated in an ongoing way into an overall wellness approach that views health as much more than “simply a set of interventions”. In this context, they stressed the need for services to think more about what might bring people in and empower them to think about and address their health.
Lastly, all key population-led networks noted the critical role that funding plays in community-led initiatives, indicating an ongoing need to prioritize funding for key population-led programming, given the serious lack of funding for community and key population-led initiatives, and highlighting the importance of achieving the Global AIDS Strategy targets; namely, 80% service delivery for HIV prevention programmes for key populations, delivered by key populations; 30% testing and treatment services, delivered by community-led organizations; and 60% programme support achievement societal enablers, to be delivered by community-led organizations.
Essential interventions for impact: critical enablers
This chapter outlines a range of structural barriers that compromise access to health services for key populations, and then identifies critical enablers to overcome these barriers. This chapter includes a number of good-practice recommendations that are based on those made in the 2014/2016 WHO consolidated key population guidelines (3) with updated references, where available. While these barriers and enablers are interrelated, we attempt to discuss each individually.
Legal and policy barriers and enablers
Key population members are entitled to the full protection of their human rights, as specified in international human rights instruments. Human rights include, but are not limited to, the right to equal enjoyment of rights and non-discrimination; security of person and privacy; recognition and equality before the law; fair trial of law; the highest attainable standard of mental and physical health; education; employment and just and favourable conditions of employment; freedom of movement; peaceful assembly and association; freedom from arbitrary arrest and detention, and from cruel and inhumane treatment; and protection from violence. States have an obligation to ensure that the above rights are enjoyed without discrimination on the basis of race, nationality, sex, age, religion, sexuality, gender identity, health status, disability, marital status or other status (57–60).
Most countries have laws, regulations or policies that are barriers to effective HIV, viral hepatitis, STI and other health services for key populations, including criminalization of sex work, drug use and possession, gender identity or expression, and sexual relations between people of the same sex. A number of countries criminalize gender identity in a de facto manner, by criminalizing cross-dressing or impersonation of the opposite sex. For trans and gender diverse people, the lack of legal gender recognition is a key barrier to access, and retention of, health services, in addition to the full enjoyment of other rights, such as freedom of mobility, housing, education and employment. This further isolates trans people and increases their vulnerabilities. In many settings, adolescents under 18 years of age are classified legally as minors and, therefore, must have consent from a legal responsible adult for medical care. Other barriers are related to restrictive or punitive policies and practices, such as criminalizing the possession of needles/syringes, which restricts the ability of programmes to operate NSPs, and using possession of condoms as evidence of sex work and as a basis for arrest (61). Other harmful practices include forced anal examinations, which are used to investigate or punish alleged same-sex behaviour between consenting men or transgender women (62).
These legal barriers have measurable, detrimental effects on the health of members of key populations, shown by modelling and other research (63–74). For example, a systematic review found associations between exposure to arrest and HIV infection in people who inject drugs (64); in countries in sub-Saharan Africa, the odds of living with HIV were found to be 7.2 times higher for sex workers in countries that criminalize sex work compared to countries that partially legalize sex work (68); repressive policing of sex workers was associated with increased risk of HIV or other STIs (odds ratio of 1.87); and sex workers exposed to repressive policing were three times more likely to be physically or sexually assaulted (75). The criminalization of the clients of sex workers has also been repeatedly shown to negatively affect sex workers’ safety and health, including reducing condom access and use, and increasing the rates of violence (68, 76). Studies show the negative effect of criminalization of same-sex practices on HIV prevalence and access to prevention, diagnosis and treatment services (77, 78).
For trans and gender diverse people, the legal recognition of preferred gender and name may be important to reduce stigma, discrimination and ignorance about gender variance. Such recognition by health services can support better access, uptake and provision of HIV services (79). Additionally, it is likely to improve trans and gender diverse people’s health and wellbeing (80). However, legal recognition must be accompanied by training, sensitization, education and enforcement.
Legal reforms, such as decriminalizing drug use or possession, sex work and same sex relationships; legal recognition of trans or gender diverse status; lowering the age of consent for accessing health services; and considering exceptions to a standard age of consent policy (such as mature minors) are critical enablers that can change a hostile environment for key populations to a supportive environment. Without protective policies and decriminalization of drug use or possession, and of diverse forms of gender identity and sexuality and sex work, barriers to essential health services will remain; many people from key populations may fear that seeking health care will expose them to adverse legal consequences. Specific consideration should be given to such legal reforms as part of any revision of policies or programmes for key populations.
Laws and policies that criminalize and punish key populations also constrain people from obtaining justice and legal services. Policies and procedures are needed to ensure that individuals from key populations can report rights violations such as discrimination, gender-based violence and other crimes, issues with policing, violations of informed consent, violations of medical confidentiality and denial of health care services. Reporting options, beyond going to the police, will encourage reporting of human rights violations. For example, persons from key populations can be trained as paralegals, and key population-led organizations and other organizations that work with key populations can serve as a third-party reporter of complaints (61, 81).
Law enforcement has a statutory duty and obligation to ensure key populations enjoy equal protection under the law, and that the human rights of key populations are not violated. Law enforcement agents should receive continual training in ways to support – or at least not to impede – key populations’ access to essential health services, including not surveilling or arresting people accessing OAMT, NSPs and drug dependence treatment clinics; avoiding confiscation of drug treatment medication, and not using possession of sterile needles or condoms to justify arrest. Systems to promote good policing practices and to provide safe avenues for reporting human rights violations will help ensure that police are protecting both the public health and the human rights of all persons (61).
Overarching recommendations related to enabling interventions to address legal and policy barriers are listed below. Please see the recommended interventions chapter for full details.
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| Overarching good practice and guidance statements: removing punitive laws, policies and practices |
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Existing good practice statement (adapted)
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| Countries should work toward decriminalization of drug use/injecting, drug possession, sex work, same-sex activity and nonconforming gender identities, and toward elimination of the unjust application of civil law and regulations against people who use/inject drugs, sex workers, men who have sex with men and trans and gender diverse people (3, 45, 79, 82–85). |
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Existing guidance statement
| Laws, legal policies and practices should be reviewed and, where necessary, revised by policy-makers and government leaders, with meaningful engagement of stakeholders from key population groups, to allow and support increased access to services for key populations (3, 79, 83, 84). |
Stigma and discrimination
Stigma is a difference that is pejoratively labelled, stereotyped or named. Stigma can lead to discrimination; namely, unfair and unjust action towards an individual or group on the basis of real or perceived status or attributes, a medical condition, socioeconomic status, employment, drug use, gender, race, sexual identity, age or other perceived differences or characteristics, with the purpose or effect of impairing or nullifying the recognition, enjoyment or exercise – on an equal basis with others – of all human rights and fundamental freedoms (61).
People from key populations are often particularly subjected to stigma, discrimination and negative attitudes related to their behaviour, sexual orientation, gender identity or engagement in sex work – and doubly so if also living with HIV, viral hepatitis or STIs. Many key populations also face intersecting forms of discrimination on the basis of their age, sex, race or ethnicity, physical or mental health status, disability, nationality, asylum or migration status, or criminal record. This is the basis for discrimination, which is common in many health facilities and law enforcement services. It may seem to be tacitly endorsed by the lack of national laws and policies that protect key populations against discrimination, and by the implementation of punitive and restrictive policies.
Within the health sector, stigma and discrimination can take many forms at the individual and systems levels. The lack of training and educational programmes to inform health workers of the needs, health issues and rights-based strategies and interventions for key populations contributes to marginalization. It leaves providers ill-equipped to address health needs and perpetuates stigmatizing and discriminating practices, even to the point of refusing services. Health care workers may be biased against certain people, but may also experience discrimination themselves when working with key populations (86).
The effects of stigma and discrimination against key populations can manifest in delayed testing and missed diagnoses, poor retention in treatment programmes and poor treatment outcomes, concealment of health status and, in general, poor uptake of health services (61, 87–102).
There are many interventions designed to reduce stigma and discrimination in health care settings, with some randomized controlled trials and observational studies showing positive effects (92, 103–114). However, given the heterogenous nature of the interventions and outcomes measured, meta-analyses are often not possible, and systematic reviews do not clearly indicate which are the most effective interventions when it comes to reducing stigma and discrimination in health care settings (86, 115–117). Instead, it is useful to consider a range of interventions that can address different aspects of stigma and discrimination as listed below (61, 115).
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| Intervention approach | Description |
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Information based
| Providing information about health and health-related stigma |
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Skills building
| Conducting sensitization or other skills-building activities for health care workers, law enforcement officers and others |
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Counselling and support
| Supportive services for members of key population groups |
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Contact with key populations
| Facilitating interactions between key population members and health care workers, law enforcement officers and others |
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Structural
| Institute anti-stigma and anti-discrimination policies and codes of conduct with monitoring, oversight and opportunities for key population members to report discrimination, including redress and accountability mechanisms |
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Biomedical
| Ensuring UHC and professional, non-discriminatory provision of care, including HIV, viral hepatitis and STI services for key populations |
Enabling interventions to address barriers related to stigma and discrimination are listed below:
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| Overarching good practice and guidance statements: stigma and discrimination |
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| Existing good practice statement | Countries should work towards implementing and enforcing anti-discrimination and protective laws, derived from human rights standards, to eliminate stigma, discrimination and violence against people from key populations (3). |
| Existing good practice statement | Policy-makers, parliamentarians and other public health leaders should work together with civil society organizations in their efforts to monitor stigma, confront discrimination against key populations and change punitive legal and social norms (3, 79, 81, 83–85, 118, 119). |
| Existing guidance statement | Health services should be made available, accessible and acceptable to people from key populations, based on the principles of medical ethics, avoidance of stigma, non-discrimination and the right to health (3, 79, 81, 83–85, 118–120). |
Community empowerment
Key populations often have little or no control over HIV, STI and viral hepatitis risk factors driven by the legal, political and social and programmatic environment, and the context of their lives. These constraints can hinder people’s control over their health and wellbeing, as well as increasing their risk of HIV, viral hepatitis and STIs. This lack of control is exacerbated if people are unaware of available health services, of their legal and human rights, specifically their right to health, and what to do if these rights are violated. Few young people from key populations receive adequate information and education centred on their sexual lives. Instead, they receive negative, critical, conflicting or confusing messages about gender, drug use, unintended pregnancy and STIs, including HIV (121).
Empowerment is the process by which people with little power work together to increase control over events that determine their lives and health. Community empowerment means increasing key population communities’ control over their health by addressing the structural constraints to health, human rights and wellbeing; making social, economic and behavioural changes; and improving access to health services. Community empowerment can take many forms, such as fostering key population-led groups and key population-led programmes and service delivery; meaningful participation of people from key populations in designing and operating services; peer education or navigation; task shifting to key population peers; self-care; implementation of legal literacy and service programmes; and ensuring civil space in which key populations can function without fear of reprisals.
Evidence, mainly among sex workers, shows that community empowerment has a measurable impact on key populations’ health (122–134), including reductions in STI incidence (127), HIV incidence (128, 134), high-risk sex (131) and increased uptake of family planning (132).
shows a framework for fostering key population services included in key population networks’ developed implementation tools (135–138).
Framework for community empowerment.
It is important to foster and support services, facilities and research led by organizations of people from key populations. Key population-led organizations, collectives and networks can play key roles in training staff of health services, law enforcement and social service agencies; facilitating interaction with the communities of key populations; and developing, implementing, monitoring and managing services. Key population communities can build understanding of, and alliances with, other neglected, at-risk groups, such as youth networks, persons with disabilities, adolescent girls and young women. They have special strengths in providing and leading community-based and outreach services.
Meaningful participation can mean not only having a voice in decision-making, but also contributing to service delivery and monitoring and evaluation (M&E). Community-led monitoring, an accountability mechanism led by key populations and other affected communities, which involves trained peer monitors and structured reporting mechanisms, is particularly important (139).
WHO has several relevant recommendations related to roles for key population peers in service delivery, which can be found in the service delivery chapter.
The meaningful participation of key populations in programming is critical to ensure the appropriateness and acceptability of services to the intended clientele. It is also important for building trusting relationships between the community and service providers, who may be accustomed to establishing the parameters by which services are provided, and prescribing how relationships or partnerships are to be conducted, a norm that needs to be shifted to allow for community empowerment and service access.
Meaningful participation means that key populations: 1) choose whether to participate; 2) choose how they are represented, and by whom; 3) choose how they are engaged in the process; and 4) have an equal voice in how partnerships are managed.
Enabling interventions to improve community empowerment are listed below.
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| Overarching good practice and guidance statements: community empowerment3 |
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Existing guidance statement
| Key population-led groups and organizations should be made essential partners and leaders in designing, planning, implementing and evaluating health services (3). |
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Existing good practice statement
| Programmes should implement a package of interventions to enhance community empowerment among key populations (3, 79, 84, 85). |
Violence
Violence against people from key populations is a common occurrence and can take various forms – physical, sexual or psychological, and can be perpetrated by different people, including intimate partners, clients, family members, strangers, service providers, law enforcement officers and others in positions of power (140–147). Violence can be fuelled by the imbalance in the power dynamics of gender – by prejudice and discrimination against persons perceived to depart from conventional gender and sexuality norms and identities. Other characteristics such as age, disability or race can increase vulnerability to violence. Also, multiple structural factors influence vulnerability to violence, including discriminatory or harsh laws, and policing practices and cultural and social norms that legitimize stigma and discrimination.
Experience of violence has been shown to negatively impact on key populations’ health, including increasing drug-related harms (142, 148–152), reduced uptake of sexual and reproductive health services (141), inconsistent condom use (141, 147, 149, 153), depression and other mental health issues (143, 154), and increased HCV infection risk (155, 156), as well as having a direct impact on HIV and STI acquisition (157). A modelling study estimated that reduced sexual violence against sex workers could reduce new HIV infections by 25% among sex workers and their clients (158). Women, especially young women from key populations, including women who use drugs, female sex workers, people in prisons and transgender women, experience particularly high rates of physical, sexual and psychological abuse (159).
The health sector has an important role to play in addressing violence by providing comprehensive health services, including: for sexual and reproductive health; providing referrals to other support services; gathering evidence through data and research; fostering prevention policies in other sectors; and advocating for violence to be recognized as a public health problem and for resource allocation (160).
Those who experience sexual violence need timely access to post-rape care, including emergency contraception, safe abortion, post-exposure prophylaxis for HIV and other STIs, hepatitis B immunization and psychosocial care and support, as well as referrals to legal services (161). HIV, viral hepatitis and STI prevention, diagnosis and treatment for key populations should include, either on site or through strong referral and linkage, clinical and psychosocial care and support for survivors of violence, in line with WHO guidelines for responding to sexual violence (161–162). Survivors may need treatment for physical injuries and longer-term mental health care. Health services also can document medico-legal evidence, which can assist survivors’ access to justice. Supportive services also include hotlines, staffed by trained peer and other counsellors, to offer psychosocial support, as well as crisis response interventions, with multidisciplinary teams that link survivors to various services and safe spaces, without restrictions based on ongoing drug use (84).
Efforts to address violence against people from key populations must involve other sectors along with the health sector. Together, they must create an enabling environment to promote physical, sexual and emotional wellbeing and safety. Critical enablers include mechanisms for documenting and monitoring violence, training people from key populations and other stakeholders to understand human rights, and for fostering the accountability of law enforcement officials to prevent and respond to violence and infringements of human rights (162, 164). Evidence shows the effectiveness of participatory programmes that engage multiple stakeholders as well as community mobilization interventions (165). Law enforcement practices can increase the risk of violence faced by key populations. Indeed, law enforcement officers themselves can be perpetrators. Work with law officers can involve training on the human rights of key populations, as well as promoting accountability for rights-based law enforcement (162). Efforts to prevent violence can be promoted by advocacy for law and policy reforms that protect the rights and safety of key populations; increasing awareness of reporting mechanisms and disciplinary action; conducting sensitization workshops for people with pivotal roles (for example, government officials, law enforcement officers, prison staff, media, health care workers and religious leaders); the creation of safe spaces; and by creating early warning and rapid response mechanisms with the involvement of key population community members, health workers and law enforcement officials. Integrating community representatives into these efforts also helps to create channels of communication among key populations, civic officials and law enforcement officers (162).
It also is important to monitor and document incidents of violence, both as evidence for advocacy and to inform programme design. Documenting the levels of violence faced by key populations is often the first step in creating awareness.
Enabling interventions to address violence against key populations are listed below.
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| Overarching good practice statements: violence |
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Existing good practice statement
| Violence against people from key populations should be prevented and addressed in partnership with key population-led organizations. All violence against people from key population groups should be monitored and reported, and redress mechanisms should be established to provide justice (3, 79, 84, 85, 162). |
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These are referred to as societal enablers in the Global AIDS Strategy 2021–2026 (45).
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In the 2014 Consolidated Guidelines for HIV prevention, diagnosis, treatment and care, the wording of this good practice statement was: Countries should work toward decriminalization of behaviours such as drug use/injecting, sex work, same-sex activity and nonconforming gender identities, and toward elimination of the unjust application of civil law and regulations against people who use/inject drugs, sex workers, men who have sex with men and trans and gender diverse people.
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Please note, in the WHO guideline: Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low and middle-income countries: recommendations for a public health approach, WHO recommended a package of interventions to enhance community empowerment among sex workers. This was a strong recommendation with very low quality of evidence. In 2014, all WHO recommendations related to key populations were consolidated, and a new good practice statement developed to expand this recommendation to all key population groups, as included in the table above.
