Background
Based on the principal of the human right to health, health services for key populations (as for all populations) should be:
Available – There needs to be sufficient number of functioning health care facilities, goods and services that can, in coordination, provide a package of interventions as described in these guidelines for all key populations.
Accessible – Health facilities, goods and services must be accessible to all key populations. This means they should be physically accessible, affordable and non-discriminatory.
Acceptable – Health services must respect medical ethics, be culturally and developmentally appropriate, sensitive to gender, and non-judgemental. Acceptability requires that health facilities, goods, services and programmes are people-centred, and cater for the specific needs of key population groups, and do so in accordance with international standards of medical ethics of confidentiality and informed consent.
Quality – Quality health services are: evidence-based, safe, effective, people-centred, timely, equitable, integrated and efficient.
The coronavirus disease (COVID-19) pandemic highlighted deficiencies in health systems, with most countries unprepared and experiencing considerable disruptions to health services, including HIV, viral hepatitis and STI services for key populations. This is due in part to divergence of funds from essential health services and barriers to health service access, such as restricted movement, reduced ability to pay and fear of infection. The inequities experienced by key populations increased their vulnerability to COVID-19 as well as HIV, viral hepatitis and STIs. At the same time, there are positive examples of resilience from key population communities to help their peers to continued access to life-saving services, such as ART and harm reduction.
To strengthen health systems to respond to the current and potential future pandemics, WHO recommends: investment in essential public health functions; building a strong primary health care foundation; increased domestic and global investment in health system foundations; involving communities (including key population communities) and societies; and addressing pre-existing inequities and the disproportionate impact of COVID-19 on marginalized and vulnerable populations, including key populations (1).
The service delivery and enabling interventions recommended in these guidelines will not only increase accessibility, availability and acceptability of HIV, viral hepatitis and STI services for key populations, but will strengthen systems to provide universal health coverage and mitigate the impact of health emergencies.
The majority of health interventions included in these guidelines are relevant for all populations, but key populations experience particular structural barriers to access health services, as described in the chapter on enabling interventions. In combination with the recommended enabling interventions, service delivery strategies described in this chapter, particularly community and key population-led delivery of services, can address these barriers, as well as contribute to person-centred care and UHC, ensuring key populations’ right to health.
While different in every country, key populations access health interventions through a range of services. Traditional, facility-based services, which may not be targeted towards key populations, offer a range of health interventions, including for HIV, STI and viral hepatitis prevention, testing and treatment, which should be able to be accessed by key populations. However, stigma, discrimination and restrictive policies often deter key populations from accessing these services.
Other services include community-based services, which may or not be key population led. Youth-friendly services can be accessed by young key populations. Often these services also conduct regular outreach and can provide mobile prevention, testing and/or treatment services as well. Some of these community-based services provide integrated HIV, STI and viral hepatitis interventions, as well as other health and social interventions, such as family planning, additional reproductive health and cancer screening, and sometimes legal services; these are often referred to as “one-stop-shops”. Methadone and buprenorphine are often provided by specialized services, which may or may not integrate HIV, viral hepatitis, TB and/or STI services as well.
This chapter describes a range of service delivery strategies: integration; decentralization; online services; self-care; involvement of peers and task sharing.
Community-led services, task-sharing and involvement of key population peers
Key populations have a central role to play in leading programmes and services: reaching groups; providing prevention, testing and treatment services; as well as helping their peers navigate and remain in treatment services. Qualitative research conducted by four key population networks (for detailed report, please see Web Annex B) found that community-led services were unanimously endorsed and preferred by participants. Key populations described community-led services as being critical to promoting the health and human rights of marginalized groups, especially as a counterbalance to stigma experienced by some in traditional health care environments. Accordingly, participants across all population networks advocated for the scale-up of community-led interventions, as well as resources to support community-led services.
UNAIDS defines community-led organizations, groups and networks as those that are led by and for the constituencies they serve. They are self-determining and autonomous entities: for which the majority of governance, leadership, staff, spokespeople, membership and volunteers reflect and represent the experiences, perspectives and voices of their constituencies, and who have transparent mechanisms of accountability to their constituencies (246).
UNAIDS further defines community-led responses as the actions and strategies undertaken by these groups to improve the health and human rights of their constituencies. These responses are informed and implemented by and for communities themselves and the organizations, groups and networks that represent them. Community-led responses are determined by and respond to the needs and aspirations of their constituents, and include a range of activities, such as advocacy, campaigning and holding decision-makers to account; monitoring of policies, practices, and service delivery; participatory research; education and information-sharing; capacity-building; and funding of community-led organizations, groups and networks. Community-led organizations and responses must be understood as distinct from those that are community-based. “Community-based” refers to where a response happens, regardless of who is implementing it, while “community-led” refers to who leads and implements the response (246).
Community-led services with peers as providers have a positive impact on HIV, STI and viral hepatitis, with increased access, availability and acceptability of services (247–252). Peers have an important role in reaching other key populations through outreach (253), giving information, providing commodities (such as condoms, lubricants, needles/syringes, PrEP, PEP and naloxone) and providing services, including testing and treatment.
As well as key population peers, other non-specialist health care providers and lay people can provide health interventions, including nurses and outreach workers, which can reduce the workload of doctors and increase access and equity.
This guideline includes a new GRADE recommendation specific to key population peers.
Peer navigation
★ NEW RECOMMENDATION
Peer navigators are recommended to support people from key populations to start HIV, viral hepatitis or STI treatment, and to remain in care
(conditional recommendation, moderate certainty of evidence).
Remarks:
A peer navigator’s role is to assist key population members to access health services, navigate these services and stay in care.
Peer navigators require adequate remuneration, recognition, training and other support to fulfil their role.
Peer navigators are often highly valued by their peers.
Further details on evidence, decision-making, implementation considerations and research gaps related to this new recommendation can be found in Chapter 9.
Relevant WHO guidelines include those related to task sharing and peer navigation for:
Integration
Integration is the management and delivery of health services so that people receive a continuum of prevention, testing and treatment services, according to their needs, over time and across different levels of the health system. This is particularly relevant for people, such as some key population members, who have complex health needs and who are affected by health issues. Health systems organized around the needs of people and communities perform more effectively, cost less, improve health literacy, increase patient engagement, and are better prepared to respond to health crises (254). Health service integration includes the development of referral systems and networks, and empowering patients and communities to participate in their own care, as well as the provision of multiple interventions at one site.
provides one way of classifying health service integration, and how these can be applied to the recommendations and implementation of prioritized packages as outlined in these guidelines (255).
Types of health service integration.
WHO recommends the integration of HIV, viral hepatitis and STI services, and also the integration of these with a range of other relevant clinical services, such as those for TB, maternal and child health, mental health, sexual and reproductive health services, and drug dependence treatment.
The following WHO guidelines related to integration are particularly relevant to key populations. However, this is not an exhaustive list of integration strategies, and programmes should endeavour to integrate services based on the needs of their clients.
Decentralization
Decentralization is the transfer of formal responsibility and power to make decisions regarding the management, provision and/or financing of health services to geographically or organizationally separate actors. In effect, this moves services out of tertiary health care facilities, physically and managerially, and means that health interventions can be provided and managed at different lower- level sites, including community-based services. Key populations may feel less comfortable and may experience stigma and discrimination in tertiary hospitals, and so the provision of health services outside of hospital settings in community-based and key population-targeted services can increase acceptability and accessibility. Decentralizing health services can also reduce barriers such as transport costs and long waiting times in central hospitals. However, decentralization of services for key populations may not always be appropriate or acceptable, and people may prefer to receive services in tertiary facilities where there is greater anonymity.
Differentiated service delivery
Differentiated service delivery can be defined as a client-centred approach that simplifies and adapts services, in ways that both serve the needs of affected people better and reduce unnecessary burdens on the health system (256). Differentiated service delivery for key populations considers where, when and by whom relevant interventions are provided, with the goal of increasing access to health services, increasing equity and increasing efficiencies in health systems. For example, to achieve these goals, service planners may decide to reduce the frequency at which people need to collect methadone doses for OAMT and support community-based distribution.
WHO has several recommendations related to differentiated service delivery for ART, including rapid ART initiation, reduced frequency clinical visits and ART pick-up and adherence support, as well as recommendations for differentiated HIV testing services.
Virtual interventions
Increasingly, services designed for key populations are using virtual platforms, conducting outreach to reach people at risk; providing information about available services; providing self-test information and tests; booking appointments for testing; and linking people diagnosed with HIV, viral hepatitis or STIs with treatment service providers (257–259). This approach to service delivery may be of particular relevance and importance to complement and enhance existing health infrastructure and service delivery for the younger key population community, always under the condition that potential concerns about sensitive content and data privacy can be addressed (257).
Different interventions are implemented online. Common categories include the following.
Online outreach to potential key populations service users through online platforms. This involves reaching out to those who had not been reached before, by using systems and structures like websites and social media apps, where key populations can communicate, access information and socialize.
Online case management for key populations diagnosed with
HIV,
HCV or STIs who need to engage in services to assess risk and adhere to necessary treatment. Providing case management through online systems can potentially reduce loss to follow-up, provide helpful prompts (such as reminders to book an appointment or take a medication) and support for key populations.
Targeted health information uses internet sites and social networking apps to allow for communication to be targeted, based on user demographics and characteristics. For example, social media advertisements can target users of certain ages, political profiles, geographic locations, etc. Population segmentation may allow for more specific targeting of key population audiences to provided tailored information or linkage to health services.
The potential advantages of online services include reaching a broader audience, reaching people who are geographically isolated, targeting information to specific people, improved efficiencies and convenience for clients.
Online services should be complementary to face-to-face services and not replace them. Online services may not reach all key populations, and some key population members may prefer face-to-face services, or have concerns about privacy when accessing online. Some key population members, often the most vulnerable, have additional barriers, such as the cost associated with network data, illiteracy, language barriers and limited access to phones, tablets or computers.
Online platforms can provide a safe space for key populations to access information and services; however, efforts to protect the safety of users and eliminate online mistreatment need to also be implemented and monitored closely. The engagement and involvement of key populations, in all their diversity and ages, in the development of apps or online tools and services will increase the likelihood of apps being culturally and age-appropriate and friendly, and ensure the information is age-appropriate (257, 260). Lastly, it is important to ensure trustworthy platforms, with staffing by trained operators, counsellors, and key populations themselves, to provide developmentally appropriate health and welfare information to young key populations, as well as the opportunity for referrals to relevant services (257).
Online interventions
★ NEW RECOMMENDATION
Online delivery of HIV, viral hepatitis, and STI services to key populations may be offered as an additional option, while ensuring that data security and confidentiality are protected
(conditional recommendation, low certainty of evidence).
Remarks:
Choice is important, and online services should form a part of a menu of interventions, not stand-alone interventions, and should not be a replacement for face-to-face services.
Efforts should be made to increase equitable access to the internet, improve literacy and provide appropriate training for key population members where needed.
Consideration should be given to the preferences of different key population groups, given the current lack of published evidence from sex workers and people who inject drugs.
Further details on evidence, decision-making, implementation considerations and research gaps related to this new recommendation can be found in Chapter 9.
Self-care
WHO uses the following working definition of self-care: Self-care is the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health worker (182). The scope of self-care as described in this definition includes health promotion; disease prevention and control; self-medication; self-testing; providing care to dependent persons; seeking hospital/specialist/primary care if necessary; and rehabilitation, including palliative care. It includes a range of self-care modes and approaches. While this is a broad definition that includes many activities, it is important for health policy to recognize the importance of self-care, especially where it intersects with health systems and health professionals.
For key populations, who may feel a lack of control of their health in the face of persistent structural barriers, engagement in self-care can be empowering, as well as increasing accessibility and availability of health interventions.
Relevant, recommended approaches that can be self-administered or managed include:
emergency contraception;
abortion and post-abortion contraception;
HPV, chlamydia, and gonorrhoea self-sampling;
self-care after sexual assault and violence;
pregnancy testing; and
For more details on self-care, please see WHO guideline on self-care interventions for health and well-being.
For more details on HIV self testing, see WHO Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach.
For more details on HCV self-testing, see Recommendations and guidance on hepatitis C virus self-testing.
