Declining HIV incidence and a steady increase in the number of people gaining access to antiretroviral therapy has been coupled with a reduction in AIDS-related morbidity and mortality in many of the countries most affected by the HIV/AIDS pandemic in sub-Saharan Africa.1 Often in countries with the most broadly generalized epidemics, there has been an assumption that the burden of HIV and risk factors for HIV acquisition and transmission are evenly distributed across the population. However, emerging data have consistently suggested that there are specific populations—including female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and transgender persons—that have been disproportionately affected across HIV epidemic patterns, including concentrated and generalized epidemics. Moreover, these key populations (KP) have not benefited equally from recent improvements in HIV-related outcomes relative to other populations, especially in the context of sub-Saharan Africa. Meta-analyses focused on the continent have characterized burdens of HIV among these populations as being significantly higher than among other reproductive age adults, with HIV prevalence estimated to be approximately 37% among FSW, 18% among MSM, and 12% among PWID.2–4 Although Africa-specific data are lacking, globally, transgender women seem to have the highest disproportionate risk of HIV infection, which is about 48 times higher than the general population.1,5 Additionally, self-identifying as a gender other than the 1 assigned at birth has been shown to be significantly associated with HIV among people accrued for a study focused on MSM in Swaziland.6
In addition to the increased HIV acquisition and transmission risks associated with certain behavioral and biological factors, the widespread stigma and discrimination experienced by KP have been shown to exacerbate HIV risks through the exclusion or self-exclusion from HIV prevention, treatment, and care services.7 One of the most extreme forms of enacted stigma is the criminalization of sexual orientation, consensual adult sex practices, and occupation in the case of sex work. Same-sex practices are criminalized to differing extents in 31 countries in sub-Saharan Africa with allowed punishments including the death penalty in some jurisdictions.8 Although a few countries in the region have decriminalized adult sex work, such as Senegal, the majority continue to criminalize it.9 All countries in sub-Saharan Africa criminalize illicit drug use, with the punishment for even minor drug offenses on the continent being as high as 10–15 years in prison.4,10 Although the extent to which such laws are enforced varies, their existence has often served to perpetuate discriminatory attitudes within large portions of society. Social exclusion, human rights violations, and violence toward these men and women are common and have significant implications for their risk of acquiring HIV and inability to access adequate health services.11 Furthermore, criminalization has, in part, contributed to health officials' hesitance to advocate for KP-appropriate policies in their respective national responses.12 As such, these populations are often not accounted for in the planning of HIV prevention, treatment, and care programs, leading to very low coverage of targeted services in many countries.1
In light of this, there is evidence to support the importance of extending targeted services to KP, including through the provision of defined population-specific minimum packages of services (MPS). For example, it has been estimated that providing MSM with a comprehensive package of prevention services has the potential to reduce HIV transmission by as much as 40%.13 However, it is also estimated that less than 10% of MSM globally have access to comprehensive services, with the majority of this access being in higher income settings.14 For PWID, harm reduction services such as opioid substitution therapy (OST) and needle and syringe exchange programs can be effective in preventing HIV transmission.15 The definition and adoption of such service packages is a crucial component of ensuring that the response for KP is both comprehensive and evidence based. Although services, such as OST, are globally ascertained to be effective, there are still locally selected services without any evidence. Lack of and/or inconsistency in definitions of MPS for different groups may hamper the effectiveness of the programs and cause incomparability of program results.
Exacerbating the challenges faced by KP is inadequate data characterizing their HIV prevention, treatment, and care needs. Although strides have been made to increase research in the region, FSW, MSM, PWID, and transgender persons are still identified as “populations left behind” by the Joint United Nations Program in HIV/AIDS (UNAIDS) and others.1 Their marginalization has contributed to their frequent exclusion from epidemiological reporting and national behavioral surveys in many countries.2,14 Disaggregated data on HIV prevalence, including prevalence for KP, remain largely unavailable, and progress toward reaching KP with core HIV prevention services is not regularly tracked or reported.16 This has resulted in a limited understanding of the epidemic with significant implications for the design, implementation, financing, and evaluation of interventions for KP.
To address this gap, amfAR, The Foundation for AIDS Research and the Center for Public Health and Human Rights at the Johns Hopkins University Bloomberg School of Public Health partnered with The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) to undertake a comprehensive literature search of strategic data on FSW, MSM, PWID, and transgender persons in West and Central Africa (WCA) with the dual goal of identifying gaps in epidemiologic and HIV prevention service coverage data, and evaluating the extent to which KP are being included in national target setting, service surveillance, and efforts to define and provide essential services. Although FSW, MSM, PWID, and transgender individuals live in every country across the continent of Africa—and, indeed, the world—the epidemic in WCA, in particular, has been concentrated among them compared with the areas of Southern and Eastern Africa.17 As such, there is particular need to evaluate the current state of the response to HIV for KP in the region.
Search strategies have been previously described.7 Briefly, peer-reviewed publications were identified using the PubMed and MEDLINE databases. The medical subject headings terms for HIV and AIDS and key terms relating to the 4 populations were cross referenced with terms related to the countries to generate a list of potential articles. Search criteria and terms were based on other validated peer-reviewed systematic reviews regarding the 4 populations. Four reviewers reviewed titles and abstracts of articles that met initial literature screening criteria. Articles were included if a reviewer found the title and/or abstract pertained to one of the target populations or was relevant to study objectives. Articles classified as relevant were then downloaded for full-text evaluation. Exclusion criteria included articles not published in English, French, or Spanish. Data were collected for all years available; however, this article only reports data published from 2007 onward.
All non–peer-reviewed publications were identified using an Internet search of national government Web sites, including those for each country's respective ministry of health and national AIDS authority. The Web sites for other relevant agencies, including UNAIDS, the US President's Emergency Plan for AIDS Relief, and the United States Agency for International Development, as well as certain nongovernmental organizations, were also searched. As the search was initially conceptualized to assist Global Fund Country Teams at the Global Fund Secretariat in understanding the data gaps in the selected countries, no internal Global Fund documentation was reviewed. All non–peer-reviewed data collected were freely available in the public domain. Reports of quantitative data extracted from secondary sources during our search were verified by searching for a primary source; every attempt was made to identify the original source for unique data points. Data collection was completed by June 2014.
There are several limitations with the methods used here. Primarily, data included were those available in the public domain. There is recognition that many reports are published yet not available in the public domain or as peer-reviewed publications. To complete sensitivity analyses for potential missing data, the Public Health and Monitoring and Evaluation Specialists from the Global Fund reviewed the reports from their respective countries to see if there were additional studies or estimates of which they were aware. There were also difficulties in verifying the original sources of data in non–peer-reviewed literature. As such, although the reported data are useful to compare the amount of available data across countries, we are limited in our ability to verify the validity of some data. In addition, there was limited ability to assess the quality of the data included with the recognition of the varying quality of size estimation studies, HIV prevalence studies, and estimation of the coverage of services. This study relied on government reports as wherever available as a proxy for validated data of the burden of HIV or size of populations.
The 8 countries included in this review are Cameroon, Chad, Cote d'Ivoire, Democratic Republic of Congo (DRC), Ghana, Guinea-Bissau, Niger, and Nigeria. These countries were purposely selected to represent the demographic, epidemiologic, linguistic, and economic diversity of the WCA subregion. The income status of 4 countries—Ghana, Nigeria, Cameroon, and Cote d'Ivoire—is classified by The World Bank as lower middle income, whereas the remaining 4—Guinea-Bissau, Niger, Chad, and DRC—are classified as low income. Four are linguistically Francophone (Cote d'Ivoire, Niger, DRC, and Chad), 2 are Anglophone (Ghana, Nigeria), and 1 is Lusophone (Guinea-Bissau). Both French and English are official languages of Cameroon.
This search focused on 4 types of strategic information: (1) KP HIV prevalence, (2) KP size estimates, (3) availability of an MPS for KP, and (4) targets for and coverage of specific HIV prevention services for KP. These specific services were limited to 8 core HIV prevention service coverage indicators for KP included in the Global Fund's HIV Programmatic Gap Table.18 They include the following:
- Sex workers reporting the use of a condom with their most recent client.
- Men reporting the use of a condom the last time they had anal sex with a male partner.
- PWID who reported using sterile injecting equipment the last time they injected.
- KP reached with HIV prevention programs (defined package of services).
- KP reached with HIV prevention programs (individual and/or smaller group level interventions).
- KP who received an HIV test during the reporting period and who know the results.
- Needles and syringes distributed per PWID per year by needle and syringe programs.
- Individuals receiving OST who received treatment for at least 6 months.
Nationally endorsed targets pertaining to the coverage of these HIV prevention services among KP were also sought. For the sake of comparability, only targets explicitly outlined in a country's most recent National Strategic Plan for HIV/AIDS (NSP) were included in the results. Similarly, the search for an MPS was limited to those defined or endorsed by a country's national government. When an MPS was identified, it was evaluated against the most recent iteration of the Consolidated Guidelines for HIV Prevention, Diagnosis, Treatment and Care for KP published by the World Health Organization (WHO).
Any size estimation study result for KP, published after 2007, was included in this review; this encompasses national estimates and data at the local or subnational level.
No results were found for transgender persons in any of the 8 countries. As such, the results presented here only pertain to FSW, MSM, and PWID. For studies including epidemiologic (HIV prevalence and population size estimates) and HIV prevention service coverage data, 31 were found for FSW, 16 for MSM, and 8 for PWID.
Data for at least 1 population were found in 7 of the 8 countries. Data on FSW were found in 7 countries, and data for MSM were available in 6 of the 8 countries. Only 2 countries had any HIV prevalence data on PWID: Ghana and Nigeria. Complete results are displayed in Table 1.
Key Population Size Estimates
Population size estimates were less common than HIV prevalence data. Two countries, Ghana and Nigeria, had a recent estimate for all 3 populations. However, in Nigeria, the size estimate for PWID was found in a secondary source, and the data's origin was not identified. Three additional countries, Cameroon, Cote d'Ivoire, and Niger, had size estimates for FSW. Complete results are displayed in Table 2.
HIV Prevention Targets Service Coverage
Current NSPs were not available for all countries. Although this made comparisons between countries more difficult, it also pointed to current gaps in data availability by country. For those countries that did have an NSP, the number of targets identified ranged from 0 to 6. No country had targets pertaining to all 8 indicators of interest. Table 4 displays any relevant targets identified by country. Targets were most common for FSW, followed by MSM and then PWID. Three countries, Cote d'Ivoire, Ghana, and Nigeria, had PWID-specific targets. However, not all countries with defined targets for PWID reported corresponding coverage data. Generally, every target that was identified for FSW or MSM across countries had corresponding coverage data available in 7 of the 8 countries.
Minimum Package of Services
Three countries were found to have an MPS for at least 1 of the 3 populations: Cote d'Ivoire, Ghana, and Nigeria. Services targeting MSM and FSW were found in the packages provided by all 3 countries. Defined services targeting PWID were identified in Ghana and Nigeria, but services targeting FSW and MSM who also inject drugs were not included.
The extent to which efforts were made to address violence against KP varied substantially between countries. Ghana and Nigeria included provisions for addressing violence toward FSW in their MPS. Only Ghana included such a provision specifically for MSM, and no country included a provision on addressing violence toward PWID. A notable finding was that a provision to support progressive legislation for KP was included in Ghana and Nigeria's MPS. Sex work and same-sex practices are both legal in Cote d'Ivoire, possibly explaining the absence of any provision on legislation in that country's MPS.
The results of this search point to a high degree of variability in the collection and reporting of data, adoption of targets, reporting of HIV prevention service coverage data, and availability and level of comprehensiveness of defined MPS for FSW, MSM, and PWID in WCA. Broadly speaking, data are more widely available for FSW, and this population is, generally, also better represented in national targets. Data on MSM were less common, as were targets specifically pertaining to them. With a few notable exceptions, data on PWID remain largely unavailable, and this population is not widely included in national targets nor are targeted services for PWID commonly identified in most MPS. Overall, more data concerning HIV prevalence were available than KP size estimates. Data availability also varied widely by context, with Ghana having the most complete set of data for all populations, and other countries representing differing stages of completeness. The level of country-specific epidemiologic data corresponded generally to the degree to which KP were included in national targets, suggesting that countries that show increased prioritization of KP also have more available data.
By highlighting the disproportionate burden of disease across different populations, HIV prevalence and KP size estimates play an important role in informing HIV surveillance and the development of effective interventions for both KP and the general population. These data can support health officials to make evidence-based decisions on how to allocate resources, as well as act as evidence to support the inclusion of KP in programming.63 High-quality epidemiologic data and population size estimates can also help in the setting of evidence-based targets that accurately reflect the current state of the epidemic. The timely collection of data can also support efforts to measure progress toward reaching those targets and advocating for targeted resource allocation. Conversely, the absence of data may advance a response not representative of the HIV epidemic and not designed to achieve the greatest impact for those populations most affected.
The endorsement of a defined MPS is a crucial step toward developing a more robust and evidence-based response for KP. Given the level of stigma and discrimination experienced by these men and women that may serve as barriers to accessing health services, implementing a package of culturally competent interventions that target their specific needs can help increase uptake of health services.54,64–66 As such, the provision of a package of targeted population-specific services can have a real impact on HIV transmission. Despite this, core interventions for PWID, including OST and needle and syringe exchange programs, were only included in Ghana's MPS, and would only be available if “sufficient numbers of PWID are identified” in the country.
An encouraging finding was the inclusion of efforts to support progressive policy and legislation concerning KP in the MPS for Ghana and Nigeria. Criminalization of same-sex behaviors, sex work, and drug use continues to create additional barriers to accessing HIV services for populations that already face societal discrimination. Recent modeling work has estimated that decriminalizing sex work worldwide would avert 33%–46% of new HIV infections in the next decade.9 Cote d'Ivoire does not include strategies to encourage supportive legislation surrounding KP in their MPS; however, sex work and homosexuality are legal in the country, in contrast to Ghana and Nigeria, which may result in less-perceived need to advocate for policy changes in Cote d'Ivoire. Despite the relative progressiveness of legislation in Cote d'Ivoire, structural inequalities, discrimination, and police harassment of KP persist, which could be combated with policy changes and increased protections of KP. Additionally, the recent enactment of new antihomosexuality legislation in Nigeria exemplifies a frequent and enduring discord between the recognized need for legal reforms to improve health care for KP and the realization of such priorities in practice.
The frequent lack of even the most basic epidemiologic and population data on KP has serious implications for the effectiveness of national and international efforts to control the HIV epidemic in WCA. Without high-quality data and defined service targets that reflect the burden of disease in country, any effort to monitor progress toward reaching KP with essential services will be stunted. The persistent lack of data can also serve to reinforce the prevailing marginalization of these men and women in many countries. Widespread stigma, discrimination, and criminalization not only increase the risk of HIV infection for KP but also discourage the adoption of interventions targeting them. If these populations are not counted and if they are not adequately reflected in the data, there is even less pressure on policy makers to address their needs in the creation of health policy or direction of resources toward them.
This search highlighted the great variability that still exists in the availability of KP data across countries and populations in WCA. Service targets are not comprehensively defined in NSPs, and the extent to which those services are reaching KP is not consistently reported. Furthermore, few countries have defined or adopted an MPS that targets each of these populations. And despite evidence of high HIV prevalence in other regions of the world, data on transgender individuals were completely absent in the results of this search of WCA countries.
In a time of increased demand for resources, it is essential that the populations most affected by HIV are being counted. As a number of countries begin to take on greater ownership over the direction of their response to the HIV epidemic, it is also vital that data on KP and evidence on the effectiveness of adopting interventions that target them are collected and made available to inform strategic planning and policy. This review makes clear that the current data landscape for KP in WCA is varied, inconsistent, and broadly inadequate. As the Global Fund moves forward with its New Funding Model, there is a need to take advantage of opportunities to strengthen data systems and improve the timeliness and quality of data collection and reporting practices in WCA. Countries should be encouraged and supported in efforts to do this and to ensure that data are being incorporated into national planning and the setting of health policy priorities.
The authors thank Tina Draser, Sandra Kuzmanovska, Owen Ryan, and Nathalie Zorzi for their contributions to the conceptualization of this work, and Erica Kuhlik, Sahnah Lim, John Power, and Ryan Zahn for their work on data collection.
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Keywords:Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
key populations; female sex workers; men who have sex with men; people who inject drugs; minimum package of services