Voices from the Field: Treating HIV in Key Populations

As we approach World AIDS Day each year, the global health community takes stock of the past year’s achievements towards ending the HIV epidemic.

In this interview with Humphrey Ndondo, Senior Technical Specialist for Key Populations at PSI Zimbabwe, we discuss PSI’s work addressing a critical challenge facing the HIV response everywhere: supporting key, marginalized populations. These include the LGBTQ community, sex workers, those who inject drugs, and those who have been in prison.

PSI Impact: You recently joined PSI Zimbabwe as a manager for key populations (KP) programs. How did you get started working in public health and what motivates you?

Humphrey Ndondo: I joined PSI three months ago after six years with the Sexual Rights Centre (SRC), a non-profit based in Bulawayo, Zimbabwe. My motivation comes from the tragedy of growing up witnessing the effects of the HIV/AIDS epidemic. Living through this was difficult; in my community, we often saw people gathering to bury their dead who had succumbed to AIDS.

Also, Zimbabwe is a country where denial of LGBTQ culture has been normalized. For most of my life, no one publicly discussed how men who have sex with men (MSM) are disproportionately affected by AIDS. I attended my first HIV/AIDS conference in 2012 in Washington, DC, where it became clear that the global health community needed to start talking to MSM about their vulnerability to HIV. They thought they were not at risk because they were not having sex with women.

Through my work on the frontlines of the HIV epidemic in communities, and now with PSI, I am proud to sit at the table with experts to design programs citing my personal and professional lived experiences—and things are changing!

PSI Impact: UNAIDS reports that the risk of becoming infected with HIV among key populations is 12 to 22 times higher than for the general population. Meanwhile, data from UNAIDS and other sources shows that many members of key populations are not accessing HIV services – particularly treatment – at the same levels as other populations. Why is that?

Humphrey Ndondo: Several factors lead members of key populations to stay hidden and not seek information or treatment for HIV/AIDS.

Criminalization: We still have laws, inherited from British colonialism, that criminalize sodomy and same-sex marriage. There is also the criminalization of sex work both directly and indirectly. For example, sex workers can be arrested for “blocking the pavement” or being a “public nuisance.”

Culture: In Zimbabwe, we have a very traditional culture overall, where families will reject and ostracize family members based on sexual orientation, gender identity, or expression.

Communications: To date, messaging to key populations regarding their increased risk of HIV/AIDS has been inadequate; many KPs are simply not aware of their heightened vulnerability to HIV.

Religion: Many citizens speak about Zimbabwe as a “Christian Nation,” and members of key populations are often criticized according to conservative religious standards. They may be viewed as an abomination, immoral, dirty, sinful or shameful.

Politics: Given the pervasive legal, cultural, and religious attitudes towards key populations, politicians may speak out against key populations to win votes.

Violence: The stigma attached to key populations makes violence against them culturally permissible. This is especially true with regards to the lesbian and transgender communities, where individuals have been subjected to “corrective rape” and “forced sexual experiences” at the hands of family members, faith and religious healers, and communities at large.

Poverty: Getting access to general healthcare is already challenging for those living on the margins, rendering them more vulnerable to diseases in addition to HIV/AIDS. For key populations living at the fringes, economic impoverishment further exacerbates their vulnerability to HIV.

PSI Impact: When we talk about key populations, we encounter lots of stereotypes, especially the perception that their members are “making bad choices.” What do you think most people don’t know about key populations that they should?

Humphrey Ndondo: It is only now that the government is communicating directly with key populations regarding their risks and options, as well as tailoring interventions to these groups who have been left behind for so long.

Unfortunately, sometimes this leads to the perception that key populations are taking healthcare resources away from the general population; that is simply not true. Speaking from an HIV perspective and a public health lens, when we talk about access to services or basic human rights, key populations are not asking for special treatment. They are asking for equitable access to testing, medication, and resources alongside everyone else.

Speaking of communications, PSI Zimbabwe is working to challenge stereotypes, bridge knowledge gaps and bust myths about key populations. One of our recent campaigns, in partnership with the SRC, focused on presenting key populations as regular people. We developed a message, “this is what a sex worker looks like,” which challenged harassment and profiling of women who walk alone at night unaccompanied by men. Just like everyone else, we are your brothers and sisters, your parents and colleagues. We are a part of your lives, and a part of the teams designing community-based interventions for the HIV/AIDS response.

PSI Impact: What do you see as the biggest challenges and opportunities facing the HIV response, especially as they relate to key populations?

Humphrey Ndondo: On a macro level, our biggest challenges for key populations stem from a restrictive legal and policy environment. We need to decriminalize and destigmatize key populations to make it safe for them to seek prevention and treatment for HIV/AIDS. We have the science to define and tailor appropriate interventions: anti-retroviral therapy (ART) for those who are HIV-positive, and pre-exposure prophylaxis (PrEP) for those who are HIV-negative. Our goals are to reduce viral loads to the point where clients cannot pass HIV/AIDS to their partners and to boost the immune systems of healthy clients in high-risk environments to prevent them from contracting HIV.

On a micro level, we need to create services that are friendly and inviting, by talking about sex and sexuality in a positive light. We want clients to feel just as comfortable going to a clinic to discuss a health problem as they are going out on Friday night to meet a partner.

PSI Impact: What is PSI Zimbabwe doing to address these challenges or take advantage of these opportunities?

Humphrey Ndondo: We have a tremendous opportunity in that one year ago, PSI was awarded $95 million to continue to reduce the HIV incidence rate and accelerate the HIV response in Zimbabwe. The project, “Going the Last Mile for HIV Control,” also known as Project Last Mile, was granted with support from the U.S. President’s Emergency Plan for AIDS Relief through USAID and the Zimbabwean Ministry of Health and Child Care (MOHCC).

We have completed the first year of Project Last Mile, and our leadership is supporting the organization as we shift how we engage with communities disproportionately affected by HIV/AIDS. We have invested in “looking in:” helping PSI staff, from our receptionists to our doctors, to understand the challenges and experiences of key population clients and provide the training they need to deliver friendly care.

Our work is focused on identifying, mobilizing, linking and retaining key populations in the HIV care continuum. We offer HIV testing; screening for other STIs and TB; ART and PrEP; voluntary medical male circumcision; as well as follow-up with clients for additional care until they are stable. UNAIDS gives guidance that 30% of the HIV response must be community-led, so we collaborate with KP-led community-based organizations and members of the KP community. We also make efforts to embrace members of key populations into the PSI family. Our strategy has been dynamic and adaptive to meet the needs of our clients, navigating communities to serve clients at their doorstep.

In collaboration with the Zimbabwe Ministry of Health and Child Care and the National AIDS Council, PSI is building the capacity of KP-led and KP-dedicated organizations to transition to receiving funding from PEPFAR. Among other efforts of ensuring the sustainability of the HIV/AIDS response, PSI is supporting the preparedness and transitioning of stable KP clients on ART to receive care in KP-friendly public sector facilities.

PSI Impact: Do you have any additional insights from your work?

Humphrey Ndondo: Our programming needs to move faster into the digital landscape. KPs are using multiple social apps to connect with each other. People are not waiting for the laws to be ready, for the culture around them to change, they are living their lives, hooking up and making life choices that impact their wellbeing. We need to move quickly using health technology to serve key populations. They should be able to connect with us as fast as they connect with each other.

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