In line with the combination prevention approach, interventions must reach and respond to the specific needs of populations most vulnerable to HIV infection and transmission.
PSI prioritizes populations at greatest risk for acquiring and transmitting HIV in the countries where we work. In many parts of the world, these populations include men who have sex with men (MSM), sex workers, people who inject drugs (PWID) and transgendered women. In certain countries, these groups might include adolescent girls and young women, migrants, uniformed men and prison populations.
Regardless of where we work, PSI always uses evidence on the prevalence and incidence of HIV to determine which populations to prioritize for our interventions.
Female sex workers
HIV prevalence among sex workers in low- and middle-income countries is approximately 12%. This makes female sex workers (FSW), their clients and regular partners priority populations at risk for HIV infection. .
Factors that contribute to the high prevalence of HIV in this population include:
- High frequency of sexual contacts and sexual partners.
- Barriers to negotiating consistent condom use.
- Pervasive violence against FSW.
- Stigma and discrimination that discourage FSW to seek care from health facilities.
- Social and legal barriers contributing to FSW vulnerability.
- Unequal access to appropriate health services.
We implement a range of interventions to deliver services to FSW, including the creation of drop-in centers. There, FSW can access HIV prevention materials, HIV testing and counseling, HIV treatment and screening for STIs. We also implement mobile HIV testing campaigns that bring this important service directly to sex workers.
When a sex worker is diagnosed with HIV, we use a variety of approaches to ensure she is linked to care and treatment, and provide psychosocial support to help her cope with her diagnosis and adhere to treatment.
We train peer educators and popular opinion leaders within sex worker networks to endorse risk-reduction behaviors. This includes the promotion of correct and consistent condom use. Our work also expands access to condoms by designing marketing campaigns specifically for FSW and their clients. Through sensitization workshops with healthcare providers, police and brothel owners, we work to build a work environment in which FSW can safely access condoms and accurate information about HIV, and live free from abuse and harassment.
Men who have sex with men
Globally, men who have sex with men (MSM) are 19 times more likely to be HIV-positive than the general population. This figure is rising in some regions such as Asia. Factors that contribute to a higher HIV prevalence among MSM include:
- Higher rates of unprotected anal sex, which has a higher risk of transmitting HIV than vaginal sex.
- Unequal access to HIV prevention like condoms and pre-exposure prophylaxis (PrEP)
- Widespread stigma and discrimination that prevents MSM from accessing health services or other support. For example, as of May 2016, 75 countries (one-third of the world) still criminalize same-sex conduct. This exacerbates the stigma MSM face and their need to remain “hidden.”
We currently implement and support MSM interventions in countries in Africa, Asia, and Latin America. These programs aim to increase perception and reduce risky behaviors among MSM through:
- Targeted behavior change communication activities.
- Increased access to condoms and lubricant.
- Training of providers to deliver MSM-friendly services, including HIV testing and treatment.
- Work with policymakers to reduce stigma and discrimination through improved laws and policies.
People who inject drugs
Globally, HIV prevalence among people who inject drugs (PWID) is 28 times higher than among the rest of the adult population. On average, one in ten new HIV infections are caused by needle sharing and almost one-third of HIV infections outside of sub-Saharan Africa are caused by injecting drugs. Factors that contribute to the spread of HIV among PWID include:
- Sharing of needles among injection drug users.
- Legislation that criminalizes possession and use of drugs for personal consumption leads to riskier forms of drug use.
- Criminalization and stigma that discourage people who inject drugs from accessing harm reduction and other healthcare services.
We serve PWID in Laos, Myanmar, Kazakhstan, Kyrgyzstan, Tajikistan and Vietnam, focusing on:
- Reducing initiation of injecting drug use among youth.
- Reducing needle sharing.
- Increasing condom use.
- Mobilizing private sector pharmacy networks to scale up delivery of sterile injecting equipment.
- Reducing drug and sex-related risk behaviors.
- Increasing uptake of drug treatment among PWID.
- Preventing overdoses by increasing access to Nalaxone (an antidote for opioid overdose).
- Increasing access to health services such as HIV testing and counseling, STI screening, tuberculosis diagnosis and treatment, and mental health support.
Adolescent girls and young women
The number of new HIV infections among adolescent girls and young women (AGYW) aged 15 to 24 in sub-Saharan Africa remains exceptionally high. In 2015, 450,000 new infections occurred among AGYW. According to 2015 UNAIDS estimates, the vast majority of countries where HIV prevalence among AGYW exceeds 1% are in sub-Saharan Africa (with the exception of the Bahamas). However, even within sub-Saharan Africa, there are large differences in epidemic levels among young women.
Factors that influence high HIV incidence among young women include:
- Age-disparate sex: older men in relationships with young women are not only more likely to be infected with HIV, they are also less likely to be on treatment meaning that they may be more infectious. In addition the unequal power dynamics within the relationship may prevent safer sex.
- Multiple partnerships either of the young women, or their male partners.
- Transactional sex where young women engage in relationships for three main reasons: to gain access to basic needs, increase their social status and/or receive material expressions of love from male partners.
- Harmful social and gender norms, gender inequality and unequal power dynamics.
Making a Difference
In Liberia, youth peer educators with low levels of literacy are able to deliver HIV prevention workshops using audio-based tools on their mobile phones.
In Latin America, PASMO has employed cyber-educators to reach young MSM with HIV prevention information through online chat rooms. Check out this video explaining their approach:
In Trinidad and Tobago, PSI’s youth condom campaign, ‘Got It, Get It’ has one of the most popular Facebook pages in the region.
- Can Online Interventions Enhance HIV Case Finding and Linkages to Care? Comparing Offline and Online Monitoring Data from a Combination Prevention Program with MSM and Transgender Women in Central America (WEPEC166)
Under the USAID Combination Prevention Program for HIV in Guatemala, El Salvador, Honduras and Panama, the Pan American Social Marketing Organization (PASMO) implements offline and online interventions to increase HIV testing services (HTS) uptake among at-risk MSM and transgender women (TW), and link reactive cases to care.
- “Stigma And Discrimination-Free Zones”: An Innovative Approach to Engaging the Private and Public Sectors in Creating More Inclusive Environments for Key Populations in Central America (TUPED509)
Central America's HIV epidemic is concentrated in key populations (KPs). Despite existing HIV laws and policies that respond to KP's specific needs, there is evidence of widespread discriminatory attitudes and practices towards these populations, and stigma and discrimination continue to be important barriers to accessing HIV services and care. In 2016, under the USAID Combination Prevention Program for HIV in Central America, PASMO designed an intervention entitled “stigma and discrimination-free zones” as part of a broader initiative known as Generation Zero, contributing to the goal of “getting to zero discrimination.”
- Social Network Methods for HIV Case-Finding Among People Who Inject Drugs in Tajikistan (THSA16)
HIV testing programs have struggled to reach the most marginalized populations at risk for HIV. Social network methods such as respondent-driven sampling and peer-based active case-finding may be effective in overcoming barriers to reaching these populations. Under the USAID Central Asia HIV Flagship Project, we compared the client characteristics, yield, and number of new cases found through two RDS strategies and an ACF approach to HIV case-finding among people who inject drugs (PWID) in Tajikistan.
- Community HIV Care and Treatment for Female Sex Workers in Ethiopia: Successful Service Provision Through Drop-In Centers (THPEE774)
Female sex workers (FSWs) in Ethiopia are disproportionately affected by HIV, with a prevalence of 23%. To improve uptake of ART among FSWs living with HIV, the USAID-funded MULU/MARPs project began offering ART in 25 FSW-friendly drop-in-centers (DICs) in October, 2016. DICs are safe hubs for FSW located in hot-spots, and providing integrated behavioural and clinical services including peer support in a “one-stop-shop” format.
- HIV Care is Fine, But What if I Get the Flu? (THPED546)
In Guatemala, a concentrated epidemic within a highly stigmatizing social context creates an environment fraught with challenges for reaching, testing, and linking vulnerable men who have sex with men (MSM) and transgender women (TW) with HIV testing and care. PASMO commissioned an ethnographic study in 2016-2017 to understand the sexuality, identity construction, health care seeking behaviors, and MSM/TW-health provider relationships to design consumer-focused strategies to facilitate access to HIV services.
- Understanding the Uptake and Retention Patterns of PrEP Users in Zimbabwe by Sub Population (THPEC343)
PSI Zimbabwe has been offering PrEP as an additional HIV prevention method at New Start centers in six districts in Zimbabwe since August 2016. The New Start PrEP program is one of the demonstration projects that will help inform the national PrEP implementation plan to introduce PrEP nationwide as a new HIV prevention strategy. The primary target populations include adolescent girls and young women (AGYW) aged 15-24 years, female sex workers (FSWs), men who have sex with men (MSM), and serodiscordant couples.
- Sexual Practices of Men Who Have Sex with Men (MSM) in Madagascar (WEPED432)
MSM are a vulnerable population with a high prevalence of HIV (14.8%) and low HIV testing coverage (16.5%) in Madagascar. This study aims to examine barriers and motivation to HIV prevention, specifically on HIV testing, and condom and lubricant use among MSM in order to refine behavior change communication and programmatic strategies.
- Quantifying the Levels of Violence Towards Men Who Have Sex with Men (MSM) in Three Cities of Honduras (WEPED382)
In Honduras, a social context of traditional values, homophobia and machismo create an environment that makes MSM vulnerable. There has been no recent quantification of violence towards them. The Pan American Social Marketing Organization conducted a population-based study to assess the USAID Combination Prevention Program for HIV and quantify the proportion of this population experiencing violence.
- “If you don’t have the courage to go get a test, you won’t have the courage to go for treatment”: Consumer Perspectives on the Introduction of HIVST in Central America (WEPEC187)
The introduction HIV self-testing (HIVST) could overcome stigma-related barriers to HIV testing among Central America''s vulnerable populations, including men who have sex with men (MSM), female sex workers (FSW) and transgender women (TW). The Pan American Social Marketing Organization, through the USAID Combination Prevention Program in Central America, explored knowledge and acceptability of HIVST among vulnerable populations in four studies.
- Quadrupling HIV Case Finding: Social Media Improves HIV Testing and HIV Case Finding Among Key Populations in Myanmar (WEPEC169)
At PSI's TOP clinics serving key populations, there was consistently high HIV yield among peers using social media. Myanmar experienced a digital technology leapfrog. In January 2017, PSI invested in a dedicated social media team at TOP to responded to private messages (on Facebook, Line, Bee-talk, GRINDR and Viber), fielded hotline calls and offered online referral vouchers, which allowed us to track each conversation from online messaging to arrival at the clinic.