A sex worker in Mozambique receives health information from Zita, a local health counselor.
Increased availability of highly-effective treatment for HIV within the last 10 years has transformed the AIDS epidemic from an emergency to a chronic but manageable disease. As a result, the urgency to continue focusing on prevention and treatment for HIV and AIDS has ebbed.
While we have indeed seen huge gains over the past twenty years, worldwide responses to the HIV epidemic are still failing to address the needs of gay men and other men who have sex with men, sex workers, people who inject drugs, and transgender people. Female sex workers are 14 times more likely to have HIV than other women; men who have sex with men are 19 times more likely to have HIV than the general population; and studies show the risks of HIV infection among people who inject drugs can be 50 times higher than the general population.
These vulnerable, often marginalized individuals need access to friendly services, safe havens where they can learn about their rights and develop a sense of identity and community. Too often, health systems – through compartmentalized service delivery models, limited training and guidelines, and application of outdated legal frameworks that criminalize certain behaviors – instead reinforce social prejudices and create barriers to care for these key populations.
Community health systems play a pivotal role in ensuring key populations’ access to HIV prevention, care and treatment services. Programs such as drop-in centers, mobile clinics, moonlight testing, peer education, community mobilization, group sessions, and condom outlets have successfully reached these hard-to-reach populations and provided them with high-quality services. However, as successful as these community level interventions have been, the ongoing compartmentalization of services for key populations – in addition to being inefficient – can contribute to increased social exclusion and discrimination.
Many of the health needs of a female sex worker are the same as the needs of any other woman; so why not integrate health service delivery for vulnerable populations into broader community health services with a connection to the primary health care system? Community-based providers should be skilled in reaching out to these groups with high-quality services, just as they provide services to any other population. Most importantly, key populations should be included as partners in the development, design and implementation of these community-based services.
In Mozambique, for example, we trained a group of female sex workers to be peer educators and built their capacity to advocate for their rights and health needs and to organize. This led to the creation of Tiyani Vavasati, the first association of female sex workers in Mozambique, which is now a key player in the country’s HIV response.
We also trained more than 300 health providers and about 500 peer educators to provide prevention and care services for key populations in both community and facility settings, strengthening the linkages between these platforms and empowering key populations to participate in the health governance mechanisms (e.g., co-management committees). This work – and similar experiences in Kenya, Peru and India – have been based on the development of solid community platforms where these groups can access services, often provided by members of these groups themselves.
Where we have implemented consolidated continuum of care approaches, which encompass integrated services across the community- and facility-based platforms, we are seeing success in providing high-quality, comprehensive prevention and care services to these groups. Community-based services are an opportunity to provide comprehensive services that go beyond the simple health needs of key populations; increasing their political and technical capacity offers a window of opportunity that should not be missed. It is through these approaches that key populations can be empowered as citizens who can govern their own health and, therefore, their own history.
Marcos Benedetti, Senior Technical Advisor for Sexual Health and Rights/Pathfinder International
This blog is part of the Institutionalizing Community Health Conference blog series. We encourage those unable to join the conference to stay virtually connected and to add your voice to the conversation at #HealthForAll. As part of this series, we are posting blogs from our staff and partners around the world highlighting the necessity of community health in reaching those not currently accessing key health services.