Why do critical enablers include a focus on key populations?

Why do critical enablers include a focus include a on key populations?

Key populations are defined in the Global Fund Key Populations Action Plan 2014-2017 as populations that have a high epidemiological impact from AIDS, TB and malaria, combined with reduced access to services and/or being criminalized or otherwise marginalized.

Key populations include populations that are stigmatized, discriminated against and marginalized by society, in law, policy and practice. They may also be criminalized in law. These populations may struggle to fulfil their human rights, including their rights to access health and social services. They live in environments of inequality where they are unable to thrive, feel safe and actively participate in all aspects of society.

Key populations in the HIV response include:  

  • Gay and bisexual men and other men who have sex with men
  • Transgender people
  • Sex workers
  • People who inject drugs
  • Women and girls, and
  • Young people.

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Key populations in the TB response include:

  • People living with HIV
  • Prisoners and incarcerated populations
  • Asylum seekers, refugees and other migrants
  • Internally displaced people, and
  • Indigenous populations.

The concept of key populations in the malaria response is relatively new and less well defined, but those that fall within the definition include:

  • Asylum seekers, refugees and other migrants, and
  • Indigenous populations in malaria-endemic areas.

These populations are “key” to successful responses to HIV, TB and malaria, as their participation, engagement and involvement in designing, developing, delivery and evaluation of programmes and services is critical. 

Critical enablers work to address the various legal, political, social, cultural and economic factors that make key populations more vulnerable to infection, or that create barriers to their access to prevention, treatment, care and support. Ongoing consultation and dialogue with key populations throughout the planning process is essential to understanding and addressing critical enablers and developing appropriate programmatic responses.

Examples: Key populations and critical enablers

Prisoners are at high risk of HIV and TB exposure and infection. In many countries of the world, prisoners are kept in settings that violate their human rights – prisons are often overcrowded, lack hygienic sanitation and provide poor nutrition and limited access to adequate HIV and TB health care services and harm reduction measures. Prison conditions may expose prisoners to violence and sexual abuse. Weak justice systems may result in awaiting-trial prisoners spending unnecessarily long periods of time in detention, exposing them to higher risks of infection. Criminal laws prohibiting same-sex sexual activity and correctional laws prohibiting sex in prisons are often raised as barriers to providing condoms in prisons; the failure to provide condoms in prisons places prisoners at further risk of HIV exposure.

Policies and activities that address critical enablers and that seek to, for example a) review and reform criminal and correctional laws and policies to allow for the provision of condoms and harm reduction programmes to prisoners b) strengthen access to justice to provide for measures to reduce overcrowding in prisons and c) train prisoners on their rights and how to enforce them will support national efforts to reduce vulnerability to HIV and TB in prisons.

Sex work, or aspects of sex work is criminalized in many countries across the world. Sex workers report experiences of stigma, discrimination and violence from health care workers and law enforcement officers. They experience denial of health care, discrimination and humiliation, as well as violence, rape, harassment, extortion and detention by police. This deters them from accessing and being able to use HIV prevention services effectively, increasing their vulnerability to HIV.

Activities that address critical enablers and that seek to, for example a) strengthen the protection of sex workers’ rights in law and policy b) train health care workers to treat sex workers with dignity and respect and c) sensitize law enforcement officials to the human rights and health rights of sex workers, will support access to HIV-related health care for sex workers.
The Global Fund Key Populations Action Plan - distinction between key populations and vulnerable populations

“It is always important to look at the epidemiology, but in every context there are communities and groups who fall outside of the definition of “key populations”, but experience a greater vulnerability to and impact of HIV, TB and malaria. These may include people whose situations or contexts make them especially vulnerable, or who experience inequality, prejudice, marginalization and limits on their social, economic, cultural and other rights.

Depending on the context, this might include groups such as orphans, street children, people with disabilities, people living in extreme poverty, mobile workers and other migrants. Some occupations – in particular mining – and contexts may enhance the risk of TB even more by limiting access to healthy environments. Children and pregnant women – in particular women with HIV - are particularly vulnerable to malaria as their immunity is reduced. In many African countries women and girls who are not marginalized – and so would not be defined as “key affected women” – are highly affected by HIV, and must be considered as a vulnerable population. Depending on the local context, vulnerable populations require focused efforts and resources that address their enhanced needs and protect and promote their human rights, even though they do not fall under the general definition of “key populations”. The Global Fund’s new funding model directs resources to priority services where needs are greatest in order to achieve impact.”

Critical Enablers