Strategic Considerations for Mitigating the Impact of COVID-19 on Key-Population-Focused HIV Programs

According to the Maintaining Epidemic Control (EpiC) project, a priority during the COVID-19 pandemic is ensuring continuity of treatment and support for viral suppression among people living with HIV (PLHIV) and helping those who are at risk of HIV acquisition remain HIV negative. This resource offers strategies to reduce the impact of COVID-19 on key population (KP) programme beneficiaries and staff while safely maintaining access to HIV prevention, care, and treatment services. Developed for KP-focused HIV programmes implemented or supported by FHI 360, an EpiC partner, in the Caribbean, Asia, and Africa, it may be used and adapted more broadly. (Also available, below, are related resources shared as part of a webinar hosted around this strategy document.)

EpiC explains that members of KPs, including sex workers (SWs), men who have sex with men (MSM), people who inject drugs (PWID), and transgender (TG) people, are vulnerable to COVID-19 due to a variety of factors outlined in the document, including high mobility and close physical contact with others through social and sexual practices. Furthermore, evidence shows that groups already experiencing a disproportionate burden of poverty and marginalisation are more affected by severe COVID-19 complications, in part because of a greater concentration of underlying health conditions. The stigma and discrimination often experienced by KP members in healthcare settings, which can limit access to and uptake of HIV services, may also affect their access to COVID-19-related services. Measures to prevent the spread of COVID-19, such as stay-at-home orders, may impede the lives of KPs to a greater extent than others. For example, they may not have consistent internet or other trustworthy news sources, leading to further misinformation, confusion, and panic. Crises such as pandemics also lead to problems such as increases in violence within relationships, which stay-at-home orders can amplify; the economic distress caused by widescale job losses that will harm the most vulnerable first (e.g., SWs) are particularly at risk in this regard.

In addition, programme implementers, especially those moving through the community, may face risks, such as accusations of spreading COVID-19. They also face increased mental health strain as they themselves lose access to previous coping methods that involved in-person support while attempting to support others. HIV programme staff, such as health facility staff and community-based cadres providing outreach services, are also at heightened risk of COVID-19 because of their proximity to patients, a risk they may not fully understand or know how to find support to offset.

In this context, mitigation strategies refer to efforts to reduce exposure to and impact of COVID-19 on HIV programme beneficiaries and staff and safely maintain HIV services within KP-focused HIV programmes. The considerations and approaches outlined as part of this strategy include:

1. Safeguard providers and beneficiaries from COVID-19 by:
   • Preventing COVID-19 infection among programme staff and beneficiaries - for example: Develop or adapt social and behaviour change (SBC) materials to support adoption of COVID-19 prevention behaviours and to provide reliable information on COVID-19 to programme beneficiaries that reiterates HIV core messages and is adapted to their realities. This may involve, among other actions, directly addressing misperceptions and myths about COVID-19, especially those related to individuals living with HIV, and creating alternative spaces, including on virtual platforms, where community members brainstorm together and discuss harm reduction strategies that minimise COVID-19 exposure while taking into account that many suggested prevention strategies can result in other harms.
   • Supporting links to COVID-19-related screening and care among beneficiaries and staff - for example: list nearby COVID-19 testing locations/options and isolation facilities, including online resources and hotlines for COVID-19 information.
   • Addressing broader needs of KP members that may be exacerbated by COVID-19 - for example: Provide guidance and tips to KP members who are deciding whether and how to engage in online programming as more activities shift to this medium. Help them decide how much information they can safely provide about themselves in online settings (e.g., what can be said in a chat with an outreach worker versus in a closed Facebook group).
   • Considering KP programme implementer safety holistically - for example: Make mental health support available to frontline workers and project staff, and encourage the use of these services.
2. Support safe, sustained HIV service connections by:
   • Preparing programmes for physical distancing - for example: Help clinics procure and use devices (tablets and smartphones) and mobile data plans to offer telemedicine services, such as providing routine counseling and pre-appointment COVID-19 screening virtually.
   • Continuing delivery of HIV outreach services - for example: Use virtual support groups and communication channels for beneficiaries to report experiences of violence, stigma, discrimination, and economic distress to staff who are trained to respond to such disclosures. Use encrypted platforms for communication, and explain to participants the risks and rules for maintaining privacy and security.
   • Continuing delivery of HIV testing services - for example: Expand the use of social network strategies, such as the enhanced peer outreach approach, for creating demand for HIV testing.
   • Continuing delivery of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) services - for example: Advocate for and support revision of government policy to permit multimonth dispensing (MMD) for more clients on ART, including relaxing the criteria for eligibility for MMD.
   • Promoting access to essential wrap-around services - for example: For clients who use or desire a long-acting contraceptive method, provide them with an updated list of facilities where they can access that service.
3. Monitor and improve client outcomes by:
   • Preparing strategic information systems for physical distancing - for example: Consider scaling up the use of online and virtual data collection and reporting tools for outreach and clinical staff.
   • Using strategic information systems to monitor the impact of COVID-19 on programmes and beneficiaries - for example: Ask community service organisations (CSOs) about challenges faced by their staff on a weekly basis and use these data for immediate decision-making (e.g., the need for more laptops as all staff begin to work from home).

This is a living document that EpiC plans to update regularly in order to respond to the rapidly evolving nature of the COVID-19 pandemic and needs of KP-focused programme implementers and beneficiaries.

EpiC is led by FHI 360 with core partners Right to Care, Palladium International, Population Services International (PSI), and Gobee Group. It is funded by the United States Agency for International Development (USAID) and President's Emergency Plan For AIDS Relief (PEPFAR).

Click here to access related resources (audio, PowerPoints, a Q&A document) shared as part of an April 8 2020 webinar, "Mitigating the impact of COVID-19 on key-population-focused HIV programs".