Reaching those at high risk of HIV: how WHO learns from experiences on the ground

July 2014

“Health for all” reads one of the murals at Kirketon Road Centre in Sydney, Australia. Most of the people who come into the centre are sex workers, people who use drugs, and other young people whose lifestyles put them at greater risk of HIV and hepatitis C infection. They are often among the least able - or willing - to seek medical help so staff try to make the most of any visit.

Mural at Kirketon Road
Kirketon Road Centre

"If someone comes in because they have a nasty cough, we will treat that. But we have a standardised intake form we use to ask questions about their sexual and injecting risk behaviour and to check their full medical history, so we can screen them where applicable and focus in on their particular situation," says Kirketon Road's director Dr Ingrid van Beek. The important thing, she says, is to be non-judgmental in dealing with individuals who often suffer stigma and discrimination.

“I previously came here for general health advice. They treated me like a person I suppose, not just a number in and out like in some other places. Now I get my methadone here and counselling,” says 25-year-old Ashley.

“Key populations”, new infections

Jeremy, 39, who uses the centre’s needle exchange programme, says it has always been easy to talk to the staff and ask for advice. “They actually taught me to inject safely. I’m sure that played a big role in me not ending up with HIV because of the messages they drove home, not just about using a clean needle every time but other information like not sharing injecting equipment like tourniquets and spoons,” he says.

"The experiences of centres like Kirketon Road are invaluable in developing effective guidelines and recommendations," says Dr Rachel Baggaley of WHO’s HIV Department. This is particularly true with what are known as “key populations”: men who have sex with men (MSM), people who inject drugs, people in prison and other closed settings, sex workers and transgender people.

Key populations represent most of the HIV cases outside sub-Saharan Africa, and also an increasingly recognised share of new infections in urban areas in sub-Saharan Africa. Yet they are often the groups least well served by the health sector.

“Without communities and without community support, we’re never going to reach those people in greatest need, to and keep them healthy, and ultimately to end the HIV epidemics devastating key populations.”

Dr Rachel Baggaley, WHO’s HIV Department

To help to address this, WHO has produced "Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations" which contain clinical recommendations but also outline the critical factors needed to enable these groups to access care.

“This includes tackling stigma and discrimination, including by health workers. It includes legal issues, so for example with adolescent key populations it is about age of consent to access services. It’s about offering social protection and public health alternatives to criminalisation, of sex work and drug use, and about tackling violence directed at these groups,” Dr Baggaley says.

Partnership with communities

Kirketon Road Centre

WHO consulted more than 500 organizations and community groups and has incorporated examples from more than 70 case studies into its guidelines and also into specific recommendations for young people aged 10 to 24 in these groups.

Health workers may be operating in a country where homosexuality is illegal or where drug use is punished by strict laws but their first duty of care should be patients or others seeking health care, Dr Baggaley stresses.

“If we can get ministries to start training their health-care workers to be respectful to all patients, that would be a fantastic first step,” says Dr Baggaley. “It’s also important for them to acknowledge that communities play a critical role in providing comprehensive services for key populations. Without communities and without community support, we’re never going to reach those people in greatest need, to and keep them healthy, and ultimately to end the HIV epidemics devastating key populations.”