PEPFAR can’t keep burying its head in the sand when it comes to Key Populations

The HIV response is faltering in Kenya. While at the national level the country reports gains in reaching everyone with HIV treatment, and argues that it is a “success story,” when we dig deeper the picture is much more troubling. 

For key populations (KPs), this off-track response is a crisis. The national KP program is starved for funding and starved of political will, contradicting PEPFAR’s commitment to equity and human rights. For PEPFAR to be fully responsive to the needs of KPs and center the rights of vulnerable communities, it can no longer bury its head in the sand. 

The harms from PEPFAR’s disconnection with KP realities was made all too clear on July 20, when police unlawfully raided a US government-funded training I and my comrades were leading for KP organizations, violating our rights by harassing, attacking, and arresting us. The effects of PEPFAR’s under-prioritization of the KP program could not have been more clear. Our meeting was designed to improve HIV treatment and prevention services for KPs in Kenya by strengthening skills in community-led monitoring (CLM). But this police attack offended, threatened, and traumatized us and undermined the integrity of the KP program. To make matters worse, efforts to engage PEPFAR in mediation with the Government of Kenya have been in vain, with PEPFAR refusing to make a bold statement in protection of the rights of vulnerable communities.

The impact of these harms extend far beyond KP communities. In the Kenya People’s COP22, a set of civil society recommendations to PEPFAR regarding its HIV program for 2022, KPs urged PEPFAR to increase funding to the KP program to guarantee access to quality services, arguing that finding and retaining KPs in the program is the linchpin of PEPFAR’s program success or failure. For example, during the fourth quarter of the U.S. Fiscal Year 2022, viral load coverage and rates of suppression were poor among key populations—pointing to faltering program quality and accessibility for a community already at disproportionately greater risk of HIV infection and poor clinical outcomes. Only 54% of sex workers, 51% of men who have sex with men, 32% of people who use drugs, and 15% of transgender people received viral load tests during that period.  

During multiple years of CLM we have carried out together with the Kenya Key Population Consortium, we found that the bulk of PEPFAR’s KP program funding is channeled into implementers that provide services to non-KPs, in clinics KPs only use as a last resort because they are too often the sites of discrimination, harassment, and criminalisation. 

PEPFAR’s driving strategy in Kenya—of shifting responsibility for HIV prevention and treatment to the government of Kenya and implementing a premature “transition” to the government of Kenya—would disproportionately harm key populations. PEPFAR’s withdrawal from service provision in five counties in Kenya in 2015 has already resulted in consistently poor HIV program quality. And the criminalisation of Key Populations, set out in Kenya’s colonial-era Penal Code Act, only fuels barriers to prevention and treatment. 

PEPFAR’s intransigence on KP issues must be corrected. In 2021, 176 civil society organizations and KP activists produced a community analysis of PEPFAR’s Key Populations program successes, challenges, and recommendations called Where Is PEPFAR’s Strategy for Key Populations? During Kenya’s planning process for its 2023 PEPFAR workplan, PEPFAR must: 

• Directly fund KP organizations to carry out Community-Led Monitoring. We celebrated when PEPFAR began investing in CLM about four years ago, with South Africa leading its rollout. Activists commended the new direction taken by PEPFAR to increase transparency, accountability, and community leadership for improved health outcomes in the HIV program. But in Kenya, KP communities have expressed major concerns: KPs are not being prioritized in the funding, leadership, and implementation of CLM in Kenya. PEPFAR, through the Ambassador Small Grants initiative, a platform that is not fit for the purpose of supporting multi-year, robust CLM programs, has issued awards to partners, entrusting non-KP-led organizations with KP CLM but has yet to award Key Population-led applicants with resources for community-led monitoring for KPs. To ensure a reliable base of CLM evidence and advocacy, PEPFAR needs to holistically disperse CLM funds and exercise flexibility in application criteria to ensure that smaller KP-led organizations with strong implementation skills have access to resources.

• Create an earmark for PEPFAR funding of the KP program, in order to increase accountability for KP funding and ensure that minimum levels of investment are maintained. Similar to the earmark for DREAMS programs, this approach would nurture success and guard the program against fluctuations in COP funding.

• Renew and reinvigorate Key Population funding—for Kenya and beyond. The Key Population Investment Fund ended in 2020 with no strategy for continuation. PEPFAR should double Key Population funding to $100 million each year to build a more sustainable program.

• Push for changes in Kenya’s bad laws; invest in KP communities to advocate for changes that promote the health and rights of LGBTI and other criminalised communities. Kenya, like most PEPFAR-funded countries, still grapples with colonial laws targeting Key Populations. The harmful effects of these laws are felt not only by KPs but also non-KPs in their families, among their sex partners, and in their communities. KP-led organizations report that funding is needed urgently for human rights interventions: including removing harmful laws and policies and addressing stigma, discrimination, and violence, and supporting advocacy to overturn these laws and policies. While the U.S. government has stated its commitment to fighting for decriminalisation, this is little more than hot air as long as the social and structural factors (such as stigma, discrimination, violence, and human rights violations) that negatively impact KP’s access to and retention in HIV treatment and prevention programs are not systematically and publicly challenged by PEPFAR as a matter of diplomatic priority. 

It is a fantasy to think Kenya can achieve epidemic control of HIV while communities of Key Populations are targeted and harmed by criminalising laws that perpetuate stigma, discrimination, bigotry, and violence. PEPFAR will need to make bold, affirmative, and political decisions to fully fund the KP program and guarantee access to quality HIV and related services. PEPFAR must ensure that structural interventions are taken to scale to overcome barriers blocking KPs from getting the lifesaving services they require and that are their right as Kenyans. As PEPFAR begins its third decade of work and launches its new five-year strategy, it must make strategic program shifts for KPs or the factors prolonging the HIV epidemic in Kenya will only worsen.