Mind the gap: implementation challenges break the link between HIV/AIDS research and practice.

ObjectivesHIV prevalence and incidence are higher among key populations including Men who have Sex with Men (MSM) and transgender women in low and middle income countries, when compared to the general population. Despite World Health Organisation guidelines on the provision of services to key populations recommending an evidence-based, culturally relevant and rights-based approach, uptake of HIV services in many resource-limited and rights-constrained settings remains low. Médecins Sans Frontières (MSF) has been offering health services for MSM and transgender women in Beira, Mozambique since 2014 using a peer-educator driven model, but uptake of services has not been as high as expected. This qualitative study aimed to learn more about these key populations in Beira, their experiences of accessing MSM- and transgender-friendly services and their use of face-to-face and virtual networks, including social media, for engagement with health care.MethodsIn-depth interviews were carried out with MSM and transgender women who were 1) enrolled in, 2) disengaged from or 3) never engaged in MSF’s programme. Purposive and snowball sampling were used to recruit the different groups of interviewees. Interviews were conducted in Portuguese, transcribed and translated into English before being coded and manually analysed using a thematic network framework.ResultsNine transgender women and 18 cisgender MSM participated in the study. Interviewees ranged in age from 19 to 47 years, with a median age of 29. Three main themes emerged from the data: perceptions of stigma and discrimination, experiences of the peer-educator driven model and the use of face-to-face and virtual platforms for communication and engagement, including social media. Interviewees reported experiencing stigma and discrimination because of their gender or sexual identity. HIV-related stigma and health-care setting discrimination, including gossip and breach of confidentiality, were also reported. Although the presence of the peer-educators and their outreach activities were appreciated, they had limited visibility and an over-focus on health and HIV. The face-to-face networks of MSM and transgender women were small and fragmented. Virtual networks such as Facebook were mainly used for flirting, dating and informal communication. Most interviewees were at ease using social media and would consider it as a means of engaging with health messaging.ConclusionsMSM and transgender women have challenges in accessing health services due to being stigmatised because of their gender identity and their sexual behaviour, and often experience stigma at home, in health-care facilities and in their communities. Peer-driven models of engagement were appreciated but have limitations. There is an untapped potential for further expansion and engagement with face-to-face and virtual platforms to reach MSM and transgender women in settings with a high HIV burden, and to provide them with essential information about HIV and their health.

Accurate measurements of HIV prevalence and associated risk factors among hidden and high-risk groups are vital for program planning and implementation. However, only two sampling methods are purported to provide representative estimates for populations without sampling frames: time-location sampling (TLS) and respondent-driven sampling (RDS). Each method is subject to potential biases and questionable reliability. In this paper, we evaluate surveys designed to estimate HIV prevalence and associated risk factors among people who inject drugs (PWID) sampled through TLS versus RDS. In 2012, males aged ≥16years who reported injecting drugs in the previous month and living in Haiphong, Vietnam, were sampled using TLS or RDS. Data from each survey were analyzed to compare HIV prevalence, related risk factors, socio-demographic characteristics, refusal estimates, and time and expenditures for field implementation. TLS (n = 432) and RDS (n = 415) produced similarly high estimates for HIV prevalence. Significantly lower proportions of PWID sampled through RDS received methadone treatment or met an outreach worker. Refusal estimates were lower for TLS than for RDS. Total expenditures per sample collected and number of person-days of staff effort were higher for TLS than for RDS. Both survey methods were successful in recruiting a diverse sample of PWID in Haiphong. In Vietnam, surveys of PWID are conducted throughout the country; although the refusal estimate was calculated to be much higher for RDS than TLS, RDS in Haiphong appeared to sample PWID with less exposure to services and required fewer financial and staff resources compared with TLS.

Key populations (KPs) are particularly vulnerable to HIV infection and efforts to prevent HIV infections among KPs have been less successful, largely due to existing laws and legislation that classify the groups as illegal. Understanding the HIV infection pathway and the burden of HIV infection among Female Sex Workers (FSWs), Transgender people (TG), Men who have sex with Men (MSM), People who Inject Drugs (PWID), and Prison Inmates (PIs) is critical to combatting the HIV epidemic globally. This study aims to estimate HIV prevalence and model the risk factors of HIV positivity rate among the aforementioned KPs in Sierra Leone. This study used Time Location Sampling, Respondent Driven Sampling (RDS), and Conventional cluster Sampling designs to generate a representative sample of FSWs, MSM, TG, PI, and PWID. HIV prevalence and the corresponding 95% confidence intervals among each KP were estimated by adjusting for sampling weight using the logit-transformed confidence intervals. To determine correlates of HIV test positivity among KPs, a multivariable modified Poisson regression model that adjusts for RDS survey weights was used and sensitivity analysis was conducted using a multivariable logistic regression model with cluster robust standard errors. The prevalence of HIV among FSWs in the six regional headquarter towns was estimated to be 11.8% (95% CI: 7.9–17.1); MSM was 3.4% [95% CI: 1.9–5.8]; TGs was 4.2% (95% CI: 2.9–6.1); PWIDs was 4.2% (95% CI: 2.7–6.4) and PI was 3.7% (95% CI: 1.4–9.6). The correlates of HIV test positivity among KPs and PIs include HIV-related knowledge, marital status, district, income, age and sex of KP, level of education, alcohol intake, injecting drugs, and use of lubricants. HIV prevalence is relatively high among FSWs, MSMs, PWID, and TGs as compared to the previous estimate of the general population. There is a need to scale up and strengthen evidence-based HIV prevention interventions such Pre-Exposure Prophylaxis and needle and syringe exchange programmes targeting KPs, including prison inmates. Government must scale up both non-clinical and clinical routine HIV and STI testing and counseling services at the correctional center and drop-in centers for KPs screening/testing, and ensure that services are responsive to the needs of KP.

We appreciate the letter in response to the recent JIAS supplement on engaging African men who have sex with men (MSM) and transgender women (TGW) who have sex with men in HIV research. The authors point out that no papers in the supplement focused solely on TGW and called for the publication of studies that explore issues affecting TGW independently from other key populations. We agree wholeheartedly with this call. In our guest editorial accompanying the supplement, we noted that TGW have historically been conflated with MSM, but are “deserving of separate consideration and tailored, rights-affirming engagement” [1]. The supplement arose from a symposium at the R4P conference in Madrid that addressed MSM engagement in longitudinal research in Africa. Despite not being designed to do so, several studies presented there had enrolled both MSM and TGW populations. A well-known example is the HPTN 075 study to assess MSM cohort feasibility in Kenya, Malawi and South Africa, which found that one in seven enrolled “MSM” identified as a woman or transgender female [2]. Recognizing an opportunity to help fill knowledge gaps related to this under-studied population, the guest editors encouraged disaggregation of data by gender identity in all supplement manuscripts. In 2019, JIAS published the first HIV incidence estimate among a small group of TGW from Kenya as 20.6 (95% confidence interval 6.6 to 63.8) cases per 100 person-years (PY), and several-fold higher than incidence estimates among MSM [3]. The recent JIAS supplement has added two new HIV incidence estimates among TGW from South Africa (31.0 [3.7 to 111.2]/100PY) and TGW from Nigeria (23.8 [13.6 to 39.1]/100PY), confirming an exceptional burden of new HIV infections among African TGW [4, 5]. These estimates indicate a need for urgent and targeted prevention interventions, deliberate efforts to monitor and promote uptake of pre-exposure prophylaxis, and the development of guidelines for HIV prevention and care programming for TGW in sub-Saharan Africa. The JIAS supplement demonstrated that there has been progress in the engagement of African MSM and TGW. While more work involving TGW in their own right is overdue and much needed, we think that the inclusion of both TGW and MSM concurrently in research has moved the field in the right direction. Such studies also provide opportunities for comparative evaluations across key populations that underscore the unique features and needs of each population. We are excited, for example, by the planned phase III trial involving both MSM and TGW populations for an efficacy assessment of monthly long-acting islatravir (formerly MK-8591) for HIV prevention (IMPOWER 24), which will enroll in Kenya and other global sites. But, as we emphasized in our guest editorial, much more must be done. There are several actionable lessons from the supplement, including a need for training programs to sensitize healthcare providers, capacity building programs for sociobehavioral researchers, and administrative support programs to build capacities of community-based organizations representing TGW. We concur strongly that studies focused on TGW experiences in sub-Saharan Africa are worthy of publication to inform differentiated delivery of HIV prevention and care services to this unique and vulnerable population. The authors report no competing interests. TAC, PEF, LGB and EJS conceptualized the manuscript. TAC and EJS authored the first draft of the manuscript, which was reviewed by PEF and LGB. All authors have read and approved the final manuscript for publication. TAC is an employee of the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., (HJF) in support of the U.S. Military HIV Research Program at the Walter Reed Army Institute of Research which is funded by a cooperative agreement between HJF and the U.S. Department of Defense (W81XWH-18-2-0040). PEF is an employee of IAVI. LGB has no specific funding in support of this editorial to disclose. EJS is supported by IAVI, receiving generous support of the American people through the United States Agency for International Development (USAID); a National Institutes of Health (NIH)–funded programme (R01AI124968), and by the Wellcome Trust. The KEMRI-Wellcome Trust Research Programme at the Centre for Geographical Medicine Research–Kilifi is supported by core funding from the Wellcome Trust (203077). This work was also supported in part through the sub-Saharan African Network for TB/HIV Research Excellence (SANTHE), a DELTAS Africa Initiative (DEL-15-006). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS) Alliance for Accelerating Excellence in Science in Africa (AESA) and is supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (107752) and the U.K. government. The views expressed are those of the authors and should not be construed to represent the positions of the U.S. Army, U.S. Department of Defense, U.S. Agency for International Development, U.S. Government, African Academy of Sciences, New Partnership for Africa's Development, Wellcome Trust, or U.K. government.

We present a comparison of respondent-driven sampling (RDS) and time-location sampling (TLS) for behavioral surveillance studies among men who have sex with men (MSM). In 2010, we conducted two simultaneous studies using TLS (N = 609) and RDS (N = 507) in Guatemala city. Differences in characteristics of the population reached based on weighted estimates as well as the time and cost of recruitment are presented. RDS MSM were marginally more likely to self-report as heterosexual, less likely to disclose sexual orientation to family members and more likely to report sex with women than TLS MSM. Although RDS MSM were less likely than TLS MSM to report ≥2 non-commercial male partners, they were more likely to report selling sex in the past 12 months. The cost per participant was $89 and $121 for RDS and TLS, respectively. Our results suggest that RDS reached a more hidden sub-population of non-gay-identifying MSM than TLS and had a lower implementation cost.

IntroductionProviding outreach HIV prevention services at venues (i.e. “hotspots”) where people meet new sex partners can decrease barriers to HIV testing services (HTS) for key populations (KP) in sub‐Saharan Africa (SSA). We offered venue‐based HTS as part of bio‐behavioural surveys conducted in urban Malawi and Angola to generate regional insights into KP programming gaps and identify opportunities to achieve the “first 90” for KP in SSA.MethodsFrom October 2016 to March 2017, we identified and verified 1054 venues in Luanda and Benguela, Angola and Zomba, Malawi and conducted bio‐behavioural surveys at 166 using the PLACE method. PLACE interviews community informants to systematically identify public venues where KP can be reached and conducts bio‐behavioural surveys at a stratified random sample of venues. We present survey results using summary statistics and multivariable modified Poisson regression modelling to examine associations between receipt of outreach worker‐delivered HIV/AIDS education and HTS uptake. We applied sampling weights to estimate numbers of HIV‐positive KP unaware of their status at venues.ResultsWe surveyed 959 female sex workers (FSW), 836 men who have sex with men (MSM), and 129 transgender women (TGW). An estimated 71% of HIV‐positive KP surveyed were not previously aware of their HIV status, receiving a new HIV diagnosis through PLACE venue‐based HTS. If venue‐based HTS were implemented at all venues, 2022 HIV‐positive KP (95% CI: 1649 to 2477) who do not know their status could be reached, including 1666 FSW (95% CI: 1397 to 1987), 274 MSM (95% CI: 160 to 374), and 82 TG (95% CI: 20 to 197). In multivariable analyses, FSW, MSM, and TGW who received outreach worker‐delivered HIV/AIDS education were 3.15 (95% CI: 1.99 to 5.01), 3.12 (95% CI: 2.17 to 4.48), and 1.80 (95% CI: 0.67 to 4.87) times as likely, respectively, as those who did not to have undergone HTS within the last six months. Among verified venues, <=68% offered any on‐site HIV prevention services.ConclusionsAvailability of HTS and other HIV prevention services was limited at venues. HIV prevention can be delivered at venues, which can increase HTS uptake and HIV diagnosis among individuals not previously aware of their status. Delivering venue‐based HTS may represent an effective strategy to reach the “first 90” for KP in SSA.

IntroductionDespite the higher risk of HIV among female sex workers (FSWs), men who have sex with men (MSM) and transgender women (TGW), these populations are under‐represented in the literature on HIV in Haiti. Here, we present the first nationally representative estimates of HIV prevalence and the first care and treatment cascade for FSWs, MSM and TGW in Haiti. We also examine the social determinants of HIV prevalence in these groups and estimate FSW and MSM population size in Haiti.MethodsData were collected between April 2016 and February 2017 throughout the 10 geographical departments of Haiti. The Priorities for Local AIDS Control Efforts (PLACE) method was used to: (1) recruit participants for a behavioural survey; (2) provide rapid testing, counselling and linkage to care for syphilis and HIV; and (3) measure viral load using dried blood spots for participants testing HIV positive.ResultsStudy participants included 990 FSWs, 520 MSM and 109 TGW. HIV prevalence was estimated at 7.7% (95% CI 6.2%, 9.6%) among FSWs, 2.2% (0.9%, 5.3%) among MSM and 27.6% (5.0%, 73.5%) among TGW. Of participants who tested positive for syphilis, 17% of FSWs, 19% of MSM and 74% of TGW were co‐infected with HIV. Economic instability and intimate partner violence (IPV) were significantly associated with HIV among MSM; food insecurity, economic instability and history of rape were significantly associated with HIV among TGW. Fewer than one‐third of participants living with HIV knew their status, and more than a quarter of those who knew their status were not on treatment. While approximately four in five FSW and MSM participants on treatment for HIV were virally suppressed, viral suppression was less common among TGW participants at only 46%.ConclusionsThis study demonstrates a need for targeted interventions to prevent and treat HIV among key populations in Haiti. Potential high‐impact interventions may include venue‐based, peer navigator‐led outreach and testing for HIV and syphilis and improving screening and case management for structural violence and IPV. TGW are in urgent need of such interventions due to our observations of alarmingly high HIV prevalence and low frequency of HIV viral suppression among TGW.

IntroductionIn Thailand, where the HIV epidemic is concentrated among key populations (KPs), particularly men who have sex with men (MSM) and transgender women (TGW), an HIV service delivery model tailored to KPs was piloted. This study evaluated the acceptability and retention of clients who accepted and declined the KP‐led HIV treatment service.MethodsA retrospective cohort study was conducted using secondary data from three community‐based organizations (CBOs) and three hospitals in Thailand. KP lay providers were trained to lead HIV treatment service in which MSM and TGW living with HIV received counselling and a 3‐month antiretroviral therapy (ART) supply at CBOs. Thai MSM and TGW who were at least 18 years, on ART for at least 6–12 months, without co‐morbidities/co‐infections, and virally suppressed were eligible and offered the service. Those who declined received ART via other service models offered by the hospitals and served as a comparison group.ResultsOf 220 clients screened between February 2019 and February 2020, 72% (159/220) were eligible of which 146 were MSM and 13 were TGW. Overall, 45% (72/159) accepted the KP‐led service. Of those who declined, 98% (85/87) preferred to see the physician at the hospital. After 12 months of follow‐up, among those accepted, 57% were in care at the CBO, 32% were referred back to and in care in other service models offered by the hospital, 10% were successfully transferred out to other hospital and 1% were lost to follow‐up (LTFU); among those declined, 92% were in care in any service models offered by the hospital, 5% were successfully transferred out to other hospital, 2% were LTFU and 1% died (p‐value<0.001).ConclusionsDespite moderate acceptability and retention in care at the CBO among the clients accepting the KP‐led service, almost all clients were engaged in care overall. Multiple service models that meet the preferences and needs of KPs living with HIV should be available to optimize engagement in care.

Men who have sex with men (MSM) and Transgender Women (TGW) in Thailand contribute to more than half of all new HIV infections annually. This cross-sectional study describes epidemiologic profiles of these key populations (KP) in Key Population-led Test and Treat study. Baseline data were collected using self-administered questionnaires and HIV/STI testing from MSM and TGW aged ≥18 years enrolled in a cohort study in six community sites in Thailand between October 2015 and February 2016. Factors associated with HIV prevalence were determined by logistic regression. TGW in the cohorts had lower education and income levels than MSM. TGW also engaged in sex work more, though similar proportions between MSM and TGW reported to have multiple sexual partners and STI diagnosis at baseline. HIV prevalence was 15.0% for MSM and 8.8% for TGW in the cohorts. HIV prevalence among TGW was more associated with sociodemographic characteristics, whereas factors related to behavioral risks were determined to be associated with HIV prevalence among MSM. TGW and MSM in the cohorts also had high prevalence of STI. Key Population-driven HIV services are able to capture harder-to-reach key populations who are at heightened risk for HIV.

Introduction: Nepal is considered as a concentrated HIV epidemic among key population like Migrant Labour Worker (MLW), Sex Worker (SW), Injecting Drug User (IDU) and Spouse of Migrant Labour Worker (SMLW). Hence, the HIV infection has significantly contributed to be HIV/TB co-infected among key population. Intervention of Anti Retroviral Therapy (ART) and Direct Observed Short Course (DOTS) have significantly reduced HIV associated morbidity and mortality in Nepal. The objective of this study was to analyze coping strategies to access the HIV/TB services in relation to socio-economic status of key study population.&#x0D; Methods: The study was conducted in five districts Jhapa, Morang, Sunsari, Kavre and Parsa of Nepal. The HIV/TB respondents were selected from previous background of key population: MLW, SW, IDU, and SMLW. 343 respondents were selected through snowballing and convenient sampling technique. The data were collected through face to face interview using pretested questionnaire. Descriptive statistics, Chi-square, and ANOVA test were applied to analyze the collected data.&#x0D; Results: Among 343 HIV/TB co-infected respondents, more than two fifth (44.3%) were belonged to MLW, followed by one third (34.1%) of respondents were SMLW. Therefore, the HIV/TB co-infection was significant association (p=0.001) with employment status and key study population. In addition to this, the study showed that there was significant difference between facing stigma/discrimination and study districts (F=11.03, p=0.001) of respondents. Similarly, there was significant difference between used of previous saving and occupation of family (F=10.461, p=0.001) as coping strategies to access HIV/TB services.&#x0D; Conclusion: Despite the existing stigma and discrimination, the key study population had used various coping strategies to access the health care services in relation to their socio-economic status.

BackgroundTrans women have high HIV prevalence and lag behind 90–90-90 targets for HIV care. In San Francisco in 2017, 96% of trans women were aware of their status, 75% were on antiretroviral therapy, 88% had viral suppression. Initiatives to address gaps include peer navigators, free gender-affirming surgery, and housing. Our study updates HIV prevalence and engagement in care among trans women.MethodsCross-sectional community-based survey of trans women living in San Francisco sampled by respondent-driven sampling, 7/2019–2/2020 (N = 201). Eligibility was: self-identified trans women or other gender and assigned male at birth; living in San Francisco; English/Spanish-speaking; and 18 years or older.ResultsHIV prevalence was 42.3% (95%CI 35.4.-49.4) and associated with having a partner who injected drugs (adjusted odds ratio [AOR] 3.30, 95%CI 1.58–6.90), ever injected drugs (AOR 2.28, 95%CI 1.06–4.89), cost not a barrier to healthcare (AOR 2.63, 95%CI 1.02–6.67), emotional support from family (AOR 2.85, 95%CI 1.43–5.65), and Black/African-American (AOR 2.59, 95%CI 1.16–5.79). Of trans women with HIV, 92.9% were previously diagnosed, 89.9% were on ART, 91.5% reported viral suppression.ConclusionsTrans women met 90–90–90 targets in 2020, at 93–90–92. Interventions need to reach Black/African-American trans women, trans women who inject drugs, and partners of trans women.

BackgroundNovel, technology-based methods are rapidly increasing in popularity across multiple facets of quantitative research. Qualitative research, however, has been slower to integrate technology into research methodology. One method, computer-mediated communication (CMC), has been utilized to a limited extent for focus group discussions.ObjectiveThis study aimed to assess feasibility of an online video conferencing system to further adapt CMC to facilitate synchronous focus group discussions among transgender women living in six cities in eastern and southern United States.MethodsBetween August 2017 and January 2018, focus group discussions with adult transgender women were conducted in English and Spanish by research teams based in Boston, MA, and Baltimore, MD. Participants were sampled from six cities: Baltimore, MD; Boston, MA; New York, NY; Washington, DC; Atlanta, GA; and Miami, FL. This was formative research to inform a technology-enhanced cohort study to assess HIV acquisition among transgender women. This analysis focused on the methodologic use of CMC focus groups conducted synchronously using online software that enabled video or phone discussion. Findings were based on qualitative observations of attendance and study team debriefing on topics of individual, social, technical, and logistical challenges encountered.ResultsA total of 41 transgender women from all six cities participated in seven online focus group discussions—five English and two Spanish. There was equal racial distribution of black/African American (14/41, 34%) and white (14/41, 34%) attendees, with 29% (12/41) identifying as Hispanic/Latina ethnicity. Overall, 29 of 70 (41%) eligible and scheduled transgender women failed to attend the focus group discussions. The most common reason for nonattendance was forgetting or having a scheduling conflict (16/29, 55%). A total of 14% (4/29) reported technical challenges associated with accessing the CMC focus group discussion. CMC focus group discussions were found to facilitate geographic diversity; allow participants to control anonymity and privacy (eg, use of pseudonyms and option to use video); ease scheduling by eliminating challenges related to travel to a data collection site; and offer flexibility to join via a variety of devices. Challenges encountered were related to overlapping conversations; variable audio quality in cases where Internet or cellular connection was poor; and distribution of incentives (eg, cash versus gift cards). As with all focus group discussions, establishment of ground rules and employing both a skilled facilitator and a notetaker who could troubleshoot technology issues were critical to the success of CMC focus group discussions.ConclusionsSynchronous CMC focus group discussions provide a secure opportunity to convene participants across geographic space with minimal time burden and without losing the standardized approach that is expected of focus group discussions. This method may provide an optimal alternative to engaging hard-to-reach participants in focus group discussions. Participants with limited technological literacy or inconsistent access to a phone and/or cellular data or service, as well as circumstances necessitating immediate cash incentives may, however, require additional support and accommodation when participating in CMC focus group discussions.

Background Human herpesvirus 2 (HSV-2) is a major cause of sexually transmitted infections (STIs) worldwide and often occurs synergistically with syphilis, and human immunodeficiency virus (HIV) infection. Transgender women (TGW) are disproportionately affected by STIs. The aim of this study was to estimate the prevalence of HSV-2 monoinfection, and HSV-2, syphilis, and HIV coinfection (triple infection) among TGW in Central Brazil. Methods A seroprevalence survey was conducted among TGW in Central Brazil from 2018 to 2019. Participants were recruited using respondent-driven sampling and interviewed about their sociodemographic characteristics and STI risk behaviors, and were tested for antibodies to HSV-2, Treponema pallidum, and HIV. Multivariable logistic regression models were used to identify variables associated with HSV-2 monoinfection and triple infection. Results Of the 431 participants, 345 (80%) were positive for HSV-2 antibodies, of whom 36 were HSV-2 immunoglobulin M–positive, and 340 were HSV-2 immunoglobulin G–positive. Human herpesvirus 2 and HIV coinfection, HIV and syphilis coinfection, and triple infection were detected in 38 participants (9.0%), 58 participants (13.8%), and 27 participants (6.4%), respectively. Report of a previous STI was associated with a decreased risk of HSV-2 monoinfection (adjusted odds ratio, 0.39), and an increased risk of triple infection (adjusted odds ratio, 4.4). Participants who reported sex not only with men had a 2.42-fold increased risk of triple infection. Conclusions The high prevalence of HSV-2, syphilis, and HIV coinfection among TGW is a cause for concern. Transgender women should be screened for HIV and other STIs. Further studies of risk factors for triple infection among TGW are warranted.

ABSTRACTHIV epidemic control requires improving access and uptake of HIV services by key populations (KPs). In Zambia, the behaviors of female sex workers (FSWs), men who have sex with men (MSM), and people of who use drugs (PWUD) are criminalized, and little information exists about their HIV/STI service use. Using a quality of care (QOC) framework, we compared barriers to and opportunities for HIV/STI service access and uptake among the three KPs. We conducted in-depth interviews and focus group discussions with 314 KP members between July 2013 and September 2015 in eight districts. Poorer QOC was received at public health facilities compared to private, NGOs and traditional healers. Stigma and discrimination, confidentiality, and legal prosecution were barriers to service use and more salient among MSM than FSWs and PWUD. Invasive facility policies were barriers and more prominent among FSWs than MSM and PWUD. Service unavailability was of equally high salience among MSM and PWUD than FSWs. Comfort in the clinic and perceived treatment effectiveness were facilitators for all three KPs. The health care experiences of KPs are not monolithic; HIV/STI service improvement strategies should address the concerns and be tailored to the needs of each key population.

IntroductionSexually Transmitted Infections (STIs) disproportionately affect transgender women (TGW). This group faces barriers to accessing health care, especially due to stigma and discrimination. The literature is scarce on data of...