key populations

Improved Monitoring of the Key Population Cascade: The Need for Use of Customized Indicators

What is the problem?

Specialized non-governmental organizations (NGOs) frequently provide testing and prevention services for key populations (KPs). However, HIV care and treatment are typically only accessible via government facilities. NGOs, then, act as the mechanism to link KPs to HIV testing and treatment services. Existing monitoring and evaluation (M&E) frameworks do not enable NGOs to measure and report these linkage services. As a result, it is difficult to track progress toward epidemic control among key populations.

What is the tool?

LINKAGES, which is the largest global project dedicated to key populations, created by PEPFAR and the U.S. Agency for International Development (USAID), introduced a set of standardized, custom indicators for the KP clinical cascade in 2017. These new indicators were created with the intention of improving monitoring of the non-clinical activities conducted by NGOs in their engagement with KPs.

The Peer Navigator Enrollment Frontline Tool  (doc) is used at the point of enrollment in services to track client characteristics and history, services rendered, and health outcomes (including reporting on the customized indicators described in the below Customized Indicator Reference Sheet). 

Selection of New Indicators: These indicators were developed because MER indicators often do not represent the full package of services provided by KP programs. The list was generated by key staff from PEPFAR, USAID, and LINKAGES based on common gaps described in MER guidance and input was also requested from selected country teams and civil society partners. These new indicators are:





See the Customized Indicator Reference Sheet (pdf).

Integrating New Indicators into Reporting Process: Minimal effort is required for the data collection required by these indicators. Dara are collected at the NGO/community level as the interventions described are conducted by non-clinical staff. One required input for the implementation of these indicators is the update of data collection forms to include the indicators for the NGOs.

Once proven useful for measuring NGO activities with KPs, larger-scale rollout can occur and these indicators can be integrated into the national reporting system. Minor edits and additions to existing strategic information tools will be needed.

Expected Outcomes: The expected outcomes of using these new indicators include: capturing information about KPs missed by MER indicators, closer monitoring of NGO activities and achievements, and identifying gaps in the services offered to KPs. The use of KP-specific custom indicators will more accurately track the number of KPs living with HIV (KPLHIV) that PEPFAR supports, as well.

Graphs demonstrating the gaps in existing data coverage, which Customized Indicators aim to fill.

Expedited Biobehavioral Surveys and Data Availability

What is the problem?

Data is necessary for targeted service delivery. Key population (KP) programs need relevant and timely data about KPs—sex workers, men who have sex with men, transgender individuals, people who inject drugs, and people in prison and other closed settings—engaged and not engaged in services in order to target their services. Biobehavioral surveys (BBS) provide population-based information about KP risk behaviors, HIV prevalence and, importantly, the 90-90-90 cascade to inform service provision and policy. The time BBSs take to plan, implement, and make available the results for remediated actions, is a major limitation to their utility.

What is the tool? 

These tools aim to make BBS planning, implementation, and results provision efficient and timely.

1.       Key factors and interventions to consider for timely and successful implementation of the BBS are summarized in the Technical Considerations Fast Tracking Quality Key Population Biobehavioral Surveys (doc).

2.       Data management and cleaning for a BBS survey can take upwards of three months. It is therefore essential to begin these processes during data collection. This also allows problems to be addressed in near real-time and means that data analysis can begin soon after the end of data collection. The Priority Results Table (doc) is a minimum set of variables whose results should be shared with key stakeholders within two months of the end of data collection. The survey team should collaborate with stakeholders to identify context-specific modifications to the Priority Results Table, including of response categories and additional priority variables.

3.       The sample size and thus duration of BBS implementation can heavily influence the budget. The WHO Blue Book (external link) offers a budget template for costing BBS. As the bulk of the budget is associated with implementation, expediting BBS does not necessarily result in substantial cost savings as survey duration may remain unchanged.

Examples of outcomes related to use of BBS data: BBS data can be used to advocate for, and inform, the development of a Ministry of Health key populations policy and provide new insight into areas where key populations congregate. For example, a BBS in South Sudan revealed additional areas where service providers can find sex workers, through the geospatial mapping component of BBS. In Papua New Guinea, early release of BBS data prompted the use of social-network methods for reaching and testing KPs.

Additional Resources:

WHO BBS Survey Guidelines for Populations at Risk for HIV: Supplementary Materials (pdf)