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AbstractIntroductionDespite the global scale‐up of HIV testing, prevention and treatment, these services remain inaccessible to groups most vulnerable to HIV. Globally, most new HIV infections are concentrated among members of key populations (KP), including female sex workers, men who have sex with men, transgender people, people who inject drugs and their sexual partners. These populations lag in access to HIV prevention and antiretroviral therapy (ART) and have less favourable HIV outcomes compared to the general population. Intersecting behavioural and structural factors contribute to these gaps in service access for at‐risk KP and those living with HIV; corresponding comprehensive approaches to improving service delivery for KP are urgently needed. Differentiated service delivery (DSD) models tailor HIV programmes to the needs and preferences of specific groups but are rarely implemented at scale for KP. We describe the FIKIA Project, which implemented innovative approaches to scaling up DSD models to reach and engage KP in Tanzania.MethodsThe FIKIA Project worked with diverse KP communities in Tanzania to tailor HIV services to their needs and to pair healthcare workers with trained peer educators and expert client counsellors to expand uptake of community‐based HIV testing and ART services. We analysed routine aggregate project data from 2016 to 2020 to describe project implementation, outcomes and best practices.Results and discussionThe FIKIA Project conducted 1,831,441 HIV tests in community settings; of the 98,349 (5.4%) individuals with new HIV diagnoses, 89,640 (91.1%) initiated ART. The project reached substantial numbers of KP: 203,233 received HIV tests, 28,830 (14.2%) received a new HIV diagnosis and 25,170 KP (87.3%) initiated ART at the point of diagnosis. Over time, HIV testing increased by 1.6 times overall (2.3 times among KP), HIV diagnoses increased by 8.7 times (10.9 times among KP) and ART initiation at the point of diagnosis increased from 80.0% to 95.9% overall (from 69.6% to 94.9% among KP).ConclusionsOver four years, the FIKIA Project scaled up HIV testing, diagnosis and treatment by using DSD principles to design services that meet the needs of KP and their communities.

BACKGROUND: Community randomised trials have had mixed success in implementing combination prevention strategies that diagnose 90% of people living with HIV, initiate and retain on antiretroviral therapy (ART) 90% of those diagnosed, and achieve viral load suppression in 90% of those on ART (90-90-90). The Bukoba Combination Prevention Evaluation (BCPE) aimed to achieve 90-90-90 in Bukoba Municipal Council, Tanzania, by scaling up new HIV testing, linkage, and retention interventions. METHOD: We did population-based, cross-sectional surveys before and after our community-wide intervention in Bukoba—a mixed urban and rural council of approximately 150 000 residents located on the western shore of Lake Victoria in Tanzania. BCPE interventions were implemented in 11 government-supported health-care facilities throughout Bukoba from Oct 1, 2014, to March 31, 2017, when national ART-eligibility guidelines expanded from CD4 counts of less than 350 cells per μL (Oct 1, 2014–Dec 31, 2015) and 500 or less cells per μL (Jan 1, 2016–Sept 30, 2016) to any CD4 cell count (test and treat, Oct 1, 2016–March 31, 2017). We used pre-intervention (Nov 4, 2013–Jan 25, 2014) and post-intervention (June 21, 2017–Sept 20, 2017) population-based household surveys to assess population prevalence of undiagnosed HIV infection and ART coverage, and progress towards 90-90-90, among residents aged 18–49 years. FINDINGS: During the 2·5-year intervention, BCPE did 133 695 HIV tests, diagnosed and linked 3918 people living with HIV to HIV care at 11 Bukoba facilities, and returned to HIV care 604 patients who had stopped care. 4795 and 5067 residents aged 18–49 years participated in pre-intervention and post-intervention surveys. HIV prevalence before and after the intervention was similar: pre-intervention 8·9% (95% CI 7·5–10·4); post-intervention 8·4% (6·9–9·9). Prevalence of undiagnosed HIV infection decreased from 4·7% to 2·0% (prevalence ratio 0·42, 95% CI 0·31–0·57), and current ART use among all people living with HIV increased from ...