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Over the past 15 years, the world has made remarkable strides in halting and reversing the HIV epidemic: annual new infections have declined 35% since 2000 and 15 million people living with HIV (PLHIV) are now on antiretroviral therapy (ART). However, the key populations (KPs) of sex workers, men who have sex with men (MSM), transgender people, and people who inject drugs (PWID) remain disproportionately affected; 40-50% of all new HIV infections among adults worldwide occur among these populations and their sex partners.

KPs are a high priority in efforts to reach the ambitious 90-90-90 goals of the Joint United Nations Program on HIV/AIDS (UNAIDS) – by 2020, 90% of all PLHIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained ART, and 90% of all people receiving ART will have durable viral suppression. Similarly, PEPFAR 3.0 lays out a data-driven approach that stresses evidencebased interventions focusing on the highest risk populations in areas of highest HIV incidence. This “epidemic control” model necessitates that KPs flow efficiently, consistently, and sustainably through the entire HIV continuum of prevention, care, and treatment (CoPCT) services. This seamless integration of interventions requires strong linkages among program elements so that HIV transmission is reduced and people diagnosed with HIV obtain early access to services, including ART.

Global efforts to prevent new HIV infections and link HIV-positive KPs into treatment and care require the concerted efforts of researchers, policymakers, providers and KPs themselves. As a component of the guidelines, tools and resources presented in this document, the cascade framework identifies “leaks” in the system, allowing resources to be targeted to interventions needed most to improve KP uptake of and retention in the continuum of HIV services. Constructing cascades will help programs monitor HIV service system performance and focus human, financial, and programmatic resources on the ultimate aim of the HIV response: viral suppression. By knowing where the drop-offs are most pronounced, decision makers and service providers can implement system improvements and service enhancements that make the greatest impact on individuals, communities, and society.