Hiv Prevention, Diagnosis, Treatment and Care For Key Populations
Hiv Prevention, Diagnosis, Treatment and Care For Key Populations
Hiv Prevention, Diagnosis, Treatment and Care For Key Populations
CONSOLIDATED GUIDELINES ON
HIV PREVENTION,
KEY POPULATIONS
DIAGNOSIS, TREATMENT
AND CARE FOR
KEY POPULATIONS
JULY 2014
CONSOLIDATED GUIDELINES ON
HIV PREVENTION,
DIAGNOSIS, TREATMENT
AND CARE FOR
KEY POPULATIONS
JULY 2014
WHO Library Cataloguing-in-Publication Data :
Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations.
1.HIV Infections - prevention and control. 2.HIV Infections - therapy. 3.HIV Infections – diagnosis.
4.Risk Factors. 5.Vulnerable Populations. 6.Guideline. I.World Health Organization.
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CONTENTS
ACKNOWLEDGEMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
1 INTRODUCTION.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2 Establishing guideline groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.3 Defining the scope of the guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
vi Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
4.1 Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.1.1 Comprehensive condom and lubricant programming. . . . . . . . . . . . . . . . . 26
4.1.2 Harm reduction for people who inject drugs. . . . . . . . . . . . . . . . . . . . . . . 29
4.1.3 Behavioural interventions.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.1.4 Prevention of transmission in health-care settings. . . . . . . . . . . . . . . . . . . 43
4.1.5 ARV-related prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.1.6 Voluntary medical male circumcision for HIV prevention. . . . . . . . . . . . . . . 54
4.2 HIV testing and counselling.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4.3 Linkage and enrolment in care.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.4 HIV treatment and care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.4.1 Antiretroviral therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.4.2 Prevention of mother-to-child transmission. . . . . . . . . . . . . . . . . . . . . . . . 63
4.4.3 ART drug interactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Contents vii
5 CRITICAL ENABLERS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
ANNEXES
ACKNOWLEDGEMENTS
Elie Aaraj # (Middle East & North Africa Harm Reduction Association (MENAHRA),
Lebanon), Eliot Albers* (The International Network of People who Use Drugs (INPUD),
United Kingdom), George Ayala* (The Global Forum on MSM and HIV (MSMGF),
USA), Carlos F. Cáceres (Sexuality and Human Development, Cayetano Heredia
University, Peru), Kate Montecarlo Cordova # (Association of Transgender People in
the Philippines (A.T.P), Philippines), Tetiana Deshko # (International HIV/AIDS Alliance
in Ukraine), Daouda Diouf # (Enda Santé, Senegal), Zoë Dodd # (The International
Network of People who Use Drugs (INPUD), Canada), Frits van Griensven (Thai Red
Cross Society, Chulalongkorn University, Thailand), Mengjie Han # (National Center for
AIDS/STD Control and Prevention, China CDC, People’s Republic of China), Ralf Jürgens
(Open Society Foundations, USA), Mehdi Karkouri # (Centre Hospitalier Universitaire
Ibn Rochd, Morocco), JoAnne Keatley (Center of Excellence for Transgender Health,
USA), Anita Krug # (Youth RISE, Australia), Joep Lange* (University of Amsterdam,
Netherlands), Keletso Makofane # (The Global Forum on MSM and HIV, South Africa),
Jessie Mbwambo # (Muhimbili University of Health and Allied Sciences, Tanzania),
Fabio Mesquita (Ministry of Health, Brazil), Noah Metheny* (The Global Forum
on MSM and HIV (MSMGF), USA), Ruth Morgan Thomas (Global Network of Sex
Work Projects (NSWP), United Kingdom), Debbie Muirhead (Department of Foreign
Affairs and Trade (DFAT), Indonesia), Patrick Mutua Mburugu (Ministry of Public
Health & Sanitation, Kenya), Ed Ngoksin (Global Network of People Living with HIV/
AIDS (GNP+), South Africa), Sam Nugraha # (Community Based Treatment (Rumah
Singgah PEKA), Indonesia), Tonia Poteat (Office of the U.S. Global AIDS Coordinator
(OGAC), USA), Ganesh Ramakrishnan (Bill and Melinda Gates Foundation, India) and
Sushena Reza-Paul # (University of Manitoba, Canada; Ashodaya Samithi, India).
# Guidelines Development Group only
* Steering group only
Kevin Rebe (ANOVA Health Institute, South Africa), Helen Rees (Wits Reproductive
and HIV Research Institute, South Africa), Gary Reid (independent consultant, India),
Kirill Sabir (FtM Phoenix Group, Russia), Bettina Schunter (independent consultant,
Pakistan), Sopheap Seng (National Center for HIV/AIDS, Cambodia), Maninder Singh
Setia (consultant dermatologist and epidemiologist, India), Sally Shackleton (Sex
Workers Education and Advocacy Taskforce (SWEAT), South Africa), Kate Shannon
(British Columbia Centre for Excellence in HIV/AIDS, Canada), Oscar Ozmund Simooya
(The Copper Belt University, Zambia), Tim Sladden (United Nations Population Fund,
Turkey), Mat Southwell (Coact, United Kingdom), Rosario Jessica Tactacan-
Abrenica (San Lazaro Hospital, Philippines), Siti Nadia Tarmizi (Ministry of Health,
Indonesia), Pham Thi Minh (Viet Nam Network of People who Use Drugs (VNPUD),
Viet Nam), Marguerite Thiam-Niangoin (Ministère de la santé et de la lutte contre
le SIDA, Côte d’Ivoire), Tengiz Tsertsvadze (AIDS and Clinical Immunology Research
Center, Georgia), Bea Vuylsteke (Institute of Tropical Medicine, Belgium), Darshana
Vyas (Pathfinder International, India), Daniel Wolfe (Open Society Foundations, USA),
William Chi Wai Wong (The University of Hong Kong, China) and Tariq Zafar (Nai
Zindagi, Pakistan).
Special thanks to the following WHO consultants who contributed to the writing,
coordination and research for the guidelines: Cadi Irvine, Alice Armstrong, Bradley
Mathers, Michelle Rodolph, Amee Schwitters (CDC), and Graham Shaw. The
following WHO consultants were also involved in developing these guidelines: Katie
Curran, Cheryl Johnson and Kevin O’Reilly. Interns who supported the process:
Carmen Figueroa, Pramudie Gunaratne and George Mugambi.
Overall coordination
Rachel Baggaley coordinated the overall guideline development process with Annette
Verster and Cadi Irvine, under the supervision of Andrew Ball and Gottfried
Hirnschall (Department of HIV).
Funding
The Unified Budget, Results and Accountability Framework of the Joint United Nations
Programme on HIV/AIDS (UNAIDS) and the U.S. President’s Emergency Plan for AIDS
Relief (PEPFAR) provided the funding to support this work, including the systematic
reviews of evidence, evidence compilation, convening of the expert meeting, and
development, editing, and printing of the guidelines. The Global Fund to Fight AIDS,
Tuberculosis and Malaria provided funding for the background work on transgender
populations.
Definitions used in this guideline are aligned with current consensus definitions used in
the Global Health Sector Strategy on HIV/AIDS 2011–2015 (1) and by the United Nations,
as described in the Joint United Nations Programme on HIV/AIDS (UNAIDS) “Guidance
note on HIV and sex work”(2) and other relevant World Health Organization (WHO) and
other United Nations documents.
Key populations are defined groups who, due to specific higher-risk behaviours, are at
increased risk of HIV irrespective of the epidemic type or local context . Also, they often
have legal and social issues related to their behaviours that increase their vulnerability
to HIV. These guidelines focus on five key populations: 1) men who have sex with
men, 2) people who inject drugs, 3) people in prisons and other closed settings, 4) sex
workers and 5) transgender people. People in prisons and other closed settings are
included in these guidelines also because of the often high levels of incarceration of the
other groups and the increased risk behaviours and lack of HIV services in these settings.
The key populations are important to the dynamics of HIV transmission. They also are
essential partners in an effective response to the epidemic (1).
Vulnerable populations are groups of people who are particularly vulnerable to HIV
infection in certain situations or contexts, such as adolescents (particularly adolescent
girls in sub-Saharan Africa), orphans, street children, people with disabilities and
migrant and mobile workers. These populations are not affected by HIV uniformly across
all countries and epidemics. These guidelines do not specifically address vulnerable
populations, but much of the guidance can apply to them.
Men who have sex with men refers to all men who engage in sexual and/or romantic
relations with other men. The words “men” and “sex” are interpreted differently in
diverse cultures and societies and by the individuals involved. Therefore, the term
encompasses the large variety of settings and contexts in which male-to-male sex takes
place, regardless of multiple motivations for engaging in sex, self-determined sexual and
gender identities, and various identifications with any particular community or social
group.
People who inject drugs refers to people who inject psychotropic (or psychoactive)
substances for non-medical purposes. These drugs include, but are not limited to,
opioids, amphetamine-type stimulants, cocaine, hypno-sedatives and hallucinogens.
Injection may be through intravenous, intramuscular, subcutaneous or other injectable
routes. People who self-inject medicines for medical purposes – referred to as
“therapeutic injection” – are not included in this definition. The definition also does
not include individuals who self-inject non-psychotropic substances, such as steroids
or other hormones, for body shaping or improving athletic performance. While these
guidelines focus on people who inject drugs because of their specific risk of HIV
transmission due to the sharing of blood-contaminated injection equipment, much of
this guidance is relevant also for people who inject other substances.
Definitions of key terms xv
People in prisons and other closed settings: There are many different terms used to
denote places of detention, which hold people who are awaiting trial, who have been
convicted or who are subject to other conditions of security. Similarly, different terms
are used for those who are detained. In this guidance document, the term “prisons and
other closed settings” refers to all places of detention within a country, and the terms
“prisoners” and “detainees” refer to all those detained in criminal justice and prison
facilities, including adult and juvenile males and females, during the investigation of
a crime, while awaiting trial, after conviction, before sentencing and after sentencing.
This term does not formally include people detained for reasons relating to immigration
or refugee status, those detained without charge, and those sentenced to compulsory
treatment and to rehabilitation centres. Nonetheless, most of the considerations in these
guidelines apply to these people as well (3).
People who use drugs include people who use psychotropic substances through any
route of administration, including injection, oral, inhalation, transmucosal (sublingual,
rectal, intranasal) or transdermal. Often this definition does not include the use of such
widely used substances as alcoholic and caffeine-containing beverages and foods.
Sex workers include female, male and transgender adults (18 years of age and
above) who receive money or goods in exchange for sexual services, either regularly
or occasionally. Sex work is consensual sex between adults, can take many forms, and
varies between and within countries and communities. Sex work also varies in the
degree to which it is more or less “formal”, or organized (4).
As defined in the Convention on the Rights of the Child (CRC), children and adolescents
under the age of 18 who exchange sex for money, goods or favours are “sexually
exploited” and not defined as sex workers (5).
Sexual risk differs among different subgroups within the transgender community. For
example, sexual risk may be higher among transgender women (male to female) or
transgender men (female to male) who have receptive anal intercourse with men than
among transgender men or transgender women who have sex only with women. The
prevalence of HIV among transgender women in many countries is as high as or higher
than among men who have sex with men. Owing to these differing sexual risk profiles,
the focus of this consolidated guideline is on transgender women or transgender men
who have sex with men rather than on transgender women and transgender men who
have sex only with women (8).
Adolescents: Individuals between the ages of 10 and 19 years old are generally
considered adolescents. Adolescents are not a homogenous group; physical and
emotional maturation comes with age, but its progress varies among individuals of the
same age. Also, different social and cultural factors can affect their health, their ability
to make important personal decisions and their ability to access services (9).
This document primarily uses the term “adolescents”. Other terms covering overlapping
age groups include:
Youth: This term refers to individuals between the ages of 15 and 24 (10).
Young people: This term refers to those between the ages of 10 and 24 (10).
xvii
EXECUTIVE SUMMARY
Purpose
In this new consolidated guidelines document on HIV prevention, diagnosis, treatment
and care for key populations, the World Health Organization (WHO) brings together
all existing guidance relevant to five key populations – men who have sex with men,
people who inject drugs, people in prisons and other closed settings, sex workers and
transgender people – and updates selected guidance and recommendations. These
guidelines aim to: provide a comprehensive package of evidence-based HIV-related
recommendations for all key populations; increase awareness of the needs of and issues
important to key populations; improve access, coverage and uptake of effective and
acceptable services; and catalyze greater national and global commitment to adequate
funding and services.
The risk behaviours and vulnerabilities of key populations result in their being
disproportionately affected by HIV in all countries and settings. These disproportionate
risks reflect both behaviour common among members of these populations and
specific legal and social issues that increase their vulnerability. Yet HIV services for
key populations remain largely inadequate. In many settings HIV incidence in key
populations continues to increase, even as incidence stabilizes or declines in the general
population.
To date, WHO has developed normative guidance separately for each of the five key
populations, but, in general, guidance has not adequately addressed overarching issues
relating to key populations. Similarly, the WHO global HIV guidance, including the
2013 consolidated ARV guidelines, did not specifically consider issues relating to key
populations. These guidelines aim to address these gaps and limitations. Countries and
other end-users have indicated the importance of consolidating WHO’s key population
guidance to aid national programme managers and service providers, including
those from community-based and community-led programmes, in planning for and
implementing services for these populations. Thus, this consolidated guidance addresses
the issues and elements for effective HIV service delivery that are common to all key
populations as well as those specific to one or more groups.
Chapter 1: Background, context, rationale, guiding principles, objectives and the target
audience.
The External Steering Group proposed that the consolidated key populations guidelines
provide recommendations along the continuum of HIV care – prevention, diagnosis,
linkage, treatment and care – and include recommendations and guidance on the critical
enablers that are essential to support provision of safe, effective and acceptable HIV
services. New areas identified included re-reviewing evidence concerning the provision
of pre-exposure prophylaxis of HIV (PrEP) for men who have sex with men and assessing
evidence concerning PrEP for people who inject drugs, a group not considered in
the previous guidance. The External Steering Group also prioritized development of
recommendations on the community delivery of naloxone for treating opioid overdose
and updating of recommendations for people in prisons and other closed settings.
Following the October 2013 meeting of the External Steering Group, a Guidelines
Development Group was formed, comprising the majority of the External Steering
Group members along with some additional expert members. Meeting in March
2014, the Guidelines Development Group unanimously supported a reworded PrEP
recommendation for men who have sex with men; a majority vote determined the
strength of the recommendation. In addition, the Guidelines Development Group
reviewed and fully supported all other areas of the existing guidelines. In March
2014 a separate Guidelines Development Group reviewed proposed new guidance on
community delivery of naloxone.
Following these meetings the draft consolidated key populations guidelines were
reviewed by external peer reviewers, UN agency reviewers and WHO staff members
from the Department of HIV and the Department of Mental Health and Substance Abuse,
other WHO departments and regional teams.
Recommendations
The accompanying table summarizes the recommendations presented in this document.
All recommendations and guidance in the document derive from existing WHO
guidance with the exception of the new recommendations on PrEP and community
opioid overdose management. The new PrEP recommendation constitutes a change
Executive summary xix
Further research
With partner organizations, the Department of HIV is developing a comprehensive HIV
service implementation science framework, highlighting key research priorities, including
those for key populations.
CRITICAL ENABLERS
1 Laws, policies and practices should be reviewed and, where necessary, revised by policy-
makers and government leaders, with meaningful engagement of stakeholders from key
population groups, to allow and support the implementation and scale-up of health-care
services for key populations.
2 Countries should work towards implementing and enforcing antidiscrimination and
protective laws, derived from human rights standards, to eliminate stigma, discrimination and
violence against people from key populations.
3 Health services should be made available, accessible and acceptable to key populations,
based on the principles of medical ethics, avoidance of stigma, non-discrimination and the right
to health.
4 Programmes should work toward implementing a package of interventions to enhance
community empowerment among key populations.
5 Violence against people from key populations should be prevented and addressed in
partnership with key population-led organizations. All violence against people from key
populations should be monitored and reported, and redress mechanisms should be established
to provide justice.
INTRODUCTION
1
1.1 Key populations and vulnerable groups 2
1 INTRODUCTION
These disproportionate risks reflect both behaviour common among members of these
populations and specific legal and social barriers that further increase their vulnerability.
Key populations influence epidemic dynamics and play a key role in determining the
nature and effectiveness of the response to HIV. People living with HIV are central to
the response to HIV and, therefore, are also often considered as a key population. This
document, however, does not discuss all people living with HIV as a separate population.
In most countries inadequate coverage and poor quality of services for key populations
continue to undermine responses to HIV. All countries should consider the importance
of reaching these key populations, understanding their needs and providing equitable,
accessible and acceptable services. To accomplish this, it is essential to work with key
population groups and networks as partners in developing and providing services (1).
Vulnerable groups. In certain contexts other groups also are particularly vulnerable
to HIV infection, for example, migrant workers, refugees, long-distance truck drivers,
military personnel, miners, and, in southern Africa, young women. These populations
are not uniformly vulnerable or equally affected across different countries and epidemic
settings. Countries should also identify these additional populations specific to their
settings and focus attention and develop and tailor services accordingly.
A focus on key populations. Overall, countries should prioritize their HIV responses
to focus on the populations that are most vulnerable, experience the greatest
burden of HIV and are currently underserved. These populations will include both
specific vulnerable populations and, in all settings, key populations. These guidelines
provide recommendations for the five key populations listed above (both adults and
adolescents), while recognizing that countries will need to tailor their response to the
1
UNAIDS currently defines ”key populations” as men who have sex with men, sex workers, persons who inject drugs and transgender
people, but recognizes that prisoners, too, are particularly vulnerable to HIV and frequently lack adequate access to services.
Chapter 1: Introduction 3
size of these populations and also address the needs of vulnerable populations (see
box). Detailed guidance on treatment and care of people living with HIV is provided
in the WHO Consolidated guidelines on the use of antiretroviral drugs for treating and
preventing HIV infection (2).
Without addressing the needs of key populations, a sustainable HIV response will not
be achieved. To date, however, in most countries with generalized HIV epidemics, the
response has focused almost exclusively on the general population. Even countries
recognizing that HIV epidemics are concentrated in key populations often are reluctant
to implement adequate interventions that reach those most in need.
An effective response requires more than supporting services and programmes for key
populations; it also requires systemic and environmental changes that only concerted
action can bring about. For members of both key populations and vulnerable groups,
many factors that influence a person’s risk are largely outside that person’s control.
Particularly for key populations, social, legal, structural and other contextual factors
both increase vulnerability to HIV and obstruct access to HIV services. Such factors
include punitive legislation and policing practices, stigma and discrimination, poverty,
violence and high levels of homelessness in some sub-populations. These factors affect
how well individuals or populations can protect themselves from, and cope with, HIV
infection; they can limit access to information, prevention services and commodities,
and care and treatment. In addition, other health services specific to the needs of key
populations are often scarce or non-existent – for example, gender affirming treatment
for transgender people and harm reduction services for people who inject drugs.
Geographic setting and social context also can affect a person’s vulnerability.
In general, health data, including HIV prevalence data, are less robust for key
populations than for general populations due to complexities in sampling (and lack
of size estimation data), legal concerns and issues of stigma and discrimination. Laws
criminalizing the behaviour of key populations make it difficult to collect representative
data. Under such circumstances people are reluctant to be counted as members of these
populations.
38 of 53 countries in Africa (9). In the Americas, Asia, Africa and the Middle East,
83 countries have laws that make sex between men illegal (10). The range of legal
sanctions and the extent to which criminal law is enforced differs among countries (11).
In addition to HIV risk behaviours in prison (unsafe sexual activities, injecting drug
use and tattooing), factors related to the prison infrastructure, prison management
and the criminal justice system contribute to increased risk of HIV, hepatitis B and
C and tuberculosis in prisons (20). Due to the conditions of imprisonment, including
overcrowding, sexual violence, drug use and lack of access to HIV prevention
commodities such as condoms and lubricants, transmission risk is very high (18).
In some settings HIV prevalence rates are higher among women in prisons than among
men and much higher than among women in the general population. For example,
in Moldova in 2005, HIV prevalence among female prisoners was 9.6% compared
with male prisoners at 1.5–5% and women in the general populations at <0.5% (21).
In Canada in 2002 HIV prevalence was reported at 3.71% among female prisoners
compared with 1.96% among male prisoners and <0.5% among women in the general
population (22).
Rates of HIV infection are high among people who inject drugs. For example, in Pakistan
HIV prevalence among people who inject drugs is estimated at 37.8%, based on 2011
surveillance data, almost quadruple the rate in 2005 (15). In Indonesia HIV prevalence
among people who inject drugs is estimated to be 36.4% (compared with 0.4% in the
general population ages 15–49 years); in Ukraine at least 20% (compared with 0.9%),
and in Myanmar 18% (compared with 0.6%) (16). Based on data from 49 countries, the
risk of HIV infection averaged 22 times greater among people who inject drugs than
among the general population. In 11 of these countries the risk was at least 50 times
higher. In Eastern Europe an estimated 40% of new HIV infections occur among people
who inject drugs and their sexual partners (3).
6 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Because of the illegality of sex work, drug use, and same-sex behaviour in many
countries, many people from various key populations are incarcerated at some point in
their lives. Since being held in detention is itself a risk factor for HIV, it further increases
HIV risk for people from other key populations. Settings with forced gender segregation
(e.g. prisons) are important contexts for male-to-male sexual activity not linked to
homosexual identity.
Access to HIV testing and counselling and to HIV prevention, treatment, and care
programmes is often poor in prisons and other closed settings. Few countries implement
comprehensive HIV programmes in prisons (18). Not only are such services needed in
prison and other closed settings, but also they need linkages to HIV services in the
community to maintain continuity after a person is released.
Sex workers are at an increased risk due to exposure to multiple sexual partners and,
sometimes, inconsistent condom use, often due to clients’ unwillingness or coercion.
Legal issues, stigma, discrimination and violence pose barriers to HIV services for sex
workers.
Subgroups of key populations may have especially high risk for HIV infection (25, 26).
For example, a cross-sectional study of 1999 female sex workers in Viet Nam found that
HIV prevalence was significantly greater among street-based sex workers than among
Chapter 1: Introduction 7
sex workers in entertainment establishments (3.8% versus 1.8%, p = 0.02) (27). The
subgroups with higher risk for HIV are not efficiently covered by current surveillance or
intervention programmes.
Adolescents from key populations may face stigma, discrimination and violence even
greater than that faced by older people from key populations. Fearing discrimination
and/or possible legal consequences, many adolescents from key populations are
reluctant to attend diagnostic and treatment services. Consequently, they remain hidden
from many essential health interventions, further perpetuating their exclusion (31).
1
WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Population Fund (UNFPA), the United Nations
Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Office on Drugs and Crime (UNODC)
and key community networks have developed four technical briefs on young people from key populations. These policy briefs are based
on reviews of epidemiological data, the literature on service delivery, a policy analysis, and qualitative research on the values and
preferences of young people from key populations. These guidelines include key messages from this work. The technical briefs are
available in Web Annex 6.
8 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
epidemics key populations often account for a large share of HIV prevalence, and
incidence in certain key populations often has continued to rise even when rates in the
general population have stabilized or declined.
Between 40% and 50% of all new HIV infections among adults worldwide may occur
among people from key populations and their immediate partners.1 In countries in Asia
and Eastern Europe and Central Asia, people from key populations account for more than
half of new infections – from 53% to 62%. Even in the sub-Saharan African countries
with generalized epidemics that have carried out modes of transmission (MOT) analyses,
the proportion of new infections in key
Between 40% and 50% of all new HIV populations is substantial, although it
infections among adults worldwide occur varies greatly – for example, an estimated
among people from key populations and 10% in Uganda, 30% in Burkina Faso,
their immediate partners. 34% in Kenya, 37% in Nigeria, 43% in
Ghana and 45% in Benin.
In an analysis of six countries in West Africa, for example, the proportion of new infections
occurring in the sexual partners of people considered at “higher-risk” ranged from 20% in
Burkina Faso and Nigeria to around 30% in Benin, Côte d’Ivoire, and Ghana and possibly
as high as 49% in Senegal (34). Meanwhile, the proportion of HIV prevention expenditures
devoted specifically to programmes for sex workers, their clients, men who have sex with
men and people who inject drugs was 1.7% in Burkina Faso, 0.4% in Côte d’Ivoire and
0.24% in Ghana, whereas the percentage of new infections estimated to occur in these
population groups was 30%, 28% and 43%, respectively (35).
For example, in Asia HIV transmission occurs primarily through unprotected commercial
sex, injecting drug use, and unprotected sex between men. Increasing condom use
by sex workers and their clients, due to effective condom promotion, is credited with
1 Preliminary estimates based on selected countries using either published analyses of modes of transmission, estimates of new infections
modelled from estimates of HIV prevalence and of the size of the key population, or reported modes of transmission from reported HIV
diagnoses (UNAIDS, 2014).
Chapter 1: Introduction 9
reversing the rising trend in prevalence in the mid-1990s. In recent years, however,
annual incidence rates have changed little. Without further and well-focused investment,
prevalence may start rising again (36). According to a 2008 estimate, an expanded
programme of HIV interventions focused on these higher-risk behaviours would avert
five million new infections between 2007 and 2020 – a number about equal to the
number living with HIV in the region in 2007. In addition, the number of HIV-related
deaths would decrease by 40%, and in 2020 there would be 3.1 million fewer people
living with HIV (37).
In 2011 the World Bank projected that, if Peru did not increase the coverage of
programming for men who have sex with men, the number of new infections per year
in the general population would grow from about 14 000 in 2008 to about 20 000 in
2015. In contrast, expanding coverage of programmes specifically for men who have sex
with men would at least stabilize the number of new infections per year in the general
population or even start to decrease it.
Similarly, in Thailand full programme coverage for men who have sex with men would
decrease the annual number of new infections in the general population from 22 500 in
2008 to 20 000 in 2015; otherwise, the number would rise to 27 200 (38).
A number of case studies appear in Chapters 5 and 6. They include considerations for
each key population group, describing a diversity of interventions and service delivery
approaches across a range of country and regional programme experiences.
All people
■ Prevention opportunities for negatives
HIV-
Reached by ■ Prevention opportunities for people living with HIV
prevention in the
health sector
HIV-
People aware
of HIV status
HIV-
Enrolled in
HIV care Viral
On ART suppression
HIV+ HIV+ HIV+ HIV+
The background documents developed to support these guidelines include studies of the
values and preferences of key populations and service providers. The systematic reviews
and GRADE (Grading of Recommendations, Assessment, Development and Evaluation)
tables for new recommendations appear in full in Web Annexes 1 and 2.
• consolidate guidance for health sector interventions for HIV for each key
population;
• outline common HIV and related health service packages that are beneficial
and acceptable for all key populations and additional services needed for specific key
population groups;
• update guidance for planning, delivering, monitoring and evaluating HIV prevention,
diagnosis, care and treatment interventions for each key population;
• provide gender- and age-specific guidance for HIV interventions for members of
key populations, including adolescents.
• Access to quality health care is a human right. It includes the right of members
of key populations to appropriate quality health care without discrimination. Health-
care providers and institutions must serve people from key populations based on
the principles of medical ethics and the right to health (18). Health services should
be accessible to key populations. This guidance can be effective only when services
are acceptable and high quality and widely implemented. Poor quality and restricted
access to services will limit the individual benefit and public health impact of the
recommendations.
• Access to justice is a major priority for people from key populations, due to high
rates of contact with law enforcement services and the current illegality of their
behaviours in many countries. Access to justice includes freedom from arbitrary arrest
and detention, the right to a fair trial, freedom from torture and cruel, inhuman and
degrading treatment and the right, including in prisons and other closed settings,
to the highest attainable standard of health (41). The protection of human rights,
including the rights to employment, housing and health care, for people from key
populations requires collaboration between health-care and law enforcement
agencies, including those that manage prisons and other closed institutions.
Detainment in closed settings should not impede the right to maintain dignity and
health (18).
• Acceptability of services is a key aspect of effectiveness. Interventions to
reduce the burden of HIV among people from key populations must be respectful,
acceptable, appropriate and affordable to recipients in order to enlist their
participation and ensure their retention in care. Services for members of key
populations often employ appropriate models of service delivery but lack expertise in
HIV. Conversely, people from key populations may not find specialized HIV services
acceptable. There is a need to build service capacity on both fronts. Consultation with
organizations of people from key populations and including peer workers in service
delivery are effective ways to work towards this goal (42). Mechanism of regular and
ongoing feedback from beneficiaries to service providers will help inform and improve
the acceptability of services to key populations.
• Health literacy: People from key populations often lack sufficient health and
treatment literacy. This may hinder their decision-making on HIV risk behaviours and
their health-seeking behaviour. Health services should regularly and routinely provide
accurate health and treatment information to members of key populations. At the
same time health services should strengthen providers’ ability to prevent and to treat
HIV in people from key populations, including adolescents (42).
• Integrated service provision: People from key populations commonly have
multiple co-morbidities and poor social situations. For example, HIV, viral hepatitis,
tuberculosis, other infectious diseases and mental health conditions are common
in key populations. Integrated services provide the opportunity for patient-centred
prevention, care and treatment for the multitude of issues affecting key populations.
In addition, integrated services facilitate better communication and care. Thus,
wherever feasible, service delivery for key populations should be integrated. When
this is not possible, strong links among health services working with key populations
should be established and maintained (43).
METHODOLOGY AND PROCESS
FOR DEVELOPMENT OF THE
GUIDELINES 2
2.1 Overview 14
2.10 Updating 19
14 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
2.1 Overview
The WHO Department of HIV led development of these WHO consolidated key
populations guidelines, following the WHO procedures and reporting standards laid out
in the WHO handbook for guideline development, 2012 (1).
The WHO Guideline Steering Group on HIV and Key Populations, chaired
by the WHO Department of HIV, led the guideline development process. It
included participants from the WHO Department of Maternal, Newborn, Child
and Adolescent Heath, the Department of Mental Health and Substance Abuse,
the Department of Reproductive Health and Research, the Global Hepatitis
Programme, and the Global TB Programme.
The External Peer Review Group was selected in consultation with the WHO
regional offices to assure geographical and gender balance. In total over 70 peer
reviewers from academia, policy and research, implementing programmes and
key population networks and organizations reviewed the guidelines. In general,
reviewers made suggestions to improve the clarity of the document and provided
minor additions and corrections to the narrative.
Conflicts of interest
All External Steering Group participants, Guidelines Development Group participants and
External Peer Review Group members submitted Declarations of Interest (DOI) to the
WHO secretariat. The WHO secretariat and the Guidelines Development Group reviewed
all declarations and found no conflicts of interest sufficient to preclude anyone from
participating in the development of the guidelines. A full compilation of the declarations
is available on request.
Audience
The External Steering Group identified the audience for these guidelines. Health services
in low-resource settings will benefit most from the guidance presented here, as they
face the greatest challenges in providing services tailored to key populations. However,
these guidelines are relevant for all HIV epidemic and economic settings and are,
therefore, considered global guidance. Regions and countries can adapt these global
recommendations to local needs, HIV epidemic contexts and existing services in order to
facilitate their implementation.
Participants at this meeting assessed the evidence for both PICO questions concerning
PrEP, along with the risks and benefits, values and preferences and cost-benefits/
feasibility associated with each possible intervention and made recommendations (see
Section 4.1.5.1).
have to bear; adverse clinical outcomes (e.g. drug resistance, drug toxicities); and legal
ramifications where certain practices are criminalized.
A strong recommendation (for or against) is one for which there is confidence that the
desirable effects of adherence to the recommendation clearly outweigh the undesirable
effects.
The values and preferences of the end users (key populations), feasibility and cost
as well as consideration of potential benefits and harms contribute to determining the
strength of a recommendation.
Surveys, qualitative studies and literature reviews were commissioned and other
available material was appraised to investigate the values and preferences of key
populations and service providers and benefits, harms, cost and feasibility concerning
new areas of guidance, existing recommendations and service provision issues. Specific
attention was paid to the values and preferences of adolescents in key populations.1
2.10 Updating
The Department of HIV has committed to providing regular updates of consolidated
key population guidelines when new or revised evidence becomes available, including
relevant new guidance developed by other WHO departments.
1
WHO, UNAIDS, the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Nations
Development Programme (UNDP) and UNODC have developed four technical briefs on young people from key populations. These policy
briefs are based on reviews of epidemiological data, the literature on service delivery, a policy analysis, and qualitative research on the
values and preferences of young people from key populations. These guidelines include key messages from this work. See Web Annex 6.
COMPREHENSIVE PACKAGE OF
INTERVENTIONS
3
3.1 Services for all key populations 22
3 COMPREHENSIVE PACKAGE OF
INTERVENTIONS
1
Needle and syringe programmes are important for people who inject drugs and also for transgender people who require sterile injecting
equipment to safely inject hormones for gender affirmation. Other important areas include for tattooing, piercing and other forms of skin
penetration, which are particularly relevant in prisons and other closed settings.
2
Including contraception, diagnosis and treatment of STIs, cervical screening, etc. (see Chapter 4).
Chapter 3: Comprehensive package of interventions 23
In addition to the interventions listed, people from key populations need access to
general medical, social welfare and legal services so that they can attain the highest
possible standards of health and well-being.
In 2013 UNODC and partners agreed on a comprehensive package for effective HIV
prevention and treatment in prisons and other closed settings. In addition to the
recommended interventions for people in the community, interventions relevant to
closed settings include:
Some other interventions are important and should not be overlooked, such as the
distribution of toothbrushes and shavers in basic hygiene kits, adequate nutrition,
intimate visit programmes, palliative care and compassionate release for terminal
cases (4).
24 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
4
4.1 Prevention 26
4.1.1 Comprehensive condom and lubricant programming 26
4.1.2 Harm reduction for people who inject drugs 29
4.1.3 Behavioural interventions 40
4.1.4 Prevention of transmission in health-care settings 43
4.1.5 ARV-related prevention 44
4.1.6 Voluntary medical male circumcision for HIV prevention 54
4.1 Prevention
Related recommendations and contextual issues for specific key population groups
• Condoms and condom-compatible lubricants are recommended for anal sex (3).
• Adequate provision of lubricants needs to be emphasized.
Chapter 4: Health sector interventions 27
Sexual activity takes place in prisons and other closed settings, but general access
to condoms there is limited. It is important to introduce, and expand to scale,
condom and lubricant distribution programmes in prisons and other closed settings,
without quantity restriction, with anonymity and in an easily accessible manner (e.g.
condom vending machines) (9, 11).
TRANSGENDER PEOPLE
• Condoms and condom-compatible lubricants are recommended for anal sex (3).
• Adequate provision of lubricants for transgender women and transgender men
who have sex with men needs emphasis.
Implementation considerations
Legislation and law enforcement approaches need to support condom
programming. Possession of condoms should not be used as evidence of criminal
activity, and police should not harass those carrying condoms (10).
Promote access. While condoms and lubricants may be widely sold in most countries,
providing condoms with lubricants free to key populations removes any barrier that cost
may pose (17, 18). Condoms, both male and female condoms in various sizes, should
be available through multiple outlets that reach all the different key populations and
particularly young people in these populations. Condom promotion campaigns should
increase awareness, promote the acceptability and benefits of condom use and help to
overcome social and personal obstacles to their use (10).
Information and skills-building. Along with promotion and supply, programmes for
key populations should offer information and skills-building in negotiating condom
use (10). In addition, behavioural interventions can encourage consistent condom use. All
condom programmes should address the complex gender, religious and cultural factors
that can impede condom use. Particularly, before introducing condom distribution
programmes in prisons, education and information for both prisoners and prison staff
should be carefully planned (9).
Further reading
• Condom programming for HIV prevention: a manual for service providers. New York, UNFPA,
2005. http://www.unfpa.org/public/global/pid/1291
• Comprehensive condom programming: a guide for resource mobilization and country
programming. New York, UNFPA, 2010. http://www.unfpa.org/webdav/site/global/shared/
documents/publications/2011/CCP.pdf
• WHO, UNFPA, UNAIDS, NSWP, World Bank. Implementing comprehensive HIV/STI
programmes with sex workers: practical approaches from collaborative interventions.
(Chapter 4). Geneva, WHO, 2013. http://www.who.int/hiv/pub/sti/sex_worker_
implementation/en/
• Male latex condom specification, prequalification and guidelines for procurement.
Geneva, WHO, 2010. http://www.who.int/reproductivehealth/publications/family_
planning/9789241599900/en/
• WHO, UNFPA, FHI360. Use and procurement of additional lubricants with male
and female condoms – advisory note. Geneva, WHO, 2012. http://apps.who.int/iris/
bitstream/10665/76580/1/WHO_RHR_12.33_eng.pdf
Chapter 4: Health sector interventions 29
Only the first two interventions, NSP and OST and other drug dependence treatment, are
specific to drug use; they are discussed in this chapter.
A number of other interventions are not included in the comprehensive harm reduction
package because of insufficient evidence of their effectiveness for HIV prevention and
treatment. However, one new recommendation on community distribution of naloxone is
now included and described in detail at the end of this chapter.
Adolescents who inject drugs.1 Adolescents who inject drugs face additional risks
and barriers to services due to multiple legal, developmental and environmental factors.
Adolescents often have less knowledge of safer injecting practices and of services.
In many countries age restrictions and/or parental consent requirements exclude
adolescents from NSP and OST programmes. Adolescents and young people may require
specific and more creative engagement strategies to promote uptake of services.
Engaging parents of adolescents who inject drugs in harm reduction programmes may
help to ensure adequate support to the adolescent. However, it is important to obtain
the adolescent’s consent before involving the parents.
NSPs substantially and cost-effectively reduce HIV transmission among people who
inject drugs (36). NSPs may also reduce transmission of other bloodborne viruses, such
as viral hepatitis B and C, among people who inject drugs (35, 36, 38, 39, 40). At the
same time, needle and syringe programmes do not encourage drug use. There is no
evidence of major unintended negative consequences of NSPs, such as initiation of
1
See also Web Annex 6, briefs on young key populations.
Chapter 4: Health sector interventions 31
injecting among people who have not injected previously or an increase in injecting at
either the individual or societal level (41, 42, 43, 44).
NSPs may serve as an important point of entry to other services. NSPs aim to engage
their clients repeatedly on a regular basis. Thus, they have multiple opportunities
to facilitate access to other health services such as OST and other drug dependence
treatment, HTC, and treatment of HIV, TB and viral hepatitis (45). Also, NSPs may offer
basic health care and address other specific issues that commonly affect people who
inject drugs, such as wound care and overdose prevention. Various models of needle
and syringe distribution and service delivery can be employed, including distribution at
fixed sites such as pharmacies, automatic dispensing machines or vending machines, and
mobile and outreach services (8, 36). Additionally, given the high incarceration rates of
people who inject drugs, access to sterile injecting equipment and NSP are important
components of prison health services (4).
To prevent HIV transmission through injecting drug use, it is crucial to provide not
only information on how to do so, through safer injecting and avoiding sharing
injecting equipment, but also the means to do so, through distribution of free or
low-cost sterile injecting equipment. Needle and syringe programmes also provide
the opportunity for referral to other health and related services, including HTC and
drug-dependence treatment.
All individuals from key populations who inject drugs should have access to
sterile injecting equipment through needle and syringe programmes (strong
recommendation, low quality of evidence) (8, 32, 36, 46).
Additional remarks
• It is suggested that needle and syringe programmes also provide low dead-space
syringes (LDSS) along with information about their preventive advantage over
conventional syringes (39).
• Injecting equipment should be appropriate to the local context, taking into
account such factors as the type and preparation of drugs that are commonly
injected (8, 27).
32 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
TRANSGENDER PEOPLE
Transgender people who inject substances for gender affirmation should use sterile
injecting equipment and practice safe injecting practices to reduce the risk of
infection with bloodborne pathogens such as HIV, hepatitis B and hepatitis C (3).
WHO guidance does not specify age restrictions for needle and syringe programmes.
Implementation considerations
Structural change is needed to create a supportive policy, legal and social environment
that facilitates equitable access to HIV prevention and treatment for all, including NSPs
for people who inject drugs (8).
Advocacy citing public health evidence is often required with various sectors, especially
law enforcement agencies and the local community, to foster an environment that
enables NSPs to function fully (8, 36, 45, 47).
Serving key populations. It is important that NSPs are sensitized to the health
needs of each key population. Key population organizations can either provide these
interventions themselves or have effective referral pathways to services that do (32).
Safe disposal. NSPs should set up systems for safe disposal of injecting equipment
and promote their use (8, 27). There are various models for safe disposal systems,
including distributing puncture-resistant one-way containers. Effective safe disposal
reduces the amount of contaminated equipment in the community, thus reducing reuse
and unintended needle-sticks and limiting negative reactions from the community.
Information provided also can cover opportunities for reducing drug use in the
longer term.
Information and education in prisons and other closed settings. Prisoners and
prison staff should receive information about the programmes and participate in their
design and implementation. Carefully evaluated pilot programmes of prison-based NSPs
may be important to pave the way for ongoing full-scale programmes, but expansion
of programmes should not wait for results from pilot programmes, particularly where
injecting is common in prisons (9).
Further reading
• WHO, UNODC, UNAIDS. Technical guide for countries to set targets for universal access to
HIV prevention, treatment and care for injecting drug users – 2012 revision. Geneva, WHO,
2012. http://www.who.int/hiv/pub/idu/targets_universal_access/en/
• WHO, UNAIDS, UNODC. Guide to starting and managing needle and syringe programmes.
Geneva, WHO, 2007. http://whqlibdoc.who.int/publications/2007/9789241596275_eng.pdf
• Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among
injecting drug users. Geneva, WHO, 2004. http://www.who.int/hiv/pub/idu/e4a-needle/en/
• Best practices for injections and related procedures toolkit. Geneva, WHO, 2010. http://
whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf
Methadone and buprenorphine, both of which are on the WHO list of essential
medicines, are the most commonly used opioid agonists (58). Methadone is a synthetic
34 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
opioid used to treat heroin and other opioid dependence. It reduces opioid withdrawal
symptoms and the euphoric effect when opioids are used. Methadone is taken orally
on a daily basis; it is important to assure that the dose is sufficient (60–120 mg) and is
given for sufficient duration (8, 50). Buprenorphine is a partial agonist; its effectiveness
in treating opioid dependence is similar to that of methadone. It is taken mainly in its
sublingual form (8–24 mg/day). OST programmes should create supportive environments
and relationships to facilitate coordinated treatment of co-morbid mental and physical
health issues and address relevant psychosocial factors (50).
All people from key populations who are dependent on opioids should be offered
opioid substitution therapy in keeping with WHO guidance (strong recommendation,
low quality of evidence) (8, 32, 50), including those in prison and other closed
settings (9).
Additional remarks
• To maximize the safety and effectiveness of OST programmes, policies and
regulations should encourage flexible dosing structures, without restricting dose
levels or duration of treatment (50). Usual methadone maintenance doses should
be in the range of a minimum of 60–120 mg per day, and average buprenorphine
maintenance doses should be at least 8 mg per day (50). Take-home doses can be
offered when the dose and social situation are stable and when there is little risk
of diversion for illegitimate purposes (50). OST is most effective as a maintenance
treatment for longer periods of time (treatment for years may be necessary).
Detoxification or opioid withdrawal (rather than maintenance treatment) results
in poor outcomes in the long term. However, patients should be helped to
withdraw from opioids if it is their informed choice to do so (50).
• OST should be used for the treatment of opioid dependence in pregnancy rather
than attempt opioid detoxification (50, 59).
Chapter 4: Health sector interventions 35
Related recommendations and contextual issues for specific key population groups
TRANSGENDER PEOPLE
WHO guidance does not specify age restrictions for opioid substitution therapy.
36 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Implementation considerations
Documented processes should be established to ensure the safe and legal
procurement, storage, dispensing and dosing of medicines, particularly methadone and
buprenorphine (50).
Take-home doses can be recommended when the dose and social situation are stable
and when there is a low risk of diversion for illegitimate purposes (50).
Further reading
• Guidelines for psychosocially assisted pharmacotherapy for the management of opioid
dependence. Geneva, WHO, 2009. http://www.who.int/hiv/pub/idu/opioid/en/index.html
• Technical guide for countries to set targets for universal access to HIV prevention, treatment
and care for injecting drug users – 2012 revision. Geneva, WHO, 2012. http://www.who.int/
hiv/pub/idu/targets_universal_access/en/
• Operational guidelines for the management of opioid dependence in the South-East Asia
Region. New Delhi, WHO Regional Office for South-East Asia, 2008. http://www.who.int/hiv/
pub/idu/op_guide_opioid_depend/en/index.html
• Guidelines for identification and management of substance use and substance use disorders
in pregnancy. Geneva, WHO, 2014. http://www.who.int/substance_abuse/publications/
pregnancy_guidelines/en/
The available evidence on the impact of other forms of drug dependence treatment on
HIV incidence is less compelling than that for OST (8, 63). Still, these other interventions
are recommended where non-opioid drugs such as amphetamine-type stimulants,
cocaine, sedatives and hypnotics are widely used and also where OST remains
unavailable (8). Drug dependence treatment helps to prevent HIV by reducing injecting
drug use, reducing the sharing of injecting equipment, reducing sexual risk behaviours
and creating opportunities for HIV education and medical care (64).
Detention is not treatment. In a number of countries, people who use or inject drugs
are apprehended and confined to detention centres, ostensibly for the purpose of drug
treatment and rehabilitation but without trial or clinical assessment of dependence,
and clinical treatment outcomes rarely determine the duration of detention. Typically,
these centres lack medical supervision of drug withdrawal, and evidence-based drug
dependence treatment is not offered. Detainees may be forced to engage in unpaid
labour or military-style drills and may be subject to physical punishment. Following
release from these centres, many relapse to drug use, and the risk of overdose may be
increased (65).
Containing the spread of HIV is more successful where there is a comprehensive and
varied range of evidence-based services for drug dependence treatment (62).
All key populations with harmful alcohol or other substance use should have access
to evidence-based interventions, including brief psychosocial interventions involving
assessment, specific feedback and advice (conditional recommendation, very low
quality of evidence) (3, 46).
38 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
Treatment should be provided in the best interests of the adolescent concerned and
in consultation with her or him.
Implementation considerations
Psychosocial interventions should be part of comprehensive treatment for drug
dependence (39, 50).
Further reading
• mhGAP intervention guide for mental, neurological and substance use disorders in non-
specialized health settings. Geneva, WHO, 2011. http://www.who.int/mental_health/
publications/mhGAP_intervention_guide/en/index.htm
• Technical briefs on amphetamine-type substances. Manila, WHO Regional Office for the
Western Pacific, 2011. http://www.who.int/hiv/pub/idu/ats_tech_brief/en/index.html
• Basic principles for treatment and psychosocial support of drug dependent people living
with HIV/ AIDS. Geneva, WHO, 2006. http://www.who.int/substance_abuse/publications/
basic_principles_drug_hiv.pdf
Chapter 4: Health sector interventions 39
While naloxone has long been widely used by medical staff and in health-care facilities,
a number of countries in several regions have recently started community-based
distribution, i.e. allowing distribution and administration by people dependent on
opioids and their peers and family members as well as by first-responders such as police
and emergency services. Greater availability of naloxone through community-based
distribution could help reduce the high rates of opioid overdose, particularly where
access to essential health services is limited for people who inject drugs.
• People likely to witness an opioid overdose should have access to naloxone and
be instructed in its use for emergency management of suspected opioid overdose
(strong recommendation, very low quality of evidence) (69).
• Naloxone is effective when delivered by intramuscular, intranasal, intravenous
and subcutaneous routes. Persons administering naloxone should select the route
based on formulation available, skills in administration, setting and local context
(conditional recommendation, very low quality of evidence) (69).
• In suspected opioid overdose, first-responders should focus on maintaining an
airway, assisting ventilation and giving naloxone (strong recommendation, very
low quality of evidence) (69).
• After successful resuscitation following administration of naloxone, the affected
person’s level of consciousness and breathing should be closely observed –
where possible, until the person has fully recovered (strong recommendation,
very low quality of evidence) (69).
40 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
WHO guidance does not specify age restrictions for overdose management.
Implementation considerations
Legal and policy issues. There may be both legal and policy barriers to the access
and use of naloxone by lay first responders, which may need to be reviewed in order to
implement this recommendation.
Dose. Where possible, efforts should be made to tailor the dose to avoid marked
opioid withdrawal symptoms. The choice of initial dose will depend on formulation and
context, however doses above 0.8mg IM/IV/SC are more likely to precipitate significant
withdrawal symptoms.
Further reading
• Community management of opioid overdose. Geneva, WHO, forthcoming.
• WHO model list of essential medicines, 18th list. Geneva, WHO, 2013. http://www.who.int/
medicines/publications/essentialmedicines/18th_EML_Final_web_8Jul13.pdf
• UNODC, WHO. Discussion paper. Opioid overdose: preventing and reducing opioid
overdose mortality. Vienna, United Nations, 2013. http://www.unodc.org/docs/treatment/
overdose.pdf
Adolescents deserve specific consideration as at this stage the urge to explore and
experiment normally develops ahead of decision-making ability (70). Adolescents’
evolving cognitive abilities are an important consideration in the design of behavioural
interventions for them.
A range of behavioural interventions can provide information and skills that support
risk reduction, prevent HIV transmission and increase uptake of services among all
key populations. There is insufficient evidence to make general recommendations
for all key populations. However, specific behavioural approaches for particular key
population groups have been assessed and can be recommended.
Related recommendations and contextual issues for specific key population groups
• People who inject drugs and relevant community networks should participate in
developing and delivering messages.
• Behavioural interventions for people who inject drugs need to address risk related
to both drug use and sexual behaviour (27).
• For people who inject drugs, peer interventions are particularly effective for the
prevention of HIV and viral hepatitis (39).
• Information and education about safe injecting and overdose prevention are also
important.
SEX WORKERS
TRANSGENDER PEOPLE
The following strategies are recommended to increase safer sexual behaviours and
increase uptake of HIV testing and counselling among transgender people:
• targeted Internet-based information
• social marketing strategies
• sex venue-based outreach (3, 32)
Implementing both individual-level behavioural interventions and community-level
behavioural interventions is suggested (3, 32).
Chapter 4: Health sector interventions 43
Further reading
• Kennedy CE et al. Behavioural interventions for HIV positive prevention in developing
countries: a systematic review and meta-analysis. Bulletin of the World Health Organization,
2010, 88(8):615–623. http://www.who.int/bulletin/volumes/88/8/09-068213/en/
• Prevention and treatment of HIV and other sexually transmitted infections among men who
have sex with men and transgender people. Geneva, WHO, 2011. http://www.who.int/hiv/
pub/guidelines/msm_guidelines2011/en/
Further reading
• Blood donor selection. Guidelines on assessing donor suitability for blood donation. Geneva,
WHO, 2012. http://www.who.int/bloodsafety/publications/bts_guideline_donor_suitability/en
44 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
NEW Among men who have sex with men, PrEP is recommended as an additional
HIV prevention choice within a comprehensive HIV prevention package (strong
recommendation, high quality of evidence) .
Background
The conditional recommendations of 2012 to offer PrEP to men who have sex with men,
transgender people and the HIV-negative partner in serodiscordant relationships in the
context of demonstration projects (74) was reconsidered in 2014 in the light of evolving
evidence. In addition, continuing high rates of HIV incidence are increasingly reported in
men who have sex with men in all regions, despite the availability of current prevention
interventions, suggesting that additional prevention options could be important.
Chapter 4: Health sector interventions 45
The systematic review that provided the evidence base for the 2012 WHO guidelines
on PrEP (74) was updated in January 2014. This review examined the following PICO1
question: “Should oral PrEP (containing tenofovir (TDF)) be used for HIV prevention
among men who have sex with men?”
The review of values and preferences of men who have sex with men about PrEP also
was updated in January 2014, through a review of published literature (see Web Annex 1
for the full report). Also, further values and preference research was undertaken by the
Global Forum on MSM (MSMGF) (Web Annex 3).
Results
Combining results from the 2012 and 2014 searches for the systematic reviews yielded
764 citations and 139 conference abstracts. Following screening and review, four studies
reported in five articles were deemed eligible for inclusion in the review. Of these, one
was a Phase III efficacy trial, while three were smaller pilot feasibility/acceptability or
extended safety studies. Given the differences in the studies’ purposes, drug regimens/
dosing schedule and size/statistical power (and, thus, in imprecision and quality,
according to the GRADE framework), only results from the primary Phase III efficacy trial
were included in the GRADE tables. These are the results presented below. For further
information on the other four studies, see Web Annex 1.
The primary Phase III efficacy trial meeting all inclusion criteria was the iPrEx trial (75).
This was a randomized controlled trial to evaluate the safety and efficacy of once-daily
oral tenofovir-emtricitabine (FTC-TDF) compared with placebo for the prevention of
HIV acquisition among men who have sex with men and among transgender women.
The trial involved 2499 participants in six countries: Brazil, Ecuador, Peru, South Africa,
Thailand and the United States of America. All study participants were born male; 29
(1%) reported their current gender identity as female. The study measured all five key
outcomes for this review: 1) HIV infection, 2) any adverse event, 3) any stage 3 or 4
adverse event, 4) condom use and 5) number of sexual partners.
HIV infection. Oral PrEP was associated with reduced risk of new HIV infection in
both intention-to-treat analysis (HR: 0.53, 95% CI 0.36–0.78, p= 0.001) and modified
intention-to-treat analysis (HR: 0.56, 95% CI 0.37–0.85, p= 0.005).
Adverse events. There were no significant differences in the rates of reported adverse
events between the FTC-TDF and control arms for either any adverse event (RR: 0.99,
95% CI 0.94–1.04) for grade 3 and 4 adverse events (RR: 0.92, 95% CI 0.75–1.13).
Quality of the evidence. The quality of evidence was high for all outcomes, without
serious limitations.
Values and preferences. While the relevant literature has proliferated recently,
the reported values and preferences on PrEP use of men who have sex with men and
transgender people have remained fairly consistent with findings of the systematic
review conducted in 2011.
Globally, awareness of PrEP among men who have sex with men continues to be limited,
although several studies suggest awareness has increased since the release of the iPrEx
1
PICO stands for “patients, intervention, comparison and outcome”.
46 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
results. Willingness to use PrEP varies across studies, but the majority report that 40%
to 70% of respondents are willing to use PrEP.
Main factors that would influence PrEP use include effectiveness, side-effects and
cost. Respondents also mentioned concerns about accessibility, mistrust of health-
care providers, stigma and risk compensation. All studies measuring potential risk
compensation found that at least some participants anticipated changing their sexual
behaviour as a result of PrEP. Providers generally expressed awareness and support
of PrEP, although few had prescribed it. Providers’ concerns included drug resistance,
risk compensation, limited availability of ART (in Peru), poor adherence, lack of local
guidelines and concern that PrEP does not fit well in current (US) models of care, which
do not include frequent, regular clinic visits.
Feasibility. Oral PrEP for men who have sex with men has proved feasible in various
trial settings and acceptability studies (including among young men who have sex with
men). Implementation may prove challenging, however, where access to services and
provision of alternative prevention tools are limited or lacking. Issues of criminalization,
stigma and discrimination, and violence should be considered during implementation,
especially where same-sex behaviour is illegal.
Additional considerations
In formulating the new recommendation, the Guidelines Development Group took into
consideration the overall high quality of the evolving evidence base, with benefits clearly
outweighing harms (see Web Annex 1). In addition, several new studies indicate no
major variability in values and preferences, with men who have sex with men broadly in
support of PrEP.
Data on the cost-effectiveness of PrEP vary widely, depending greatly on drug price. The
Group noted that in low-income countries PrEP is considerably cheaper than in many
middle- and high-income countries.
All men who have sex with men should have the opportunity to choose PrEP if they
feel that it meets their HIV prevention needs. However, the choice is theirs to make.
Men who have sex with men should be offered the full range of evidence-based HIV
prevention options. The decision to use PrEP – and other prevention options – will be an
individual one, based on lifestyle, preferences, sexual behaviour, experience with other
prevention options and the environment, and it should always follow discussion with a
specialized and specifically trained health worker. The decision to use PrEP is likely time-
bound: It is not likely to be for life but rather only for a period when a man feels that he
is at a higher risk of infection.
trust of men who have sex with men. This process should include an assessment at local
levels of:
• sexual and HIV stigma
• stigma associated with receipt of a particular prevention intervention
• provider attitudes and knowledge about the sexual health needs of men who have sex
with men
• availability, accessibility, quality and use of basic HIV services
• knowledge and acceptability of ART-based prevention strategies
• laws that criminalize sex between men
• personal safety and security
• privacy and confidentiality protections
• legal literacy among and legal protections and services for men who have sex with
men and their service providers
• community engagement
• other concerns particular to the location (identified by local staff of community-based
organizations and recipients of services).
• No new recommendation was made for use of oral PrEP for people who inject
drugs.
• The existing recommendation to offer daily oral PrEP as an additional HIV
prevention choice for the negative partner in a serodiscordant relationship
remains relevant for people who inject drugs and are in a serodiscordant
relationship (conditional recommendation, high quality of evidence) (74).
Background
In the scoping meeting of October 2013, the External Steering Group decided that the
use of PrEP for people who inject drugs should be reviewed.
systematic review examined the following PICO question: “Should oral PrEP (containing
tenofovir (TDF)) be used for people who inject drugs?” More detailed information on the
systematic review is available in Web Annex 2.
Results
The search yielded 183 citations and 243 conference abstracts; following screening and
review only one study (with data for PICO outcomes reported in one article and one
conference abstract) was deemed eligible for inclusion in the review – the Bangkok
Tenofovir Study (76, 77). This was a randomized controlled trial to assess whether daily
oral use of tenofovir disoproxil fumarate (tenofovir), compared with placebo, reduces
HIV transmission in injecting drug users. Conducted in Bangkok, Thailand, the trial
recruited 2413 participants from 17 drug treatment clinics. Participants’ ages ranged
from 20 to 59 years (mean=32.4), 80% were male, and 63% reported injecting drugs
in the past 12 weeks. The study measured all seven key outcomes for this review: 1)
HIV infection, 2) any adverse event, 3) any stage 3 or 4 adverse event, 4) condom use,
5) number of sexual partners, 6) injection frequency and 7) needle/syringe sharing.
HIV infection. Oral PrEP was associated with reduced risk of HIV in both intention-to-
treat analysis (HR 0.53, 95% CI 0.36–0.78, p = 0.001) and modified intention-to-treat
analysis (HR: 0.56, 95% CI 0.37–0.85, p = 0.005).
Injection frequency and needle/syringe sharing. Both the TDF and control arms
reported reduced injection behaviour and less injecting with used needles over the
course of the study. There were no significant differences between study arms over time
or at 12-month follow-up (p = 0.520 for injection frequency and p = 0.874 for needle/
syringe sharing).
Condom use and number of sexual partners. Both the TDF and placebo arms
reported increased condom use with live-in partners and reduced numbers of sexual
partners over the course of the study. There was no significant difference between study
arms over time or at 12-month follow-up.
Quality of the evidence. The quality of evidence was moderate for all outcomes based
on one RCT that was downgraded because of risk of bias due to a significant loss to
follow-up (attrition bias).
Values and preferences. The systematic review described above identified one
published study examining acceptability of PrEP and factors likely to influence uptake
among people who inject drugs. This quantitative study involved 128 people in Ukraine.
Most participants said that they would definitely (53%) or probably (32%) use PrEP
if it became available. These results changed little when participants were prompted
on potential side-effects, the need to continue condom use while taking PrEP and the
need for regular HIV testing. Respondents considered route of administration the most
important attribute influencing PrEP uptake; they preferred injections over pills.
and activists from all geographic regions about their values and preferences regarding
PrEP. Those interviewed gave qualified support to PrEP based on its potential usefulness
for some people who inject drugs in countries where other harm reduction options are
not available and that have good ART access. Reticence about PrEP as a useful HIV
prevention option for people who inject drugs was based on perceptions that investment
should be made in other proven interventions that are already available (e.g. NSP, OST
and hepatitis C screening, diagnosis and treatment), that PrEP is “not proven” for people
who inject drugs, and that it is unethical to give PrEP when not all people living with
HIV can get ART for treatment; and on concern about “hidden agendas”. The Guidelines
Development Group concluded: “A recommendation for the use of PrEP as a harm
reduction intervention for people who inject drugs is not supported by the community at
this time.”
Feasibility. Groups of people who inject drugs (78) and some members of the Guidelines
Development Group raised concerns about the operational feasibility of the Bangkok
Tenofovir Study and whether it could be replicated in standard service delivery settings.
In addition, members of the Guidelines Development Group commented that PrEP should
not be seen as a substitute for NSP and other prevention programmes already proven
to reduce the risk of HIV transmission among people who inject drugs. The Guidelines
Development Group also stated that issues of criminalization, stigma and discrimination,
and violence should be considered during implementation, especially where injection
drug use is illegal.
Additional considerations
After reviewing all the available evidence, the Guidelines Development Group concluded
that no recommendation should be made on PrEP for people who inject drugs.
There was uncertainty regarding the benefits versus harms and about resource
utilization and feasibility.
The Guidelines Development Group pointed out that existing acceptable, cost-effective
methods of preventing HIV in people who inject drugs (such as NSP, OST) are not
implemented in many settings. While the Group acknowledged that further effectiveness
and safety studies are unlikely given the positive efficacy shown in the Bangkok trial,
the Group considered that further research is needed into the values and preferences of
injection drug users and to determine the feasibility of implementing PrEP in the context
of these proven prevention strategies. Therefore, the Group concluded, it was premature
to make a recommendation, but a recommendation could be reconsidered when further
information becomes available.
SEX WORKERS
The existing recommendation to offer daily oral PrEP as an additional HIV prevention
choice for the HIV-negative partner in a serodiscordant couple remains relevant
for sex workers who are in serodiscordant couple relationships (conditional
recommendation, high quality of evidence) (74) .
50 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
TRANSGENDER PEOPLE
Where HIV transmission occurs among transgender women who have sex with men
and additional HIV prevention choices for them are needed, daily oral PrEP (specifically
the combination of tenofovir and emtricitabine) may be considered as a possible
additional intervention (conditional recommendation, high quality of evidence) (74).
Implementation considerations
Issues of criminalization, stigma and discrimination, and violence should be considered
during implementation.
Further reading
• Web Annexes 1, 2 and 3.
• Guidance on oral pre-exposure prophylaxis (PrEP) for serodiscordant couples, men and
transgender women who have sex with men at high risk of HIV: recommendations for use
in the context of demonstration projects. Geneva, WHO, 2012. http://apps.who.int/iris/
bitstream/10665/75188/1/9789241503884_eng.pdf
WHO PEP guidelines will be updated in late 2014 for all populations. The current PIPELINE
recommended duration of PEP is 28 days; the first dose should be taken as soon as
possible and within 72 hours after exposure. There has been a progressive trend
favouring the adoption of better tolerated PEP regimens, often composed by once daily
triple ARV drug combinations including nucleotide analogues and heat stable boosted
protease inhibitors. More recently, other alternative drug classes such as non-nucleside
analogues and integrase inhibitors have been considered. The 2014 WHO PEP guidance
will provide updated regimens for adults, adolescents and children.
Despite its short duration, reported completion rates for PEP are low. Therefore,
counselling and other adherence support measures are recommended. PEP should
not be considered 100% effective. It is, therefore, imperative that HIV post-exposure
prophylaxis policies reinforce the importance of primary prevention and risk prevention
counselling in all settings where HIV could be transmitted (79).
Offering pre-exposure prophylaxis after completion of the 28 day PEP course could
be considered for people who present with repeated high risk behaviour or for repeat
courses of PEP.
PEP should be available to all eligible people from key populations on a voluntary
basis after possible exposure to HIV.
52 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
PEP should be made accessible to all people in prisons and other closed settings
who have possibly been exposed to HIV, just as in non-prison settings. Clear
guidelines need to be developed and communicated to prisoners, health-care staff
and other employees (9, 11).
Implementation considerations
An HIV risk assessment and counselling specific to HIV and PEP should be part of the PEP
intervention (79).
Comprehensive ongoing services should be available for people following PEP, including
treatment and care for people who seroconvert (79).
Further reading
• Guidelines on post-exposure prophylaxis (PEP) to prevent HIV infection. Geneva, WHO and
ILO, 2007. http://whqlibdoc.who.int/publications/2007/9789241596374_eng.pdf
• Responding to intimate partner violence and sexual violence against women:
WHO clinical and policy guidelines. Geneva, WHO, 2013. http://apps.who.int/iris/
bitstream/10665/85240/1/9789241548595_eng.pdf
HIV transmission by lowering viral load. This evidence supports early initiation of ART in
individuals, irrespective of CD4 count, for prevention of HIV transmission (4).
Current WHO ARV guidelines recommend initiation of ART regardless of CD4 count
for the HIV-positive partner in serodiscordant couples for HIV prevention and for all
pregnant and breastfeeding women living with HIV (option B+) (4). Early ART initiation
is also recommended for clinical reasons for people coinfected with HIV and hepatitis B
virus with severe hepatic disease and/or active TB.
The 2013 WHO ARV consolidated guidelines recommend initiation of ART at a CD4
count of ≤500 cells/mm3 in all populations, including people from key populations.
WHO will periodically update this guidance and will reconsider this recommendation in
2015. At this time the guidelines group did not re-review the data or consider earlier
or immediate ART for key populations, although some countries are considering or
providing immediate or early ART to key populations for prevention.
The rationale for initiating ART regardless of CD4 count for people in key populations
living with HIV is both operational (to increase access to ART in populations that
currently have low access, poor linkage and high loss to follow-up following diagnosis)
and for the public health benefits of decreasing HIV transmission. More research and
implementation evidence are required to evaluate the posited longer-term individual
health benefits. For its 2015 update WHO will draw on implementation evidence from
pilot studies and programmes currently underway.
ART should be initiated in all individuals with HIV regardless of WHO clinical stage
or CD4 count in the following situations:
• Individuals with HIV and active TB disease (strong recommendation, low quality
of evidence) .
• Individuals coinfected with HIV and hepatitis B virus (HBV) with evidence of
severe chronic liver disease (strong recommendation, low quality of evidence) .
• For programmatic and operational reasons, particularly in generalized epidemics,
all pregnant and breastfeeding women with HIV should initiate ART as lifelong
treatment (conditional recommendation, low quality of evidence) (4).
• Partners with HIV in serodiscordant couples should be offered ART to reduce HIV
transmission to uninfected partners (strong recommendation, high quality of
evidence) (4).
54 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
TRANSGENDER PEOPLE
VMMC is not recommended for HIV prevention among transgender women (3).
Countries with hyperendemic and generalized HIV epidemics and low prevalence of
male circumcision should increase access to male circumcision services as a priority
for adolescents and young men (84).
Implementation considerations
Partial protection. Male circumcision provides only partial protection against female-
to-male HIV infection. Therefore, male circumcision services should not be delivered
in isolation but rather as part of a recommended minimum package that also includes
information about the risks and benefits of the procedure, counselling on safer sex
practices, access to HIV testing, condom promotion and provision, and management of
STIs (84).
56 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Further reading
• Male circumcision for HIV prevention. Geneva, WHO, 2014. http://www.who.int/hiv/topics/
malecircumcision/en/
• Clearinghouse on male circumcision for HIV prevention. Research Triangle Park NC, USA,
FHI360, 2014. http://www.malecircumcision.org/
• New data on male circumcision and HIV prevention: policy and programme implications.
Geneva, WHO, 2007. http://libdoc.who.int/publications/2007/9789241595988_eng.pdf
For key populations, especially those whose behaviour is criminalized, HTC services
are sometimes used in punitive or coercive ways. To the contrary, HTC must always be
voluntary and free from coercion, in particular by health-care providers, partners, family,
clients of sex workers or within a prison or other closed setting (4, 8, 9, 10, 86). Like all
testing and counselling, HTC for key populations needs to emphasize the WHO 5 Cs
of HTC: consent, confidentiality, counselling, correct results and linkage to care (87) –
particularly consent and confidentiality.
Unaware of HIV status. It is estimated that, globally, about half of the people currently
living with HIV do not know their HIV status (88). For people from key populations,
access to HTC and, thus, knowledge of HIV status tend to be much less. People from key
populations often test late and often fail to link from HTC to care and assessment for
ART (88). Thus, many start treatment when already significantly immunocompromised,
Chapter 4: Health sector interventions 57
when poor health outcomes – and, for pregnant women presenting late in antenatal care
or at delivery, vertical HIV transmission – are more likely (4).
Multiple settings. Rapid HIV testing enables health workers to provide clients with
same-day results. Thus, HTC can be offered in a variety of settings, including primary
care clinics (e.g. maternal, neonatal and child health clinics), and by a variety of
providers, including outreach workers.
Community-based testing, linked to prevention, care and treatment, has the potential to
reach greater numbers of people than clinic-based HTC – particularly those unlikely to
go to a facility for testing and those who are asymptomatic (89). It is important to have
clear procedures in place, following national HIV testing strategies and algorithms, to
confirm positive HIV test results and to link clients to treatment and care (9).
Provider-initiated HIV testing and counselling (PITC), where HTC is offered routinely
in health-care settings, aims to increase coverage of HTC. It is recommended so long as
it is not compulsory, is not coercive and is linked to treatment and care, in line with WHO
guidelines. Particular attention should go to providing accurate information; informed
consent must always be obtained; and results should remain confidential.
All forms of HTC should be voluntary and adhere to the five Cs: consent,
confidentiality, counselling, correct test results and connections to care, treatment
and prevention services. Quality assurance of both testing and counselling is
essential to all HTC approaches (4, 90).
• Voluntary HTC should be routinely offered to all key populations in both the
community and clinical settings (3, 4, 8, 10, 86, 91).
• Community-based HIV testing and counselling for key populations, with linkage
to prevention, care and treatment services, is recommended, in addition to
provider-initiated testing and counselling (strong recommendation, low quality of
evidence) (4).
Additional remark
Couples and partners should be offered voluntary HTC with support for mutual
disclosure (92).
58 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
In all epidemic settings accessible and acceptable HTC services must be available
to adolescents and provided in ways that do not put them at risk (86). Countries
are encouraged to examine their current consent policies and consider revising
them to reduce age-related barriers to access and uptake of HTC and to linkages to
prevention, treatment and care following testing (86). Young people should be able
to obtain HTC without required parental or guardian consent or presence.
• HIV testing and counselling, with linkages to prevention, treatment and care, is
recommended for adolescents from key populations in all settings (generalized,
low and concentrated epidemics) (strong recommendation, very low quality of
evidence) (4, 86).
• Adolescents should be counselled about the potential benefits and risks of
disclosure of their HIV status and empowered and supported to determine when,
how and to whom to disclose (conditional recommendation, very low quality of
evidence) (86).
• Children of school age should be told their HIV-positive status (strong
recommendation, low quality of evidence) (86).
Implementation considerations
Rapid tests. Rapid HIV diagnostic tests at point of care greatly facilitate access to
testing, return of same-day results and appropriate referral and follow-up (4).
Prison systems should be an integral part of national efforts to scale up access to HTC.
Scaling up HIV HTC services in prisons should not be undertaken in isolation, but rather
as part of a comprehensive HIV programme aimed at improving health care and achieving
universal access to HIV prevention services in prisons and other closed settings (93).
Couples HTC. There are many potential advantages to supporting couples to test
together and mutually disclose their HIV status; together, they can make informed
decisions about HIV prevention and offer each other support for obtaining and adhering
to ART. HTC for couples or partners should be offered to anyone, regardless of how
they define their relationships. The principle – and the policy – should be that providers
support all people in a sexual relationship to receive testing as a couple or as partners,
irrespective of their sexual orientation or the length or stability of their relationship.
Self-testing for HIV (HIVST) is a process whereby a person who wants to know his or her
HIV status collects a specimen, performs a test and interprets the test result in private.
HIVST is a screening test; it does not provide a diagnosis (96), and so confirmatory
testing is required if the initial result is positive. HIVST may increase the number of
people who test, know their status and, if testing positive, link to treatment. To date,
evidence on this potential is limited, however.
While HIV self-testing kits may have been approved for sale and use, many countries do
not have formal regulations or policies on their use. WHO has not yet issued normative
global guidance on HIVST. However, UNAIDS and WHO have issued a short technical
update to inform stakeholders who are considering or already implementing HIVST (97, 98).
Further reading
• Guidance on provider-initiated HIV testing and counselling in health facilities. Geneva, WHO,
2007. http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf
• UNODC, WHO, UNAIDS. HIV testing and counselling in prisons and other closed settings.
Vienna, UNODC, 2009. http://www.who.int/hiv/pub/idu/tc_prison_tech_paper.pdf
• Delivering HIV test results and messages for re-testing and counselling in adults. Geneva,
WHO, 2010. http://whqlibdoc.who.int/publications/2010/9789241599115_eng.pdf
• Service delivery approaches to HIV testing and counselling: a strategic policy framework.
Geneva, WHO, 2010. http://apps.who.int/iris/bitstream/10665/75206/1/9789241593877_eng.
pdf
• Guidance on couples HIV testing and counselling and antiretroviral therapy for treatment
and prevention in serodiscordant couples. Geneva, WHO, 2012. http://apps.who.int/iris/
bitstream/10665/44646/1/9789241501972_eng.pdf
• Report on the first International Symposium on Self-testing for HIV: the legal, ethical, gender,
human rights and public health implications of HIV self-testing scale-up. Geneva, WHO,
2013. www.who.int/iris/bitstream/10665/85267/1/9789241505628_eng.pdf
• HIV and adolescents: guidance for HIV testing and counselling and care for adolescents
living with HIV: recommendations for a public health approach and considerations
for policy-makers and managers. Geneva, WHO, 2013. http://www.who.int/iris/
bitstream/10665/94334/1/9789241506168_eng.pdf
60 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Health system factors affecting linkage to care include reliance on passive referral as
the only linkage strategy, inadequate staffing, long wait times, poor service offered in
HIV clinics, and poor attitudes of health-care staff.
Key operational issues need to be considered and addressed in order to improve linkage
to care, including better partnerships between community and clinical providers and
increased efforts to improve the quality of services (see Chapter 6).
Updated guidance. The 2013 revision of WHO ART guidelines includes new
recommendations on when to initiate ART, what drug regimens to use for first-line,
second-line and third-line treatment, and how to monitor people on ART. These
guidelines (4) should be consulted for full details on ART management.
Key populations living with HIV should have the same access to ART and care and
the same ART management as other populations.
ART initiation
• As a priority ART should be initiated in all individuals with severe or advanced
HIV clinical disease (WHO clinical stage 3 or 4) and individuals with CD4 counts
of ≤350 cells/mm3 (strong recommendation, moderate quality of evidence) (4).
• ART should be initiated in all individuals with HIV with CD4 counts between 350
and 500 cells/mm3 regardless of WHO clinical stage (strong recommendation,
moderate quality of evidence) (4).
• ART should be initiated in all individuals with HIV, regardless of WHO clinical
stage or CD4 count, in the following situations (4) :
– individuals with HIV and active TB disease (strong recommendation, low quality
of evidence) ;
– individuals co-infected with HIV and HBV with evidence of severe chronic liver
disease (strong recommendation, low quality of evidence) ;
– partners with HIV in serodiscordant couples, to reduce HIV transmission to
uninfected partners (strong recommendation, high quality of evidence) ;
– pregnant and breastfeeding women (strong recommendation, moderate quality
of evidence) .
Additional remark
There are no special clinical ART recommendations specific to any key population.
However, because of stigma, discrimination and marginalization, they frequently
present late for treatment.
62 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
• Current WHO guidance on the use of ART for treatment of HIV infection in adults
and adolescents applies to people living with HIV who inject drugs (4).
• When ART is provided in a supportive environment, people who inject drugs have
treatment outcomes similar to others’ outcomes (115).
Implementation considerations
ART service delivery. The 2013 WHO consolidated ARV guidelines (4) offer a number of
service delivery recommendations, including decentralization of ART care and integrating
ART services into other clinical services such as TB services, ANC and services where OST
is provided.
ART in prisons and other closed settings. HIV treatment, including ART, care and
support, in prisons should be equivalent to that available to people living with HIV in the
community and should be in line with national guidelines.
People who are incarcerated have the additional risk of acquiring TB. However, with
adequate support and structured treatment programmes, excellent outcomes can
be achieved in the prison setting (4, 9). Given the high incarceration rates in key
populations, efforts should be made to ensure that ART (and TB treatment) is available
as part of prison health services (4, 9).
Further reading
• Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV
infection: recommendations for a public health approach. Geneva, WHO, 2013. http://www.
who.int/iris/bitstream/10665/85321/1/9789241505727_eng.pdf
All pregnant women from key populations should have the same access to PMTCT
services and follow the same recommendations as women in other populations.
• All pregnant and breastfeeding women living with HIV should initiate triple
antiretrovirals (ARV), which should be maintained at least for the duration of
risk of mother-to-child transmission. Women meeting treatment eligibility criteria
should continue ART for life (CD4 <500 cells/mm3 ) (strong recommendation,
moderate quality of evidence) (4).
• For programmatic and operational reasons, particularly in generalized epidemics,
all pregnant and breastfeeding women living with HIV should initiate ART and
maintain it as lifelong treatment (option B+) (conditional recommendation, low
quality of evidence) (4).
Related recommendations and contextual issues for specific key population groups
1
This includes pregnant transgender men.
Chapter 4: Health sector interventions 65
All pregnant women and their families affected by substance use disorders should
have access to affordable prevention and treatment services and interventions
delivered with a special attention to confidentiality, national legislation and
international human rights standards; women should not be excluded from health
care because of their substance use (119).
Implementation considerations
Equity and overcoming barriers to access. In most countries women from key
populations have less access to PMTCT than women in the general population. In
particular, people who inject drugs, their partners, and sex workers have less access.
Also, adolescent girls generally and adolescent girls from key populations in particular
have less access to PMTCT interventions and have worse outcomes. Special efforts
should be made to understand and overcome barriers to access and to provide
acceptable services that reach adult and adolescent women from key populations.
Later presentation. Adult and adolescent women from key populations often
present late to antenatal care (ANC) or first present at labour without any ANC, and
consequently they access PMTCT interventions very late. Also, they often face special
challenges to follow-up and ongoing interventions postpartum. This has adverse
consequences for their own health and their infants’, and it decreases the effectiveness
of PMTCT interventions. Strategies need to be developed to promote and support earlier
attendance at ANC by pregnant women from key populations.
Supporting adherence. Special effort and initiatives are needed to optimize access to
care and adherence support for women from key populations and to support effective
linkages to long-term treatment. This is especially true during breastfeeding, a period
when follow-up is often poor.
Further reading
• Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV
infection: recommendations for a public health approach. Geneva, WHO, 2013. http://www.
who.int/iris/bitstream/10665/85321/1/9789241505727_eng.pdf
• Guidelines for the identification and management of substance use and substance use
disorders in pregnancy. Geneva, WHO, 2014. http://apps.who.int/iris/bitstream/
10665/107130/1/9789241548731_eng.pdf
66 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Tuberculosis
WHO TB treatment guidelines review key considerations for managing coinfection with
TB and HIV (120). A key contraindicated drug combination is rifampicin and protease
inhibitors (PIs). When people coinfected with TB and HIV are receiving a boosted PI,
rifabutin may need to be substituted for rifampicin. If rifabutin is not available, only
lopinavir/ritonavir (LPV/r) can be concomitantly used for the duration of TB treatment,
provided the boosting dose of ritonavir is increased or double the standard dose of LPV/r
is used.
Hepatitis C
Ribavirin and pegylated interferon alpha-2a are often used to treat chronic hepatitis C
virus (HCV) infection. Administration of these agents along with zidovudine (AZT) has
been associated with increased risk of anaemia and hepatic decompensation. People
co-infected with HCV and HIV and receiving AZT may need to be switched to tenofovir
(TDF) (121).
Hormones used in cross-hormonal treatment protocols for transgender women and men
There are limited data on the interactions between ARVs and a variety of other drugs
used in cross-hormonal treatment protocols for transgender women, particularly with
Chapter 4: Health sector interventions 67
anti-androgens (e.g. cyproterone acetate, flutamide). The same is true for androgens
(e.g. dihydrotestosterone) commonly used by transgender men. Currently, there are
no documented drug interactions between these medications and ARVs. However,
this issue deserves more research, as transgender women and men often use several
drugs combined and sometimes at high doses, with potential for multidirectional
drug interactions. Meanwhile, as ARV treatment may lead to hormonal fluctuations
among transgender women taking gender-affirming medications, close monitoring is
recommended.
In addition, some ARV drugs may potentiate glucose and lipid metabolic abnormalities
associated with alterations in hormone levels as well as increase the risk of thrombotic
events and hepatic toxicity (123). All these risks are further increased by the frequent
practice of self-medication, which often involves products and doses that are less safe than
those typically prescribed by health workers. More research in these areas also is needed.
Opioids
WHO recommends methadone and buprenorphine to treat opioid dependence (50).
Co-administering efavirenz (EFV) decreases methadone concentrations. This could
subsequently cause withdrawal symptoms and increase the risk of relapse to opioid
use. People receiving methadone and EFV should be monitored closely, and those
experiencing opioid withdrawal may need to adjust their methadone dose (50).
The limited evidence suggests no interactions between ARVs and recreational drugs.
There can be dangerous interactions between recreational drugs, however. For
example, concomitant amyl nitrite (“poppers”) and sildenafil may cause cardiovascular
complications.
1
If rifabutin is not available, only LPV/r can be used, provided the boosting dose of ritonavir is increased or double the standard dose of
LPV/r is used.
68 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Further reading
• HIV-drug interactions. The University of Liverpool. http://www.hiv-druginteractions.org/
4.5.1 Tuberculosis
Background and rationale
Despite being preventable and curable, TB is
Tuberculosis is preventable and the leading cause of HIV-associated mortality,
treatable, but it accounts for one accounting for one of every five HIV-related deaths.
in every five HIV-related deaths. The risk of developing TB is 30 times higher among
people living with HIV than among people who
do not have HIV infection (124). In 2012 there were an estimated 1.1 million cases of TB
among the 35 million people living with HIV worldwide (124). Independent of their HIV
status, key populations, in particular people who inject drugs and prisoners, have an
increased risk of TB, including multidrug-resistant TB (MDR-TB) (50, 125, 126, 127, 128).
In addition, outbreaks of TB and MDR-TB have been reported among men who have
sex with men and transgender sex workers (129, 130). Common risk factors and social
determinants that put key populations at increased risk of TB include HIV infection,
poverty, malnutrition, stress, alcoholism, smoking, diabetes, indoor air pollution, drug
use, incarceration and poor living and working conditions (131).
Prisons play a key role in fuelling the epidemic of TB and MDR-TB, and TB is believed
to be the leading cause of death among prisoners in high burden settings (132, 133).
Similarly, other congregate settings frequently attended by people living with HIV and
marginalized groups can expose them to increased risk of TB if adequate TB infection
control measures are not in place. Such settings could include brothels, bars, drop-in
centres, drug treatment centres, health facilities and shelters (130, 134, 135, 136).
To address TB among people living with HIV, including key populations, WHO
recommends a 12-point package of collaborative TB/HIV activities. The package seeks to
establish and strengthen mechanisms for delivering integrated TB and HIV services, to
reduce the burden of TB among those living with HIV, and to reduce the burden of HIV in
TB patients (4, 65, 137, 138, 139).
Chapter 4: Health sector interventions 69
Barriers to prevention and care for key populations need to be addressed to ensure
access to integrated, client-centred services, preferably at the initial point of care, and to
encourage treatment adherence (65).
Prevention of TB. Isoniazid preventive therapy (IPT) and ART, given together, can
reduce the risk of TB among people living with HIV by up to 97% (140). Alone, IPT has
been shown to reduce the risk of TB among people living with HIV by 68% (137). Once
active TB is ruled out, people living with HIV should be offered at least six months, IPT
and support should be provided to ensure adherence. Also, appropriate TB infection
control measures and contact tracing are essential to reduce transmission of TB in
congregate settings (50, 125).
Screening and diagnosis of TB. All people living with HIV should be screened
regularly with the WHO-recommended four TB symptom screening algorithm – that is,
a current cough, fever, night sweats or weight loss – at each contact with a health-care
worker (137). This screening helps determine eligibility for IPT by ruling out the likelihood
of active TB and to identify those who need further evaluation, diagnosis and treatment
for TB as necessary. WHO recommends using Xpert MTB/RIF as the first diagnostic test
for all TB in all people living with HIV and for anyone suspected of MDR-TB (irrespective
of HIV status) (141). Stakeholders providing support to key populations can offer
gateways to early TB detection and timely prevention and treatment of both TB and HIV.
It is crucial, therefore, that personnel are aware of the symptoms of TB.
Timely initiation of ART significantly reduces the risk of mortality from HIV-associated
TB. As TB is one of the most common AIDS-defining illnesses, all those with presumptive
or diagnosed TB should be offered HIV testing and counselling as a priority so that those
testing positive can start ART as soon as possible, in any case no later than eight weeks
after initiation of TB treatment, regardless of CD4 count.
Key populations should have the same access to TB prevention, screening and
treatment services as other populations at risk of or living with HIV (138).
70 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
• Routine HIV testing should be offered to all people with presumptive and
diagnosed TB (strong recommendation, low quality of evidence) (138).
• ART should be initiated in all individuals with HIV and active TB disease
regardless of WHO clinical stage or CD4 cell count (strong recommendation, low
quality of evidence) (4).
Additional remark
• ART should be initiated as soon as possible, no later than eight weeks after
initiation of TB treatment (4).
• Alcohol dependence, active drug use and mental health disorders should not be
used as reasons to withhold TB treatment (65).
Related recommendations and contextual issues for specific key population groups
• People with TB who inject drugs should have equitable access to TB treatment
(50).
• Co-morbidity, including viral hepatitis infection, should not contraindicate TB
treatment for people who inject drugs and should be properly managed (65).
• For patients with TB, OST should be administered in conjunction with medical
treatment; there is no need to wait for abstinence from opioids to commence
either anti-TB medication or antiretroviral medication (50).
• Rifampicin, one of the first-line drugs used to treat TB, can significantly reduce
the concentration and effect of both methadone and buprenorphine, resulting in
opioid withdrawal (142, 143, 144). See Section 4.4.3.
SEX WORKERS
Clinical programmes or community outreach services for sex workers can carry
out TB screening and can support sex workers throughout the cycle of care, from
TB prevention through diagnosis and treatment. They can teach sex workers to
recognize TB symptoms and understand TB transmission, as well as to appreciate
the importance of infection control and cough etiquette. They also can inform their
clients of nearby health facilities for TB diagnosis and treatment (71).
Implementation considerations
Collaboration. TB and HIV programmes, social services, drug treatment services and
prison health services should collaborate in referrals and services for people from key
populations to ensure access to comprehensive TB and HIV prevention, treatment and
care in a holistic, person-centred way – in one setting if possible – that maximizes
access and adherence (65).
TB infection control. Every health-care and other congregate setting should have a
TB infection control plan (preferably included in the general infection control plan),
supported by all stakeholders, that includes administrative, environmental and personal
protection measures to reduce transmission of TB and surveillance of TB among workers
(65).
Further reading
• WHO, UNODC, UNAIDS. Policy guidelines for collaborative TB and HIV services for injecting
and other drug users – an integrated approach. Geneva, WHO, 2008.
http://whqlibdoc.who.int/publications/2008/9789241596930_eng.pdf
• WHO policy on collaborative TB/HIV activities: guidelines for national programmes and other
stakeholders. Geneva, WHO, 2012.
http://whqlibdoc.who.int/publications/2012/9789241503006_eng.pdf
• Guidelines for intensified tuberculosis case finding and isoniazid preventive therapy for
people living with HIV in resource-constrained settings. Geneva, WHO, 2011.
http://whqlibdoc.who.int/publications/2011/9789241500708_eng.pdf
HCV seroprevalence rates in prisons are even higher than HIV rates, and in many
countries a history of HCV infection is associated with a history of incarceration (146, 147,
148, 149, 150).
1
Hepatitis B, Fact sheet N° 204 Geneva, WHO, 2014. http://www.who.int/mediacentre/factsheets/fs204/en/
2
Hepatitis C, Fact sheet N°164 Geneva, WHO, 2014. http://www.who.int/mediacentre/factsheets/fs164/en/
Chapter 4: Health sector interventions 73
Because modes of transmission for viral hepatitis overlap those for HIV, many
interventions that prevent HIV also prevent HBV and HCV. Examples include correct
and consistent condom use, needle and syringe programmes, OST and sterile tattooing
practices.
Hepatitis B vaccine
HBV vaccine is safe, effective and fairly inexpensive. Most countries have both targeted
and population-wide HBV vaccination programmes, including infant, catch-up and risk-
group vaccination. Risk groups include people who inject drugs, men who have sex with
men, sexual partners of people living with HIV, prisoners, and others such as recipients
of blood products and health-care workers. By 2012, 181 countries had incorporated
HBV vaccination into their national schedule as an integral part of national infant
immunization (155). An estimated 79% of the 2012 birth cohort globally received three
doses of the HBV vaccine (156). The implication of national HBV vaccination programmes
is that HBV vaccination of high-risk groups will become less crucial over time as,
increasingly, people are immunized in infancy and thus protected (39).
There is currently no vaccine for HCV. Hence, there is an even greater need to intensify
current efforts to prevent HCV transmission among key populations (39).
Key populations should have the same access to hepatitis B and C prevention,
screening and treatment services as other populations at risk of or living with HIV.
74 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Hepatitis B
• Catch-up hepatitis B immunization strategies should be instituted in settings
where infant immunization has not reached full coverage (3, 10, 32).
• People from key populations with HIV and HBV coinfection who have severe
chronic liver disease should be offered ART with a tenofovir (TDF) and lamivudine
(3TC) (or emtricitabine (FTC))-based regimen irrespective of CD4 count or WHO
clinical stage (strong recommendation, low quality of evidence) (4).1
Hepatitis C
• HCV serology testing should be offered to individuals from populations with high
HCV prevalence or who have a personal history of HCV risk exposure/behaviour
(strong recommendation, moderate quality of evidence) (158).
• An alcohol intake assessment is recommended for all persons with HCV infection,
followed by the offer of a behavioural alcohol reduction intervention for persons
with moderate-to-high alcohol intake (strong recommendation, moderate quality
of evidence) (158).
• Assessment for antiviral treatment of all adults and children with chronic
HCV infection is recommended, including for people who inject drugs (strong
recommendation, moderate quality of evidence) (158).
• In addition, a number of recommendations on diagnosis and antiviral treatment
regimens for HCV are available (158).
Additional remarks
PIPELINE • WHO is developing clinical guidance on hepatitis B treatment and screening
strategies for hepatitis B and C. This guidance should be available in early 2015.
• WHO HCV guidelines provide detailed guidance on treatment and care (158).
• There are challenges in diagnosing and treating active HCV infection in certain
populations such as people who inject drugs, particularly in settings with limited
access to HCV antibody and RNA assays, diagnostic tools for staging of liver
disease and HCV therapy. People receiving ART and HCV drugs require close
monitoring for possible drug interactions (158, 159).
1
There is insufficient evidence or favourable risk-benefit profile to support initiating ART in everyone coinfected with HIV and HBV with
a CD4 count >500 cells/mm3 or regardless of CD4 cell count or WHO clinical stage. Initiating ART regardless of CD4 count is, therefore,
recommended only for people with evidence of severe chronic liver disease, who are those at greatest risk of progression and mortality
from liver disease. For people without evidence of severe chronic liver disease, ART initiation should follow the same principles and
recommendations as for other adults.
Chapter 4: Health sector interventions 75
Related recommendations and contextual issues for specific key population groups
Implementation considerations
Lost opportunities. Opportunities to vaccinate people who inject drugs often may
be lost because of their poor access or reluctance to be vaccinated (160). Providing
incentives to people who inject drugs and offering convenient access may increase
uptake and completion of the HBV vaccination schedule (87, 152). Even partial
immunization confers some immunoprotection, however (89). The decision whether to
offer incentives depends on local acceptability and resources (161).
1
The standard vaccination schedule for infants and unvaccinated adults is 0, 1, and 6 months, while the rapid schedule is 1, 7 and 21 days
(39).
76 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Further reading
• Hepatitis B, Fact sheet N° 204. Geneva, WHO, 2014. http://www.who.int/mediacentre/
factsheets/fs204/en/
• Hepatitis C, Fact sheet N°164. Geneva, WHO, 2014. http://www.who.int/mediacentre/
factsheets/fs164/en/
• Guidelines for the screening, care and treatment of persons with hepatitis C infection.
Geneva, WHO, 2014. http://apps.who.int/iris/bitstream/10665/111747/1/9789241548755_
eng.pdf
• Guidance on prevention of viral hepatitis B and C among people who inject drugs. Geneva,
WHO, 2012. http://www.who.int/iris/bitstream/10665/75357/1/9789241504041_eng.pdf
Studies suggest that mental health disorders in people living with HIV may interfere
with treatment initiation and adherence and lead to poor treatment outcomes (162).
The presence of mental health co-morbidities may affect adherence to ART, due to
forgetfulness or poor organization, motivation or understanding of treatment plans.
Psychosocial support, counselling, appropriate drug therapies, and interventions such
as case management may help to improve adherence to ART and retention in care (4).
The WHO Mental Health Gap Action Programme (mhGAP) intervention guide for
mental, neurological and substance use issues in non-specialized health settings makes
recommendations related to general mental health care that can be relevant to people
living with HIV, including those from key populations (4, 46).
Chapter 4: Health sector interventions 77
Related recommendations and contextual issues for specific key population groups
Peer support groups and safe spaces can help improve self-esteem and address
self-stigma. Additionally, individual and family counselling can address adolescents’
mental health co-morbidities. The involvement of supportive parents or guardians
can be beneficial, especially for those requiring ongoing treatment and care. It is
important, however, to have the adolescent’s express permission before contacting
parents or care-givers (86).
Implementation considerations
Integrated and comprehensive services provide the opportunity for patient-centred
prevention, care and treatment for the multiple emotional and mental health issues
affecting key populations. In addition, integrated services enhance the likelihood of
improved communication among, and thus of better care by, the different service
providers working with key populations (39).
Further reading
• mhGAP intervention guide for mental, neurological and substance use disorders in non-
specialized health settings. Geneva, WHO, 2011. http://www.who.int/mental_health/
publications/mhGAP_intervention_guide/en/
78 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
4.6.1 Nutrition
Background and rationale
Low energy intake combined with increased
Collaboration between HIV energy demand because of HIV infection and
programmes and existing national related infections or conditions often leads to
programmes for nutritional HIV-related weight loss and wasting. In addition,
support is necessary and feasible. an altered metabolism, reduced appetite, and
diarrhoeal diseases may lower nutrient intake
and absorption and so can also contribute to nutrient losses (164). These effects may
be magnified in low-income and food-insecure contexts, such as those experienced
by many key populations. In turn, poor nutritional status can hasten the progression
of HIV disease; low body mass index (BMI) in adults (BMI less than 18.5 kg/m2) is an
independent risk factor for HIV disease progression and mortality (4).
PIPELINE WHO is currently developing recommendations for nutritional care and support of
adolescents and adults living with HIV.
Inadequate nutrition is a major problem for many people in prisons and can have
a significant impact on people with HIV or TB, jeopardizing treatment outcomes
and adherence. Protecting and promoting the health of people in prisons and other
closed settings should include provision of adequate nutrition, including access to
safe drinking water and nutritional supplements (11).
STIs, but also other reproductive health issues. Health-care providers, however, often
overlook the sexual and reproductive health of people living with HIV.
In both men and women, STIs, particularly those involving genital ulcers, increase
susceptibility to HIV infection. Also, acute STIs are an important marker for unsafe
sexual behaviour and risk of HIV transmission. Men who have sex with men, sex workers
and transgender people are often at increased risk of STIs.
Thus, it is important to offer clinical management of STIs to people from key populations
who present with STIs, in keeping with existing WHO guidance (138). In the absence of
laboratory tests, syndromic management can be used. Testing and treatment should
always be voluntary and free from coercion. Because the majority of STI cases are
asymptomatic, particularly in women, STI screening programmes should be made
available to key population groups.
Full updating of WHO STI guidelines is underway and should be completed by the end of PIPELINE
2014.
Related recommendations and contextual issues for specific key population groups
Health-care providers need to be alert to provide STI control and management for
people who inject drugs. People who inject drugs may also engage in sex work, and
men who inject drugs may have sex with other men, and thus they face higher STI
risks (153, 167).
SEX WORKERS
TRANSGENDER PEOPLE
Implementation considerations
Possible strategies to increase STI screening and treatment rates include the
following (3) :
• Mainstream STI treatment services should be accessible and responsive to the needs
of key populations.
• In settings where key populations are largely marginalized, specific and targeted
services should be considered, including outreach and peer support.
• Active referral pathways should be established, and screening and testing
programmes should be integrated with other services used by key populations.
• STI diagnosis and treatment services should be co-located with HIV services used by
key populations.
Prisons and other closed settings should provide STI testing and related treatment
that are voluntary, confidential and ensure the informed consent of the patient. If
Chapter 4: Health sector interventions 81
adequate care cannot be provided in prisons, detainees should be able to obtain health
services in the community (11).
Further reading
• Guidelines for the management of sexually transmitted infections. Geneva, WHO, 2004.
http://www.who.int/hiv/pub/sti/pub6/en/
• Training modules for the syndromic management of sexually transmitted infections. Geneva,
WHO, 2007. http://www.who.int/reproductivehealth/publications/rtis/9789241593407/en/
index.html
• WHO, UNFPA, UNAIDS, NSWP, World Bank. Implementing comprehensive HIV/STI
programmes with sex workers: practical approaches from collaborative interventions.
Geneva, WHO, 2013. http://www.who.int/hiv/pub/sti/sex_worker_implementation/en/
Members of key populations, including people living with HIV, should be able to
experience full, pleasurable sex lives and have access to a range of reproductive
options (32, 122).
It is important that contraceptive services are free, voluntary and non-coercive for
all people from key populations.
82 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Related recommendations and contextual issues for specific key population groups
It is important that health-care providers in contact with women who use drugs
offer contraception, including hormonal contraceptives, as part of a standard
package of care.
SEX WORKERS
Women at higher risk of HIV, including sex workers, initiating or using hormonal
contraceptives should be strongly advised always to use condoms, male or female,
and other HIV prevention measures because of evidence, albeit inconclusive, of
possibly increased risk of HIV acquisition among women using progestogen-only
injectable contraception (4, 168).
Additional remarks
Female sex workers should be offered contraceptive counselling to explore
pregnancy intention and offered a range of contraceptive options including dual
protection.
TRANSGENDER PEOPLE
Further reading
• Ensuring human rights in the provision of contraceptive information and services:
guidance and recommendations. Geneva, WHO, 2014. http://apps.who.int/iris/
bitstream/10665/102539/1/9789241506748_eng.pdf
• Medical eligibility criteria for contraceptive use: fourth edition. Geneva, WHO, 2010. http://
whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf. Currently updating, next
edition 2015.
Abortion laws and services should protect the health and human rights of all
women, including those from key populations.
Related recommendations and contextual issues for specific key population groups
Adolescents may be deterred from accessing health services if they think they will be
required to obtain permission from their parents or guardians; this can increase the
likelihood that they will go to providers of unsafe abortion (174).
Implementation consideration
Safe abortion services. To the full extent permitted by law, safe abortion services
should be readily available and affordable to all. This means services should be available
at the primary care level, with referral systems in place for all required higher-level care.
Further reading
• Safe abortion: technical and policy guidance for health systems. Geneva, WHO 2012 http://
www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en/
It is important to offer cervical screening to all women from key populations, and
to transgender men where appropriate, as indicated in the WHO 2013 cervical
screening guidelines (178).
Related recommendations and contextual issues for specific key population groups
It is important in areas with high rates of endemic HIV infection to offer cervical
cancer screening to sexually active girls and women as soon as they have tested
positive for HIV (178).
Chapter 4: Health sector interventions 85
TRANSGENDER PEOPLE
• HPV vaccination does not replace cervical cancer screening. In countries where
the HPV vaccine is introduced, screening programmes may need to be developed
or strengthened (179).
• The WHO recommended target group for HPV vaccination is girls ages 9–13 years
who have not yet become sexually active, including those living with HIV (179).
Further reading
• WHO guidelines for screening and treatment of precancerous lesions for cervical cancer
prevention. Geneva, WHO, 2013. http://www.who.int/reproductivehealth/publications/
cancers/screening_and_treatment_of_precancerous_lesions/en/
86 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
It is important that all women from key populations have the same support and
access to services related to conception and pregnancy care as women from other
groups, as indicated by WHO guidelines.
Related recommendations and contextual issues for specific key population groups
• All adult and adolescent women from key populations who are living with HIV
and are pregnant should receive appropriate HIV treatment and care, in line with
WHO guidance, to prevent HIV transmission from mother to child (4).
• Women living with HIV and those in serodiscordant couples who wish to have
children should be provided information and support to help them to conceive as
safely as possible.
• Many women from key populations, in particular adolescents, have inadequate
access to antenatal care, attend late in pregnancy and have less access to PMTCT
services (see Section 4.4.2).
CRITICAL ENABLERS
5
5.1 Law and policy 90
5.1.1 Legal barriers 90
5.1.2 Critical enablers 90
5 CRITICAL ENABLERS
HIV epidemics, particularly among key populations, continue to be fuelled by stigma and
discrimination, gender inequality, violence, lack of community empowerment, violations
of human rights, and laws and policies criminalizing drug use and diverse forms of
gender identity and sexuality. These socio-structural factors limit access to HIV services,
constrain how these services are delivered and diminish their effectiveness.
Thus, it is important to understand the varied political, geographic and social contexts
in which key populations live and where HIV services for them are delivered. It also
needs to be recognized that each key population group is heterogeneous, and effective
programmes must account for this diversity.
Integrating HIV and related health services into primary health care can contribute to
increased and more equitable access to HIV services for key populations. To increase the
effectiveness of HIV services in primary health care, health-care providers will benefit
from understanding gender identity and the diversity of sexual behaviours and identities,
as well as drug use and dependence, and how to address these when providing services.
The health sector can take action to change the attitudes and behaviours of health-care
providers to reduce stigma and discrimination, particularly that relating to homophobia,
transphobia, sex work and drug use. Health-care workers should be given the necessary
resources, training and support to provide services to key populations. At the same
time, health-care providers should be held accountable when they fail to meet standards
based on professional ethics and internationally agreed human rights principles (1).
Monitoring and evaluation is important to ensure not only technical quality and impact
of services but also the spirit in which they are provided and, thus, their acceptability to
people from key populations.
The barriers and critical enablers outlined in this chapter apply to both adults and
adolescents in key populations. For adolescents from key populations, these factors may
be further exacerbated by their rapid physical and mental development and complex
psychosocial and socioeconomic vulnerabilities. Also, adolescents from key populations
experience socio-structural barriers to services, notably policy and legal barriers related to
age of consent. Those close to people from key populations, including partners and children,
also can experience stigma and discrimination and so face the same difficulties in access to
services. Thus, including dependents in the provision of HIV services can be important.
Additionally, transgender people are legally unrecognized in many countries (5) and
face restrictive policies toward their gender expression. In many settings punitive
policies on drug use call for harsh penalties for the possession of small amounts of
drugs for personal use, and in some settings policies mandate compulsory detention as
“treatment” for people who use or inject drugs (5). In many prisons and other closed
settings, HIV services are sub-standard or entirely lacking (6).
While laws vary, in many settings adolescents under 18 years of age are classified legally
as minors and, therefore, must have parental consent for medical care, including HIV-
related services. Such laws and policies can be barriers to or can discourage adolescents
from seeking services (7). These restrictions may create complex dilemmas for providers
who endeavour to act in the best interest of their clients but who may have concerns
about their own legal liability as well as for the safety of their young clients.
Laws, legal policies and practices should be reviewed and, where necessary,
revised by policy-makers and government leaders, with meaningful engagement of
stakeholders from key population groups, to allow and support increased access to
services for key populations (10, 11, 13).
Countries should work toward developing policies and laws that decriminalize same-
sex behaviours (11).
• Countries should work toward developing policies and laws that decriminalize
injection and other use of drugs and, thereby, reduce incarceration.
• Countries should work toward developing policies and laws that decriminalize the
use of clean needles and syringes (and that permit NSPs) and that legalize OST
for people who are opioid-dependent.
• Countries should ban compulsory treatment for people who use and/or inject
drugs (12, 13, 14).
SEX WORKERS
TRANSGENDER PEOPLE
• Countries should work toward developing policies and laws that decriminalize
same-sex behaviours and nonconforming gender identities.
• Countries should work towards legal recognition for transgender people (11).
• Countries are encouraged to examine their current consent policies and consider
revising them to reduce age-related barriers to HIV services and to empower
providers to act in the best interest of the adolescent (7).
• It is recommended that sexual and reproductive health services, including
contraceptive information and services, be provided for adolescents without
mandatory parental and guardian authorization/notification (15).
Recognize transgender people in the law. For transgender people the legal
recognition of preferred gender and name may be important to reduce stigma,
discrimination and ignorance about gender variance. Such recognition by health services
can support better access, uptake and provision of HIV services (11).
Improve access to justice and legal support for key populations. Policies that
criminalize and punish the behaviour of key populations constrain people from obtaining
justice and legal services. Policies and procedures are needed to ensure that individuals
from key populations can report rights violations such as discrimination, gender-based
violence, issues with policing, violations of informed consent, violations of medical
confidentiality and denial of health-care services. Reporting options beyond going to
the police will encourage reporting of human rights violations. For example, persons
from key populations can be trained as paralegals; an organization that works with key
populations can serve as a third-party reporter of complaints.
Additionally, countries can review laws that penalize health-care providers for working
with key populations (e.g. laws that make it illegal for outreach workers to carry
condoms or clean needles and syringes for distribution).
Law enforcement can play an important role by ensuring that the human rights of key
populations are not violated. Police should receive continual training on ways to support
– or at least not to impede – key populations’ access to essential health services,
including not arresting people leaving drug treatment clinics; avoiding confiscation of
drug treatment medication; avoiding surveillance of harm reduction centres; and not
using possession of clean needles or condoms to justify arrest. Systems to promote good
policing practices and to provide safe avenues for reporting human rights violations will
help ensure that police are protecting both the public health and the human rights of all
persons. Ensuring that medical records are kept confidential is one step that health-care
providers can take to increase trust between health services and key populations.
SEX WORKERS
• The police practice of using possession of condoms as evidence of sex work and
grounds to arrest sex workers should be eliminated (10).
• The wide latitude of the police to arrest and detain sex workers without cause,
including police extortion, should be eliminated (10).
TRANSGENDER PEOPLE
• Countries should work towards legal recognition for transgender people (11).
5.2.1 Barriers
People from key populations are often particularly subjected to stigma, discrimination
and negative attitudes related to their behaviour – and doubly so if also living with HIV
– by their families, communities and health workers. Such stigma is common in many
health facilities and law enforcement services. It may seem to be tacitly endorsed by
the lack of national laws and policies against discrimination. The effects of such HIV-
related stigma and discrimination against key populations can be delayed HIV testing,
concealment of positive serostatus, and poor uptake of HIV services (21, 22, 23, 24, 25).
It can undermine the efforts of national health programmes to effectively link people to
HIV care and to engage and retain them in long-term care (26, 27).
Within the health sector stigma and discrimination can take many forms at the individual
and systems levels. The lack of training and educational programmes to inform health
workers of the needs, health issues and strategies and interventions for key populations
contributes to marginalization. It leaves providers ill-equipped to address health needs
and perpetuates stigmatizing and discriminating practices, even to the point of refusing
services.
Skills. It is important that health workers be able to respond to the specific needs of key
populations and provide quality services, know what interventions, tools and materials
are available to provide information, can advise on HIV risk reduction strategies, and
know how to support treatment adherence and retention in care (20).
Health services should be made available, accessible and acceptable to people from
key populations, based on the principles of medical ethics, avoidance of stigma,
non-discrimination and the right to health (3, 7, 10, 11, 12, 13, 15).
Case study: In South Africa expanding competence to serve men who have
sex with men
Health4Men, Anova Health Institute
www.anovahealth.co.za
The Health4Men project addresses men’s diverse sexual health needs, particularly those of
vulnerable and marginalized groups including men who have sex with men. The project’s goal is
to institutionalize competence in serving men who have sex with men in existing public clinics.
The process involves:
• sensitization, to change attitudes
• medical training, to expand knowledge
• mentoring, to translate knowledge into skill
• on-going technical support including consultation, training and mentoring and provision of
educational materials.
Under the leadership of the Anova Health Institute, Health4Men has developed two MSM Centres of
Excellence, in Cape Town and Johannesburg, each supported by satellite clinics. The clinics provide
services for men who have sex with men, while outreach activities stimulate demand for services.
Health4Men has developed innovative training content and materials to equip nurses,
counsellors and medical officers to respond to the special needs of men who have sex with men
in a sensitive and empathic manner. In partnership with provincial departments of health, the
project establishes at least one Regional Leadership Site in each province to serve as the hub
for competency development; nurse mentors and outreach teams operate from these sites. As of
mid-2014, over 3000 health workers have been trained, 584 clinicians have been mentored and
64 clinics in four provinces have been declared medically competent to serve men who have sex
with men. By the end of 2014, there will be over 120 competent sites across six provinces and,
by the end of 2015, over 160 sites nationally.
100 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
5.3.1 Barriers
Key populations often have little or no control over HIV risk factors driven by the legal,
political and social environment and the context of their lives. For instance, sex workers
are frequently exposed to HIV and other STIs, but they may not have the power to
negotiate consistent condom use (30, 31). This lack of control is exacerbated if people
are unaware of available HIV-related services and of their legal and human rights,
specifically their right to health, and what to do if these rights are violated.
In particular, few young people from key populations receive adequate information and
education for their sexual lives. Instead, they receive conflicting or confusing messages
about gender and sexuality. This leaves young people vulnerable to coercion, abuse
and exploitation and to unintended pregnancy and STIs, including HIV (18). The lack of
community empowerment, too, and of community-wide awareness and knowledge limits
the overall effectiveness of interventions to reduce HIV risk (10, 20).
service agencies, facilitating interaction with the communities of key populations, and
managing services. In fact, they may have special strengths in providing community-
based and outreach services.
Case study: Building health literacy among young injecting drug users in
Mexico
Programa de Política de Drogas (Espolea, A.C), Mexico
http://www.espolea.org/
Espolea, a youth-led organization in Mexico City, opened its Drug Policy and Harm Reduction
Programme in 2008 and has since developed online and face-to-face channels to provide
objective information about drugs and risk reduction to young people ages 15–29 years.
The organization has found that information is most effective when disseminated at places
where young people use drugs, particularly electronic dance music festivals, rock concerts and
cultural gatherings. At these events Espolea sets up a stand as a safe space for young people to
obtain information about drugs that may be being consumed. The organization also facilitates
workshops in schools and in communities with concentrations of most-at-risk young people.
Espolea has an active outreach strategy, using social media, including Facebook and Twitter as well
as Internet blogs. One blog – www.universodelasdrogas.org – serves as a databank on drugs and
has become the axis of the programme’s harm reduction campaign. Staff members, collaborators,
and young people produce the information. Printed materials offer facts and recommendations
about nightlife, alcohol consumption, risky sexual behaviours, HIV and other STIs.
Fig. 5.2 Key elements of community empowerment among sex workers (20)
While this figure refers to sex workers, these community empowerment elements could
be adapted for other key populations.
Working with
communities
of sex workers
Shaping policy
Community Developing
and creating sex worker
enabling Empowerment collectives
environments
Adapting to
Strengthening
the collective local needs
and contexts
Promoting a
human-rights
framework
102 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Meaningful participation
Even if key population-led organizations are not taking the lead, the meaningful
participation of representatives of the community in programming is critical to assure
the appropriateness and acceptability of services to the intended clientele. It is also
important for building trusting relationships between the community and service
providers, who may be accustomed to establishing the parameters by which services are
provided and prescribing how relationships or partnerships are to be conducted (20).
Meaningful participation means that key populations: 1) choose whether to participate;
2) choose how they are represented, and by whom; 3) choose how they are engaged in
the process; and 4) have an equal voice in how partnerships are managed.
Partnerships are crucial, but they must be built and maintained in a way that risks no
harm to the persons involved. The success of interventions that facilitate participation
is measured not only by effectiveness of outcomes but also by the degree to which key
populations are engaged and by the process and mechanisms of engagement (35).
Key population-led groups and organizations should be made essential partners and
leaders in designing, planning, implementing and evaluating health services.
• Men’s health groups and organizations of men who have sex with men are
essential partners in providing comprehensive training on human sexuality and
delivering services and so should be actively engaged. They also can facilitate
interaction with members of sexually diverse communities, thereby generating
greater understanding of their emotional health and social needs and the cost of
inaction against homophobia (11).
SEX WORKERS
TRANSGENDER PEOPLE
NewGen uses a range of participatory activities to help young people to think critically about
the way in which social, political and institutional environments influence the well-being of
members of key populations. Participants learn formal advocacy and communication skills and
the use of data through speech-making and participation in meetings as representatives of their
communities.
Overall, participants rate NewGen very highly. Participants find the training particularly
useful for learning new leadership and advocacy skills, and they enjoy the participatory
training methodology. Through working and learning together, participants develop a sense of
community. Course graduates have helped establish new community networks of young people
from key populations in many countries, often through social media.
5.4 Violence
5.4.1 Barriers
Violence against people from key populations has been shown to be a risk factor for HIV
acquisition (36). Such violence is common. It can take various forms – physical, sexual
or psychological (37). Violence is fuelled by the imbalance in the power dynamics of
gender and by prejudice and discrimination against persons perceived to depart from
conventional gender and sexuality norms and identities. Also, multiple structural factors
influence vulnerability to violence, including discriminatory or harsh laws and policing
practices and cultural and social norms that legitimate stigma and discrimination.
Women, especially young women, from key populations, including female drug users,
female sex workers and transgender women, experience particularly high rates of
physical, sexual, and psychological abuse (38, 39, 40). Reported rates of violence against
sex workers and transgender women are high (41, 42, 43) but nonetheless are likely to be
underreported where certain behaviours of key populations are illegal.
Homophobic violence, too, is increasing in some countries, as more policies and laws
have banned same-sex activity and made it a criminal offense (44). This is likely to
increase HIV risk (45).
can involve training on the human rights of key populations as well as promoting
accountability for rights-based law enforcement (46). Efforts to prevent violence can
be promoted through advocacy for law and policy reforms that protect the rights
and safety of key populations, by increasing awareness of reporting mechanisms and
disciplinary action, by conducting sensitization workshops for people with pivotal roles
in the community (e.g. government officials, police, media, health-care workers and
religious leaders), through the creation of safe spaces, and by creating early warning
and rapid response mechanisms with the involvement of key population community
members, health workers and law enforcement officials. Integrating community
representatives into these efforts also helps to create channels of communication among
key populations, civic officials and police (47).
It also is important to monitor and document incidents of violence, both as evidence for
advocacy and to inform programme design. Documenting the levels of violence faced by
key populations is often the first step in creating awareness.
• Violence against people from key populations should be prevented and addressed
in partnership with key population-led organizations. All violence against people
from key population groups should be monitored and reported, and redress
mechanisms should be established to provide justice (10, 11, 12, 46).
• Health and other support services should be provided to all persons from
key populations who experience violence. In particular, persons experiencing
sexual violence should have timely access to comprehensive post-rape care in
accordance with WHO guidelines.
• Law enforcement officials and health- and social-care providers need to be
trained to recognize and uphold the human rights of key populations and to be
held accountable if they violate these rights, including perpetration of violence
(10, 11, 12, 46).
Chapter 5: Critical enablers 107
Further reading
• UNAIDS guidance for partnerships with civil society, including people living with HIV
and other key populations. Geneva, UNAIDS, 2011. http://www.unaids.org/en/media/
unaids/contentassets/documents/unaidspublication/2012/JC2236_guidance_partnership_
civilsociety_en.pdf
• Chapter 2: Addressing violence against sex workers. In: Implementing comprehensive HIV/
STI programmes with sex workers: practical approaches from collaborative interventions.
Geneva, WHO, 2013. http://www.who.int/hiv/pub/sti/sex_worker_implementation/en/
• Ensuring human rights in the provision of contraceptive information and services:
guidance and recommendations. Geneva, WHO, 2014. http://apps.who.int/iris/
bitstream/10665/102539/1/9789241506748_eng.pdf?ua
• Evidence for action technical papers: effectiveness of interventions to address HIV in prisons.
Geneva, WHO, UNODC, 2007. http://whqlibdoc.who.int/publications/2007/9789241596190_
eng.pdf?ua=1
• Global Commission on HIV and the Law. HIV and the law: risks, rights and health. New York,
UNDP, 2012. http://www.hivlawcommission.org/index.php/report
• Responding to intimate partner violence and sexual violence against women: WHO clinical
and policy guidelines. Geneva, WHO, 2013. http://www.who.int/reproductivehealth/
publications/violence/9789241548595/en/index.html
• The human rights costing tool (HRCT): a tool to cost programs to reduce stigma and
discrimination and increase access to justice. Geneva, UNAIDS, 2012. http://www.unaids.
org/en/media/unaids/contentassets/documents/data-and-analysis/tools/The_Human_Rights_
Costing_Tool_v_1_5_May-2012.xlsm
• The user guide for the HIV-related human rights costing tool: costing programmes to
reduce stigma and discrimination and increase access to justice in the context of HIV.
Geneva, UNAIDS, 2012. http://www.unaids.org/en/media/unaids/contentassets/documents/
document/2012/The_HRCT_User_Guide_FINAL_2012-07-09.pdf
• UNAIDS guidance note: key programmes to reduce stigma and discrimination and increase
access to justice in national HIV responses. Geneva, UNAIDS, 2012. http://www.unaids.
org/en/media/unaids/contentassets/documents/document/2012/Key_Human_Rights_
Programmes_en_May2012.pdf
• Understanding and acting on critical enablers and development synergies for strategic
investment. New York, UNDP, 2011. http://www.unaids.org/en/media/unaids/contentassets/
documents/unaidspublication/2012/201211_UNAIDS_UNDP_Enablers_and_Synergies_
en.pdf
• Guidance for HIV testing and counselling and care for adolescents living with HIV. Geneva,
WHO, 2013. http://www.who.int/hiv/pub/guidelines/adolescents/en/
SERVICE DELIVERY
6
6.1 Overview 110
6.3 Key factors to consider when providing services for all key populations 120
110 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
6 SERVICE DELIVERY
6.1 Overview
The comprehensive package of interventions, outlined in Chapters 3 and 4, includes
health interventions common to all key populations as well as additional services for
specific population groups. Most of these interventions are the same HIV prevention,
diagnosis, treatment and care interventions as for the general population (1). However,
there are often complex challenges and barriers, as discussed in Chapter 5, to
implementation and delivery of these services to key populations. Programmes need to
address these challenges and barriers and provide sustainable HIV services for diagnosis,
linkage, retention and adherence for key populations. To maximize impact, services
should be made 1) accessible, 2) acceptable, 3) affordable and 4) equitable.
Furthermore, key populations need to be made aware of the available services.
This chapter focuses on the service delivery elements important to the comprehensive
package of health interventions for key populations. Box 6.1 lists a number of WHO tools
that can help guide implementation.
Delivering ART in antenatal care and maternal and other child health settings
• In generalized epidemic settings ART should be initiated and maintained in
eligible pregnant and postpartum women and in infants at maternal, newborn
and child health-care settings, with linkage and referral to ongoing HIV care
and ART where appropriate (strong recommendation, very low quality of
evidence) (1).
Chapter 6: Service delivery 113
An example of integrating services is provided by the next case study, where specific
health services for transgender people are provided within a general health facility.
Peer-support workers can provide valuable services and can link the community and
health services. Like other health workers, they need regular training, mentoring
and supervision (1). They should receive adequate wages and/or other appropriate
incentives (14).
• Trained non-physician clinicians, midwives and nurses can initiate first-line ART
(strong recommendation, moderate quality of evidence) .
• Trained non-physician clinicians, midwives and nurses can maintain ART (strong
recommendation, moderate quality of evidence) .
• Trained and supervised community health workers can dispense ART between
regular clinical visits (strong recommendation, moderate quality of evidence) (1).
See Section 4.1.2.4 for specific recommendations on peer support and community
delivery of naloxone.
1
See also Web Annex 6 briefs on young key populations.
120 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
6.3 Key factors to consider when providing services for all key
populations
In summary, assuring access, acceptability and affordability requires attention to multiple,
specific elements of programme design and delivery. Action on all these elements,
appropriate to the specific context, will yield programmes that best serve key populations.
ACCESS
Generate demand
Demand for HTC and prevention services can be generated through targeted
campaigns in identified key population settings, using community-based outreach,
mobile phone technology, social networking and broadcast and online media.
Decentralize services
Shifting services from centralized locations to community-based and/or mobile
outreach and peripheral health facilities can increase access. For example, school-
based sex education, peer counselling and community-level activities can disseminate
behavioural messages, promote follow-up on referrals to services, improve adherence
to treatment and increase people’s participation in their own health care.
Chapter 6: Service delivery 121
Case study: Promoting regular testing and supporting linkage to care in Spain
Projecte dels NOMS-Hispanosida (BCN Checkpoint), Spain
http://www.bcncheckpoint.com/
BCN Checkpoint is a community-based centre in the gay district of Barcelona for the detection of HIV
and other STIs among men who have sex with men. Managed by the nongovernmental organization
Projecte dels NOMS-Hispanosida, BCN Checkpoint offers free rapid HIV and syphilis testing by
peers for early detection, vaccination against hepatitis A and B and promotion of sexual health. To
encourage annual repeat HIV testing, BCN Checkpoint uses e-mail, text messages and telephone
reminders.
Between 2007 and 2013 the programme performed over 22 000 HIV tests, detecting 756 new
infections. For those with HIV-positive results, BCN Checkpoint offers an education and information
programme with trained HIV-positive peer counsellors and referrals within one week to the hospital’s
HIV treatment unit. To ensure linkage to care, all recently diagnosed individuals are followed through
a register. Currently, nearly 90% are linked directly to care, while 5% find their own care, and about
4% are in Barcelona only temporarily and obtain care in their home countries. Less than 2% are lost
in linkage to care.
122 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Case study: Using social media in Ghana to reach men who have sex with men
SHARPER project, FHI360, Ghana
http://www.fhi360.org/projects/strengthening-hivaids-response-partnership-evidenced-based-results-
sharper
The SHARPER project tested use of social media by community liaison officers to identify unreached
networks of men who have sex with men. The project launched MSM.net in two locations through
informal mapping of the community’s networks. Community liaison officers were selected from
networks not previously reached by peer educators and were trained on HIV, health information and
services. They used social media on smart phones and laptop computers to reach men who have sex
with men. “Reached” is defined as receiving a risk assessment, information on HIV prevention and a
referral to HIV testing and counselling (or another HIV service).
In 2013 more than 15 000 men who have sex with men were reached through Facebook (45.6%),
WhatsApp (13.4%) and other social media platforms. In Accra 82% of the men reached by this
approach had not had previous contact with a peer educator. In Kumasi 66% had never been reached
before by any intervention. The community liaison officer in Accra identified eight male sex worker
brothels and networks previously unknown to the project and other MSM organizations.
Social media proved to be an important means to reach men who have sex with men that peer
educators would not usually reach. MSM reached by community liaison officers tended to be older,
more educated, single, have a higher monthly income, and (in Accra) to report a larger social network
of men who have sex with men than those reached by peer educators.
ACCEPTABILITY
Train health-care providers
Sensitize and educate health-care providers (including community workers,
peer outreach workers, support staff and management) on issues specific to key
populations and on non-discriminatory practices and eliminating stigma, using pre-
service and in-service training, job aids, supportive supervision, and training follow-
up. Where possible, training should involve representatives of key populations.
Ensure confidentiality
Attention should be devoted to protecting privacy and confidentially, e.g. closing the
consultation room door or finding a private place to talk. Clients should be reassured
of confidentiality, e.g. seeking permission before disclosing information to other
health-care providers. Programmes should address the complexities of maintaining
confidentiality in community, outreach and peer approaches particularly.
Case study: Online and telephone counselling assures anonymity for young
men who have sex with men living with HIV in the Russian Federation
Positive Life programme, menZDRAV Foundation & Phoenix PLUS NGO, Russia
In partnership with a nongovernmental organisation, the menZDRAV Foundation offers services
to young men who have sex with men, ages 18–25, living with HIV in six regions of the Russian
Federation. Many young men are reluctant to attend support groups for fear that their sexual
orientation or HIV status will be publicly identified, and so the Positive Life programme offers
individual counselling via phone, social media and Skype.
In each of six cities, peer counsellors staff a telephone hotline with a publicized number. Counselling
is also offered via Skype, and young men can send questions to counsellors via email, Facebook,
Vkontakte or via a counsellor’s profile on gay-oriented web sites.
Counsellors offer callers information on sexuality, safe sex, STIs, adherence to ART, ARV side-effects
and disclosure of HIV status to sexual partners. Callers are informed about project services and
encouraged to visit the project office for assessments or referrals. Those who are reluctant to visit for
fear of being identified can be referred to one of 20 medical specialists across the six regions who
have been trained and sensitized to the specific needs of men who have sex with men living with HIV
and will provide services without stigma or discrimination.
There are about 80 trained peer counsellors, both project staff members and volunteers. All Positive
Life counsellors take part in a centralized training. They receive further training and supervision at
the project’s regional offices as well as from central project staff who travel to the regions. In 2013
Positive Life counsellors provided almost 1900 phone consultations and 1350 online consultations.
Case study: Capacity building for transgender community services in the USA
Center of Excellence for Transgender Health, University of California, USA
http://transhealth.ucsf.edu
The mission of the Center of Excellence for Transgender Health is to increase access to
comprehensive, effective and affirming health-care services for transgender and gender-variant
communities. The ultimate goal is to improve the overall health and well-being of transgender people
by developing and implementing programmes in response to community-identified needs. Core
faculty and staff with diverse backgrounds and experience offer programmes informed by a national
advisory board of 14 trans-identified leaders from throughout the United States of America.
The projects of the Center of Excellence address a wide range of health issues for transgender
people. One activity is developing guidelines on a range of primary care topics, including primary and
preventive care, hormone therapy, mental health, youth and surgery. Protocols have been published
online (http://Transhealth.UCSF.edu/protocols). In addition, the Transitions Project helps build the
capacity of community-based organizations to adapt, implement and evaluate evidence-based HIV
prevention interventions for transgender communities.
Chapter 6: Service delivery 125
AFFORDABILITY
Ensure monetary resources
Government commitment and funding are important. Public–private partnerships can
spread costs.
Reduce costs
Costs to the health system and for the user can be reduced through the integration
and decentralization of services, community outreach and venues, and convenient
locations. Costs to the individual can be reduced also by shortening waiting times at
the facility through a flexible appointment systems and separating clinic consultation
visits from picking up medicines.
DEVELOPING THE RESPONSE:
THE DECISION-MAKING,
PLANNING AND MONITORING
PROCESS
7
7.1 Overview 128
7.1.1 Guiding principles 129
7.1 Introduction
Action on the recommendations in these guidelines requires a strategy informed by
evidence and appropriate to the local context. Planning, decision-making and monitoring
are parts of an ongoing process: Once an evidence-based plan is developed and
implemented, it must be monitored and evaluated. The resulting findings then inform
revision of the strategy and its implementation (Fig. 7.1).
Understand
the situation
People from key populations face greater HIV risk than the general population and have
specific health-related needs. While many of these risks and needs may be common to
people from key populations in different settings, some factors will differ among key
populations, and some will be specific to a particular context. Accordingly, for a local
Chapter 7: Developing the response: the decision-making, planning and monitoring process 131
response to be appropriate, acceptable and most effective, these risks and needs must
be examined locally, and local people from key populations must be consulted and
actively involved in the situational analysis.
It is also important to recognize the considerable diversity and varying levels of risk
within each key population. Those most at risk are likely to be people who could be
considered members of more than one key population; for example, some men who have
sex with men may also inject drugs or engage in sex work. Thus, they risk exposure to
HIV by several routes. People from key populations may also have other characteristics
that could increase their risk or vulnerability or create additional health or welfare
needs. For example, people from key populations may be homeless, experience mental
health conditions or have other acute or chronic health concerns.
It is critical that information gathering processes, and the information itself, serve to
protect, and not put at risk, the safety and privacy of people from key populations.
At all times ethical principles must be observed, and the human rights of people from
key populations, protected. In some circumstances, determining population size or
mapping key populations can unintentionally endanger community members or subject
them to stigma by identifying these populations and where they are located. Such
information could also lead to arrest or imprisonment of people from key populations
whose behaviour is criminalized. When undertaking information-gathering exercises,
it is important to strictly maintain privacy, confidentiality and the security of the
information collected. If the safety and the human rights of people from key populations
cannot be protected, collection of certain data, such as mapping where people from key
populations congregate, is better avoided.
The makeup, characteristics and needs of key populations change over time, as do
various contextual and environmental factors. Ongoing M&E will identify changing
parameters and make it possible to refine or refocus the response.
A situational analysis will almost certainly identify gaps in knowledge. An agenda for
further research can address these gaps.
It is also important, whenever analysing and interpreting data, to evaluate the quality of
the data and the presence of any sources of bias.
132 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Rapid assessment and response guides are available to help guide initial and
ongoing assessments, using multiple methods to gather data and to conduct
analyses at multiple levels:
• Rapid assessment and response adaptation guide on HIV and men who have
sex with men. Geneva, WHO, 2002. http://www.who.int/hiv/pub/prev_care/en/
msmrar.pdf?ua=1
• The rapid assessment and response guide on injecting drug use (IDU-RAR).
Geneva, WHO, 1998. http://www.who.int/substance_abuse/publications/en/
IDURARguideEnglish.pdf?ua=1
• The rapid assessment and response guide on psychoactive substance use and
sexual risk behaviour (SEX-RAR). Geneva, WHO, 2002. http://www.who.int/
entity/mental_health/media/en/686.pdf?ua=1
• Rapid assessment and response adaptation guide for work with especially
vulnerable young people. Geneva, WHO, 2004 http://www.who.int/hiv/pub/
prev_care/en/youngpeoplerar.pdf?ua=1
Chapter 7: Developing the response: the decision-making, planning and monitoring process 133
Implementation
• Which interventions need to be implemented, and how should their implementation
be prioritized?
• Where and at what scale do interventions need to be provided?1
• What targets and timelines should be set for the implementation and scale-up of
interventions?
• How and to what extent should services be decentralized and integrated to provide
the best service coverage for key populations?
• Which modes of service delivery are most appropriate?
• What are the roles and responsibilities of the various stakeholders in implementing
the response and achieving the agreed targets?
Resources required
• Do the costs of implementing the response outweigh the costs of inaction?
• What financial, human and other resources and infrastructure are required to
implement the response? What resources are currently available, what additional
inputs will be required, and how might these be obtained? What types of health-care
and other workers are required, and how will they be recruited and trained? How can
task shifting and sharing optimize the use of available human resources and expand
service delivery?
• How will economies of scale and synergies among HIV interventions and with other
health interventions save on costs and improve service provision?
1
For ART the WHO Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection (2013) provides
information on considerations for implementing and scaling up services in line with key recommendations.
134 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
• Operational guidelines for monitoring and evaluation of HIV programmes for sex
workers, men who have sex with men and transgender people. Geneva, UNAIDS,
2012. http://unaids.org.cn/en/index/Document_view.asp?id=712
• Operational guidelines for monitoring and evaluation of HIV programmes for people
who use drugs. Geneva, UNAIDS, 2011, draft. http://www.cpc.unc.edu/measure/
tools/hiv-aids/operational-guidelines-for-m-e-of-hiv-programmes-for-people-who-
inject-drugs/idu-service-delivery-level-guidelines/view
The M&E process requires data from a variety of sources, including behavioural and
sero-surveillance surveys, programmatic and administrative data, as well as information
gathered through reviewing policy documents and legislation and consultation with
Chapter 7: Developing the response: the decision-making, planning and monitoring process 135
experts and stakeholders (Box 7.4). The quality and limitations of these data should be
assessed and considered when undertaking analysis and interpretation.
Outcome and impact indicators seek to gauge the impact that interventions have
had on outcomes that affect exposure to risk, such as changes in risk behaviours (for
example, the percentage of people who use condoms consistently) or on impacts on the
course of HIV or STI epidemics (for example, reductions in incidence of HIV or STIs).
Baseline assessment. Initial assessment should measure the scale of the current
response, assessing the availability, coverage, and quality of current interventions, and
appraising current environmental enablers and barriers. This information serves as a
baseline for tracking progress. Also, currently available resources and technical capacity
must be determined in order to estimate what more is needed and how to scale the
intervention appropriately. From this information, realistic, achievable targets can be set
and the time frame, specified.
Estimating cost. Estimating the costs associated with implementation is a key step
in planning the roll-out. Several costing tools and resources are available. Spectrum,
for example, is a suite of models and analytical tools to support decision-making. It
comprises several software applications, including AIM (AIDS Impact Model) and Goals
(Cost and Impact of HIV Interventions). Most countries already have AIM files prepared
as part of their national epidemiological estimates, and so both modules can be rapidly
applied. Spectrum can be accessed online at: http://www.unaids.org/en/dataanalysis/
datatools/spectrumepp2013/.
OneHealth is a software tool designed to strengthen health system analysis and costing
and to develop financing scenarios at the country level. It is specifically designed for
low- and middle-income countries. It provides planners with a single framework for
136 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
planning, costing, impact analysis, budgeting and financing of strategies for all major
diseases and health system components. OneHealth can be downloaded free of charge
(Futures Institute, 2013) at: http://www.futuresinstitute.org/onehealth.aspx.
UNAIDS has developed The human rights costing tool (HRCT) , a flexible tool for costing
investments in critical enablers (such as integrated treatment and rights literacy
programmes, legal services, stigma and discrimination reduction programmes, and training
for health-care workers and law enforcement). This, too, can be downloaded free of charge
along with a user guide (2,3) at: http://www.unaids.org/en/media/unaids/contentassets/
documents/data-and-analysis/tools/The_Human_Rights_Costing_Tool_v_1_5_May-
2012.xlsm and http://www.unaids.org/en/media/unaids/contentassets/documents/
document/2012/The_HRCT_User_Guide_FINAL_2012-07-09.pdf
These indicators are described in detail in WHO key population guidance: Tool
for setting and monitoring targets for prevention, treatment and care for HIV and
other sexually transmitted infections among men who have sex with men, sex
workers and transgender people, forthcoming; and Technical guide for countries
to set targets for universal access to HIV prevention, treatment and care for
injecting drug users – 2012 revision, http://www.who.int/hiv/pub/idu/targets_
universal_access/en/.
Sources of guidance
• Tool for setting and monitoring targets for prevention, treatment and care for HIV and
other sexually transmitted infections among men who have sex with men, sex workers and
transgender people. Geneva, WHO, forthcoming.
• Technical guide for countries to set targets for universal access to HIV prevention, treatment
and care for injecting drug users – 2012 revision. Geneva, WHO, 2012. http://www.who.int/
hiv/pub/idu/targets_universal_access/en/
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For more information, contact:
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keypopulations/