EXECUTIVE SUMMARY

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. This edition includes updates with regard to recent new WHO recommendations, in particular on ARV treatment and on Pre Exposure Prophylaxis (PrEP).

Format of the guidelines

The guidelines are presented in seven chapters:

Table

Guidelines development methodology

In October 2013 an External Steering Group met and reviewed all relevant existing WHO guidance and identified recommendations requiring updating and new areas to be addressed. This group consisted of people from key population networks and organizations, academics, researchers, programme managers and implementers, United Nations partner organizations, supported by a WHO secretariat.

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 from a recommendation for PrEP use in demonstration projects to a recommendation to consider PrEP as part of a package of prevention services for men who have sex with men. (See Chapter 2 for methodology and Chapter 4 for the updated recommendation.) The new recommendation on opioid overdose management supports providing naloxone to people in the community who might witness an overdose and instructing them on its administration. The updated evidence reviews for the HIV recommendations for people in prisons and other closed settings reinforced the existing recommendations. For all other recommendations, the original guidance documents, which are referenced in this document, describe how that guidance was developed.

Implications for programming

Both public health and equity considerations underlie the need to prioritize and improve HIV services for key populations. These guidelines for key populations aim to support countries to provide more effective and acceptable comprehensive HIV services for key populations, to increase coverage and to address current inequities in access. Countries will need to assess their specific situations, taking into account current population sizes and reviewing current coverage levels and the quality of programmes. It is also important to assess and, where possible, to address social and legal barriers to access and to make progress as country-specific circumstances allow.

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.

Summary of WHO recommendations concerning key populations

Table

Publication Details

Copyright

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Publisher

World Health Organization, Geneva

NLM Citation

Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations – 2016 Update. Geneva: World Health Organization; 2016. EXECUTIVE SUMMARY.

Chapter 1:	Background, context, rationale, guiding principles, objectives and the target audience.
Chapter 2:	Methods and process for developing the guidelines.
Chapter 3:	Comprehensive package of interventions.
Chapter 4:	Clinical interventions for key populations.
Chapter 5:	Critical enablers required for successful implementation.
Chapter 6:	Service delivery issues and case studies.
Chapter 7:	Guidance on prioritizing and planning services, monitoring and evaluation, target setting, indicators and costing tools.

HEALTH SECTOR INTERVENTIONS
HIV PREVENTION
1	The correct and consistent use of condoms with condom-compatible lubricants is recommended for all key populations to prevent sexual transmission of HIV and sexually transmitted infections (STIs).
2	Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) should be offered as an additional prevention choice for key populations at substantial risk of HIV infection as part of combination HIV prevention approaches. NEW RECOMMENDATION
3	Post-exposure prophylaxis (PEP) should be available to all eligible people from key populations on a voluntary basis after possible exposure to HIV.
4	Voluntary medical male circumcision (VMMC) is recommended as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men, particularly in settings with hyperendemic and generalized HIV epidemics and low prevalence of male circumcision.
HARM REDUCTION FOR PEOPLE WHO USE DRUGS
5	All people from key populations who inject drugs should have access to sterile injecting equipment through needle and syringe programmes.
6	All people from key populations who are dependent on opioids should be offered and have access to opioid substitution therapy.
7	All people from 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.
8	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. NEW RECOMMENDATION
HIV TESTING AND COUNSELLING (HTC)
9	Voluntary HTC should be routinely offered to all key populations both in the community and in clinical settings. Community-based HIV testing and counselling for key populations, linked to prevention, care and treatment services, is recommended, in addition to provider-initiated testing and counselling.
HIV TREATMENT AND CARE
10	Key populations living with HIV should have the same access to antiretroviral therapy (ART) and to ART management as other populations.
11	All pregnant women from key populations should have the same access to services for prevention of mother-to-child transmission (PMTCT) and follow the same recommendations as women in other populations.
PREVENTION AND MANAGEMENT OF COINFECTIONS AND CO-MORBIDITIES
12	Key populations should have the same access to tuberculosis (TB) prevention, screening and treatment services as other populations at risk of or living with HIV.
13	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.
14	Routine screening and management of mental health disorders (depression and psychosocial stress) should be provided for people from key populations living with HIV in order to optimize health outcomes and improve their adherence to ART Management can range from co-counselling for HIV and depression to appropriate medical therapies.
SEXUAL AND REPRODUCTIVE HEALTH
15	Screening, diagnosis and treatment of sexually transmitted infections should be offered routinely as part of comprehensive HIV prevention and care for key populations.
16	People from key populations, including those living with HIV, should be able to experience full, pleasurable sex lives and have access to a range of reproductive options.
17	Abortion laws and services should protect the health and human rights of all women, including those from key populations.
18	It is important to offer cervical cancer screening to all women from key populations.
19	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.

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.