Background

Sex workers include female, male, trans and gender diverse 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 (3, 84). Increasingly, sex workers are meeting and staying in contact with their clients online.

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 (203, 204). (Please see Chapter 7 on young key populations.)

Sex workers in many places are highly vulnerable to HIV and STIs due to multiple factors, including large numbers of sex partners, unsafe working conditions, barriers to the negotiation of consistent condom use, and intersecting social determinants of poor health. These include lack of social protection and housing, food insecurity, reduced education opportunities and disability. Moreover, sex workers often have reduced control over these factors due to structural barriers that increase their risk of unprotected sex and reduce access to health services (please see the chapter on critical enablers). In particular, sex workers may be harassed by law enforcement officers, including the practice of officers confiscating and using condoms and mobile phones as evidence of sex work; be subjected to violence from law enforcement officers, clients and intimate partners; and experience stigma and discrimination in health and other settings. As a result, sex workers are disproportionately affected by HIV and STIs. For the most recent data related to HIV, syphilis and sex workers, please access UNAIDS Key Populations Atlas.

The recommended package of interventions for sex workers includes enabling interventions that should be implemented as a priority, including the decriminalization of sex work (namely, removing all offences that criminalize sex workers, clients and third parties). Addressing these barriers would not only ensure sex workers’ human rights, but also have an impact on HIV, STIs and viral hepatitis in all settings where sex work is criminalized and sex workers experience stigma, discrimination and violence (68, 75). Other essential interventions are health interventions related to HIV and STI prevention, testing and treatment.

The majority of participants in the key populations values and preferences qualitative research (for the detailed report, please see Web Annex B) were opposed to the periodic presumptive treatment (PPT) of STIs, citing both health and ethical concerns. Participants noted an array of potential health risks associated with prolonged antibiotic use, including antibiotic resistance, kidney damage, depression and impacts on vaginal health. Additionally, participants expressed concerns surrounding the ethical implications of PPT and its role in perpetuating stigma and vulnerability. Others attested to the role of PPT in reinforcing stereotypes of sex workers as vectors of disease. Rather than offering sex workers PPT for STIs, participants stressed the need for increased access to STI testing and evidence-based prevention methods. For these reasons, the recommendation to provide PPT for STIs for sex workers is not included in these guidelines. If sex workers wish to prevent STI acquisition through PPT, this should always be voluntary, in full understanding of the potential complications, only in settings where aetiological diagnosis is not possible, and in consultation with health care providers.

WHO recommends expanding access to aetiological diagnosis of STIs for sex workers as a priority, as well as suggesting offering periodic screening for asymptomatic STIs to sex workers. Offering voluntary periodic screening for HIV and the other main curable STIs, such as syphilis, gonorrhoea and clamydia, is particularly relevant for sex workers, due to the severe consequences of STIs, including infertility. In cases of pregnancy, untreated STIs can also lead to severe adverse pregnancy outcomes, such as prematurity, neonatal death, low-birth weight and congenital anomalies. WHO has specific recommendations for the treatment of the main STIs, suppressive therapy for genital herpes, and for the management of syndromes when the aetiology cannot be investigated for the most appropriate treatment (183).

While evidence of increased prevalence of HCV and HBV in men who have sex with men is clear (12), concerns about viral hepatitis in female and trans and gender diverse sex workers are new and emerging, and there is little data available to understand global prevalence of HBV and HCV among these populations. For female and trans and gender diverse sex workers who are living with HIV, there may be an increased risk of HCV and HBV (205), although evidence is scarce, and additional small studies have shown increased risk for mono-infections (18). However, HCV prevalence is high in people who inject drugs (206) and in people in prisons (207), and there is considerable intersection between female and trans and gender diverse sex workers and these other key populations, indicating a need to ensure access to viral hepatitis prevention, testing and treatment for these groups. For this reason, viral hepatitis prevention, testing and treatment are included in the package of essential health interventions for all sex workers.

Other health issues are of particular concern to sex workers, including: those related to sexual and reproductive health (safe abortion, contraception, conception and antenatal care); those related to cervical and anal cancer prevention; and those related to screening and treatment for mental health issues, and for hazardous or harmful alcohol and substance use. In particular, the results of qualitative research undertaken by four global networks of key populations showed that addressing mental health was a priority for key populations. While global data on TB among sex workers is not available, sex workers who live and work in cramped conditions may be at increased risk of TB. These are essential interventions to address broader health beyond HIV, STIs and viral hepatitis, and access for key populations should be ensured.

The package of essential interventions for sex workers does not include those that are specifically related to HIV and viral hepatitis prevention for people who inject drugs (namely, NSPs, OAMT and naloxone for overdose management), or to gender-affirming care for trans and gender diverse people. However, for sex workers who inject drugs or who are trans and gender diverse, these are relevant interventions that should be made available, as outlined in the specific packages for these key populations.

Background

People who inject drugs refers to people who inject psychoactive substances for non-medical purposes. These drugs include, but are not limited to, opioids, amphetamine-type stimulants, cocaine and hypno-sedatives including new psychoactive substances.¹ 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. While these guidelines focus on people who inject drugs because of their specific risk of HIV and HCV transmission, due to the sharing of blood-contaminated injection equipment, much of this guidance is also relevant for people who use substances through other routes of administration, such as snorting, smoking and ingestion (3).

In many countries drug use or possession is criminalized, and in almost every country it is considered immoral and significant stigma and discrimination is experienced by people who use drugs (please see the critical enablers chapter). At the time of writing there is extremely low coverage of the evidence-based package of NSPs and OAMT (208). As a direct result, people who inject drugs are disproportionately affected by HIV and viral hepatitis. For most recent data related to HIV, viral hepatitis and people who inject drugs, please access UNAIDS Key Populations Atlas, the World Drug Report and the Global state of harm reduction.

For impact on HIV and viral hepatitis, structural barriers for people who inject drugs need to be addressed, including decriminalizing drug use and possession for personal use, ending forced detention in compulsory drug treatment centres, addressing violence, stigma and discrimination, and empowering communities of people who use drugs. People who use drugs in particular face additional barriers to accessing health services where cessation of drug use is a condition for eligibility. Women who inject drugs may be more stigmatized than their male counterparts, and many sell sex to pay for both their and their partner’s drugs. Fear of losing custody of their children may make mothers who inject drugs less likely to access reproductive and other health services (209). They may experience more police harassment and violence than men who inject drugs. The impact of these barriers on HIV and viral hepatitis acquisition is clear (64, 73, 210), and for this reason the enabling interventions listed in the table below are considered essential for impact for people who inject drugs.

Harm reduction is one of the key elements of a public health promotion framework (or response) that has been proven highly effective in reducing and mitigating the harms of injecting drug use for individuals and communities. WHO defines harm reduction as a comprehensive package of evidence-based interventions, based on public health and human rights, including NSPs, OAMT and naloxone for overdose management. Harm reduction also refers to policies and strategies that aim to prevent major public and individual health harms, including HIV, viral hepatitis and overdose, without necessarily stopping drug use.

High prevalence and incidence of HIV and viral hepatitis B and C in people who inject drugs call for countries to prioritize the provision of HIV and viral hepatitis prevention (particularly NSPs, OAMT and naloxone for overdose management), testing and treatment interventions.

Pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention intervention. Although there is strong evidence that PrEP is highly protective for sexual HIV transmission, evidence is more limited for the prevention of parenteral HIV transmission. PrEP services for people who inject drugs and their sexual partners can provide benefits both in the prevention of sexual transmission, and likely in the prevention of HIV, acquired through unsafe injection practices. PrEP services should not replace NSPs. NSPs have the greatest impact in preventing the transmission of HIV and other bloodborne infections, including HCV associated with injecting drug use.

More research is needed on the values and preferences of people who inject drugs on PrEP as part of comprehensive HIV prevention approaches, and on how to best deliver PrEP services for this population to improve uptake and effective use (including through comprehensive and integrated community-based delivery models).

While global estimates of STIs among people who inject drugs are not known, people who inject and use drugs may be at increased risk of STIs, particularly those engaging in chemsex or those using stimulants. Values and preferences research showed a strong preference for STI services among women who inject drugs. For this reason, people who inject drugs should have access to STI testing, diagnosis and treatment.

People who inject drugs are at increased risk of TB, irrespective of their HIV status, and TB is a leading cause of HIV-related mortality among people who inject drugs (211, 212). For this reason, TB prevention, screening, diagnosis and treatment are included in the package of interventions essential for broader health of people who inject drugs. Other common health issues related to unsafely injecting drugs include nerve and vein damage, abscesses and skin infections.

Background

Men who have sex with men refers to all men who engage in sexual relations with other men. The words men and sex can be 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.

Men who have sex with men are disproportionately affected by HIV, hepatitis C (12), hepatitis B (213) and STIs (28, 31, 214). Hepatitis A outbreaks among men who have sex with men are common (215–219) and could be prevented with vaccination. This heightened risk is in part due to greater efficiency of transmission of the three disease groups through unprotected anal sex and syndemic features, such as increased risk of HIV acquisition in those with STIs (221), or increased risk of HCV acquisition in men who have sex with men who live with HIV (12).

Some men who have sex with men may also engage in chemsex – defined as when individuals engage in sexual activity while taking primarily stimulant drugs, typically involving multiple participants and over a prolonged time, which increases risk to all three infectious disease groups when there is no access to, and use of, prevention, diagnosis and treatment services.

Persistent structural barriers, such as criminalization of male-to-male consensual sex, stigma, discrimination and violence against men who have sex with men, reduces access to prevention, testing and treatment services, contributing to increased risk of infection (please see the critical enablers chapter).

The essential package of interventions for men who have sex with men includes enabling interventions to address structural barriers as a priority, including the decriminalization of same-sex intimacy. Essential health interventions for impact on HIV, STIs and viral hepatitis include prevention, such as PrEP, diagnosis and treatment for the three disease groups. Men who have sex with men who inject drugs also need access to harm reduction interventions (NSPs, OAMT and naloxone for overdose management).

Those interventions essential for broader health, and to which access for men who have sex with men should be ensured, include screening and treating mental health, and hazardous or harmful alcohol and drug use. Additionally, given the disproportionate rates of anal cancers among men who have sex with men, screening and treatment for anal cancer should be considered for men who have sex with men.

For most recent data related to HIV, syphilis and men who have sex with men, please access UNAIDS Key Populations Atlas.

Background

Trans and gender diverse people is an umbrella term for those whose gender identity, roles and expression does not conform to the norms and expectations traditionally associated with the sex assigned to them at birth; it includes people who are transsexual, transgender or otherwise gender nonconforming or gender incongruent. Trans and gender diverse people may self-identify as transgender, female, male, transwoman or transman, trans-sexual or one of many other gender nonconforming identities. They may express their genders in a variety of masculine, feminine and/or androgynous ways. The high vulnerability and specific health needs of trans and gender diverse people necessitates a distinct and independent status in the global HIV response (3, 222).

Trans and gender diverse people experience structural barriers such as criminalization, stigma and discrimination, as do all key populations, but experience very high rates of sexual and physical violence (223–226). High levels of stigma and discrimination against trans and gender diverse people in health care settings have been widely reported (100). Violence and stigma and discrimination increase vulnerability to substance use disorders, eating disorders, depression, suicide attempts, HIV and other sexually transmitted infections, among others, and compromise trans and gender diverse people’s access and utilization of health services (101, 102, 222). Depression, for example, has been reported to affect more than half of the trans and gender diverse population in certain settings (222), and their quality of life has been shown to be significantly poorer than that of the general population prior to receiving hormonal treatment, when desired (227). Additionally, there are specific barriers caused by the lack of legal recognition of other gender identities and expressions, which hinder access to health and other services, and limit entry into both public and private health insurance schemes. In particular, gender-sensitive care for trans and gender diverse people is often not available, with health care providers untrained regarding the specific needs of trans and gender diverse people (228).

Trans and gender diverse people are disproportionately affected by HIV and STIs (30, 229). While data are limited, studies have also shown high prevalence of viral hepatitis B and C in trans and gender diverse people (20). For the most recent data related to HIV, syphilis and trans and gender diverse people, please access UNAIDS Key Populations Atlas.

Gender-affirming care can include any of the following: hormone therapy; upper (for example, face, chest, breast) surgery; and/or lower (for example, vaginoplasty, phalloplasty, metoidioplasty, etc.) surgery. Gender affirmation is often a priority intervention for the trans and gender diverse community, but access is often hindered by poor availability, high cost and exclusion of gender-affirming interventions from national health service packages. Administration of industrial-grade silicone or other illicit subcutaneous injections, as well as non-medical-grade fillers, are reported to be common, especially in low- and middle-income countries (LMICs) (231, 232). These interventions can cause body disfigurement, skin damage, allergic reactions, thrombosis, pulmonary silicone embolism and severe autoimmune and connective tissue disorders, among others (233). Likewise, the use of unsafe and unregulated hormones was reported to be very common among trans and gender diverse people (234).

It is important that hormones administered for gender affirmation remain within appropriate physiological levels to avoid negative health consequences, and trans and gender diverse people who self-administer hormones need access to evidence-based information, products and sterile injection equipment (182, 235). Moreover, other non-medical body modification strategies are often used by both youth and adult trans and gender diverse people, including genital tucking and chest binding; little research has described either the prevalence or health risks and benefits of these methods of gender affirmation (235).

The recommended package of interventions for trans and gender diverse people includes enabling interventions that should be implemented as a priority to address barriers, in particular, recognizing gender diversity in laws, policies and practices.

The health intervention package reflects the complex and varied needs of trans and gender diverse people. Trans and gender diverse people need access to the entire range of HIV, viral hepatitis and STI prevention, testing and treatment interventions for greatest impact. These interventions include access to prevention of vertical transmission of HIV, HBV and syphilis for pregnant trans and gender diverse people; and include harm reduction (NSPs, OAMT and naloxone for overdose management) for trans and gender diverse people injecting drugs, including the injection of hormones and other products, such as silicon gel, for gender affirmation. Interventions for broader health include sexual and reproductive health interventions; screening for and treating hazardous or harmful drug and alcohol use and mental health issues; and preventing, assessing and treating cervical and anal cancers. Access to safe and evidence-based gender-affirming care should be seen as central to trans and gender diverse people’s broader health, as well as an important entry point for HIV, STI and viral hepatitis health services, and other health services in general.

The international classification of diseases (ICD–11) has redefined gender identity-related health as gender incongruence, and has reclassified gender incongruence as a condition related to sexual health rather than a mental and behavioural disorder (236). This reflects evidence that trans and gender diverse identities are not conditions of mental ill health and classifying them as such can cause enormous stigma. Inclusion of gender incongruence in the ICD should ensure trans and gender diverse people’s access to gender-affirming health care, as well as adequate health insurance coverage for such services.

Background

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; included are adult and juvenile males, and females and trans and gender diverse people, who are detained 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, including people who use drugs and sex workers. Nonetheless, most of the considerations in these guidelines may apply to these populations as well (3). Prison staff are also affected by HIV, viral hepatitis, STIs and other health issues, and may lack access to health services, particularly if they live in prison compounds without health services (237).

People in prison are disproportionately affected by HIV (212), hepatitis B and C (207, 238) and TB (11, 212). This is, in part, due to the crossover between other key populations, particularly considering the criminalization of behaviours such as drug use, drug possession and sex work, and their overrepresentation in prison populations. Besides this, there is the transmission of HIV and viral hepatitis within prison through unprotected sex, sexual violence, sharing injection equipment, tattooing or parent-to-child transmission. HIV and hepatitis prevention interventions are often unavailable in prisons, although the risks persist (239). There is a frequent intersection with people in prisons and those who are poor, have little education, and come from socioeconomically deprived sectors of the population, and in many prisons there is an overrepresentation of racial minorities. In particular, the prevalence of substance use and dependence in prison populations is much higher than in the community, particularly for women (240–242).

People in prisons also have high exposure to TB, including multi-drug resistant TB, because of factors including overcrowding, poor ventilation and poor infection control practices. Assuring equitable access to TB services for all people in prisons, regardless of HIV status, is critical for reducing increased burden of HIV-associated TB among people in prisons. Contributing to poor health of people in prisons are: limited access to health care, with delays in diagnosis (due to insufficient laboratory capacity and diagnostic tools); inadequate treatment; frequent transfer of people in prisons between prisons, without continuity of treatment; and poor nutrition. Additionally, after release from prison there is often little support for ongoing health and social care.

For most recent data related to HIV and people in prisons and other closed settings, please access UNAIDS Key Populations Atlas.

The right to equivalent health services for people in prisons (namely, equivalent to that available outside of prisons) is enshrined in several internationally recognized documents (243), and respect for these should be reflected in prison policies and practices. Violence in prisons is common and often clandestine because of the fear of reprisal when it is reported, therefore it is easily overlooked or underestimated (244). Structural barriers within prisons, in particular regarding violence, where it is also important to develop measures for safe reporting and protection of victims, need to be urgently addressed, and are essential and priority interventions for impact.

People in prisons are adolescents, adults, male, female, trans and gender diverse and have urgent, varied and complex health needs. For impact on HIV, viral hepatitis and STIs, the package of interventions which prevent, diagnose and treat these diseases is essential, and should be provided within prisons and other closed settings, with continuity during inter- and intra-prison transfers and after release. This package should include condoms and lubricant and harm reduction interventions (NSPs, OAMT and naloxone for overdose management), given that drug use is prevalent in prisons.

People in prisons have broader health needs, and the package of interventions includes mental health and hazardous or harmful drug and alcohol use screening and treatment; sexual and reproductive health interventions; and prevention, screening and treatment of cervical and anal cancers. Importantly, TB prevention, screening and treatment should be implemented in all prisons and closed settings.

UNODC recommends a package of 15 interventions for HIV prevention, diagnosis and treatment for people in prisons (245). These guidelines address multiple disease areas and present a different package, although almost all the 15 UNODC recommended interventions are included here.³