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Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations [Internet]. Geneva: World Health Organization; 2022.

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Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations [Internet].

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CHAPTER 4The recommended package of interventions

Introduction

This guideline consolidates WHO recommendations related to the prevention, diagnosis and treatment of HIV, viral hepatitis and STIs for key populations. The majority of these recommendations are described in full in other WHO guideline documents, including many that were first described in the 2014/2016 consolidated key populations guidelines (3). For simplicity, in most cases the background, evidence and decision-making process related to each recommendation are not included in this guideline; rather the source document, which includes this information, is referenced. Certain recommendations were newly developed or updated in 2021/2022 as part of this guideline process; these are marked with a star, and details of evidence and decision-making are provided in the additional information chapter.

The interventions listed here have been categorized as follows:

  1. Essential for impact: enabling interventions
    This includes all interventions recommended to reduce structural barriers to health services access for key populations.
  2. Essential for impact: health interventions
    This includes health sector interventions that have a demonstrated direct impact on HIV, viral hepatitis and STIs in key populations.
  3. Essential for broader health
    This includes health sector interventions to which access for key populations should be ensured, but do not have direct impact on HIV, viral hepatitis or STIs.
  4. Supportive
    This includes health sector interventions which support the delivery of other interventions, such as creating demand, and providing information and education.

The tables below include recommendations which have been made through the GRADE process (see methods for details), good practice statements and summaries and links to relevant documents. The GRADE recommendations include the strength of the recommendation and certainty of the evidence as agreed by relevant Guideline Development Groups.

Packages of recommended interventions are provided for each key population group in Chapter 5.

Recommended package

Note that these interventions are not in order of priority.

Also please note that this package includes a mix of existing and new recommendations, good practice statements and guidance statements. These can be classified as follows:

★ New GRADE recommendation – a recommendation which was newly developed as part of this guideline’s development process, using the GRADE methodology as described in the methods section;

Existing GRADE recommendation – a recommendation which was developed as part of an already published WHO guideline;

★ New good practice statement – a good practice statement newly developed by the guideline development group as part of this guideline’s development process, as described in the methods section;

Existing good practice statement – a good practice statement which was developed as part of an already published WHO guideline;

Existing guidance statements – overarching statements which summarize groups of existing recommendations and approaches;

WHO position – from position papers of the WHO Strategic Advisory Group of Experts (SAGE) on immunization; and

Adapted – for some of the recommendations and good practice statements, small changes to the wording have been made without substantial change.

Essential for impact: enabling interventions
Overarching good practice statements: removing punitive laws, policies and practices
Existing guidance statement 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 (3, 79, 83, 84).
Existing good practice statement (adapted) 1 Countries should work toward decriminalization of behaviours such as drug use/injecting, sex work, same-sex activity and nonconforming gender identities, and toward elimination of the unjust application of civil law and regulations against people who use/inject drugs, sex workers, men who have sex with men and trans and gender diverse people (3, 79, 82–85).
Other good practice statements: removing punitive laws, policies and practices
Existing good practice statement (adapted) 2 Where criminalization continues, countries should work toward developing non-custodial alternatives to incarceration of people who use drugs, trans and gender diverse people, sex workers and people who engage in same-sex activity (3, 82, 85).
Existing good practice statement (adapted) 3 Countries should ban compulsory treatment4 for key populations (3, 82, 83, 85, 166).
Existing good practice statement Countries should work toward developing policies and laws that decriminalize the use of sterile needles and syringes (and that permit NSPs) and that legalize OAMT for people who are opioid dependent (3).
Existing good practice statement The police practice of using possession of condoms as evidence of sex work and grounds for arrest should be eliminated (3, 84).
Existing good practice statement Countries should work towards legal recognition for trans and gender diverse people (3, 79).
Existing good practice statement Countries are encouraged to examine their current consent policies and consider revising them to reduce age-related barriers to HIV, STI and viral hepatitis services, and to empower providers to act in the best interests of adolescents (3, 120).
Overarching good practice and guidance statements: stigma and discrimination
Existing good practice statement Countries should work towards implementing and enforcing anti-discrimination and protective laws, derived from human rights standards, to eliminate stigma, discrimination and violence against people from key populations (3).
Existing good practice statement Policy-makers, parliamentarians and other public health leaders should work together with civil society organizations, including key population-led organizations, in their efforts to monitor stigma, confront discrimination against key populations and change punitive legal and social norms (3, 79, 81, 83–85, 118, 119).
Existing guidance statement 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, 79, 81, 83–85, 118–120).
Other good practice statements: stigma and discrimination
Existing good practice statement Health care workers should receive appropriate recurrent training and sensitization to ensure that they have the skills and understanding to provide services for adults and adolescents from key populations, based on all persons’ right to health, confidentiality and non-discrimination (3).
Existing good practice statement Services should be safe spaces that increase protection from the effects of stigma and discrimination, where adolescents can freely express their concerns, and where providers demonstrate patience, understanding, acceptance, non-judgement and knowledge about the choices and services available to the adolescent (120).
Overarching guidance statement: community empowerment
Existing guidance statement Key population-led groups and organizations should be made essential partners and leaders in designing, planning, implementing and evaluating health services (3).
Other good practice statements: community empowerment
Existing good practice statement Programmes should implement a package of interventions to enhance community empowerment among key populations (3, 79, 84, 85).
Existing good practice statement Programmes should be put in place to provide legal literacy and legal services for and by key populations, so that they know their rights and applicable laws and can receive support from the justice system when aggrieved (3, 79, 84, 85).
Overarching good practice statement: addressing violence
Existing good practice statement 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 (3, 79, 84, 85, 162).
Other good practice statements: addressing violence
Existing good practice statement 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 (3, 162).
Existing good practice statement 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 (3, 79, 84, 85, 162).
Essential for impact: health interventions
Prevention of STIs, HIV and viral hepatitis
Harm reduction (NSPs, OAMT and naloxone for overdose management)
Existing GRADE recommendation All individuals from key populations who inject drugs should have access to sterile injecting equipment through NSPs (strong recommendation, low certainty of evidence) (3, 83, 167).
Existing GRADE recommendation It is suggested that NSPs also provide low dead-space syringes (LDSSs), along with information about their preventive advantage over conventional syringes (this recommendation is conditional on local acceptability and resource availability) (168).
Existing GRADE recommendation

All people from key populations who are dependent on opioids should be offered OAMT5 in keeping with WHO guidance (strong recommendation, low certainty of evidence) (3, 83, 169), including those in prison and other closed settings (170).

Important considerations related to OAMT, including recommended doses, use in pregnancy and drug interactions are included in:

Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence

Guidelines for the identification and management of substance use and substance use disorders in pregnancy

Existing GRADE recommendation 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 certainty of evidence) (27).
More details of community distribution of naloxone for overdose management can be found in the WHO guideline Community management of opioid overdose.
Condoms and lubricant
Existing GRADE recommendation The correct and consistent use of insertive and receptive condoms with adequate supply of condom compatible lubricants is recommended to prevent sexual transmission of HIV, viral hepatitis and STIs through anal or vaginal sex6 (strong recommendation, moderate certainty of evidence) (3).
Pre-exposure prophylaxis (PrEP) for HIV
Existing GRADE recommendation Oral PrEP (containing tenofovir disproxyl fumarate) should be offered as an additional prevention choice for people at substantial risk of HIV infection as part of combination HIV prevention approaches (strong recommendation, high certainty of evidence) (171).
Existing GRADE recommendation The dapivirine vaginal ring may be offered as an additional prevention choice for cisgender women at substantial risk of HIV infection as part of combination prevention approaches (conditional recommendation, moderate certainty of evidence) (171).

★

New GRADE recommendation

Long-acting injectable cabotegravir may be offered as an additional prevention choice for people at substantial risk of HIV infection, as part of combination prevention approaches (conditional recommendation, moderate certainty of evidence) (172).

For detailed guidance on PrEP please see Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach.

For implementation guidance, please see Differentiated and simplified pre-exposure prophylaxis for HIV prevention: Update to WHO implementation guidance.

Post-exposure prophylaxis (PEP) for HIV and STIs
Existing guidance statement PEP should be available to all eligible people from key populations on a voluntary basis after possible exposure to HIV (3).
Existing guidance statement For women who have been raped, a package of PEP, emergency contraception and presumptive treatment of STIs is recommended (173).

For detailed guidance on HIV PEP regimens, please see Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach.

For detailed guidance on PEP for adults who have been sexually abused, please see WHO guidelines Responding to intimate partner violence and sexual violence against women.

For detailed guidance on PEP for children and adolescents who have been sexually abused, please see WHO guidelines Responding to children and adolescents who have been sexually abused.

Prevention of vertical transmission of HIV, syphilis and HBV
Existing GRADE recommendation (adapted) 7

HIV, syphilis and hepatitis B surface antigen (HBsAg)* tests should be offered at least once and as early as possible in pregnancy, ideally at the first antenatal care (ANC) visit (syphilis: strong recommendation, moderate quality of evidence; HBsAg*: strong recommendation, low certainty of evidence) (174, 175).

* Particularly in settings with a ≥2% HBsAg seroprevalence in the general population.

Recommended time points for HIV retesting for pregnant and postpartum key populations: early in pregnancy (first ANC visit); late in pregnancy (third trimester ANC visit); one additional postpartum retest (14 weeks, six months or nine months postpartum) (175).

Please see also STI testing below; chlamydia and gonorrhoea screening is recommended for all key populations, including those who are pregnant.

Existing guidance statement Dual HIV/syphilis rapid diagnostic tests (RDTs) can be the first test in HIV testing strategies and algorithms in ANC (176). HBsAG testing should be considered in addition when dual testing is performed.
Existing good practice statement (adapted) 8 ART should be initiated urgently among all pregnant and breast and chest feeding people living with HIV, even if they are identified late in pregnancy or postpartum, because the most effective way to prevent HIV vertical transmission is to reduce maternal viral load (171).
Existing GRADE recommendation (adapted) 9 For early syphilis in pregnancy, the WHO STI guideline suggests using benzathine penicillin G 2.4 million units once intramuscularly over procaine penicillin 1.2 million units intramuscularly once daily for 10 days (conditional recommendation, very low certainty of evidence) (177).
Existing GRADE recommendation (adapted) 10 WHO recommends that those who test positive for HBV infection (HBsAg positive) with an HBV DNA ≥ 5.3 log10 IU/mL (≥ 200,000 IU/mL) during pregnancy receive tenofovir prophylaxis from the 28th week of pregnancy until at least birth, to prevent vertical transmission of HBV. This is in addition to three-dose hepatitis B vaccination in all infants, including timely birth dose (conditional recommendation, moderate certainty of evidence) (178).
Existing GRADE recommendation (adapted) 11

WHO recommends that in settings in which antenatal HBV DNA testing is not available, hepatitis B e antigen (HBeAg) testing can be used as an alternative to HBV DNA testing to determine eligibility for tenofovir prophylaxis to prevent vertical transmission of HBV2 (conditional recommendation, moderate certainty of evidence) (178).

Please see also: WHO technical brief: preventing HIV during pregnancy and breastfeeding in the context of PrEP.

Hepatitis B vaccination
Existing WHO position

WHO recommends hepatitis B vaccination of persons at high risk of HBV infection.12

Please find further details in WHO position paper: Hepatitis B vaccines: – July 2017

Existing GRADE recommendation It is suggested to offer people who inject drugs the rapid hepatitis B vaccination regimen13 (conditional recommendation, very low certainty of evidence) (168).
Addressing chemsex

★

New good practice statement

Addressing chemsex*, especially for key populations and their sexual partners, requires a comprehensive, non-judgemental and person-centred approach. This can include integrated sexual and reproductive health, mental health, access to sterile needles and syringes and OAMT services, with linkages to other evidence-based prevention, diagnostic and treatment interventions.

*Chemsex, for the purpose of these guidelines, is defined as when individuals engage in sexual activity, while taking primarily stimulant drugs, typically involving multiple participants and over a prolonged period.

Further details on evidence, decision-making, implementations, considerations and research gaps related to this new recommendation can be found in Chapter 9.

Diagnosis
HIV testing services
Existing guidance statement In high and low HIV-burden settings, HIV testing should be offered to all key populations and their partners in all services as an efficient and effective way to identify people with HIV (175).
Existing guidance statement

It is recommended to offer retesting at least annually to all people from key populations. Depending on individual risk behaviours, more frequent voluntary retesting can be offered (175).

Mathematical modelling among key populations in Viet Nam shows that retesting for key populations is cost effective. Bi-annual testing for key populations may be considered in similar settings, and should prioritize those at higher risk (179).

Existing GRADE recommendation Community-based HIV testing services for key populations linked to prevention, treatment and care services are recommended, in addition to routine, facility-based HIV testing services in all settings (strong recommendation, low certainty of evidence) (175).
Existing GRADE recommendation Lay providers who are trained can, using rapid diagnostic tests, independently conduct safe and effective HIV testing services (strong recommendation, moderate certainty of evidence) (175).
Existing GRADE recommendation

HIV self-testing should be offered as an approach to HIV testing services (strong recommendation, moderate certainty of evidence) (175).

Please note that self-testing means an individual performing a test on themselves in private or under observation of a professional if they so desire. It should be voluntary and cannot be forced or coerced by anyone. Importantly, people who have self-tested should not be forced to disclose the results of that test to anyone, and should only do so on a voluntary basis.

Existing GRADE recommendation Social network-based approaches can be offered as an approach to HIV testing key populations as part of a comprehensive package of care and prevention (conditional recommendation, very low certainty of evidence) (175).
Existing GRADE recommendation

Provider-assisted referral should be offered for all people with HIV as part of a voluntary comprehensive package of testing and care (including key populations) (strong recommendation, moderate certainty of evidence) (175).

Please note that particularly for sex workers, the risks associated with disclosing an HIV diagnosis to either clients or regular partners must be carefully considered and should always be voluntary. People who are experiencing intimate partner or other violence need assessment, support, documentation, treatment of any injuries and referral to appropriate services (162).

Existing guidance statement

Dual HIV/syphilis RDTs may be considered for use among key populations and can increase access to both HIV and syphilis testing services (181).

Further testing to confirm syphilis diagnosis or offer of treatment depends on local epidemiology, past treatment history, available resources and confirmatory testing capacity, and national protocols.

Mathematical modelling among key populations in Viet Nam shows that using dual HIV/syphilis RDT is cost-saving compared to separate HIV and syphilis tests at current coverage (179).

For detailed guidance on HIV testing, please see Consolidated guidelines on HIV testing services.
STI testing
Existing guidance statement Screening and diagnosing STIs for key populations is a crucial part of a comprehensive response to HIV and STIs (3).
Existing GRADE recommendation Offering periodic testing for asymptomatic urethral and rectal N. gonorrhoeae and C. trachomatis infections using nucleic acid amplification tests (NAAT) is suggested over not offering such testing for men who have sex with men and trans and gender diverse people (conditional recommendation, low certainty of evidence) (79).
Existing GRADE recommendation Offering periodic serological testing for asymptomatic syphilis infection to men who have sex with men and trans and gender diverse people is strongly recommended over not offering such screening (strong recommendation, moderate certainty of evidence) (79).
Existing GRADE recommendation

WHO suggests offering periodic screening for asymptomatic sexually transmitted infections* to sex workers (conditional recommendation, low certainty of evidence) (84).

*Chlamydia, gonorrhoea and syphilis

Existing GRADE recommendation Self-collection of samples for Neisseria gonorrhoeae and Chlamydia trachomatis should be made available as an additional approach to deliver STI testing services (strong recommendation, moderate certainty of evidence) (182).
Existing GRADE recommendation For people with symptoms of: 1) urethral discharge from the penis or 2) anorectal discharge and report receptive anal sex, management is recommended to be based on the results of quality-assured molecular assays. However, in settings with limited or no molecular tests or laboratory capacity, WHO recommends syndromic treatment to ensure treatment on the same day of the visit (strong recommendation, moderate certainty of evidence) (183).
Existing GRADE recommendation For people who present with genital ulcers (including anorectal ulcers), WHO recommends treatment based on quality-assured molecular assays of the ulcer. However, in settings with limited or no molecular tests or laboratory capacity, WHO recommends syndromic treatment to ensure treatment on the same day of the visit (strong recommendation, moderate certainty of evidence) (183).

For detailed guidance screening and diagnosis of different STIs please see:

Guidelines for the management of symptomatic sexually transmitted infections

WHO guidelines for the treatment of Neisseria gonorrhoeae

WHO guidelines for the treatment of Treponema pallidum (syphilis)

WHO guideline on syphilis screening and treatment for pregnant women

WHO guidelines for the treatment of Chlamydia trachomatis

WHO guidelines for the treatment of genital herpes simplex virus

Hepatitis C testing
Existing GRADE recommendation

In all settings (and regardless of whether delivered through facility- or community-based or self-testing testing), it is recommended that serological testing for HCV antibody (anti-HCV) be offered, with linkage to prevention, confirmatory diagnosis, care and treatment services, to the following individuals (184):

  • adults and adolescents from populations most affected by HCV infection (i.e., who are either part of a population with high HCV seroprevalence or who have a history of exposure and/or high-risk behaviours for HCV infection)14; and
  • adults, adolescents and children with a clinical suspicion of chronic viral hepatitis C (i.e., symptoms, signs, laboratory markers).
(strong recommendation, low certainty of evidence).

For detailed guidance on HCV testing: how to test, how to confirm viraemic HCV infection and which assays to use, please see Guidelines on hepatitis B and C testing.

★

New GRADE recommendation

People at ongoing risk and a history of treatment-induced or spontaneous clearance of HCV infection may be offered 3–6-monthly testing for presence of HCV viremia (conditional recommendation, very low certainty of evidence).

Remarks:

  • Testing should be voluntary and not be used to further stigmatize any populations at ongoing risk.
  • Testing should be offered alongside primary prevention services that are evidence-based and reduce transmission risks, and in combination with appropriate treatment access and linkage.
  • To detect presence of viremic infection, the use of quantitative or qualitative nucleic acid testing (NAT) for detection of HCV RNA, or alternatively an assay to detect HCV core antigen, can be performed.
Further details on evidence, decision-making, implementation considerations and research gaps related to this new recommendation can be found in Chapter 9.

Existing GRADE recommendation HCV self-testing should be offered as an additional approach to HCV testing services (strong recommendation, moderate certainty of evidence) (185).
Hepatitis B testing
Existing GRADE recommendation

In all settings (and regardless of whether delivered through facility- or community-based testing), it is recommended that HBsAg serological testing and linkage to prevention, care and treatment services be offered to the following individuals (184):

  • adults and adolescents from populations most affected by HBV infection (i.e., who are either part of a population with high HBV seroprevalence or who have a history of exposure and/or high-risk behaviours for HBV infection);
  • adults, adolescents and children with a clinical suspicion of chronic viral hepatitis (i.e., symptoms, signs, laboratory markers);
  • all pregnant women (at least once and as early as possible, ideally at the first ANC visit); and
  • sexual partners, children and other family members, and close household contacts of those with HBV infection.
(strong recommendation, low certainty of evidence)

For detailed guidance on HBV testing and diagnosis, please see Guidelines on hepatitis B and C testing.

Treatment
HIV treatment
Existing GRADE recommendation ART should be initiated in all adults living with HIV, regardless of WHO clinical stage and at any CD4 cell count (strong recommendation, moderate certainty of evidence) (171).

For detailed guidance on HIV treatment, please see Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach.

Please also see the service delivery chapter for details of differentiated service delivery for ART.

★

New guidance statement

Successful ART with viral suppression prevents HIV transmission to sexual partners: there is no transmission when viral load is undetectable or suppressed (less than or equal to 1000 copies/ML) (186–188).
HIV-associated TB
Existing GRADE recommendation People living with HIV should be systematically screened for TB disease at each visit to a health facility (strong recommendation, very low certainty of evidence) (189).
Existing GRADE recommendation

ART should be started as soon as possible within two weeks of initiating TB treatment, regardless of CD4 cell count, among people living with HIV* (strong recommendation, low-moderate certainty of evidence for adults and adolescents, very low certainty of evidence for children).

*Except when signs and symptoms of meningitis are present

Existing GRADE recommendation WHO recommends ART for all people with HIV and drug-resistant TB, requiring second-line anti-TB drugs irrespective of CD4 cell count, as early as possible (within the first eight weeks) following initiation of anti-TB treatment (strong recommendation, very low certainty of evidence) (190, 191).
Existing GRADE recommendation Adults and adolescents living with HIV who are unlikely to have active TB should receive TB preventive treatment as part of a comprehensive package of HIV care. Treatment should also be given to those receiving ART, to pregnant women and to those who have previously been treated for TB, irrespective of the degree of immunosuppression, and even if TB infection testing is unavailable (strong recommendation, high certainty evidence) (192).
Existing GRADE recommendation Routine co-trimoxazole prophylaxis should be given to all people living with HIV with active TB disease regardless of CD4 cell count (strong recommendation, high certainty of evidence) (190).

For detailed guidance on TB/HIV, please see Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach.

WHO guidelines on TB can be accessed here.

STI treatment

STIs disproportionately affect key populations and should be diagnosed and treated in a timely manner following WHO guidelines.

For detailed guidance on treating different STIs please see:

Guidelines for the management of symptomatic sexually transmitted infections

WHO guidelines for the treatment of Neisseria gonorrhoeae

WHO guidelines for the treatment of Treponema pallidum (syphilis)

WHO guideline on syphilis screening and treatment for pregnant women

WHO guidelines for the treatment of Chlamydia trachomatis

WHO guidelines for the treatment of genital herpes simplex virus

HCV treatment
Existing GRADE recommendation WHO recommends offering treatment to all individuals diagnosed with HCV infection who are 12 years of age or older, irrespective of disease stage (strong recommendation, moderate certainty of evidence) (193).
Existing GRADE recommendation

WHO recommends the use of pan-genotypic direct-acting antiviral (DAA) regimens for treatment of all adults, adolescents and children aged 3 years and above with chronic hepatitis C virus infection, regardless of stage of disease.

Adults (18 years and above): (strong recommendation, moderate certainty of evidence).

Adolescents (12–17 years): (strong recommendation; moderate-low certainty of evidence).

For detailed guidance on HCV treatment, please see:

Guidelines for the care and treatment of persons diagnosed with chronic hepatitis C virus infection and,

Updated recommendations on treatment of adolescents and children with chronic HCV infection and HCV simplified service delivery and HCV diagnostics

★

New GRADE recommendation

Pan-genotypic DAA-HCV treatment should be offered without delay to people with recently acquired HCV infection and ongoing risk (strong recommendation, very low certainty of evidence).

Remarks:

  • Individuals with recently acquired infection must have the option to make an informed choice about starting treatment immediately or delaying treatment initiation.
  • Treatment for recently acquired infection should be offered alongside additional, evidence-based interventions to reduce HCV risk and primary prevention services.

Further details on evidence, decision-making, implementation considerations and research gaps related to this new recommendation can be found in the Chapter 9.

HBV treatment
Existing GRADE recommendation As a priority, all adults, adolescents and children with chronic hepatitis B and clinical evidence of compensated or decompensated cirrhosis (or cirrhosis based on APRI score >2 in adults) should be treated, regardless of ALT levels, HBeAg status or HBV DNA levels (194) (strong recommendation, moderate certainty of evidence).
Existing GRADE recommendation Treatment is recommended for adults with chronic hepatitis B who do not have clinical evidence of cirrhosis (or based on APRI score ≤2 in adults), but are aged more than 30 years (in particular), and have persistently abnormal ALT levels and evidence of high-level HBV replication (HBV DNA >20 000 IU/mL), regardless of HBeAg status (194) (strong recommendation, moderate certainty of evidence).
Existing GRADE recommendation

Where HBV DNA is not available: Treatment may be considered based on persistently abnormal ALT levels alone, regardless of HBeAg status (194) (conditional recommendation, low certainty of evidence).

For detailed guidance on HBV treatment, please see Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection.

Essential for broader health: health interventions
Anal health

★

New guidance statement

WHO does not have specific recommendations about anal health or anal cancer, but people infected with HIV are at least 20 times more likely to be diagnosed with anal cancer than uninfected people (195). Like cancer of the cervix, anal cancer is associated with human papillomavirus (HPV) and HPV is vaccine-preventable for all people.15

Cytological screening can be performed for anal cancer and its precursors, known as anal high-grade squamous intraepithelial lesions, particularly for men who have sex with men, trans and gender diverse people and other people who are more likely to engage in anal sex.

Conception and pregnancy care
Existing guidance statement (adapted) 16 It is important that all members of key population groups have the same support and access to services related to conception and pregnancy care as pregnant people who are not members of key population groups, as indicated by WHO guidelines (3).

WHO has various guidelines on conception and pregnancy. Please see the WHO maternal health webpage.

For specific recommendations related to pregnancy and HIV, please see Consolidated guideline on sexual and reproductive health and rights of women living with HIV.

Contraception
WHO does not have an overarching recommendation related to contraception for key populations, but publishes medical eligibility criteria for contraceptive use (MEC), which provides guidance on the safety of various contraceptive methods for use in the context of specific health conditions and characteristics (197).
Existing guidance statement All hormonal contraceptive methods and intrauterine devices (IUDs) now fall into Category 1 of the MEC for women at high risk of HIV. Thus, women at high risk of HIV can use all methods of contraception without restriction.

For detailed guidance on contraception, please see:

Medical eligibility criteria for contraceptive use

Selected practice recommendations for contraceptive use

Contraceptive eligibility for women at high risk of HIV

Please see also the service delivery chapter for details of integrating HIV, family planning and STI services.

Gender-affirming care17
Existing guidance statement

Trans and gender diverse individuals who self-administer gender-affirming hormones require access to evidence-based information, quality products and sterile injection equipment (182).

The principles of gender equality and human rights in the delivery of quality gender-affirming hormones are critical to expanding access to this important intervention and reducing discrimination based on gender identity (182).

Mental health
Existing guidance statement Routine screening and management for mental health issues (particularly depression and psychosocial stress) should be provided for people from key populations in keeping with the principles of consent, confidentiality and evidence-based quality (3).

WHO does not have overarching recommendations related to preventing or treating mental health issues for key populations. Instead, specific mental health issues and recommendations and a practical guide on addressing mental health issues in non-specialized health settings is provided by the mental health gap action programme (MhGAP):

MhGAP Evidence Resource Centre

MhGAP intervention guide

Prevention, assessment and treatment of cervical cancer
Existing WHO position

WHO recommends that all countries proceed with nationwide introduction of HPV vaccination.

For the preven tion of cervical cancer, the WHO-recommended primary target population for HPV vaccination is girls aged 9–14 years, prior to becoming sexually active. Vaccina tion strategies should initially prioritize high coverage in this priority population (196).

Existing GRADE recommendation HPV self-sampling should be made available as an additional approach to sampling in cervical cancer screening services for individuals aged 30–60 years (strong recommendation, moderate certainty of evidence) (182).
Existing guidance statement

All people with a female reproductive system are at risk for cervical cancer. Recommendations for cervical cancer prevention, screening and treatment can be found in the WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, which includes 16 new and updated recommendations and good practice statements for women living with HIV (198, 199).

For detailed guidance on cervical cancer prevention, screening and treatment, please see:

WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention

New WHO recommendations on screening and treatment to prevent cervical cancer among women living with HIV

Safe abortion
Existing guidance statement Abortion laws and services should protect the health and human rights of all women, including those from key populations (3).
Existing GRADE recommendation

WHO recommends the full decriminalization of abortion; recommends against laws and other regulations that restrict abortion by grounds; recommends that abortion be available on the request of the woman, girl or other pregnant person; and recommends against laws and other regulations that prohibit abortion based on gestational age limits (strong recommendations) (200).

For detailed guidance on safe abortion, please see Abortion care guideline.

Screening and treatment for hazardous and harmful alcohol and other substance use
Existing GRADE recommendation (adapted) 18 All key populations with hazardous and 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 certainty of evidence) (3, 201, 202).

For details on recommended, evidence-based interventions for the screening and treatment of hazardous and harmful drug and alcohol use please see:

MhGAP Evidence Resource Centre

MhGAP intervention guide

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

International standards for the treatment of drug use disorders

TB prevention, screening, diagnosis and treatment
Existing GRADE recommendation Systematic screening for TB disease should be conducted in prisons and penitentiary institutions (strong recommendation, very low certainty of evidence) (189).
Existing GRADE recommendation Systematic screening for TB disease may be conducted among subpopulations with structural risk factors for TB. These include urban poor communities, homeless communities, communities in remote or isolated areas, indigenous populations, migrants, refugees, internally displaced persons and other vulnerable or marginalized groups with limited access to health care (conditional recommendation, very low certainty of evidence) (189).
Existing GRADE recommendation Systematic TB infection testing and treatment may be considered for people in prisons, health workers, immigrants from countries with a high TB burden, homeless people and people who use drugs (conditional recommendation, low to very low certainty in the estimates of effect) (192).
TB prevention, screening, diagnosis and treatment
Existing GRADE recommendation

In settings where the TB prevalence in the general population is 100/100 000 population or higher, systematic screening for TB disease may be conducted among people with a risk factor for TB* who are either seeking health care or who are already in care (conditional recommendation, very low certainty of evidence) (189).

*Substance use disorders and alcohol use disorders are considered risk factors.

Additional guidance on TB prevention, screening, diagnosis and treatment is available:

Consolidated guidelines on tuberculosis Module 1: Prevention: Tuberculosis preventive treatment

Consolidated guidelines on tuberculosis Module 2: Screening – Systematic screening for tuberculosis disease

Consolidated guidelines on tuberculosis Module 3: Diagnosis – Rapid diagnostics for tuberculosis detection

Consolidated guidelines on tuberculosis Module 4: Treatment – Drug-resistant tuberculosis treatment

Supportive interventions

Behavioural interventions, counselling, demand creation, information and education can all support the interventions listed above. In the development of this guideline, we did not find evidence for the effectiveness of counselling behavioural interventions that aim to change risk behaviours (see below).

While we did not review evidence related to other types of behavioural or supportive interventions, and there is limited WHO guidance on these interventions, they may be helpful depending on the context and population. These include:

  • information and education which support key populations to understand their health, health risks, available services and legal rights;
  • interventions which aim to increase demand (demand creation) for evidence-based HIV, viral hepatitis and STI services;
  • supportive counselling which does not aim to change behaviours; and
  • counselling for mental health issues.

In general, the structural barriers which are described in the previous chapter make changing behaviours and improving uptake and retention in services for key populations difficult, and these should be addressed as a priority.

Behavioural interventions

★

New good practice statement

When planning and implementing a response for HIV, viral hepatitis and STIs, policy-makers and providers should be aware that counselling behavioural interventions that aim to change behaviours to reduce risks associated with these infections for key populations have not been shown to have an effect on HIV, viral hepatitis and STI incidence nor on risk behaviour such as condom use and needle sharing. Counselling and information-sharing, not aimed at changing behaviours, can be a key component of engagement with key populations, and when provided it should be in a non-judgmental manner, alongside other prevention interventions and with involvement of peers.

Remarks:

  • Addressing structural and social barriers is critical to create environments which permit supportive and impactful counselling.
  • Counselling interventions which promote abstinence from drug use, rehabilitation or cessation of sex work or drug use, or a so-called cure for homosexuality or gender incongruence (for example, so-called conversion therapy)* are not recommended, and create barriers to key population service access.
* Compulsory, or involuntary, treatment for drug dependence, so-called conversion therapy or rehabilitation of sex workers is against human rights and medical ethics principals of consent, freedom from arbitrary arrest, access to quality health, freedom from torture and cruel, inhuman and degrading treatment.

Further details on evidence, decision-making, implementation considerations and research gaps related to this new practice statement can be found in Chapter 9.

Footnotes

1

In the 2014 Consolidated guidelines for HIV prevention, diagnosis, treatment and care for key populations, the wording of this good practice statement was: Countries should work toward decriminalization of behaviours such as drug use/injecting, sex work, same-sex activity and nonconforming gender identities, and toward elimination of the unjust application of civil law and regulations against people who use/inject drugs, sex workers, men who have sex with men and trans and gender diverse people.

2

In the 2014 Consolidated guidelines for HIV prevention, diagnosis, treatment and care for key populations, the wording of this good practice statement was: Countries should work toward developing non-custodial alternatives to incarceration of drug users, sex workers and people who engage in same-sex activity.

3

In the 2014 Consolidated guidelines for HIV prevention, diagnosis, treatment and care for key populations, the wording of this good practice statement was: Countries should ban compulsory treatment for people who use and/or inject drugs.

4

Compulsory, or involuntary, treatment includes treatment for drug dependence, so-called conversion therapy or rehabilitation of sex workers, which is against human rights and medical ethics principals of consent, freedom from arbitrary arrest, access to quality health, freedom from torture and cruel, inhumane and degrading treatment.

5

Methadone or buprenorphine.

6

Both HCV and HBV can be transmitted sexually, although sexual transmission of HCV is rare as it requires blood contact.

7

Recommendations related to prevention of vertical transmission of HIV, syphilis and HBV have been reworded to be more gender inclusive.

8

Ibid.

9

Ibid.

10

Recommendations related to prevention of vertical transmission of HIV, syphilis and HBV have been reworded to be more gender inclusive.

11

Ibid.

12

Including key populations, persons with chronic liver disease, including those with hepatitis C, persons with HIV infection, and sexual contacts of persons with chronic HBV infection, as well as health care workers and others who may be exposed to blood, blood products or other potentially infectious body fluids.

13

While this recommendation includes only people who inject drugs, this approach may be appropriate for all key populations receiving HBV vaccination.

14

Includes those who are either part of a population with higher seroprevalence (e.g., some mobile/migrant populations from high/intermediate endemic countries, and certain indigenous populations), or who have a history of exposure or high-risk behaviours for HCV infection (e.g., people who inject drugs, people in prisons and other closed settings, men who have sex with men and sex workers, and HIV-infected persons, children of mothers with chronic HCV infection, especially if HIV-coinfected).

15

Achieving high HPV vaccination coverage in girls (>80%) reduces the risk of HPV infection for boys. Vaccination of secondary target populations, e.g., females aged ≥15 years or males, is recommended only if this is feasible, affordable, cost-effective, and does not divert resources from vaccination of the primary target population or from effective cervical cancer screening programmes (196).

16

This guidance statement has been reworded to be more gender inclusive.

17

WHO guidelines on health services for trans and gender diverse people are under development at the time of writing. They should be available in 2023.

18

The original wording of the recommendation was: 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.

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