1.1. Key populations and vulnerable groups
Key populations. The risk behaviours and vulnerabilities of specific populations and their networks determine the dynamics of HIV epidemics. These guidelines focus on five key population groups, which in almost all settings are disproportionately affected by HIV:
Without addressing the needs of key populations, a sustainable response to HIV will not be achieved.
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 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.
Members of all key populations continue to experience intense stigma and discrimination, legal barriers and constraints to accessing services and often low prioritization by the public health system, including ministries of health. In many settings community-based organizations provide important services for key populations. Better partnerships and linkages between community organizations and ministries of health are crucial. Equitable access to, and provision of, HIV and related health services to key populations are a high priority, requiring adequate domestic and external funding.
Rationale for consolidated guidelines on key populations
World Health Organization (WHO) guidance exists on each of the five key populations, but it has not adequately addressed issues common to all these key populations nor has it addressed countries' needs for a coherent approach informed by situational analysis. This document seeks to bring together WHO and UN partners' guidelines on the five key population groups into one document. This document also makes reference to WHO tools and other documents on programme activities relevant to the health of key populations, such as strategic information/monitoring and evaluation for key populations, along with publications from United Nations partners and new material to fill identified gaps.
These guidelines consider the elements common to all key populations as well as highlighting specific issues and risks unique to each group. This approach is meant to help countries to plan, develop and monitor, more effectively and efficiently, acceptable and appropriate programmes for key populations relevant to their particular epidemiological context. The guidelines discuss implementation issues that services must address to achieve equity and maximize impact.
1.2. HIV in key populations
Key populations experience significant HIV burden, and they influence the dynamics of HIV epidemics.
There is a clear epidemiological rationale for HIV programmes to focus on key population groups. In many settings HIV incidence in the general population has stabilized or fallen. However, globally, key populations continue to experience significant HIV burden, and they influence the dynamics of HIV epidemics.
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.
1.2.1. Men who have sex with men
Epidemics of HIV in men who have sex with men continue to expand in most countries. In major urban areas HIV prevalence among men who have sex with men is on average 13 times greater than in the general population (3). One reason for the high HIV prevalence among men who have sex with men may be that HIV transmission through anal intercourse without a condom is more efficient than through vaginal intercourse without a condom, and individual-level risks for HIV acquisition among men who have sex with men include unprotected receptive anal intercourse, high number of male partners, and concomitant injecting drug use (4, 5, 6).
Globally, epidemics of HIV in men who have sex with men continue to expand.
By region, estimates of HIV prevalence among men who have sex with men range from 3.0% in the Middle East and North Africa to 25.4% in the Caribbean (4). In Kenya, the only African country with HIV incidence data, an annual incidence of greater than 20% was reported recently in Mombasa (4). Other countries in Africa report high prevalence, for example, Côte d'Ivoire, where the prevalence of HIV among men who have sex with men has been estimated at 18% (7, 8). In other regions where HIV incidence among men who have sex with men is reported or modelled, there is no evidence of decrease. In fact, for example, China and Thailand report increasing incidence.
Discriminatory legislation, stigma (including by health workers) and homophobic violence in many countries pose major barriers to providing HIV services for men who have sex with men and limit their use of what services do exist. Many countries criminalize sex with the same gender (either male–male only or both male–male and female–female). As of December 2011 same-sex practices were criminalized in 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).
1.2.2. People in prisons and other closed settings
There are more than 10 million men and women in prisons and other closed settings, with an annual turnover of around 30 million moving between prison and the community (17). Globally, the prevalence of HIV, sexually transmitted infections, hepatitis B and C and tuberculosis in prison populations is estimated to be twice to ten times higher than in the general population (18). Higher HIV prevalence and HIV risk are seen among both prisoners and those working in prisons and their families in many settings (19).
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).
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.
1.2.3. People who inject drugs
Worldwide, 158 countries have reported injecting drug use, and 123 of these countries (78%) have reported HIV among people who inject drugs (12, 13). Prevalence data on the extent of injecting drug use is not available for almost half of these countries, in particular in Africa, the Middle East and Latin America. The United Nations Office on Drugs and Crime (UNODC) jointly with WHO, UNAIDS and the World Bank estimated that in 2012 worldwide about 12.7 million (range: 8.9 million–22.4 million) people had recently injected drugs and that, of these, 1.7 million (range: 0.9 million–4.8 million) people (13.1%) were living with HIV.
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).
1.2.4. Sex workers
Globally, the average HIV prevalence among sex workers is estimated to be approximately 12%. There is large variation within regions in HIV prevalence and odds ratios for HIV infection. In 26 countries with medium and high HIV prevalence in the general population, 30.7% of sex workers were HIV-positive (3, 23). For example, HIV prevalence among sex workers in Nigeria was estimated at 24.5% (compared with 3.7% among the general population ages 15–49 years), in Latvia at 22.2% (compared with 0.7% in the general population), and in Rwanda at 50.8% (compared with 2.9% in the general population) (3).
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.
1.2.5. Transgender people
A meta-analysis published in 2013 highlighted the particular vulnerability to HIV of transgender women. Data were available only for countries with male-predominant HIV epidemics, which included the United States of America, six Asia–Pacific countries, five in Latin America, and three in Europe. The pooled HIV prevalence was 19.1%. Among 7197 transgender women sampled in 10 low- and middle-income countries, HIV prevalence was 17.7%. Among 3869 transgender women sampled in five high-income countries, HIV prevalence was 21.6% (24).
1.2.6. Overlapping vulnerabilities and differing risks
Many people from key populations engage in more than one high-risk behaviour (e.g. injecting drugs and sex work, or a man who has sex with other men who also injects drugs). Thus, they are likely to have higher HIV prevalence rates than those with only one type of risk.
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 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.
1.2.7. Adolescents and young people from key populations
Adolescents and young people from key populations are at significant HIV risk, higher than that of their older peers in these populations. Studies are limited, but they consistently show that adolescents and young people from key populations are even more vulnerable than older cohorts to STIs, HIV and other sexual and reproductive health problems (28). Rapid physical, emotional and mental development, complex psychosocial and socio-economic factors and poor access to and uptake of services increase their vulnerability and risk (29). Particularly for those under age 18 years, policy and legal barriers related to age of consent often prevent access to a range of health services, including HIV testing and counselling (HTC), harm reduction and other services provided specifically for key populations (30). Such barriers also limit adolescents' ability to exercise their right to informed and independent decision-making.
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).
Reliable and representative epidemiological and behavioural data on adolescents and young people from key population groups remain limited (32). Young people remain largely invisible in routine HIV surveillance and in research on HIV prevalence and risk. This lack of data often leads to neglect of their specific needs by policies and programmes designed for youth generally and by services for adults from key populations (32).1
The specific needs of young people from key populations are neglected both by programmes designed for youth generally and by programmes for adults from key populations.
1.3. Addressing key populations: a wise investment
The recent move toward more strategic use of HIV resources (33) draws attention to the value of addressing HIV in key populations. In both concentrated and generalized epidemics, greater investment in a country's key populations is likely to improve the cost-effectiveness of the response to HIV.
To date, investments in most countries have focused on the general population. In concentrated epidemics, however, almost by definition the great majority of infections are in key populations and, sometimes, specific vulnerable groups. Even in generalized 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 populations is substantial, although it varies greatly – for example, an estimated 10% in Uganda, 30% in Burkina Faso, 34% in Kenya, 37% in Nigeria, 43% in Ghana and 45% in Benin.
Between 40% and 50% of all new HIV infections among adults worldwide occur among people from key populations and their immediate partners.
1.3.1. Key to the dynamics of epidemics
Another reason that investment in key populations is cost-effective is the central role of key populations in the dynamics of epidemics. People from key populations can also transmit HIV to other populations – for example, sex workers' clients and the sexual partners of people who inject drugs. Thus, infections in people from key populations can have a multiplier effect.
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).
1.3.2. Expanding coverage can make a difference
For a country the impact of improved coverage for key populations could range from averting a considerable number of new infections to stabilizing or even turning around growing overall incidence rates.
Projections suggest that the impacts of improved service coverage of key populations could range from averting a considerable number of new infections in countries with generalized epidemics to stabilizing or even turning around growing incidence rates in countries with concentrated epidemics.
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 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).
1.4. Scope of these key population guidelines
These guidelines outline a public health response to HIV for the five key populations. They present and discuss new recommendations and a range of recommendations and guidance from current WHO guidelines, including the 2013 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection (2). They summarize the components of a comprehensive package of interventions for key populations and consider implementation issues, challenges, and opportunities. The guidelines also provide help on prioritizing and planning services.
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.
1.5. Using these guidelines
As in the consolidated ARV guidelines, these guidelines consider the need to support services across the cascade of HIV prevention, diagnosis, care and treatment ().
Cascade of HIV prevention, diagnosis, care and treatment.
Symbols used throughout the document
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| overarching WHO recommendations are in line with existing WHO recommendations and are shaded in blue (see below), and the source of the recommendation is provided for further reference, |
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| NEW | new WHO recommendations developed specifically for this guidance, |
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| PIPELINE | recommendations under development – key clinical areas where WHO is developing guidelines. |
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Within these guidelines the heading “Good practice recommendations” indicates recommendations that may be helpful but do not need grading and are those in which it is sufficiently obvious that desirable effects outweigh undesirable effects. They often pertain to human rights principles reflected in a number of international agreements and to issues of equity and ethics.
Colour coding in this document
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| All key population groups |
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| Men who have sex with men |
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| People in prisons and other closed settings |
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| People who inject drugs |
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| Sex workers |
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| Transgender people |
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| Adolescents from key populations |
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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.
1.6. Goal and objectives
These guidelines seek to provide consolidated guidance to inform the development and implementation of HIV policies, programmes and services for key populations.
The guidelines have the following specific objectives:
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.
1.7. Target audience
These guidelines are addressed primarily to national HIV programme managers and other decision-makers within ministries of health and those responsible for health policies, programmes and services in prisons. In addition, the guidelines will be relevant for managers at national and sub-national levels responsible for services for TB, viral hepatitis, sexual and reproductive health, harm reduction and drug dependence, and mental health; community-led civil society organizations and implementing programmes; and development and funding agencies.
1.8. Guidelines principles
The framework for the development of these guidelines is based on human rights principles reflected in a number of international agreements (39, 40).
Guiding principles
human rights
access to quality health care
access to justice
acceptability of services
health literacy
integrated service provision.
Human rights: Fundamental to development of these guidelines is the protection of human rights for all members of each key population. Legislators and other government authorities should establish and enforce antidiscrimination and protective laws, derived from international human rights standards, in order to eliminate stigma, discrimination and violence faced by key populations and to reduce their vulnerability to HIV (
40).
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).
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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.
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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.
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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).
