Purpose

In this new consolidated guidelines document on HIV prevention, diagnosis, treatment and care for key populations, the World Health Organization (WHO) brings together all existing guidance relevant to five key populations – men who have sex with men, people who inject drugs, people in prisons and other closed settings, sex workers and transgender people – and updates selected guidance and recommendations. These guidelines aim to: provide a comprehensive package of evidence-based HIV-related recommendations for all key populations; increase awareness of the needs of and issues important to key populations; improve access, coverage and uptake of effective and acceptable services; and catalyze greater national and global commitment to adequate funding and services.

The risk behaviours and vulnerabilities of key populations result in their being disproportionately affected by HIV in all countries and settings. These disproportionate risks reflect both behaviour common among members of these populations and specific legal and social issues that increase their vulnerability. Yet HIV services for key populations remain largely inadequate. In many settings HIV incidence in key populations continues to increase, even as incidence stabilizes or declines in the general population.

To date, WHO has developed normative guidance separately for each of the five key populations, but, in general, guidance has not adequately addressed overarching issues relating to key populations. Similarly, the WHO global HIV guidance, including the 2013 consolidated ARV guidelines, did not specifically consider issues relating to key populations. These guidelines aim to address these gaps and limitations. Countries and other end-users have indicated the importance of consolidating WHO's key population guidance to aid national programme managers and service providers, including those from community-based and community-led programmes, in planning for and implementing services for these populations. Thus, this consolidated guidance addresses the issues and elements for effective HIV service delivery that are common to all key populations as well as those specific to one or more groups. This edition includes updates with regard to recent new WHO recommendations, in particular on ARV treatment and on Pre Exposure Prophylaxis (PrEP).

Format of the guidelines

The guidelines are presented in seven chapters:

Guidelines development methodology

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

The External Steering Group proposed that the consolidated key populations guidelines provide recommendations along the continuum of HIV care – prevention, diagnosis, linkage, treatment and care – and include recommendations and guidance on the critical enablers that are essential to support provision of safe, effective and acceptable HIV services. New areas identified included re-reviewing evidence concerning the provision of pre-exposure prophylaxis of HIV (PrEP) for men who have sex with men and assessing evidence concerning PrEP for people who inject drugs, a group not considered in the previous guidance. The External Steering Group also prioritized development of recommendations on the community delivery of naloxone for treating opioid overdose and updating of recommendations for people in prisons and other closed settings.

Following the October 2013 meeting of the External Steering Group, a Guidelines Development Group was formed, comprising the majority of the External Steering Group members along with some additional expert members. Meeting in March 2014, the Guidelines Development Group unanimously supported a reworded PrEP recommendation for men who have sex with men; a majority vote determined the strength of the recommendation. In addition, the Guidelines Development Group reviewed and fully supported all other areas of the existing guidelines. In March 2014 a separate Guidelines Development Group reviewed proposed new guidance on community delivery of naloxone.

Following these meetings the draft consolidated key populations guidelines were reviewed by external peer reviewers, UN agency reviewers and WHO staff members from the Department of HIV and the Department of Mental Health and Substance Abuse, other WHO departments and regional teams.

Recommendations

The accompanying table summarizes the recommendations presented in this document.

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

Implications for programming

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

Further research

With partner organizations, the Department of HIV is developing a comprehensive HIV service implementation science framework, highlighting key research priorities, including those for key populations.

Summary of WHO recommendations concerning key populations