Consolidated guidelines on HIV,

viral hepatitis and STI prevention,

diagnosis, treatment and care for
key populations
Policy brief

1
Photo credits
Cover image: © Women’s Network South Africa NPUD
Consolidated guidelines on HIV,
viral hepatitis and STI prevention,
diagnosis, treatment and care for
key populations
Policy brief
Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and
care for key populations: policy brief
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Key populations for HIV, viral hepatitis and STIs
The Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for
key populations July 2022 outline a public health response to HIV, viral hepatitis and sexually transmitted
infections (STIs) for five key populations (men who have sex with men, sex workers, people in prisons
and other closed settings, people who inject drugs and trans and gender diverse people). The guidelines
present and discuss new recommendations and consolidate a range of recommendations and
guidance from current WHO guidelines which are summarised here in this policy brief.
Key populations in the HIV response are also critical to the achievement of the global elimination
goals for viral hepatitis and STIs. This is for the following reasons.
• The structural barriers which limit the five key populations’ access to HIV services also limit
their access to viral hepatitis and STI services.
• HIV risk behaviours, such as condomless sex and unsafe injecting, which in general are
more common in key populations, are also among those that increase risk of acquiring viral
hepatitis and STIs; therefore, integrating a response to address these risk behaviours brings
greater efficiency both for people and for public health.
• Many of the interventions recommended for HIV prevention also have an impact on
transmission of viral hepatitis and STIs.
In most countries, inadequate coverage and often poor quality of health services for key populations
continue to undermine responses to HIV, viral hepatitis and STIs. All countries should prioritize
reaching these key populations for greatest impact and supporting key population communities to
lead the response and provide equitable, accessible and acceptable services.
These guidelines are developed with the following principles:
• human rights
• gender equality
• equity and inclusion
• medical ethics
• universal health coverage
• evidence-based public health
• key population community-led response.

Structural barriers
Particularly for key populations, social, legal, structural and other contextual factors both increase
vulnerability to HIV, viral hepatitis and STIs, and obstruct access to health and other essential
services. In many settings, one or more aspects of key population members’ behaviour, work or
gender expression are criminalized, and members are subject to punitive legislation and policing
practices. Stigma and discrimination from/by the general population and health workers and law
enforcement officials are perpetuated by criminalization, which also means that legal or policy
change is more difficult to achieve. Stigma and discrimination in health care settings are common
experiences among key populations, and create significant barriers to achieving universal health
coverage. Stigma and discrimination are related to unemployment and poverty as well as violence
and human rights abuse. Violence and other human rights abuses are exacerbated by criminalization,
making key population members less likely to report abuses and increase vulnerability to such
abuses. In combination, these reduce access to HIV, STI, viral hepatitis and other health services; can
lead to poorer uptake and inconsistent use of prevention methods, such as condoms, pre-exposure
prophylaxis (PrEP) and post exposure prophylaxis (PEP) for HIV and sterile injecting equipment, and to
delayed diagnosis and poorer linkage and retention in treatment programmes (see Fig. 1.).

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 Fig. 1. Factors contributing to HIV, STIs and viral hepatitis in key populations

Criminalization
Stigma Punitive, restrictive policies

Violence Gender
Other human rights Unemployment Race
abuses Poverty Disability
Discrimination Education

Reduced access to prevention, testing and treatment services

Barriers to safe sex or safe injecting
Higher risk behaviors: unprotected sex, needles/syringe sharing

Biological factors Social factors

Enhance transmission efficiency of: Number of sexual or injecting
1. anal intercourse; partners
2. needle/syringe sharing
Social and sexual networks with
Direct effects of viral hepatitis, shared risks
acute STIs and inflammation on HIV
acquisition

Untreated infections

HIV, viral hepatitis and STIs

Responding to HIV, viral hepatitis and STIs in key populations

Sustainable Development Goal (SDG) 3 and related target 3.3 are: “By 2030, end the epidemics of AIDS,
tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and
other communicable diseases”. This can only be achieved by prioritizing the prevention, diagnosis
and treatment of these infections in key populations and focusing on impact. Fig. 2. describes a
theory of change for meeting these global targets by 2030 and is detailed in the text below.
To prevent, diagnose and treat infections, key populations need equitable access to services at an
adequate scale to have impact. The Joint United Nations Programme on HIV/AIDS (UNAIDS) set HIV
coverage targets for 2025 as part of its global strategy to end AIDS (1), which applies to all populations:
95% use combination prevention; 95% of people living with HIV know their HIV status; 95% of
people living with HIV who know their status initiate treatment; 95% of people on HIV treatment
are virally suppressed and 95% of women access HIV and sexual and reproductive health services.

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Global targets for viral hepatitis include 90% of people living with HCV or HBV diagnosed and 80%
treated (HBV) or cured (HCV) by 2030. For STIs targets are that by 2030 >90% of priority populations
are screened for gonorrhoea or syphilis and >95% treated if positive. Few countries reach this
proportion of key populations with services, contributing to ongoing epidemics.
Access to services for key populations to have an impact on HIV, viral hepatitis and STIs can only
be improved if structural barriers are removed, such as stigma and discrimination, criminalization,
restrictive policies and violence and other human rights abuses, and if enabling environments exist
(please see Chapter 4 on enabling interventions for references).
The global response to HIV, STIs and viral hepatitis has not reached adequate numbers of young
key populations. Young key populations’ lower access to prevention, diagnosis and treatment is due
to a range of factors: misconceptions about risks; lack of knowledge and accurate age-appropriate
information; lack of comprehensive sexuality education; low awareness of available, friendly health
services; and barriers to access and uptake of services (including legal and policy barriers around
consent requirements).
Women who belong to key populations, as well as women who are partners of key population
members, experience alarmingly high risks of acquiring HIV and are less likely to access services. The
UNAIDS global strategy to end AIDS (1) includes 2025 targets related to structural barriers: less than
10% of countries have punitive laws and policies that deny or limit access to services, less than 10%
of people experience stigma and discrimination and less than 10% experience gender inequality and
violence. Relatedly, community empowerment is needed to both increase access and coverage and to
support necessary structural changes.
Putting key populations at the centre of health systems – by organizing services around people’s
needs rather than around diseases, and by promoting integrated patient-centred approaches and
linkages with primary health care services – is key to ending these epidemics. Different service
delivery approaches, including task shifting to key population peers as health workers, decentralizing
provision of services to key population community-led programmes, providing services online and
service integration are also needed to increase access to and availability of HIV, viral hepatitis and STI
services for key populations (2).
Prevention, diagnosis and treatment of STIs, viral hepatitis and HIV can only be achieved if people are
provided with correct and evidence-based interventions with consideration for their individual health
needs through providing person-centred care. This requires understanding of what works to prevent,
diagnose and treat these conditions (see Fig. 2.).
Finally, several effective interventions which prevent and treat HIV, STI and viral hepatitis in key
populations are cost effective and cost saving (3–6), especially when combined and provided in an
integrated manner, but without adequate funding their impact cannot be realized. Funding needs to
be sustainable, predictable and focused on supporting communities.

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 Fig. 2. Theory of change: addressing HIV, viral hepatitis and STIs in key populations

End AIDS, STI and viral hepatitis as public health threats by 2030
End discrimination

Prevent, diagnose and treat HIV, viral hepatitis and STIs in key populations

Ensure access to HIV, viral hepatitis and STI services for

key populations at scale

Reduce structural Community Service delivery Provide Fund priority,

barriers: end stigma, empowerment, approaches: evidence-based, impactful and
discrimination sustainable decentralization, people- sustainable
and inequality, community-led task sharing, centred, quality packages of
decriminalization, services and online service interventions interventions
adapt policy, self-care delivery,
effectively address integration
violence and human
rights violations

The Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for
key populations consolidates WHO recommendations relevant to these population groups.
The interventions have been categorized as follows:
1. Essential for impact: enabling interventions
This includes all interventions recommended to reduce structural barriers to health servicesʼ
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.

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Recommended package
Note that these interventions are not in order of priority.
It is important to note that while we have provided recommended packages of interventions
separately for each key population, people can be members of more than one key population group
or have more than one behaviour that increases their vulnerability to HIV and/or viral hepatitis and
STIs, and some people may have risk behaviours without identifying as members of a particular
group. Therefore, a person who injects drugs, including those that belong to another key population
group, should have access to harm reduction interventions, and any trans or gender diverse person,
whether they also belong to another key population group or not, should have access to gender-
affirming care, and so on.

Essential for impact: enabling interventions

MSM PWID TGD SW PRIS
Removing punitive laws, policies and practices x x x x x
Reducing stigma and discrimination x x x x x
Community empowerment x x x x x
Addressing violence x x x x x

Essential for impact: health interventions

Prevention of HIV, viral hepatitis and STIs
Harm reduction (needle and syringe programmes (NSPs),
opioid agonist maintenance therapy (OAMT) and naloxone x x
for overdose prevention)
Condoms and lubricant x x x x x
PrEP for HIV x x x x x
PEP for HIV and STIs x x x x x
Prevention of vertical transmission of HIV, syphilis and HBV x x x x
Hepatitis B vaccination x x x x x
Addressing chemsex x x x x x
Diagnosis
HIV testing services x x x x x
STI testing x x x x x
Hepatitis B and C testing x x x x x
Treatment
HIV treatment x x x x x
Screening, diagnosis, treatment and prevention of HIV
x x x x x
associated tuberculosis (TB)
STI treatment x x x x x
Hepatitis B virus and hepatitis C virus treatment x x x x x

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 Essential for broader health: health interventions
MSM PWID TGD SW PRiS
Anal health x x x x
Conception and pregnancy care x x x x
Contraception x x x x
Gender-affirming care x
Mental health services x x x x x
Prevention, assessment and treatment of cervical cancer x x x x
Safe abortion x x x x
Screening and treatment for hazardous and harmful alcohol
x x x x x
and other substance use
TB prevention, screening, diagnosis and treatment1 x x x

New recommendations
As part of the development of these guidelines, certain new or updated recommendations and
good practice statements were developed using the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) methodology. Four new recommendations and two good
practice statements are detailed below (for full details on the supporting evidence, please see
Chapter 9 in the full guidelines).

Virtual interventions
Online delivery of HIV, viral hepatitis and STI services to key populations may
be offered as an additional option, while ensuring that data security and
GRADE confidentiality are protected (conditional recommendation, very low certainty
recommendation of evidence).
Remarks
• Choice is important, and online services should form a part of a menu
of interventions, not stand-alone interventions, and should not be a
replacement for face-to-face services.
• Efforts should be made to increase equitable access to the internet,
improve literacy and provide appropriate training for key population
members where needed.
• Consideration should be given to the preferences of different key
population groups, given the current lack of published evidence from sex
workers and people who inject drugs.

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In high TB burden settings TB services could be considered across all populations.

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Peer navigators

Peer navigators are recommended to support people from key populations

to start HIV, viral hepatitis or STI treatment and to remain in care (conditional
GRADE recommendation, very low certainty of evidence).
recommendation
Remarks
• A peer navigator’s role is to assist key population members to access
health services, navigate these services and stay in care.
• Peer navigators require adequate remuneration, recognition, training and
other support to fulfil their role.
• Peer navigators are often highly valued by their peers.

More frequent HCV testing for people at ongoing risk

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
GRADE HCV viremia (conditional recommendation, very low certainty of evidence).
recommendation
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.

HCV treatment for people at ongoing risk

Pan-genotypic direct-acting antiviral (DAA)-HCV treatment should be offered

without delay to people with recently acquired HCV infection and ongoing risk
GRADE (conditional recommendation, very low certainty of evidence).
recommendation
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.

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 Behavioural interventions

When planning and implementing a response for HIV, viral hepatitis and STIs,
policy-makers and providers should be aware that counselling behavioural
Good practice interventions, which aim to change behaviours to reduce risks associated
statement with these infections for key populations, have not been shown to have an
effect on HIV, viral hepatitis and STIsʼ 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-judgemental 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.

Addressing chemsex

Addressing chemsex*, especially for key populations and their sexual

partners, requires a comprehensive, non-judgemental and person-centred
Good practice approach. This can include integrated sexual and reproductive health, mental
statement health, access to sterile needles/syringes and OAMT services with linkages to
other evidence-based prevention, diagnostic and treatment interventions.
It is acknowledged that in some settings the definition for chemsex may vary
and that it may take place in the context of other harmful drug and alcohol
use.
* 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 time.

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