2021 WHO Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring


Analysis of evidentiary value

The World Health Orga­ni­za­tion (WHO) is the UN’s direct­ing and coor­di­nat­ing author­ity for health. WHO’s Sec­re­tariat serves the organ­i­sa­tion’s 194 Mem­ber States by imple­ment­ing the res­o­lu­tions and deci­sions of the World Health Assem­bly through its global and regional head­quar­ters as well as its 150 coun­try offices. The WHO Sec­re­tariat derives nor­ma­tive author­ity from its exper­tise and polit­i­cal neu­tral­ity. It is a widely respected pub­lic health author­ity in the UN sys­tem and beyond. Its guide­lines and tech­ni­cal reports are author­i­ta­tive sources of evi­dence.

Used as precedent

sexual rights

A pack­age of inter­ven­tions includ­ing screen­ing, treat­ment and/or pro­phy­laxis for major oppor­tunis­tic infec­tions, rapid ART ini­ti­a­tion and inten­si­fied adher­ence sup­port inter­ven­tions should be offered to every­one pre­sent­ing with advanced HIV dis­ease (strong rec­om­men­da­tion, mod­er­ate-cer­tainty evi­dence).

harm reduction

Nee­dle and syringe pro­grammes are highly effec­tive in reduc­ing HIV and hepati­tis C trans­mis­sion through inject­ing drug use. Opi­oid sub­sti­tu­tion ther­apy with methadone or buprenor­phine is the most effec­tive form of treat­ment for opi­oid depen­dence and has the addi­tional ben­e­fit of effec­tively reduc­ing HIV trans­mis­sion through inject­ing drug use. Opi­oid sub­sti­tu­tion ther­apy is also effec­tive in improv­ing ART uptake and adher­ence for peo­ple depen­dent on opi­oids.

key population and community leadership

Com­mu­nity engage­ment and com­mu­nity-based ser­vices play an impor­tant role in sup­port­ing HIV-exposed infant care. These clear and highly con­text-spe­cific ser­vices play a boost­ing role in sup­port­ing facil­ity-focused ser­vices and include com­mu­nity-based HIV test­ing. The engage­ment of net­works of women liv­ing with HIV has been effec­tive in sev­eral coun­tries and has been used to improve com­mu­nity HIV lit­er­acy to cre­ate demand, form sup­port groups at the facil­ity and com­mu­nity lev­els, strengthen link­age to care by escort­ing newly diag­nosed clients to treat­ment clin­ics, con­duct­ing defaulter track­ing and pro­vid­ing active fol­low-up of mother–infant pairs. In sev­eral set­tings, these inter­ven­tions led to reduced loss to fol­low-up among mother–infant pairs.Com­mu­nity-based ser­vice deliv­ery, includ­ing through peers, has shown to be more effec­tive in many set­tings, espe­cially where laws crim­i­nal­ize same-gen­der sex, sex work or drug use.A study among female sex work­ers in the United Repub­lic of Tan­za­nia found that those receiv­ing com­mu­nity ART ini­ti­a­tion were more likely to have started treat­ment and be retained in care and less likely to have inter­rupted treat­ment or feel high lev­els of inter­nal­ized stigma.A sys­tem­atic review and net­work meta-analy­sis iden­ti­fied 85 ran­dom­ized tri­als of inter­ven­tions to improve adher­ence. The review found mod­er­ate-cer­tainty evi­dence that peer coun­selling results in improved adher­ence and sup­pres­sion of viral loads. Peer-based inter­ven­tions are gen­er­ally well accepted, espe­cially among ado­les­cents who find that hear­ing expe­ri­ences and learn­ing from oth­ers fac­ing the same chal­lenges are crit­i­cal for sup­port­ing adher­ence and engage­ment in care.Peer-dri­ven mod­els of care have demon­strated impact on improv­ing health-seek­ing behav­iour and HIV treat­ment out­comes for ado­les­cents liv­ing with HIV, such as link­age, adher­ence to ART, reten­tion in care and viral sup­pres­sion.Com­mu­nity-led mon­i­tor­ing and related advo­cacy engen­ders account­abil­ity of ser­vice providers and local and national offi­cials to stan­dards of high-qual­ity health care, includ­ing the avail­abil­ity and acces­si­bil­ity of ser­vices; such account­abil­ity leads to improved health out­comes. HIV mul­ti­lat­eral donor and nor­ma­tive agen­cies (PEP­FAR, Global Fund to Fight AIDS, Tuber­cu­lo­sis and Malaria, L’Ini­tia­tive and UNAIDS) have increas­ingly acknowl­edged the impor­tance of com­mu­nity-led mon­i­tor­ing and the related advo­cacy and have required recip­i­ent coun­tries to include com­mu­nity-led mon­i­tor­ing in costed work­plans.

universal health coverage

Global ART cov­er­age for peo­ple liv­ing with HIV had reached 26 mil­lion peo­ple as of mid-2020. More than 120 low- and mid­dle-income coun­tries have adopted the “treat-all” pol­icy. Although the median CD4 cell count at the time of ART ini­ti­a­tion is increas­ing, about 25% of peo­ple liv­ing with HIV con­tinue to present late to care, with low CD4 cell count and asso­ci­ated high early mor­tal­ity rates, higher direct health-care costs and poor reten­tion in care.

access to health products

The lack of access to appro­pri­ate anti­fun­gal ther­a­pies and in vitro diag­nos­tics for rapid detec­tion of histo­plas­mo­sis and the co-occur­rence of other infec­tious dis­eases, espe­cially TB, may affect clin­i­cal out­comes and under­lie the high mor­tal­ity of dis­sem­i­nated histo­plas­mo­sis among peo­ple liv­ing with HIV.

stigma and discrimination

In HIV care, sev­eral stud­ies have shown that peo­ple are will­ing to travel longer dis­tances to con­sult a health-care provider with a respect­ful and car­ing atti­tude, and neg­a­tive health-care worker atti­tudes con­tribute to loss to care and poor pro­gramme out­comes. For key pop­u­la­tions in par­tic­u­lar, expe­ri­enc­ing stigma and dis­crim­i­na­tion in health-care set­tings is a struc­tural bar­rier to access­ing ser­vices.

combination prevention

A global con­sul­ta­tion of ado­les­cents and young adults liv­ing with HIV was con­ducted among 388 respon­dents across 45 coun­tries, sup­ple­mented by 10 focus group dis­cus­sions with 61 ado­les­cents and young adults with HIV across 10 coun­tries. There was near uni­ver­sal agree­ment (95–98% of respon­dents) that psy­choso­cial sup­port inter­ven­tions would help sub­stan­tially across the HIV cas­cade and a range of out­comes. Psy­choso­cial sup­port was con­sid­ered crit­i­cal to both the men­tal and phys­i­cal health of ado­les­cents and young adults liv­ing with HIV.