2021 WHO Updated Recommendations on HIV Prevention, EID and ART

March 2021

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.

Most of these rec­om­men­da­tions are clin­i­cal; the pref­ace notes that “the pri­mary audi­ence for this guide­line is national HIV pro­gramme man­agers, peo­ple liv­ing with HIV, health-care providers and pol­icy-mak­ers in low- and mid­dle-income coun­tries.”

Used as precedent

key and vulnerable populations

Ado­les­cent girls and young women are still dis­pro­por­tion­ately affected by HIV and sub­ject to many forms of dis­crim­i­na­tion across the globe. In 2017, 79% of the ado­les­cents 10 to 19 years old newly infected with HIV in east­ern and south­ern Africa were female.Sub­stan­tial risk of HIV infec­tion is pro­vi­sion­ally defined as HIV inci­dence greater than 3 per 100 per­son-years in the absence of PrEP. HIV inci­dence greater than 3 per 100 per­son-years has been iden­ti­fied among men who have sex with men, trans­gen­der women and het­ero­sex­ual men and women who have sex­ual part­ners with undi­ag­nosed or untreated HIV infec­tion. Indi­vid­ual risk varies within groups at sub­stan­tial risk depend­ing on indi­vid­ual behav­iour and the char­ac­ter­is­tics of sex­ual part­ners.

reproductive rights

Sup­port­ing this evi­dence are stud­ies demon­strat­ing that women’s needs and pref­er­ences for sex­ual and repro­duc­tive health are het­ero­ge­neous. Expand­ing PrEP options to include a long-act­ing, woman-con­trolled option, such as the dapivirine vagi­nal ring, could help to meet unmet HIV pre­ven­tion needs for women.A review that included 11 arti­cles and abstracts specif­i­cally rel­e­vant for vagi­nal rings con­tain­ing dapivirine for HIV pre­ven­tion found that the use of vagi­nal rings was highly accept­able (71–98% in ran­dom­ized con­trolled tri­als and 62–100% in obser­va­tional stud­ies), and the vast major­ity of par­tic­i­pants across stud­ies reported that the rings are easy to insert and remove.

combination prevention

Women will be coun­selled on the dapivirine vagi­nal ring along with other pre­ven­tion options such as daily oral PrEP. Male and female con­doms and part­ner ser­vices must also be avail­able and offered along­side the dapivirine vagi­nal ring. Some women may switch from oral daily PrEP to using the dapivirine vagi­nal ring and poten­tially back to oral PrEP use. These pos­si­ble pat­terns of using ARV drugs for pre­ven­tion are cur­rently not known or under­stood and require care­ful sup­port and assess­ment.