2022 WHO Consolidated Guidelines on HIV, Viral Hepatitis and STI Prevention, Diagnosis, Treatment and Care for Key Populations


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


Impor­tantly, the com­plex inter­sec­tions between the struc­tural bar­ri­ers which affect key pop­u­la­tions and their gen­der, dis­abil­ity, edu­ca­tion, race, reli­gion and socioe­co­nomic sta­tus can­not be ignored. For exam­ple, cis­gen­der women and trans and gen­der diverse peo­ple expe­ri­ence extremely high rates of vio­lence, racial minori­ties are over-rep­re­sented in many prison set­tings, and all these fac­tors increase stigma and dis­crim­i­na­tion.

universal health coverage

HIV infec­tion is more likely to occur if another STI is present and vice versa, cre­at­ing syn­er­gies and syn­demics which are often over­looked. For exam­ple, STIs increase infec­tious­ness of peo­ple liv­ing with HIV who are not on treat­ment by increas­ing the viral con­cen­tra­tion in the gen­i­tal tract, and by increas­ing the poten­tial for HIV trans­mis­sion. Gen­i­tal her­pes and syphilis almost triple the risk of HIV acqui­si­tion; while women liv­ing with HIV are at high-risk of infec­tion with HPV and are approx­i­mately six times more likely to develop cer­vi­cal can­cer.

key population and community leadership

Finally, sev­eral effec­tive inter­ven­tions which pre­vent and treat HIV, STI and viral hepati­tis in key pop­u­la­tions are cost effec­tive and cost sav­ing, but with­out ade­quate fund­ing their impact can­not be real­ized. Fund­ing needs to be sus­tain­able, pre­dictable and focused on sup­port­ing com­mu­ni­ties.Com­mu­nity empow­er­ment was empha­sized across all key pop­u­la­tion-led net­works par­tic­i­pat­ing in the qual­i­ta­tive research project. Par­tic­i­pants dis­cussed the impor­tance of key pop­u­la­tion-led responses, includ­ing peer out­reach and other peer-based ser­vices, aware­ness-rais­ing, advo­cacy, drop-in-cen­tres, capac­ity-build­ing and resource mobi­liza­tion to ensure sus­tain­able, com­mu­nity-led pro­gram­ming. These ini­tia­tives were seen both as a means to improve access to ser­vices, as well as an essen­tial mea­sure for address­ing struc­tural bar­ri­ers under­min­ing key pop­u­la­tions’ health and human rights.Evi­dence, mainly among sex work­ers, shows that com­mu­nity empow­er­ment has a mea­sur­able impact on key pop­u­la­tionsʼ health, includ­ing reduc­tions in STI inci­dence, HIV inci­dence, high-risk sex and increased uptake of fam­ily plan­ning.Com­mu­nity-led ser­vices with peers as providers have a pos­i­tive impact on HIV, STI and viral hepati­tis, with increased access, avail­abil­ity and accept­abil­ity of ser­vices. Peers have an impor­tant role in reach­ing other key pop­u­la­tions through out­reach, giv­ing infor­ma­tion, pro­vid­ing com­modi­ties (such as con­doms, lubri­cants, nee­dles/syringes, PrEP, PEP and nalox­one) and pro­vid­ing ser­vices, includ­ing test­ing and treat­ment.

negative legal determinants, stigma and discrimination

Qual­i­ta­tive research con­ducted by the global key pop­u­la­tion-led net­works for the devel­op­ment of this guide­line found that all key pop­u­la­tions reported crim­i­nal­iza­tion, stigma and dis­crim­i­na­tion as per­sis­tent bar­ri­ers to access­ing health ser­vices and remain­ing in treat­ment, as well as being dri­ving fac­tors in per­pet­u­at­ing vul­ner­a­bil­ity, human rights abuses and poor health out­comes. Par­tic­i­pants from the trans and gen­der diverse peo­ple’s net­work addi­tion­ally empha­sized struc­tural bar­ri­ers to legal gen­der recog­ni­tion.

negative legal determinants

The crim­i­nal­iza­tion of drug use or pos­ses­sion, sex work, same-sex rela­tions and gen­der expres­sion deter mem­bers of key pop­u­la­tions from access­ing ser­vices due to fears of legal reper­cus­sions. It was also noted how crim­i­nal­iza­tion per­pet­u­ates the exclu­sion of key pop­u­la­tion-led and rights- based health pro­gram­ming from fund­ing mech­a­nisms and state health responses. Par­tic­i­pants in the qual­i­ta­tive study addi­tion­ally noted that law enforce­ment using the pos­ses­sion of con­doms and inject­ing equip­ment as so-called evi­dence of sex work and drug use or pos­ses­sion fur­ther hin­ders the use of evi­dence-based pre­ven­tion ser­vices and com­modi­ties.These legal bar­ri­ers have mea­sur­able, detri­men­tal effects on the health of mem­bers of key pop­u­la­tions, shown by mod­el­ling and other research. For exam­ple, a sys­tem­atic review found asso­ci­a­tions between expo­sure to arrest and HIV infec­tion in peo­ple who inject drugs; in coun­tries in sub-Saha­ran Africa, the odds of liv­ing with HIV were found to be 7.2 times higher for sex work­ers in coun­tries that crim­i­nal­ize sex work com­pared to coun­tries that par­tially legal­ize sex work; repres­sive polic­ing of sex work­ers was asso­ci­ated with increased risk of HIV or other STIs (odds ratio of 1.87); and sex work­ers exposed to repres­sive polic­ing were three times more likely to be phys­i­cally or sex­u­ally assaulted. The crim­i­nal­iza­tion of the clients of sex work­ers has also been repeat­edly shown to neg­a­tively affect sex work­ers’ safety and health, includ­ing reduc­ing con­dom access and use, and increas­ing the rates of vio­lence. Stud­ies show the neg­a­tive effect of crim­i­nal­iza­tion of same-sex prac­tices on HIV preva­lence and access to pre­ven­tion, diag­no­sis and treat­ment ser­vices.

gender identity and expression, positive legal determinants

For trans and gen­der diverse peo­ple, the legal recog­ni­tion of pre­ferred gen­der and name may be impor­tant to reduce stigma, dis­crim­i­na­tion and igno­rance about gen­der vari­ance. Such recog­ni­tion by health ser­vices can sup­port bet­ter access, uptake and pro­vi­sion of HIV ser­vices. Addi­tion­ally, it is likely to improve trans and gen­der diverse peo­ple’s health and well­be­ing. How­ever, legal recog­ni­tion must be accom­pa­nied by train­ing, sen­si­ti­za­tion, edu­ca­tion and enforce­ment.

stigma and discrimination

The effects of stigma and dis­crim­i­na­tion against key pop­u­la­tions can man­i­fest in delayed test­ing and missed diag­noses, poor reten­tion in treat­ment pro­grammes and poor treat­ment out­comes, con­ceal­ment of health sta­tus and, in gen­eral, poor uptake of health ser­vices.

sexual rights

A mod­el­ling study esti­mated that reduced sex­ual vio­lence against sex work­ers could reduce new HIV infec­tions by 25% among sex work­ers and their clients. Women, espe­cially young women from key pop­u­la­tions, includ­ing women who use drugs, female sex work­ers, peo­ple in pris­ons and trans­gen­der women, expe­ri­ence par­tic­u­larly high rates of phys­i­cal, sex­ual and psy­cho­log­i­cal abuse.

reproductive rights

All hor­monal con­tra­cep­tive meth­ods and intrauter­ine devices (IUDs) now fall into Cat­e­gory 1 of the MEC for women at high risk of HIV. Thus, women at high risk of HIV can use all meth­ods of con­tra­cep­tion with­out restric­tion.

harm reduction

At the time of writ­ing there is extremely low cov­er­age of the evi­dence-based pack­age of NSPs and OAMT. As a direct result, peo­ple who inject drugs are dis­pro­por­tion­ately affected by HIV and viral hepati­tis.

gender identity and expression, stigma and discrimination

High lev­els of stigma and dis­crim­i­na­tion against trans and gen­der diverse peo­ple in health care set­tings have been widely reported. Vio­lence and stigma and dis­crim­i­na­tion increase vul­ner­a­bil­ity to sub­stance use dis­or­ders, eat­ing dis­or­ders, depres­sion, sui­cide attempts, HIV and other sex­u­ally trans­mit­ted infec­tions, among oth­ers, and com­pro­mise trans and gen­der diverse peo­ple’s access and uti­liza­tion of health ser­vices.