Men who have sex with men, incarcerated people, people who inject drugs, people involved in sex work, and transgender people are focus of first consolidated guidelines addressing issues common to all, as well as specific needs
They are the people on whom the global AIDS pandemic has had the highest impact, and yet who have the least access to prevention, diagnosis, care and treatment. Although the current general term for these individuals is “key populations,” their needs, and sometimes their very existence frequently goes unaddressed in national AIDS plans. When they are included, it is often on paper only, with laws, policies and funding restrictions standing between them and services, and with violence, harassment, fear of blackmail, and institutionalized neglect serving as further barriers.
The World Health Organization Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations released today notes that attention to the most neglected populations will be essential to managing and continuing a response to HIV worldwide.
The guidelines include a “strong” recommendation that the daily use of oral antiretroviral drugs to prevent acquiring HIV be included among prevention measures for men who have sex with men. Previous guidelines, issued in 2012 had recommended the measure, pre-exposure prophylaxis, or PrEP, be considered as an addition for men who have sex, as well as transgender people and uninfected sexual partners of people living with HIV. The new, more emphatic, recommendation was based on continued high HIV incidence rates among men who have sex with men and continued evidence of the effectiveness of PrEP as well as of its acceptability among men who have sex with men. At the same time the guidelines caution that the many barriers standing between men who have sex with men and services, as well as awareness of services, including anti-homosexuality laws, lack of targeted outreach, threats of violence and harassment must be evaluated and addressed for PrEP to be extended effectively.
WHO continues to make no recommendation for PrEP for people who inject drugs because other acceptable cost-effective measures exist in needle and syringe exchange programs and opioid substitution therapy. The guidelines urge that these be made more widely available. The guidelines do not strengthen the previous guidelines’ recommendation that PrEP be considered as an additional prevention measure to transgender women, citing limited participation in PrEP trials by transgender women and lack of new evidence of effectiveness. The guidelines also note potential concerns of interactions between hormone therapy and PrEP.
The guidelines also include a new recommendation that naloxone, a drug included on WHO’s list of essential medicines, used to counter opioid overdoses, as well as instructions for its use be accessible to all people likely to see an opioid overdose. Community-based distribution of the drug and instructions in its use could avert preventable deaths among people with limited access to critical health services, the guidelines note.
The guidelines also stress access to condom compatible lubricants with condoms for all members of key populations, access to needle and syringe exchange and opioid substitution therapy for all people who inject drugs, abortion laws and services to protect the health and rights of all women, equal access for all women to reproductive health care, and a review of all laws and policies standing between members of key populations and services. Strengthening community involvement by members of key populations is termed critical in the guidelines.
The guidelines also include case studies of successful approaches to meeting the needs of key populations.