The World Health Organization (WHO) has issued its first ever guidelines on the prevention and treatment of HIV for populations of men who have sex with men (MSM) and transgender individuals (TG). The guidelines have been in preparation since the September 2008 WHO global consultation in Geneva. Both populations – MSM and TG – are known to suffer particular high incidence of HIV (globally, one in twenty for MSM).
The guidelines (21 in total) are intended specifically for policy-makers, health service providers and community leaders in low- and middle-income nations (who apparently requested them), though the WHO recommends they should also “be available” in high-income countries.
Where possible the approach aims to be “evidence-based”, with discussion of relevant findings and risk ratios given for each recommended intervention – even where (as in the majority of recommendations) the evidence base is small and low quality (often no “biological outcomes”), and the recommendation has to be given on the grounds that benefit will exceed harm. Still the discussion attached to individual recommendations (about 500 words on each) provides a short systematic review of the relevant literature, commenting on the nature of the evidence, the findings, the feasibility and acceptability of the intervention, likely benefits and risks.
What about the content of recommendations themselves? Anything surprising?
Two things in particular.
First, there is a strong insistence on the importance of the development of legal frameworks to protect human rights and protect minorities from stigma (and worse); also on the development of an inclusive approach in the provision of health care (e.g. inclusive of MSM and TG). This is very much in line with UNAIDS frameworks, and understandable where you remember there are 70 countries in which homosexuality is punishable by law (WHO is clearly venturing into a cultural mine-field here).
Second, consistent condom use is recommended over sero-sorting for MSM and TG, and male circumcision is not recommended as a specific intervention for HIV prevention.
Elsewhere, there are few surprises.
Provision of testing and counselling is recommended, as are behavioural interventions on an individual and community basis, including internet-based information, social marketing and sex venue-based outreach – all on the basis of rather low-grade evidence.
There are also recommendations covered by existing WHO guidance respecting: the provision of ART at CD4 count of <350; opioid substitution and the provision of clean needles for intravenous drug users; “catch-up” HBV vaccination. Testing and treatment for STIs is recommended as per existing WHO guidance (management algorithms are given). Recommendations also include periodic syphilis serological testing (moderate quality evidence), and periodic Gonorrhoea and Chlamydia testing with NAAT where available (low-quality evidence). However, periodic culture based testing for Gonorrhoea is not recommended.
A final section addresses developments in PrEP, but without giving any recommendations. Rendez-vous 2015 for the next planned revision of the guidelines!
World Health Organization Report, Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people: Recommendations for a public health approach, World Health Organization, Geneva 2011