Priority Interventions: HIV/AIDS Prevention, Treatment and Care in The Health Sector

Priority
Interventions
HIV/AIDS prevention, treatment
and care in the health sector
2010
WHO Library Cataloguing-in-Publication Data

Priority interventions: HIV/AIDS prevention, treatment and care in the health sector.
1.Acquired immunodeficiency syndrome - prevention and control. 2.HIV infections - prevention and
control. 3.Acquired immunodeficiency syndrome therapy. 4.HIV infections therapy. 5.Health services
accessibility. 6.Antiretroviral therapy, Highly active.I.World Health Organization. Dept. of HIV/AIDS.
ISBN 978 92 4 150023 4
(NLM classification: WC 503.6)
World Health Organization 2010

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Priority
Interventions
Version 2.0 July 2010
HIV/AIDS Department
Contents
Acknowledgements
Glossary
Foreword
Introduction
Purpose of Priority Interventions ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ..2
Target users... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 3
Structure of Priority Interventions .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . 3
Chapter 1: The health sector response to HIV/AIDS

1.1 Key elements of the health sector response . . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 4
1.2 Linkages with other health priorities ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . 5
1.3 Strategic planning for the health sector response to HIV/AIDS .. . .. . .. . .. . .. . .. . .. . .. . 6
1.4 Tailoring priority interventions to the context of the epidemic... . .. . .. . .. . .. . .. . .. . .. . .. 8
1.5 Planning for low-level HIV epidemics ... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 9
1.6 Planning for concentrated HIV epidemics... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 11
1.7 Planning for generalized HIV epidemics .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . 13
Chapter 2: Priority interventions for HIV/AIDS prevention, treatment and

care in the health sector
2.1 Background... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 17
2.2 Enabling people to know their HIV status... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 18
2.2.1 Client-initiated HIV testing and counselling. . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2.2 Provider-initiated HIV testing and counselling . . . . . . . . . . . . . . . . . . . . . . . 20
2.2.2.1 Family and partner HIV testing and counselling . . . . . . . . . . . . . 21
2.2.2.2 Infant and children HIV testing and counselling . . . . . . . . . . . . . 22
2.2.3 Blood donor HIV testing and counselling . . . . . . . . . . . . . . . . . . . . . . . . . 24

2.2.4 Laboratory services for HIV diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.3 Maximizing the health sectors response to HIV prevention .. . .. . .. . .. . .. . .. . .. . .. . .. . 29

2.3.1 Preventing sexual transmission of HIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.3.1.1 Promoting and supporting condom use. .
30
2.3.1.2 Detecting and managing sexually transmitted infections. . . . . . . . . . 31

2.3.1.3 Safer sex and risk reduction counselling . .
. 33
2.3.1.4 Male circumcision. .
. 34
2.3.1.5 Prevention among people living with HIV . . . . . . . . . . . . . . . 36

2.3.1.6 Interventions targeting most-at-risk populations. . . . . . . . . . . . . 37
2.3.1.6.1 Interventions targeting sex workers .
. 37
2.3.1.6.2 Interventions targeting men who have sex with men and transgender people. 39
2.3.1.6.3 Specific considerations for HIV prevention in young people5 .
2.3.1.7 Specific considerations for vulnerable populations. .
2.3.1.7.1 Displaced, mobile and migrant populations .

2.3.1.7.2 Prisoners and people in other closed settings .
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. 42
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43
2.3.1.8 Non-occupational post-exposure prophylaxis. . . . . . . . . . . . . . 44
iv
Priority Interventions - HIV/AIDS prevention, treatment and care in the health sector
2.3.2 Interventions for injecting drug users. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2.3.2.1 Needle and syringe programmes . . . . . . . . . . . . . . . . . 46
2.3.2.2 Drug dependence treatment. . . . . . . . . . . . . . . . . . . 48
2.3.2.3 Information, education and communication for injecting drug users. . . . . . . 49
2.3.3 Treatment and prevention of HIV in pregnant women, infants

and young children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.3.3.1 Family planning, counselling and contraception . . . . . . . . . . . . . 52
2.3.3.2 Antiretroviral medicines to prevent HIV infection in infants. . . . . . . . . . 53
2.3.3.3 Treatment, care and support for women living with HIV, their children and families . . 55
2.3.4 Prevention of HIV transmission in health settings. . . . . . . . . . . . . . . . . . . . . 57

2.3.4.1 Safe injections . . . . . . . . . . . . . . . . . . . . . . . 58
2.3.4.2 Safe waste disposal management. .
. 59
2.3.4.3 Occupational health of healthcare workers . . . . . . . . . . . . . . 60

2.3.4.4 Occupational post-exposure prophylaxis. .
. 61
2.3.4.5 Blood safety. . . . . . . . . . . . . . . . . . . . . . . . 62
2.4 Scaling up HIV/AIDS treatment and care... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 63

2.4.1 Interventions to prevent illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
2.4.1.1 Cotrimoxazole prophylaxis . . . . . . . . . . . . . . . . . . . 65
2.4.1.2 Preventing fungal infections . . . . . . . . . . . . . . . . . . . 66
2.4.1.3 Vaccinations. . . . . . . . . . . . . . . . . . . . . . . . 66
2.4.1.4 Nutritional care and support . . . . . . . . . . . . . . . . . . . 68
2.4.1.5 Providing safe water, sanitation and hygiene. . . . . . . . . . . . . . 69
2.4.1.6 Preventing malaria. . . . . . . . . . . . . . . . . . . . . . 69
2.4.2 Treatment and care interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

2.4.2.1 Antiretroviral therapy for adults, adolescents and children. . . . . . . . . . 70
2.4.2.1.1 Treatment preparedness and adherence support.
. 75
2.4.2.1.2 Patient monitoring.
. 76
2.4.2.2 Managing HIV-associated opportunistic infections and comorbidities . . . . . . 76

2.4.2.2.1 Managing HIV-related conditions .
2.4.2.2.2 Managing pneumonia .
2.4.2.2.3 Managing diarrhoea.
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2.4.2.2.4 Managing malnutrition.
2.4.2.2.5 Treating viral hepatitis.
2.4.2.2.6 Managing malaria.
2.4.2.2.7 Preventing and treating mental health disorders .
2.4.2.2.8 Counselling.
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77
79
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2.4.2.3 Palliative care . . . . . . . . . . . . . . . . . . . . . . . 84

2.4.2.4 Tuberculosis prevention, diagnosis and treatment . .
2.4.2.4.1 Treating HIV-associated tuberculosis .
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88
2.4.3 Laboratory services for HIV monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Chapter 3: Operationalizing the priority interventions strengthening health

systems
3.1 Background... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 90
3.2 Service delivery ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 92
3.2.1 Integration and linkage of health services. . . . . . . . . . . . . . . . . . . . . . . . . 92
3.2.2 Infrastructure and logistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
3.2.3 Demand for services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
3.2.4 Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
3.2.4.1 Strengthening management systems . .
. 99
3.2.4.2 Ensuring the technical quality of services. . . . . . . . . . . . . . . 99
3.3 Health workforce... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ..
3.4 Medical products and technologies ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...
3.5 Financing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...
3.6 Leadership and governance... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . ..
101
104
106
108
3.6.1 Coalition building and partnerships. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

3.6.1.1 Involving people living with HIV . . . . . . . . . . . . . . . . . 111
3.6.1.2 Involving civil society and the private sector. .
111
3.6.2 Addressing stigma and discrimination. . . . . . . . . . . . . . . . . . . . . . . . . . . 113

3.6.3 Delivering gender-responsive HIV interventions. . . . . . . . . . . . . . . . . . . . . 114
Chapter 4: Investing in strategic information

4.1 Strengthening health information systems... ... ... ... ... ... ... ... ... ... ... ... ... ... 116
4.2 Surveillance of HIV/AIDS and sexually transmitted infections ... ... ... ... ... ... ... ... 117
4.2 Monitoring and evaluation of the health sector response ... . .. . .. . .. . .. . .. . .. . .. . .. 120
4.2.1 Monitoring health sector HIV programmes. . . . . . . . . . . . . . . . . . . . . . . . 120
4.2.2 Global monitoring and reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
4.2.3 Patient monitoring systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
4.2.4 Prevention and assessment of HIV drug resistance . . . . . . . . . . . . . . . . . . . 125
4.2.5 Pharmacovigilance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
4.2.6 Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
4.3 Research ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 128
4.3.1 Operational research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
4.4 Using data effectively for programme improvement ... ... ... ... ... ... ... ... ... ... ... 130
4.4.1 Situation analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
4.4.2 Setting targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
4.4.3 Data quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Chapter 5: Resources
Annexes: Tables 79
Table 7. Example of health sector interventions by level of health system in low-level epidemic ... ... ... ... . 155
Table 8. Example of health sector interventions by level of health system in concentrated epidemic ... . .. . .. 158
Table 9. Example of health sector interventions by level of health system in generalized epidemic
with high prevalence ... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. 161
vi
Acknowledgements
This work was coordinated by the HIV/AIDS Department, World Health Organization (WHO)
Headquarters Office with contributions from staff in the six WHO Regional Offices and from
Headquarters staff in the Family and Community Health, and Health Systems and Services Clusters.
For their input, the World Health Organization wishes to thank the scientific and technical
committees, guidelines review committees, ministries of health of Member States, national AIDS
programmes, national AIDS commissions, government and nongovernment sectors, technical
partners, donor agencies, communities of people living with and affected by HIV and UN agencies.
for their continuous support to the health sector response to HIV/AIDS and the work of WHO.
vii
Glossary
3TC
Lamivudine
ABC
Abacavir
AFASS
Acceptable, feasible, affordable, sustainable and safe
AFB
Acid fast bacilli
ALT
Alanine aminotransferase
ART
Antiretroviral therapy
ARV
Antiretroviral
AZT
Azidothymidine, Zidovudine
BCG
Bacille Calmette-Guerine (vaccine)
BMI
Body mass index
CCM
Country Coordinating Mechanism
CITC
Client-initiated testing and counselling
CPT
Cotrimoxazole prophylactic treatment
CTX
Cotrimoxazole
DBS
Dried blood spot
DNA
Deoxyribonucleic acid
DOTS
Directly observed treatment, short course; refers to the internationally

recommended strategy for TB control
EFV
Efavirenz
EIA/ELISAs Enzyme immunoassays
viii
FTC
Emtricitabine
HBV
Hepatitis B virus
HCV
Hepatitis C virus
HIV
Human immunodeficiency virus
HIVDR
HIV drug resistance
HPV
Human papillomavirus
IDU
Injecting drug users/use
IMAI
Integrated management of adult and adolescent illness
IMPAC
Integrated management of pregnancy and childbirth
LPV
Lopinavir
LPV/r
Lopinavir with a booster dose of ritonavir
M & E
Monitoring and evaluation
MARP
Most-at-risk population
MDR
Multidrug-resistant
MSM
Men who have sex with men
NAT
Nucleic acid testing
NGO
Nongovernmental organization
NNRTI
Non-nucleoside reverse transcriptase inhibitor
NRTI
Nucleoside reverse transcriptase inhibitor
NSP
Needle and syringe programmes
NVP
Nevirapine
OST
Opioid substitution therapy
PCP
Pneumocystis pneumonia
PEP
Post-exposure prophylaxis
PI
Protease inhibitor
PITC
Provider-initiated testing and counselling
PLHIV
People living with HIV
PMTCT
Prevention of mother-to-child transmission
RAR
Rapid assessment and response
RDA
Recommended daily allowance
RFB
Rifabutin
RMP
Rifampicin
RNA
Ribonucleic acid
RPR
Rapid plasma reagin
RTV
Ritonavir
sd-NVP
Single-dose Nevirapine
SIGN
Safe Injection Global Network
STI
Sexually transmitted infection
TB
Tuberculosis
TDF
Tenofovir
UNAIDS
Joint United Nations Programme on HIV/AIDS
UNFPA
United Nations Population Fund
VCT
Voluntary counselling and testing, now referred to as client-initiated testing and

counselling (CITC)
WHO
World Health Organization
XDR
Extensively drug-resistant
ix
Foreword
Defining knowledge and knowledge gaps relevant to health, helping to establish health policy,
issuing technical guidance and recommendations, and monitoring health trends are core functions
of the World Health Organization (WHO). Since the early 1980s, WHO has been active in
translating the evolving science of HIV/AIDS into practical advice for countries as they respond to
this severe, heterogeneous and complex epidemic.
WHO coordinated the early global response to HIV/AIDS through its Special (later Global)
Programme on AIDS. Working closely with ministries of health in low- and middle-income
countries, WHO provided evidence-based programmes to combat this new disease. Following the
establishment of the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 1996 and the
agreed division of labour between its cosponsoring organizations, WHO remained the lead agency
for the health sector response to HIV/AIDS.
The rapidity of change in scientific understanding of HIV/AIDS, along with the breadth of the
response, meant that technical advice on its prevention, diagnosis, treatment and care could
quickly become obsolete. The range of technical guidance was diverse, and there was no single
place where it could be easily accessed in a one-stop shopping approach.
The years 2002 and 2003 saw the launch of three key initiatives in the global AIDS response: the
Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States Presidents Emergency
Plan for AIDS Relief (more commonly known as PEPFAR) and the WHO/UNAIDS 3 by 5 initiative.
The resulting programmatic scale-up highlighted a need for sound, evidence-based, impartial
guidance for public health action.
In the years following the 3 by 5 initiative, WHO has been acutely aware of the increasing
importance of the health sector in the quest for universal access to prevention, treatment and care,
and in tracking the epidemic and monitoring the response. The original call by G8 leaders for a
package of interventions coupled with the need for ongoing and updated user-friendly technical
guidance led WHO to develop Priority interventions: HIV/AIDS prevention, treatment and care in
the health sector, an umbrella document that brings together in one place key WHO guidance and
references for the health sector response to HIV/AIDS. It is the intent to revise it periodically as
new evidence becomes available. This is the 2010 update of the second edition, published online
and as a CD-ROM. The next edition is planned for release in 2011. We hope this regularly updated
resource will prove useful for all people who work in the health sector as they confront the realities
of HIV and AIDS throughout the world.
Gottfried Hirnschall,
Director
HIV/AIDS Department
World Health Organization
Geneva, Switzerland
July 2010
Introduction
With 33 million people living with HIV and 2.7 million new infections in 2007, the HIV epidemic
continues to be a major challenge for global health. Although political and financial commitments
and country efforts have resulted in increasing access to HIV services in recent years, the
annual number of new infections remains high and continues to outpace the annual increase in
the number of people receiving treatment. The availability and coverage of priority health sector
interventions for HIV prevention, treatment and care continued to expand in low- and middleincome countries in 2008 but is still insufficient, and progress has been uneven across and within
countries. Thus, the HIV pandemic remains the most serious infectious disease challenge to global
public health,1 and it continues to undermine six of the eight key areas covered by the Millennium
Development Goals, namely reduced poverty and child mortality, increased access to education,
gender equality, improved maternal health and increased efforts to combat major infectious
diseases.2 The impact of HIV and AIDS illustrates the interdependence of global efforts to foster
development and provides a strong rationale for people working on HIV/AIDS to seek synergies
between their actions and efforts to make progress in other development fields, in particular child
and maternal health. Reaching and exceeding the Millennium Development Goals and achieving
universal coverage of essential health interventions are part of WHOs primary health care and
health system strengthening strategies.
Purpose of Priority Interventions

The priority interventions described in this document are the complete set of interventions
recommended by WHO to mount an effective and comprehensive health sector response
to HIV and AIDS.
This document aims to:
describe the priority health sector interventions that are needed to achieve universal access to
HIV prevention, treatment and care;
summarize key policy and technical recommendations developed by WHO and its partners and
related to each of the priority health sector interventions;
guide the selection and prioritization of interventions for HIV prevention, treatment and care;
direct readers to the key WHO resources and references containing the best available
information on the overall health sector response to HIV/AIDS and on the priority health sector
interventions with the aim of promoting and supporting rational decision-making in designing and
delivering HIV-related services.
1
2
WHO. Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector. Progress report,
September 2009. Geneva, WHO, 2009. Available at: http://www.who.int/hiv/pub/2009progressreport/en/
WHO. Progress on global access to HIV antiretroviral therapy: A report on 3by5. Geneva, WHO, 2005.
Available at: http://www.who.int/3by5/publications/progressreport/en/
Target users
This document is intended for a broad readership of public health decision-makers, national
AIDS programme managers, health providers and workers (governmental, nongovernmental
and private), international, national and local donors, and civil society, including people living
with and affected by HIV.
Structure of Priority Interventions

This chapter discusses the basic principles of strategic planning for HIV and its linkage with
broader health sector planning. It also provides guidance on critical issues to consider when
selecting and prioritizing interventions in different types of HIV epidemics.
Chapter 2: Priority interventions for HIV/AIDS prevention, treatment and care in the health sector
This chapter describes the priority health sector interventions for HIV/AIDS that are recommended
by WHO. It summarizes relevant technical recommendations in each intervention area and
provides references to the Key resources, with links to online versions if they are available.
Chapter 3: Operationalizing the priority interventions strengthening health systems

This chapter discusses specific components of health system strengthening that need to
be considered when scaling up the priority health sector interventions for HIV/AIDS. These
components include integration and linkage of health services; infrastructure and logistics; human
resource development; equitable access to medical products and technologies; health financing;
advocacy and leadership; mobilizing partnerships including with people living with HIV; and
addressing gender, stigma and discrimination.

This chapter highlights the importance of strategic information about the epidemic to guide planning,
decision-making, implementation and accountability of the health sector response to HIV/AIDS.
Chapter 5: Key resources

This chapter is organized by intervention area and provides references to and descriptions of a
wide range of tools and other resources to support the health sector response to HIV.

1.1 Key elements of the health sector response
As defined by WHO, the health sector is wide ranging and encompasses organized public
and private health services (including those for health promotion, disease prevention,
diagnosis, treatment and care); health ministries, nongovernmental organizations;
community groups; and professional associations; as well as institutions which directly
input into the health care system (e.g. pharmaceutical industry and teaching institutions). 3
WHO has established priorities in critical areas where the health sector in each country must
invest if it is to make significant progress towards achieving the universal access goal and MDGs:4
1. enabling people to know their HIV status
2. maximizing the health sectors contribution to HIV prevention
3. accelerating the scale-up of HIV/AIDS treatment and care
4. strengthening and expanding health systems
5. investing in strategic information to guide a more effective response.
Health sector interventions for HIV prevention, treatment and care include:
interventions based in health facilities, including information, education and supplies and services
for preventing HIV transmission in health care settings; preventing sexual HIV transmission;
managing sexually transmitted infections (STIs); preventing mother-to-child HIV transmission;
providing harm reduction for injecting drug users (IDUs); HIV testing and counselling; preventing
HIV transmission by people living with HIV; preventing the progression of HIV infection to AIDS;
and the clinical management of treatment and care for people living with HIV;
interventions based in communities, including community-based prevention; treatment
preparedness and support for HIV and tuberculosis (TB); condom promotion; provision of clean
injecting equipment; HIV testing and counselling; home-based care; and psychosocial support,
including peer support;
interventions delivered through outreach to most-at-risk populations, including integrated HIV
testing; and counselling, treatment and care services in drop-in centres and similar locations,
including mobile sites;
activities in the health sector supporting service delivery and enabling action in other sectors,
including providing leadership and governance; advocacy; strategic planning; programme
management; access to medicines, diagnosis and technology to treat and prevent HIV infection
and its complications; human resources; financing; and HIV and STI strategic information
management systems.
3
4
WHO. Global health sector strategy for HIV/AIDS 20032007: providing a framework for partnership and
action. Geneva, WHO, 2002. Available at http://www.who.int/hiv/pub/advocacy/hiv2002_25en.pdf
WHO. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress
Report. WHO. April 2007
The principles that should guide the health sector response include those underpinning primary
health care, with particular emphasis on:
ensuring the full and proactive involvement of governmental, nongovernmental (NGO) and
private sector organizations and civil society, especially people living with HIV, including people
most at risk of infection;
tailoring interventions to the people and places that carry the burden of the disease, taking into
account the nature of the epidemic and the context (e.g. cultural traditions, social attitudes,
political, legal and economic constraints) in specific settings;
creating a supportive enabling environment by addressing stigma and discrimination, applying
human rights principles and promoting gender equity, and reforming laws and law enforcement to
ensure that they adequately respond to the public health issues raised by HIV and AIDS;
offering a continuum of home, community and health facility services in conjunction with outreach
to and consultation with community leaders and members, and especially with people living with
and affected by HIV.
1.2 Linkages with other health priorities

Decisions over which interventions to include in the national HIV/AIDS programme are usually
made during strategic planning, as are decisions about how to prioritize the interventions so that
available resources can be allocated accordingly. Most disease control programmes do this every
five years or so. The national strategy for the health sector response to HIV/AIDS, in whatever
form it exists, should be directly related to the multisectoral national HIV/AIDS framework, the
national health sector plan and the national development framework (see Figure 1 below).
Fig. 1 Linkage between HIV, health and development plans and strategies
National Development Framework
Multisectoral
AIDS Plan
Health Sector
AIDS Plan
National Health
Sector Plan
A National Development Framework (which often exists as a Poverty Reduction Strategy)

provides a national macroeconomic framework that guides overall social and economic
development activity. It outlines measures aimed at enhancing economic growth, reducing
inequality and improving quality of life. Health outcomes are usually clearly recognized within the
National Development Framework (or Plan) and reflected in the accompanying Medium-Term
Expenditure Frameworks (MTEF). HIV/AIDS needs to be clearly articulated here in terms of the
expected HIV/AIDS outcomes and how they are linked to the larger development issues and the
wider macroeconomic policy debate.
National health priorities are normally described in a National Health Sector Plan, which outlines
the direction and provides the goal and objectives for the entire country during a planning
cycle. Coordinated by the Ministry of Health, a National Heath Sector Plan provides a national
framework for prioritizing interventions to strengthen health care systems to deliver quality health
care to populations. Strategies and actions to respond to HIV/AIDS within the health sector
should be included in it.
In most countries, the Multisectoral National HIV/AIDS Framework or National Multisectoral
AIDS Strategic Plan is coordinated by the National AIDS Commission or its equivalent. The
multisectoral response is guided by the principle of the Three Ones, which recognizes
one coordinating authority, draws from one planning framework and follows one system for
monitoring and evaluating the response. A strong national response to HIV/AIDS evolves when
each concerned sector brings to bear the full extent of its unique contribution and comparative
advantage and does so in a manner that ensures effective coordination and alignment with other
sectors. As the health sector is usually the largest element of such a multisectoral strategic plan,
it should take the lead in shaping its own contribution to the multisectoral national HIV/AIDS
framework in coordination and alignment with the other sectors.
Efforts to deliver HIV/AIDS interventions must be harmonized with efforts to

strengthen health systems to achieve both HIV and other health goals.
1.3 Strategic planning for the health sector response to HIV/AIDS

According to the International Health Partnership and related initiatives (IHP+) in which WHO is an
active member, the components of a good national strategic plan include:
A situation analysis: epidemiological status, response analysis, health system readiness,
stakeholder identification and resource analysis;
Clearly defined goals, objectives and interventions based on the situation analysis;
Mechanisms through which national plans and strategies have been developed;
Financing, auditing and procurement arrangements;
Implementation and management arrangements; and
A framework for monitoring and evaluation of results.
A strategic plan should ensure coherence and follow a logical approach, from defining the
problem (through a situation and response analysis), to defining priorities (in terms of goals,
objectives, interventions), to costing and measuring results (through indicators). As illustrated in
Figure 2 below, it is vital that all these elements hold together with strategic coherence, as they
are all related to each other.
Fig. 2 Components of a National Strategic Plan
Strategic planning
Situation
analysis
Strategic
framework
M&E
framework
Financial
framework
Operational
framework
(evidence,
context,
response)
(goal, objectives,
targets
interventions)
(indicators,
methods,
information,
systems)
(costs, financing,
gaps, flows,
tracking)
(implementation
plans and
budgets)
Linked in strategic coherence
A results-based strategic plan should clearly define goals, objectives and interventions.
Goals indicate what should be the long-term impact of the health sector response to HIV/AIDS.
They must state clearly what needs to change by the end of the five-year strategic cycle and by
what order of magnitude. The goal(s) need to include a target element.
Objectives directly contribute to achieving a goal. Objectives should indicate the specific outcomes
required during a certain period of time and the target that this can be measured against.
Interventions are packages of activities that will help achieve the objectives. Interventions
produce a set of outputs which contribute to the desired outcomes and ultimately the impact.
Interventions need to be:
feasible;
locally appropriate;
equitable;
based on evidence and good practice;
taking into consideration cost effectiveness and sustainability (both financial and programmatic);
avoiding possible negative effects on other health outcomes; and
synergistic with other health interventions.
1.4 Tailoring priority interventions to the context of the epidemic

While priority interventions should be appropriate to the type of epidemic (see Box 1 below),
planning for all epidemics should:
place top priority on accelerating prevention;
select prevention interventions that match current patterns of HIV transmission;
focus on geographic areas and populations where HIV is spreading most rapidly;
select HIV testing and counselling approaches that will optimize entry to prevention,
treatment and care;
plan treatment and care services that are accessible and will be used by those affected or
targeted (this requires designing/configuring services that are acceptable to injecting drug users,
sex workers and men who have sex with men);
select the most effective service delivery approaches for implementing the interventions
through households, communities, health centres, hospitals or outreach to most-at-risk
populations; and
ensure HIV testing, counselling, prevention, and treatment and care services include outreach
services to most-at-risk populations.
Box 1. Typology of HIV epidemics according to WHO

Low-level HIV epidemics
HIV may have existed for many years but has never spread to substantial levels in any
subpopulation. Recorded infection is largely confined to individuals with higher-risk behaviour,
e.g. sex workers, drug injectors, men who have sex with other men. Numerical proxy: HIV
prevalence has not consistently exceeded 5% in any defined sub-population.
Concentrated HIV epidemics
HIV has spread rapidly in a defined sub-population but is not well established in the general
population. This epidemic state suggests active networks of risk within the subpopulation. The
future course of the epidemic is determined by the frequency and nature of the links between
highly infected subpopulations and the general population. Numerical proxy: HIV prevalence is
consistently over 5% in at least one defined subpopulation but is below 1% in pregnant women
in urban areas.
Generalized HIV epidemics
In generalized epidemics, HIV is firmly established in the general population. Although
subpopulations at high risk may contribute disproportionately to the spread of HIV, sexual
networking in the general population is sufficient to sustain an epidemic independent of
subpopulations at higher risk of infection. Numerical proxy: HIV prevalence consistently over 1%
in pregnant women.
Within generalized epidemics, there is a large range of HIV prevalence, even in countries with
HIV prevalence greater than 15%. The guidance provided for generalized epidemics in this
document also applies to these epidemics.
1.5 Planning for low-level HIV epidemics

In low-prevalence settings, it is particularly important to focus on implementing effective prevention
programmes so that HIV incidence remains low. Serological and behavioural surveillance of HIV
and sexually transmitted infections (STI) is particularly important. It provides the data on which to
base estimates of size and geographical location of populations living with HIV or those most at risk
of infection. It also provides data on the behaviours that may have resulted in HIV infection or could
result in new infection. This information should guide planning, with priority given to populations and
geographical locations where people are most at risk of transmitting infection or becoming newly
infected. Priority should also be given to interventions targeting particular behaviours.
In low-level epidemics, STIs are sensitive markers of high-risk sexual activity. Monitoring STI rates
can help identify HIV vulnerability and also help evaluate the success of prevention programmes. In
addition, early diagnosis and treatment of STIs will decrease their related morbidity and the likelihood
of HIV transmission. STI services are a critical entry point for HIV prevention in low-level epidemics.
Targeting most-at-risk populations with HIV/AIDS programmes and services is an efficient way of
responding to HIV in all epidemic situations, but it should be the key strategy for scaling up HIV
prevention, treatment and care in low-level epidemics.
Targeted interventions are aimed at offering services to specific populations within the general
population. They are also aimed at geographical locations where those specific populations are
most likely to be found so that they can be given the information, skills and tools (e.g. condoms,
water-based lubricants, safe injection equipment) that will minimize the risk of HIV transmission
and access to HIV treatment and care services. The best HIV/AIDS programmes also improve
sexual and reproductive health and well-being among these populations and address general
health concerns by reducing the harm associated with practices such as female and male sex
work and injecting drug use.
Successful targeted interventions do not stigmatize populations at risk; they respect their rights
and endeavour to protect them. In low-level epidemics, targeted interventions optimize the use of
resources by focusing on the people and places where risk is greatest and where access to HIV
prevention, treatment and care is most needed.
Even in low-level epidemics, interventions to prevent HIV transmission in health facilities must
ensure safe blood transfusion and provide infection control measures, standard precautions
and safe injections. Client-initiated testing and counselling (CITC) should be available, and
provider-initiated testing and counselling (PITC) may also be considered in STI and TB services,
services for most-at-risk populations, and antenatal, childbirth and postpartum health. Essential
interventions for HIV prevention and care, as well as antiretroviral therapy, should be provided for
people living with HIV. However, some of these interventions may be offered in fewer facilities,
depending on health system capacity and resources.
In low-level epidemics, the scale-up of HIV treatment and care services is more likely to be
concentrated at provincial or regional hospitals, with some private service providers increasing
access to these services. Developing special treatment and care facilities to cater to the
particular needs of extremely marginalized high-risk groups such as injecting drug users
may also be appropriate. In any case, when these services are provided in only a few facilities, a
well performing system of referrals is critical. It is also important to create services that promote
patient self-management, home- and community-based care, and mutual support by networks of
people living with HIV.
Clinical teams that support self-management and involve expert patients on those teams are basic
tenets of good chronic care in any epidemic setting. However, some community-based services
may not be resource-efficient in low-prevalence settings. Components of chronic HIV care may be
decentralized to health service providers over time, given the well known advantages of an integrated
primary care approach close to home for adherence, community support and quality of life.
Box 2 Key points to consider when planning services for low-level epidemics
In low-level epidemics:
recognize that affected individuals are often from marginalized populations and subject to
stigma and discrimination;
plan service delivery to match the distribution of people most at risk of infection and people living
with HIV;
define an optimal package of services and referral linkages to reach these groups; and
emphasize prevention so HIV incidence remains low.
10
1.6 Planning for concentrated HIV epidemics

Targeted interventions are the key strategy for scaling up HIV prevention, treatment and care in
concentrated epidemic settings. Targeted interventions:
are for people within the community who are most at risk of HIV infection;
are located in settings where risk behaviours and HIV transmission are concentrated;
are adapted to be culturally and socially appropriate for the target population;
effectively use the language and culture of the people being targeted;
focus on where limited resources can be used to best advantage;
acknowledge that barriers to accessing health care services exist for some populations
within communities;
recognize that people who are at risk of HIV transmission are often marginalized from the
broader community, and are experiencing stigma and discrimination.
In many countries experiencing concentrated epidemics, a continuum-of-care network revolving

around a range of linked services is the preferred model for implementing HIV treatment and care.
CITC serves as an entry point, supplemented by PITC and entry from TB clinics, general health
services, NGOs and outreach to most-at-risk populations. Private practitioners clearly linked with
HIV care services often follow up all those identified as being HIV positive.
It is important to remember that most-at-risk populations, such as sex workers and men who have
sex with men, are not homogeneous. For example, there are many different types of sex workers
with varying levels of HIV risk and access to health services. The same can be said of other mostat-risk populations. Some men who have sex with men, for example, adopt a cultural identity
associated with this behaviour and join community groups and frequent venues where other men
who have sex with men congregate. Others may not identify or socialize with this community
and may have female partners on a long- or short-term basis. Having a detailed understanding
of most-at-risk populations, especially those hardest to reach, is critical for programme planning
purposes and assists in the prioritizing of interventions for service delivery.
Targeted interventions take many forms; selecting the right intervention depends on the degree of
marginalization of the group being targeted, the availability of other services and the capacity of
the focus population to participate in or lead the design and implementation of services. In many
concentrated HIV epidemics, the populations that require priority interventions are sex workers,
men who have sex with men, transgender people, drug users (particularly injecting drug users)
and prisoners. Sometimes it is necessary to target other populations (such as minority, ethnic and
displaced, mobile or migrant populations) that do not have the same access to health information
and services as the general population.
Selecting the most appropriate service delivery models for promoting and distributing
prevention commodities and securing entry into care and treatment involves ensuring that
condoms, sterile needles and syringes are available through outreach workers and outlets in
venues accessible and acceptable to the target population. The design of HIV messaging also
needs to be relevant to a specific population, using language that they understand and that best
suits their educational needs. Several suitable service delivery models exist.
11
Outreach: This approach involves peers or people who are trusted by the target population (or
are making efforts to build this trust). Outreach workers make direct contact with members of the
community, providing them with information and tools to protect themselves, as well as help in
accessing services. Examples of outreach include:
training sex workers or community health workers to visit brothels, provide information and
condoms, and link sex workers with STI and HIV services;
training men who have sex with men to go to bars and sex venues to talk to other men about
HIV, distribute condoms and help them access STI and HIV services;
training current and ex-drug users to go into drug-user environments to distribute clean needles
and syringes, provide information, assist in overdose prevention and abscess care, and help
people access drug dependence treatment and HIV services;
arranging mobile vans to visit sex workers, men who have sex with men or injecting drug users at
night to provide information, prevention commodities, clinical services and referrals.
Support for self-help and community groups: This involves facilitating self-help or community
groups from target populations and providing them with resources and facilities where they can
work together to address HIV and related issues in their communities. Building the capacity of
target groups to create partnerships in prevention and care services has been successfully used in
many settings.
Establish local clinics and link these to other services: This involves providing clinical services
for particular populations such as sex workers, men who have sex men and clients of sex
workers in their own neighbourhoods, with links to other services. It may also include introducing
HIV services within already existing health, social or welfare services targeting these populations
(e.g. conducting regular clinics in drop-in centres for sex workers).
Box 3 Key points to consider when planning services for concentrated epidemics
In concentrated epidemics:
recognize that effective targeted interventions require information on most-at-risk populations
and their access to services;
target interventions to most-at-risk populations , usually sex workers, transgender people,
injecting drug users and men who have sex with men;
prioritize special interventions for injecting drug use wherever the practice occurs;
ensure adequate coverage of prevention interventions for identified most-at-risk populations;
and use outreach by peers or people trusted by the target population, self-help and
community groups, and local clinics able to provide friendly services for particular populations.
12
1.7 Planning for generalized HIV epidemics

Prevention efforts have led to declines in levels of HIV in some countries with generalized
epidemics, but this has yet to take place in many others. Furthermore, in many countries with
generalized epidemics, it disproportionately affects women.
Comprehensive prevention interventions, informed by evidence, could have broader success.
Making better use of opportunities to integrate HIV prevention within health services is especially
critical to this success. Providing PITC, condoms and counselling for women who take their children
for immunization and other child care services is one example. The female condom remains an
under-exploited option, as does safer sex counselling, which should occur after HIV testing but also
on many other occasions when health workers and patients interact. Safer sex counselling should
reinforce the message that concurrent sexual partnership is a very high risk behaviour.
The health sector can also play an important role in promoting progressive delay of the age of
coital debut for young people and in advocating for the control of alcohol use, since the latter
is increasingly recognized as a significant contributor to risk-taking behaviour. Hazardous or
harmful patterns of alcohol use are associated with unsafe sex, high partner numbers and condom
accidents. Addressing this problem is now recognized as an essential part of HIV prevention.
In generalized epidemics with high HIV prevalence, the large numbers of people living with HIV
mean that providing efficient and decentralized services is a key strategy in moving towards
universal access. This requires a public health approach to scaling up services with emphasis
on achieving broader coverage with key interventions; simple, standardized regimens and
formularies; algorithmic clinical decision-making; effective supervision and patient monitoring;
and integrated delivery of primary health care through health centres and in the community,
within a district health network.
Increasing evidence underscores the greater complexity and cost of caring for patients presenting
with advanced HIV disease. Increasing the number of people who are tested and for those who
test positive regularly following up with pre-antiretroviral care can prevent illness and ensure the
timely initiation of antiretroviral therapy.
Good survival rates have been reported for patients on antiretroviral therapy, and the numbers of
patients in chronic HIV care have increased steadily. This has led to the development of megaclinics in some hospitals. Decentralizing chronic HIV care to the health centre and community
level and integrating it with other priority health sector interventions are challenges that must be
met if universal access is to be achieved in an effective and cost-efficient way. People living with
HIV require multiple interventions for TB, substance use, pregnancy, child health and so on. In
many countries, these interventions are delivered through a number of different facilities with
specialized personnel. This is an inefficient use of resources and an increased burden on patients.
Integration of these services in health facilities, together with standardized protocols and training
for health workers, enables more effective co-management of patients and promotes family-based
care that addresses the needs of adults, adolescents and children.
13
To support scale-up and to avoid inefficient use of resources and increased burden on health
workers and patients, coherent and integrated packages of essential interventions appropriate
for each level of the health system are necessary. These should be developed and delivered
through a shared programme of work. Operational collaboration is important, both internationally
and between national HIV/AIDS programmes and those focusing on TB, maternal and newborn
services, child health, STIs, mental health and oral health; programmes organized around specific
health cadres (such as nursing and midwifery); and those with a cross-cutting mandate such as
human resources for health, health system strengthening, palliative care, chronic care, essential
drugs and essential health technologies.
Successful programming requires negotiation of a shared programme of HIV/AIDS work at the national
level within a clear health sector strategy. Cosponsorship of integrated implementation at facility and
district level with co-supervision by several programmes (usually HIV, TB and maternal and child
health) are essential to support integrated services. Cooperation within the district management team
and at point of care is often substantially better (and easier) than at the national or international level.
Meanwhile, the kind of integration described above is already happening as those responsible for
HIV and TB services recognize the advantages of working together on prevention, treatment and
care for both diseases.
Most HIV interventions can be decentralized to health centres by using simplified, operational
guidelines. Nurse-led clinical teams in health centres (and in district hospital outpatient clinics) are
able to deliver most of the interventions provided they have backup from district hospital clinicians and
periodic clinical mentoring. Nurse-led teams can initiate and monitor antiretroviral therapy, manage
uncomplicated opportunistic infections and provide primary mental health and neurological care.
Managing the broad range of opportunistic infections and other comorbidities experienced by
people living with HIV requires an integrated and coordinated response from a wide range of
health services. Clinical teams at the health centre level are able to manage uncomplicated
opportunistic infections but need to be able to refer patients with severe or complicated conditions
to a district hospital clinician for diagnosis and management. Cotrimoxazole prophylaxis should be
started promptly for all eligible patients, in all clinical services.
Community mobilization and involvement of people living with HIV

Community mobilization is critical for scaling up HIV prevention, testing and counselling, and
for preparing communities to prevent and support adherence to drug regimens. Civil society
organizations and networks, including those involving people living with HIV and people most
at risk of infection, complement formal health services. They provide preventive information and
supplies, create demand for formal health services, ensure that the services are acceptable and of
good quality, prepare communities for treatment by providing relevant education and information,
support adherence to drug regimens and provide various care and support services, including
palliative care. Moving towards universal access requires reinforcing support for civil society
organizations and networks, as well as strengthening the links between them and formal health
services. Strong civil society organizations and networks are especially important given the crisis
in human resources for health that many countries are experiencing.
14
Most-at-risk groups in generalized epidemics

Even though an epidemic may be generalized, it is important to identify and reach marginalized
or neglected populations who are at higher risk of HIV infection or who have poor access to
clinical and community-based services. These often-neglected groups include sex workers,
men who have sex with men, injecting drug users and prisoners. Unprotected male-to-male
sex is increasingly recognized as a major contributor to HIV infection, and injecting drug use is
increasing in some cities and ports in Africa.
HIV-negative people in sero-discordant relationships may be numerically the single largest
group at risk in countries with generalized epidemics. Special efforts are required to identify and
support them, both through facility- and community-based interventions. These interventions
include partner and couples testing and counselling, and risk reduction counselling and support.
Adolescent girls and young women are also at disproportionately high risk in countries with
generalized epidemics. They require special attention through youth-friendly services and active
support for interventions that may be delivered predominantly in other sectors, such as efforts to
address transactional sex, intergenerational sex and rape.
Where to implement: health facility or community?

With high HIV prevalence and large numbers of people living with HIV, community- and homebased service delivery become increasingly important. Trained and paid community health
workers, home-based caregivers, and a treatment supporter for each patient on antiretroviral
therapy and TB treatment can play a crucial role in assisting patients in care (e.g. through
adherence support and home-based refills) and in promoting methods to prevent HIV
transmission. Community-based testingbased on outreach from an index case receiving facilitybased care or on large scale know your status campaignsare important both for prevention
(e.g. to identify discordant couples and support safer sex and risk reduction in both HIV-positive
and HIV-negative persons) and to ensure early entry into HIV care and treatment.
Box 4 Key points to consider when planning services for generalized epidemics
In generalized epidemics:
select service delivery approaches able to address the high risk of infection, many new
infections, multiple affected groups and large numbers of people requiring treatment and
care;
decentralize HIV services to health centres and into the community;
integrate HIV prevention, treatment and care services within primary care;
emphasize prevention for people living with HIV; and
recommend PITC to all patients seeking care and to pregnant or breast-feeding women.
15
Key resources:
1. National AIDS programme management: A set of training modules
http://www.searo.who.int/en/Section10/Section18/Section356_13495.htm
Preliminary pages: http://www.searo.who.int/LinkFiles/Publications_Preliminar__pages.pdf
Introduction: http://www.searo.who.int/LinkFiles/Publications_Introduction.pdf
Module 1 Situation analysis: http://www.searo.who.int/LinkFiles/Publications_NAP_Module_1.pdf
Module 2 Policy and planning: http://www.searo.who.int/LinkFiles/Publications_NAP_Module_2.pdf
Module 3 Determining programme priorities and approaches: http://www.searo.who.int/LinkFiles/
Publications_NAP_Module_3.pdf
Module 4 Targeted HIV prevention and care interventions: http://www.searo.who.int/LinkFiles/
Module 5 Setting coverage targets and choosing key outcome indicators: http://www.searo.who.int/
LinkFiles/Publications_NAP_Module_5.pdf
Module 6 Implementation of HIV Prevention, Care and Treatment Strategies:
Module 6.1 Minimizing sexual transmission of HIV and other STIs: http://www.searo.who.int/LinkFiles/
Publications_NAP_Module_6.1.pdf
Module 6.2 HIV prevention and care among drug users: http://www.searo.who.int/LinkFiles/
Module 6.3 HIV counseling and testing: http://www.searo.who.int/LinkFiles/Publications_NAP_
Module_6.3.pdf
Module 6.4 The continuum of care for people living with HIV/AIDS and access to antiretroviral therapy:
http://www.searo.who.int/LinkFiles/Publications_NAP_Module_6.4.pdf
Module 6.5 Prevention of mother-to-child transmission: http://www.searo.who.int/LinkFiles/
Module 6.6 Prevention of HIV transmission through blood: http://www.searo.who.int/LinkFiles/
Module 7 Managing the AIDS programme: http://www.searo.who.int/LinkFiles/Publications_NAP_
Module7.pdf
Module 8 Management systems for the AIDS programme: http://www.searo.who.int/LinkFiles/
Publications_NAP_Module8.pdf
Module 9 Strategic information: http://www.searo.who.int/LinkFiles/Publications_NAP_Module9.pdf
2. IMAI general principles of good chronic care

English: http://www.who.int/hiv/pub/imai/generalprinciples082004.pdf
French: http://www.who.int/hiv/pub/imai/imai_general_2008_fr.pdf
Tables 7, 8 and 9 in the annex outline priority health sector interventions appropriate for low-level,
concentrated and generalized HIV epidemics, respectively.
16
Chapter 2: Priority interventions for HIV/AIDS

prevention, treatment and care in the health sector
2.1 Background
To achieve a comprehensive response to HIV/AIDS, the health sector has to take responsibility
for delivering interventions to prevent new HIV infections and to improve quality of life and avert
premature death in adults and children living with HIV. When implemented together at sufficient
scale and intensity, the priority interventions outlined in this chapter constitute an effective and
equitable health sector response to HIV/AIDS.
Based on the best available evidence, these priority interventions are recommended by WHO.
They include a wide range of interventions for providing knowledge of HIV status, preventing
transmission of HIV and other sexually transmitted infections, and providing treatment and care for
HIV/AIDS. Section 2.2 discusses interventions under the first strategy for action: enabling people
to know their HIV status. Section 2.3 discusses interventions under the second strategy for action:
maximizing the health sectors contribution to HIV prevention. Section 2.4 discusses interventions
under the third strategy for action: accelerating the scale-up of HIV/AIDS treatment and care.
The effectiveness of the HIV response depends on the scale of implementation of the priority
interventions. It is also contingent on the quality and characteristics of service provision, the broad
cultural and social context, and the level of community commitment to and participation in efforts
to counter stigma and discrimination.
HIV-related stigma and discrimination are often prevalent within health services and are critical
obstacles to provision and uptake of health sector interventions. Stigma and discrimination often
pervasive at all levels of society sustain an environment where it is difficult for health services
to attract the people who most need the interventions. HIV-related stigma and discrimination can
be reduced through strong leadership and concrete measures in national strategic planning and
programme design and implementation. Such measures can help countries reach key targets for
universal access and can also promote and protect human rights and foster respect for people
living with and affected by HIV/AIDS.
Other factors that can enhance the effectiveness of the HIV response include a coordinated
and participatory national strategic plan for HIV; a level of commitment to an HIV response
consistent with human rights and fundamental freedoms; and a level of commitment to informing
and consulting with the community during all phases of policy and programme design and
implementation. Collaboration with the community should include promoting a supportive and
enabling environment for women; addressing underlying prejudices and inequalities; and including
womens involvement in the design of social and health services that work for them.
For each priority intervention, there is a brief description and, in some cases, a discussion
of the actions required to support its implementation. There is also a summary of relevant
recommendations from current technical guidelines and references to the full guidelines and other
Key resources. The Key resources provide a more comprehensive list of current tools, guidelines
and resources to support implementation of the priority interventions.
17
2.2 Enabling people to know their HIV status

Increasing the numbers of people who know their HIV status especially among most-at-risk
populations through HIV testing and counselling is key to expanding access to HIV prevention,
treatment and care.
WHO guidance on HIV testing and counselling aims to achieve synergies between medical ethics,
human rights and clinical and public health objectives. The fundamental principle of HIV testing
is that it must be accompanied by basic pre-test information to enable the client to make an
informed and voluntary decision to be tested. The Three Cs informed Consent, Counselling and
Confidentialityshould always be maintained. Additional tools are being developed to address the
Three Cs as they apply to children and adolescents.
The UNAIDS/WHO policy on HIV testing and counselling defines two main categories:
i. client-initiated HIV testing and counselling (CITC);
ii. provider-initiated HIV testing and counselling (PITC).
For both categories the following applies: it is crucial that those who will be tested receive pre-test
counselling so they can provide informed consent. After testing, those found to be HIV-negative
should learn how to remain free from HIV infection. Those found to be HIV-positive should learn
how to prevent transmission to others and maintain their own good health. Additionally, they
should receive clinical assessment and referral to appropriate services.
Pre-test information can be provided in the form of individual counselling sessions or in group
health information talks and should provide information on: the clinical and prevention benefits
of testing; the potential risks, including stigma and discrimination, abandonment or violence; the
measures that will be taken to guarantee confidentiality of test results; services that are available
in the case of either an HIV-negative or an HIV-positive test result; and the fact that individuals
have the right to decline the test.
Post-test counselling for HIV-negative persons should provide basic information that includes
an explanation of the test result, the window period for the appearance of HIV-antibodies and a
recommendation to re-test, if appropriate. It should also include advice on methods to prevent
sexual transmission, and provision of male or female condoms and their use. In the case of
injecting drug users, it might also include provision or advice on where to obtain substitution
therapy and safe injection equipment and how to use it.
Post-test counselling for HIV-positive persons should provide psychosocial support to cope with
the emotional impact of the test result, referral to treatment and care services, disclosure to sexual
and injecting partners, basic advice on methods to prevent HIV transmission, provision of male
and female condoms and guidance on their use, and other measures outlined in Section 2.3.1.5
for people with HIV/AIDS.
WHO and UNAIDS recommend beneficial disclosure where HIV-positive individuals themselves
notify sexual or drug-injecting partners of their HIV status, where appropriate. Informing partners
is an effective means of reducing HIV transmission. It also facilitates prevention, care, support and
adherence to treatment, and promotes greater openness about HIV within communities.
18
Key resources:
3. UNAIDS/WHO policy statement on HIV testing
http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf
4. Opening up the HIV/AIDS epidemic: Guidance on encouraging beneficial disclosure, ethical partner
counselling & appropriate use of HIV case-reporting
English:
http://data.unaids.org/Publications/IRC-pub05/JC488-OpenUp_en.pdf
French:
http://data.unaids.org/Publications/IRC-pub05/JC488-OpenUp_fr.pdf
5. HIV counselling and testing e-library
http://www.who.int/hiv/topics/vct/elibrary/en/index.html
6. Guidelines for the implementation of reliable and efficient diagnostic HIV testing,
Region of the Americas
English:
http://www.paho.org/English/AD/FCH/AI/LAB_GUIDE_ENG.PDF
Spanish:
http://www.paho.org/Spanish/AD/FCH/AI/LAB_GUIDE_SPAN.PDF
2.2.1 Client-initiated HIV testing and counselling

Client-initiated testing and counselling (CITC), also called voluntary counselling and testing (VCT),
occurs when people come to a service to find out their HIV status.
CITC emphasizes individual risk assessment and counselling that addresses the implications of
taking an HIV test and the strategies for reducing risk. Counselling covers prevention both prior to and
after receiving test results and, if results are positive, referral to care, treatment and support services.
Summary of recommendations
WHO and UNAIDS recommend that known and innovative approaches be used to scale up and
expand access to CITC. These approaches should optimize convenience for clients, decentralize
services and provide testing and counselling in a wide variety of settings including health
facilities, community-based locations and work places and through outreach services that may
be stationary or mobile. They should offer services outside normal working hours and remove any
financial barriers to testing and related services.
In the case of low-level or concentrated epidemics, the programmatic focus should be on
increasing access and uptake among most-at-risk populations. In the case of generalized
epidemics, CITC should be made widely available using a variety of approaches.
Key resources:
7. WHO HIV testing and counselling (TC) toolkit
http://www.who.int/hiv/topics/vct/toolkit/en/index.html
8. International Organization for Migration guide for counsellors: IOM HIV counselling in the context of
migration health assessment
http://www.iom.int/jahia/webdav/site/myjahiasite/shared/shared/mainsite/published_docs/brochures_and_
info_sheets/HIV%20counselors%20GUIDE%20FINAL_Apr2006%20(4).pdf
19
2.2.2 Provider-initiated HIV testing and counselling

Provider-initiated testing and counselling (PITC) occurs when HIV testing and counselling is
recommended by health providers as a standard part of medical care to individuals attending
health facilities. The purpose of PITC is to enable specific clinical decisions to be made and/
or specific medical services to be offered that would not be possible without knowledge of the
persons HIV status.
PITC includes testing and counselling for adults, children and infants when HIV is suspected; the
routine recommendation of testing for all patients or specified groups of patients accessing health
facilities; and the recommendation of testing for family members and partners of HIV-positive people.
WHO and UNAIDS recommend that PITC start with basic pre-test information provided either
on an individual or group basis. PITC should require informed consent, with the client given all
necessary information to make a rational decision and given the opportunity to decline testing.
This opportunity should be given in private, in the presence of a health provider. Post-test
counselling should be tailored to the test result and, in the case of a positive result, should be
more extensive. As with all HIV testing, confidentiality should be guaranteed and health providers
should take measures to ensure that this guarantee is upheld.
The UNAIDS/WHO guidance on PITC specifies situations in which health providers should
recommend testing and counselling based on the characteristics of the epidemic in a given setting.
In all HIV epidemics, HIV testing and counselling is recommended for all patients whose
clinical presentation might result from underlying HIV infection. Testing and counselling is also
recommended for all HIV-exposed children and prior to HIV post-exposure prophylaxis.
In low-level or concentrated epidemics, PITC is not recommended for all patients attending
health facilities but should be considered in a range of specific situations (where patients have
come for STI services; where services are provided to most-at-risk populations; where patients
have come for antenatal, childbirth and postpartum services, or tuberculosis (TB) and hepatitisrelated services).
In generalized epidemics, PITC is recommended for all patients attending health facilities,
regardless of whether they show signs or symptoms of underlying HIV infection or their reason for
coming to a health facility, including for men prior to circumcision.
HIV testing and counselling as early as possible during pregnancy enables pregnant women to
access interventions for reducing HIV transmission to their infants and to benefit from prevention,
treatment and care, and is therefore recommended.
20
Key resources:
9. Guidance on provider-initiated HIV testing and counselling in health facilities
English:
http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf
Russian:
http://whqlibdoc.who.int/publications/2007/9789244595565_rus.pdf
10. WHO case definitions of HIV for surveillance and revised clinical staging and immunological
classification of HIV-related disease in adults and children
http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf
11. HIV testing and counselling in TB clinical settings tools
http://www.cdc.gov/globalaids/resources.html
Agenda: http://www.cdc.gov/globalaids/docs/tb_tools/TB%20Agenda_12.1.06.pdf
Overview: http://www.cdc.gov/globalaids/docs/tb_tools/TB%20An%20Overview_12.1.06.pdf
Module 1: http://www.cdc.gov/globalaids/docs/tb_tools/TB%20Module%201_12.6.06.pdf
Module 6: http://www.cdc.gov/globalaids/docs/tb_tools/TB%20Module%206%20Demo_12.1.06.pdf
12. IMAI PITC core training course and PITC counselling training video (free registration required to
access the site)
http://www.who.int/hiv/topics/capacity/sharespace/en/index.html
2.2.2.1 Family and partner HIV testing and counselling

It is important that people diagnosed HIV-positive be encouraged to disclose their HIV status to
those who need to know (e.g. sexual and needle-sharing partners) and to propose HIV testing
and counselling to their sexual or needle-sharing partners. It is equally important that they be
supported in these endeavours. Couple testing and counselling approachs can faciliate disclosure.
The testing and counselling of sexual and needle-sharing partners can be done either in the health
facility for example, following counselling of a couple or through referral to another facility that
welcomes client-initiated HIV testing and counselling.
Since parents generally accompany their children during visits to child health services, opportunities
arise to recommend HIV testing and counselling for both parents and siblings of HIV-infected children.
This should be done especially for mothers and fathers of HIV-infected children, and for women who
were not tested while using prevention of mother-to-child transmission (PMTCT) services.
21
HIV testing and counselling should be recommended for sexual partners, drug-injecting partners,
children and other immediate family members of all people with HIV, in cases where horizontal
or vertical transmission may have occurred. Identifying family members, sexual partners and
drug-injecting partners is often dependent on providing active support for beneficial disclosure,
where HIV-positive individuals can notify their partners and encourage them to seek HIV testing
and counselling. Within a family-centred or couple-centred approach to HIV testing, once a family
member is identified as having HIV, health workers should encourage and actively facilitate HIV
testing for other family members, where possible and appropriate, through couples or family
testing and counselling services.
Key resources:
English:
Russian:
4. Opening up the HIV/AIDS epidemic: Guidance on encouraging beneficial disclosure, ethical partner
counselling & appropriate use of HIV case-reporting
English:
http://data.unaids.org/Publications/IRC-pub05/JC488-OpenUp_en.pdf
French:
2.2.2.2 Infant and children HIV testing and counselling

WHO and UNAIDS provider-initiated testing and counselling (PITC) guidelines and antiretroviral
therapy (ART) guidelines already provide general guidance on when health care providers should
recommend HIV testing and counselling for infants and children. The HIV exposure status of
infants should be established at their first contact with the health system, ideally before six weeks
of age. Maternal, newborn and child health clinics, where a child receives her or his first set of
vaccinations, provide important opportunities for ensuring that the mothers HIV status is known
and that the infants HIV exposure is determined. Recently published data confirming the dramatic
survival benefits for infants started on ART as early as possible after the diagnosis of HIV prompted
a review of the WHO paediatric treatment guidelines, which now recommend immediate initiation of
ART in HIV-infected infants and children under 24 months. In order to identify those infants who will
need immediate ART, early confirmation of HIV infection is required and specific and more detailed
recommendations on diagnosis of HIV infection in infants and children were reviewed by WHO in
2009 to establish further guidance on HIV testing and counselling for infants and children.
22
PITC should be recommended for all infants and children when HIV is suspected or HIV
exposure is recognized. This includes testing for all infants and children suspected of having TB
and those with malnutrition who do not respond to appropriate nutritional therapy.
All HIV-exposed infants should have viral testing at or around four to six weeks of age, or at the
earliest opportunity for those seen in health services after six weeks. If HIV viral testing is not
available, presumptive clinical diagnosis in accordance with nationally defined algorithms will be
required. HIV infection should be confirmed through HIV antibody testing at or around 18 months
as part of clinical management.
WHO recommends that maternal or infant HIV antibody testing and counselling be performed
for infants of unknown HIV exposure status in all settings when local or national antenatal HIV
prevalence is greater than 5% (or locally determined thresholds). In such settings, infant testing
can initially be done using HIV antibody testing, and those with detectable HIV antibody should
then go on to have viral testing.
HIV testing and counselling should be recommended for all immediate family members of
infants and children known to be exposed to or infected with HIV.
In children older than 18 months, HIV infection can be diagnosed based on HIV antibody
testing, as in adults.
In infants and children younger than 18 months, viral tests (HIV DNA, HIV RNA or Us p24
antigen) are recommended to diagnose HIV infection.
In infants with an initial positive viral test result, ART should be started without delay and at the
same time a second specimen should be collected to confirm the initial result. Infants with a
negative initial positive viral test should have HIV serological testing at around 9 months of age.
Those who have a reactive (positive) serological test should have a viral test performed to confirm
HIV status and initiate ART if positive. Those with a non-reactive (negative) result can be confirmed
as HIV-unifected children provided there is no ongoing HIV exposure through breastfeeding. If
signs and symptoms suggestive of HIV infection develop, the exposed infant should be re-tested as
soon as possible using HIV serological testing and if reactive, with a viral test. If viral testing is not
available, HIV serological testing and use of a clinical algorithm for presumptive diagnosis of severe
HIV disease is recommended for decision-making on ART initiation.
Key resources:
13. WHO recommendations on the diagnosis of HIV infection in infants and children, July 2010
http://www.who.int/hiv/topics/paediatric/en/index.html
14. Scale up of HIV-related prevention, diagnosis, care and treatment for infants and children: A
programming framework
http://www.who.int/hiv/pub/paediatric/paediatric_program_fmwk2008.pdf
Antiretroviral therapy for HIV infection in infants and children. Recommendations for a public health
approach (2010 revision)
http://www.who.int/hiv/pub/paediatric/infants/en/index.html
23
2.2.3 Blood donor HIV testing and counselling

It is the responsibility of a blood transfusion service to provide an adequate supply of safe blood
and blood products while ensuring the safety of both the recipient and the donor. Globally, more
than 81 million units of whole blood are collected annually and at least seven million donors are
deferred from blood donation.
In accordance with national protocols and standards, quality-assured screening of all donated
blood for transfusion-transmissible infections is a critical HIV prevention strategy. Inadequate
screening coverage or poor quality control systems compromise the safety of the blood supply
and also hinder the management of blood donors who test HIV-positive. About one million donated
units are excluded annually because they contain transfusion-transmissible infections.
The blood transfusion service is often the first point of contact of the general public with the health
system. It is uniquely suited to promote healthy living and to advise millions of blood donors on
lifestyle issues that affect their health. Counselling of blood donors is necessary before (predonation counselling) and after (post-donation counselling) blood is collected and should be
preceded by pre-donation information and discussion. Effective pre-donation discussion and
counselling are vital activities of the blood transfusion service and are needed to encourage
appropriate donor self-deferral.
Post-donation counselling is a necessary part of care for infected donors. It is also important
in promoting health maintenance and regular donation by healthy donors. Donors need to be
informed of the test result since it has an impact on their health and prevents the use of their
donated blood. Blood transfusion services have responsibilities to confirm test results and notify
donors of HIV, hepatitis B and C, or any other infections identified, thus giving an opportunity to
donors to access treatment and care. These services also have responsibilities to promote lowrisk behaviour that reduces the risk of the spread of infection. Effective blood donor counselling
can make significant contributions to national initiatives that aim to prevent future transmission
of infection and promote healthy lifestyles. It can also lead to family testing and counselling and
advice on follow-up and referral.
24
Develop and implement a national strategy to screen all donated blood for HIV and other
transfusion-transmissible infections, using the most appropriate and effective technologies.
Maintain good laboratory practice and quality assurance systems that ensure the use of standard
operating procedures in all aspects of blood screening and processing.
Include blood donor deferral, confirmatory testing, notification, counselling and referral in the
national blood policy.
Encourage donors and the general public to avoid using blood transfusion services as health
assessment services or alternatives to HIV testing and counselling services. Defer individuals who
wish to donate blood mainly to have an HIV test.
Conduct effective pre-donation discussion and counselling to encourage appropriate donor selfdeferral, and to promote health maintenance and regular donation by HIV-negative donors.
Provide post-donation counselling by staff with HIV counselling skills for donors who require this service.
Refer those donors found infected with HIV, hepatitis or other transfusion-transmissible infections
for long-term follow-up and care.
Key resource:
16. WHO Blood transfusion safety (WHO web page)
http://www.who.int/bloodsafety/en/
25
2.2.4 Laboratory services for HIV diagnosis

Adequate quantities of high-quality laboratory services, skills and commodities are required to
meet increased demand for HIV testing. WHO laboratory recommendations for HIV testing cover:
selection of affordable technologies;
strategies and algorithms for HIV testing protocols suited to different purposes, e.g. for blood
transfusion safety, surveillance or clinical care; and
quality assurance of testing and quality management of testing and laboratory services.
The WHO recommendations describe various testing strategies appropriate for different HIV
testing purposes/objectives, such as HIV diagnosis in clinical care settings, surveillance or
ensuring blood transfusion safety. These strategies take into consideration the characteristics of
the epidemic and HIV prevalence in the populations to which the people being tested belong. A
testing algorithm describes the combination and sequence of specific HIV assays used for a given
HIV testing strategy. WHO recommendations for the selection and use of HIV antibody tests are
regularly reviewed and updated. In addition, all HIV assays, rapid tests and ELISAs need to be
validated at the national reference laboratory.
National HIV testing guidelines should provide specific testing algorithms for each of the testing
purposes and specify which test kits should be used and in what order. Selection of test kits and the
order in which they are used are critically important for the good performance of the testing algorithm.
Serial testing is generally recommended for HIV testing purposes. For clinical care, if the result of
the first HIV antibody test is negative, then the HIV serostatus is reported as negative. However, if
the client/patient has been exposed to a very high risk of HIV infection recently, the client/patient
will be advised to be tested again after four weeks. If the initial test result is reactive (positive), the
specimen is tested with a second test which is based on different antigens and/or platforms. In
populations with an HIV prevalence of 5% or more, a second positive test result is considered to
indicate a true positive result. In lower prevalence settings where false positive results are more
likely to occur, a third test is recommended. WHO and UNAIDS recommend serial testing in most
settings because it is a reliable and cost-effective approach, as a second HIV test is required only
when the initial test is reactive.
Parallel testing can be considered in special circumstances where time is crucial for example,
at the onset of labour to determine a mothers HIV status and whether or not there is need for
antiretroviral prophylaxis to prevent mother-to-child transmission of HIV. Obviously parallell testing
is more costly and more labour intensive because all specimens are tested with two different HIV
assays. The cost difference is substantial particularly in low-prevalence settings.
26
Key resource:
17. UNAIDS/WHO revised recommendations for the selection and use of HIV antibody tests
http://www.who.int/docstore/wer/pdf/1997/wer7212.pdf
Quality management systems should be implemented and established at all sites carrying out
HIV testing. The systems should include validated standard operating procedures, internal and
external quality assessment (e.g. proficiency testing), testing aligned with national algorithms
and use of HIV assays approved and validated by the national reference laboratory. Daily quality
control samples should be used to monitor the validity of the HIV assays used.
Key resources:
18. Guidelines for assuring the accuracy and reliability of HIV rapid testing: Applying a quality system approach
19. Overview of HIV rapid test training package
http://wwwn.cdc.gov/dls/ila/hivtraining/Overview.pdf
20. HIV rapid test training: Framework for a systematic roll-out
http://wwwn.cdc.gov/dls/ila/hivtraining/Framework.pdf
21. Revised recommendations for HIV testing of adults, adolescents and pregnant women in
health care settings
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm?s_cid=
27
Rapid HIV tests are recommended when there are efforts to expand access to HIV testing and
counselling services, particularly within community settings or health facilities where laboratory
services are weak or absent. They do not require specialized equipment, allow a quick turn-around
period, usually have internal controls and can be operated by trained non-laboratory personnel,
including lay service providers.
Key resource:
22. HIV assays: Operational characteristics (Phase 1). Report 14: Simple/rapid tests
http://www.who.int/diagnostics_laboratory/publications/hiv_assays_rep_14.pdf
Enzyme immunoassays (EIA or ELISAs) are very well suited to the needs of blood transfusion
services and other high-volume testing services such as regional and reference laboratories
and busy inpatient facilities, and for the purposes of surveillance. However, these tests require
specialized laboratory equipment and staff. Some EIA and rapid tests allow combined detection of
HIV antigen and antibody.
Key resources:
23. HIV assays: Operational characteristics (Phase 1). Report 15: Antigen/Antibody ELISAS
http://www.who.int/diagnostics_laboratory/publications/en/HIV_Report15.pdf
24. Guidelines for appropriate evaluations for HIV testing technologies in Africa
English:
http://whqlibdoc.who.int/afro/2002/a82959_eng.pdf
French:
http://www.who.int/entity/diagnostics_laboratory/publications/FR_HIVEval_Guide.pdf
National HIV/AIDS programmes should establish laboratories with the capacity to perform viral
testing for HIV infection in infants. Assays suitable to use for early infant diagnosis include HIV
DNA nucleic acid tests (NATs) such as polymerase chain reaction (PCR) and HIV RNA nucleic acid
testing technologies. For HIV testing in infants, blood samples can be collected on filter paper (dried
blood spots or DBSs), which offers advantages over other specimen collection methods, including
ease of collection and transport. Currently HIV DNA and RNA detection assays can be used to
diagnose HIV in infants using specimens collected on DBS. HIV RNA assays demonstrate the
presence of HIV for the purposes of diagnosis and allow quantitative measurement of HIV RNA.
28
2.3 Maximizing the health sectors response to HIV prevention

Primary prevention of HIV transmission requires implementation of a wide range of activities
involving the health sector and others.
HIV prevention in the health sector should include interventions aimed at changing individuals
behaviour and addressing cultural norms, social attitudes and behaviour that may increase
peoples vulnerability to HIV infection. It should also include biomedical interventions such as
condoms, clean needles and prevention of mother-to-child transmisson of HIV, which comprises
a combination of several interventions. In sub-Saharan African countries with very high HIV
prevalence, male circumcision in HIV-negative men may also be a priority intervention, combined
with HIV testing and counselling and promotion of condom use.
It is critical to complement HIV prevention for those who are uninfected with prevention for people
already living with HIV. A key concern for people living with HIV is to prevent inadvertent HIV
transmission. Other concerns include preventing illness, receiving care for opportunistic infections
and accessing antiretroviral treatment. Interventions to address their need to engage in sexual
activity without fear of transmitting the virus to their sexual partners are highlighted below (see
Section 2.3.1.5). Recommendations for preventing illness and other aspects of care and treatment
are outlined in Section 2.4.1. Also, since the meaningful involvement of people living with HIV
is instrumental in facilitating patient-provider understanding and effective HIV responses, it is
described in Section 3.6.1.1.
When prioritizing HIV prevention interventions, emphasis should be placed on those interventions
that are likely to have the greatest impact and that can be implemented at sufficient scale to
have such impact. Interventions should be tailored to the burden of disease and the nature of the
epidemic in specific settings (Section 1.4), as well as to the capacity and level of health services in
those settings (See Chapter 3).
Key resources:
25. Practical guidelines for intensifying HIV prevention: Towards universal access
http://data.unaids.org/pub/Manual/2007/20070306_prevention_guidelines_towards_universal_access_en.pdf
26. Essential prevention and care interventions for adults and adolescents living with HIV in resourcelimited settings
http://www.who.int/hiv/pub/prev_care/OMS_EPP_AFF_en.pdf
27. Glion consultation on strengthening the linkages between reproductive health and HIV/AIDS: Family
planning and HIV/AIDS in women and children
http://www.who.int/entity/hiv/pub/advocacymaterials/glionconsultationsummary_DF.pdf
28. Linkages between HIV and sexual and reproductive health: Technical documents and advocacy
materials (WHO web page)
http://www.who.int/reproductivehealth/publications/linkages/en/index.html
29
2.3.1 Preventing sexual transmission of HIV

2.3.1.1 Promoting and supporting condom use
The correct and consistent use of male condoms reduces the risk of sexual transmission of HIV
by 80% to 90%. Evidence indicates that female condoms may offer similar levels of protection
against HIV infection.
Essential HIV prevention interventions include providing free condoms to those most in need and
ensuring that condoms are available to all sexually active people. Social marketing combines
marketing strategies that increase the demand and supply of condoms at a subsidized cost.
Promotion of male and female condom use should be scaled up as part of comprehensive HIV
prevention programmes. These programmes should ensure that quality condoms are accessible to
those who need them when they need them and that people have the knowledge and skills to use
them correctly and consistently. Male and female condoms should be made available universally,
either free or at low cost, and should be promoted in ways that help overcome social and personal
obstacles to their use.
For some high risk populations, such as male sex workers and men who have sex with men,
providing water-based lubricant is absolutely essential. Female and male condoms should be
procured according to the standards and quality assurance procedures established by WHO,
the United Nations Population Fund (UNFPA) and UNAIDS. Condoms should be stored and
distributed according to international norms and standards.
As part of a multisectoral response, the health sector should provide guidance on sex education,
school-based HIV education, mass media communications and education messaging, and other
behaviour change interventions designed to increase demand and improve use of condoms by
young people and high-risk groups.
Key resources:
29. Position statement on condoms and HIV prevention
http://www.who.int/hiv/pub/prev_care/en/Condom_statement.pdf
30. The male latex condom: Specification and guidelines for condom procurement
http://www.who.int/reproductivehealth/publications/family_planning/9241591277/en/
31. The female condom: A guide for planning and programming
http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.8.pdf
English: http://www.who.int/reproductive-health/publications/RHR_00_8/PDF/female_condom_guide_
planning_programming.pdf
French: http://www.who.int/reproductive-health/publications/rhr_00_08_fr/female_condom_guide_
planning_programming.fr.pdf
32. Sexual and reproductive health of women living with HIV/AIDS: Guidelines on care, treatment and
support for women living with HIV/AIDS and their children in resource-constrained settings
http://whqlibdoc.who.int/publications/2006/924159425X_eng.pdf
30
2.3.1.2 Detecting and managing sexually transmitted infections

Similar behaviours put people at risk for both sexually transmitted infections (STIs) and HIV.
People with STIs may be at higher risk of acquiring or transmitting HIV infection.
Programmes for the prevention and treatment of STIs, especially among populations at higher risk
for sexual transmission of HIV, remain important elements of HIV prevention programmes.
Services for STI prevention, case management and partner treatment also contribute to HIV
prevention by promoting correct and consistent condom use and supporting health education and
behaviour change. A range of models for delivering STI services are required to ensure most-atrisk and vulnerable populations have access to these services. STI services provide opportunities
for access to HIV testing and counselling.
WHO recommends that countries expand the provision of good quality STI care into primary
health care, sexual and reproductive health services and HIV services. Comprehensive
STI services include:
correct diagnosis by syndrome or laboratory test;
provision of effective treatment at first encounter;
reduction in further risk-taking behaviour through age-appropriate education and counselling;
promotion and provision of condoms, with clear guidance on correct and consistent use;
notification and treatment of STIs in sexual partners, when applicable;
screening and treatment for syphilis in pregnant women;
provision of hepatitis and human papillomavirus (HPV) vaccines to prevent genital and liver
cancers; and
HIV testing and counselling in all settings providing care for STIs.
For primary care settings in low- and middle-income countries, WHO recommends syndromic
management of STIs in patients presenting with consistently recognized signs and symptoms.
Treatment for each syndrome should be directed against the main organisms responsible for the
syndrome within that geographical setting. National guidelines based on identified patterns of
infection and disease should be developed and disseminated to all providers of STI care.
Every country should ensure that interventions for STI prevention and care are integrated or
closely coordinated with national AIDS programmes.
31
Key resources:
33. Global strategy for the prevention and control of sexually transmitted infections, 2006 - 2015:
Breaking the chain of transmission
English:
Arabic:
http://whqlibdoc.who.int/publications/2007/9789246563470_ara.pdf
Chinese:
http://whqlibdoc.who.int/publications/2007/9789245563471_chi.pdf
Russian:
34. Guidelines for the management of sexually transmitted infections
English:
http://www.who.int/hiv/pub/sti/en/STIGuidelines2003.pdf
French:
http://www.who.int/hiv/pub/sti/STIguidelines2003_fr.pdf
Portuguese: http://www.who.int/entity/hiv/pub/sti/STIguidelines2003_pt.pdf
Spanish:
http://www.who.int/entity/hiv/pub/sti/STIguidelines2003_es.pdf
35. STI interventions for preventing HIV: Appraisal of the evidence
Publication anticipated in 2010.
36. IMAI acute care STI/genitourinary problem training course participants manual (part of IMAI acute
care guideline module).
37. Periodic presumptive treatment for sexually transmitted infections: Experience from the field and
recommendations for research
http://www.who.int/reproductivehealth/publications/rtis/9789241597050/en/
38. WHO regional strategy for the prevention and control of sexually transmitted infections 2007-2015
http://www.searo.who.int/LinkFiles/Publications_WHO_Regional_Strategy_STI.pdf
32
2.3.1.3 Safer sex and risk reduction counselling

Behavioural interventions at an individual, group or community level can generate safer sexual
behaviour. However, it is critically important to sustain interventions for behaviour and to provide
prevention tools over long periods of time. Counselling (i.e. a confidential dialogue between a
client and a counsellor) can enable clients to take personal decisions related to HIV and to adopt
safer sexual behaviours to reduce their risk of transmitting or acquiring HIV. The counselling
process should include evaluating the personal risk of HIV transmission, discussing how to
prevent infection, and assisting in identifying and overcoming impediments to safer behaviour.
Individual and small-group dialogue between providers and clients in health settings serves as an
important opportunity for providing information and counselling on safer sex and risk reduction.
Health care providers should routinely assess whether patients are at risk or have symptoms
of STIs. Those identified as being at ongoing risk may require more intensive counselling and
support to reduce risky behaviour, including a reduction in the number of partners.
Risk reduction counselling includes, for example, information on prevention of transmission of
STIs and HIV through condom use, including for most-at-risk populations. Counselling on delay
of sexual debut and reduction of number of sexual partners, including visits to sex workers and
reduction of concurrent partnership, is recommended to prevent sexual transmission among
heterosexual partners. However, the benefit of this counselling for men who have sex with men
has not been established.
Specific measures may be needed to support and counsel discordant couples and individuals in
multiple concurrent partnerships, as well as for men who have sex with men.
Safe sex counselling for prevention of transmission of HIV and other STIs should be integrated into
sexual and reproductive health services, especially those dealing with family planning and STI services.
Community-based behavioural interventions complement facility-level provider-client interactions.
Community-based interventions should include peer outreach for hard-to-reach populations for whom
the following should be provided: information on HIV and other STIs; risk reduction counselling; and
the distribution of prevention commodities such as condoms, clean needles and syringes.
Key resources:
39. SEX-RAR guide: The rapid assessment and response guide on psychoactive substance use and
sexual risk behaviour
http://www.who.int/mental_health/media/en/686.pdf
40. Youth-centered counseling for HIV/STI prevention and promotion of sexual and reproductive health:
A guide for front-line providers
http://www.paho.org/english/ad/fch/ca/sa-youth.pdf
33
2.3.1.4 Male circumcision

Randomized trials in areas of high HIV prevalence have demonstrated that male circumcision
reduces the risk of heterosexually acquired HIV in men by approximately 60%. This evidence
supports the findings of many observational studies. There is no definitive evidence that male
circumcision reduces the risk of HIV transmission from men to women, or between men who
have sex with men.
WHO recommends that male circumcision undertaken by appropriately trained health providers be
considered as part of a comprehensive HIV prevention package. Services should be scaled up for
defined geographic settings and priority should be given to males in areas where HIV prevalence
in the general populations exceeds 15%.
Male circumcision does not provide complete protection against HIV, so men and women who
consider male circumcision as an HIV prevention method should continue to use other prevention
methods such as male and female condoms, delaying sexual debut and reducing the number of
sexual partners.
HIV testing and counselling should be recommended for all males seeking circumcision but should not
be mandatory. Surgery should be done in an appropriate clinical setting by trained health providers.
Where access to male circumcision services is limited, priority could be given to HIV-negative men who
have indications of being at higher risk for HIV, such as men presenting with an STI.
Counselling should stress that resumption of sexual relations before complete wound healing may
increase the risk of acquisition of HIV infection among recently circumcised HIV-negative men.
Men who undergo circumcision should abstain from sexual activity for at least six weeks or until
surgical wounds are completely healed.
There should be broad community engagement to introduce or expand access to safe male
circumcision services. Such engagement also serves as a means of communicating accurate
information about the intervention to both men and women.
Careful monitoring and evaluation of the impact of male circumcision for HIV prevention should be
conducted to monitor and minimize potential negative gender-related impacts of male circumcision.
34
Key resources:
41. Male circumcision information package
http://www.who.int/hiv/mediacentre/infopack_en_1.pdf
42. New data on male circumcision and HIV prevention: Policy and programme implications (WHO/
UNAIDS technical consultation on male circumcision and HIV prevention: Research implications for
policy and programming, Montreux, 6-8 March 2007: conclusions and recommendations)
English:
http://whqlibdoc.who.int/unaids/2007/male_circumcision_eng.pdf
French:
http://www.who.int/entity/hiv/mediacentre/MCrecommendations_fr.pdf
43. Male circumcision: Global trends and determinants of prevalence, safety and acceptability
44. Manual for male circumcision under local anaesthesia
http://www.who.int/hiv/pub/malecircumcision/who_mc_local_anaesthesia.pdf
45. Male circumcision quality assurance: A guide to enhancing the safety and quality of services
http://www.who.int/hiv/pub/malecircumcision/qa_guide/
46. Male circumcision quality assurance toolkit
http://www.who.int/hiv/pub/malecircumcision/qa_toolkit/
47. Safe, voluntary, informed male circumcision and comprehensive HIV prevention programming:
Guidance for decision-makers on human rights, ethical and legal considerations
http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf
48. Male circumcision and HIV prevention in Eastern and Southern Africa communications guidance
http://www.malecircumcision.org/programs/documents/mc_hiv_prevention_eastern_southern_
africa_5_15_08.pdf
49. Operational guidance for scaling up male circumcision services for HIV prevention
http://www.who.int/hiv/pub/malecircumcision/op_guidance/
35
2.3.1.5 Prevention among people living with HIV

Addressing the prevention needs of people living with HIV is a critical challenge for the health
sector. Expanding access to HIV testing and antiretroviral therapy will increase the number of
people living with HIV who can benefit from comprehensive HIV prevention, treatment and care
services in the health sector.
Most people living with HIV will remain sexually active. Health providers should respect their right
to do so and support them and their partners in preventing further HIV transmission, including
through the provision of condoms and ART when clinically appropriate. For some, knowledge
about their HIV infection may not prompt a change in behaviour to reduce further HIV transmission
and additional support may be needed.
A large proportion of HIV infections occur within HIV discordant, stable partnerships. HIV-negative
partners in discordant couples (where one partner is HIV-negative and the other HIV-positive) are
at high risk of HIV infection and represent an important group for prevention efforts. Evidence from
studies of individual partners and both partners in HIV discordant couples shows that counselling
and condom provision and ART are effective in preventing HIV transmission.
Recommendations to prevent HIV-associated illness are described in Section 2.4.1.
People living with HIV should be counselled on safer sex interventions to prevent HIV transmission
to others, and on how to avoid contracting sexually transmitted infections. They should also be
provided with condoms.
Ongoing behavioural counselling and psychosocial support should be given to HIV-discordant
couples through couples counselling and support groups that cover topics such as HIV transmission
risk reduction, reproductive health issues, couples communication and condom provision.
Key resources:
26. Essential prevention and care interventions for adults and adolescents living with HIV in
resource-limited settings
50. IMAI-IMCI chronic HIV care with ARV therapy and prevention: Interim guidelines for health workers
at health centre or district hospital outpatient clinic
English:
http://www.who.int/hiv/pub/imai/Chronic_HIV_Care7.05.07.pdf
French:
http://www.who.int/hiv/pub/imai/imai_chronic_2008_fr.pdf
36
2.3.1.6 Interventions targeting most-at-risk populations

The health sector is responsible for configuring and supporting comprehensive programmes
and service delivery models that address the needs of populations most-at-risk for HIV and for
ensuring that these services are accessible, acceptable and equitable. In many countries, sex
workers and men who have sex with men are criminalized and stigmatized, which increases highrisk behaviours and discourages them from accessing health services. Where these barriers to
implementing priority interventions exist, there is a need to actively create a supportive policy,
legal and social environment that facilitates equitable access to prevention, treatment and care.
The interventions listed below are often best delivered through community-based organizations
doing outreach or at health facilities.
Key resource:
http://data.unaids.org/pub/Manual/2007/20070306_prevention_guidelines_towards_universal_access_en.pdf
2.3.1.6.1 Interventions targeting sex workers

Sex workers are among the groups most vulnerable to and affected by HIV. Specific behaviours
can place sex workers, their clients and regular partners at risk, and contextual factors can further
exacerbate their vulnerability to HIV. The evidence base is firmly established to support a range
of interventions to prevent transmission of HIV and other sexually transmitted infections (STIs) in
sex work settings, to provide care and support services, and to empower sex workers to improve
their own health and well-being. Interventions can be tailored for brothel or other entertainment
establishments, or for more informal street-based and home-based settings.
Worldwide, only a few countries have implemented sex worker programmes of sufficient scale to
prevent transmission of HIV and other STIs. There is solid public health evidence demonstrating
the effectiveness of comprehensive condom use programmes targeting sex workers or
entertainment establishment workers, but most countries still have structural barriers that must be
addressed to facilitate equitable access to services.
A comprehensive set of interventions is recommended to increase condom use and safe sex,
reduce the STI burden and maximize sex worker involvement in and control over their working
and social conditions.
Systematic collection of strategic information on HIV and other STIs among sex workers and their
clients is required to guide comprehensive programme implementation.
Programme planning must include formative assessments to determine the needs and
vulnerabilities of sex workers, and sex workers should be proactively involved in the design and
delivery of programmes.
The health sector should also promote legal and social frameworks that are rights-based and
consistent with public health and HIV prevention goals.
37
Priority interventions targeting sex workers to prevent sexual transmission of HIV and other STIs include:
promoting and supporting condom use, including water-based lubricants for male sex workers
(see Section 2.3.1.6.2);
detecting and managing STIs (see Section 2.3.1.2);
information, education and communication through peer outreach;
enabling people to know their HIV status (see Section 2.2).
Other health sector interventions for HIV prevention, treatment and care of sex workers are
described in the following sections:
Family planning, counselling and contraception (see Section 2.3.3.1);
HIV treatment and care (see Section 2.4);
Prevention of HIV in infants and young children (see Section 2.3.3);
Prevention of viral hepatitis (see Section 2.4.1.3);
Prevention of HIV transmission through drug use (see Section 2.3.2);
Social support, including income generation and legal services.
HIV and STI prevention activities for sex workers can be delivered at health facilities, in
community-based settings, and through peer outreach.
Key resources:
51. Toolkit for targeted HIV/AIDS prevention and care in sex work settings
http://whqlibdoc.who.int/publications/2005/9241592966.pdf
52. Guidelines for the management of sexually transmitted infections in female sex workers
http://www.wpro.who.int/NR/rdonlyres/90F80401-5EA0-4638-95C6-6EFF28213D34/0/Guidelines_for_
the_Mgt_of_STI_in_female_sex_workers.pdf
38. Regional strategy for the prevention and control of sexually transmitted infections 2007-2015
53. 100% condom use programme in entertainment establishments 2000
http://www.wpro.who.int/NR/rdonlyres/5F1C719B-4457-4714-ACB1-192FFCA195B1/0/condom.pdf
37. Periodic presumptive treatment for sexually transmitted infections: Experience from the field and
recommendations for research
English:
French:
http://whqlibdoc.who.int/publications/2009/9789242597059_fre.pdf
54. HIV and sexually transmitted infection prevention among sex workers in Eastern Europe
and Central Asia
English:
http://whqlibdoc.who.int/unaids/2006/9291734942_eng.pdf
Russian:
http://whqlibdoc.who.int/unaids/2006/9291734950_rus.pdf
38
2.3.1.6.2 Interventions targeting men who have sex with men and transgender people
While much is known about the HIV epidemic among men who have sex with men (MSM)
and transgender people in high-income countries, information is limited on the prevalence
of HIV among MSM and transgender people in low- and middle-income countries. Overall,
HIV transmission among MSM in low- and middle-income countries appears to be greatly
underreported. There is also a lack of information on access to services for HIV prevention,
treatment and care among MSM and transgender people in those countries.
Recent evidence suggests that sexual transmission of HIV and other sexually transmitted
infections (STIs) among MSM is resurfacing as a problem in the major cities of Asia, Europe, Latin
America and North America. Unprotected anal sex between men is increasingly being reported in
sub-Saharan Africa as well. Surveys in several countries have also shown that many MSM have
female partners or are married.
MSM and transgender people still face stigma or are driven underground through laws or policies
criminalizing MSM behaviours in many countries. Adopting a rights-based approach will ensure
that MSM, transgender people and their male and female sexual partners have the right to
information and commodities, enabling them to protect themselves against HIV and other STIs
as well as information on where to seek appropriate care for these infections. Importantly, this
approach also ensures their right to access appropriate and effective prevention and care services
of the highest possible quality, delivered free from discrimination.
The health sector has an important role to play by including services for MSM and transgender
people in its programme priorities and by advocating for decriminalization of same-sex acts and for
legislation against discrimination based on sexual orientation.
Programme planning needs to include formative assessments to determine the risks and needs
of MSM and transgender people, and these affected groups should be fully engaged in designing
and implementing the interventions.
Priority interventions targeting MSM and transgender people to prevent sexual transmission of HIV
and other sexually transmitted infections should include:
promoting and supporting condom use, including water-based lubricants (see Section 2.3.1.1
and Section 2.3.1.6.2);
detection and management of STIs (see Section 2.3.1.2);
prevention and treatment of viral hepatitis (see Section 2.4.2.2.5);
enabling people to know their HIV status (see Section 2.2);
outreach through peers, the internet and fixed or mobile services to MSM and transgender people
to broaden their access to information, education and communication, condoms and water-based
lubricants, as well as prevention interventions including STI care, and counselling and referral.
39
Other health sector interventions for HIV prevention, treatment and care for MSM and transgender
people are described in the following sections:
HIV treatment and care (see Section 2.4);
prevention of viral hepatitis (see Section 2.4.2.2.5):
prevention of HIV transmission through drug use (see Section 2.3.2);
Community-based behaviour change communication (e.g. posters and brochures in venues
frequented by MSM and transgender people);
social support and legal services.
Key resources:
55. Rapid assessment and response: Adaptation guide on HIV and men who have sex with men
(MSM-RAR)
http://www.who.int/entity/hiv/pub/prev_care/en/msmrar.pdf
56. Policy brief: HIV and sex between men
http://data.unaids.org/Publications/IRC-pub07/jc1269-policybrief-msm_en.pdf
57. Between men: HIV STI prevention for MSM
http://www.aidsalliance.org/includes/Publication/msm0803_between_men_Eng.pdf
58. AIDS and men who have sex with men
http://whqlibdoc.who.int/unaids/2000/a62375_eng.pdf
59. 2007 European guideline (IUSTI/WHO )on the management of proctitis, proctocolitis and enteritis
caused by sexually transmissible pathogens
http://www.iusti.org/sti-information/pdf/proctitis-guideline-v7.pdf
2.3.1.6.3 Specific considerations for HIV prevention in young people51

In order for young people to benefit from HIV prevention, health services must take their unique
concerns and needs into consideration. In terms of content, the basic package of interventions
to prevent HIV is much the same for young people as it is for adults. However, young people are
unlikely to use available services unless:
staff have been trained to understand young people and their concerns and to address any
needs relating to consent and confidentiality;
facilities and services have been designed or modified to be adolescent/youth-friendly with
consideration given to appropriate opening times, affordability and privacy;
attention is paid to fostering parents and communities support for youth-friendly services, and to
attracting young people to those services.
Prevention services for adults can be modified so that they are also appropriate for young people,
but there should also be youth-specific prevention in settings where young people are more likely
to access them. These may include schools, universities, youth clubs, popular youth hang-outs,
workplaces and pharmacies.
15
Young people includes adolescents and youth 1024 years.
40
The health sector should support community outreach to young people by providing guidance
and linkages between services in the health sector and other sectors. Some young people belong
to most-at-risk groups. Therefore, services targeting those groups should also be designed or
modified to be youth-friendly or else supplemented with services specifically geared to young
members of those most-at-risk groups.
The health sector also has a responsibility to ensure that there is serological and behavioural
surveillance to provide strategic information on young people and HIV (see Section 4.2). This
requires data to be disaggregated by age and sex, analysed and used to guide policies and
programming. The health sector should play a stewardship and advocacy role for young people
(see Section 3.6), and it should ensure a supportive political, legal and social environment that
addresses the specific needs of young people.
Prevention for young people provided by the health sector should include:
information and counselling to help young people acquire the knowledge and skills to delay
sexual initiation, limit the numbers of sexual partners, use condoms correctly and consistently,
and avoid substance use or, if injecting drugs, use sterile equipment;
condoms for sexually active young people;
harm reduction for young people who are injecting drug users;
diagnosis and treatment of sexually transmitted infections;
male circumcision (in high-prevalence settings);
HIV testing and counselling;
access to HIV treatment and care services;
consideration of human papillomavirus (HPV) vaccination for young females.
Key resources:
60. Preventing HIV/AIDS in young people: a systematic review of the evidence from developing
countries
http://whqlibdoc.who.int/trs/WHO_TRS_938_eng.pdf
61. Global consultation on the health services response to the prevention and care of HIV/AIDS among
young people: Achieving the global goals - access to services
62. Adolescent friendly health services: An agenda for change
http://whqlibdoc.who.int/hq/2003/WHO_FCH_CAH_02.14.pdf
41
2.3.1.7 Specific considerations for vulnerable populations

2.3.1.7.1 Displaced, mobile and migrant populations
In 2007, 67 million people were forced to flee their homes throughout the world: 26 million were
internally displaced due to armed conflict, 25 million due to natural disasters, and 16 million were
refugees. Increased vulnerability to HIV associated with displacement, sexual violence, and
disruption of families and social and community structures, has been evident in some complex
emergencies. However, in some instances, refugees or populations in conflict situations may
be less at risk of HIV transmission than surrounding populations when protected in camps and
supported by international organizations, or when living in isolation.
In emergency situations, access to HIV services is often limited by the breakdown of health
systems. Often emergency situations occur in remote areas where populations have little
access to HIV-related services; these may provide opportunities to extend HIV services to new
populations and then sustain them after the emergencies are over.
Millions of people each year migrate within countries or across countries and along borders.
Increased vulnerability to HIV associated with displacement and the disruption of families and
social and community structures has been evident in many settings with migrant and mobile
populations. Sex workers are among highly mobile populations, and labour migrants and truckers
constitute a large portion of their clientele. In many cases, their work is illegal and their presence is
not documented; these factors limit their access to HIV care and antiretroviral treatment services.
All migrant and mobile populations are difficult to reach with behaviour change communications
and other prevention interventions. This is due, in part, to the fact that their movement places them
in situations where they are ethnic minorities and face cultural and language barriers.
Access to health services should be based on the principle of equity, ensuring equal access
according to need without discrimination that could lead to the exclusion of displaced,
migrant or mobile people.
Displaced, migrant and mobile populations should have access to services and levels of care
equivalent to those provided to surrounding populations.
Interventions to provide information and education about prevention of HIV and other sexually
transmitted infections (STIs) should be made available at points of departure and arrival of migrant
and mobile populations, including ethnic minorities, who may require information and education in
their own languages.
Universal access to antiretroviral treatment for those who need it is now considered a minimum
standard of care; displaced, mobile and migrant populations should receive this treatment
as a human right.
42
Key resources:
63. Consensus statement: delivering antiretroviral drugs in emergencies: neglected but feasible
http://www.who.int/hac/techguidance/pht/HIV_AIDS_101106_arvemergencies.pdf
64. Guidelines for HIV/AIDS interventions in emergency settings
English:
http://www.who.int/3by5/publications/documents/en/iasc_guidelines.pdf
French:
http://www.who.int/3by5/publications/en/directivesvihfinalesfr.pdf
65. Antiretroviral medication policy for refugees
http://data.unaids.org/pub/Report/2007/20070326_unhcr_art_en.pdf
2.3.1.7.2 Prisoners and people in other closed settings

Prisons and other closed settings are key points of contact; millions of people in such settings
are living with or at high risk of HIV infection. It is in the interest of public health that all people in
these settings have access to HIV prevention, treatment and care. They are entitled to the same
standard of health as all other members of society.
A wide range of services is required for people in prisons and similar settings, including condom
distribution, clean needle and syringe provision, opioid substitution therapy, HIV testing and
counselling, provision of antiretroviral therapy and treatment for sexually transmitted infections.
Prison authorities should work with people in other branches of the criminal justice system and
with health authorities and nongovernmental organizations to ensure continuity of care, including
antiretroviral therapy (ART), from community to prison and back to community, and also
between prisons.
Prisons and other closed settings should offer a full range of HIV prevention, treatment and care
services and commodities, including HIV testing and counselling and ART.
Key resources:
66. Effectiveness of interventions to address HIV in prisons (Evidence for action series web site)
http://www.who.int/hiv/topics/idu/prisons/en/index.html
67. Policy brief: Reduction of HIV transmission in prisons (Evidence for action on HIV/AIDS and
injecting drug use)
http://www.who.int/hiv/pub/advocacy/en/transmissionprisonen.pdf
68. Status paper on prisons, drugs and harm reduction
http://www.euro.who.int/document/e85877.pdf
43
2.3.1.8 Non-occupational post-exposure prophylaxis

HIV post-exposure prophylaxis involves the short-term use of antiretroviral drugs for preventing
HIV infection in individuals who may have been exposed to HIV.
WHO recommends that HIV post-exposure prophylaxis be included in the management of sexual
assault and be made available to all HIV-negative people who may have been exposed to HIV
through sexual assault.
Sexual and reproductive health facilities should have up-to-date policies and procedures for
managing and assisting individuals who have experienced significant mucous membrane
exposure to HIV through sexual violence.
Whether comprehensive services are provided on-site or through referral, providers should follow
clear and consistent protocols for management. The necessary supplies, materials and referral
information should be made available to deal confidentially, sensitively and effectively with people
who have experienced sexual violence.
WHO recommends that management of non-occupational post-exposure prophylaxis include:
evaluation of the person with potential non-occupational exposure to HIV;
counselling;
assessing the HIV status of the source (e.g. the assailant) if possible;
provision of antiretrovirals for prophylaxis based on a defined protocol;
emergency contraception;
presumptive treatment of sexually transmitted infections; and
follow-up counselling.
Key resource:
69. Post-exposure prophylaxis to prevent HIV infection: Joint WHO/ILO guidelines on post-exposure
prophylaxis (PEP) to prevent HIV infection
44
2.3.2 Interventions for injecting drug users

Wherever injecting drug use occurs, countries should implement a comprehensive set of
interventions for HIV prevention, treatment and care for injecting drug users (IDUs). These
interventions are also known as harm reduction programmes.
Despite overwhelming public health evidence demonstrating the effectiveness of harm reduction
interventions, many decision-makers remain reluctant to implement or scale up these interventions
because of their controversial nature. Intense advocacy, citing public health evidence, is often
required to initiate and sustain harm reduction programmes.
Where there are barriers to implementing harm reduction interventions, there is a need to create a
supportive policy, legal and social environment that facilitates equitable access to prevention and
treatment for all, including IDUs. There is also a need for appropriate models of service delivery,
health systems strengthening and strategic information to guide harm reduction programmes. For
example, procuring and distributing opioid agonist medicines, such as methadone, may require
special measures and procedures.
Comprehensive harm reduction programminga comprehensive package of HIV prevention,
treatment and care for IDUs includes the following nine interventions:
1. needle and syringe programmes (NSPs) (see Section 2.3.2.1);
2. drug dependence treatment, in particular opioid substitution therapy (see Section 2.3.2.2);
3. targeted information, education and communication for IDUs (see Section 2.3.2.3);
4. enabling people to know their HIV status (see Section 2.2);
5. HIV treatment and care (see Section 2.4);
6. promoting and supporting condom use (see Section 2.3.1.1);
7. detection and management of sexually transmitted infections (see Section 2.3.1.2);
8. prevention and treatment of viral hepatitis (see Section 2.3.2 and Section 2.4.2.2.5;
9. tuberculosis prevention, diagnosis and treatment (see Section 2.4.2.4).
Community-based outreach is the most effective way of delivering HIV prevention, treatment
and care to IDUs, and of referring them to specific services for opioid substitution therapy and
antiretroviral therapy. Services for IDUs should take into account that the majority of IDUs are
male and have sexual partners, that some sell sex to pay for their habit and that injecting drug use
occurs at all levels of society.
Stand-alone interventions are known to have little impact so policy-makers should insist on
a comprehensive package of interventions. All key interventions should be scaled up at the
necessary intensity until they cover all drug users. The comprehensive package should be tailored
to the countrys known drug-use patterns and to other unique elements of the national context.
The health sector should play a major role in advocacyusing evidence to support that
advocacyto obtain the political commitments necessary to initiate and sustain harm
reduction programmes for IDUs.
45
Key resources:
70. Policy and programming guide for HIV/AIDS prevention and care among injecting drug users
http://www.who.int/hiv/pub/prev_care/policyprogrammingguide.pdf
71. Advocacy guide: HIV/AIDS prevention among injecting drug users
http://www.who.int/hiv/pub/advocacy/en/advocacyguideen.pdf
72. Policy briefs and technical papers on HIV/AIDS and injecting drug users (Evidence for
action series web site)
http://www.who.int/hiv/pub/idu/idupolicybriefs/en/index.html
73. HIV/AIDS: Injecting drug use and prisons (WHO web site)
http://www.who.int/hiv/topics/idu/en/index.html
74. Evidence for action: Effectiveness of community-based outreach in preventing HIV/AIDS among
injecting drug users
75. Treatment of injecting drug users with HIV/AIDS: Promoting access and optimizing service delivery
http://www.who.int/substance_abuse/publications/treatment_idus_hiv_aids.pdf
76. Training guide for HIV prevention outreach to injecting drug users: workshop manual
English: http://whqlibdoc.who.int/hq/2004/9241546352.pdf
2.3.2.1 Needle and syringe programmes

Access to and use of sterile injecting equipment is highly effective in reducing HIV risk behaviour
and transmission. Evidence shows that needle and syringe programmes (NSPs) also provide
opportunities for delivering harm reduction information and related services, including referrals for
drug dependence treatment. NSPs can reduce the risk of other infections (such as viral hepatitis,
septicaemia and abscesses) and do not increase injecting drug frequency or prevalence.
NSPs increase access to sterile injecting equipment and should be diversified to include outreach
through communities and peer groups, dedicated needle and syringe exchange and dispensing
services, pharmacy programmes, vending machines and drug dependence treatment services.
The full range of injecting equipment should be covered, including needles, syringes, sterile mixing
water, alcohol swabs and containers for mixing, dispensing and transporting drugs.
It is also critical that NSPs cover the safe disposal of used equipment to minimize re-use or
accidental needle-stick injuries. Safe disposal can be promoted through education of IDUs,
needle exchange programmes and placement of sharps containers in drug-using locations.
Decontamination methods for cleaning used injection equipment, such as bleach programmes,
are not recommended as a first line of intervention and should be used only if sterile injecting
equipment cannot be obtained.
Access to sterile injecting equipment through NSPs is a key evidence-based intervention to reduce
transmission of HIV in IDUs.
46
Key resources:
77. Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug
users (Evidence for action technical papers)
78. Guide to starting and managing needle and syringe programmes
http://www.who.int/hiv/idu/Guide_to_Starting_and_Managing_NSP.pdf
79. Treatment and care for HIV-positive injecting drug users (training curriculum)
Module 1: Drug use and HIV in Asia
http://www.searo.who.int/LinkFiles/Publications_Module_01_Treatment_&_Care_for_HIV_positive_IDUs.pdf
Module 2: Comprehensive services for injecting drug users
Module 3: Initial patient assessment
Module 4: Managing opioid dependence
Module 5: Managing non-opioid drug dependence
Module 6: Managing ART in injecting drug users
Module 7: Adherence counselling for injecting drug users
Module 8: Drug interactions
Module 9: Management of coinfections in HIV-positive injecting drug users
Module 10: Managing pain in HIV-infected injecting drug users
Module 11: Psychiatric illness, psychosocial care and sexual health
Module 12: Continuing medical education
Trainer manual
47
2.3.2.2 Drug dependence treatment

Approaches to drug and alcohol dependence management include pharmacotherapy and
psychosocial interventions that are often delivered in combination.
For individuals with opioid dependence, the most effective treatment is opioid substitution therapy
(OST). There is good evidence that OST leads to substantial reductions in illicit opioid use,
criminal activity, deaths attributable to overdose and risk behaviour related to HIV transmission
(including injection frequency and sharing of injecting equipment). Studies have also demonstrated
that OST improves retention rates in drug dependency treatment, adherence to antiretroviral
therapy and overall health and well-being. Both buprenorphine and the more widely used
methadone are included on the WHO Model List of Essential Medicines.
Psychosocial treatment of opioid dependence alone has limited effectiveness in managing opioid
dependence and has high relapse rates. There is no evidence that this treatment reduces HIV
transmission rates, though it sowns effectiveness when adopted to complement opioid substitution
therapy OST. Unlike in the case of opioid dependence, there are no effective substitution therapies
for the treatment of amphetamine-type stimulants, cocaine, hallucinogen or hypnosedative
dependence. Psychosocial treatment remains the only option for the treatment of non-opioid
dependence today.
There is no evidence that compulsory treatment programmes are effective for treating drug
dependence of any kind or for preventing HIV transmission.
Alcohol dependence and the use of a range of other psychotropic substances are also associated
with unsafe sexual behaviour.62
Opioid substitution therapy is recommended as the most effective treatment for opioid dependence
and requires initial supervised administration, adequate treatment doses and longer-term
maintenance regimens (at least six months). Inadequate doses of methadone are a common
cause of OST failure and relapse. Average effective methadone doses range from 60120 mg,
although higher doses may be required.
http://www.who.int/substance_abuse/publications/en/index.html
48
Key resources:
80. Treatment of opioid dependence (WHO web page)
http://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/index.html
81. WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy
and prevention in resource-constrained settings
82. Effectiveness of drug dependence treatment in prevention of HIV among injecting drug users
(Evidence for action technical papers)
http://www.who.int/hiv/pub/idu/en/drugdependencefinaldraft.pdf
83. WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the management of
opioid dependence and HIV/AIDS prevention
English:
Chinese:
http://whqlibdoc.who.int/unaids/2004/9241591153_chi.pdf
Russian:
http://whqlibdoc.who.int/unaids/2004/9241591153_rus.pdf
Cambodian: http://whqlibdoc.who.int/unaids/2004/9241591153_cam.pdf
Lao: http://whqlibdoc.who.int/unaids/2004/9241591153_lao.pdf
Vietnamese:http://whqlibdoc.who.int/unaids/2004/9241591153_vie.pdf
2.3.2.3 Information, education and communication for injecting drug users

HIV risk-reduction messages for IDUs should address all modes of HIV transmission, including
sexual risk taking. Messages on reducing risk from injecting should be based on a harm reduction
hierarchy and should encourage IDUs to adopt progressively less risky behaviours, moving from
indiscriminate sharing of injecting equipment; to reducing the number of sharing partners and
frequency; to decontaminating used equipment; to using only sterile equipment and adopting noninjecting drug use (e.g. smoking or ingesting); to stopping drug use all together.
Community-based and peer-led outreach is an effective strategy for providing information,
education and communication to IDUs.
Key resource:
74. Evidence for Action: Effectiveness of community-based outreach in preventing HIV/AIDS among
injecting drug users
49
2.3.3 Treatment and prevention of HIV in pregnant women, infants

and young children
WHO recommends implementing all four components of the comprehensive approach. It also
promotes integrating prevention of mother-to-child transmission (PMTCT) of HIV with maternal,
newborn and child health care; antiretroviral therapy; family planning; reproductive health; and
sexually transmitted infection (STI) services to ensure the delivery of a package of essential
services for quality maternal, newborn and child care. HIV testing is recommended for all pregnant
women, as explained in the section on provider-initiated testing and counselling (see Section 2.2.2).
A comprehensive approach to preventing HIV in infants and young children consists of four elements:
primary prevention of HIV transmission (also see Section 2.3);
prevention of unintended pregnancies among women living with HIV (see Section 2.3.3.1);

prevention of HIV transmission from women living with HIV to their children (see Section 2.3.3.2); and
provision of treatment, care and support for women living with HIV and their children and families
(see Section 2.3.3.3).
Health services should provide effective interventions to reduce sexual transmission of HIV,
with a particular focus on preventing new HIV infections in women during pregnancy or the
breastfeeding period.
Women with HIV should be supported in the choices they make for their reproductive life. Health
services should ensure women with HIV are (1) provided with the skills, knowledge and commodities
necessary to avoid unintended pregnancy or (2) are given support for planning a pregnancy.
All pregnant women with HIV should receive antiretroviral (ARV) medicines: either ARV treatment
for life, if eligible for therapy, or combined ARVs for prophylaxis to reduce HIV transmission.
All women with HIV should have access to an essential package of services during childbirth,
including assistance from a skilled birth attendant.
All infants born to women living with HIV should receive ARV prophylaxis and follow-up care and support.
Health services should ensure that women with HIV and their infants have access to the skills,
knowledge and support needed to make infant feeding safe, so as to reduce HIV transmission and
promote child survival.
Please refer also to the report sections referenced above.
50
Key resources:
84. Strategic approaches to the prevention of HIV infection in infants. Report of a WHO meeting,
Morges, Switzerland, 20-22 March 2002
http://www.who.int/hiv/mtct/StrategicApproaches.pdf
85. Guidance on global scale-up of the prevention of mother to child transmission of HIV: towards
universal access for women, infants and young children and eliminating HIV and AIDS among children
English:
French:
Russian:
86. Report of the WHO technical reference group, paediatric HIV/ART care guideline group meeting,
WHO Headquarters, Geneva, Switzerland, 10-11 April 2008
http://www.who.int/hiv/pub/paediatric/WHO_Paediatric_ART_guideline_rev_mreport_2008.pdf
87. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards
universal access. Recommendations for a public health approach (2010 version)
http://www.who.int/hiv/pub/mtct/antiretroviral/en/index.html
88. Testing and counselling for prevention of mother-to-child transmission of HIV support tools
English:
http://www.womenchildrenhiv.org/wchiv?page=vc-10-00#S3.4X
French:
http://www.womenchildrenhiv.org/wchiv?page=vc-10-00-fr
89. IMAI-IMPAC integrated PMTCT training course
51
2.3.3.1 Family planning, counselling and contraception

Family planning helps women and men make informed choices about their sexual and
reproductive lives, including the timing and spacing of births, which can improve their own health
and substantially increase their childs chances of survival and good health. Most women, men
and young people with HIV are sexually active and need information and assistance to make
decisions about family planning and reproduction. Preventing unintended pregnancies is an
important, though often neglected, component of preventing HIV transmission to infants.
The consistent and correct use of condoms continues to be the most effective contraceptive
method that protects against both (1) acquiring and transmitting HIV and other sexually
transmitted infections (STIs), and (2) unintended pregnancy.
Counselling and family planning services for women living with HIV should provide information on:
effectiveness and safety of contraceptive methods to prevent pregnancy, if so desired;
risk of HIV transmission for HIV-discordant couples;
risk of HIV transmission to the infant, and the effectiveness of antiretroviral medicines in reducing
HIV transmission;
the benefits and risks of various infant feeding choices.
Women living with HIV can safely and effectively use most of the same contraceptive methods
used by women without HIV. However, to also reduce risk of transmission of HIV and other
sexually transmitted infections, these methods must be combined with condom use.
Women living with HIV and taking antiretroviral therapy need to consider that several antiretroviral
drugs either decrease or increase the bioavailability of steroid hormonal contraceptives.
Key resources:
90. Reproductive choices and family planning for people living with HIV - Counselling tool
http://www.who.int/reproductivehealth/publications/family_planning/9241595132/en/index.html
91. IMAI one-day orientation on adolescents living with HIV
http://www.who.int/child_adolescent_health/documents/fch_cah_9789241598972/en/index.html
92. Strengthening linkages between family planning and HIV: reproductive choices and family planning
for people living with HIV
http://www.who.int/reproductive-health/hiv/hiv_tecbrief_fp.pdf
English:
French:
52
2.3.3.2 Antiretroviral medicines to prevent HIV infection in infants

HIV may be transmitted to the infant during pregnancy, delivery or through breastfeeding. If
no interventions are provided, an estimated 2025% of the infants of HIV-infected women will
acquire HIV up to and including during delivery. It can be as high as 45% if the child is breastfed.
Transmission is increased in women with more clinically advanced disease, low CD4 cell counts
and high HIV viral load. Antiretroviral (ARV) medicines and optimal infant feeding practices are
necessary to reduce HIV transmission to the infant and to promote child survival.
WHO recommends that all pregnant women with HIV receive antiretroviral medicines, either ARV
therapy (ART) for life or short term ARV prophylaxis to reduce transmission to infants.
Women with clinical and/or immunological criteria to start ART must do so as early as possible in
pregnancy (also see Section referring to PMTCT) and should continue it throughout their lives.
Pregnant women living with HIV with CD4 < 350 should start ART irrespective of clinical
symptoms. As well, pregnant women with HIV and WHO clinical stage 3 or 4 should start ART
irrespective of CD4 count. These recommendations for starting ART are the same for all adults.
Pregnant women in need of ART can be asymptomatic, so CD4 testing should be performed
whenever HIV is diagnosed in pregnancy.
Pregnant women with HIV who need ART should be treated with a full combination regimen,
and AZT or TDF-containing regimens are recommended (see Table 1 below). In HIV-infected
pregnant women with prior exposure to PMTCT regimens, see WHO 2010 guidelines for
recommendations on what ART to start.
For HIV-positive women who do not yet need ART for their own health, combination ARV
regimens for prophylaxis are recommended during pregnancy, labour and delivery and during the
breastfeeding period (see Table 2).
The HIV-exposed infant requires ARV prophylaxis from birth and until the end of breastfeeding.
The 2009 HIV and infant feeding rapid advice recommends HIV-positive mothers to breastfeed
for 12 months (see Table 2).
For HIV-positive women who present to health services late in the pregnancy or at labour and
delivery, ARVs are also recommended for both the mother and newborn.
53
Table 1. Recommended first-line combination antiretroviral treatment regimens for a pregnant woman
Mother
Treatment
Antepartum + intrapartum + after delivery
AZT + 3TC + NVP or

AZT + 3TC + EFV or
TDF + 3TC (or FTC) + NVP
TDF + 3TC (or FTC) + EFV
AZT: Azidothymidine, Zidovudine; 3TC: Lamivudine; NVP: Nevirapine; TDF: Tenofovir; FTC: Emtricitabine; EFV: Efavirenz
(do not start EFV in first trimester of pregnancy)
Source: WHO 2009. Rapid Advice. Use of antiretroviral drugs for treating pregnant women and preventing
HIV infection in infants.
Table 2. Recommended antiretroviral regimen options for prophylaxis in pregnant women not yet eligible for ART
Option A
Maternal AZT
Option B
Maternal triple ARV prophylaxis
Mother
Antepartum AZT (from as early as 14 weeks
gestation)
Sd-NVP at onset of labour*
AZT+3TC during labour and delivery*
AZT+3TC for 7 days postpartum*
Mother
Triple ARV from 14 weeks until one week after
all exposure to breast milk has ended
AZT + 3TC + LVP/r
AZT + 3TC + ABC
AZT + 3TC + EFV
TDF + 3TC (or FTC) + EFV
* Sd-NVP and AZT+3TC can be omitted if mother receives >4 weeks of AZT antepartum
Infant
Breastfeeding infant
Daily NVP or sd-NVP plus twice daily AZT for
4-6 weeks
Infant
All exposed infants
Daily NVP or sd-NVP plus twice daily AZT for
4-6 weeks
AZT: Azidothymidine, Zidovudine; 3TC: Lamivudine; NVP: Nevirapine; sd-NVP: single-dose Nevirapine; TDF: Tenofovir;
FTC: Emtricitabine; EFV: Efavirenz (do not start EFV in first trimester of pregnancy)
Source: WHO 2009. Rapid Advice. Use of antiretroviral drugs for treating pregnant women and preventing HIV
infection in infants.
Key resources:
93. HIV and infant feeding: Revised principles and recommendations. Rapid advice. November 2009
94 Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. November 2009
http://www.who.int/hiv/pub/arv/rapid_advice_art.pdf
http://www.who.int/hiv/pub/arv/rapid_advice_art_fr.pdf
English: http://www.who.int/hiv/pub/imai/Chronic_HIV_Care7.05.07.pdf
French: http://www.who.int/hiv/pub/imai/imai_chronic_2008_fr.pdf
54
2.3.3.3 Treatment, care and support for women living with HIV, their children and families
During pregnancy, women living with HIV also need the other prevention and care interventions
listed in Section 2.4.1 and Section 2.4.2 of this chapter, including cotrimoxazole prophylaxis,
screening for and treatment of TB, counselling and care relating to nutrition and psychosocial
support. Pregnant women already receiving cotrimoxazole should continue prophylaxis throughout
pregnancy and postpartum.
HIV-exposed infants need a range of interventions to promote their survival, protect them from HIV
infection and provide them with early antiretroviral treatment if they have acquired HIV infection.
Infants known to be exposed to HIV should have a virological test (HIV nucleic acid test, or NAT)
at four to six weeks of age or at the earliest opportunity thereafter.
HIV-exposed infants should be regularly followed up.
Virological test results for infants should be returned to the clinic and child/mother/carer as soon as
possible but at the very latest within four weeks of specimen collection. Positive test results should
be fast-tracked to the motherbaby pair as soon as possible to enable prompt initiation of ART.
All infants with unknown or uncertain HIV exposure being seen in health care facilities at or around
birth, at the first postnatal visit (usually 46 weeks) or at another child health visit should have their
HIV exposure status ascertained.
HIV-exposed infants should undergo HIV serological testing at around 9 months of age (or at the
time of the last immunization visit). Those with a positive serological test at 9 months should have a
virological test to identify infected infants who need ART.
In settings where local or national antenatal HIV seroprevalence is greater than 5%, infants under
six weeks of age and with unknown HIV exposure status should be offered maternal or infant HIV
antibody testing and counselling in order to establish exposure status.
Health services should provide a full set of child survival interventions to HIV-exposed and HIVinfected infants.
All HIV-infected infants and children under two years of age should start ART without delay
(see Section 2.4.2.1).
55
Key resources:
14. Scale up of HIV-related prevention, diagnosis, care and treatment for infants and children: A
programming framework
http://www.who.int/hiv/paediatric/Paeds_programming_framework2008.pdf
15. Antiretroviral therapy for HIV infection in infants and children. Recommendations for a public health
English:
French:
56
2.3.4 Prevention of HIV transmission in health settings

Though estimates vary by region, as many as 510% of new HIV infections in low- and middleincome countries may be attributable to exposures in health care settings, including unsafe
injections, unsafe blood and occupational exposures. However, experts acknowledge that there is
substantial uncertainty around this estimate.
In health care settings, transmission of HIV can be prevented through primary prevention measures
such as standard precautions, injection safety, blood safety and safe waste disposal, as well as
secondary prevention measures such as post-exposure prophylaxis for occupational exposure.
Comprehensive infection control strategies and procedures can dramatically reduce the risk of
transmission associated with health care. However, implementing infection control guidelines does require
a permanent HIV prevention and control structure, specific equipment and trained and motivated staff.
All health facilities should:
have a zero tolerance policy for HIV transmission, an infection control plan, a person or
team responsible for infection control and available supplies to ensure the implementation of
preventive measures; and
use standard precautions.
Standard precautions minimize the spread of infection associated with health care and avoid
direct and indirect contact with blood, body fluids, secretions and non-intact skin. They are the
basic infection control precautions in health care and include:
attention to hand hygiene before and after any patient contact, and after contact with
contaminated items, whether or not gloves are worn;
wearing personal protective equipment, based on risk assessment, to avoid contact with blood,
body fluids, excretions and secretions;
appropriate handling of patient care equipment and soiled linen;
safe disposal of sharps immediately after use; and
not recapping needles.
Key resources:
95. Aide memoire: Infection control: Standard precautions in health care
English:
http://www.who.int/csr/resources/publications/EPR_AM2_E7.pdf
French:
http://www.who.int/csr/resources/publications/EPR_AM2_FR3.pdf
96. Joint ILO/WHO guidelines on health services and HIV/AIDS
English:
French:
http://www.who.int/entity/hiv/pub/prev_care/who_ilo_guidelines_fr.pdf
Spanish:
http://www.who.int/entity/hiv/pub/prev_care/who_iloguidelines_sp.pdf
Russian:
http://www.who.int/entity/hiv/pub/guidelines/ilowhoguidelines_ru.pdf
Arabic:
http://www.who.int/entity/hiv/pub/guidelines/who_ilo_guidelines_arabic.pdf
Chinese:
http://www.who.int/entity/hiv/pub/guidelines/ilowhoguidelineschinese-pdf.pdf
Indonesian: http://www.who.int/entity/hiv/pub/guidelines/who_ilo_guidelines_indonesian.pdf
Vietnamese:http://www.who.int/entity/hiv/pub/guidelines/who_ilo_guidelines_vietnamese.PDF
57
2.3.4.1 Safe injections

Injection is one of the most common health procedures. Each year some 16billion injections are
administered in low- and middle-income countries. The vast majority, around 95%, are given as part
of curative care. Immunization accounts for around 3% of all injections and the remainder is for other
indications, including use of injections for transfusion of blood and blood products and for contraceptives.
In certain regions of the world, use of injections has overtaken the real need, reaching levels
that are not based on rational medical practice. In some situations, as many as 90% of patients
who visit a primary health provider receive an injection; more than 70% of these injections are
unnecessary, or could be given in an oral formulation.
A safe injection does no harm. However, unsafe injections expose millions of health care patients to
infections, including hepatitis B and C viruses, and HIV. Worldwide, up to 39% of injections are given with
syringes and needles re-used without sterilization, and in some countries this proportion is as high as 70%.
The Safe Injection Global Network (SIGN) promotes injection safety and provides normative
guidance related to injection safety and infection prevention.
Promote and coordinate the development of strategies, tools and guidelines to ensure
rational and safe use of injections.
Develop a behavioural change strategy targeting health care workers and patients. This
includes culturally adapted communication strategies targeting health workers and the community
to reduce injection overuse and create consumer demand for safety devices. Twenty years into the
HIV pandemic, knowledge of HIV among patients and health workers in some countries has driven
consumer demand for safe injection equipment and has substantially improved injection practices.
Ensure continuous availability of good quality equipment and supplies. Simply increasing
the availability of safe injection equipment can stimulate demand and improve practices.
Manage waste safely and appropriately. Waste disposal is frequently not an integral part of
health planning, and unsafe waste management is common. National health waste management
strategies require a national policy, a comprehensive system for implementation and improved
awareness and training of health workers at all levels, as well as the selection of appropriate
options for local solutions.
Key resource:
97. Injection safety toolbox: Resources to assist in the management of national safe and appropriate
use of injection policies (WHO web page)
http://www.who.int/injection_safety/toolbox/en/
58
2.3.4.2 Safe waste disposal management

Safe waste disposal is key to preventing the transmission of blood-borne pathogens. Sharps
waste, although produced in small quantities, is highly infectious. Contaminated needles and
syringes, when poorly managed, represent a particular threat to staff and patients. They also pose
a threat to the community at large when waste ends up in uncontrolled areas and dump sites at
the health facility, where needles and syringes may be scavenged and re-used.
Promote environmentally sound management policies for health waste.
Key resources:
98. Healthcare waste and its safe management (WHO web page)
http://www.healthcarewaste.org/en/115_overview.html
99. Operations manual for the delivery of HIV prevention, care and treatment at primary health centres
in high-prevalence resource-constrained settings
59
2.3.4.3 Occupational health of healthcare workers

For health workers, exposure to the blood of those receiving care occurs most often via accidental
injuries from sharps, such as syringe needles, scalpels, lancets, broken glass or other objects
contaminated with blood. Poor patient care practices by HIV-infected medical staff may also expose
the patient to infection. Also, when injecting and other equipment is poorly sterilized, HIV may be
passed from an HIV-infected individual to an uninfected patient within the health care setting.
Protecting the occupational health of health workers and ensuring that they know their status and
receive HIV treatment as appropriate is an important priority for the health sector. Please also see
infection control in Section 2.4.2.4.
A good occupational health programme aims to identify, eliminate and control exposure to hazards
in the workplace.
Designate a person to be responsible for the occupational health programme.
Allocate a sufficient budget to the programme and procure the necessary supplies for the personal
protection of health workers.
Provide training to health care workers and involve them in identifying and controlling hazards.
Promote health workers knowledge of their own HIV, hepatitis and TB status through employment/
pre-placement screening.
Provide immunization against hepatitis B.
Implement standard precautions.
Provide free access to post-exposure antiretroviral prophylaxis for HIV.
Promote reporting of incidents and quality control of services provided.
Key resources:
English:
French:
Spanish:
Russian:
Arabic:
Chinese:
100. Protecting healthcare workers: Preventing needlestick injuries toolkit (WHO web site)
http://www.who.int/occupational_health/activities/pnitoolkit/en/index.html
101. Occupational health of health workers: Meeting report, October 2009
http://www.who.int/occupational_health/network/health_workers_workshop_report.pdf
102. WHO best practices for injections and related procedures toolkit, March 2010
60
2.3.4.4 Occupational post-exposure prophylaxis

Post-exposure prophylaxis (PEP) is a necessary secondary HIV prevention measure in health
settings. This is because there will always be rare instances in which primary prevention fails and
health workers or patients may be accidentally (or through unsafe procedures) exposed to the risk
of HIV transmission.
The vast majority of incidents of occupational exposure to blood-borne pathogens, including
HIV, occur in health settings. PEP for HIV consists of a comprehensive set of services to
prevent infection developing in an exposed person, including: first-aid care; counselling and risk
assessment; HIV testing and counselling; and, depending on the risk assessment, the short term
(28-day) provision of antiretroviral drugs, with support and follow-up.
WHO recommends that PEP be provided as part of a comprehensive prevention package that
manages potential exposure to HIV and other infectious hazards.
Occupational PEP should also be available not just to health workers but to all other workers who
could be exposed while performing their duties (e.g. social workers, police or military personnel,
rescue workers and refuse collectors).
There should be appropriate training for service providers to ensure the effective management and
follow-up of PEP.
Antiretroviral (ARV) drugs for PEP should be initiated as soon as possible after exposure, within
the first few hours and no later than 72 hours.
ARV drugs for PEP should not be prescribed to people already known to have been infected with
HIV prior to the exposure incident.
HIV testing is recommended. The administration of ARV drugs for PEP should never be delayed
because of testing procedures. If the first test is negative, it should be repeated after three
and six months.
WHO recommends that the PEP ARV regimen contain two Nucleoside Reverse Transcriptase
Inhibitor (NRTI) drugs. If HIV drug resistance is suspected, the addition of a protease inhibitor may
be considered.
ARVs for PEP should be administered for 28 days.
Any occupational exposure to HIV should lead to an evaluation of the working environment and
procedures. When appropriate, working conditions and safety precautions should be improved.
Key resources:
69. Post-exposure prophylaxis to prevent HIV infection: Joint WHO/ILO guidelines on post-exposure
prophylaxis (PEP) to prevent HIV infection
61
2.3.4.5 Blood safety

Unsafe blood transfusion is a well-documented mode of transmission of HIV and other infections.
Millions of patients requiring transfusion do not have timely access to safe blood. In many
countries, even if blood is available, many recipients of blood and blood products are at risk of
transfusion-transmissible infections, including HIV, as a result of poor blood donor recruitment and
selection practices and the use of unscreened blood.
Access to safe blood transfusion is an essential part of modern health care. Every national AIDS
programme needs to promote the establishment of national blood programmes to ensure the
availability of safe blood and blood products through a nationally coordinated blood transfusion
service. A well-organized blood transfusion service based on voluntary non-remunerated
donations, with quality systems in all areas, is a prerequisite for the safe and effective use of blood
and blood products. WHO has developed an integrated strategy to promote the provision of safe
and adequate supplies of blood and to reduce the risks associated with transfusion.
Establish well-managed and nationally-coordinated blood transfusion services, with countrywide quality systems that can provide adequate and timely supplies of safe blood for all
patients who require it.
Collect blood, plasma, platelets and other blood components only from voluntary unpaid blood
donors from low-risk populations, and use stringent donor selection procedures.
Ensure good laboratory practice in all aspects of the provision of safe blood, from donation to
testing for transfusion-transmissible infections (HIV, hepatitis viruses, syphilis and other infectious
agents) to blood grouping to compatibility testing to the issuing of blood.
Reduce unnecessary transfusions through the appropriate clinical use of blood including, where
possible, the use of intravenous replacement fluids and other simple alternatives to transfusion.
Key resources:
16. WHO Blood transfusion safety (WHO web page)
103. WHO blood safety: Aide-memoire for national blood programmes
English:
http://www.who.int/entity/bloodsafety/transfusion_services/en/Blood_Safety_Eng.pdf
French:
http://www.who.int/entity/bloodsafety/transfusion_services/en/Blood_Safety_French.pdf
Portuguese: http://www.who.int/entity/bloodsafety/transfusion_services/en/Blood_Safety_Port.pdf
Spanish:
http://www.who.int/entity/bloodsafety/transfusion_services/en/Blood_Safety_Span.pdf
104. Global database on blood safety (WHO web page)
http://www.who.int/bloodsafety/global_database/en/
105. Prioritizing second-line antiretroviral drugs for adults and adolescents: a public health approach.
Report of a WHO working group meeting, Geneva, Switzerland, 21-22 May 2007
http://www.who.int/hiv/pub/meetingreports/Second_Line_Antiretroviral.pdf
62
2.4 Scaling up HIV/AIDS treatment and care

For infants, children or adults living with HIV, a comprehensive package of prevention, treatment
and care interventions should be made available. Early referral after HIV diagnosis is essential
and is most urgent for infants, children or adults with signs and symptoms of HIV and also for
all pregnant women. Interventions to prevent HIV transmission and prevent ill health are often
referred to as positive prevention or prevention for positives.
Health services should deliver a complete package of interventions for all people with HIV, ideally
starting well before the need for antiretroviral therapy (ART), with pre-ART care that includes
regular assessment of the clinical and immunological stage of infection. Interventions for treatment
and care include ART, and treatment and management of common infections, comorbidities and
toxicities. However, the interventions should also address cardiovascular disease, malignancies,
palliative care and end-of-life care.
To optimize and maximize the benefit of ART, specific efforts to prepare for and support adherence
are required. Nutritional support is critical, particularly for infants, children and pregnant women.
Mental health disorders, including alcohol and other substance use, need to be addressed,
as does the need for psychosocial support. The interventions described in this document are
recommended to improve quality of life and to prevent morbidity and mortality, and the health
sector is largely responsible for providing these interventions.
Health services should be configured to provide the complete range of interventions described
in this document, or a so-called continuum of care. There should be careful consideration of the
special needs of injection drug users, sex workers, young people and men who have sex with
men. There should also be family care, built around the family as a unit needing care, even where
only one or two members have HIV.
Not all interventions will be necessary or equally important in all countries, or for all target populations
or settings within those countries. Local and national epidemiology and context will largely determine
which interventions are most appropriate. Attention must also be paid to costs, including the costs of
making interventions available and accessible to all who need them. The hidden costs of laboratory
testing, transportation and time away from work need to be taken into account. None of these costs
should be allowed to impede access to services by people who need them.
Laboratory services required to accelerate the scale up of treatment and care are discussed
in Section 2.4.3.
63
2.4.1 Interventions to prevent illness

Interventions to prevent illness in HIV-infected individuals include chemoprophylaxis against
common opportunistic infections; measures to reduce the incidence of pneumonia, diarrhoea
and other clinical conditions that are more common or more serious in children or adults with HIV
infection; screening to detect common malignancies and other comorbidities; and immunizations.
Table 3 summarizes those and other essential and optional interventions to prevent illness in
people living with HIV, including viral hepatitis B, tuberculosis (TB) and other conditions. These
interventions are further discussed in Section 2.4.2.2.
Table 3. Interventions to prevent illness in people living
Recommended
Consider
Cotrimoxazole prophylaxis
Influenza vaccination
Safe water, water treatment methods
Yellow fever vaccination if no advance or severe

HIV disease
Sanitation, proper disposal of faeces and

other biological fluids
Hand washing with soap after defecation or
handling faeces and other biological fluids
Hepatitis B vaccination for Hepatitis B core
antibody-negative adults
TB screening
Optional
Isoniazid preventive therapy for TB
Chemoprophylaxis for Cryptococcus sp
Intermittent preventive treatment for

malaria in pregnant women in malarious
areas, if cotrimoxazole prophylaxis (CPT) is
not in use
Pneumococcal vaccine for adults (polysaccharide

vaccine) if CD4 > 200 cells/mm3
Indoor residual spraying and insecticidetreated bednets if living in malarious areas

Full nutritional assessment
Key resources:
English:
French:
64
2.4.1.1 Cotrimoxazole prophylaxis

Cotrimoxazole is an effective, well-tolerated and inexpensive antimicrobial agent that has been
used since the mid-1980s to prevent Pneumocystis jirovecci pneumonia (PCP) and toxoplasmosis
in adults and children with advanced HIV disease. Several studies showed that it is also effective
against other bacterial and parasitic diseases, and it reduces the incidence of malaria in HIVinfected individuals. Furthermore, cumulative evidence from observational data and randomized
clinical trials on cotrimoxazole prophylactic treatment (CPT) conducted in resource-limited
settings has shown reduced hospitalization, morbidity and mortality among people living with HIV
who are on CPT, even if they are already on ART. Therefore, CPT should be implemented as an
integral component of the chronic care package.
WHO recommends that all HIV-infected adults and children living with HIV/AIDS should initiate
CPT if they have symptomatic disease (WHO clinical stage 2 or higher) irrespective of CD4 count
or if they have a CD4 count below 350 cells/mm3 irrespective of HIV clinical stage.
All children born to HIV-positive women should commence CPT at around four to six weeks of
age, or on first contact with health services, and should stay on CPT until HIV infection can be
definitively excluded.
Some countries may choose to simplify these recommendations in settings with high prevalence
of HIV and very limited health infrastructure, and instead recommend universal CPT for everyone
living with HIV, irrespective of their CD4 count or HIV clinical staging.
The current recommendation is to continue CPT in HIV-infected adults and children indefinitely,
but the discontinuation of CPT in HIV-infected individuals may be considered in the context of drug
toxicity, pregnancy and immune recovery in response to ART, and should be based on clinical
judgment, including both clinical and laboratory parameters.
Trials from developed countries have shown that cotrimoxazole used for prevention of PCP
and toxoplasmosis may be safely stopped following immune recovery on ART. In other settings,
observational data have also demonstrated that cessation of CPT is safe when the decision is
guided by CD4 count. Data on stopping CPT in the absence of CD4 monitoring are limited, and
there is concern over the use of ART duration as a guide to determine when CPT may be safely
stopped, especially where no baseline CD4 count is available. In situations where CPT has been
discontinued, CPT should be restarted if the CD4 count falls below the initiation threshold or if new
or recurrent WHO clinical events (stage 2 or higher) occur. A review of CPT recommendations,
particularly regarding discontinuation after immune recovery, is planned for 2010.
Key resource:
106. Co-trimoxazole prophylaxis for HIV-exposed and HIV-infected infants and children. Practical
approaches to implementation and scale up | WHO and UNICEF
http://www.who.int/hiv/pub/paediatric/co-trimoxazole/en/index.html
65
2.4.1.2 Preventing fungal infections

Cryptococcus is a significant cause of illness and death in children and adults with HIV infection,
particularly in sub-Saharan Africa. Other fungal infections may also be important, depending on
local epidemiological patterns (e.g. Penicillium marneffei in South-East Asia).
In areas where cryptococcal disease is common, antifungal prophylaxis with fluconazole
should be considered for people with HIV if they have clinically severe disease or very low
CD4 cell counts (< 100 cells/mm3), whether or not they are receiving antiretroviral therapy.
Prior to beginning primary prophylaxis with azoles (antifungal agents), active cryptococcal and
other invasive fungal infections should be excluded. People with HIV infection who are taking
fluconazole, especially those who are taking other hepatotoxic drugs, require monitoring for
adverse events. Secondary prophylaxis is recommended for all HIV-positive patients after
completing treatment for cryptococcal disease.
Key resource:
2.4.1.3 Vaccinations
Recommendations on routine childhood and catch-up vaccinations for adults and children living
with HIV are being reviewed by WHO expert committees in 2008, and readers are encouraged to
check for updated guidance.
Summary of recommendations for infants and children

As early in life as possible, HIV-exposed infants and children should receive all vaccines under
the Expanded Programme for Immunization, including Haemophilus influenzae type B and
pneumococcal vaccine. This should be done according to recommended national immunization
schedules. However, the schedules may require some modification for infants and children with HIV.
Because of the increased risk of early and severe measles infection, infants with HIV should
receive a dose of standard measles vaccine at six months of age with a second dose as soon
after nine months of age as possible, unless they are severely immunocompromised at that time.
Similarly, immunization with pneumococcal conjugate vaccine or Haemophilus influenzae type B
conjugate vaccine should be delayed if the child is severely immunocompromised.
New findings indicate a high risk of disseminated Bacille Calmette-Gurin (BCG) disease
developing in infants who have HIV, and BCG vaccine should therefore not be given to children
known to have HIV. However, infants cannot normally be identified as being infected with HIV
at birth, so BCG vaccination should usually be given to all infants at birth, regardless of HIV
exposure, in areas with high prevalence of TB and of HIV.
66
Summary of recommendations for adults

Vaccine-preventable diseases, especially hepatitis B and influenza, are among the major causes of
illness among adults with HIV. However, the efficacy of hepatitis B vaccine is related to the degree
of immunosuppression induced by HIV. Where serological testing for hepatitis B virus is available,
WHO recommends three doses of standard- or double-strength hepatitis B vaccine for adults with
HIV who are susceptible (i.e. antibody to hepatitis B core antigen-negative) and have not been
vaccinated previously. Vaccine response (titre of hepatitis B surface antibody after three doses
of hepatitis B vaccine) can be measured and, if suboptimal, revaccination may be considered.
In settings where serologic testing is not available and hepatitis B prevalence is substantial,
programme managers may choose to offer three doses of hepatitis B vaccine to all adults with HIV.
Where available and feasible, annual influenza vaccination with the inactivated subunit influenza
vaccine should be offered to adults with HIV. Moreover, if influenza vaccine is indicated in the context
of a large epidemic or pandemic, adults with HIV should receive inactivated influenza vaccine.
There is insufficient information to make recommendations about human papillomavirus
vaccination for young females with HIV.
Key resources:
107. Vaccine-preventable diseases, vaccines and vaccination
http://whqlibdoc.who.int/publications/2005/9241580364_chap6.pdf
108. Revised BCG vaccination guidelines for infants at risk for HIV infection
http://www.who.int/wer/2007/wer8221.pdf (see p. 193)
67
2.4.1.4 Nutritional care and support

Children and adults with HIV have increased energy needs, but symptoms of HIV or opportunistic
infections may lead to reduced dietary intake, decreased appetite, difficulty swallowing and
malabsorption. This, combined with environmental factorssuch as a lack of regular access to a
nutritious, balanced dietmeans HIV and nutrition interactions are complex.
Evidence-based nutrition interventions should be part of all national HIV care and treatment
programmes. Routine assessment should be made of diet and nutritional status (weight and weight
change, height, Body Mass Index or mid-upper arm circumference, symptoms and diet) for people
living with HIV. Assessment of diet should aim to ensure that protein and micronutrient intake are
adequate for the patients energy needs and that potential drug-food (including herbal and traditional
remedies) interactions are avoided. Individual and household food security should also be evaluated.
WHO recommends that all children and adults receive one recommended daily allowance (RDA)
of micronutrients, regardless of their HIV status. This is best provided by food, including fortified
food. Where the micronutrient content of the daily diet is inadequate, a daily multi-micronutrient
supplement is required (one RDA is recommended). There is no evidence for increased protein
requirements exceeding that of a balanced diet, where protein contributes about 1015% of the
total energy intake.
Whenever feasible, people with HIV and their families who lack the means to meet their basic
dietary needs should be assisted in achieving food security. Assistance might, for example, include
supplements to their income or direct provision of some of their food.
Key resources:
109. Nutrition counselling, care and support for HIV-infected women
http://www.who.int/hiv/pub/prev_care/en/nutri_eng.pdf
111. Nutrition and HIV/AIDS: A Report by the Secretariat. WHO Executive Board EB116/12, 116th
Session, 12 May 2005
http://www.who.int/gb/ebwha/pdf_files/EB116/B116_12-en.pdf
112. Guidelines for an integrated approach to the nutritional care of HIV-infected children (6 months-14
years): Preliminary version for country introduction
http://www.who.int/nutrition/publications/hivaids/9789241597524/en/index.html
113. Nutritional care and support for people living with HIV/AIDS: A training course
68
2.4.1.5 Providing safe water, sanitation and hygiene

Simple, accessible and affordable interventions to ensure safe household water and sanitation (i.e.
management of human waste) reduce the risk of transmission of water-borne and other enteric
pathogens. Where programmes offer replacement feeding or early weaning from breastfeeding
for infants of women with HIV, effective water treatment is essential to protect the infants health.
Interventions for point-of-use water, sanitation and personal hygiene require continued motivation
and reinforcement of behaviour change. Over the long term, governments and development partners
should address the larger problem of inadequate access to piped supplies of safe water in homes.
Household-based water treatment and storage of water in containers that reduce manual contact
are recommended for people living with HIV and their households. Steps should be taken to
ensure that they have a minimum of 20 litres of water per person per day.
To reduce diarrhoeal disease among people living with HIV and their families or households,
disposal of faeces in a toilet, latrine or, at a minimum, burial in the ground is recommended. Hygiene
interventions should include hygiene education and promotion of hand washing with soap, along with
the provision of soap for people living with HIV and their caregivers and households.
Key resource:
2.4.1.6 Preventing malaria

In malarious areas, infants and children under five years of age and pregnant women with HIV are
at high risk of complications resulting from coinfection with malaria, so they should be provided
with malaria prevention and treatment.
Infants, children under five and pregnant women with HIV who live in malarious areas should
be provided with insecticide-treated mosquito nets and/or residual spraying of their rooms and
homes to reduce their exposure to malaria. Pregnant women with HIV who are already receiving
cotrimoxazole prophylaxis do not require sulfadoxine-pyrimethamine-based intermittent preventive
therapy for malaria. However, in areas of malaria transmission, pregnant women living with HIV
who are not taking cotrimoxazole should be given at least three doses of intermittent preventive
treatment for malaria as part of their routine antenatal care.
Key resource:
69
2.4.2 Treatment and care interventions

Management of the large range of HIV-related conditions should be based on clear guidelines and
standardized protocols.
Major interventions for care and treatment are discussed in the following sections and include,
for example:
Regular, periodic clinical assessment, both pre-antiretroviral therapy (ART) and post-ART
initiation (see Section 2.4.2.1.2);
Treatment preparedness and adherence support (see Section 2.4.2.1.1);
Management of opportunistic infections and comorbidities (see Section 2.4.2.2);
Prevention and treatment of mental health disorders (see Section 2.4.2.2.7); and
Palliative care (see Section 2.4.2.3).
2.4.2.1 Antiretroviral therapy for adults, adolescents and children

A public health approach to antiretroviral therapy (ART) facilitates quality HIV treatment for all
who need it, an essential component of the universal access goal. It promotes simplified and
standardized clinical decision-making, drug regimens and formularies, and patient data recording
systems. It requires that national drug prescription and clinical care guidelines be supported by
regular supplies of quality-assured drugs and that these drugs be made available to patients free
of charge at the point of service delivery.
Early referral to ART services and measures to retain patients in care are essential to the
achievement of good patient and programme outcomes. To maintain the effectiveness of first- and
second-line antiretroviral regimens, WHO recommends that countries develop a national strategy
for HIV drug resistance prevention and assessment (see Section 4.2.4). WHO also recommends
any expansion or improvement of laboratory services that may be necessary for diagnosis and
treatment of HIV, opportunistic infections and related conditions, and to support monitoring of
treatment effectiveness (see Section 2.4.2.1.2).
70
Current recommendations for initiating ART in adults, adolescents and children are shown in Table
4Table 6. These recommendations are reviewed and updated regularly. WHO recommends that
criteria for starting ART be defined in national protocols and that these be based at a minimum on
clinical stage and CD4 counts. The 2009 revised ART recommendations recommend an earlier
start for ART, including for all HIV-infected individuals with CD4 cell count of 350 cells/mm3 or less
and those with advanced HIV clinical disease, active TB or active chronic hepatitis B, irrespective
of CD4 cell count values. This is based on evidence of both individual and public health benefits
of earlier treatment initiation identified in several observational studies and recent clinical trials.
In addition, and while WHO has not made specific recommendations, there are claims and some
data suggesting that starting ART earlier has prevention benefits, too.
Laboratory eligibility criteria, including any requirements that may be in place for CD4 cell count, should
not be used to delay starting ART, especially for patients who meet the clinical criteria for starting ART.
Currently recommended first-line regimens for adults, adolescents and children contain two
nucleoside reverse transcriptase inhibitors (NRTIs) plus one non-nucleoside reverse transcriptase
inhibitor (NNRTI) drug. WHO recommends the use of fixed-dose combination regimens to
support adherence and programme delivery. For adults, Azidothymidine (AZT, also Zidovudine) or
Tenofovir (TDF) combined with Lamivudine (3TC) or Emtricitabine (FTC) are the preferred first-line
NRTI medicines. In children, AZT or Abacavir (ABC) combined with 3TC are preferred. Countries
have also been advised to phase out more toxic Stavudine-based therapy and transition patients
towards either AZT- or TDF-based regimens. First-line regimens for people with active hepatitis B
should contain TDF and 3TC or FTC. For people with HIV-2 infection, which is naturally resistant
to all NNRTI drugs, a triple nucleoside regimen is recommended.
The 2009 recommendations also emphasize the importance of using these drugs as fixed-dose
combinations and outline an expanded role for laboratory monitoring, including both CD4 and
viral load testing.
For pregnant women, ART is also essential to prevent vertical (mother-to-child) transmission and
the new recommendations have emphasized the critical need for CD4 testing to identify those who
are in need of ART and at greatest risk of transmission. Pregnant women who are not eligible for
ART should receive ARV prophylaxis using one of the more efficacious options, including triple
ARV prophylaxis (see Section 2.3.3.2). Revised recommendations have been developed for ART
in infants and children (see Table 6 below), which include guidance on the management of infants
who have been exposed to Nevirapine pre-delivery, perinatally or post-delivery. WHO recommends
that all infants and children <24 months with a confirmed diagnosed of HIV start ART immediately.
Patients who develop failure of their first-line therapy will need second-line therapy. Treatment failure
is recognized by using clinical, immunological and, where feasible, virological parameters. WHO
recommends changing the drug regimen if treatment failure has occurred. The protease inhibitor (PI)
class of drugs is usually reserved for second-line treatment, together with at least one new NRTI drug.
2009 WHO guidelines have addressed which second-line drugs are most feasible, affordable and safe,
and how clinical, immunological and viral load criteria are best used to recognize treatment failure.
71
Table 4. WHO recommendations for initiating antiretroviral therapy in adults and adolescents (2009)
Target population
Clinical condition
Recommendation
Asymptomatic individuals
(including pregnant women)
WHO clinical stage 1
Start ART if CD4 350
Symptomatic individuals
(including pregnant women)
WHO clinical stage 2
Start ART if CD4 350
WHO clinical stage 3 or 4
Start ART irrespective of CD4

cell count
Active TB disease

cell count
Hepatitis B coinfection
requiring therapy

cell count
TB & hepatitis B coinfections
Source: Antiretroviral therapy for HIV infection in infants and children. Recommendations for a public health

Table 5. WHO recommendations for initiating antiretroviral treatment in infants and children (2010)
Age
Infants <24 months 24 months through

59 months
5 years or over
% CD4
All**
<25%
N/A
<750 cells/mm3
As in adults
(<350 cells/mm3)
Absolute CD4*
* Absolute CD4 count is naturally less constant and more age-dependent than % CD4; it is not therefore appropriate to
define a single threshold. Where % CD4 is not available, absolute CD4 count thresholds may be used. All HIV-infected
infants should receive ART due to the rapid rate of disease progression.
** Countries with reliable affordable access to CD4 and viral load monitoring may choose to use immunological and/or
virological thresholds for initiation of children aged 12-23 months.

72
Table 6. Summary of WHO preferred antiretroviral treatment recommendations for infants, children and adults
Patient group
Preferred first-line
regimen
Preferred second-line
regimen
Infants and children <24months

not exposed to NNRTI
NVP + 2 NRTI
Boosted PI + 2 NRTI
with unknown NNRTI

exposure
NVP + 2 NRTI
Boosted PI + 2 NRTI
exposed to NNRTI
LPV/r + 2 NRTI
NNRTI + 2 NRTI
NNRTI + 2 NRTI
Boosted PI + 2 NRTI
Adult or adolescent
NNRTI + 2 NRTI
Boosted PI + 2 NRTI
Woman starting ART in

pregnancy
NVP + AZT + 3TC
Does not apply
Woman starting ART within 6

months of single-dose NVP
NNRTI + 2 NRTI or 3 NRTI
Boosted PI + 2 NRTI
Child, adolescent or adult with

severe anaemia
NVP + 2NRTI (avoid AZT)
Boosted PI + 2 NRTI (avoid

AZT)
Child, adolescent or adult with

TB
EFV + 2 NRTI or 3 NRTI
Boosted PI* + 2 NRTI
Adult or adolescent with

hepatitis B
TDF + 3TC + NNRTI
Boosted PI + 2 NRTI**
Adult or adolescent with

hepatitis C
EFV + 2 NRTI (avoid NVP)
Boosted PI + 2 NRTI
Injection drug user
NNRTI + 2 NRTI
Boosted PI + 2 NRTI
HIV-2 infection
3 NRTI
Boosted PI + 2 NRTI
Children
Children 2 years or over
Adults and adolescents
Concomitant conditions
* If using RMP in the TB regimen, superboosted LPV or SQV are the recommended PI options (based on limited pK studies). If RFB or an alternative TB regimen without RMP is used, any boosted PI at its conventional dosage can be used.
** If long-term anti-HBV therapy is still needed, maintain 3TC and TDF in addition to the new NRTI backbone.
3TC= Lamivudine, AZT = Azidothymidine, Zidovudine, EFV = Efavirenz, HBV = Hepatitis B virus, LPV/r = Lopinavir with
booster dose of Ritonavir, NNRTI = Non-nucleoside reverse transcriptase Inhibitor, NRTI = Nucleoside/nucleotide reverse
transcriptase inhibitor, NVP = Nevirapine, PI = Protease inhibitor, RFB = Rifabutin, RMP= Rifampicin, TDF = Tenofovir.

73
Key resources:
10. WHO case definitions of HIV for surveillance and revised clinical staging and immunological
classification of HIV-related disease in adults and children
15. Antiretroviral therapy for HIV infection in infants and children. Recommendations for a public health
English:
French:
86. Report of the WHO technical reference group, paediatric HIV/ART care guideline group meeting,
WHO Headquarters, Geneva, Switzerland, 10-11 April 2008
http://www.who.int/hiv/pub/paediatric/art_meeting_april2008/en/index.html
94. Antiretroviral therapy for HIV infection in adults and adolescents. Recommendations for a public
health approach (2010 revision)
http://www.who.int/hiv/pub/arv/adult/en/index.html
105. Prioritizing second-line antiretroviral drugs for adults and adolescents: a public health approach.
Report of a WHO working group meeting, Geneva, Switzerland, 21-22 May 2007
114. Prequalification programme: A United Nations Programme managed by WHO (WHO web site)
http://apps.who.int/prequal/
115. IMAI basic ART aid (lay counsellor) training modules
116. Patient treatment cards
117. Flipchart for patient education: HIV prevention, treatment and care
118. HIV/AIDS treatment and care: clinical protocols for the WHO European Region
English:
Russian:
http://www.euro.who.int/document/e90840R.pdf
119. WHO consultation on ART failure in the context of a public health approach: 2008 meeting report
http://www.who.int/hiv/pub/arv/failure/en/index.html
120. ART failure and strategies for switching ART regimens in the WHO European RegionWHO
consultation on ART failure in the context of a public health approach: 2008 meeting report
http://www.euro.who.int/__data/assets/pdf_file/0020/78104/E91257.pdf
74
2.4.2.1.1 Treatment preparedness and adherence support

Interventions to ensure treatment preparedness and support adherence optimize the effectiveness
of ART and minimize the development of drug resistance. The ability of patients to follow treatment
plans is frequently compromised by various factors, including stigma and discrimination against
patients and their families, treatment costs they cannot afford, and the nature and tolerability of
available ARV therapies. The level of readiness by patients to follow health worker recommendations
is a major factor that can be addressed through information, education and counselling. Equally
important are practical matters, such as the need for free or affordable transportation to and from
treatment centres and the need for those centres to have convenient opening hours for patients.
Treatment preparedness and adherence support for children requires support from their parents
or other primary caregivers. Children on the verge of adolescence and adolescents require special
attention; they are at a stage of life where they may be inclined to ignore or rebel against the
advice of adults, unless adults show respect for their emerging autonomy. Health care providers
have a responsibility to assess risk of non-adherence by children and adolescents and to deliver
necessary interventions to support adherence. This requires a multidisciplinary approach involving
key staff at health centres to ensure convenient opening hours, free or affordable transportation,
reduced direct or indirect costs of care, the provision of meals if appropriate, and so on.
Community and patients organizations often play key roles in supporting adherence through peer
monitoring, home visits and other means. Informal or formal social support from family, friends,
community and patients organizations has consistently shown to be important for treatment
preparedness, adherence and good health outcomes.
Interventions that target adherence should be tailored to the particular illness-related needs of
each patient. Health care providers should be prepared to assess their patients readiness to
adhere, offer advice and monitor the patients progress at every contact. For particular patient
groups, such as infants and pregnant women, expedited treatment preparedness is often
necessary, and more intensive and ongoing adherence support may be required.
Effective adherence support interventions include client-centred behavioural counselling and support,
support from peer educators trained as expert patients, and community treatment supporters. These
interventions involve encouraging people to disclose their HIV status and providing them with treatment
tools such as pillboxes, diaries and patient reminder aids. There should be site-based assessments to
evaluate the extent to which services such as free transport might improve adherence.
Key resources:
121. Adherence to long-term therapies: Evidence for action
http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf
http://www.who.int/hiv/pub/prev_care/lttherapies/en/
English:
French:
75
2.4.2.1.2 Patient monitoring

Infants, children and adults with HIV require clinical and laboratory monitoring at predetermined
intervals. Monitoring may include clinical assessment, CD4 cell count and other tests, depending
on the symptoms or signs identified. Regular patient monitoring can identify problems with
adherence, toxicity and effectiveness of ART and TB-HIV co-treatment. Nationally standardized
patient monitoring tools (patient records, registers and reports) facilitate high-quality patient
monitoring (see Section 4.2.3).
2.4.2.2 Managing HIV-associated opportunistic infections and comorbidities

Standardized clinical protocols should reflect the burden of HIV and prevalent comorbidities.
Certain conditions are common in infants, children or adults living with HIV and may herald
disease progression. Clinical care should manage the common acute and chronic conditions
associated with HIV.
Key resources:
English:
French:
122. IMAI acute care
English:
http://www.who.int/hiv/pub/imai/acute_care.pdf
French:
http://www.who.int/hiv/pub/imai/acute_care_fr.pdf
123. IMCI chart booklet for high HIV settings
English:
French:
http://whqlibdoc.who.int/publications/2008/9789242594379.cb_fre.pdf
124. IMAI OI training course (based on IMAI Acute Care guideline module)
125. Global action plan for the prevention and control of pneumonia (GAPP): report of an informal
consultation
76
2.4.2.2.1 Managing HIV-related conditions

At a minimum, case management protocols for adults and children with HIV should include the
conditions listed below, as well as other locally prevalent conditions.
Infections:

Candida (oesophageal and mucosal)

Cryptococcal meningitisCytomegalovirus infection
Herpes virus infections (zoster and simplex)
Hepatitis B and C
Pneumocystis jirovecci pneumonia (PCP)
Severe bacterial infections (including pneumonia and septicemia)
Malaria
Toxoplasmosis
Tuberculosis, including multidrug-resistant (MDR) and extensively drug-resistant (XDR) (see
Section 2.4.2.4)
Neurological conditions:

Neuropathies
Encephalopathies
Dementia
Developmental delay in children
Skin disorders:

Seborrhoeic dermatitis
Prurigo
Skin infections
Drug reactions
Malignancies:
AIDS-defining malignancies:
Kaposis sarcoma
Non-Hodgkins lymphoma, including primary cerebral lymphoma
Cervical cancer
Hodgkins lymphoma
Hepatocellular carcinoma
Cardiovascular, liver, renal and metabolic conditions:

77
Atherosclerosis
Cirrhosis
Dyslipidemia
Diabetes
Lipodystrophy syndrome
Cardiomyopathy
Nephropathy
Mental health disorders:

Substance use disorders

Attempted suicide
Major depression
Psychoses
Anxiety disorders
Others:
Lymphocytic interstitial pneumonia (LIP) in children
Key resources:
English:
French:
English:
French:
English:
French:
126. Integrated management of childhood illness (IMCI) complementary course on HIV/AIDS
Introduction: http://whqlibdoc.who.int/publications/2006/9789241594370.intro_eng.pdf
Module 1: http://whqlibdoc.who.int/publications/2006/9789241594370.m1_eng.pdf
Facilitator guide for modules: http://whqlibdoc.who.int/publications/2006/9789241594370.fg_eng.pdf
Photo booklet: http://whqlibdoc.who.int/publications/2006/9789241594370.pb_eng.pdf
Chart booklet: http://whqlibdoc.who.int/publications/2006/9789241594370.cb_eng.pdf
French (all modules): http://www.who.int/child_adolescent_health/documents/9241594373/en/
127. Policy for prevention of oral manifestations in HIV/AIDS: The approach of the WHO Global Oral
Health Programme
http://adr.iadrjournals.org/cgi/reprint/19/1/17.pdf
128. Pocket book of hospital care for children: guidelines for the management of common illnesses with
limited resources
English:
French:
Portuguese: http://whqlibdoc.who.int/publications/2005/9789248546709_por.pdf
Russian:
78
2.4.2.2.2 Managing pneumonia

Children and adults living with HIV have higher rates of pneumonia and mortality in both resourceconstrained and high-income settings. In sub-Saharan Africa, pneumonia is the leading cause of
hospital admission and the most common cause of death among children younger than five years
who have HIV. The case fatality rate for pneumonia in infants and younger children with HIV is very
high. In adults, pneumonia is often more serious and may be caused by a range of aetiologies.
In patients with presumed pneumonia who fail to respond to standard antibiotics, TB, PCP
pneumonia, fungal and other opportunistic pathogens need to be considered. PCP is a common
cause of severe pneumonia in people with HIV infection and should always be considered.
Key resources:
English:
French:
English:
French:
2.4.2.2.3 Managing diarrhoea

Chronic persistent diarrhoea is common in infants, children and adults living with HIV and may be
more difficult to diagnose and manage.
Clinical protocols should cover case management for the full range of opportunistic pathogens.
Key resources:
128. Pocket book of hospital care for children: guidelines for the management of common illnesses with
limited resources
English:
French:
Russian:
129. Implementing the new recommendations on the clinical management of diarrhoea: Guidelines for
policy makers and programme managers
English:
French:
Chinese:
http://whqlibdoc.who.int/publications/2006/9241594217_chi.pdf
Russian:
http://www.euro.who.int/document/9244594218R.pdf
79
2.4.2.2.4 Managing malnutrition

Weight loss and malnutrition are common symptoms of HIV in infants, children and adults and may
be due to reduced food intake, impaired absorption, increased food needs due to opportunistic
infections or other causes. Evaluation of weight loss should include assessing symptoms and
signs that could indicate underlying disease, notably chronic diarrhoea and TB. Successful
treatment of the underlying disease may result in weight gain. Usually, standard management
protocols can be followed, but responses may be poor and antiretroviral therapy may be required.
Specialized therapeutic foods are required for persons with Body Mass Index (BMI) <16 and for
infants and children with moderate or severe malnutrition. Supplementary feeding may be required
for mild-to-moderately malnourished adults (BMI <18.5) and children.
Key resources:
129. Community-based management of severe acute malnutrition: A joint statement by the World Health
Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition
and the United Nations Childrens Fund
English:
http://www.who.int/child_adolescent_health/documents/pdfs/severe_acute_malnutrition_

en.pdf
French:
http://www.who.int/child_adolescent_health/documents/pdfs/severe_acute_malnutrition_

fr.pdf
2.4.2.2.5 Treating viral hepatitis

In many areas of the world, chronic liver disease caused by either hepatitis B virus (HBV) or
hepatitis C virus (HCV) in patients with HIV is common, and this disease is now becoming one
of the leading causes of morbidity and mortality among people living with HIV in many regions.
Globally, approximately 10% of people with HIV have chronic hepatitis B. Men who have sex with
men have higher rates of HBV/HIV coinfection than injecting drug users or heterosexuals.
HCV and HIV coinfection is particularly frequent in areas with a high prevalence of injection
drug users; in some areas, up to two-thirds of injection drug users have chronic hepatitis C. In
Europe, up to 30% of HIV-infected individuals are coinfected with HCV. The course of HBV- and
HCV-related liver disease may be accelerated with HIV. Liver toxicity and related morbidity is not
uncommon when using ARVs in the presence of underlying chronic hepatitis B and/or C. In HBV/
HIV-coinfected patients with cirrhosis, hepatocellular carcinoma may appear at an earlier age and
be more aggressive in those with HIV infection.
WHO recommends that national health authorities establish prevention and treatment strategies
for HBV and HCV in HIV-coinfected individuals as well as activities to prevent HBV and
HCV transmission.
In addition to the key resources listed below, detailed recommendations for clinical management
can be found in clinical protocols from the WHO Regional Office for Europe75.
7
HIV/AIDS Treatment and Care Clinical Protocols for the WHO European Region, 2007. http://www.euro.who.int/
InformationSources/Publications/Catalogue/20071121_1
80
Key resources:
131. Management of Hepatitis C and HIV coinfection: clinical protocol for the WHO European region
English:
http://www.euro.who.int/__data/assets/pdf_file/0008/78146/E90840_Chapter_6.pdf
Russian:
http://www.euro.who.int/__data/assets/pdf_file/0010/78148/HEP_C_rus.pdf
132. Prevention of hepatitis A, B and C and other hepatotoxic factors in people living with HIV: Clinical
protocol for the WHO European Region
English:
Russian:
http://www.euro.who.int/__data/assets/pdf_file/0007/78163/HEP_A_B_C_rus.pdf
133. WHO EURO hepatitis web site
http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/hepatitis
2.4.2.2.6 Managing malaria

Current recommendations on diagnosis and management of malaria in people living with HIV
are no different than those for the general population. These recommendations are due to be
reviewed in late 2008.
For adults and children with HIV living in malarious areas who have a fever, evaluation of the
cause of fever and, where possible, laboratory confirmation of malaria infection are preferred,
instead of presumptive treatment of fever as malaria. Available malaria tests may include
microscopy or rapid diagnostic tests. People with HIV who develop malaria require standard
recommended antimalarial treatment. Patients with HIV who are receiving cotrimoxazole
prophylaxis should not be given sulfadoxine-pyrimethamine.
Key resources:
134. Guidelines for the treatment of malaria, second edition
http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf
135. Malaria and HIV interactions and their implications for public health policy
English:
French:
http://www.who.int/entity/hiv/pub/meetingreports/malariahivfr.pdf
81
2.4.2.2.7 Preventing and treating mental health disorders

Prevention and treatment of mental health disorders and provision of psychological and social
support are often neglected in people living with HIV, despite the fact that they are critical
components of care. HIV infection itself can lead to poor mental health including impaired
cognition. In infants and children, it can lead to impaired neurological development and low
attainment of developmental milestones. Timely antiretroviral therapy effectively prevents HIV
related encephalopathy, but other conditions common in people with HIV include depression,
anxiety and substance use. These can interfere with treatment adherence. Alcohol use is also a
risk factor for unsafe sex and HIV transmission.
Promoting and supporting mental health throughout a chronic illness require a number of
interventions, including psychosocial support delivered by trained lay providers and clinicians,
basic counselling for depression and psychotherapeutic interventions to address recognized
psychiatric disorders. Brief interventions can address harmful and hazardous alcohol use. Mental
health-related issues for people living with HIV should be addressed at all levels of the health
system. This requires referrals connecting HIV-related services with mental health services and
linkages with psychological and social support resources in the community.
All people living with HIV should be offered or referred to a comprehensive set of psychosocial
interventions (e.g. individual and group counselling, peer support groups, family and couples
counselling, and adherence support). People living with HIV who have mental health conditions,
such as depression or alcohol or other substance dependence, should be provided with specific
psychosocial and psychotherapeutic interventions and, when indicated, medication for these
conditions. Services should be configured to support families and ensure that the needs of infants,
children and adolescents are met. Delirium, dementia, suicide, major depression, psychoses and
anxiety disorders all need specific interventions and may require psychotropic medication.
Key resources:
136. WHO mental health and HIV/AIDS series
Module 1 - Organization and systems support for mental health interventions in ARV therapy
programmes: http://whqlibdoc.who.int/publications/2005/9241593040_eng.pdf
Module 2 - Basic counselling guidelines for ARV therapy programmes: http://whqlibdoc.who.int/
publications/2005/9241593067_eng.pdf
Module 3 - Psychiatric care in ARV therapy (for second level care): http://whqlibdoc.who.int/
Module 4 - Psychosocial support groups in ARV therapy: http://whqlibdoc.who.int/
Module 5 - Psychotherapeutic interventions in ARV therapy (for second level care): http://whqlibdoc.who.
int/publications/2005/9241593091_eng.pdf
English:
French:
82
2.4.2.2.8 Counselling
Counselling is an essential component of HIV services that requires specific skills and
competencies in health workers and lay providers.
Counselling is required in a range of clinical situations in order to:
provide emotional support;
help patients cope with challenges and fears related to diagnosis of HIV and transmission to
infants, sexual partners and other family members;
help patients cope with the need for lifelong antiretroviral therapy;
help patients prioritize problems and find their own solutions;
help patients who are depressed or anxious;
address other aspects of HIV prevention, care and treatment (post-testing counselling, disclosure
of HIV status, safe sex, negotiating condom use, adherence);
intervene in crisis situations (e.g. bereavement or to prevent suicide).
Health workers, including counsellors, also require support to prevent and respond to burnout.
Key resources:
English:
http://www.who.int/hiv/pub/imai/generalprinciples082004.pdf
French:
http://www.who.int/hiv/pub/imai/imai_general_2008_fr.pdf
English:
French:
136. WHO mental health and HIV/AIDS series: Module 2 - Basic counselling guidelines for ARV
programmes
83
2.4.2.3 Palliative care

Palliative care can improve the quality of life of patients and their families. It offers prevention
and relief of suffering by means of early identification, assessment and treatment of pain and
other physical, psychosocial and spiritual needs. It calls for a multidisciplinary team approach that
addresses the needs of patients and their families.
Palliative care provides relief from pain and other distressing symptoms; integrates psychological
and spiritual aspects of patient care; and provides support systems to help patients and their
families live as actively as possible until death and to cope during both illness and death.
A central focus of palliative care is pain assessment and treatment with the use of opioid and nonopioid analgesics according to an analgesic ladder. The analgesics are provided together with
non-medical treatments. This requires addressing any limitations in access to opioid analgesics as
well as reservations some health workers may have about prescribing or administering analgesics.
Pain demands both specific management of the cause and control of the pain itself. The
analgesic ladder involves starting pain relief with a non-opioid analgesic such as aspirin,
paracetamol or ibuprofen. If pain persists or increases, an opioid analgesic such as codeine
should be added for mild to moderate pain. If the pain is still not controlled or increases, codeine
should be stopped and oral morphine added to the aspirin, paracetamol or ibuprofen. Morphine
for home use is available as a liquid.
Quality of life can be significantly improved by: treating other physical symptoms with medication
and home remedies; ensuring preventive care in the bedridden patient, with careful attention to
mobility, skin care and hygiene; providing psychosocial support to patients and families, including
support for caregivers and bereavement counselling; and spiritual support.
People living with HIV should be encouraged to manage most symptoms themselves, and
community and peer groups and organizations can provide much of the other support.
Key resources:
137. Palliative care: symptom management and end-of-life care
English:
http://www.who.int/hiv/pub/imai/genericpalliativecare082004.pdf
French:
http://www.who.int/hiv/pub/imai/imai_palliative_2008_fr.pdf
138. WHOs pain ladder (web page)
http://www.who.int/cancer/palliative/painladder/en/index.html
139. IMAI palliative care training course
140. Caregiver booklet: Symptom management and end of life care (draft)
http://www.who.int/hiv/pub/imai/patient_caregiver/en/index.html
84
2.4.2.4 Tuberculosis prevention, diagnosis and treatment

Tuberculosis (TB) is a leading cause of illness and death of people living with HIValmost one
in four of the worlds 2 million AIDS-related deaths each year is associated with TB, despite TB
being largely preventable and curable. In countries with high HIV prevalence, up to 80% of people
with TB test positive for HIV, and HIV-positive individuals are more likely to have reactivation and
reinfection of TB. The majority (83%) of these deaths occur in Africa, where the HIV-positive TB
mortality rate is 48 per 100 000 population, compared with 2 or fewer AIDS-related TB deaths per
100 000 in the rest of the world. Even for those that it does not kill, TB places a heavy burden on
people living with HIV, causing significant illness that requires a minimum of six months treatment,
with the associated economic costs to the individual, his or her family and the health care system.
This is of increasing concern, given the emergence of TB drug resistance, including multidrug- and
extensively drug-resistant disease. Some most-at-risk groups (e.g. IDUs, prisoners and health
workers in some settings) are at greater risk of infection and developing active TB.
In response to the dual epidemics, WHO recommends 12 collaborative TB/HIV activities as part
of core HIV and TB prevention, care and treatment services (see Box 2 below). In addition to the
provision of ART, which markedly reduces the risk of TB morbidity and mortality in people living
with HIV, it is recommended that service providers focus on the Three Is for HIV/TB: intensified
case finding (ICF) for TB, Isoniazid preventive therapy (IPT) and infection control for TB. In 2009
WHO produced up-to-date infection control guidelines and in January 2010 sixty experts from five
regions met to review the evidence regarding ICF and IPT, and to revise the 1998 WHO UNAIDS
Policy statement to produce new IPT/ICF guidelines.
WHO-recommended collaborative TB/HIV activities

Establish mechanisms for communication:
Set up a coordinating body for TB/HIV activities effective at all levels;
Conduct surveillance of HIV prevalence among TB patients;
Carry out joint TB/HIV planning; and
Conduct monitoring and evaluation (M & E).
Decrease the burden of TB in people living with HIV the Three Is for HIV/TB
Establish Intensified TB case-finding;
Introduce Isoniazid prevention therapy (IPT); and
Ensure TB Infection control in health care and congregate settings.
Decrease the burden of HIV in TB patients
Provide HIV testing and counselling;
Introduce HIV prevention methods;
Introduce co-trimoxazole preventive therapy (CPT);
Ensure HIV care and support; and
Introduce antiretroviral therapy (ART).
85
To summarize the above, WHO recommends that TB and HIV/AIDS control programmes
collaborate through an established coordinating body, undertake joint TB/HIV planning, ensure
surveillance of HIV prevalence among TB patients and also ensure the monitoring and evaluation
of activities (see Section 4.2 of Chapter 4).
The burden of HIV in TB patients should be reduced through HIV testing and counselling for TB
patients and those suspected of having TB, and through provision of condoms and other HIV
preventive interventions (see Section 2.3, cotrimoxazole prophylaxis (see Section 2.4.1) and HIV
treatment and care. Early HIV diagnosis and ART is a critical intervention both for preventing the
development of TB in people living with HIV and for reducing morbidity and mortality if they
need TB treatment.
The burden of TB in people living with HIV should be reduced through the Three Is for HIV/TB:
intensified TB case finding, Isoniazid preventive therapy and infection control for TB. Programmes
providing HIV services should include TB prevention as part of high quality care. Early ART is a
critical intervention for TB prevention since TB risk increases dramatically with immune status
deterioration. Should TB develop, all TB patients living with HIV are eligible for ART as soon as
possible and not later than 8 weeks under the new WHO 2009 ART guidelines.
WHO-recommended three Is for HIV/TB

Infection control for TB: A combination of measures aimed at minimizing the risk of TB
transmission within populations
Intensified case finding for TB: Screening for TB cases among people living with HIV
Isoniazid preventive therapy: The use of Isoniazid to treat individuals with latent TB infection
in order to prevent progression to active disease.
Intensified TB case finding in people living with HIV is essential since TB is a curable disease.
Intensified HIV case finding in people with TB is also essential because cotrimoxazole prophylaxis
can prevent complications.
WHO strongly recommends TB screening for all infants, children and adults with HIV. In addition,
the information provided to all patients with HIV and caregivers of infants and children with HIV
should address the risk of acquiring TB, ways of reducing exposure, the clinical manifestations of
TB, the risks of transmitting TB to others and, where appropriate, TB preventive therapy. Regular
screening for TB is also essential to quickly identify and treat TB and to determine whether
patients are eligible for Isoniazid preventive therapy.
The TB status of HIV-infected patients should be monitored on all visits to health providers. Those
with symptoms or signs suggestive of TB should undergo further clinical investigation. Most-at-risk
populations, including injecting drug users, require specific targeting. Approaches to reducing the
risk of latent TB infection progressing to TB-disease include treatment of the latent TB itself and
improvement in immune function as a result of antiretroviral therapy.
86
TB infection control measures are essential to prevent the spread of TB to individuals, their
families and others. Appropriate infection control measures (for example, developing a TB
infection control plan, fast-tracking coughing patients, assuring rapid TB diagnosis and improving
ventilation) should be implemented and reviewed periodically to minimize the transmission risk.
These measures are particularly important in congregate settings and health care facilities where
there may be significant exposure and risk for TB transmission.
Isoniazid is an effective, well tolerated and inexpensive antibiotic for TB preventive therapy and
should be provided to all people with HIV after screening for TB disease using fever, weight loss,
current cough and night sweats as indicators. WHO strongly recommends Isoniazid daily for at
least six months and conditionally recommends 36 months (evidence is emerging that longer
duration may have benefits). Children and pregnant women are also eligible after screening for
TB (see guidelines for dosing and indications). Specialist advice should be sought for preventive
therapy for those thought to have been infected with multidrug-resistant or extensively drugresistant TB. Previous TB is not a contraindication to TB-preventive therapy.
Key resources:
142. Guidelines for implementing collaborative TB and HIV programme activities
English:
http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.319.pdf
Russian:
http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.319_rus.pdf
143. Three Is Meeting: Intensified Case Finding (ICF), Isoniazid Preventive Therapy (IPT) and TB
Infection Control (IC) for people living with HIV
http://www.who.int/hiv/pub/meetingreports/WHO_3Is_meeting_report.pdf
144. Isoniazid preventive therapy (IPT) for people living with HIV
http://www.stoptb.org/wg/tb_hiv/assets/documents/IPT%20Consensus%20Statement%20TB%20HIV%20
Core%20Group.pdf
145. Guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings
English:
http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269.pdf
English
Addendum (Tuberculosis infection-control in the era of expanding HIV care and treatment):
http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269_ADD_eng.pdf
Russian:
http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269_rus.pdf
146. Tuberculosis infection control in the era of expanding HIV care and treatment. Addendum to the
WHO Guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings
http://www.who.int/tb/publications/2006/tbhiv_infectioncontrol_addendum.pdf
148. Tuberculosis care with TB-HIV co-management: Integrated Management of Adolescent and Adult
Illness (IMAI)
Facilitators guide: http://www.who.int/hiv/pub/imai/primary/tbhiv_comgt_fac.pdf
Participants manual: http://www.who.int/hiv/pub/imai/primary/tbhiv_comgt_partman.pdf
149. IMAI TB infection control at health facilities
http://www.who.int/hiv/pub/imai/TB_HIVModule23.05.07.pdf
Facilitators guide: http://www.who.int/hiv/pub/imai/primary/tb_infec_control_fac.pdf
Participants manual: http://www.who.int/hiv/pub/imai/primary/tb_infec_control_partman.pdf
87
2.4.2.4.1 Treating HIV-associated tuberculosis

The Directly Observed Treatment, Short-course (DOTS) principles are well recognized as the most
effective approach to managing TB in people living with HIV. They may develop TB at any stage in
the course of HIV infection, but the incidence increases with the severity of immunosuppression.
Among children under five, there is often rapid progression from infection with TB to serious TB
disease. Since people living with HIV are more likely to have smear-negative extrapulmonary TB,
the reliance on smear microscopy is a concern. In addition, chest X-ray patterns may be atypical
in people with HIV, particularly where there is severe immunosuppression, and this can also make
diagnosis of TB difficult. The 2009 WHO guidelines recommend that all TB patients with HIV
should be started on ART as soon as possible and not later than 8 weeks following TB diagnosis.
The 2009 WHO guidelines recommend that all TB patients with HIV should be started on ART as
soon as possible and not later than 8 weeks. WHO recommends scaling up access to culturebased diagnosis for people living with HIV. Recommended TB treatment based on a four-drug
initial phase and a continuation phase remains the same for adults and children with HIV.
Thioacetazone is contraindicated, as it can result in potentially fatal skin hypersensitivity.
Key resources:
Illness (IMAI)
150. Guidance for national tuberculosis programmes on the management of TB in children
http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf
151. TB/HIV: a clinical manual: 2nd edition
English:
Portuguese: http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.329_por.pdf
88
2.4.3 Laboratory services for HIV monitoring

Objective care and treatment of HIV infected individuals requires clinical and laboratory
monitoring. Laboratory monitoring is done by measuring the viral load and/or CD4+
T-lymphocytes, both of which have been found to be good predictors of clinical patient outcome.
CD4+ T-cell count is the commonly used marker in deciding when to start ART; initiate medical
intervention to prevent opportunistic infections; monitor HIV disease progression; determine
level of immune suppression; and provide overall assessment of immune restoration in patients
receiving ARV. An increase in viral load and synchronous reduction in CD4 counts are good
indicators to change to the next line of ARV drugs. However, HIV viral load measurement is more
expensive than CD4 enumeration, though both require well established laboratories, depending
on the type of CD4 technology selected.
National HIV/AIDS programmes should establish laboratories with the capacity to validate the
performance of available CD4 technolgoies and viral load tests and place them in laboratories
according to the levels of available infrastructure and expertise. WHO guidance on selection and
use of CD4 technologies in Resource limited settings is being updated
Key resource:
152. CD4+ T-cell enumeration technologies: technical information (will be published in 2010)
89
Chapter 3: Operationalizing the priority

interventions strengthening health systems
3.1 Background
While one can identify priority interventions that the health sector should integrate in its response
to the HIV epidemic, it is clear that they must all be delivered through channels in organizations
or by peoplehealth services, outreach, community actionswhich will themselves need to
be resourced in order to happen. In keeping with the ideas underlying the primary health care
movement, people working on and with HIV have always maintained that those actions should
be informed by concerns such as human rights, equity, efficiency, the need to provide services
of good quality that are responsive to the needs of target populations who should be able to
access these services without risking financial catastrophe. WHO defines the sum total of all the
organizations, people and actions whose primary intent is to promote, restore or maintain health
as the health system.80 6The health sectorthat part of the health system regulated by the health
ministryis an important part of the health system. However, as many actions to improve health
(such as increasing access to water and sanitation, improving road safety or providing social
support to people living with HIV/AIDS) are under the purview of other sectors, health systems
span many parts of society, including civil society, home-based carers and the private sector.
It is increasingly recognized that the weakness of health systems remains a major barrier for
the response to HIV and the realization of other health objectives. The biggest challenges for
the response to HIV lie in countries with generalized HIV epidemics, where HIV increases the
workload of the health sector while undermining the capacity of its workforce. But high-income
countries with low-level or concentrated epidemics face health system challenges toofor
example, in reaching most-at-risk and marginalized groups or deciding where to integrate
interventions in the health system.
While the structure and operations of health systems vary from country to country and from area
to area within countries, WHO has identified six building blocks of all health systems. These are
illustrated in the figure below and include:
1. service delivery;
2. health workforce;
3. information;
4. medical products, vaccines and technologies;
5. financing; and
6. leadership and governance.
Everybodys business: Strengthening health systems to improve health outcomes. WHOs framework for action.
Geneva, World Health Organization, 2007. Available at: http://www.who.int/healthsystems/strategy/everybodys_
business.pdf
90
Health systems strengthening is defined as improving these six building blocks and managing
their interactions in ways that achieve more equitable and sustained improvements across health
services and health outcomes. In keeping with the primary health care strategy of WHO, it is
proposed that they be strengthened to reach universal coverage (to improve health equity), which
will require service delivery reforms, public policy reforms and leadership reforms.9 7
In this chapter, five of these building blocks will be discussed as they relate to scaling up the
response to HIV within a primary health care approach. The remaining building block, information
is covered in Chapter 4.
Figure 3. Health system building blocks, desirable attributes, goals and outcomes
System building blocks

Service delivery
Health workforce
Information
Overall goals/outcomes
Access
Coverage
Responsiveness
Medical products, vaccines and technologies
Financing
Leadership/governance
Improved health (level and equity)
Social and financial risk protection
Quality
Improved efficiency
Safety
Source: Everybodys business: Strengthening health systems to improve health outcomes. WHOs framework for action.
Geneva, World Health Organization, 2007. Available at http://www.who.int/healthsystems/strategy/everybodys_business.pdf
91
The World Health Report 2008. Primary Health Care - Now more than ever. Geneva, World Health Organization,
2008. Available at: http://www.who.int/whr/2008/en/index.html
3.2 Service delivery

Good health services are those that deliver effective, safe, high-quality health interventions to the
people who need them, when and where they need them and with minimum waste of resources.
These interventions may target individuals or entire populations, whether defined by geography
(e.g. national, district or local) or characteristics (e.g. gender, age, nature of illness, occupation,
behaviour). In the case of HIV, health services should take into account that people living with
HIV or most-at-risk of infection often face stigma and discrimination because of their infection or
because they may belong to groups with particular behavioural or disempowering characteristics,
such as sex workers, injecting drug users, prisoners, youth and men who have sex with men.
Reaching these groups with HIV prevention, treatment and care requires special interventions that
are often best delivered through outreach, community groups or their own organizations.
Those planning and implementing HIV-related service delivery programmes should consider
the need for: integration and linkage of health services; infrastructure and logistics; demand for
services; and management.
3.2.1 Integration and linkage of health services

There are no universal models for good service delivery. However, in the case of HIV-related
services, it is agreed that services should be delivered across a continuum of care. This
requires integrated and linked service provision at all levels of the health system, from primary
to secondary to tertiary (specialist) care, embracing all elements of the health system, including
home-based and community-based outreach care.
Linkage refers to a relationshipfor example, between a local health centre and a district hospital.
Integration refers to delivering multiple services or interventions to the same patient by an
individual health care worker or by a team of health care workers and, possibly, workers from other
fields. Strong linkages (with referral and coordination between service providers) and integrated
services are needed in particular areas of health care, such as family planning, care for mothers
and newborn infants, mental health care and care for people living with HIV. All of these may involve
a range of services and service providers, including home-based and community-based ones.
A particularly strong case can be made for integrating HIV-related services into all maternal and
newborn care and sexual and reproductive health care service delivery. Integrating HIV-related
and TB-related services into one package of services is also recommended.
In many large health centres and hospitals, pregnant women with HIV are identified in the
antenatal clinic and then referred for HIV-related services that are in another area of the facility or
in another facility altogether. This often results in a significant loss to follow-up; many women do
not appear at an HIV clinic even if it is in the same facility. This is a reason why pregnant women
who need ART often do not receive it.
92
To avoid this sequence of events, full integration of HIV intervention delivery within services for
antenatal care, childbirth, newborn and postpartum care is a minimum requirement in any country,
district or locality where HIV infection is common. Such integration should include HIV testing
and counselling, assessment of whether antiretrovirals for treatment or prophylaxis are needed,
initiation and monitoring of antiretrovirals in women and exposed infants, follow-up HIV testing for
infants, clinical review and cotrimoxazole prophylaxis when infants return for immunization.
Sexual and reproductive ill health and HIV infection share the same driving forces, causes
or contributors: poverty, limited access to information, gender inequality, cultural norms and
social marginalization of the most vulnerable and at-risk populations. This explains why there is
international consensus around the need for effective linkages between responses to HIV and
responses to sexual and reproductive health concerns, as well as consensus around the need
for integration of related services whenever feasible. These integrated services should include:
promoting condom use for preventing unintended pregnancy, sexually transmitted infections (STIs)
and HIV; reproductive choice counselling and counselling for family planning and contraception;
education on sexual health for people living with HIV; and youth-friendly health services covering
sexual and reproductive health.The high incidence of TB among people living with HIV and the
frequent occurrence of HIV infection among people with TB provide the rationale for linkages
between responses to TB and HIV, and integration of TB-related and HIV-related services. Such
linkages and integration have already resulted in substantial increases in the proportion of TB
patients tested for HIV and then referred to HIV care services (or provided with some HIV services
on-site). In addition, HIV programmers are increasingly committed to TB control, intensified TB case
finding among HIV-infected patients and to offering Isoniazid prophylaxis after excluding active TB.
How exactly to go about linking and integrating services will depend on how the health service
is organized and also on the characteristics of the HIV epidemic. For more on the latter, see
Chapter 1, Section 1.4.
Services for HIV should be linked or integrated with other services in the health sector, including
those for TB, sexual and reproductive health, and maternal and newborn health. They should
also be linked or integrated with services provided by other sectors, such as education and social
welfare, and to those provided within homes and communities by families, international and national
NGOs, community-based organizations, faith-based organizations and groups or networks of
people living with HIV. All of these services should be provided as close to clients as possible.
However, when considering the integration of health services, planners should opt for a pragmatic
approach that takes into account and balances the specific needs of target populations (that might
be marginalized), the characteristics of the particular health system and the aim of providing a
comprehensive package of services.
93
Key resources:
28. Linkages between HIV and sexual and reproductive health: Technical documents and advocacy
materials (web page)
99. Operations manual for the delivery of HIV prevention, care and treatment at primary health centres in
high-prevalence resource-constrained settings
153. Integrated health services: What and why?
http://www.who.int/healthsystems/service_delivery_techbrief1.pdf
154. WHO IMAI/IMCI/IMPAC tools (IMAI includes a series of tools that addresses the overall health of the
patient by supporting a shift from an exclusively acute care model to a chronic care model that includes
ART and prevention. IMAI also strengthens health systems by providing tools for patient monitoring,
referral and back-referral to district hospitals, clinical team building, clinical mentoring and district planning.)
http://www.who.int/hiv/topics/capacity/
http://www.who.int/hiv/pub/imai/imai_publication_diagram.pdf
155. Interim policy on collaborative TB/HIV activities
English:
French:
http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.330_fre.pdf
Spanish:
http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.330_spa.pdf
Russian:
http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.330_rus.pdf
156. Rapid assessment tool for sexual & reproductive health and HIV linkages: A generic guide prepared
and published by IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW and Young Positives
http://whqlibdoc.who.int/hq/2009/91825_eng.pdf
94
3.2.2 Infrastructure and logistics

Service delivery requires infrastructure and logistics, including physical space, equipment, utilities,
waste management, transport and communications.
Physical space is required for receiving clients, triage, waiting, clinical management, counselling,
care delivery, surgery, pharmacy, storage, management and equipment. Space is also needed for
laboratories, deliveries, communications, infection control, waste management and so on.
For people living with HIV, particular attention should be paid to their needs for privacy and
confidentiality, safe water, sanitation and hygiene, and infection control. The latter should take
into account the need to reduce the risk of bloodborne infections such as HIV and hepatitis, and
of other infections such as TB. Reducing the risk of TB infection is particularly important given
the high incidence of TB among people living with HIV and the emergence of multidrug-resistant
(MDR) and extensively drug-resistant (XDR) TB.
With the recent scale-up of treatment for HIV infection, the limitations of laboratory infrastructure
are increasingly recognized as major obstacles to the roll-out of services. For follow-up on ART,
it is important to have access to some laboratory support in the periphery of the health system
(until recently not routinely available), as well as at higher levels of the system (see Section 2.4.3
in Chapter 2). This means essential tests should be available on site at a local health centre or
district hospital, as should the capacity to transport specimens to higher levels. Laboratory support
for antiretroviral therapy, early infant diagnosis and TB diagnosis are important priorities for HIVrelated laboratory services.
Section 2.4.3 in Chapter 2 provides detailed guidance on the types of laboratory tests needed
to support treatment of people living with HIV and to manage conditions frequently found among
them, such as TB. Providing the tests is a huge challenge, the dimensions of which can be
understood best if laboratory support is considered as a health sub-system. When planning to
scale up laboratory services, service delivery, health workforce and the other building blocks of a
health system should be considered as well (see Figure 3).
Infection control in all facilities is also important. This includes safe medical waste management
with separate containers and adequate disposal systems for sharps, other infectious or hazardous
waste, and non-infectious and non-hazardous waste.An emerging issue is the relatively low
access to information technology in resource-limited settings. Computerization has the potential to
markedly enhance efficiency of HIV service delivery, as computerized record keeping, monitoring
and supply management can free up time for clinical tasks.
Communication between staff at local health centres and staff in health facilities and laboratories at
higher levels of the health system is essential to provide HIV care of the highest quality. Facilitating
this communication involves ensuring that telephone, radio or other communications infrastructure is
adequate. Ideally, the infrastructure should include computers connected by intranet or internet.
95
The infrastructure and logistics of health service delivery should be designed to last. They
should be configured to enable delivery on demand of services to people who need them,
wherever they may be located. For managing HIV infection, it is especially important that health
facilities are designed for privacy and confidentiality, infection control and ready access to
laboratories and imaging services.
Every effort should be made to limit the spread of nosocomial infections (resulting from treatment in
health settings) and bloodborne infections (such as HIV and hepatitis). Support should be provided
for comprehensive infection control, including specific consideration of the risk of the spread of TB.
Key resources:
99. Operations manual for the delivery of HIV prevention, care and treatment at primary health centres in
high-prevalence resource-constrained settings
145. Guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings
English:
http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269.pdf
English Addendum (Tuberculosis infection-control in the era of expanding HIV care and treatment): http://
whqlibdoc.who.int/hq/1999/WHO_TB_99.269_ADD_eng.pdf
Russian:
http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269_rus.pdf
Illness (IMAI)
Facilitators guide: http://www.who.int/hiv/pub/imai/primary/tb_infec_control_fac.pdf
Participants manual: http://www.who.int/hiv/pub/imai/primary/tb_infec_control_partman.pdf
157. District health facilities: guidelines for development and operations
http://www.wpro.who.int/NR/rdonlyres/C0DAA210-7425-4382-A171-2C0F6F77153F/0/DistHealth.pdf
158. Management of resources and support systems: Equipment, vehicles and buildings
(WHO web page)
http://www.who.int/management/resources/equipment/en/index1.html
159. WHO consultation on technical and operational recommendations for scale-up of laboratory services
and monitoring HIV antiretroviral therapy in resource-limited settings (Expert meeting, Geneva, 2004)
http://www.who.int/hiv/pub/meetingreports/labmeetingreport.pdf
160. WHO policy on TB infection control in health care facilities, congregate settings and households
96
3.2.3 Demand for services

In health service planning, most attention usually goes to planning on the supply side of services.
The question as to whether the services will be used is often neglected, even when it is clear
that there are factors that could limit demand. Denial, fear, stigma, discrimination and high costs
are among the factors that limit demand for and uptake of health services. This is especially the
case for the uptake of services related to HIV and TB, conditions surrounded by fear, stigma
and discrimination. Chapter 2, Sections 2.3.1 and 2.3.2 discuss interventions that can generate
demand, such as outreach to people in most-at-risk populations.
Increasing demand requires understanding the users perspective, raising public awareness and
overcoming cultural, social or financial obstacles. Overcoming such obstacles demands various
forms of social engagement in planning, delivery and monitoring services. In the case of HIVrelated services, people living with HIV and those vulnerable or most at risk should be involved in
the design, management, delivery and monitoring of services. This can ensure that services meet
their unique needs and concerns, such as fear of disapproval or open hostility on the part of staff,
and fear of disclosure of their HIV status and the possible consequences.
Key resources:
161. Missing the target #5: Improving AIDS drug access and advancing health care for all
http://www.aidstreatmentaccess.org/itpc5th.pdf
162. Service delivery model on access to care and antiretroviral therapy for people living with HIV/AIDS
http://www.ifrc.org/Docs/pubs/health/service-delivery-en.pdf
97
3.2.4 Management
Good leadership and management are about providing direction to and gaining commitment
from partners and staff, facilitating change and achieving better health services through
efficient, creative and responsible deployment of people and other resources. Good leaders set
the strategic vision and mobilize action towards that vision. Good managers ensure effective
organization and use of resources to achieve results and meet goals and targets.
The health sector response to the HIV epidemic requires different types of management action.
There is a need for strategic planning at the national and sub-national levels; for operational
planning throughout the service delivery system; and for facility management.
At the highest level of a health system, good management requires situation analysis, review
of the health sector response (including existing policies and strategies), setting programme
priorities, selecting key indicators and setting targets. The next step is coordinating and
managing the development and implementation of programmes. Good management also
requires strengthening management systems and ensuring the technical quality of services, both
of which are dealt with below.
Increasingly, the management of implementation occurs at district, facility and community level.
The district management team, facility managers and community organizations need skills to plan
the implementation, to mobilize resources and to manage staff, finances and supplies. Training
is usually organized and delivered at the regional or district level; it is then followed up by regular
supportive supervision from the district team and by mentoring from experienced managers from
other districts, communities or facilities.
At the health facility level, the aim of good management is to provide services to the community
in an appropriate, efficient, equitable and sustainable manner. This can only be achieved if key
resources for service provision, including human input, information, finances and the hardware
and process aspects of care delivery are brought together at the point of service delivery and
are carefully synchronized.
98
3.2.4.1 Strengthening management systems

Deficiencies in health system management are well-recognized as obstacles to efficient service delivery.
WHO recommends action to strengthen management capacity in the health sector. Such action
should include ensuring an adequate number of managers at all levels of the health system,
ensuring managers have appropriate competencies, creating better management support systems
and creating enabling working environments.
Key resources:
163. Strengthening management in low-income countries
http://www.who.int/management/general/overall/Strengthening%20Management%20in%20LowIncome%20Countries.pdf
164. The health managers web site (WHO web site)
http://www.who.int/management/en/
165. Strengthening management capacity in the health sector (WHO web site)
http://www.who.int/management/strengthen/en/index.html
3.2.4.2 Ensuring the technical quality of services

Universal access to HIV prevention, treatment and care provided by the health sector requires that
the package of interventions be accessible and affordable by the people who need those services
and that interventions are of good quality so that they achieve the intended results.
Ensuring quality during scale-up of HIV-related services requires:
Establishing external and internal quality management systems. These should address clinical
care, laboratory testing, and workplace improvement. It is of critical importance to involve the
community and beneficiaries (people living with HIV and those vulnerable and most-at-risk of
infection) in assessing and improving the quality of care.
Regularly updating national normative guidelines and tools so that they continue to reflect the
best international practices and the latest recommendations. This requires convening technical
advisory committees and working groups regularly, since HIV and AIDS are rapidly changing
areas with new information constantly becoming available.
Establishing standardized procedures to accredit health facilities and to certify health care
providers in the delivery of HIV prevention, treatment and care. All facilities and providers,
whether run by government, private business or NGOs, should be covered.
Establishing national standards for HIV prevention, treatment and care.
Ensuring quality of training through, for example, the use of experienced facilitators and attention
to facilitator-trainee ratios.
Establishing supervision and clinical mentoring systems and a budget to prepare and deploy
supervisors and mentors for post-training and on-the-job supervision.
Establishing well-functioning patient and programme monitoring systems that the clinical team is
able to use to measure and improve the quality of care they provide.
99
Key resources:
81. WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy
and prevention in resource-constrained settings
166. Standards for quality HIV care: a tool for quality assessment, improvement, and accreditation
English:
http://whqlibdoc.who.int/hq/2004/9241592559.pdf
French:
http://www.who.int/entity/hiv/pub/prev_care/standardsquality_fr.pdf
167. Guidelines for organising national external quality assessment schemes for HIV serological testing
http://www.who.int/diagnostics_laboratory/quality/en/EQAS96.pdf
168. Guidelines for establishment of accreditation of health laboratories
http://www.searo.who.int/LinkFiles/Publications_SEA-HLM-394.pdf
169. A guide to monitoring and evaluation for collaborative TB/HIV activities
http://www.who.int/hiv/pub/tb/hiv_tb_monitoring_guide.pdf
170. Toolkit on monitoring health systems strengthening: Service delivery (2008 draft document)
http://www.who.int/healthinfo/statistics/toolkit_hss/EN_PDF_Toolkit_HSS_ServiceDelivery.pdf
171. Male circumcision quality assurance guide: A guide to enhancing the safety and quality of services
http://www.who.int/hiv/pub/malecircumcision/qa_guide/en/
172. Monitoring and evaluation of health systems strengthening: An operational framework
http://www.who.int/healthinfo/HSS_MandE_framework_Nov_2009.pdf
100
3.3 Health workforce

Effective service provision requires trained service providers in the right number, at the right place,
at the right time, working with the right attitude, knowledge and skills, commodities (medicines,
disposables, reagents) and equipment, and with adequate financing. It also requires an
organizational environment that provides the right incentives to providers and users.
In many of the countries with the highest burden of HIV, international migration and domestic
movement out of health sector employment contribute to the crisis in human resources. In some of
these countries, the crisis is aggravated by civil service hiring caps and long delays between the
end of education and service posting.
HIV itself contributes to the crisis, as it increases the demand for services and infects and
affects health workers. They may be disabled by illness, lost to death or required to spend less
time at work and more at home taking care of HIV-infected family members, attending to those
family members usual chores and attending funerals. Thus, the supply of healthy and productive
health workers is reduced.
Working with people living with HIV is labour intensive and can also be emotionally stressful
and draining. When there are many HIV-infected people, the demand for services increases.
High workloads, poor pay and bad working conditions are added disincentives for health care
workers to deal with HIV.
Working in the HIV field may also be unpopular with some health providers because they fear
becoming infected with HIV or TB, or because they cannot relate easily to clients with risk
behaviours of which they disapprove. The latter is a problem especially in countries with low or
concentrated epidemics, where many people living with HIV come from marginalized groups such
as sex workers, injecting drug users, men who have sex with men and prisoners.
The combined results of the above are that firstly, it may be difficult to motivate health workers to
take jobs providing HIV services unless they are provided with special incentives, and secondly,
there is a severe shortage of skilled health workers in areas with high HIV prevalence.
Despite those challenges, a defining feature of the response to the HIV pandemic has been the
ability of communities to mobilize resources to address the impact of HIV and prevent its further
spread. Groups of people living with HIV, community- and faith-based organizations, and many
others have taken responsibility for advocacy and action. They have learned to play a wide range
of roles in the response to HIV, serving as outreach workers, home carers, adherence supporters,
providers of psychosocial support, counsellors and managers. This has led to the creation of
entirely new health professions in some countries. It has led to strong momentum in the direction of
task shifting and to persuasive calls for recognition and payment for some of the essential services
they provide. Their roles are increasingly recognized and institutionalized and are beginning to
transform the debate on universal primary health care from a distant dream to an achievable goal.
101
To counter difficulties in motivating and retaining health workers, WHO recommends the
following actions:
training additional health workers;
sensitizing health workers for work with people living with HIV;
ensuring health workers have access to prevention and other HIV- and TB-related services;
ensuring health workers have access to immunization against vaccine-preventable diseases,
especially hepatitis B immunization; and
considering task shifting as a way of increasing the pool of knowledgeable HIV-related service
providers.
A full package of HIV prevention, treatment and care services should be made available to health
workers and their families on a priority basis and should be tailored specifically to their needs. Please
also refer to Section 2.4.2.4 for additional information on programmes for health care workers.
In countries with generalized HIV epidemics and health worker shortages, efforts should be made
to increase the number and the competence of health care workers. WHO recommends:
recruiting and training additional health workers;
ensuring relevant HIV content in pre-service curricula;
shifting tasks from more- to less-specialized health workers; and
developing in-service training and support for continued learning (including mentoring and
continuing medical education).
To retain existing health workers, the following policy changes should be considered:
instituting codes of practice and ethical guidelines to minimize migration of health workers from
low-income to high-income countries;
reducing the draw of private and NGO-run programmes on workers in public health programmes
and agreeing on nationwide standard incentive practices;
improving the quality of the workplace, including:
establishing occupational health and safety procedures to reduce the risk of contracting
HIV and other blood-borne diseases;
addressing stress and burnout;
guaranteeing job security;
prohibiting HIV-related and other forms of discrimination;
providing social benefits;
adjusting work demands;
providing financial incentives;
providing non-financial incentives, such as career and training opportunities.
102
WHO also recommends recognition and support for the vital roles played by people living with HIV,
community organizations and lay workers. It recommends that the recognition and support take
tangible forms, such as certification of skills in service delivery, and pay. These measures should
be integrated into national plans for developing human resources for health and HIV.
Key resources:
English:
French:
Spanish:
Russian:
Arabic:
Chinese:
173. Tools for planning and developing human resources for HIV/AIDS and other health services
http://www.who.int/hrh/tools/tools_planning_hr_hiv-aids.pdf
174. Task shifting: Rational redistribution of tasks among health workforce teams: Global
recommendations and guidelines
http://www.who.int/healthsystems/TTR-TaskShifting.pdf
175. How IMAI (and IMCI) support national adaptation and implementation of task shifting (IMAI-IMCI
task-shifting implementation support brochure)
http://www.who.int/hiv/pub/imai/IMAI_IMCI_taskshifting_brochure.pdf
103
3.4 Medical products and technologies

Many health systems continue to have weak procurement and supply management systems, and
the result is frequent stock-outs of antiretroviral drugs, medicines and other essential commodities,
including gloves, needles and testing reagents.
Methadone and buprenorphine were added to the WHO list of essential medicines in 2005. These
medicines, powerful opioid analgesics used to treat opioid addiction, are controlled substances
under the international drug control conventions and are not sufficiently available in many countries,
mainly due to: (1) greatly exaggerated fears of dependence; (2) overly restrictive national drug
control policies; and (3) problems in procurement, manufacture, storage and distribution of
controlled substances. It is estimated that more than 80% of the worlds population has no proper
access to controlled medications (including opioids and psychoactive substances) due to regulatory
barriers, prejudice and lack of proper information at national and international levels.
Another concern is for the quality, safety and efficacy of the medicines that are available. The
supply of good antiretroviral medicines is reasonably well secured by the WHO prequalification
scheme, by the US Federal Drug Administrations practice of giving provisional approval to generic
medicines and by quality standards insisted on by the Global Fund to Fight AIDS, Tuberculosis
and Malaria. However, the same is not the case for other essential medicines brought in by a
variety of suppliers under the oversight of national regulatory authorities, which face challenges in
carrying out their duties.
A well-functioning health system should ensure equitable access to essential medical products,
vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, as well as
access to their scientifically sound and cost-effective use. WHO recommends:
establishing national policies, standards, guidelines and regulations for procurement of drugs and
other commodities;
providing health authorities with information on prices, international trade agreements and
capacity to set and negotiate prices;
ensuring reliable manufacturing practices and quality control for priority products;
establishing procurement, supply, storage and distribution systems that minimize leakage and
other waste;
providing support for rational use of essential medicines, commodities and equipment through
guidelines, strategies and training to ensure enforcement, reduce resistance and maximize
patient safety;
delivering on countries obligations under UN Conventions to provide access to analgesics and
opioids for substitution therapy.
104
Key resources:
114. Prequalification programme: A United Nations Programme managed by WHO (WHO web site)
176. AIDS medicines and diagnostics service (WHO web site)
http://www.who.int/hiv/amds/
177. Essential medicines and pharmaceutical policies (WHO web site)
http://www.who.int/medicines/en/
178. Global price reporting mechanism (GPRM)
http://www.who.int/hiv/amds/gprm/en/index.html
179. A step-by-step algorithm for the procurement of controlled substances for drug substitution
treatment.
http://www.unodc.org/documents/hiv-aids/Step-by-Step%20procurement%20subs%20treat.pdf
180. Access to controlled medications programme: Framework
http://www.who.int/medicines/areas/quality_safety/Framework_ACMP_withcover.pdf
181. Global Fund Quality Assurance Policy for Pharmaceutical Products
http://www.theglobalfund.org/documents/psm/Annex1-%20FullTextRevisedQualityAssurancePolicy_
en.pdf
182. Procurement and supply management toolbox (web site)
http://www.psmtoolbox.org/
183. CCM grant oversight tool (web site)
http://www.theglobalfund.org/en/ccm/guidelines/#dashboard
105
3.5 Financing
After the UN General Assemblys Declaration of Commitment on HIV/AIDS in 2001, funding for
the response (including the health sector response) increased sharply each year until it reached
an estimated US$ 10 billion in 2007. However, WHO and UNAIDS estimated that there was still
a US$ 8 billion gap between what was available and what was actually needed to scale up the
response to HIV at an acceptable pace. There is a similar gap between available resources and
needs for other health priorities. In 2002, the WHO Commission on Macroeconomics and Health
recommended that low- and middle-income countries spend a minimum of US$ 40 per capita on
essential health services, but many still spend far less than that amount.101 This figure has been
revised to US$ 54 in 2009 by the Taskforce on Innovative Financing for Health Systems11 of the
International Health Partnership. 8
In many countries, the majority of people and governments cannot afford the costs of HIV
treatment and care, particularly antiretroviral therapy. In most countries heavily burdened by HIV,
sustainable provision of HIV treatment and care will require external funding for the foreseeable
future. This would be true even if these countries increased their domestic funding for the health
sector to 15% of national gross domestic product, as many African countries pledged to do in
the 2001 Abuja Declaration.129
External and domestic government funding for the HIV response has increased considerably,
but many people living with HIV still find it difficult to access essential services. Even when
drugs are provided free of charge, they incur out of pocket expenditures for the treatment and
prevention of concurrent diseases and opportunistic infections, laboratory diagnosis and formal
and informal fees. This limits their access to essential services when they are poor or depend on
others to cover their health care costs.
10
11
12
Report of the WHO Commission on macroeconomics and health. Geneva, WHO, Fifty-fifth World Health Assembly,
23 April 2002.
More money for health, and more health for the money. London, Taskforce on Innovative International Financing
for Health Systems, 2009. Available at: http://www.internationalhealthpartnership.net//CMS_files/documents/taskforce_report_EN.pdf
Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Disease. Abuja, Nigeria, Organization for African
Unity (OAU), 27 April 2001.
106
Health systems should raise and secure adequate funds for health in order to ensure that people can
use the services they need and are protected from financial catastrophe or impoverishment because
they have to pay for services. In 2005, the World Health Assembly urged its Member States to:1310
ensure that health financing systems include a method for prepayment of financial contributions
for health care, with a view to sharing risk among the population and avoiding catastrophic health
care expenditure and impoverishment of individuals as a result of seeking care;
ensure adequate and equitable distribution of good-quality health care infrastructures and human
resources for health so that those insured receive equitable and good-quality health services
according to their benefits package;
ensure that external funds for specific health programmes or activities are managed and
organized in a way that contributes to the development of sustainable financing mechanisms for
the health system as a whole;
plan the transition to universal coverage of their citizens in ways that contribute to: meeting the
needs of the population for quality health care; reducing poverty; attaining internationally agreed
development goals, including those contained in the United Nations Millennium Declaration; and
achieving health for all.
With regard to access to services for HIV, WHO recommends that countries implement a public
health approach to scale-up of services and also adopt a policy of free access at the point of
service delivery to basic HIV services, including consultation fees, HIV testing and antiretroviral
therapy.
Key resources:
184. GTZ-ILO-WHO consortium on social health protection in developing countries
http://www.socialhealthprotection.org/
185. Health financing policy (WHO web site)
http://www.who.int/health_financing/en/
186. WHO discussion paper: The practice of charging user fees at the point of service delivery for HIV/
AIDS treatment and care
http://www.who.int/hiv/pub/advocacy/promotingfreeaccess.pdf
187. HIV financing (WHO web site)
http://www.who.int/hiv/topics/systems/health_financing/en/
188. Global Fund HIV proposals costing tool (and user manual)
http://www.who.int/hiv/pub/toolkits/gfatm_costing_tool_user_manual_v1.1.pdf
13
107
Sustainable financing, universal coverage and social health insurance. Geneva, WHO, Fifty-eighth World Health
Assembly, Ninth plenary meeting, 25 May 2005.
3.6 Leadership and governance

Good leadership and governance can ensure that strategic policy frameworks exist and are
combined with effective oversight, coalition building, the provision of appropriate regulations and
incentives, attention to system design and accountability.
Leaders with consistent messages are needed to: counter stigma and discrimination; support the
involvement of people living with HIV in the response to HIV; ensure equity in access to services;
deal with the gender dimensions of the epidemic; speed progress towards reducing the gap
between resources available and resources required to scale up the response; and achieve the
universal access goal. Leaders with consistent messages are also needed to help people envision
a better futureand to achieve that future through research and innovation that finds new tools
and new ways of putting them to effective use.
Calls for leadership often seem to be aimed at politicians and others in positions of great power.
However, accelerating the response to HIV will also require leadership from business, industry,
trade unions, and academic and research institutions. As well, it will require leadership within
neighbourhoods and communities, from community councils, faith-based and other communitybased organizations, formal and informal groups, networks of people living with HIV, people
vulnerable or at high-risk of infection, youth and so on. Health workers at all levels have
opportunities to play leadership roles and use their professional and personal connections to
advance the cause of scaling up the response to HIV.
Governance of the response to HIV has evolved considerably over the last few years. It was once
dominated by the health sector and led by national AIDS programmes within ministries of health.
It then shifted to national AIDS commissions with representatives from multiple sectors and HIVrelated programmes in ministries and other organizations responsible for action in those sectors.
In many low- and middle-income countries, UN Theme Groups on AIDS have been established.
These groups were originally intended to coordinate the UN systems contribution to national
responses to HIV, but they have expanded to include representatives from government, donors,
civil society and the private sector, and now seek to harmonize and coordinate action by all of
these stakeholders.11 12 13
When the Global Fund to Fight AIDS, Tuberculosis and Malaria became operational in 2002, it
introduced Country Coordinating Mechanisms (CCMs) to foster national ownership and engage
government, donors, civil society and the private sector in the response to all three diseases.14
CCMs are meant to build on already existing mechanisms, such as national AIDS commissions
and Expanded UN Theme Groups on AIDS, while also increasing transparency and accountability
of financing and implementation of the response to HIV. All of these mechanisms have the
potential to make governance more complicated and difficult, and to increase rather than reduce
duplication and waste if roles and responsibilities are not clearly defined.
14
More information available at: http://www.theglobalfund.org/en/ccm/
108
The increasingly complicated governance of the response to HIV may call upon health sector
stakeholders to participate in several multisectoral country coordinating mechanisms. Participating
is vital to ensure their compliance with and their contributions to application of the Three Ones
principles: a) one agreed HIV/AIDS action framework that provides the basis for coordinating the
work of all partners; b) one national AIDS coordinating authority with a broad-based multisectoral
mandate; and c) one agreed country level monitoring and evaluation system.
In addition, health sector stakeholders are called upon to ensure that health sector HIV interventions
are included and given appropriate priority and weight in national AIDS plans and action frameworks,
as well as in national health sector plans, medium-term expenditure frameworks and Poverty
Reduction Strategy Papers. There are also calls for stakeholders working in other sectors to commit
to collaborating with the health sector and to support health sector HIV interventions.
While participating in all of these mechanisms and processes, health sector stakeholders need to
maintain strong and coherent adherence to principles guiding the health sector in its contributions
to the response to HIV, including commitment to universal access, respect for human rights and
community involvement in planning, governance and delivering and monitoring HIV-related services.
These principles should be upheld within the health sector and through regular reviews of policies,
legislation and regulations governing different aspects of the epidemic and any appropriate
actions that may arise from such reviews. For example, reviewing legislation that contributes
to marginalization of most-at-risk populations might lead to advocating for legislative reform.
Reviewing a ministrys workplace policies might lead to promoting and supporting improvement
of those policies. Other areas calling for attention include legislation or government regulations
pertaining to the confidentiality of medical records. Regulations governing the health workforce, for
example shifting certain tasks, need also to be reviewed. .
Effective leadership in HIV creates momentum for and provides oversight of the HIV response. It
is defined both by its actions and by its outcomes. Leadership should create an environment that
accelerates scale-up of the HIV response, defines the values and principles that should underlie
the process, holds the different stakeholders accountable and supports innovation to maximize the
impact of the interventions.
Among the outputs that should be expected of leadership are development, implementation
and adaptation of Strategic Policy Frameworks, policies, legislation and regulations that create
a favourable environment for an effective response to HIV, coalitions and partnerships that
contribute to a better response, and new and more effective interventions.
109
To promote and support effective coordination, health sector stakeholders should participate
in and liaise regularly with key country mechanisms that have a coordination function, such as
national AIDS councils/commissions, CCMs, UN Theme Groups and donor forums. They should
also secure commitment of stakeholders from other sectors to actively participate in and commit
to development and implementation of the response to HIV. For the health sector, establishing and
strengthening coalitions and partnerships with a range of stakeholders (e.g. nongovernmental,
community-based and faith-based organizations, people living with HIV, marginalized groups,
academic institutions and the private sector) are critical to scaling up to universal access.
Leadership should also support innovation and foster an environment that promotes human rights,
including gender equality, womens empowerment and the reduction of stigma and discrimination.
Key resources:
189. The Global Fund country coordinating mechanisms (CCMs) web site
http://www.theglobalfund.org/en/ccm/
190. Three ones key principles: Coordination of national responses to HIV/AIDS: Guiding principles for
national authorities and their partners
http://data.unaids.org/UNA-docs/Three-Ones_KeyPrinciples_en.pdf
191. WHOs global health sector strategy for HIV/AIDS 2003-2007
http://www.who.int/hiv/pub/advocacy/GHSS_E.pdf
192. International guidelines on HIV/AIDS and human rights: 2006 consolidated version
193. Ensuring equitable access to antiretroviral treatment for women: WHO/UNAIDS policy statement
http://www.who.int/hiv/pub/advocacy/en/policy%20statement_gwh.pdf
110
3.6.1 Coalition building and partnerships

For the health sector, building coalitions and partnerships with a range of stakeholders is critical to
scaling up towards universal access.
3.6.1.1 Involving people living with HIV

People living with HIV (PLHIV) are a vital resource in the response to the epidemic. The
involvement of PLHIV in advocacy efforts, in policy dialogue, in service delivery and in the effort
to reduce stigma and discrimination has already been documented extensively. Innovative
mechanisms have been developed to involve them in HIV-related services, e.g. on clinical teams,
as links with communities and as community health workers. People living with HIV can also serve
as expert patients and trainers.
Integrated Management of Adolescent and Adult Illness (IMAI), a WHO-organized initiative,
provides tools to support the involvement of PLHIV in clinical teams; they serve as triage officers
and lay counsellors who support HIV testing, adherence to ART and TB treatment, and infant
feeding, as well as data clerks, laboratory assistants and links to community support services. To
be effective in these roles, PLHIV require training, appropriate supervision and remuneration. In
many countries, there are policy constraints that prevent PLHIV from taking on these roles, and
these constraints need to be addressed.
WHO and UNAIDS believe the meaningful involvement of people living with HIV is central to
an effective, rights-based HIV response. They should be engaged in all aspects of planning,
implementing, monitoring and evaluating health sector responses to HIV at global, regional,
national and local levels; this includes the development and adaptation of normative policies, tools
and guidelines, and the delivery of services.
Key resources:
194. The greater involvement of people living with HIV (GIPA): UNAIDS policy brief
http://data.unaids.org/pub/BriefingNote/2007/JC1299_Policy_Brief_GIPA.pdf
195. IMAI expert patient-trainer curriculum
3.6.1.2 Involving civil society and the private sector

Governments, particularly ministries of health, may take overall responsibility for health sector
responses to HIV. However, an effective and comprehensive response that ensures equitable
access to HIV services demands the active involvement of the private sector and civil society, as
well as nongovernmental, faith-based and academic organizations.
Community mobilization is key to promoting HIV testing and counselling and prevention, to
preparing people for treatment and to providing adherence support. Civil society organizations
complement and supplement formal health services by playing key roles in: HIV education and
prevention, especially in reaching most-at-risk populations; creating demand for HIV services;
ensuring that HIV/AIDS services are acceptable and of good quality; preparing people for
111
treatment through information and education; supporting adherence to treatment; and providing
other forms of prevention, care and support. These roles need to be reinforced as much as
possible through providing adequate resources for community-health activities and building
strong links between health services and community organizations. Academic institutions have
an important role in capacity building, adapting guidelines and tools for local use, supporting
operational research and providing technical assistance.
In many countries, health services (including those related to HIV) are largely provided by faithbased organizations, NGOs and private businesses, rather than by governments. It is important
to include them in any key mechanisms or processes for planning, coordinating, financing, and
monitoring and evaluating the overall response to HIV.
National health sector strategies and plans should call for the active and meaningful engagement
of civil society, NGOs, faith-based organizations, private businesses and academic institutions
in strategic planning, programme development, implementation, and monitoring and evaluation.
These nongovernment players often constitute a significant portion of all health care providers and
can play critical roles in expanding access to services, particularly for most-at-risk, vulnerable and
marginalized populations.
There should be country mechanisms to ensure that all providers of HIV-related services in the
health sector meet minimum standards.
Appropriate referral and communication systems should be established or expanded and strengthened
to ensure continuity of care and services across the different sectors and service providers.
Key resources:
196. WHOs stakeholder analysis tool
http://www.who.int/hac/techguidance/training/stakeholder%20analysis%20ppt.pdf
197. Scaling up effective partnerships: A guide to working with faith-based organisations in the response
to HIV and AIDS
http://www.e-alliance.ch/media/media-6695.pdf
198. Partnership work: the health servicecommunity interface for the prevention, care and treatment of
HIV/AIDS
http://www.who.int/hiv/pub/prev_care/en/37564_OMS_interieur.pdf
199. Working with civil society (UNAIDS web site)
http://www.unaids.org/en/Partnerships/Civil+society/default.asp
200. Universal access targets and civil society organizations: A briefing for civil society organizations
http://www.unaids.org/unaids_resources/images/Partnerships/061126_CSTargetsetting_en.pdf
112
3.6.2 Addressing stigma and discrimination

HIV-related stigma and discrimination are often prevalent within health services and have been
consistently identified as critical obstacles to provision and uptake of health sector interventions.
Stigma or, more correctly, stigmatization devalues people because of their traits, behaviours or
illnesses, and it is often followed by unfair and unjust treatment. Stigma results in lower uptake
of HIV prevention, care and treatment services and makes people living with HIV reluctant
to disclose their status to their sexual partners, family members and health care providers. It
disproportionately affects women and girls (who are often devalued merely because of their
gender), sex workers, men who have sex with men, injecting drug users and ethnic minorities,
whose minority status may be due to the fact that they are displaced persons or migrants.
Though stigma and discrimination are often pervasive throughout societies, they are seldom
adequately addressed in national responses to HIV. Both can be tackled through simple and
practical measures within a health system, such as providing people with accurate information
that allays their fears and dispels their misconceptions about HIV and its transmission. The health
sector can also advocate for and play its part in implementing a multifaceted national approach
to combating stigma and discrimination. In order to reduce stigma and discrimination in health
facilities, health workers attitudes and practices need to be addressed, and they should be given
information and supplies to prevent occupational exposure to HIV. These efforts will help countries
reach targets for universal access while promoting respect for human rights, for vulnerable
minorities and for people living with HIV.
Strategic information about stigma and discrimination should be systematically collected using
existing tools (e.g. questionnaires used in behavioural surveillance) to measure their prevalence
and impact on the response to HIV.
Efforts to reduce stigma and discrimination should be included in national strategic planning and
programming activities.
Health care workers should be provided with training on non-discrimination, and codes of conduct
and oversight for service providers should be established.
As they scale up national responses to stigma and discrimination (and thus access to HIV
prevention, treatment and care), planners should employ a range of approaches to prevent and
reduce stigma and discrimination among different key groups (politicians, religious leaders, health
authorities, law enforcers and so on). In this way, they can challenge stigma and discrimination in
institutional settings and build capacity for recognizing human rights, including the establishment
and enforcement of human rights legislation.
Key resources:
201. Reducing HIV stigma and discrimination: a critical part of national AIDS programmes
http://data.unaids.org/pub/Report/2008/jc1420-stigmadiscrimi_en.pdf
113
3.6.3 Delivering gender-responsive HIV interventions

Gender inequalities are a key driver of the HIV epidemic. Gender inequalities make women and
girls especially, but also men, vulnerable to HIV in several ways. In sub-Saharan Africa, women
constitute 60% of people living with HIV and in other parts of the world women continue to be
disproportionately affected as sex workers, injecting drug users and as partners of injecting
drug users, men who have sex with men and clients of sex workers. Harmful gender norms
and practices, such as violence against women, and denial of womens access to and control
over resources, contribute to women and girls vulnerability to HIV. Social norms related to
masculinity encourage men to take sexual risks. These norms also contribute to homophobia,
which stigmatizes men who have sex with men. Norms related to femininity discourage women,
especially young women, from accessing sexual and reproductive health information and services.
In many settings, women and girls face barriers to HIV services because they lack the financial
means to access care or they require permission from their husbands or other family members to
go to a health care facility. In some cases, they may be afraid of being labelled as promiscuous if
they are seen to seek services for STIs or HIV. Health services can reinforce gender inequalities
by stigmatizing those who seek HIV services, especially if they belong to marginalized groups.
Violence or fear of violence prevents many women from negotiating safe sex and also from
accessing HIV testing and counselling services or disclosing their status. For these reasons,
achieving universal access to HIV prevention, treatment and care is contingent on the health
sector taking action to reduce gender inequalities.15
15
United Nations. Scaling up HIV prevention, treatment, care and support. Note by the Secretary-General. 24 March
2006
114
Know your epidemic in gender terms: Programme managers and policy-makers in the health
sector should understand who is at risk for HIV in different epidemic settings and the underlying
sociocultural, economic and political factors that increase their vulnerability. Knowing your
epidemic in gender terms requires disaggregating data, including figures from programme
monitoring and evaluation (by sex, age and other appropriate equity parameters), in order to
identify who is at risk, whether they are being reached equitably and whether programmes are
working for those most in need.
Build the capacity of programme managers, policy-makers and health care providers to
understand and address the links between gender inequalities and HIV.
Ensure that national health sector HIV policies and programmes explicitly integrate gender and
allocate financial and human resources to promote gender-responsive strategies.
Support prevention by promoting equality between women and men in sexual decision-making and
building womens skills to negotiate safer sex including through use of female and male condoms.
Address womens fear of, or potential experience of, negative consequences of HIV testing and
counselling by incorporating safety planning as part of disclosure and risk-reduction counselling.
Reduce gender-related barriers to accessing services, including: non-affordability; the need for
women to obtain permission from husbands or other family members to go to a health facility;
stigma and discrimination against those most-at-risk for or living with HIV including marginalized
groups; and providing an appropriate mix of male and female health care providers.
Support women care givers who provide the bulk of care for those living with and affected by HIV.
Advocate for gender equality in policies and laws related to womens rights, including those related to
violence against women, property and inheritance rights for women and access to education for girls.
Key resources:
202. Integrating gender into HIV/AIDS programmes: A review paper
http://www.who.int/hiv/pub/prev_care/en/IntegratingGender.pdf
203. Gender, women and health: gender inequalities and HIV/AIDS (WHO web site)
http://www.who.int/gender/hiv_aids/en/
204. Integrating gender into HIV/AIDS programmes in the health sector: a tool to improve responsiveness
to womens needs
http://www.who.int/gender/documents/gender_hiv/en/index.html
205. Addressing violence against women and HIV testing and counselling: a meeting report
http://www.who.int/gender/documents/VCT_addressing_violence.pdf
115

Strategic information guides health policy, planning, resource allocation, programme management,
service delivery and accountability. It is essential for action at all levels of the health system.
As countries scale up their HIV responses towards universal access, there is an increasing
recognition of the need to invest in strategic information to guide programme planning and sustain
national and international commitment and accountability.
This chapter presents the key elements in strengthening health information systems, one of the six
building blocks of a health system mentioned in the previous chapter. It then addresses the three
main activities related to strategic information for the HIV response:
surveillance of HIV and sexually transmitted infections;
monitoring and evaluation (including patient monitoring, prevention and assessment of HIV drug
resistance, and pharmacovigilance); and
research.
The chapter concludes by discussing the effective use of data for improving programmes,
including for setting targets and conducting situation analyses.
4.1 Strengthening health information systems

A well-functioning health information system is one that generates reliable and timely strategic
health information on which to base decisions at different levels of the health system. Information
systems for HIV programmes must be strengthened within the context of more robust, integrated
and harmonized overall health information systems.
Efforts to strengthen information systems to support the HIV response must consider three key
dimensions:
1. Content: What information is needed? What are the sources of information? HIV programmes
require a wide range of strategic information on the epidemic and the response. HIV surveillance
provides data to monitor the determinants and trends of the epidemic, develop interventions and
measure impact. Monitoring and evaluation is required to plan and implement programmes and
document outcomes. Drug resistance monitoring and pharmacovigilance are needed to support
treatment programmes. Research provides evidence to improve interventions. Both populationbased and health facility-based data sources generate strategic information in these areas.
Information needs and sources vary in relation to the type of epidemic and country context.
2. Processes: How is information collected, managed and used? Effective generation and use of
strategic information requires optimal processes for data collection, sharing, management and
feedback among the different levels of the health system. This involves: the definition of norms
and standards, including ethical standards, for collecting and disseminating data; procedures for
using data to conduct situation analyses, set targets, guide planning and implementation, and
support advocacy efforts; and investment in data quality. The UNAIDS Three Ones principles
for coordinating national HIV responses emphasize the importance of national ownership and
coordination among stakeholders, including international partners, around one agreed framework
for national monitoring and evaluation.
116
3. Resources: What resources are needed to support strategic information activities? A fully
functional health information system requires the infrastructure and tools for data collection,
storage and management, including data recording tools, data reporting forms, databases
and electronic systems for data-sharing and analysis. It requires investment in building human
resource capacity (including epidemiologists, surveillance and monitoring and evaluation officers,
and information technology and management information system specialists) at all levels of
the health system through training, mentoring and supervision. As programmes are scaled up,
there is also a need to protect the security and confidentiality of patient data. Infrastructure (e.g.
laboratories) is needed to scale up research. Strengthening information systems also requires an
appropriate policy, management and financial environment.
Key resource:
206. Guidelines on protecting the confidentiality and security of HIV information: Proceedings from a
workshop, May 2006. Interim guidelines
http://data.unaids.org/pub/manual/2007/confidentiality_security_interim_guidelines_15may2007_en.pdf
4.2 Surveillance of HIV/AIDS and sexually transmitted infections

HIV surveillance provides essential data to understand the magnitude and determinants of
the epidemic in a country, assess the burden of disease, monitor trends over time, develop
interventions and evaluate their impact. In addition, second generation HIV and STI surveillance
systems measure trends in risk behaviours.
HIV surveillance systems should be capable of being adapted and modified to meet the specific
needs of each epidemic. For example, surveillance methods and activities in a country with a
predominantly generalized heterosexual epidemic should differ greatly from those in countries
where HIV infection is mostly concentrated among populations at high risk of infection, such
as sex workers, men who have sex with men and injecting drug users, as well as the sexual
partners of these groups.
In addition to collecting data from HIV surveillance, countries also use statistical modelling
to better understand their specific HIV epidemics, including trends in HIV prevalence in the
general population and most-at-risk populations, and estimates of the numbers of people who
need particular interventions, such as antiretroviral therapy and antiretrovirals for preventing
mother-to-child transmission. Based on the recommendations of the UNAIDS Reference Group
on Estimates, Modelling and Projections, WHO and UNAIDS provide technical assistance and
training to country teams to generate country estimates.
117
Summary of recommendations:
The health sector plays the lead role in comprehensive HIV surveillance. National HIV/AIDS
programmes should build surveillance systems that provide data in a routine, standard manner
with consistency of methods, tools and populations surveyed. Vital elements of a comprehensive
HIV surveillance system include:
HIV infection and HIV advanced infection case reporting;
HIV sentinel surveillance among clients attending antenatal clinics;
integrated biological and behavioural data among most-at-risk populations;
periodic national population-based surveys (e.g. Demographic and Health Surveys) with HIV
testing in countries with HIV prevalence above 1%; and
data from HIV surveillance among TB patients.
Sentinel surveillance among antenatal clinic attendees and population-based surveys with
HIV testing are relevant for generalized HIV epidemics. Integrated biological and behavioural
surveillance among high-risk groups may be relevant for all epidemic levels and are a priority for
concentrated and low-level epidemics.
Developing reliable estimates of the size of populations at high risk for HIV is another important aspect of
surveillance, to inform assessment of needs and development of appropriate policies and programmes.
Estimates of the population size of high-risk groups should be calculated using standard methods in
conjunction with data from integrated biological and behavioural surveillance and service data.
Surveillance of new cases of HIV infection (HIV incidence) is challenging; it cannot be done
through case reporting because early HIV infection has no distinct clinical features that bring
newly-infected people to medical attention. Current laboratory-based tests for recent infection are
not useful for individual determinations; however, they may be employed with suitable caution
at the population level to produce incidence estimates. In countries or sites with linked testing,
dynamic cohorts may be used to measure recent infections. Countries with more than one
national population-based survey can apply mathematical models to estimate HIV incidence. STI
surveillance is strongly recommended both in its own right and as a useful early warning system
for expansion of an HIV epidemic.
Key resources:
207. Guidelines for measuring national HIV prevalence in population-based surveys
http://www.who.int/hiv/pub/surveillance/guidelinesmeasuringpopulation.pdf
208. The pre-surveillance assessment: Guidelines for planning serosurveillance of HIV, prevalence of
sexually transmitted infections and the behavioural components of second generation surveillance of HIV
http://www.who.int/hiv/pub/surveillance/psaguidelines.pdf
209. Guidelines for HIV surveillance among tuberculosis patients. Second edition
English:
http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.339.pdf
French:
Spanish:
http://whqlibdoc.who.int/hq/2004/OMS_HTM_TUB_2004.339_spa.pdf
Russian:
118
210. Guidelines for effective use of data from HIV surveillance systems
English:
http://www.who.int/hiv/strategic/surveillance/en/useofdata.pdf
Spanish:
http://www.who.int/hiv/pub/surveillance/useofdata_sp.pdf
211. Guidelines for conducting HIV sentinel serosurveys among pregnant women and other groups
English:
http://www.who.int/hiv/pub/surveillance/en/ancguidelines.pdf
French:
http://www.who.int/hiv/pub/epidemiology/en/guidelinesforconduction_fr.pdf
212. Estimating the size of populations at risk for HIV: Issues and methods
http://www.who.int/hiv/pub/surveillance/en/EstimatingSizePop.pdf
213. Guidelines for using HIV testing technologies in surveillance: selection, evaluation and
implementation
http://www.who.int/hiv/pub/surveillance/en/guidelinesforUsingHIVTestingTechs_E.pdf
214. HIV surveillance training modules, WHO Regional Office for South-East Asia
Module 1: Overview of the HIV epidemic with an introduction to public health surveillance
http://www.searo.who.int/LinkFiles/Publications_Module-1.pdf
Module 2: HIV clinical staging and case reporting
Module 3: HIV serosurveillance
Module 4: Surveillance for sexually transmitted infections
Module 5: Surveillance of HIV risk behaviours
Module 6: Surveillance of populations at high risk for HIV transmission
Facilitator training guide for HIV surveillance
http://www.searo.who.int/LinkFiles/Publications_facilitator.pdf
119
4.2 Monitoring and evaluation of the health sector response

A comprehensive health sector response to HIV requires sound strategies to monitor and evaluate
progress. Monitoring refers to the routine tracking of essential data related to the implementation
of a programme and its inputs, processes, outputs, outcomes and impacts. Evaluation is a
collection of activities designed to assess the effectiveness of a programme. Regular monitoring
and evaluation are essential to guide programme planning and implementation, measure progress
and sustain commitment and accountability.
4.2.1 Monitoring health sector HIV programmes

A key step in strengthening monitoring and evaluation (M & E) systems is to determine what data
should be collected, at which levels of the system, and by whom. Decisions should be made on
what data need to be reported upwards and for what purpose. The main purpose is generally
to measure inputs, outputs, outcomes and impacts against a limited number of key indicators
limited so as to avoid overburdening the system.
National HIV/AIDS programmes, ministries of health and other stakeholders should collaborate on
the design, implementation and strengthening of national M & E systems. A national strategy for M
& E of health sector HIV/AIDS programmes should include tools and processes to generate a wide
range of data, plus analysis and reporting on HIV prevention, treatment and care interventions at
the national, sub-national and facility levels.
The data should include input indicators (e.g. budgets, human resources, supplies), process
indicators (e.g. training, interventions to review and update procedures, availability and adequacy
of national policies and guidelines); output indicators (e.g. newly trained health workers, improved
procedures, geographical coverage of interventions); outcome indicators (e.g. increased uptake
of services, increased knowledge of HIV, behavioural change); and impact indicators (e.g.
longer survival of people living with HIV). As national programmes expand, it is also increasingly
important to monitor the quality of services and to measure impacts on the health system.
Data for monitoring the health sector response to HIV come from several sources. These
include routine medical and other records that are part of the broader health information
management system; mapping available services in health facilities and other health settings;
health facility surveys; population-based surveys; cohort studies of people living with HIV;
monitoring procurement and supply of HIV medicines and diagnostics; and impact assessment.
Other sources include surveillance data (e.g. behavioural and biological surveys) and mortality
records and reports. Special studies should be considered when routine data collection and
analysis is inappropriate or not feasible. Data from organizations providing community-based
HIV services are also essential.
120
M & E activities should use ongoing data collection systems as far as possible to minimize burden
of data collection and optimize use of resources. It is important that indicators are defined and
measured in a consistent and standard way in order to assess trends and measure progress
towards programme goals. It is also important that M & E systems are able to capture data
disaggregated by age, sex, population groups (including most-at-risk population groups, such as
sex workers, men who have sex with men and injecting drug users; patients with TB and hepatitis
B and C coinfection) and by geographical regions or socioeconomic groups as appropriate.
Key resources:
215. National guide to monitoring and evaluating programmes for the prevention of HIV in infants and
young children
216. National AIDS programmes: A guide to indicators for monitoring and evaluating national HIV/AIDS
prevention programmes for young people
English:
http://www.who.int/hiv/pub/epidemiology/napyoungpeople.pdf
French:
http://www.who.int/hiv/pub/me/napyoungpeople_fr.pdf
Spanish:
http://www.who.int/hiv/pub/me/napyoungpeople_sp.pdf
Russian:
http://www.who.int/hiv/pub/me/napyoungpeople_ru.pdf
217. National AIDS programmes: A guide to indicators for monitoring national antiretroviral programmes
English:
http://www.who.int/hiv/pub/me/naparv.pdf
French:
http://www.who.int/hiv/strategic/me/naparvfr.pdf
Spanish:
http://www.who.int/hiv/pub/me/napart_sp.pdf
218. A guide to monitoring and evaluation for collaborative TB/HIV activities: Field test version
English:
http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.342.pdf
Russian:
219. Core indicators for national AIDS programmes: Guidance and specifications for additional
recommended indicators
http://data.unaids.org/pub/BaseDocument/2009/20090305_additionalrecommendedindicators_
finalprintversio_en.pdf
Updated guidelines on monitoring and evaluation for PMTCT, male circumcision, and testing and
counselling programmes can be accessed at http://www.who.int/hiv/pub/me/en/
121
4.2.2 Global monitoring and reporting

At the international level, demonstrating the impact of investments in HIV programmes is critical
to sustaining commitment and ensuring accountability. Since the World Health Assembly in
2006, WHO is mandated to monitor and report annually on global progress in the health sector
response to HIV/AIDS with a view to achieving universal access by 2010. Data from national
programmes are also necessary to monitor progress towards meeting other international
commitments such as the Millennium Development Goals and the UN General Assemblys
Declaration of Commitment on HIV/AIDS.
To facilitate global monitoring and reporting, WHO has developed a core framework of
recommended national level indicators on the health sector response to HIV/AIDS. The framework
includes indicators to measure the availability and coverage of interventions, as well as their
outcomes and impact in terms of survival and improvements in quality of life. The selection of
indicators has been guided by the principle of maximum alignment with existing international
processes. National programmes are requested to report data on an annual basis, and data from
national programmes are aggregated and analysed to produce an annual global progress report.
Key resources:
220. Global framework for monitoring and reporting on the health sectors response towards universal
access to HIV/AIDS treatment, prevention, care and support
http://www.who.int/hiv/pub/me/framework/en/index.html
221. Monitoring the declaration of commitment on HIV/AIDS: Guidelines on construction of core
indicators
http://data.unaids.org/pub/Manual/2007/20070411_ungass_core_indicators_manual_en.pdf
122
4.2.3 Patient monitoring systems

Patient monitoring systems are essential to support individual management of patients in longterm HIV care, as well as for clinical teams to monitor outcomes of groups of patients enrolled
in HIV care and to maintain high-quality services. Patient monitoring systems also contribute to
programme monitoring and evaluation at the health centre, sub-national and national levels since
they generate essential information on the outcome and impact of programmes (e.g. survival of
patients on ART) to report up to the national level.
The WHO HIV care/ART patient monitoring system lays out an internationally agreed minimum
data set and definitions, and includes an illustrative system to collect these data. This system
includes summary HIV care/ART patient cards, pre-ART and ART registers, and cross-sectional
and cohort reports. The ART register organizes patients into monthly treatment cohorts, which
allows group cohort analysis and is useful for monitoring and comparing programme performance
over time and across sites. The tools should be adapted for use at the country level.
WHO has also developed (and made available for free) an OpenMRS Express electronic medical
record that uses the same data elements as the paper forms and produces the same reports. It
can be readily customized to meet local requirements and can be used to collect all elements
on the patient card or only the register elements. The standard data set is available and can be
implemented in other software.
In collaboration with multiple partners, WHO has developed three interlinked patient monitoring
systems to track longitudinal information on patients in HIV care/ART, TB-HIV management and
maternal and child health/PMTCT monitoring. The latter integrates monitoring the care of pregnant
women and infants with monitoring of PMTCT interventions and malaria prevention (cotrimoxazole
or intermittent preventative therapy for malaria with sulfadoxine-pyrimethamine). Countries are
beginning to adapt these three interlinked systems, particularly as decentralization of services
becomes more widespread.
Many patient monitoring systems are paper-based at the health facility level and then require that
paper-based data be entered again into electronic systems for transmission, aggregation and
analysis. Higher-volume facilities may use electronic medical records with entry of patient-level
data; or data may be entered from patient cards into an electronic register; or entry may happen at
the district or national levels, where data are aggregated and analysed on a spreadsheet or other
software (such as the HealthMapper extension for ART data).
Depending on the context, each way of doing things has its strengths and weaknesses. Simple
and practical paper forms should provide the foundation of any patient monitoring system. In
high-volume sites (>1500 patients), however, aggregating data manually to produce monthly or
quarterly reports will be a great burden on the clinical team and requires a data clerk. Electronic
systems facilitate generating such reports easily and sometimes automatically, but electronic
systems require attention to security and confidentiality, space, equipment, human resources and
training. In any case, there will be a continuum of paper to electronic data entry, depending on the
needs and resources of each health facility.
123
In keeping with the Three Ones principles, WHO recommends developing and implementing one
national patient monitoring system that supports a minimum standard data set and standardized
forms and reports. Electronic forms should mirror paper forms in order to ensure that the same
information is collected and reported, regardless of whether this is done through paper or
electronically, and so that patients can transfer between facilities without loss of information.
WHO recommends nationally standardized and interlinked patient monitoring systems that
track delivery of integrated HIV care/ART, maternal and child health with integrated PMTCT and
malaria prevention interventions, and TB/HIV services. This can facilitate patient and programme
management during scale-up.
Key resources:
220. Global framework for monitoring and reporting on the health sectors response towards universal
access to HIV/AIDS treatment, prevention, care and support
http://www.who.int/hiv/pub/me/framework/en/index.html
221. Monitoring the declaration of commitment on HIV/AIDS: Guidelines on construction of core
indicators
222. Patient monitoring guidelines for HIV care and antiretroviral therapy
http://www.who.int/hiv/pub/ptmonguidelines.pdf
Three Interlinked Patient Monitoring Systems for HIV care/ART, MCH/ PMTCT (including malaria
prevention during pregnancy), and TB/HIV: Standardized Minimum Data Set and Illustrative Tools:
http://www.who.int/hiv/pub/imai/three_patient_monitor/en/
Training materials: http://www.who.int/hiv/topics/capacity/sharespace/en/index.html
124
4.2.4 Prevention and assessment of HIV drug resistance

Given the high replication and mutation rates of HIV and the necessity of lifelong antiretroviral
treatment, the emergence of some level of HIV drug resistance (HIVDR) is inevitable. However,
the risk of HIVDR can be reduced with appropriate action.
To maintain the effectiveness of first- and second-line antiretroviral regimens, WHO recommends
that countries develop a national strategy for HIVDR prevention and assessment. Surveys of HIV
drug resistance emergence and prevention during ART, and of transmitted drug resistance, can be
used to inform optimal selection of ARV regimens on a population basis.
Interventions for preventing the emergence of resistance are required at all levels of the health
system. The recommended prevention and assessment strategy was developed in consultation
with WHO HIVResNet, a global network of institutions, specialists and participating countries.
Technical assistance is available from the WHO HIV Drug Resistance Team and from other
members of the network.
Key interventions for preventing and managing HIV drug resistance include:
promoting use of standard ART regimens;
supporting use of standardized individual treatment records;
active monitoring of adherence;
removing barriers to continuous adherence;
providing quality assurance/control for drugs, and an adequate and continuous drug supply;
preventing HIV transmission by persons receiving ART;
monitoring programmes for early warning of HIVDR;
doing surveillance for HIVDR transmission, and monitoring HIVDR emergence in treated
populations;
taking appropriate actions based on the results of monitoring and surveillance.
Key resource:
223. HIV drug resistance (WHO web site)
http://www.who.int/hiv/drugresistance/
125
4.2.5 Pharmacovigilance
The objectives of pharmacovigilance are to enhance patient care and patient safety in relation to
the use of medicines; to improve public health and safety in relation to the use of medicines; and
to contribute to assessing the risk-benefit profile of medicines.
As HIV/AIDS treatment programmes are scaled up in low- and middle-income countries, there is
a risk that their effectiveness may be compromised as a result of adverse events related to using
antiretrovirals. These include problems of toxicity, intolerance, drug-drug interactions and adverse
events linked with comorbidities such as hepatitis. Pharmacovigilance is critically important for
clinicians as they seek to optimize patient adherence to treatment and treatment outcomes,
and to ensure their safety. Assessing the likelihood of adverse events in a given population is
also important for policy-makers and programme managers as it informs the initial selection,
forecasting, procurement and distribution of antiretroviral drugs.
WHO recommends the development of national pharmacovigilance programmes for ARV drugs with
passive and active surveillance of adverse events that are potentially linked to these medicines. The
main focus of these programmes should be on treatment monitoring and post-monitoring surveillance
that covers detection, assessment and the understanding and prevention of adverse effects or other
ARV drug-related problems. Pharmacovigilance programmes should also include communication of
information about benefits, harms and risks of drugs to practitioners, patients and the public.
Using standardized methods to collect reports of suspected adverse drug reactions through
spontaneous reporting should be a core activity of national pharmacovigilance centres. In the
context of antiretroviral therapy, pharmacovigilance activities are also important for programmatic
decision-making. Active surveillance of adverse reactions to antiretrovirals through cohort event
monitoring and special studies is critical for supporting regular updates of national and global
treatment, care and prevention guidelines; improving patient and public care and safety; and
standardizing management of toxicity and drug-drug interactions based on local data on adverse
drug reactions, as well as international recommendations.
To optimize monitoring and managing adverse events associated with antiretroviral drugs, national
pharmacovigilance programmes should:
enable clinicians to identify, report and manage adverse events and toxicity related to ARV use;
stimulate improved reporting and analysis of ARV adverse events and toxicity;
integrate active surveillance and cohort event monitoring in national pharmacovigilance
programmes;
carry out focused in-depth studies aimed at improving ARV use and safety;
pool and analyse data on adverse events as a basis for developing national and global
antiretroviral therapy policies, and draft or improve treatment guidelines;
promote information sharing on issues relating to ARV adverse events, including management of
toxicity, intolerance and drugdrug interactions.
Key resources:
224. Pharmacovigilance for antiretrovirals in resource-poor countries
http://www.who.int/medicines/areas/quality_safety/safety_efficacy/PhV_for_antiretrovirals.pdf
126
4.2.6 Evaluation
Evaluation is an essential, but often neglected, component of a comprehensive M & E system.
It assesses the value or impact of a programme or intervention through a detailed analysis of
inputs and outcomes. There are three sequential phases of evaluationprocess, outcomes
and impact evaluation.
Strengthening evaluation is essential for programme managers and decision-makers since
it enables them to assess how successfully programmes are meeting their goals. Evaluation
is also critical for countries and their development partners since it demonstrates the
effectiveness of aid and argues for sustaining or increasing it. The effective use of evaluation
data will ensure that the HIV response is based on the best available evidence and will guide
continued programme improvement.
Ideally, sound monitoring provides much of the data required for evaluation, including baseline
data. In practice however, additional data collection is often required because health information
systems may be weak, and complete, high-quality data may not be readily available. Capacity
for conducting evaluations may also be limited in many countries.
The main steps in planning evaluation include:
conducting a country readiness assessment that includes gauging the strengths of national
strategic and M & E plans and the links between them, and assessing the availability of data and
resources for an evaluation;
creating a multidisciplinary national evaluation task force that brings together key stakeholders
from government, civil society, the private sector, and technical and financial aid agencies;
reviewing and cataloguing relevant materials and documents such as national plans, programme
data, census data, data from behavioural and biological surveillance and other surveys,
programme monitoring and evaluation reports, and research studies;
developing an agenda for the evaluation, including prioritizing key questions and agreeing on an
action plan and timelines.
This is followed by implementation of the evaluation agenda. Evaluations bring together data
from multiple sources. In order to strengthen monitoring and evaluation, it is important that
any additional necessary data collection be integrated into the existing health information
system which, in turn, should be linked to the country review and strategic planning processes
(see Section 4.4). (In other words, the process of doing an evaluation should strengthen the
monitoring and evaluation system and, thus, facilitate future evaluations.) The evaluation
process should involve collaboration among policy-makers, project managers, international
stakeholders and evaluation experts.
127
4.3 Research
An effective response to HIV/AIDS requires that interventions and approaches be continually
improved over time. Over the past 25 years, sustained research efforts have produced new
scientific evidence and have enabled the evolution of HIV interventions, policies and programmes.
The importance of investing in research was acknowledged by the Sydney Declaration of the
4th International AIDS Society Conference on Pathogenesis, Treatment and Prevention held in
Sydney, Australia in July 2007. The Declaration called on national governments and bilateral,
multilateral and private donors to allocate 10% of all resources for HIV programming to research,
which provides more and better evidence on which to base the response to HIV.
The HIV response can be strengthened through different types of researchclinical/epidemiologic,
socio-behaviouraland health systems. In each of these areas, new evidence should be collected,
assessed and then brought to bear on policies, strategies and programmes. Operational research
builds on the different disciplines that are used for basic research to address questions related to
programmes. Performing research alone is not enough; there must also be processes for bringing
it quickly to bear on decisions so they are informed by the most up-to-date evidence.
There are many examples of research that is urgently needed. These include research aimed
at: discovering effective prevention technologies (vaccines, microbicides and cervical barriers,
and pre-exposure prophylaxis) and effective treatment and care interventions; expanding
understanding of socio-behavioural factors that increase or decrease risk behaviour or hinder or
facilitate access to interventions; and discovering the optimal models of service delivery within a
variety of national and sub-national contexts.
To scale up research, countries need to invest in building research capacity. This means training
human resources and developing research infrastructure, including laboratories. It also requires
stronger health information systems to capture and use information generated through research.
Greater collaboration between researchers and policy-makers is needed to ensure that the role of
research is appreciated and the findings are translated into practice. Collaboration among national
partners, donors and north/south research organizations and networks is also necessary to devise
and conduct research that is relevant to country situations.
128
4.3.1 Operational research

Operational research covers all programme areas and is vital to improving programme operations
and making the most effective use of available resources.
Operational research involves the use of systematic research techniques to solve programme
problems. It is used to gather evidence to inform treatment and prevention programmes, and
it looks at such matters as different approaches to task-shifting for ART delivery, the factors
that influence adherence to medical regimens and the factors that influence uptake of testing
and counselling. It uses a variety of qualitative and quantitative analytical techniques, favours
multidisciplinary approaches and should be owned by country partners.
A first step for implementing operational research is to conduct a rapid assessment of what is
known about the selected topic in the country, and to formulate questions that can be addressed
through such research. This is best done through consulting major stakeholders from the research
community, the ministry of health and NGOs. Once general priorities are established, it is
important to identify individuals who can form the nucleus of the project so that they can design
an appropriate study and seek resources to support the project. Data collection methods can build
on available tools that can be adapted, translated and tested in the country in order to ensure that
they fit with local realities. Data triangulation is recommended.
Key resources:
225. Guide to operational research in programs supported by the Global Fund
http://www.who.int/hiv/pub/epidemiology/SIR_operational_research_brochure.pdf
226. Framework for operations and implementation research in health and disease control programmes
http://www.theglobalfund.org/documents/me/FrameworkForOperationsResearch.pdf
227. HIV testing, treatment, and prevention: generic tools for operational research
http://www.who.int/hiv/pub/operational/generic/en/index.html
129
4.4 Using data effectively for programme improvement

The main reason for generating strategic information is to provide evidence to inform the
development and implementation of policies, strategies and programmes at all levels of the health
system. This means strategic information activities should be linked to the needs for evidence and
to the people who need it, and that the evidence must be packaged and disseminated in ways that
make it easy for those people to digest and use. Plans for disseminating the evidence should keep
different readers or audiences in mind, whether they be political decision-makers, programme
planners and managers, health workers, people living with HIV or at risk of infection, and so on.
Feedback from readers or audiences at all levels of the health system should ensure that the
information is presented in ways that meet their needs and that it encourages a culture of data
generation and application for programme improvement at all levels.
4.4.1 Situation analysis

In order to remain effective, planning and programming of the HIV response must be linked to regular
review of the epidemiological situation and programme performance. National HIV/AIDS programmes
need a clear understanding of the country situation in order to prioritize and tailor interventions.
For example, to interrupt HIV transmission, it is important to know the geographical areas and
populations where the epidemic is spreading most rapidly and to plan interventions accordingly.
Similarly, organizing services for care, support and treatment requires an understanding of
the location of people living with HIV. There may be considerable overlap in initiatives for HIV
prevention, care and treatment in terms of geographic and population focus.
HIV/AIDS programme managers need to regularly track, analyse and use data from multiple
sources, including:
biological and behavioural sentinel and periodic surveillance;
HIV/AIDS case reporting from the health services;
sexually transmitted infection (STI) clinics;
patient monitoring from testing and counselling services, HIV care and ART services, TB and
maternal and child health services;
surveys to assess HIV drug resistance prevention and site indicators for monitoring HIV drug
resistance;
situation assessments, mapping studies and rapid assessments among target populations;
population surveys (demographic and health surveys, HIV indicator surveys, etc);
national census reports;
social, cultural and behavioural research;
operational research; and
periodic AIDS, TB and maternal and child health programme reviews.
130
Rapid assessment and response (RAR) methods can be used to generate information in situations
where data are needed extremely quickly, when time or cost constraints rule out using more
conventional research techniques, and when current, relevant data are needed to develop,
implement, monitor or evaluate programmes. RAR methods use existing information from multiple
sources and are flexible and cost-effective. They can provide information on the country situation
or context; target populations and settings; risk behaviours; and HIV infection and other HIVrelated outcomes and responses. Both qualitative and quantitative methods and data should be
considered. All RARs should include recommendations and plans of action. They should also
encourage community participation.
An analytical approach known as triangulation integrates multiple data sources to improve
the understanding of a public health problem. It is used to guide programmatic decision-making
to address such problems.
Key resources:
39. SEX-RAR guide: The rapid assessment and response guide on psychoactive substance use and
sexual risk behaviour
55. Rapid assessment and response: Adaptation guide on HIV and men who have sex with men (MSMRAR)
226. Framework for operations and implementation research in health and disease control programmes
228. A guide to rapid assessment of human resources for health
http://www.who.int/hrh/tools/en/Rapid_Assessment_guide.pdf
229. Rapid assessment and response: Adaptation guide for work with especially vulnerable young people
(EVYP- RAR)
http://www.who.int/hiv/pub/prev_care/en/youngpeoplerar.pdf
230. HIV triangulation resource guide: Synthesis of results from multiple data sources for evaluation and
decision-making
http://www.who.int/hiv/pub/surveillance/triangulation/en/
131
4.4.2 Setting targets

Setting targets is an integral part of national health sector strategic planning and is necessary
to monitor progress. Even the best interventions will have little public health impact if they are
implemented on a limited scale.
All countries strive towards the goal of universal access, but individual country targets will differ
in a given year depending on the country context. For example, the guidance for global scale-up
of the prevention of mother-to-child transmission of HIV suggests the following coverage levels to
guide setting country-level targets:
at least 80% of all pregnant women attending antenatal care are tested for HIV, including those
previously confirmed to be living with HIV;
at least 80% of pregnant women living with HIV receive antiretroviral prophylaxis or antiretroviral
therapy to reduce the risk of mother-to-child transmission;
at least 80% of infants born to women living with HIV receive a virological HIV test within two
months of birth.
Similarly, the Global Plan to Stop TB 20062015 sets global targets. For example, by 2015, 85%
of TB patients in DOTS programmes are to receive HIV testing and counselling, and 57% of
TB patients in DOTS programmes (HIV-positive and eligible) are to be enrolled on antiretroviral
therapy. National target-setting is necessary to translate international commitments into country
action plans and to monitor implementation.
A number of factors need to be taken into consideration in order to set targets for scaling up
priority health sector interventions for HIV/AIDS (such as the proportion of people in need who
are receiving antiretroviral therapy, or the proportion of HIV-positive pregnant women receiving
antiretrovirals to prevent mother-to-child transmission). These include:

considering the epidemiological context, geographical distribution and the size of populations in need;
reviewing the programmatic context and health service delivery infrastructure, including human
and financial resources;
assessing current coverage and the possible impact under different target scenarios;
developing plans and time-bound targets for scaling up towards a standard or a benchmark.
Depending on the information available, targets can be set and coverage monitored in several
ways: by geographical distribution, such as on the basis of administrative units (district,
province, etc.); by population sub-groups (such as antiretroviral therapy targets for pregnant
women, all adults, adolescents, children, or most-at-risk populations); or by combining methods
for a more complete picture.
Target-setting must be integrated with programme planning and budgeting. It must be linked to
related, ongoing efforts such as situation analyses and the collection of well-defined indicators
and other monitoring and evaluation activities. Targets should be regularly evaluated and
revised as necessary.
132
Key resources:
85. Guidance on global scale-up of the prevention of mother to child transmission of HIV: towards
universal access for women, infants and young children and eliminating HIV and AIDS among children
English:
French:
Russian:
231. Technical guide for countries to set targets for universal access to HIV prevention, treatment and
care for injecting drug users (IDUs)
http://www.who.int/hiv/pub/idu/targetsetting/en/index.html
232. Setting national targets for moving towards universal access: operational guidance
http://data.unaids.org/pub/Guidelines/2006/20061006_report_universal_access_targets_guidelines_en.pdf
233. Scaling up towards universal access: Considerations for countries to set their own national targets
for HIV prevention, treatment and care
http://data.unaids.org/pub/Report/2006/Considerations_for_target_setting_April2006.pdff
133
4.4.3 Data quality

A sound information system depends largely on the quality of data. This includes measures such
as optimizing the amount of data to be collected, reducing the burden of data collection, using
clear definitions, conducting local quality controls and checks, providing training, and providing
feedback to data collectors and users to help to improve data quality.
Data quality assessments should be carried out periodically to identify weaknesses in data
collection and reporting systems, and to constantly improve data quality and accuracy.
The Health Metrics Network Assessment Tool for health information systems (available at: http://
www.who.int/healthmetrics/tools/hisassessment/en/index.html) lists the following criteria to assess
the quality of health-related data and indicators:
timeliness the period between data collection and its availability to a higher level, or its publication;
periodicity the frequency with which an indicator is measured;
consistency the internal consistency of data within a dataset, as well as consistency between
datasets and over time, and the extent to which revisions follow a regular, well-established and
transparent schedule and process;
representativeness the extent to which data adequately represent the population and relevant
subpopulations;
disaggregation the availability of statistics stratified by sex, age, socioeconomic status, major
geographical or administrative region and ethnicity, as appropriate;
confidentiality, data security and data accessibility the extent to which practices are in
accordance with guidelines and established standards for storage, backup, transport of
information (especially over the Internet) and retrieval.
Key resource:
234. Routine data quality assessment tool (RDQA): Guidelines for implementation GFATM, WHO and
partners (Draft July 2008)
http://www.cpc.unc.edu/measure/tools/monitoring-evaluation-systems/data-quality-assurance-tools/
RDQA%20Guidelines-Draft%207.30.08.pdf
134
Chapter 5: Resources
1. National AIDS programme management: A set of training modules
Preliminary pages: http://www.searo.who.int/LinkFiles/Publications_Preliminar__pages.pdf
Introduction: http://www.searo.who.int/LinkFiles/Publications_Introduction.pdf
Module 1 Situation analysis: http://www.searo.who.int/LinkFiles/Publications_NAP_Module_1.pdf
Module 2 Policy and planning: http://www.searo.who.int/LinkFiles/Publications_NAP_
Module_2.pdf
Module 3 Determining programme priorities and approaches: http://www.searo.who.int/
LinkFiles/Publications_NAP_Module_3.pdf
Module 4 Targeted HIV prevention and care interventions: http://www.searo.who.int/LinkFiles/
Module 5 Setting coverage targets and choosing key outcome indicators: http://www.searo.
who.int/LinkFiles/Publications_NAP_Module_5.pdf
Module 6 Implementation of HIV Prevention, Care and Treatment Strategies:
Module 6.1 Minimizing sexual transmission of HIV and other STIs: http://www.searo.who.int/
LinkFiles/Publications_NAP_Module_6.1.pdf
Module 6.2 HIV prevention and care among drug users: http://www.searo.who.int/LinkFiles/
Module 6.3 HIV counseling and testing: http://www.searo.who.int/LinkFiles/Publications_
NAP_Module_6.3.pdf
Module 6.4 The continuum of care for people living with HIV/AIDS and access to antiretroviral
therapy: http://www.searo.who.int/LinkFiles/Publications_NAP_Module_6.4.pdf
Module 6.5 Prevention of mother-to-child transmission: http://www.searo.who.int/LinkFiles/
Module 6.6 Prevention of HIV transmission through blood: http://www.searo.who.int/LinkFiles/
Module 7 Managing the AIDS programme: http://www.searo.who.int/LinkFiles/Publications_
NAP_Module7.pdf
Module 8 Management systems for the AIDS programme: http://www.searo.who.int/LinkFiles/
Publications_NAP_Module8.pdf
Module 9 Strategic information: http://www.searo.who.int/LinkFiles/Publications_NAP_
Module9.pdf
English: http://www.who.int/hiv/pub/imai/generalprinciples082004.pdf
French:
http://www.who.int/hiv/pub/imai/imai_general_2008_fr.pdf
3. UNAIDS/WHO policy statement on HIV testing
http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf
4. Opening up the HIV/AIDS epidemic: Guidance on encouraging beneficial disclosure,
ethical partner counselling & appropriate use of HIV case-reporting
English: http://data.unaids.org/Publications/IRC-pub05/JC488-OpenUp_en.pdf
French:
135
5. HIV counselling and testing e-library

http://www.who.int/hiv/topics/vct/elibrary/en/index.html
6. Guidelines for the implementation of reliable and efficient diagnostic HIV testing, Region of
the Americas
English: http://www.paho.org/English/AD/FCH/AI/LAB_GUIDE_ENG.PDF
Spanish: http://www.paho.org/Spanish/AD/FCH/AI/LAB_GUIDE_SPAN.PDF
7. WHO HIV testing and counselling (TC) toolkit
http://www.who.int/hiv/topics/vct/toolkit/en/index.html
8. International Organization for Migration guide for counsellors: IOM HIV counselling in the
context of migration health assessment
http://www.iom.int/jahia/webdav/site/myjahiasite/shared/shared/mainsite/published_docs/
brochures_and_info_sheets/HIV%20counselors%20GUIDE%20FINAL_Apr2006%20(4).pdf
English: http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf
Russian: http://whqlibdoc.who.int/publications/2007/9789244595565_rus.pdf
10. WHO case definitions of HIV for surveillance and revised clinical staging and
immunological classification of HIV-related
disease in adults and children
11. HIV testing and counselling in TB clinical settings tools
http://www.cdc.gov/globalaids/pa_hiv_tools.htm
Agenda: http://www.cdc.gov/globalaids/docs/tb_tools/TB%20Agenda_12.1.06.pdf
Overview: http://www.cdc.gov/globalaids/docs/tb_tools/TB%20An%20Overview_12.1.06.pdf
Module 6: http://www.cdc.gov/globalaids/docs/tb_tools/TB%20Module%206%20Demo_12.1.06.pdf
12. IMAI PITC core training course and PITC counselling training video (free registration
required to access the site)
13. WHO recommendations on the diagnosis of HIV infection in infants and children, April 2010
http://www.who.int/hiv/pub/paediatric/diagnosis/en/index.html
14. Scale up of HIV-related prevention, diagnosis, care and treatment for infants and children:
A programming framework
http://www.who.int/hiv/pub/paediatric/paediatric_program_fmwk2008.pdf
15. Antiretroviral therapy for HIV infection in infants and children. Recommendations for a public
health approach (2010 revision)
136
16. Blood transfusion safety (WHO web page)

17. UNAIDS/WHO revised recommendations for the selection and use of HIV antibody tests
http://www.who.int/docstore/wer/pdf/1997/wer7212.pdf
18. Guidelines for assuring the accuracy and reliability of HIV rapid testing: Applying a quality
system approach
19. Overview of HIV Rapid Test Training Package
http://wwwn.cdc.gov/dls/ila/hivtraining/Overview.pdf
20. HIV rapid test training: Framework for a systematic roll-out
http://wwwn.cdc.gov/dls/ila/hivtraining/Framework.pdf
21. Revised recommendations for HIV testing of adults, adolescents and pregnant women in
health care settings http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm?s_cid=
22. HIV assays: Operational characteristics (Phase 1). Report 14: Simple/rapid tests
http://www.who.int/diagnostics_laboratory/publications/hiv_assays_rep_14.pdf
23. HIV assays: Operational characteristics (Phase 1). Report 15: Antigen/Antibody ELISAS
http://www.who.int/diagnostics_laboratory/publications/en/HIV_Report15.pdf
24. Guidelines for appropriate evaluations for HIV testing technologies in Africa
English: http://whqlibdoc.who.int/afro/2002/a82959_eng.pdf
French: http://www.who.int/entity/diagnostics_laboratory/publications/FR_HIVEval_Guide.pdf
http://data.unaids.org/pub/Manual/2007/20070306_prevention_guidelines_towards_universal_
access_en.pdf
27. Glion consultation on strengthening the linkages between reproductive health and HIV/
AIDS: Family planning and HIV/AIDS in women and children
http://www.who.int/entity/hiv/pub/advocacymaterials/glionconsultationsummary_DF.pdf
28. Linkages between HIV and sexual and reproductive health: Technical documents and
advocacy materials (WHO web page)
29. Position statement on condoms and HIV prevention
http://www.who.int/hiv/pub/prev_care/en/Condom_statement.pdf
30. The male latex condom: Specification and guidelines for condom procurement
http://www.who.int/reproductivehealth/publications/family_planning/9241591277/en/
31. The female condom: A guide for planning and programming
http://whqlibdoc.who.int/hq/2000/WHO_RHR_00.8.pdf
English: https://www.unfpa.org/public/publications/pid/376
137
32. Sexual and reproductive health of women living with HIV/AIDS: Guidelines on care,
treatment and support for women living with HIV/AIDS and their children in resourceconstrained settings
33. Global strategy for the prevention and control of sexually transmitted infections, 2006 2015: Breaking the chain of transmission
Arabic:
http://whqlibdoc.who.int/publications/2007/9789246563470_ara.pdf
Chinese: http://whqlibdoc.who.int/publications/2007/9789245563471_chi.pdf
34. Guidelines for the management of sexually transmitted infections
English: http://www.who.int/hiv/pub/sti/en/STIGuidelines2003.pdf
French:
http://www.who.int/hiv/pub/sti/STIguidelines2003_fr.pdf
Portuguese: http://www.who.int/entity/hiv/pub/sti/STIguidelines2003_pt.pdf
Spanish: http://www.who.int/entity/hiv/pub/sti/STIguidelines2003_es.pdf
35. STI interventions for preventing HIV: Appraisal of the evidence
Publication anticipated in 2010.
36. IMAI acute care STI/genitourinary problem training course participant's manual (part of
IMAI acute care guideline module)
37. Periodic presumptive treatment for sexually transmitted infections: Experience from the
field and recommendations for research
http://www.who.int/reproductivehealth/publications/rtis/9789241597050/en/
38. WHO regional strategy for the prevention and control of sexually transmitted infections
2007-2015
39. SEX-RAR guide: The rapid assessment and response guide on psychoactive substance
use and sexual risk behaviour
40. Youth-centered counseling for HIV/STI prevention and promotion of sexual and
reproductive health: A guide for front-line providers
http://www.paho.org/english/ad/fch/ca/sa-youth.pdf
41. Male circumcision information package
42. New data on male circumcision and HIV prevention: Policy and programme implications (WHO/
UNAIDS technical consultation on male circumcision and HIV prevention: Research implications for
policy and programming, Montreux, 6-8 March 2007: conclusions and recommendations)
English: http://whqlibdoc.who.int/unaids/2007/male_circumcision_eng.pdf
French:
http://www.who.int/entity/hiv/mediacentre/MCrecommendations_fr.pdf
138
43. Male circumcision: Global trends and determinants of prevalence, safety and acceptability
44. Manual for male circumcision under local anaesthesia
http://www.who.int/hiv/pub/malecircumcision/who_mc_local_anaesthesia.pdf
45. Male circumcision quality assurance: A guide to enhancing the safety and quality of services
http://www.who.int/hiv/pub/malecircumcision/qa_guide/
46. Male circumcision quality assurance toolkit
http://www.who.int/hiv/pub/malecircumcision/qa_toolkit/
47. Safe, voluntary, informed male circumcision and comprehensive HIV prevention
programming: Guidance for decision-makers on human rights, ethical and legal considerations
http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf
48. Male circumcision and HIV prevention in Eastern and Southern Africa communications guidance
http://www.malecircumcision.org/programs/documents/mc_hiv_prevention_eastern_southern_
africa_5_15_08.pdf
49. Operational guidance for scaling up male circumcision services for HIV prevention
http://www.who.int/hiv/pub/malecircumcision/op_guidance/
50. IMAI-IMCI chronic HIV care with ARV therapy and prevention: Interim guidelines for health
workers at health centre or district hospital outpatient clinic
English: http://www.who.int/hiv/pub/imai/Chronic_HIV_Care7.05.07.pdf
French:
51. Toolkit for targeted HIV/AIDS prevention and care in sex work settings
52. Guidelines for the management of sexually transmitted infections in female sex workers
http://www.wpro.who.int/NR/rdonlyres/90F80401-5EA0-4638-95C6-6EFF28213D34/0/
Guidelines_for_the_Mgt_of_STI_in_female_sex_workers.pdf
53. 100% condom use programme in entertainment establishments 2000
http://www.wpro.who.int/NR/rdonlyres/5F1C719B-4457-4714-ACB1-192FFCA195B1/0/condom.pdf
54. HIV and sexually transmitted infection prevention among sex workers in Eastern
Europe and Central Asia
English: http://whqlibdoc.who.int/unaids/2006/9291734942_eng.pdf
Russian: http://whqlibdoc.who.int/unaids/2006/9291734950_rus.pdf
55. Rapid assessment and response: Adaptation guide on HIV and men who have sex
with men (MSM-RAR)
56. Policy brief: HIV and sex between men
http://data.unaids.org/Publications/IRC-pub07/jc1269-policybrief-msm_en.pdf
57. Between men: HIV STI prevention for MSM
http://www.aidsalliance.org/includes/Publication/msm0803_between_men_Eng.pdf
139
58. AIDS and men who have sex with men

http://whqlibdoc.who.int/unaids/2000/a62375_eng.pdf
59. 2007 European guideline (IUSTI/WHO )on the management of proctitis, proctocolitis and
enteritis caused by sexually transmissible pathogens
http://www.iusti.org/sti-information/pdf/proctitis-guideline-v7.pdf
60. Preventing HIV/AIDS in young people: a systematic review of the evidence from
developing countries
http://whqlibdoc.who.int/trs/WHO_TRS_938_eng.pdf
61. Global consultation on the health services response to the prevention and care of HIV/
AIDS among young people: Achieving the global goals - access to services
62. Adolescent friendly health services: An agenda for change
http://whqlibdoc.who.int/hq/2003/WHO_FCH_CAH_02.14.pdf
63. Consensus statement: delivering antiretroviral drugs in emergencies: neglected but feasible
http://www.who.int/hac/techguidance/pht/HIV_AIDS_101106_arvemergencies.pdf
64. Guidelines for HIV/AIDS interventions in emergency settings
English: http://www.who.int/3by5/publications/documents/en/iasc_guidelines.pdf
French:
http://www.who.int/3by5/publications/en/directivesvihfinalesfr.pdf
67. Policy brief: Reduction of HIV transmission in prisons (Evidence for action on HIV/AIDS
and injecting drug use)
http://www.who.int/hiv/pub/advocacy/en/transmissionprisonen.pdf
68. Status paper on prisons, drugs and harm reduction
69. Post-exposure prophylaxis to prevent HIV infection: Joint WHO/ILO guidelines on postexposure prophylaxis (PEP) to prevent HIV infection
70. Policy and programming guide for HIV/AIDS prevention and care among injecting drug users
http://www.who.int/hiv/pub/prev_care/policyprogrammingguide.pdf
71. Advocacy guide: HIV/AIDS prevention among injecting drug users
http://www.who.int/hiv/pub/advocacy/en/advocacyguideen.pdf
72. Policy briefs and technical papers on HIV/AIDS and injecting drug users (Evidence for
action series web site)
http://www.who.int/hiv/pub/idu/idupolicybriefs/en/index.html
73. HIV/AIDS: Injecting drug use and prisons (WHO web site)
http://www.who.int/hiv/topics/idu/en/index.html
140
74. Evidence for action: Effectiveness of community-based outreach in preventing HIV/AIDS

among injecting drug users
75. Treatment of injecting drug users with HIV/AIDS: Promoting access and optimizing
service delivery
http://www.who.int/substance_abuse/publications/treatment_idus_hiv_aids.pdf
76. Training guide for HIV prevention outreach to injecting drug users: workshop manual
77. Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among
injecting drug users (Evidence for action technical papers)
78. Guide to starting and managing needle and syringe programmes
http://www.who.int/hiv/idu/Guide_to_Starting_and_Managing_NSP.pdf
79. Treatment and care for HIV-positive injecting drug users (training curriculum)
Module 1: Drug use and HIV in Asia
http://www.searo.who.int/LinkFiles/Publications_Module_01_Treatment_&_Care_for_HIV_
positive_IDUs.pdf
Module 2: Comprehensive services for injecting drug users
positive_IDUs.pdf
Module 3: Initial patient assessment
positive_IDUs.pdf
Module 4: Managing opioid dependence
positive_IDUs.pdf
Module 5: Managing non-opioid drug dependence
positive_IDUs.pdf
Module 6: Managing ART in injecting drug users
positive_IDUs.pdf
Module 7: Adherence counselling for injecting drug users
positive_IDUs.pdf
Module 8: Drug interactions
positive_IDUs.pdf
Module 9: Management of coinfections in HIV-positive injecting drug users
positive_IDUs.pdf
141
Module 10: Managing pain in HIV-infected injecting drug users

positive_IDUs.pdf
Module 11: Psychiatric illness, psychosocial care and sexual health
positive_IDUs.pdf
Module 12: Continuing medical education
positive_IDUs.pdf
Trainer manual
positive_IDUs.pdf
80. Treatment of opioid dependence (WHO web page)
http://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/index.html
81. WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral
therapy and prevention in resource-constrained settings
82. Effectiveness of drug dependence treatment in prevention of HIV among injecting drug
users (Evidence for action technical papers)
http://www.who.int/hiv/pub/idu/en/drugdependencefinaldraft.pdf
83. WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the
management of opioid dependence and HIV/AIDS prevention
English: http://whqlibdoc.who.int/unaids/2004/9241591153_eng.pdf
Chinese: http://whqlibdoc.who.int/unaids/2004/9241591153_chi.pdf
Russian: http://whqlibdoc.who.int/unaids/2004/9241591153_rus.pdf
Cambodian:http://whqlibdoc.who.int/unaids/2004/9241591153_cam.pdf
Lao:
http://whqlibdoc.who.int/unaids/2004/9241591153_lao.pdf
Vietnamese:http://whqlibdoc.who.int/unaids/2004/9241591153_vie.pdf
84. Strategic approaches to the prevention of HIV infection in infants. Report of a WHO
meeting, Morges, Switzerland, 20-22 March 2002
http://www.who.int/hiv/mtct/StrategicApproaches.pdf
85. Guidance on global scale-up of the prevention of mother to child transmission of HIV:
towards universal access for women, infants and young children and eliminating HIV and AIDS
among children
French:
86. Report of the WHO technical reference group, paediatric HIV/ART care guideline group
meeting, WHO Headquarters, Geneva, Switzerland, 10-11 April 2008
http://www.who.int/hiv/pub/paediatric/WHO_Paediatric_ART_guideline_rev_mreport_2008.pdf
87. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants:
towards universal access. Recommendations for a public health approach (2010 version)
142
88. Testing and counselling for prevention of mother-to-child transmission of HIV support tools
English: http://www.womenchildrenhiv.org/wchiv?page=vc-10-00#S3.4X
French:
http://www.womenchildrenhiv.org/wchiv?page=vc-10-00-fr
89. IMAI-IMPAC integrated PMTCT training course
90. Reproductive choices and family planning for people living with HIV - Counselling tool
http://www.who.int/reproductivehealth/publications/family_planning/9241595132/en/index.html
91. IMAI one-day orientation on adolescents living with HIV
http://www.who.int/child_adolescent_health/documents/fch_cah_9789241598972/en/index.html
92. Strengthening linkages between family planning and HIV: reproductive choices and family
planning for people living with HIV
http://www.who.int/reproductive-health/hiv/hiv_tecbrief_fp.pdf
94. Antiretroviral therapy for HIV infection in adults and adolescents. Recommendations for a
public health approach (2010 revision)
http://www.who.int/hiv/pub/arv/adult/en/index.html
95. Aide memoire: Infection control: Standard precautions in health care
English: http://www.who.int/csr/resources/publications/EPR_AM2_E7.pdf
French:
http://www.who.int/csr/resources/publications/EPR_AM2_FR3.pdf
French:
Spanish: http://www.who.int/entity/hiv/pub/prev_care/who_iloguidelines_sp.pdf
Russian: http://www.who.int/entity/hiv/pub/guidelines/ilowhoguidelines_ru.pdf
Arabic:
Chinese: http://www.who.int/entity/hiv/pub/guidelines/ilowhoguidelineschinese-pdf.pdf
97. Injection safety toolbox: Resources to assist in the management of national safe and
appropriate use of injection policies (WHO web page)
http://www.who.int/injection_safety/toolbox/en/
98. Healthcare waste and its safe management (WHO web page)
http://www.healthcarewaste.org/en/115_overview.html
99. Operations manual for the delivery of HIV prevention, care and treatment at primary health
centres in high-prevalence resource-constrained settings
100. Protecting healthcare workers: Preventing needlestick injuries toolkit (WHO web site)
http://www.who.int/occupational_health/activities/pnitoolkit/en/index.html
101. Occupational health of health workers: Meeting report, October 2009
http://www.who.int/occupational_health/network/health_workers_workshop_report.pdf
143
102. WHO best practices for injections and related procedures toolkit, March 2010 http://
whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf
103. WHO blood safety: Aide-memoire for national blood programmes
English:
http://www.who.int/entity/bloodsafety/transfusion_services/en/Blood_Safety_Eng.pdf
French:
http://www.who.int/entity/bloodsafety/transfusion_services/en/Blood_Safety_French.pdf
Portuguese:http://www.who.int/entity/bloodsafety/transfusion_services/en/Blood_Safety_Port.pdf
Spanish: http://www.who.int/entity/bloodsafety/transfusion_services/en/Blood_Safety_Span.pdf
104. Global database on blood safety (WHO web page)
http://www.who.int/bloodsafety/global_database/en/
105. Prioritizing second-line antiretroviral drugs for adults and adolescents: a public health
approach. Report of a WHO working group meeting, Geneva, Switzerland, 21-22 May 2007
106. Co-trimoxazole prophylaxis for HIV-exposed and HIV-infected infants and children.
Practical approaches to implementation and scale up | WHO and UNICEF
http://www.who.int/hiv/pub/paediatric/co-trimoxazole/en/index.html
107. Vaccine-preventable diseases, vaccines and vaccination
http://whqlibdoc.who.int/publications/2005/9241580364_chap6.pdf
108. Revised BCG vaccination guidelines for infants at risk for HIV infection
http://www.who.int/wer/2007/wer8221.pdf (see p. 193)
109. Nutrition counselling, care and support for HIV-infected women
http://www.who.int/hiv/pub/prev_care/en/nutri_eng.pdf
110. Integrating nutrition and food assistance into HIV care and treatment programmes:
operational guidance
http://www.who.int/hiv/topics/treatment/nutrition/en/index.html
111. Nutrition and HIV/AIDS: A Report by the Secretariat. WHO Executive Board EB116/12,
116th Session, 12 May 2005
http://www.who.int/gb/ebwha/pdf_files/EB116/B116_12-en.pdf
112. Guidelines for an integrated approach to the nutritional care of HIV-infected children
(6 months-14 years): Preliminary version for country introduction
113. Nutritional care and support for people living with HIV/AIDS: A training course
114. Prequalification programme: A United Nations Programme managed by WHO
(WHO web site)
115. IMAI basic ART aid (lay counsellor) training modules
116. Patient treatment cards
144
117. Flipchart for patient education: HIV prevention, treatment and care
118. HIV/AIDS treatment and care: clinical protocols for the WHO European Region
English: http://www.euro.who.int/document/e90840.pdf
Russian: http://www.euro.who.int/document/e90840R.pdf
119. WHO consultation on ART failure in the context of a public health approach:
2008 meeting report
http://www.who.int/hiv/pub/arv/failure/en/index.html
120. ART failure and strategies for switching ART regimens in the WHO European RegionWHO
consultation on ART failure in the context of a public health approach: 2008 meeting report
http://www.euro.who.int/__data/assets/pdf_file/0020/78104/E91257.pdf
121. Adherence to long-term therapies: Evidence for action
http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf
http://www.who.int/hiv/pub/prev_care/lttherapies/en/
English: http://www.who.int/hiv/pub/imai/acute_care.pdf
French:
French:
124. IMAI OI training course (based on IMAI Acute Care guideline module)
125. Global action plan for the prevention and control of pneumonia (GAPP): report of an
informal consultation
126. Integrated management of childhood illness (IMCI) complementary course on HIV/AIDS
Introduction: http://whqlibdoc.who.int/publications/2006/9789241594370.intro_eng.pdf
Facilitator guide for modules: http://whqlibdoc.who.int/publications/2006/9789241594370.
fg_eng.pdf
Photo booklet: http://whqlibdoc.who.int/publications/2006/9789241594370.pb_eng.pdf
Chart booklet: http://whqlibdoc.who.int/publications/2006/9789241594370.cb_eng.pdf
French (all modules): http://www.who.int/child_adolescent_health/documents/9241594373/en/
127. Policy for prevention of oral manifestations in HIV/AIDS: The approach of the WHO Global
Oral Health Programme
http://adr.iadrjournals.org/cgi/reprint/19/1/17.pdf
128. Pocket book of hospital care for children: guidelines for the management of common
illnesses with limited resources
English: http://whqlibdoc.who.int/publications/2005/9241546700.pdf
145
French:
129. Community-based management of severe acute malnutrition: A joint statement by the
World Health Organization, the World Food Programme, the United Nations System Standing
Committee on Nutrition and the United Nations Children's Fund
English: http://www.who.int/child_adolescent_health/documents/pdfs/severe_acute_
malnutrition_en.pdf
French:
http://www.who.int/child_adolescent_health/documents/pdfs/severe_acute_
malnutrition_fr.pdf
130. HIV/AIDS treatment and care for injecting drug users: Clinical protocols for the WHO
European Region
131. Management of Hepatitis C and HIV coinfection: clinical protocol for the WHO
European region
English: http://www.euro.who.int/__data/assets/pdf_file/0008/78146/E90840_Chapter_6.pdf
Russian: http://www.euro.who.int/__data/assets/pdf_file/0010/78148/HEP_C_rus.pdf
132. Prevention of hepatitis A, B and C and other hepatotoxic factors in people living with HIV:
Clinical protocol for the WHO European Region
English: http://www.euro.who.int/__data/assets/pdf_file/0010/78157/E90840_Chapter_8.pdf
Russian: http://www.euro.who.int/__data/assets/pdf_file/0007/78163/HEP_A_B_C_rus.pdf
133. WHO EURO hepatitis web site
http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/hepatitis
134. Guidelines for the treatment of malaria, second edition
http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf
135. Malaria and HIV interactions and their implications for public health policy
French:
http://www.who.int/entity/hiv/pub/meetingreports/malariahivfr.pdf
136. WHO mental health and HIV/AIDS series
Module 1 - Organization and systems support for mental health interventions in ARV therapy
programmes:
Module 2 - Basic counselling guidelines for ARV therapy programmes:
Module 3 - Psychiatric care in ARV therapy (for second level care):
Module 4 - Psychosocial support groups in ARV therapy:
Module 5 - Psychotherapeutic interventions in ARV therapy (for second level care):
137. Palliative care: symptom management and end-of-life care
English: http://www.who.int/hiv/pub/imai/genericpalliativecare082004.pdf
French:
http://www.who.int/hiv/pub/imai/imai_palliative_2008_fr.pdf
146
138. WHO's pain ladder (web page)

http://www.who.int/cancer/palliative/painladder/en/index.html
139. IMAI palliative care training course
140. Caregiver booklet: Symptom management and end of life care (draft)
http://www.who.int/hiv/pub/imai/patient_caregiver/en/index.html
141. Restoring hope: Decent care in the midst of HIV/AIDS
Available soon at the following web link:
http://www.palgrave.com/products/title.aspx?PID=323603
142. Guidelines for implementing collaborative TB and HIV programme activities
English: http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.319.pdf
Russian: http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.319_rus.pdf
143. Three I's Meeting: Intensified Case Finding (ICF), Isoniazid Preventive Therapy (IPT) and
TB Infection Control (IC) for people living with HIV
http://www.who.int/hiv/pub/meetingreports/WHO_3Is_meeting_report.pdf
144. Isoniazid preventive therapy (IPT) for people living with HIV
http://www.stoptb.org/wg/tb_hiv/assets/documents/IPT%20Consensus%20Statement%20
TB%20HIV%20Core%20Group.pdf
145. Guidelines for the prevention of tuberculosis in health care facilities in resource-limited
settings
English: http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269.pdf
English Addendum (Tuberculosis infection-control in the era of expanding HIV care and
treatment): http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269_ADD_eng.pdf
Russian: http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269_rus.pdf
146. Tuberculosis infection control in the era of expanding HIV care and treatment. Addendum
to the WHO Guidelines for the prevention of tuberculosis in health care facilities in resourcelimited settings
http://www.who.int/tb/publications/2006/tbhiv_infectioncontrol_addendum.pdf
147. The global plan to Stop TB 2006-2015
English: http://www.stoptb.org/assets/documents/global/plan/GlobalPlanFinal.pdf
French:
http://www.stoptb.org/assets/documents/global/plan/StopTB_GlobalPlan_FR_web.pdf
Spanish: http://www.stoptb.org/assets/documents/global/plan/GPII_SPversion%20finale.pdf
Arabic:
http://www.stoptb.org/assets/documents/global/plan/GPII_Arabic.pdf
148. Tuberculosis care with TB-HIV co-management: Integrated Management of Adolescent and
Adult Illness (IMAI)
Facilitator's guide: http://www.who.int/hiv/pub/imai/primary/tbhiv_comgt_fac.pdf
Participant's manual: http://www.who.int/hiv/pub/imai/primary/tbhiv_comgt_partman.pdf
Facilitator's guide: http://www.who.int/hiv/pub/imai/primary/tb_infec_control_fac.pdf
Participant's manual: http://www.who.int/hiv/pub/imai/primary/tb_infec_control_partman.pdf
147
150. Guidance for national tuberculosis programmes on the management of TB in children

151. TB/HIV: a clinical manual: 2nd edition
Russian: http://whqlibdoc.who.int/hq/1997/WHO_TB_96.200_rus.pdf
Portuguese:http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.329_por.pdf
152. CD4+ T-cell enumeration technologies: technical information (will be published in 2010)
153. Integrated health services: What and why?
http://www.who.int/healthsystems/service_delivery_techbrief1.pdf
154. WHO IMAI/IMCI/IMPAC tools (IMAI includes a series of tools that addresses the overall
health of the patient by supporting a shift from an exclusively acute care model to a chronic
care model that includes ART and prevention. IMAI also strengthens health systems by
providing tools for patient monitoring, referral and back-referral to district hospitals, clinical team
building, clinical mentoring and district planning.)
http://www.who.int/hiv/topics/capacity/
http://www.who.int/hiv/pub/imai/imai_publication_diagram.pdf
155. Interim policy on collaborative TB/HIV activities
English: http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.330_eng.pdf
French:
Spanish: http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.330_spa.pdf
Russian: http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.330_rus.pdf
156. Rapid assessment tool for sexual & reproductive health and HIV linkages: A generic guide
prepared and published by IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW and Young Positives
http://whqlibdoc.who.int/hq/2009/91825_eng.pdf
157. District health facilities: guidelines for development and operations
http://www.wpro.who.int/NR/rdonlyres/C0DAA210-7425-4382-A171-2C0F6F77153F/0/
DistHealth.pdf
158. Management of resources and support systems: Equipment, vehicles and buildings (WHO
web page)
http://www.who.int/management/resources/equipment/en/index1.html
159. WHO consultation on technical and operational recommendations for scale-up of
laboratory services and monitoring HIV antiretroviral therapy in resource-limited settings (Expert
meeting, Geneva, 2004)
http://www.who.int/hiv/pub/meetingreports/labmeetingreport.pdf
160. WHO policy on TB infection control in health care facilities, congregate settings and
households
161. Missing the target #5: Improving AIDS drug access and advancing health care for all
http://www.aidstreatmentaccess.org/itpc5th.pdf
148
162. Service delivery model on access to care and antiretroviral therapy for people living with
HIV/AIDS
http://www.ifrc.org/Docs/pubs/health/service-delivery-en.pdf
163. Strengthening management in low-income countries
http://www.who.int/management/general/overall/Strengthening%20Management%20in%20LowIncome%20Countries.pdf
164. The health manager's web site (WHO web site)
http://www.who.int/management/en/
165. Strengthening management capacity in the health sector (WHO web site)
http://www.who.int/management/strengthen/en/index.html
166. Standards for quality HIV care: a tool for quality assessment, improvement, and
accreditation
French:
http://www.who.int/entity/hiv/pub/prev_care/standardsquality_fr.pdf
167. Guidelines for organising national external quality assessment schemes for HIV serological testing
http://www.who.int/diagnostics_laboratory/quality/en/EQAS96.pdf
168. Guidelines for establishment of accreditation of health laboratories
http://www.searo.who.int/LinkFiles/Publications_SEA-HLM-394.pdf
169. A guide to monitoring and evaluation for collaborative TB/HIV activities
http://www.who.int/hiv/pub/tb/hiv_tb_monitoring_guide.pdf
170. Toolkit on monitoring health systems strengthening: Service delivery (2008 draft document)
http://www.who.int/healthinfo/statistics/toolkit_hss/EN_PDF_Toolkit_HSS_ServiceDelivery.pdf
171. Male circumcision quality assurance guide: A guide to enhancing the safety and quality of services
http://www.who.int/hiv/pub/malecircumcision/qa_guide/en/
172. Monitoring and evaluation of health systems strengthening: An operational framework
http://www.who.int/healthinfo/HSS_MandE_framework_Nov_2009.pdf
173. Tools for planning and developing human resources for HIV/AIDS and other health services
http://www.who.int/hrh/tools/tools_planning_hr_hiv-aids.pdf
174. Task shifting: Rational redistribution of tasks among health workforce teams: Global
recommendations and guidelines
http://www.who.int/healthsystems/TTR-TaskShifting.pdf
175. How IMAI (and IMCI) support national adaptation and implementation of task shifting (IMAIIMCI task-shifting implementation support brochure)
http://www.who.int/hiv/pub/imai/IMAI_IMCI_taskshifting_brochure.pdf
176. AIDS medicines and diagnostics service (WHO web site)
http://www.who.int/hiv/amds/
177. Essential medicines and pharmaceutical policies (WHO web site)
http://www.who.int/medicines/en/
149
178. Global price reporting mechanism (GPRM)

http://www.who.int/hiv/amds/gprm/en/index.html
179. A step-by-step algorithm for the procurement of controlled substances for drug
substitution treatment.
http://www.unodc.org/documents/hiv-aids/Step-by-Step%20procurement%20subs%20treat.pdf
180. Access to controlled medications programme: Framework
http://www.who.int/medicines/areas/quality_safety/Framework_ACMP_withcover.pdf
181. Global Fund Quality Assurance Policy for Pharmaceutical Products
http://www.theglobalfund.org/documents/psm/Annex1-%20
FullTextRevisedQualityAssurancePolicy_en.pdf
182. Procurement and supply management toolbox (web site)
http://www.psmtoolbox.org/
183. CCM grant oversight tool (web site)
http://www.theglobalfund.org/en/ccm/guidelines/#dashboard
184. GTZ-ILO-WHO consortium on social health protection in developing countries
http://www.socialhealthprotection.org/
185. Health financing policy (WHO web site)
http://www.who.int/health_financing/en/
186. WHO discussion paper: The practice of charging user fees at the point of service delivery
for HIV/AIDS treatment and care
http://www.who.int/hiv/pub/advocacy/promotingfreeaccess.pdf
187. HIV financing (WHO web site)
http://www.who.int/hiv/topics/systems/health_financing/en/
188. Global Fund HIV proposals costing tool (and user manual)
http://www.who.int/hiv/pub/toolkits/gfatm_costing_tool_user_manual_v1.1.pdf
189. The Global Fund country coordinating mechanisms (CCMs) web site
http://www.theglobalfund.org/en/ccm/
190. 'Three ones' key principles: Coordination of national responses to HIV/AIDS: Guiding
principles for national authorities and their partners
http://data.unaids.org/UNA-docs/Three-Ones_KeyPrinciples_en.pdf
191. WHOs global health sector strategy for HIV/AIDS 2003-2007
http://www.who.int/hiv/pub/advocacy/GHSS_E.pdf
194.The greater involvement of people living with HIV (GIPA): UNAIDS policy brief
http://data.unaids.org/pub/BriefingNote/2007/JC1299_Policy_Brief_GIPA.pdf
150
195. IMAI expert patient-trainer curriculum

196. WHOs stakeholder analysis tool
http://www.who.int/hac/techguidance/training/stakeholder%20analysis%20ppt.pdf
197. Scaling up effective partnerships: A guide to working with faith-based organisations in the
response to HIV and AIDS
http://www.e-alliance.ch/media/media-6695.pdf
198. Partnership work: the health servicecommunity interface for the prevention, care and
treatment of HIV/AIDS
http://www.who.int/hiv/pub/prev_care/en/37564_OMS_interieur.pdf
199. Working with civil society (UNAIDS web site)
http://www.unaids.org/en/Partnerships/Civil+society/default.asp
200. Universal access targets and civil society organizations: A briefing for civil society
organizations
http://www.unaids.org/unaids_resources/images/Partnerships/061126_CSTargetsetting_en.pdf
201. Reducing HIV stigma and discrimination: a critical part of national AIDS programmes
http://data.unaids.org/pub/Report/2008/jc1420-stigmadiscrimi_en.pdf
202.Integrating gender into HIV/AIDS programmes: A review paper
http://www.who.int/hiv/pub/prev_care/en/IntegratingGender.pdf
203. Gender, women and health: gender inequalities and HIV/AIDS (WHO web site)
http://www.who.int/gender/hiv_aids/en/
204. Integrating gender into HIV/AIDS programmes in the health sector: a tool to improve
responsiveness to women's needs
http://www.who.int/gender/documents/gender_hiv/en/index.html
205. Addressing violence against women and HIV testing and counselling: a meeting report
http://www.who.int/gender/documents/VCT_addressing_violence.pdf
206. Guidelines on protecting the confidentiality and security of HIV information: Proceedings
from a workshop, May 2006. Interim guidelines
http://data.unaids.org/pub/manual/2007/confidentiality_security_interim_
guidelines_15may2007_en.pdf
207. Guidelines for measuring national HIV prevalence in population-based surveys
http://www.who.int/hiv/pub/surveillance/guidelinesmeasuringpopulation.pdf
208. The pre-surveillance assessment: Guidelines for planning serosurveillance of HIV,
prevalence of sexually transmitted infections and the behavioural components of second
generation surveillance of HIV
http://www.who.int/hiv/pub/surveillance/psaguidelines.pdf
151
209. Guidelines for HIV surveillance among tuberculosis patients. Second edition
English: http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.339.pdf
French:
Spanish: http://whqlibdoc.who.int/hq/2004/OMS_HTM_TUB_2004.339_spa.pdf
210. Guidelines for effective use of data from HIV surveillance systems
English: http://www.who.int/hiv/strategic/surveillance/en/useofdata.pdf
Spanish: http://www.who.int/hiv/pub/surveillance/useofdata_sp.pdf
211. Guidelines for conducting HIV sentinel serosurveys among pregnant women and other groups
English: http://www.who.int/hiv/pub/surveillance/en/ancguidelines.pdf
French:
http://www.who.int/hiv/pub/epidemiology/en/guidelinesforconduction_fr.pdf
212. Estimating the size of populations at risk for HIV: Issues and methods
http://www.who.int/hiv/pub/surveillance/en/EstimatingSizePop.pdf
213. Guidelines for using HIV testing technologies in surveillance: selection, evaluation and
implementation
http://www.who.int/hiv/pub/surveillance/en/guidelinesforUsingHIVTestingTechs_E.pdf
214. HIV surveillance training modules, WHO Regional Office for South-East Asia
Module 1: Overview of the HIV epidemic with an introduction to public health surveillance
Module 2: HIV clinical staging and case reporting
Module 3: HIV serosurveillance
Module 4: Surveillance for sexually transmitted infections
Module 5: Surveillance of HIV risk behaviours
Module 6: Surveillance of populations at high risk for HIV transmission
Facilitator training guide for HIV surveillance
http://www.searo.who.int/LinkFiles/Publications_facilitator.pdf
215. National guide to monitoring and evaluating programmes for the prevention of HIV in
infants and young children
216. National AIDS programmes: A guide to indicators for monitoring and evaluating national
HIV/AIDS prevention programmes for young people
English: http://www.who.int/hiv/pub/epidemiology/napyoungpeople.pdf
French:
http://www.who.int/hiv/pub/me/napyoungpeople_fr.pdf
Spanish: http://www.who.int/hiv/pub/me/napyoungpeople_sp.pdf
Russian: http://www.who.int/hiv/pub/me/napyoungpeople_ru.pdf
152
217. National AIDS programmes: A guide to indicators for monitoring national

antiretroviral programmes
English: http://www.who.int/hiv/pub/me/naparv.pdf
French:
http://www.who.int/hiv/strategic/me/naparvfr.pdf
Spanish: http://www.who.int/hiv/pub/me/napart_sp.pdf
218. A guide to monitoring and evaluation for collaborative TB/HIV activities: Field test version
English: http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.342.pdf
220. Global framework for monitoring and reporting on the health sector's response towards
universal access to HIV/AIDS treatment, prevention, care and support
http:/ http://www.who.int/hiv/pub/me/framework/en/index.html
221. Monitoring the declaration of commitment on HIV/AIDS: Guidelines on construction
of core indicators
222. Patient monitoring guidelines for HIV care and antiretroviral therapy
http://www.who.int/hiv/pub/ptmonguidelines.pdf
Three Interlinked Patient Monitoring Systems for HIV care/ART, MCH/ PMTCT (including
malaria prevention during pregnancy), and TB/HIV: Standardized Minimum Data Set and
Illustrative Tools:
http://www.who.int/hiv/pub/imai/three_patient_monitor/en/
Training materials: http://www.who.int/hiv/topics/capacity/sharespace/en/index.html
223. HIV drug resistance (WHO web site)
http://www.who.int/hiv/drugresistance/
224. Pharmacovigilance for antiretrovirals in resource-poor countries
http://www.who.int/medicines/areas/quality_safety/safety_efficacy/PhV_for_antiretrovirals.pdf
225. Guide to operational research in programs supported by the Global Fund
http://www.who.int/hiv/pub/epidemiology/SIR_operational_research_brochure.pdf
226. Framework for operations and implementation research in health and disease control
programmes
227. HIV testing, treatment, and prevention: generic tools for operational research
http://www.who.int/hiv/pub/operational/generic/en/index.html
228. A guide to rapid assessment of human resources for health
http://www.who.int/hrh/tools/en/Rapid_Assessment_guide.pdf
153
229. Rapid assessment and response: Adaptation guide for work with especially vulnerable
young people (EVYP- RAR)
http://www.who.int/hiv/pub/prev_care/en/youngpeoplerar.pdf
230. HIV triangulation resource guide: Synthesis of results from multiple data sources for
evaluation and decision-making http://www.who.int/hiv/pub/surveillance/triangulation/en/
http://www.who.int/hiv/pub/idu/targetsetting/en/index.html
232. Setting national targets for moving towards universal access: operational guidance
http://data.unaids.org/pub/Guidelines/2006/20061006_report_universal_access_targets_
guidelines_en.pdf
233. Scaling up towards universal access: Considerations for countries to set their own national
targets for HIV prevention, treatment and care
http://data.unaids.org/pub/Report/2006/Considerations_for_target_setting_April2006.pdff
234. Routine data quality assessment tool (RDQA): Guidelines for implementation GFATM,
WHO and partners (Draft July 2008)
http://www.cpc.unc.edu/measure/tools/monitoring-evaluation-systems/data-quality-assurancetools/RDQA%20Guidelines-Draft%207.30.08.pdf
154
Annexes: Tables 79
Table 7. Example of health sector interventions by level of health system in low-level epidemic
Outreach to most-at-risk
populations (MARPs)
Increasing
knowledge
of HIV sero-status
Outreach HIV testing and

counselling
155 Priority Interventions - HIV/AIDS prevention,

treatment and care in the health sector
Community- and homebased delivery of interventions
Primary care: at health

centres or outpatient clinics (including district hospital) or private providers
CITC
CITC: at health facility

PITC:
Antenatal PITC
Family and partner testing
District hospital: second

level referral care; inpatient care
Regional or central hospital: specialist physicians, paediatricians
As in box to left, plus:

Blood donor HIV testing and
counselling
PITC for HIV-exposed infants
PITC before post-exposure
prophylaxis (PEP)
Resolve discordant results
Perform virological tests on dried

blood spot and send back results
populations (MARPs)
Prevention of HIV
transmission
HIV prevention outreach to MARPs

(e.g. sex workers, drug users,
men who have sex with men)
and vulnerable populations (e.g.
migrants, mobile populations)
including:
Peer-based information and
education
Provision and exchange of sterile
needles and syringes
Condom promotion and
programming, including 100%
condom promotion campaigns
Targeted STI and sexual and
reproductive health services,
particularly for vulnerable girls and
women
Referral to specific prevention
services

Community prevention literacy
Peer support for prevention for
people living with HIV
Pharmacy programmes for needle
and syringe access
Community family planning
If HIV-positive mothers in the
community:
Mother-to-mother support for
PMTCT
Infant feeding support, and
replacement feeding if AFASS

Prevent sexual transmission of HIV:
Condom promotion, provision to
prevent STIs in MARPs
Detect and manage STIs
Safer sex, risk reduction counselling
(as at hospital depending on people
living with HIV client population)
Special, friendly clinical services for
sex workers, men who have sex with
men
Prevent HIV infection through IDU
Comprehensive harm reduction
including:
Patient information, education
Sterile needle, syringe provision
Drug dependence treatment
(including opioid substitution
treatment)
Prevent infection in infants, young
children:
Family planning
ARV prophylaxis for PMTCT
Care, support for pregnant women
Infant feeding counselling and
support
Prevent transmission in healthcare
settings, including:
Infection control, standard
precautions
Safe injections
Safe medical waste management
Occupational health of health workers


Safe blood
Manage STI treatment failures

Prevention for people living with
HIV:
Discordant couples risk reduction
Counsel on continued possibility
of HIV transmission on ART
Condom promotion and provision
Counselling on sexual health,
return to sexuality and fertility,
reproductive choices
Counsel on substance use and
relationship to risky behaviour
Brief interventions for harmful or
hazardous alcohol use
PMTCT:
ART for eligible women; support
for complications on ART/AZT
prophylaxis
Safe blood
populations (MARPs)
HIV/AIDS
treatment
and care
Interventions delivered through

outreach to MARPs (in partnership
with other sectors)

Home-based care: Palliative care

Prevent illness:
Vaccination
Nutritional care and support
Education: safe water, hygiene,
sanitation
AFASS
AZT
ART
CITC
ARV
Antiretroviral
IDU
Injecting drug use
Second-line ART
ART:
Adherence preparation, support
Recommend or initiate first-line
regimens
Monitor, adjust dose
Clinical care, manage opportunistic
Clinical, CD4, limited laboratory
infections and comorbidities:
monitoring
Primary care for pneumonia, fever/
Support patient self-management
malaria, diarrhoea, malnutrition, other
Diagnose treatment failure (under
common conditions
supervision clinical mentor)
Mental health, psychosocial support
Manage serious complications of
Back up palliative care at home,
ART
symptom management
HIV care:
TB prevention, diagnosis, treatment: Assess and manage severe
Intensified TB casefinding
opportunistic infections
TB infection control
Inpatient care
Isoniazid preventive therapy
Manage severe malnutrition
Diagnose, start, follow TB treatment
TB-ART co-treatment plan
TB-HIV co-management
Integration of treatment support for

antiretroviral therapy, TB treatment
and prophylaxis in outreach services

Clinical mentor for district clinicians

Management of uncommon and
certain severe opportunistic
infections, ART toxicities, oncology
MARP
Most-at-risk-populations
PITC
PMTCT
Prevention of motherto-child transmission
STI
Sexually transmitted infections
Table 8. Example of health sector interventions by level of health system in concentrated epidemic
populations (MARPs)
Increasing
knowledge
of HIV serostatus

counselling to MARPs and bridge
populations; consider offering CITC
and including sites with rapid tests
Support for self-help and community
groups

Primary care: at health centres or outpatient clinics

(including district hospital) or
private providers

CITC closest to MARP settings
CITC at health centres
PITC:
Consider in health services targeting
MARPs and prison health care
Sexual and injecting partners of index
cases
Patients with TB, STIs, hepatitis B and C,
other blood-borne viruses
Patients in drug dependence settings
Bridge populations
Pregnant women
Infant testing and counselling
Prior to receiving post-exposure
prophylaxis (PEP)

counselling
Resolve discordant HIV test results
Regional or central
hospital: specialist
physicians, paediatricians
Perform virological tests on
dried blood spot and send
back results
populations (MARPs)
Prevention
of HIV transmission
HIV prevention outreach to MARPs

and bridge populations such as
mobile populations, migrants, border
populations:
Peer-mediated information and
education, and distribution of
prevention commodities
programming, including 100%
condom promotion campaigns
Provision of harm reduction
including exchange of needles and
syringes
Linkage/referral to prevention,
care and treatment sites friendly
and oriented to MARPs

Advocacy to reduce stigma,
discrimination and criminalization of
MARPs
Peer support for prevention with
MARPs
Support for self-help and community
groups
Counselling to reduce risky
behaviour
Community prevention literacy,
including STI prevention
Harm reduction, including needlesyringe programmes
PMTCT for women in MARPs

private providers
Prevention in people living with HIV with
emphasis on prevention in MARPs
Targeted STI management and sexual
and reproductive health services
Management of rape and sexual violence
including PEP
Prevent HIV infection through injecting drug
use comprehensive harm reduction including:
Drug dependence treatment (including
opioid substitution treatment)
Special and tolerant clinical services for sex
workers, MSM including mobile services to
attend MARP sites
HIV prevention among youth:
Special attention to young MARPs
Tolerant, adolescent-friendly services
Ensure access to reproductive health,
family planning
Prevent infection in infants, young
children
Family planning
ART or ARV prophylaxis
Treatment, care, support for pregnant women
Infant feeding counselling and support
Prevent transmission in health care
settings, including:
Infection control, standard precautions
Safe injections
Occupational health of health workers;


Resolve discordant HIV test
results
PMTCT for complicated cases
Safe blood
Regional or central
HIV treatment and

care (including
prevention
of illness in
people living
with HIV)
populations (MARPs)

private providers
Integration of care and support in

outreach services
Self-help and community support

groups
At prevention, care and treatment sites

friendly and oriented to MARPs
Use prevention outreach as entry

point to HIV treatment and care
services
Home-based:
Care-seeking support
Social support
Nutritional support
Counselling of people living with HIV on

adherence, ART, opportunistic infections
prevention and treatment
Palliative care:
Symptom management and endof-life care in home by caregivers
Patient self-management
Opportunistic infections prevention and

treatment
Referral to prevention, care and

treatment sites friendly and oriented
to MARPs
ART
Management of hepatitis and other

coinfections

Regional or central
Management of complicated HIV

cases
Clinical mentor for previous

level
ART including toxicities and

treatment failure
Referral for uncommon and

certain severe opportunistic
infections, ART toxicities,
oncology
If resources available: manage

severe comorbidities including
oncology and opportunistic
infections
Supervise ART prescription at

Management of non-infectious comorbidities previous level of care
Patient monitoring (including lab follow up): Inpatient care
Psychological support
Immunization
Opioid substitution treatment
TB prevention, diagnosis, treatment

Intensified TB casefinding
Diagnose, start, follow TB treatment with
focus on MARPs
AFASS
ART
ARV
AZT

Antiretroviral

CITC
IDU
MARP
MSM

Injecting drug use
Most-at-risk populations
Men who have sex with men
PEP
PITC
PMTCT
STI
Prevention of mothe- to-child transmission
Table 9. Example of health sector interventions by level of health system in generalized epidemic with high prevalence
Increasing
knowledge of
HIV serostatus
Outreach to most-atrisk populations and

vulnerable groups

vulnerable groups
Primary care: at health centre or outpatient clinics of district hospital or private providers

counselling to most-at-risk
populations
CITC
CITC at health centre
PITC:
Home-based testing and
counselling for family/partners
of index case
National and local campaigns
(Know Your Status)
PITC:
All patients in all health facilities
Infant testing and counselling
Send dried blood spot for virological testing
Family and partner testing
Prior to receiving post-exposure prophylaxis

Second level care at

district hospital; inpatient care
counselling
Resolve discordant HIV test
results
Tertiary care
at regional or
central hospital/specialist
physicians,
paediatricians
Perform virological
tests on dried
blood spot and
send back results
Prevention of HIV
transmission

vulnerable groups

vulnerable groups
HIV prevention outreach to

sex workers, drug users,
men who have sex with men,
young people and mobile
populations, including:
Peer information and
education, and distribution of
prevention commodities
provision, including
support for 100% condom
programming
Provision and exchange of
sterile needles and syringes
Targeted STI and sexual and
reproductive health services,
particularly for vulnerable
girls and women
Referral to specific
prevention services
Community prevention literacy

Support condom programming
Home-based:
Risk reduction support for
discordant couples
Peer support for prevention
with people living with HIV
Community family planning
Mother-to-mother support for
PMTCT
Assure delivery ART/ ARV
prophylaxis during home
delivery
Infant feeding support
Prevent sexual transmission of HIV
Condom promotion, provision
Detect and manage STI
Safer sex, risk reduction counselling with emphasis prevention with
people living with HIV
Discordant couples risk reduction
Continued possibility of HIV transmission on ART
Counsel on sexual health, return to sexuality and fertility on ART,
reproductive choices
Counsel on substance use and risky behaviour
Brief interventions on harmful or hazardous alcohol use
Male circumcisionin some sites or counselling, wound care
HIV prevention among youth:
Tolerant, adolescent-friendly servicesacute and chronic HIV care
Ensure access to reproductive health, family planning
Special, friendly clinical services for sex workers and men who have
sex with men
Management of rape, sexual violence including post-exposure
prophylaxis
Prevent HIV infection through IDU: comprehensive harm
reduction including:
Drug dependence treatment (including opioid substitution treatment)
Prevent infection in infants, young children:
Family planning
ART or ARV prophylaxis
Treatment, care, support for pregnant women
Infant feeding counselling and support


Male circumcision in high HIV
prevalence settings
PMTCT: support for complications
on ART/AZT prophylaxis
Safe blood
Tertiary care
at regional or
physicians,
paediatricians

vulnerable groups

vulnerable groups
Prevention of HIV
transmission
continued...

Prevent transmission in health-care settings, including:
Infection control, standard precautions
Safe injections
Occupational health of health workers; special focus on care and
treatment for health workers
Post-exposure prophylaxisall sites

Tertiary care
at regional or
physicians,
paediatricians
HIV/AIDS
treatment
and care

vulnerable groups

vulnerable groups
Interventions delivered
through outreach to mostat-risk populations (in
partnership with other
sectors)
Integration of treatment
support for antiretroviral
therapy, TB treatment and
prophylaxis in outreach
services
Treatment preparedness for

both HIV and TB
Patient self-management
Peer support groups
Home-based:
Treatment supportART, TB
treatment, and prophylaxis
Drug refill delivery
Management diarrhoea, fever
Careseeking support
Psychosocial support
Nutritional support
Water treatment and safe
storage
Hygiene
Insecticide-treated nets
Palliative care: pain and other
symptom management and
end-of-life care
First-line ART:
Adherence preparation, support
Recommend or initiate first-line treatment
Monitor, adjust dose
Clinical, CD4, limited lab; patient monitoring systems for HIV care/
ART, TB-HIV, MCH-PMTCT
Support patient self-management
Prevent illness:
Vaccination
Nutritional care and support
Education: safe water, hygiene, sanitation
Prevent malaria
Clinical care / manage opportunistic infections and
comorbidities:
Primary care for pneumonia, fever/malaria, diarrhoea, malnutrition,
other common conditions
Mental health, psychosocial support
Back up palliative care at home, symptom management

Tertiary care
at regional or
physicians,
paediatricians
Clinical mentor for

district clinicians:
ART:
Reviews cases
Initiate ART in complicated
of suspected
patients;
treatment failure
Oversee initiation of first-line
Makes
decision
ART in uncomplicated patients by
on
switching
to
primary care team
second-line ART
Diagnose treatment failure
Management of
Second-line ART (under
uncommon and
supervision clinical mentor)
certain severe
Manage serious complications
opportunistic
of ART
infections, ART
Assess and manage severe
toxicities, oncology
opportunistic infections
Inpatient care
Manage severe malnutrition
TB-ART co-treatment plan
TB prevention, diagnosis, treatment:

Intensified casefinding TB
Diagnose, start, follow TB treatment including, if referral difficult,
suspected smear-negative TB
AFASS
ART
ARV

Antiretroviral

AZT
CITC
IDU
Injecting drug use
MARP
PITC
PMTCT
STI
Most-at-risk populations
Prevention of mother-to-child transmission
Priority Interventions
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WHO Library Cataloguing-in-Publication Data

ISBN 978 92 4 150023 4

(NLM classification: WC 503.6)

World Health Organization 2010

Chapter 1: The health sector response to HIV/AIDS

Chapter 2: Priority interventions for HIV/AIDS prevention, treatment and

2.2.3 Blood donor HIV testing and counselling . . . . . . . . . . . . . . . . . . . . . . . . . 24

2.3 Maximizing the health sectors response to HIV prevention .. . .. . .. . .. . .. . .. . .. . .. . .. . 29

2.3.1.2 Detecting and managing sexually transmitted infections. . . . . . . . . . 31

2.3.1.4 Male circumcision. .

2.3.1.5 Prevention among people living with HIV . . . . . . . . . . . . . . . 36

2.3.1.7.1 Displaced, mobile and migrant populations .

2.3.1.8 Non-occupational post-exposure prophylaxis. . . . . . . . . . . . . . 44

2.3.2 Interventions for injecting drug users. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2.3.3 Treatment and prevention of HIV in pregnant women, infants

2.3.4 Prevention of HIV transmission in health settings. . . . . . . . . . . . . . . . . . . . . 57

2.3.4.3 Occupational health of healthcare workers . . . . . . . . . . . . . . 60

2.3.4.5 Blood safety. . . . . . . . . . . . . . . . . . . . . . . . 62

2.4 Scaling up HIV/AIDS treatment and care... . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 63

2.4.2 Treatment and care interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

2.4.2.1.2 Patient monitoring.

2.4.2.2 Managing HIV-associated opportunistic infections and comorbidities . . . . . . 76

2.4.2.2.4 Managing malnutrition.

2.4.2.2.5 Treating viral hepatitis.

2.4.2.2.6 Managing malaria.

2.4.2.2.7 Preventing and treating mental health disorders .

2.4.2.3 Palliative care . . . . . . . . . . . . . . . . . . . . . . . 84

2.4.3 Laboratory services for HIV monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Chapter 3: Operationalizing the priority interventions strengthening health

3.2.4.2 Ensuring the technical quality of services. . . . . . . . . . . . . . . 99

3.6.1 Coalition building and partnerships. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

3.6.2 Addressing stigma and discrimination. . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Chapter 4: Investing in strategic information

Acceptable, feasible, affordable, sustainable and safe

Acid fast bacilli

Bacille Calmette-Guerine (vaccine)

Body mass index

Country Coordinating Mechanism

Client-initiated testing and counselling

Cotrimoxazole prophylactic treatment

Dried blood spot

Directly observed treatment, short course; refers to the internationally

EIA/ELISAs Enzyme immunoassays

Human immunodeficiency virus

HIV drug resistance

Injecting drug users/use

Integrated management of adult and adolescent illness

Integrated management of pregnancy and childbirth

Lopinavir with a booster dose of ritonavir

Monitoring and evaluation

Men who have sex with men

Nucleic acid testing

Non-nucleoside reverse transcriptase inhibitor

Nucleoside reverse transcriptase inhibitor

Needle and syringe programmes

Opioid substitution therapy

Provider-initiated testing and counselling