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AbstractIntroduction: Key populations (KPs) are disproportionally affected by HIV and have low rates of access to HIV testing and treatment services compared to the broader population. WHO promotes the use of differentiated approaches for reaching and recruiting KP into the HIV services continuum. These approaches may help increase access to KPs who are often criminalized or stigmatized. By catering to the specific needs of each KP individual, differentiated approaches may increase service acceptability, quality and coverage, reduce costs and support KP members in leading the HIV response among their communities.Discussion: WHO recommends the implementation of community‐based and lay provider administered HIV testing services. Together, these approaches reduce barriers and costs associated with other testing strategies, allow greater ownership in HIV programmes for KP members and reach more people than do facility‐based services. Despite this evidence availability and support for them is limited.Peer‐driven interventions have been shown to be effective in engaging, recruiting and supporting clients. Some programmes employ HIV‐positive or non‐PLHIV "peer navigators" and other staff to provide case management, enrolment and/or re‐enrolment in care and treatment services. However, a better understanding of the impact, cost effectiveness and potential burden on peer volunteers is required.Task shifting and non‐facility‐based service locations for antiretroviral therapy (ART) initiation and maintenance and antiretroviral (ARV) distribution are recommended in both the consolidated HIV treatment and KP guidelines of WHO. These approaches are accepted in generalized epidemics and for the general population where successful models exist; however, few organizations provide or initiate ART at KP community‐based services.Conclusions: The application of a differentiated service approach for KP could increase the number of people who know their status and receive effective and sustained prevention and treatment for HIV. However, while community‐based and lay provider testing are effective and affordable, they are not implemented to scale. Furthermore regulatory barriers to legitimizing lay and peer providers as part of healthcare delivery systems need to be overcome in many settings. WHO recommendations on task shifting and decentralization of ART treatment and care are often not applied to KP settings.

AbstractIntroductionThe World Health Organization (WHO) is guided by its global programme of work and the goal that a billion more people have universal health coverage (UHC). To achieve UHC, access for those most vulnerable must be guaranteed and prioritized. WHO is committed to developing evidence‐based guidance to work towards UHC for trans and gender diverse (TGD) people. This commentary describes WHO's work related to TGD people over the last decade.DiscussionIn 2011, WHO developed guidelines for the prevention and treatment of HIV and sexually transmitted infections (STIs) in men who have sex with men and TGD people. In 2013, the "HIV civil society reference group" called on WHO to provide specific guidance for TGD people. Values and preferences of TGD people were considered by WHO for the first time, which informed the development of the 2014 WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations. The 2014 Guidelines included a comprehensive package of HIV‐related health and enabling interventions with specific considerations for TGD people, as well as a specific policy brief in 2015. Regional WHO offices developed and/or supported the development of blueprints on transgender health and HIV in 2014 and 2016. A 2015 WHO report on sexual health, human rights and the law elucidated the harmful impacts of discriminatory laws on the basis of sexual orientation and gender identity. In 2019, the 11th edition of the international classification of diseases saw the removal of "transsexualism" as a mental and behavioural disorder. WHO's first guideline on self‐care interventions, updated in 2021, included key considerations concerning TGD people. In 2022, WHO's updated key populations guidelines include a prioritized package of not just HIV, but also viral hepatitis and STI health interventions for TGD people. Still, a broader and more specific health approach and a greater focus on social issues are needed to better serve the health needs of TGD people.ConclusionsWHO's understanding and commitment to TGD people's health has evolved and improved over the past decade. Together with professional and community trans health organizations, WHO should now start developing evidence‐informed global guidance on TGD health as part of its remit to support UHC to all.

AbstractIntroductionWHO's 2019 report on HIV drug resistance (HIVDR) documents a high prevalence of pretreatment drug resistance (PDR) among populations initiating first‐line antiretroviral therapy (ART) in low‐ and middle‐income countries (LMIC). However, systematic evidence on the prevalence of PDR among key populations remains limited. We performed a systematic review to characterize levels of PDR in key population groups and compared them to levels of PDR in the "general population" across different geographical regions.MethodsTen electronic databases were searched for papers published until February 2019 that included predefined search terms. We included studies that reported the number of successfully tested genotypes and the number of genotypes with drug resistance mutations among antiretroviral therapy treatment naïve people, recently infected people, or people initiating first‐line ART from key populations. To assess the prevalence of PDR for each key population, we pooled estimates using random‐effects meta‐analysis of proportions. Where possible, we computed the differences in the odds of PDR (any, and by drug class) present in each key population compared to the "general population". The I2 statistic (a measure of heterogeneity between studies) is reported.Results and discussionA total of 332 datasets (from 218 studies) and 63,111 people with successful HIVDR genotyping were included in the analysis. The pooled prevalence estimate of any PDR was high among men who have sex with men (13.0%, 95% CI 11.0 to 14.0%, I2 = 93.19), sex workers (17.0%, 95% CI 6.0 – 32.0, I2 = 87.31%) and people in prisons (18.0%, 95% CI 11.0 to 25.0, I2 = 70.18%), but less so among people who inject drugs (7.0%, 95% CI 5.0 to 10.0, I2 = 90.23). Overall, men who have sex with men were more likely to carry any PDR compared to the "general population," a finding which was statistically significant (odds ratio (OR) 1.28, 95% CI 1.13 – 1.46, I2 48.9%).ConclusionsHigh prevalence of PDR found in key populations highlights the need to increase access to effective first‐line HIV treatment. The low prevalence of nucleotide reverse transcriptase inhibitor (NRTI) PDR suggests that current WHO recommendations for pre‐exposure prophylaxis (PrEP) regimens will remain effective and can be scaled up to prevent new HIV infections in high‐risk groups.

AbstractIntroductionKey populations (sex workers, men who have sex with men, people who inject drugs, people in prisons and other closed settings, and trans and gender diverse individuals) are disproportionately affected by HIV, sexually transmitted infections (STIs) and viral hepatitis (VH). Counselling behavioural interventions are widely used, but their impact on HIV/STI/VH acquisition is unclear.MethodsTo inform World Health Organization guidelines, we conducted a systematic review and meta‐analysis of effectiveness, values and preferences, and cost studies about counselling behavioural interventions with key populations. We searched CINAHL, PsycINFO, PubMed and EMBASE for studies published between January 2010 and December 2022; screened abstracts; and extracted data in duplicate. The effectiveness review included randomized controlled trials (RCTs) with HIV/STI/VH incidence outcomes; secondary review outcomes of unprotected sex, needle/syringe sharing and mortality were captured if studies also included primary review outcomes. We assessed the risk of bias using the Cochrane Collaboration tool, generated pooled risk ratios through random effects meta‐analysis and summarized findings in GRADE evidence profiles. Values and preferences and cost data were summarized descriptively.ResultsWe identified nine effectiveness, two values and preferences, and two cost articles. Meta‐analysis of six RCTs showed no statistically significant effect of counselling behavioural interventions on HIV incidence (1280 participants; combined risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.41–1.20) or STI incidence (3783 participants; RR: 0.99; 95% CI: 0.74–1.31). One RCT with 139 participants showed possible effects on hepatitis C virus incidence. There was no effect on secondary review outcomes of unprotected (condomless) sex (seven RCTs; 1811 participants; RR: 0.82, 95% CI: 0.66–1.02) and needle/syringe sharing (two RCTs; 564 participants; RR 0.72; 95% CI: 0.32–1.63). There was moderate certainty in the lack of effect across outcomes. Two values and preferences studies found that participants liked specific counselling behavioural interventions. Two cost studies found reasonable intervention costs.DiscussionEvidence was limited and mostly on HIV, but showed no effect of counselling behavioural interventions on HIV/VH/STI incidence among key populations.ConclusionsWhile there may be other benefits, the choice to provide counselling behavioural interventions for key populations should be made with an understanding of the potential limitations on incidence outcomes.

Transgender (trans) activists and global health partners have collaborated to develop new tools and guidance for assessing and addressing HIV and other health needs within trans populations. Trans women experience a heavy burden of HIV and other sexually transmitted infections (STIs), high incidence of violence and difficulties accessing gender‐affirming services. At the same time, little has been published on trans men's health, HIV issues, needs and experiences. Young trans people are especially marginalized and vulnerable, with few programmes and services specifically tailored to their needs. Trans‐specific data and guidance are needed to adapt the global response to HIV to meet the needs of the trans population. While the needs of this group have only recently received attention, global, regional and other technical guidance documents are being developed to address these gaps. Regional blueprints for comprehensive care for trans people in Latin America, the Caribbean, and Asia and the Pacific are now available. These tools – supported by the Pan American Health Organization, World Health Organization, US President's Emergency Plan for AIDS Relief and the United Nations Development Programme, in collaboration with regional trans groups – provide a contextual map, indicating opportunities for interventions in health, HIV, violence, stigma and discrimination, social protection and human rights. Global guidance includes the World Health Organization's Policy Brief: Transgender People and HIV, and the interagency publication, Implementing Comprehensive HIV and STI Programmes with Transgender People. Community empowerment and capacity building are the focus of the new tools for global and regional transgender guidance. The goal is to strengthen and ensure community‐led responses to the HIV challenge in trans populations. This article describes the new tools and guidance and considers the steps needed to use them to appropriately support and engage transgender populations within national AIDS, STI, and sexual and reproductive health responses and programmes. The time to use these tools and guidance for advocacy, strategic planning, capacity building, programme design and training is now.

IntroductionThe remarkable expansion in availability of antiretroviral therapy (ART) over the past two decades has transformed HIV infection into a manageable chronic condition. People with HIV infection now live long and healthy lives on treatment that is simpler, safer and cheaper. According to UNAIDS estimates, the global coverage of ART reached 46% in 2015, resulting in a 26% decrease in annual HIV‐related deaths since 2010. Such success has positioned treatment access at the centre of the global HIV response as a way to prevent mortality, morbidity and HIV transmission through a "Treat All" approach. Continuing expansion of treatment is needed to further reduce HIV‐related mortality. This progress with treatment, however, masks a stagnation in the estimated annual number of new HIV infections. Continuing levels of HIV incidence despite treatment scale‐up stem from several factors, which should be addressed in order to prevent new infections and decrease the numbers of people requiring treatment in the future.DiscussionART can only reach those already diagnosed, and although it is unclear what proportion of new infections occur during acute and early infection prior to treatment initiation, phylogenetic studies suggest that it might be substantial. Thus, better testing approaches to reach the 40% of people with undiagnosed HIV infection as early as possible are critical. New approaches to reach men, young people and key populations, where HIV risk is highest and HIV prevention, testing and treatment coverage is lowest, are also needed. Overall coverage of effective prevention interventions remains low, enabling HIV transmission to occur, or time is required to show population‐level effects. For example, the full impact of the medical male circumcision intervention will be seen once a larger proportion of men in age cohorts with high incidence are circumcised. Finally, strategically focused pre‐exposure prophylaxis interventions have the potential to prevent HIV acquisition among populations at substantial risk, averting treatment costs in coming years.ConclusionsThe United Nations (UN) targets to end AIDS include the "90‐90‐90" targets for HIV diagnosis, treatment and viral suppression. While 90‐90‐90 has been widely emphasized and adopted by countries and international funders, the focus thus far has largely been on increasing access to ART – the second "90." A similar emphasis on achieving UN HIV prevention targets and adequate funding for meeting these is essential, alongside treatment, in order to reduce population‐level incidence and change the trajectory of the HIV epidemic over the long term.

<i>Aim:</i> The study investigates patterns of cocaine powder and crack cocaine use of different groups in nine European cities. <i>Design, Setting, Participants:</i> Multi-centre cross-sectional study conducted in Barcelona, Budapest, Dublin, Hamburg, London, Paris, Rome, Vienna, and Zurich. Data were collected by structured face-to-face interviews. The sample comprises 1,855 cocaine users out of three subgroups: 632 cocaine users in addiction treatment, mainly maintenance treatment; 615 socially marginalized cocaine users not in treatment, and 608 socially integrated cocaine users not in treatment. <i>Measurements:</i> Use of cocaine powder, crack cocaine and other substances in the last 30 days, routes of administration, and lifetime use of cocaine powder and crack cocaine. <i>Findings:</i> The marginalized group showed the highest intensity of cocaine use, the highest intensity of heroin use and of multiple substance use. 95% of the integrated group snorted cocaine powder, while in the two other groups, injecting was quite prevalent, but with huge differences between the cities. 96% of all participants had used at least one other substance in addition to cocaine in the last 30 days. <i>Conclusions:</i> The use of cocaine powder and crack cocaine varies widely between different groups and between cities. Nonetheless, multiple substance use is the predominating pattern of cocaine use, and the different routes of administration have to be taken into account.

An increase in the use of cocaine and crack in several parts of Europe has raised the question whether this trend is similar to that of the USA in the 1980s. However, research in the field of cocaine use in Europe has been only sporadic. Therefore, a European multi-centre and multi-modal project was designed to study specific aspects of cocaine and crack use in Europe, in order to develop guidelines for public health strategies. Data on prevalence rates were analysed for the general population and for specific subgroups. Despite large differences between countries in the prevalence of cocaine use in the general population, most countries show an increase in the last few years. The highest rate with a lifetime prevalence of 5.2% was found for the United Kingdom, although with a plateau effect around the year 2000. With regard to specific subgroups, three groups seem to show a higher prevalence than the general population: (1) youth, especially in the party scene; (2) socially marginalized groups, such as homeless and prostitutes or those found in open drug scenes; (3) opiate-dependent patients in maintenance treatment who additionally use cocaine. Specific strategies need to be developed to address problematic cocaine use in these subgroups.