WHO publishes new guidelines on HIV, hepatitis and STIs for key populations (2) Lack of impact of behavioural interventions (2)

4 August, 2022

Dear HIFA colleagues,

In my previous message a few minutes ago, I said: 'The full text of the guideline says little more on this [behavioural interventions]'. Correction: This should read: 'The full text of the policy brief says little more on this'. The full Guideline is available here: https://www.who.int/publications/i/item/9789240052390

Below are extracts and a further comment from me:


Evidence and decision-making for new recommendations Behavioural interventions

Background and rationale

Behavioural interventions are widely used in programmes which aim to reduce transmission of HIV, STI and viral hepatitis. There are a range of different behavioural interventions, including those that focus on providing information and education and those that take a counselling approach, but all aim to increase health-seeking behaviours and/or reduce behaviours that increase risk of HIV, STIs and viral hepatitis, including needle and syringe sharing and unprotected sex...

A systematic review was commissioned by WHO to update existing recommendations, to answer the PICO question of whether counselling behavioural interventions reduces risk behaviours associated with transmission or acquisition of HIV, STIs and viral hepatitis. The primary outcomes were HBV, HCV, HIV or STI incidence and the secondary outcomes were unprotected sex (for example, condomless sex, sex without lubricant, sex without PrEP), needle and syringe sharing. A systematic review of published articles from 1 January 2010 to 1 March 2021 identified nine eligible randomized control trials (see Web Annex C). Five studies were among adult key populations and two studies were among young men who have sex with men (16–25 years old) (336) and young females (13–17 years old) released from juvenile detention (337). Together these indicated that counselling behavioural interventions probably make little to no difference on HIV (336, 338–343), viral hepatitis (341) or STI (337–340, 342–344) incidence in key populations. This was also true for unprotected sex (336–342) and needle and syringe sharing (340, 341). There was moderate certainty in the lack of effect across outcomes...

Given that a systematic review did not find any effect of counselling behavioural interventions on the incidence of HIV, viral hepatitis or STI, the choice to include counselling behavioural interventions in standard and minimum packages of interventions for key populations should be made with an understanding of the potential limitations on incidence outcomes...

While further research to measure the impact of counselling behavioural interventions on HIV, STIs and viral hepatitis is not required, future research may allow us to better understand the effect of different aspects of counselling interventions on building client and provider relationships, psychosocial improvements and mental health...


COMMENT (NPW): 'further research... is not required' is quite emphatic and it would be interesting to understand the basis for this statement. Can anyone comment on the level of cumulative evidence that is necessary to come to this conclusion?

Best wishes, Neil

Neil Pakenham-Walsh, Global Coordinator HIFA, www.hifa.org neil@hifa.org

Working in official relations with WHO