Global strategies and plans of action that are scheduled to expire within one year: the global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections, for the period 2016–2021: report by the Director-General

EXECUTIVE BOARD EB148/37 148th session 4 January 2021 Provisional agenda item 19.3 Global strategies and plans of action that are scheduled to expire within one year The global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections, for the period 2016–2021 Report by the Director-General 1. Following a broad consultation process in 2015, the Sixty-ninth World Health Assembly, held in May 2016, adopted three interlinked global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections, for the period 2016–2021 (resolution WHA69.22). An update on progress was submitted to the Seventy-first World Health Assembly in May 2018 (document A71/41 Rev.2) and in a progress report on HIV, viral hepatitis and sexually transmitted infections published in 2019.1 Progress achieved in implementing the strategies will be presented to the Seventy-fourth World Health Assembly in 2021. 2. Following adoption of the resolution in 2016, regional committees responded proactively by endorsing, adapting and promoting the strategies, including through the development of regional action plans, and they have been widely referenced at country level in national strategies, frameworks and applications for funding support. 3. In 2020, in decision WHA73(15), the Health Assembly requested that the Director-General systematically include as substantive items on the agenda of meetings of the WHO governing bodies any global strategies or action plans that are scheduled to expire within one year in order to allow Member States to consider whether the strategies or action plans have fulfilled their mandates, should be extended and/or need to be adjusted. This report responds to that request. Progress achieved between 2016 and 2021 4. The strategies are organized around a common structure and framework, as illustrated in Fig. Each of the strategies aims to end one of the three epidemics as a public health threat by 2030. However, despite considerable progress in key areas of prevention, testing, treatment and care, critical interim 2020 targets across the strategies will not be reached. 1 Progress report on HIV, viral hepatitis and sexually transmitted infections, 2019: accountability for the global health sector strategies, 2016–2021. Geneva: World Health Organization; 2019 (https://www.who.int/hiv/strategy2016- 2021/progress-report-2019/en/, accessed 3 November 2020). EB148/37 2 Fig. The five strategic directions common to the three global health sector strategies 5. The global health sector strategies promote synergies, linkages and integration across the diseases and with other programmatic and functional areas of health. Since 2016, integration and linkages have been strengthened with tuberculosis; sexual and reproductive health, and cervical cancer; mental health and other noncommunicable diseases; vaccines and innovations, including the development of broadly neutralizing antibodies against HIV as therapeutics and prevention tools; and antimicrobial resistance. 6. Key achievements include: validation of the elimination of mother-to-child transmission of HIV and/or syphilis in 13 countries or territories1 and adoption of a regional framework for the triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis in Asia and the Pacific 2018–2030;2 publication of consolidated guidelines on new HIV treatment, care and service delivery, hepatitis C, syphilis, Chlamydia trachomatis infection, genital herpes and gonorrhoea; the use of a dual HIV/syphilis rapid diagnostic test in antenatal services; and updating of the WHO Model List of Essential Medicines to include new treatments for sexually transmitted infections, the first combination 1 Armenia, for HIV only (2016); Republic of Moldova, for syphilis only (2016); dual elimination in Belarus and Thailand (2016), Anguilla, Antigua and Barbuda, Bermuda, Cayman Islands, Montserrat, and Saint Kitts and Nevis (2017), Malaysia (2018), and Maldives and Sri Lanka (2019). 2 See resolution WPR/RC68.R2 (2017). EB148/37 3 therapy effective against all six genotypes of hepatitis C virus, and antiretroviral drugs for children and for use as pre-exposure prophylaxis to prevent HIV infection. 7. Under the strategies’ framework, key partnerships have been strengthened, resulting in: the signing of a memorandum of understanding between WHO and the Global Fund to Fight AIDS, Tuberculosis and Malaria to improve the country impact of the Fund’s investments; the signing of a memorandum of understanding between WHO and UNODC that commits to joint action on HIV, viral hepatitis and tuberculosis among people who use drugs; co-signature of a joint United Nations statement on ending discrimination in health care settings; joint advocacy with the World Hepatitis Alliance to drive action to tackle viral hepatitis; and a funding agreement with Unitaid to promote research and innovation in HIV and hepatitis C prevention, diagnosis and treatment. Strengthened intersectoral collaboration on tackling the diseases has also been fostered in the context of the UNAIDS Joint Programme, by ensuring links with and contributions to a number of WHO-led intersectoral initiatives, including the Universal Health Coverage 2030 Partnership, the global action plan for healthy lives and well-being for all, and more recently, multisectoral efforts focused on the COVID-19 pandemic and its impact. WHO is also actively supporting post-2021 strategy development processes led by UNAIDS and the Global Fund. 8. HIV. The global health sector strategy on HIV is aligned with the goals and targets of the UNAIDS 2016–2021 strategy: on the fast track to end AIDS. Since 2016, treatment scale-up has continued rapidly, with 25.4 million people receiving treatment in 2019, compared with 18.2 million in 2016. Progress has been guided by new WHO policies and guidelines, including those on: treatment for all and rapid initiation of antiretroviral drugs; the use of optimized antiretroviral drugs and formulations for treatment and prevention; differentiated models of service delivery for person-centred care, patient monitoring and case surveillance; HIV-related drug resistance; key populations; HIV self-testing and partner notification; managing advanced HIV disease; and the sexual and reproductive health and rights of women living with HIV, with implementation of this guidance supported in collaboration with an official WHO advisory group of women living with HIV convened in 2019.1 9. Monitoring the uptake and implementation of WHO HIV guidance is now routine, and has demonstrated the impact of such guidance in countries: by June 2020, 96% of 137 low- and middle-income countries were following HIV “treat all” guidance, 72% had fully implemented routine viral load testing, 78% had included dolutegravir in first-line antiretroviral therapy combinations and 63% had either implemented or were developing a policy on HIV self-testing. 10. While AIDS-related mortality has declined, there were still an unacceptable 690 000 AIDS-related deaths in 2019 (compared to 1 million in 2016). Moreover, HIV prevention is facing a crisis, with little progress being made in controlling new infections: there were 1.7 million new infections in 2019 compared to 1.8 million in 2016. In 2019 the proportion of new adult HIV infections among key populations and their sexual partners was 62% globally, reaching 99% in several regions. While there are some encouraging developments in HIV prevention, including through the provision of 20 million voluntary medical male circumcisions in eastern and southern Africa, and the expansion and increased uptake of pre-exposure prophylaxis among groups with high levels of incidence, structural and political barriers still inhibit the roll-out of proven interventions to key populations. 1 WHO Advisory Group of Women Living with HIV to Meet in Geneva. Geneva: World Health Organization; 4 October 2019 (https://www.who.int/hiv/mediacentre/news/who-group-women-living-with-hiv-meeting/en/, accessed 3 November 2020). EB148/37 4 11. Viral hepatitis. The 2020 and 2030 targets and goals include targets for hepatitis B infant and birth-dose vaccination, blood and injection safety, harm-reduction measures among people who inject drugs, and testing and treatment coverage. Since publication of the first global hepatitis report in 2017,1 progress has been supported by WHO’s normative work, including the publication of guidelines on care and treatment of hepatitis C, on care and treatment of hepatitis B infection, on viral hepatitis testing, and on surveillance for viral hepatitis. By June 2020, 93 countries reported that they had viral hepatitis plans in place, compared with only 17 in 2012. 12. The number of people starting hepatitis C treatment, predominantly with the new curative direct-acting antiviral medicines, increased from 1.1 million in 2015 to an estimated total of 5 million treated today. This was supported by a substantial price reduction through generic drug competition, with costs declining for the most common regimen (sofosbuvir/daclatasvir) in low- and middle-income countries to less than US$ 200 between 2014 and 2017 and less than US$ 50 in some countries. 13. For chronic hepatitis B infection, where fewer than 20% of those infected are estimated to require treatment over their lifetime, the number of people on lifelong treatment worldwide increased from 1.7 million in 2015 to 4.5 million people in 2017, representing an increase in coverage from 8% to 16%. Between 2004 and 2017, the annual cost of treatment with generic tenofovir disoproxil difumarate (TDF) for hepatitis B decreased from US$ 208 to US$ 28 per year. With the expiration of the drug patent in 2017, all countries can now procure generic versions of TDF, which will further increase access to hepatitis B treatment. The proportion of children under five years of age chronically infected with hepatitis B virus dropped to just under 1% in 2019, down from around 5% in the pre-vaccine era of the last millennium (the period between the 1980s and the early 2000s) – marking one of the few 2020 targets of the Sustainable Development Goals and global health sector strategy to be successfully reached. Equitable access to timely birth dose for prevention of hepatitis B virus infection in early childhood for people living in many African countries, and access to harm reduction for people who inject drugs, lag behind and require urgent attention. 14. Sexually transmitted infections. Since 2016, progress has been made in the generation of global baseline incidence data. In 2019, WHO published estimates as of 2016 for four curable infections: chlamydia, gonorrhoea, syphilis and trichomoniasis. Total estimated incident cases globally were: 376.4 million chlamydia cases; 86.9 million gonorrhoea cases; 156 million trichomoniasis cases; and 6.3 million syphilis cases. According to maternal syphilis estimates derived from the WHO-developed Spectrum-STI modelling tool and based on national time trend estimation for 205 countries, there were 988 000 global maternal syphilis cases in 2016, resulting in more than 661 000 cases of congenital syphilis, with 355 000 of these occurring as adverse birth outcomes and 306 000 as non-clinical congenital syphilis cases (infants without clinical signs born to untreated mothers). Thirty-two of the 64 countries monitoring gonorrhoea antimicrobial resistance reported decreased susceptibility or resistance to extended-spectrum cephalosporins, last-line treatment in Neisseria gonorrhoeae. 15. Between 2006 and 2017, more than 100 million adolescent girls worldwide received at least one human papillomavirus (HPV) vaccine dose, of which 95% were in high-income countries. While access to HPV vaccination is improving with 106 countries, including those in low-resource settings, having introduced the vaccine, only 15% of girls worldwide are fully protected. Responses from a survey conducted by WHO assessing progress towards the 2020 targets2 indicated that knowledge and use of the global health sector strategy and WHO treatment guidelines were 92% and 84%, respectively, among 1 Global hepatitis report, 2017. Geneva: World Health Organization; 2017 (https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/, accessed 3 November 2020). 2 Results of the survey are expected to be published in early 2021. EB148/37 5 the 112 Member States responding; surveillance or monitoring for sexually transmitted infections are in place in 87% of reporting countries and that more than 70% of countries provide services or links to primary, HIV, reproductive health, family planning, and prenatal and postnatal care services. Development of new diagnostic tests and vaccines for sexually transmitted infections has advanced, an independent laboratory-based evaluation of near point-of-care tests has been completed, and new treatment options for syphilis and gonorrhoea are being explored. The case for 2022–2030 strategies 16. WHO support remains critical for the efforts of Member States and stakeholders to achieve the 2030 goals to end these epidemics as public health threats. Updated strategies would ensure that global public health goods are updated as needed and that timely country support is in place. 17. While certain elements of the three strategies remain relevant and require little change, including the interventions listed and target populations defined, significant contextual shifts require incorporation into the strategies to ensure that they are relevant for the 2022–2030 period. These include: new epidemiological trend data across the disease areas reflecting stagnating responses and increasingly regionalized and population-based epidemics; the development of, and agreement on, 2025 targets to bridge the gap between the 2020 targets and 2030 goals;1 alignment with new political commitments, including those on primary health care included in the 2018 Declaration of Astana and commitments from the political declaration of the high-level meeting on universal health coverage (United Nations General Assembly resolution A/RES/74/2); clear linking of WHO actions to the Thirteenth General Programme of Work, 2019–2023, and its accountability frameworks; shifts in donor funding, especially for middle-income countries; advances in science, technology and innovation, including for HIV prevention and treatment and hepatitis C curative treatment; and advances in community-based service delivery and differentiated care. 18. COVID-19 continues to have an impact across all three disease areas, with for example, pandemic control measures affecting both the production of essential commodities and their distribution. UNAIDS has estimated, for example, that the final cost of antiretroviral medicines exported from India could be between 10% and 25% higher than previous prices. Access to essential services continues to be compromised, with inequities growing. 19. However, further progress towards the elimination goals is now possible if increased attention is paid to prevention of mother-to-child transmission of hepatitis B alongside prevention of mother-to-child transmission in HIV and syphilis, and further innovations in testing and diagnosis, including through the expansion of self-testing across the disease areas. WHO is developing a validation of elimination framework for viral hepatitis, which will be piloted in 2021. 20. The new strategies would also seek to align with the approach described in the PAHO Disease Elimination Initiative, endorsed by the Regional Committee of WHO for the Americas in 2019 (resolution CD57.R7), and with the initiative under way within WHO to develop a global framework for multi-disease elimination. 1 WHO has worked with the UNAIDS Secretariat to develop 2025 HIV targets and estimates of the resources needed to reach the 2030 goals and targets, and plans to convene experts in 2021 to develop 2025 targets for viral hepatitis and sexually transmitted infections. EB148/37 6 Proposed development process for the strategies 21. Key development steps for the strategies would involve: establishing a virtual, three-level WHO steering group; requesting inputs from Member States in one or more dedicated consultations, and from partners and stakeholders, including civil society; alignment with the strategy development processes of WHO’s partners, including those under way at UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria; convening a new strategic and technical advisory committee for HIV, hepatitis and sexually transmitted infections, and a linked civil society and communities reference group; developing various drafts of the strategies for internal and external review, including through virtual consultations in all regions; and organizing public online consultations in the official WHO languages, with a view to presenting the final strategies for consideration by the Health Assembly in May 2022. The current strategies would remain active until that time. ACTION BY THE EXECUTIVE BOARD 22. The Executive Board is invited to note the report and to provide guidance on the proposed development of new strategies, which would take into account contextual shifts to ensure that they are relevant for the period 2022–2030. = = =