Assessment of country implementation of the WHO global health sector strategy for sexually transmitted infections (2016–2021): results of a national survey

ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016–2021) RESULTS OF A NATIONAL SURVEY ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016–2021) RESULTS OF A NATIONAL SURVEY ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY ii Assessment of country implementation of the WHO global health sector strategy for sexually transmitted infections (2016–2021): results of a national survey ISBN 978-92-4-002558-5 (electronic version) ISBN 978-92-4-002559-2 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design by 400 Communications. iii Acronyms and abbreviations vi Acknowledgements vii Introduction 1 Methods 3 Analysis 4 Results 4 Global STI Strategy and national STI strategic plan 5 STI treatment guidelines 6 National STI priorities 7 Location of STI care services 8 STI surveillance system 9 Elimination of mother-to-child transmission of HIV and syphilis 11 STI screening, diagnosis and treatment 13 Surveillance for antimicrobial resistance in Neisseria gonorrhoeae 17 HPV vaccination, screening, diagnosis and treatment 18 Technical assistance 20 Summary 21 Status: the 2020 milestones among reporting countries 22 Considerations for data interpretation 23 Use of these data 23 References 23 Annex. Global AIDS Monitoring system indicators: data year 2019 24 CONTENTS ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY iv LIST OF TABLES Table 1: Country response rates by WHO region 4 Table 2: Knowledge and dissemination of WHO and national STI strategies 5 Table 3: National strategies and programming for priority STI areas by WHO region (percentage and number of responding countries) 5 Table 4: Proportion of countries familiar with the 2016 WHO STI treatment guidelines 6 Table 5: National STI treatment guidelines and sources of reference for development 6 Table 6: Priorities of countries for STI interventions (percentage and number of responding countries) 7 Table 7: Availability of STI services within clinical platforms 8 Table 8: Elements of national STI surveillance systems 9 Table 9: STIs and STI syndromes at various levels of STI services (percentage and number of responding countries) 9 Table 10: Countries completing the Global AIDS Monitoring indicator reporting for STIs 10 Table 11: Policy and programming for eliminating mother-to-child transmission at the national level 11 Table 12: Frequency of screening for HIV and syphilis among pregnant women 12 Table 13: Screening for STIs among pregnant women by WHO region (percentage and number of responding countries) 12 Table 14: Screening of men who have sex with men and sex workers for STIs (percentage and number of responding countries) 13 Table 15: Screening of men who have sex with men and sex workers for syphilis by WHO region (percentage and number of responding countries) 13 Table 16: STI diagnostic tests available to the general population 14 LIST OF TABLES v Table 17: Countries recommending frequently recommended medications for STI syndromes (percentage and number of responding countries) 15 Table 18: Countries including medications in the national formulary 15 Table 19: Countries reporting stock-outs of STI medications 16 Table 20: Countries reporting stock-outs of STI medications by WHO region, 2018–2019 (percentage and number of responding countries) 16 Table 21: Countries conducting surveillance for antimicrobial resistance in Neisseria gonorrhoeae 17 Table 22: Countries making cervical cancer screening available by WHO region, 2014 and 2020 (percentage of responding countries) 18 Table 23: Types of cervical cancer screening and treatment available at the national level 19 Table 24: Types of technical assistance requested by countries by WHO region (percentage and number of responding countries) 20 Annex A: Global AIDS Monitoring, percentage and number of countries performing antenatal care screening for syphilis, 194 WHO Member States, 2017–2019, analysis as of July 2020 24 Annex B: Global AIDS Monitoring, percentage and number of countries carrying out syphilis screening, positivity and treatment in antenatal care, 194 WHO Member States, 2019, analysis as of July 2020 24 Annex C: Global AIDS Monitoring, percentage and number of countries with syphilis positivity in antenatal care of >1%, reflecting eligibility for a path to elimination, 194 WHO Member States, 2019, analysis as of July 2020 25 Annex D: Global AIDS Monitoring, percentage and number of countries performing syphilis screening and treatment in antenatal care, 194 WHO Member States, 2019, analysis as of July 2020 25 ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY vi HPV human papillomavirus Pap Papanicolaou (smear) STI sexually transmitted infection UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund ACRONYMS AND ABBREVIATIONS ACkNOWLEDGEMENTS vii WHO thanks the staff of the health ministries who took the time to complete the survey. The following regional advisers and staff from the six WHO regional offices provided technical assistance and guidance in communicating directly with countries to complete the survey: Saliyou Sanni, Leopold Oudraego and Amah Gnassingbe (WHO Regional Office for Africa); Monica Alonso and Maeve de Mello (WHO Regional Office for the Americas); Bharat Rewari and Mukta Sharma (WHO Regional Office for South-East Asia); Nicole Seguy, Elena Vovc and Nino Berdzuli (WHO Regional Office for Europe); Joumana Hermez and Ahmed Sabry (WHO Regional Office for the Eastern Mediterranean); Naoko Ishikawa and Anne Brink (WHO Regional Office for the Western Pacific). The following WHO staff members from the Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes and Department of Sexual and Reproductive Health and Research contributed directly to the development of the survey and analysis of the results: Nathalie Broutet, Sami Gottlieb, Sihem Landousli, Khurshed Nosirov, Melanie Taylor, Soe Soe Thwin and Teodora Wi. Theresa Babovic, Antonio Gerbase, Melanie Taylor and Teodora Wi made great efforts in developing this report. UNDP, UNFPA, UNICEF, WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and the Department of the Global HIV, Hepatitis and STI programmes provided funding for this assessment. ACkNOWLEDGEMENTS INTRODUCTION 1 The WHO global health sector strategy on sexually transmitted infections, 2016–2021 (1) includes country milestones for achievement by 2020 and global targets for achievement by 2030. In addition, countries were called to identify national sexually transmitted infection (STI) targets for 2020 and beyond. Reporting on these milestones, country targets and progress on implementation at the country level is due as a report to the World Health Assembly in 2021 (1). In 2018, a short report on the global health sector strategies on HIV, viral hepatitis and sexual transmitted infections for the period 2016–2018 (2) was presented to the World Health Assembly. The report, in relation to STIs, included provisional estimates of global STI incidence, reporting on the use of the strategy, new guidelines as well as challenges in reaching the 2020 WHO STI milestones. INTRODUCTION ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 2 BOX 1: WHO GLOBAL STI STRATEGY MILESTONES FOR 2020 AND TARGETS FOR 2030 Milestones for 2020 • 70% of countries have sexually transmitted infection surveillance systems in place that are able to monitor progress towards the relevant targets. • 70% of countries have screened at least 95% of pregnant women for syphilis; and 95% of syphilis- seropositive pregnant women have been treated with at least one dose of intramuscular benzathine penicillin. • 70% of key populations for HIV have access to a full range of services relevant to sexually transmitted infections and HIV, including condoms. • 70% of countries provide sexually transmitted infection services or links to such services in all primary, HIV, reproductive health, family planning and antenatal and postnatal care services. • 70% of countries deliver human papillomavirus (HPV) vaccines through the national immunization programme. • 70% of countries report on antimicrobial resistance in Neisseria gonorrhoeae. • 90% national coverage is sustained and at least 80% vaccinated in every district (or equivalent administrative unit) in countries with the HPV vaccine in their national immunization programme. Targets for 2030 • 90% reduction in the incidence of Treponema pallidum globally (2018 global baseline) • 90% reduction in Neisseria gonorrhoeae incidence globally (2018 global baseline) • 50 or fewer cases of congenital syphilis per 100 000 live births in 80% of countries • 90% national coverage sustained and at least 80% vaccinated in every district (or equivalent administrative unit) in countries with the HPV vaccine in their national immunization programme In 2019, an interim assessment of progress towards achieving the milestones for the three interlinked global strategies for HIV, hepatitis and STIs was published (3). This report concluded that STI control had seen little progress compared with HIV and hepatitis and identified several opportunities for strengthening STI control measures at the global, regional and national levels. From October 2019 through April 2020, a country survey was distributed to WHO Member States through WHO regional offices to measure progress towards achieving the following 2020 STI-specific milestones within the global strategy for STIs: (1) number of countries with an STI surveillance system in place; (2) number of countries with at least 95% of pregnant women screened for syphilis; and (3) number of countries with at least 95% of syphilis-positive pregnant women receiving effective treatment; (4) number of countries providing STI services or links to such services in all primary, HIV, reproductive health, family planning and pre- and postnatal care services; (5) number of countries reporting on antimicrobial resistance in Neisseria gonorrhoeae; (6) percentage of key populations with access to a full range of STI and HIV services, including condoms; and (7) number of countries delivering human papillomavirus (HPV) vaccination through national immunization programmes. National-level priority-setting for key areas of STI control will also be assessed. The data from this survey will be used to report to the World Health Assembly in 2021 and to inform the development of a new global STI strategy. METHODS 3 WHO headquarters and WHO regional advisers jointly developed a survey instrument in the form of a questionnaire for self-completion to assess the STI interventions related to the global STI strategy at the country level. The questionnaire covered elements related to the strategy as well as programme service delivery to inform the WHO report to the World Health Assembly, regional offices and countries regarding prevention and STI control. The survey also captured technical assistance needs in STI programming and surveillance. The survey was translated into French, Portuguese, Russian and Spanish. The questionnaire covered the following areas: • STI strategy: knowledge of the global strategy and use of it to develop national guidelines and disseminate them at the country level; • STI treatment guidelines: knowledge and use of the global STI strategy to develop national guidelines, the use of other guidelines and disseminate these at the country level; • national STI priorities; • location of STI care activities; • surveillance systems; • eliminating the mother-to-child transmission of HIV and syphilis; • screening, diagnosing and treating people for STIs; • surveillance for antimicrobial resistance in gonorrhoea and gonococcal isolates; • HPV vaccination, screening, diagnosis, treatment and cervical cancer registries; and • technical assistance. From September 2019 to March 2020, country STI programme managers (focal points for the survey) received and completed the questionnaire. These STI focal points liaised with various programme managers such as for HIV, reproductive health, immunization and others to gather the information needed to complete the questionnaire. Three email reminders were sent to non- responding countries. The completed questionnaires were returned through WHO regional offices to WHO headquarters. The data were compiled and entered in OpenClinica during February–May 2020 and analysed using SAS and Microsoft Excel. METHODS ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 4 The survey was distributed to the 194 WHO Member States. However, the frequency and percentage analysis for this report was calculated for each question using the number of completed responses as the denominator for each response. Countries not completing the survey and countries not responding to individual questions were not included in the denominator for percentage calculations. The analysis was based on the responses received from 112 of the 194 (58%) WHO Member States. Table 1 shows the number of responding countries by region. ANALYSIS RESULTS Table 1: Country response rates by WHO region WHO region Number of countries completing the survey Number of countries in the region Response rate (%) African Region 26 47 45 Region of the Americas 25 35 71 South-East Asia Region 10 11 91 European Region 27 53 51 Eastern Mediterranean Region 6 21 29 Western Pacific Region 18 27 67 Total 112 194 58 RESULTS 5 Ninety-two per cent (103 of 112) of the countries were familiar with the WHO global STI strategy. The strategy had been internally disseminated in 34% (38 of 112) of the countries. Sixty-four per cent of the countries (72 of 112) have an official national STI strategy, ranging from 77% (20 of 26) in the African Region to 37% (10 of 27) in the European Region. The proportion of national strategies updated after the global STI strategy was launched was 58% (42 of 72). The global STI strategy was used as a reference in all 42 of these national strategy updates. In 84% (62 of 74) of responding countries, the STI strategy or programme is integrated with the HIV national strategy. Table 2 displays the reported familiarity and methods of distribution of the global STI strategy. Table 3 describes the availability of country strategies and programming for specific STI priority areas by WHO region. GLOBAL STI STRATEGY AND NATIONAL STI STRATEGIC PLAN Table 3: National strategies and programming for priority STI areas by WHO region (percentage and number of responding countries) Region National STI strategic plan Strategy for eliminating mother-to-child transmission STI treatment guidelines Antimicrobial resistance surveillance for Neisseria gonorrhoeae HPV vaccine in national immunization plan African Region 77% (20/26) 73% (19/26) 92% (24/27) 58% (11/19) 31% (8/26) Region of the Americas 64% (16/25) 88% (22/25) 88% (22/25) 58% (11/19) 80% (20/25) South-East Asia Region 80% (8/10) 100% (10/10) 100% (10/10) 60% (6/10) 40% (4/10) European Region 37% (10/27) 48% (13/27) 70% (19/27) 82% (18/22) 77% (20/26) Eastern Mediterranean Region 67% (4/6) 83% (5/6) 67% (4/6) 50% (2/4) 20% (1/5) Western Pacific Region 78% (14/18) 53% (9/17) 94% (17/18) 60% (9/15) 67% (12/18) Total 64% (72/112) 70% (78/111) 86% (96/112) 64% (57/89) 59% (65/110) Table 2: Knowledge and dissemination of WHO and national STI strategies Global and national STI strategic responses Percentage of responding countries (number) Countries familiar with the global STI strategy 92% (103/112) Internal dissemination of the global STI strategy 34% (108/112) Countries with a national STI strategy 64% (72/112) National STI strategy is incorporated with the HIV strategy 84% (62/74) ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 6 Nearly all responding countries were familiar with the WHO 2016 STI treatment guidelines for gonorrhoea, chlamydia, genital herpes and syphilis (4–7) (Table 4). Table 5 describes the development of national guidelines for STIs, present in 96 of 112 (86%) of the responding countries. WHO STI guidelines were the most used references; however, other guidelines were also used. STI TREATMENT GUIDELINES Table 4: Proportion of countries familiar with the 2016 WHO STI treatment guidelines WHO STI treatment guidelines Percentage of responding countries (number) Neisseria gonorrhoeae (gonorrhoea) (4) 91% (102/112) Chlamydia trachomatis (chlamydia) (5) 91% (102/112) Herpes simplex virus (genital herpes) (6) 89% (100/112) Treponema pallidum (syphilis) (7) 91% (102/112) Table 5: National STI treatment guidelines and sources of reference for development National STI treatment guidelines Percentage of responding countries (number) Have national STI guidelines 86% (96/112) Use WHO guidelines as reference 84% (74/88) Use other guidelines as reference United States Centers for Disease Control and Prevention 56% (50/89) British Association for Sexual Health and HIV (BASHH) guidelines 22% (19/88) International Union against Sexually Transmitted Infections 20% (18/88) RESULTS 7 Table 6 presents the priority-level interventions for STI control and prevention in 111 countries. The intervention given the highest priority by the most countries (90%) is eliminating the mother-to-child transmission of HIV and syphilis. High priority was also given to STI screening among people living with HIV (78%) and STI screening of men who have sex with men and sex workers (72%). Condom distribution was reported as a high priority by 67% of countries followed by 56% for STI syndromic management and 50% for STI services for adolescents. HPV vaccination for young women is a high priority in the European Region (82%) and Region for the Americas (76%) but is still not considered a high priority in the African Region (35%). Syndromic management, as expected, remains a high priority in the African Region (77%), where STI diagnostic testing is rarely available, and lower in the European Region (22%), where STI diagnostic testing is routinely available. NATIONAL STI PRIORITIES Table 6: Priorities of countries for STI interventions (percentage and number of responding countries) Intervention High Medium Low Not a priority or not done Eliminating the mother-to- child transmission of HIV and syphilis 90% (100/111) 6% (7/111) 4% (4/111) 0% (0/111) STI screening conducted among people with HIV 77% (86/111) 18% (20/111) 3% (3/111) 2% (2/111) STI screening among high- risk populations of men who have sex with men and sex workers 71% (79/111) 14% (16/111) 9% (10/111) 5% (6/111) Condom distribution 67% (74/111) 25% (23/111) 8% (9/111) 3% (3/111) HPV vaccine for young women 59% (65/111) 13% (14/111) 16% (18/111) 12% (13/111) STI syndromic management 56% (62/111) 23% (26/111) 9% (10/111) 12 (13/111) STI surveillance and monitoring 56% (62/111) 27% (30/111) 14% (15/111) 4% (4/111) Providing STI services for adolescents 45% (50/111) 31% (34/111) 20% (22/111) 52% (58/111) Monitoring antimicrobial resistance in gonococcal isolates 34% (38/111) 27% (30/111) 22 (24/111) 17% (19/111) ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 8 In the survey, STI care services were defined as a clinical setting with a health professional capable of STI management, including diagnosis (syndromic or etiological), treatment, counselling and partner management. Table 7 shows the number of countries reporting the availability of STI services in various clinical platforms. More than 70% of the surveyed countries reported the availability of STI services or links to STI services in primary health centres, HIV clinics, reproductive health settings, family planning and pre- and postnatal care services. This milestone of the global STI strategy for 2020 has been achieved among these responding countries (Box 1). LOCATION OF STI CARE SERVICES Table 7: Availability of STI services within clinical platforms Location of STI services Percentage of responding countries (number) HIV services 92% (103/112) Antenatal care 89% (100/112) Primary health care clinics 88% (99/112) Reproductive health clinics 85% (95/112) Specialized STI clinics 85% (95/112) Services for key populations 83% (93/112) RESULTS 9 STI surveillance or STI monitoring is in place in 87% (97 of 110) of responding countries, thus reflecting that this group of responding countries has achieved the 2020 milestone in the global STI strategy: 70% of the countries have an STI surveillance system in place. STI SURVEILLANCE SYSTEM Table 8: Elements of national STI surveillance systems Elements of STI surveillance systems Percentage and number of reporting countries STI surveillance or monitoring 87% (97/110) STI case reporting 91% (96/98) Etiological assessment of STI syndromes 48% (48/98) Periodic STI prevalence surveys among general and high- risk populations 49% (49/97) Table 9: STIs and STI syndromes at various levels of STI services (percentage and number of responding countries) STI reported Universal STI clinic Sentinel sites Private sector Laboratories Syndrome: urethral discharge 51% (48/94) 47% (44/94) 31% (29/93) 26% (24/93) – Syndrome: genital ulcer disease 47% (45/95) 48% (46/95) 30% (28/93) 28% (26/93) – Syndrome: vaginal discharge 46% (44/95) 45% (43/95) 31% (29/93) 26% (24/93) – Causes: syphilis 74% (71/96) 67% (64/95) 45% (41/92) 46% (43/94) 60% (56/93) Causes: gonorrhoea 61% (58/95) 55% (52/95) 39% (36/92) 39% (37/94) 56% (53/94) Causes: chlamydia 44% (42/96) 46% (44/95) 30% (28/92) 31% (29/94) 50% (47/94) Causes: trichomoniasis 31% (30/96) 35% (34/95) 24% (23/94) 21% (20/94) 39% (36/93) Causes: syphilis among pregnant women 78% (75/96) 65% (62/95) 38% (35/91) 47% (44/94) 58% (54/93) Table 8 describes the elements of national STI surveillance systems. Table 9 summarizes which STIs are reported at different levels of the health system. ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 10 STI surveillance or monitoring is integrated within the national health information system in 81% (82 of 101) of countries. The data are disaggregated in most countries. The disaggregation is reported by age (97%), sex (97%), location (91%) and population (69%). Most countries (95%) enter data for HIV and STI indicators into the Global AIDS Monitoring reporting tool maintained by UNAIDS, WHO and UNICEF (8). Table 10 shows the frequencies of the various Global AIDS Monitoring indicators reporting for STIs. The reporting reflects the priority given to eliminating the mother-to-child transmission of HIV and syphilis. Table 10: Countries completing the Global AIDS Monitoring indicator reporting for STIs Global AIDS Monitoring indicator Percentage (number) Syphilis screening coverage among pregnant women in antenatal care clinics 84% (77/91) Syphilis positivity among pregnant women in antenatal care clinics 78% (71/91) Syphilis treatment coverage among pregnant women testing positive in antenatal care clinics 67% (61/91) Congenital syphilis case rate 64% (58/91) Syphilis screening and positivity among men who have sex with men 48% (44/91) Syphilis screening and positivity among sex workers 41% (37/91) Urethral discharge case rate among men 45% (41/91) RESULTS 11 Table 11 describes programming for eliminating the mother-to-child transmission of HIV and syphilis. A total of 93% (104 of 108) countries have a national policy for screening pregnant women for HIV and 93% (103 of 111) for syphilis. There has been some progress since 2014, when 86% of the countries had screening programmes for syphilis among pregnant women. Testing for HIV at delivery was reported by 60% (59 of 99) and for syphilis by 46% (44 of 95) of countries. The global STI strategy milestone for 2020 is to have at least 95% of pregnant women screened for syphilis and 90% tested for HIV, and 95% of syphilis-positive pregnant women receiving effective treatment. Global AIDS Monitoring gathers these data (Annex 1). Country- reported data from Global AIDS Monitoring for 2019 show that these milestones for syphilis were not achieved. For 2019, among 74 countries reporting antenatal care syphilis screening coverage, only 26% achieved 95% or higher coverage; among 66 countries reporting antenatal care syphilis treatment coverage for women with syphilis, only 48% achieved 95% or higher coverage. Using national policy as a surrogate, there is an indication that this milestone for HIV and syphilis screening can be achieved if the policies are in fact implemented in antenatal care settings. This can be cross-referenced using Global AIDS Monitoring data. The survey did not include a question on policy for treatment coverage of pregnant women found to be positive for syphilis in antenatal care. ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV AND SYPHILIS Table 11: Policy and programming for eliminating mother-to-child transmission at the national level Programming for eliminating mother-to-child transmission Percentage (number) National strategy for eliminating the mother-to-child transmission of HIV and syphilis 70% (78/112) National strategy only for HIV 10% (11/110) Plan to apply for validation of the elimination of mother- to-child transmission or the path to elimination for both HIV and syphilis 74% (58/79) (16 between 2020 and 2023) National policy for screening pregnant women for HIV 93% (104/108) National policy for screening pregnant women for syphilis 93% (103/111) Test for HIV at delivery 60% (59/99) Test for syphilis at delivery 46% (44/95) ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 12 Table 12 summarizes the national policies for HIV and syphilis screening among pregnant women. Besides HIV and syphilis, 74% (81 of 110) of countries test for other STIs, mainly hepatitis B (Table 13). aStock-out of test kits was frequently reported – 57% (30 of 53). Dual HIV and syphilis tests used in antenatal care clinics – 15% (16 of 110). The price of dual HIV and syphilis test kits was reported as mean US$ 6.10 and median US$ 3.75 (range US$ 0.96–19.00). Thirty of 53 responding countries had frequent stock-outs of syphilis test kits. Table 12: Frequency of screening for HIV and syphilis among pregnant women Frequency of screening during antenatal care in 101 responding countries (percentage) Once Twice Three times Four times or more HIV 49% 36% 15% 1% Syphilisa 58% 28% 13% 2% Table 13: Screening for STIs among pregnant women by WHO region (percentage and number of responding countries) Region HIV Syphilis Chlamydia Gonorrhoea Trichomoniasis Hepatitis B HPV African Region 100% (26/26) 100% (26/26) 23% (6/26) 35% (9/26) 23% (6/26) 58% (15/26) 15% (4/26)) Region of the Americas 100% (25/25) 100% (25/25) 12% (3/25) 16% (4/25) 12% (3/25) 72% (18/25) 24% (6/25) South-East Asia Region 100% (10/10) 100% (10/10) 10% (1/10) 20% (2/10) 20% (2/10) 90% (9/10) 20% (2/10) European Region 81% (22/27) 93% (25/27) 30% (8/27) 41% (11/27) 22% (6/27) 89% (24/27) 22% (6/27) Eastern Mediterranean Region 60% (3/5) 80% (4/5) 0% (0/5) 0% (0/5) 0% (0/5) 40% (2/5) 0% (0/5) Western Pacific Region 100% (17/17) 94% (17/18) 24% (4/17) 24% (4/17) 18% (3/17) 76% (13/17) 6% (1/17) Total 94% (103/110) 96% (107/110) 24% (22/110) 27% (30/110) 18% (20/110) 74% (81/110) 17% (19/110) RESULTS 13 Among key populations, screening for HIV and syphilis was the most commonly reported followed by that for hepatitis B (Table 14). Table 15 shows the countries performing syphilis screening among men who have sex with men and sex workers by WHO region. STI SCREENING, DIAGNOSIS AND TREATMENT Table 14: Screening of men who have sex with men and sex workers for STIs (percentage and number of responding countries) STI screened Men who have sex with men Sex workers HIV 83% (93/112) 81% (90/111) Syphilis 74% (83/112) 73% (81/111) Gonorrhoea 50% (56/112) 49% (54/110) Chlamydia 41% (46/111) 44% (48/110) Trichomoniasis 29% (32/111) 39% (43/110) HPV 23% (26/111) 30% (33/110) Genital herpes 32% (36/111) 33% (36/110) Hepatitis B 54% (60/111) 49% (54/110) Hepatitis C 41% (46/111) 36% (40/109) Other 13% (14/109) 13% (14/109) Table 15: Screening of men who have sex with men and sex workers for syphilis by WHO region (percentage and number of responding countries) Region African Region Region of the Americas South-East Asia Region European Region Eastern Mediterranean Region Western Pacific Region Men who have sex with men 62% (16/26) 96 (24/25)% 9/10 (90% (9/10) 63% (17/27) 50% (3/6) 78% (14/18) Sex workers 68% (17/25) 92% (23/25) 9/10 (90% (9/10) 50% (3/6) 56% (15/27) 78% (14/18) ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 14 Table 16 demonstrates the diagnostic tests available for STI diagnosis for the general population. The availability of HIV and syphilis testing was the highest (>95%) versus 60% for chlamydia, 56% for HPV and 54% for herpes. Studies or surveys conducted to identify the common causes of STI syndromes (urethral discharge, vaginal discharge and genital ulcer disease) were conducted in 31% (35/112) of the responding countries (14 in the past four years, 14 without the date being mentioned and seven before 2014). Table 16: STI diagnostic tests available to the general population Diagnostic test Percentage of responding countries (number) HIV 97% (109/112) Syphilis 96% (107/112) Gonorrhoea 74% (83/112) Chlamydia 59% (66/111) Trichomoniasis 72% (79/110) HPV 56% (62/111) Genital herpes 54% (60/111) Hepatitis B 86% (96/112) Hepatitis C 79% (88/112) Other 9% (10/108) RESULTS 15 Table 18: Countries including medications in the national formulary Medication Percentage of responding countries (number) Acyclovir 84% (90/107) Azithromycin 89% (96/108) Benzathine penicillin 92% (99/108) Ceftriaxone 89% (96/108) Cefixime 65% (70/108) Doxycycline 90% (96/111) Metronidazole 91% (97/107) Table 17: Countries recommending frequently recommended medications for STI syndromes (percentage and number of responding countries) Urethral discharge Vaginal discharge Genital ulcer disease syndrome Azithromycin 85% (91/107) 76% (80/106) Ceftriaxone 83% (89/107) 73% (77/105) Doxycycline 75% (79/106) 70% (74/106) 51% (52/103) Cefixime 55% (59/106) 52% (55/105) Metronidazole 84% (89/106) Others, including candidiasis medications 52% (54/103) Acyclovir 78% (82/105) Benzathine penicillin 89% (93/105) Table 17 shows the most frequently recommended medications for the syndromes. Table 18 shows the frequency of STI medications included in the national formulary or procurement list for STI treatment among the responding countries. ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 16 Table 19: Countries reporting stock-outs of STI medications Medication Percentage of responding countries (number) Acyclovir 16/111 (14%) Azithromycin 15/110 (14%) Benzathine penicillin 37/110 (34%) Ceftriaxone 17/111 (15%) Cefixime 15/110 (14%) Doxycycline 147111 (13%) Metronidazole 13/111 (12%) Crystalline penicillin 8/109 (7%) Table 20: Countries reporting stock-outs of STI medications by WHO region, 2018–2019 (percentage and number of responding countries) Region Benzathinepenicillin Azithromycin Cefixime Ceftriaxone Acyclovir African Region 42% (11/26) 28% (7/25) 23% (6/26) 27% (7/26) 34% (9/26) Region of the Americas 36% (9/25) 8% (2/25) 12% (3/25) 16% (4/25) 12% (3/25) South-East Asia Region 40% (4/10) 10% (1/10) 10% (1/10) 10% (1/10) 10% (1/10) European Region 20% (7/27) 7% (2/27) 4% (1/27) 7% (2/27) 0% (0/27) Eastern Mediterranean Region 20% (1/5) 0% (0/5) 20% (1/5) 20% (1/5) 0% (0/5) Western Pacific Region 29% (5/17) 17% (3/18) 18% (3/17) 11% (2/18) 17% (3/18) Total 34% (37/110) 14% (15/110) 14% (15/110) 15% (17/111) 14% (16/111) STI medication stock-outs occurred in at least 11% (11– 34%) of countries during 2018–2019. The most frequent specific stock-out was benzathine penicillin, reported by 34% of countries (37 of 110), mainly between 2018 and 2019. The first stock-outs of benzathine penicillin were in 2009 but increased in 2016 to 2019 (eight countries). Recent stock-outs were mainly identified in 2018 (10 countries) and 2019 (seven countries). Tables 19 and 20 summarize the findings. RESULTS 17 Eighty per cent (86 of 108) of the responding countries’ national reference laboratories perform antimicrobial susceptibility testing for antimicrobial resistance. Table 21 describes other programming activities related to monitoring antimicrobial resistance. Surveillance of gonococcal antimicrobial susceptibility is conducted in 64% (57 of 89) of the responding countries, with 33 countries performing studies during the past four years (Table 20). ªCompared with the 2014 situation, when 55 countries reported antimicrobial resistance studies in previous years, the situation is unchanged, since 57 countries responded to the survey. SURVEILLANCE FOR ANTIMICROBIAL RESISTANCE IN NEISSERIA GONORRHOEAE Table 21: Countries conducting surveillance for antimicrobial resistance in Neisseria gonorrhoeae Laboratory antimicrobial resistance surveillance Percentage of responding countries (number) General antimicrobial susceptibility testing 80% (86/108) Perform antimicrobial resistance for Neisseria gonorrhoeae at national reference laboratory 89% (80/90) Use results to inform Neisseria gonorrhoeae treatment schemes 79% (66/84) Surveillance of gonococcal antimicrobial susceptibilityª 64% (57/89) Performed in the past four yearsª 37% (33/89) Use minimum inhibitory concentration or E-test among countries performing testing for Neisseria gonorrhoeae antimicrobial resistance 39% (22/57) Surveillance for antimicrobial resistance of gonococcal isolates is a 2020 milestone. The milestone (70%) was almost achieved among the responding countries. Compared with the 2014 situation, when 55 countries reported antimicrobial resistance studies in previous years, the situation is unchanged, since 57 countries responded to the survey. ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 18 Of the responding countries, 59% (65 of 110) include the HPV vaccine in the national immunization schedule. This is a measure of the first 2020 milestone. The milestone of 70% of countries including HPV vaccine in the national immunization schedule was not achieved among the responding countries. Of the countries that include the HPV vaccine in the national immunization schedule, 94% (63 of 65) provide the vaccine to adolescent girls and 31% (20 of 65) to adolescent girls and boys. The HPV vaccine for people living with HIV is included in the national immunization schedule in 27% (18 of 68) of countries and, for men who have sex with men, in 18% (12 of 68) of countries. Cervical cancer is included in the national cancer registry in 84% (89 of 106) of responding countries. It is population based in 48% (43 of 90), hospital based in 66% (57 of 87), national in 75% (66 of 88) and subnational in 42% (37 of 89). Screening for cervical cancer is available for the general populations of women 35–55 years old in 94% (102 of HPV VACCINATION, SCREENING, DIAGNOSIS AND TREATMENT 109) of responding countries. All (100%) responding countries in the Region of the Americas, South-East Asia Region and European Region report that cervical cancer screening is available for general populations of women; 95% of countries in the Western Pacific Region reported that screening is available. In the African Region, 85% of responding countries had cervical cancer screening availability. Few countries in the Eastern Mediterranean Region reported on this variable, and 60% (3/5) of these reported availability of screening for cervical cancer (Table 22). The availability of cervical cancer screening in this 2019–2020 survey reflects progress compared with the 2014 survey, when coverage was 64% in the African Region, 87% in the Region of the Americas, 80% in the South-East Asian Region, 93% in the European Region and 100% in the Western Pacific Region. Few countries completed the survey from the Eastern Mediterranean Region in 2019–2020. In 2014, 31% of countries in this Region reported the availability of cervical cancer screening, 13 of 22 (59%) as compared to the current survey where only 3 of 5 countries reported having this service. Table 22: Countries making cervical cancer screening available by WHO region, 2014 and 2020 (percentage of responding countries) WHO region 2014 2020 African Region 64% 85% Region of the Americas 87% 100% South-East Asia Region 80% 100% European Region 93% 100% Eastern Mediterranean Region 31% (n = 13) 60% (n = 6) Western Pacific Region 100% 94% RESULTS 19 The countries in which cervical cancer screening is available most commonly reported the Papanicolaou (Pap) smear test: 91% (95 of 104). The HPV test is in use in 48% of countries (49 of 102). Other tests in use include acetic acid testing (53%, 53 of 100) and visual inspection only (32%, 32 of 99). Other tests reported represent 13% (12/95) (Table 23). Methods of treating people with cervical precancerous and cancerous lesions reported by countries included: loop electrosurgical excision procedure (79%, 81 of 102), cryotherapy (72%, 73 of 102), surgical removal (75%, 77 of 102) and thermal ablation (47%, 47 of 101) (Table 23). Table 23: Types of cervical cancer screening and treatment available at the national level Cervical cancer screening tests Percentage of responding countries (number) PAP smear 91% (95/104) HPV test 48% (49/102) Acetic acid testing 53% (53/100) Visual inspection only 32% (32/99) Cervical cancer treatment methods Percentage of responding countries (number) Thermal ablation 47% (47/101) Cryotherapy 72% (73/102) Loop electrosurgical excision procedure or conization 79% (81/102) Surgical removal 75% (77/102) Others 13% (13/97) ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 20 Seventy-five per cent (82 of 109) of the countries requested technical assistance. Table 24 describes the type of technical assistance requested. The main technical partners or agencies that support STI prevention and control services reported by countries include the United States Centers for Disease Prevention and Control, European Centre for Disease Prevention and Control, Global Fund to Fight AIDS, Tuberculosis and Malaria, WHO, UNAIDS, UNFPA, UNICEF and UNDP). TECHNICAL ASSISTANCE Table 24: Types of technical assistance requested by countries by WHO region (percentage and number of responding countries) Region National STI treatment STI surveillance Eliminating mother-to-child transmission Antimicrobial resistance HPV African Region 77% (20/26) 54% (14/26) 85% (22/26) 69% (18/26) 81% (21/26) 77% (20/26) Region of the Americas 62% (13/21) 62% (13/21) 76% (16/21) 76% (16/21) 81% (17/21) 68% (15/22) South-East Asia Region 100% (8/8) 75% (6/8) 88% (7/8) 75% (6/8) 88% (7/8) 62% (5/8) European Region 91% (10/11) 63% (7/11) 54% (6/11) 27% (3/11) 45% (5/11) 63% (7/11) Eastern Mediterranean Region 50% (3/6) 40% (2/5) 80% (4/5) 67% (4/6) 80% (4/5) 60% (3/5) Western Pacific Region 100% (8/10) 60% (6/10) 80% (8/10) 72% (8/11) 90% (9/10) 60% (6/10) Total 76% (62/82) 59% (48/81) 78% (63/81) 66% (55/83) 78% (63/81) 68% (56/82) The main source of funding for implementing STI- related prevention and control programmes are national governments and the Global Fund. SUMMARY 21 • The response rate was 58% in 2020 versus 51% 2014. There was no difference in the World Bank income level classification among countries reporting in the two time periods. • Knowledge and use of the global STI strategy and WHO STI treatment guidelines was high. • A large proportion of countries had formal national STI treatment guidelines (86%) that were well disseminated (81%) and used the WHO guidelines as a reference (84%). • Country priorities aligned closely with the WHO priorities included in the global STI strategy. • STI surveillance or monitoring are in place in 87% of the responding countries. • Seventy per cent of the responding countries had a strategy for eliminating mother-to-child transmission, with 74% reporting plans to validate the elimination of mother-to-child transmission. • National policies on HIV and syphilis screening among pregnant women were in place for 90% of the responding countries. • There was widespread availability of HIV and syphilis screening for men who have sex with men, sex workers and the general population among the responding countries. • Most countries reported that STI medications were adequate for use in treating people with STI syndromes, widely available and included in the national essential drugs list. • Stock-outs of benzathine penicillin (34%) and other STI drugs (13–15%) occurred mainly between 2016 and 2019 in responding countries. • Low- and middle-income countries still use syndromic management of STI diagnosis and treatment because of the limited availability and high cost of STI diagnostics. • Antimicrobial susceptibility testing for antimicrobial resistance in N. gonorrhoeae is performed in national reference laboratories in 80% of the responding countries. Of these, 89% perform antimicrobial resistance in monitoring N. gonorrhoeae and 79% used the results to inform treatment schemes. • Surveillance for gonococcal antimicrobial susceptibility is conducted in 64% of the responding countries. • HPV vaccine is included in the national immunization schedule of 59% of responding countries. • The HPV vaccine is provided to adolescent girls in 94% of countries and to adolescent girls and boys in 31% of countries. • The HPV vaccine is provided to people living with HIV in 26% of countries and to men who have sex with men in 18% of countries. • The most frequent cervical cancer screening tests reported are Pap smear in 91% and HPV test in 48% of responding countries. • The most frequent cervical cancer treatments reported were cryotherapy (72%), loop electrosurgical excision procedure or conization (79%) and surgical removal with other procedure (75%). • 76% of the responding countries reported the need for technical assistance for STI programming. SUMMARY ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 22 • Milestone: to have 70% of countries with a STI surveillance system in place. – STI surveillance or monitoring is in place in 87% of countries. This milestone has been achieved among the responding countries. • Milestone: to have at least 95% of pregnant women screened for syphilis and 90% tested for HIV, and 95% of positive pregnant women receive effective treatment. – Most countries have national policies for screening pregnant women for HIV (93%) and for syphilis (93%). As a proxy, the availability of syphilis and HIV screening policies for pregnant women demonstrates national support for this service delivery milestone of 95% screening coverage by these responding countries. The numeric indicators of syphilis screening and treatment coverage for pregnant women are measured and reported using Global AIDS Monitoring (Annex 1) . • Milestone: 70% of countries providing STI services or links to such services in all primary, HIV, reproductive health, family planning and pre- and postnatal care services. – Primary health-care services 88% – HIV services 91% – Reproductive health services 84% – Family planning services 77% – Pre- and postnatal services 89% This milestone has been achieved. • Milestone: 70% of countries delivering HPV vaccination through the national immunization programme. – Only 5% of the countries responding include HPV vaccine in the national immunization schedule. The milestone has not been achieved. • Milestone: 70% of countries responding on antimicrobial resistance of Neisseria gonorrhoeae. – Surveillance of gonococcal antimicrobial susceptibility is conducted in 64% of the countries. The milestone was almost achieved. • Milestone: 70% of key populations having access to a full range of STI and HIV services, including condoms. This survey did not assess this milestone. STATUS: THE 2020 MILESTONES AMONG REPORTING COUNTRIES CONSIDERATIONS FOR DATA INTERPRETATION, USE OF THESE DATA & REFERENCES 23 The results of this survey demonstrate that STI services are available within the responding countries. The response rate of 58% of the WHO Member States should be considered when interpreting these data. Percentage analysis of the same responses using a denominator of all surveyed countries (including nonrespondents) would yield results demonstrating that STIs and the accompanying service delivery have much lower priority. These data will be used to inform the need for technical assistance to countries related to the STI programme, surveillance and service delivery. The results of this survey 1. WHO global health sector strategy on sexually transmitted infections, 2016–2021. Geneva: World Health Organization; 2016 (https://www.who. int/reproductivehealth/publications/rtis/ghss-stis/en, accessed 15 March 2021). 2. Global health sector strategies on HIV, viral hepatitis and sexually transmitted infections, for the period 2016–2021 (resolution WHA69.22 (2016)). In: Progress reports: report by the Director- General. Geneva: World Health Organization; 2018 (https://apps.who.int/gb/ebwha/pdf_files/WHA71/ A71_41Rev2-en.pdf, accessed 15 March 2021). 3. 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 15 March 2021). 4. WHO guidelines for the treatment of Neisseria gonorrhoeae. Geneva: World Health Organization; 2016 (https://www.who.int/reproductivehealth/ publications/rtis/gonorrhoea-treatment-guidelines/en, accessed 15 March 2021). Reporting bias towards the survey being completed by countries with better developed STI programming should be considered. Only one of the nine Portuguese- speaking countries completed the survey even though a Portuguese-speaking WHO staff member translated the survey and reached out to the countries. will also be used to inform the development of the next WHO global STI strategy, considering the challenges and opportunities that exist within current health-care systems. CONSIDERATIONS FOR DATA INTERPRETATION USE OF THESE DATA REFERENCES 5. WHO guidelines for the treatment of Chlamydia trachomatis. Geneva: World Health Organization; 2016 (https://www.who.int/reproductivehealth/ publications/rtis/chlamydia-treatment-guidelines/en, accessed 15 March 2021). 6. WHO guidelines for the treatment of genital herpes simplex virus. Geneva: World Health Organization; 2016 (https://www.who.int/publications/i/ item/978924154987, accessed 15 March 2021). 7. WHO guidelines for the treatment of Treponema pallidum (syphilis). Geneva: World Health Organization; 2016 (https://www.who.int/ reproductivehealth/publications/rtis/syphilis-treatment- guidelines/en, accessed 15 March 2021). 8. UNAIDS, WHO, UNICEF. Global AIDS Monitoring online reporting tool. Geneva: UNAIDS; 2021 (https://aidsreportingtool.unaids.org, accessed 15 March 2021). ASSESSMENT OF COUNTRY IMPLEMENTATION OF THE WHO GLOBAL HEALTH SECTOR STRATEGY FOR SEXUALLY TRANSMITTED INFECTIONS (2016-2021): RESULTS OF A NATIONAL SURVEY 24 ANNEX. GLOBAL AIDS MONITORING SYSTEM INDICATORS: DATA YEAR 2019 Annex A: Global AIDS Monitoring, percentage and number of countries performing antenatal care screening for syphilis, 194 WHO Member States, 2017–2019, analysis as of July 2020 WHO region 2019 2018 2017 African Region 66% (31/47) 64% (30/47) 62% (29/47) Region of the Americas 54% (19/35) 80% (21/35) 69% (24/35) South-East Asia Region 55% (6/11) 64% (7/11) 64% (7/11) European Region 13% (7/53) 13% (7/53) 11% (6/53) Eastern Mediterranean Region 33% (7/21) 27% (6/21) 27% (6/21) Western Pacific Region 30% (8/27) 30% (8/27) 44% (12/27) Total 40% (78/194) 41% (79/194) 43% (84/194) Annex B: Global AIDS Monitoring, percentage and number of countries carrying out syphilis screening, positivity and treatment in antenatal care, 194 WHO Member States, 2019, analysis as of July 2020 WHO region Reported antenatal care syphilis screening Reporting antenatal care syphilis positivity Reporting antenatal care syphilis treatment African Region 66% (31/47) 68% (32/47) 60% (28/47) Region of the Americas 54% (19/35) 60% (21/35) 54% (19/35) South-East Asia Region 55% (6/11) 45% (5/11) 45% (5/11) European Region 13% (7/53) 13% (7/53) 13% (7/53) Eastern Mediterranean Region 33% (7/21) 27% (6/21) 24% (5/21) Western Pacific Region 31% (8/27) 33% (9/27) 22% (6/27) Total 40% (78/194) 41% (80/194) 36% (70/194) ANNEX. GLOBAL AIDS MONITORING SYSTEM INDICATORS: DATA YEAR 2019 25 Annex C: Global AIDS Monitoring, percentage and number of countries with syphilis positivity in antenatal care of >1%, reflecting eligibility for a path to elimination, 194 WHO Member States, 2019, analysis as of July 2020 WHO region Reporting antenatal care syphilis positivity Reporting antenatal care syphilis positivity >1% (the denominator is the number of countries reporting) African Region (47 countries) 68% (32/47) 72% (23/32) Region of the Americas (35 countries) 60% (21/35) 48% (10/21) South-East Asia Region (11 countries) 45% (5/11) 20% (1/5) European Region (53 countries) 13% (7/53) 0% (0/2) Eastern Mediterranean Region (21 countries) 27% (6/21) 5% (1/21) Western Pacific Region (27 countries) 33% (9/27) 33% (3/9) Total (194 countries) 41% (80/194) 48% (38/70) Annex D: Global AIDS Monitoring, percentage and number of countries performing syphilis screening and treatment in antenatal care, 194 WHO Member States, 2019, analysis as of July 2020 WHO region Test >95% Test <50% Treat >95% Treat <50% African Region (47 countries) 10% (3/31) 39% (12/31) 57% (16/28) 14% (4/28) Region of the Americas (35 countries) 37% (7/19) 0% (0/19) 26% (5/19) 16% (3/19) South-East Asia Region (11 countries) 50% (3/6) 33% (2/6) 40% (2/5) 0% (0/5) European Region (53 countries) 71% (5/7) 0% (0/7) 86% (6/7) 14% (1/7) Eastern Mediterranean Region (21 countries) 14% (1/7) 71% (5/7) 40% (2/5) 20% (1/5) Western Pacific Region (27 countries) 50% (4/8) 50% (2/4) 67% (4/6) 0% (0/6) Totals (194 countries) 29% (23/78) 27% (21/78) 50% (35/70) 13% (9/70) For more information, contact: World Health Organization Department of Global HIV, Hepatitis and STI programme 20, avenue Appia 1211 Geneva 27 Switzerland E-mail: hiv-aids@who.int www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/sti