EXECUTIVE BOARD 138th session Provisional agenda item 9.2
EB138/31 30 December 2015
Draft global health sector strategies Sexually transmitted infections, 2016–2021 Report by the Secretariat
1. In May 2015, the Sixty-eighth World Health Assembly undertook its final review of progress on the prevention and control of sexually transmitted infections: global strategy, which covered the period 2006–2015.1 The review highlighted the achievements and progress in prevention interventions and programmes, particularly in human papillomavirus control and global elimination of congenital syphilis. Remaining challenges, such as the provision of human and financial resources for programmes to include sexually transmitted infection services within the context of striving for universal health coverage, were also highlighted. 2. During the discussions, a clear need was identified for an updated global strategy on sexually transmitted infections in the post-2015 period. In addition, Member States voiced strong support for WHO’s continued work on the prevention and control of such infections, which would, ideally, address specified, achievable targets to measure success and define challenges. Member States also requested that evaluation of the previous strategy be taken further, and that Member States’ successes and best practices with regard to the goals articulated in the previous strategy be shared. 2 The Secretariat confirmed that a new global strategy on sexually transmitted infections was being developed, which would be aligned with strategy development on HIV and viral hepatitis, and which would be considered by the Executive Board at its 138th session, in preparation for its possible endorsement by the Sixty-ninth World Health Assembly in May 2016. 3. In September 2015, the United Nations General Assembly adopted the 2030 Agenda on Sustainable Development,3 which endorsed the Sustainable Developments Goals, including the targets of particular relevance here, target 3.3: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other communicable diseases”; target 3.7: “By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health 1
In line with resolution WHA59.19 (2006), in which the Director-General was requested, inter alia, to report to the Health Assembly through the Executive Board in 2009, 2012 and 2015 on progress in implementing the strategy. For the global strategy for the prevention and control of sexually transmitted infections, 2006–2015, see document WHA59/2006/REC/1, Annex 2. 2 See the summary records of the Sixty-eighth World Health Assembly, twelfth meeting, section 4 and the thirteenth meeting, section 2 (document WHA68/2015/REC/3).
United Nations General Assembly resolution 70/1 – Transforming our world: the 2030 Agenda for Sustainable Development, see http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1 (accessed 16 December 2015).
3
EB138/31
into national strategies and programmes”; and target 5.6: “Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences”. 4. In line with the 2030 Agenda for Sustainable Development, WHO has developed a draft global health sector strategy on sexually transmitted infections, 2016–2021 (see the Annex of the present report for a summary of the draft strategy). The proposed strategy is based on achievements and lessons learnt from the former global strategy, which covered the period 2006–2015. 5. The process of developing the draft global health sector strategy on sexually transmitted infections was managed together with the draft global health sector strategies on HIV and on viral hepatitis. Three organizing frameworks provided a common structure for the three draft strategies: universal health coverage; the continuum of health services; and the public health approach. Each of the strategies sets out a vision, a goal, targets and actions towards eliminating the diseases as public health threats. To achieve the targets, the actions required were organized under five strategic directions. Under each of the strategic directions, specific actions are described that need to be taken by countries, WHO and partners. 6. The proposed strategy provides a framework for joint WHO and Member State action at the global, regional and country levels. 7. The broad consultative process that led to the draft strategy involved key partners, including Member States, organizations of the United Nations system and other multilateral agencies, donor and development agencies and initiatives, civil society, nongovernmental organizations, scientific and technical institutions and networks, and the private sector. Numerous stakeholder consultations were held, and more than 90 Member States participated in consultations held in all WHO regions in the period April–July 2015. To supplement these consultations and ensure the broadest participation, the Secretariat hosted a widely-promoted public online consultation for six weeks in the period April–June 2015. An official technical briefing on the three strategies (sexually transmitted infections, HIV and viral hepatitis) was held during the Sixty-eighth World Health Assembly. 8. The process was enhanced by input from the WHO civil society reference group and meetings of the Sexually Transmitted Infections Advisory Group and the Scientific and Technical Advisory Group that deals with reproductive health and research. The consultative process was extensive.1 9. The draft strategy articulates WHO’s commitments to achieving a series of goals and targets aligned to the objectives described in the three draft strategies, aimed at ending sexually transmitted infections as a public health threat by 2030, within the context of ensuring healthy lives and promoting well-being for all at all ages. Furthermore, the draft strategy on sexually transmitted infections is aligned to the 2030 Agenda for Sustainable Development, and its focus on ensuring financial security and health equity through a commitment to universal health coverage. The proposed strategy seeks to guide national responses, articulates the Secretariat’s contributions, and is intended to be adapted by regional offices to meet their specific needs.
For more information on the consultative process and on a variety of supporting draft strategy documents and summary reports, see: http://www.who.int/reproductivehealth/ghs-strategies/en/ (accessed 8 December 2015).
1
2
EB138/31
10. The draft strategy recognizes that progress can be gauged from the information obtained through the Global AIDS Response Progress Reporting system, 1 the Gonococcal Antimicrobial Surveillance Programme, 2 and a rapid assessment of programmes related to sexually transmitted infections in Member States, conducted by questionnaire. WHO and its partners have published guidance on targeting screening to most-at-risk and vulnerable populations,3 and most national action plans include interventions targeting sex workers and their clients, men who have sex with men, people who inject drugs, people living with HIV and adolescents. 11. A shortcoming identified in the draft strategy is that screening for sexually transmitted infections is rare in resource-constrained settings, and usually involves testing blood from antenatal care attendees and blood donors for syphilis and markers of HIV and hepatitis B virus infections. 12. Regional and global surveillance and monitoring systems are in particular need of strengthening. More regular etiological studies are urgently needed to identify prevailing causative organisms. 13. Resistance of Neisseria gonorrhoeae to cephalosporins, the last-line treatment, is emerging, although globally only 67 countries, mainly in the European and Western Pacific regions, have reported on antimicrobial resistance. In response, WHO has issued information and a global action plan to control the spread and impact of gonococcal resistance, which is now also included within the broader WHO global action plan for antimicrobial resistance.4 14. The annual global surveillance reports on sexually transmitted infections5 summarize data on: the number of reported cases of sexually transmitted infections; gonococcal antimicrobial resistance; burdens of disease; and progress towards elimination of mother-to-child transmission of syphilis.6 15. The actions outlined in the draft strategy seek to ensure that the health sector response on sexually transmitted infections is strengthened to protect investments made to date and to ensure that people-centred approaches help secure sustainable financing for relevant services, interventions and programmes into the future.
1 For more information on Global AIDS Response Progress Reporting, see: http://www.unaids.org/en/dataanalysis/knowyourresponse/globalaidsprogressreporting (accessed 8 December 2015).
For more information on the Gonococcal Antimicrobial Surveillance Programme, see: http://www.who.int/reproductivehealth/topics/rtis/gonococcal_resistance/en/ (accessed 8 December 2015). See Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations, available at: http://www.who.int/hiv/pub/guidelines/keypopulations/en/ (accessed 8 December 2015). 4 More information on gonococcal antimicrobial resistance and the publication, Sexually transmitted infections, are available at: http://www.who.int/reproductivehealth/publications/rtis/articles/en/ (accessed 8 December 2015). The publication, Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae, is available at: http://www.who.int/reproductivehealth/publications/rtis/9789241503501/en/ (accessed 8 December 2015). 3
2
The report on global sexually transmitted infection surveillance 2013 is available at: http://www.who.int/reproductivehealth/publications/rtis/stis-surveillance-2013/en/ (accessed 8 December 2015). For more information on progress towards the elimination of mother-to-child transmission of syphilis, see: http://www.who.int/reproductivehealth/topics/rtis/cs_global_updates/en/ (accessed 8 December 2015). 6
5
3
EB138/31
ACTION BY THE EXECUTIVE BOARD 16. The Executive Board is invited to consider the draft global health sector strategy on sexually transmitted infections, 2016–2021, which is available on the website,1 and make a recommendation on its possible endorsement by the Sixty-ninth World Health Assembly.
The full draft global health sector strategy on sexually transmitted infections, 2016 –2021 is available at: http://www.who.int/reproductivehealth/ghs-strategies/en/ (accessed 3 December 2015)
1
4
EB138/31
ANNEX SUMMARY OF THE DRAFT GLOBAL HEALTH SECTOR STRATEGY ON SEXUALLY TRANSMITTED INFECTIONS, 2016–2021 1. The draft global health sector strategy on sexually transmitted infections, 2016–2021 1 (see Figure) builds on conclusions of an evaluation that was reviewed by the progress report presented to the Sixty-eighth World Health Assembly in May 2015,2,3 and sets out a vision, a goal, targets and actions for ending the sexually transmitted infections epidemic as a public health problem. 2. The draft strategy describes an important component of the health sector contribution towards achieving the ambitious targets of the 2030 Agenda for Sustainable Development adopted by the United Nations General Assembly in September 2015.4 It outlines what countries need to do and what WHO will do to effectively address sexually transmitted infections. The implementation of the strategy will contribute to a radical decline in new sexually transmitted infections and related deaths (such as stillbirths and cervical cancer), while also improving the health of the individual, men’s and women’s sexual health, and the well-being of all people.
WHY THE SEXUALLY TRANSMITTED INFECTION RESPONSE SHOULD BE A GLOBAL PRIORITY 3 It is estimated that, annually, there are 357 million new cases of four curable sexually transmitted infections among people aged 15–49 years: Chlamydia trachomatis (131 million), Neisseria gonorrhoeae (78 million), syphilis (6 million), and Trichomonas vaginalis (142 million).5 The prevalence of some viral sexually transmitted infection is similarly high, with an estimated 417 million people infected with herpes simplex type 2, and approximately 291 million women infected with the human papillomavirus. The prevalence of these sexually transmitted infections varies by region and gender. 4. These epidemics have a profound impact on the health and lives of children, adolescents and adults worldwide, examples of such impacts on health include: • Fetal and neonatal deaths – syphilis in pregnancy leads to over 300 000 fetal and neonatal deaths each year, and places an additional 215 000 infants at increased risk of early death;
The full draft global health sector strategy on sexually transmitted infections, 2016 –2021 is available at: http://www.who.int/reproductivehealth/ghs-strategies/en/ (accessed 3 December 2015). See the progress report presented to the Sixty-eighth World Health Assembly, document A68/36 progress report G. The evaluation report referred to is entitled, “Progress report of the implementation of the global strategy for the prevention and control of sexually transmitted infections: 2006–2015”, and is available at: http://apps.who.int/iris/bitstream/10665/183117/1/9789241508841_eng.pdf?ua=1 (accessed 11 December 2015). 3 4 2
1
Document A68/36 progress report G.
United Nations General Assembly resolution 70/1 – Transforming our world: the 2030 Agenda for Sustainable Development, see http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E (accessed 30 November 2015). 5
Most recent estimates are for 2012.
5
EB138/31
Annex
• Cervical cancer – the human papillomavirus infection is responsible for an estimated 530 000 cases of cervical cancer and 275 000 cervical cancer deaths each year; • Infertility – sexually transmitted infections such as gonorrhoea and chlamydia are important causes of infertility, especially in sub-Saharan Africa; • HIV risk – the presence of a sexually transmitted infection, such as syphilis, gonorrhoea, or herpes simplex virus infection, greatly increases the risk of acquiring or transmitting HIV infection (by two to three times in some populations); • The physical, psychological and social consequences of sexually transmitted infection severely compromise the quality of life of those infected. 5. Most of the tools required for reaching ambitious 2030 targets are available, and potentially vital innovations are on the horizon, such as point-of-care tests for sexually transmitted infections, vaccines against such infections and multipurpose technologies. Using them to full effect, however, will require a rapid increase in investment in the sexually transmitted infection response, focusing resources on the most effective programmes and on the populations and geographical locations where need is greatest, and linking sexually transmitted infection interventions with other health services, to mutual benefit. Such key directions are detailed in the present draft strategy.
PRIORITIZING THREE INFECTIONS FOR STRATEGIC FOCUS 6. The draft health sector strategy on sexually transmitted infections focuses primarily on three infections that require immediate action for control and impact: (1) Neisseria gonorrhoeae because of the rising risk of untreatable gonorrhoea;
(2) Treponema pallidum with the elimination of congenital syphilis, which implies control of syphilis in key populations and strong systems to ensure screening and treatment of all pregnant women; (3) Human papillomavirus, with an emphasis on vaccination towards the elimination of cervical cancer and genital warts.
6
Annex
EB138/31
Figure. Outline of the draft global health sector strategy on sexually transmitted infections, 2016–2021
7
EB138/31
Annex
FRAMING THE STRATEGY 7. The draft strategy is designed to contribute to the attainment of the Sustainable Development Goal on health (Goal 3). It describes how the health sector response to sexually transmitted infections can contribute to the achievement of universal health coverage and other key health and development targets. The draft strategy is also aligned with other relevant health strategies and plans, including sexual and reproductive health, HIV, violence against women and girls, adolescent health, maternal, newborn and child health, vaccines, noncommunicable diseases, the framework on integrated peoplecentred health services, viral hepatitis, tuberculosis, and blood safety. This draft strategy (see Figure) draws on three organizing frameworks: universal health coverage; the continuum of services related to sexually transmitted infections; and the public health approach.
VISION, GOAL, TARGETS AND GUIDING PRINCIPLES Global vision 8. Zero sexually transmitted infection-related complications and deaths, and zero discrimination in a world where everybody, however marginalized, has free and easy access to sexually transmitted infection prevention and treatment services resulting in people able to live long and healthy lives.
Goal 9. End sexually transmitted infection epidemics as major public health concerns1
Global targets for 2030 10. A concerted effort to rapidly scale up effective interventions and services can achieve the goal of ending sexually transmitted infection epidemics as a public health concern by 2030 by reaching this ambitious set of targets: • 90% reduction of T. pallidum incidence globally (2018 global baseline). • 90% reduction in N. gonorrhoeae incidence globally (2018 global baseline). • ≤50 cases of congenital syphilis per 100 000 live births in 80% of countries. • Sustain 90% national coverage and at least 80% in every district (or equivalent administrative unit) in countries with human papillomavirus vaccine in their national immunization programme.
1 End sexually transmitted infection epidemics as major public health concerns is defined by the reduction in N. gonorrhoea and T. pallidum; as well as by the elimination of congenital syphilis and of pre-cervical cancer lesions through the high coverage of human papillomavirus vaccines.
8
Annex
EB138/31
MILESTONES FOR 2020 11. Milestones for 2020 include: • 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 at least 95% of pregnant women screened for syphilis; 90% of pregnant women screened for HIV with free, prior and informed consent; and 95% of pregnant, infected women receiving effective treatment. • 70% of key populations have access to a full range of services relevant to sexually transmitted infection 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 contexts. • 90% national coverage achieved and 80% coverage achieved in every district (or equivalent administrative unit) in countries with the human papillomavirus vaccine in their national immunization programme. • 70% of countries report on antimicrobial resistance in N. gonorrhoeae.
THE STRUCTURE OF THE DRAFT STRATEGY 12. The draft strategy outlines a pathway towards the goal of eliminating sexually transmitted infections as a public health threat by 2030. It describes five strategic directions, under which there are priority actions that countries and WHO need to take in order to scale up a global response. 13. The proposed response capitalizes on the enormous opportunities for ending sexually transmitted infection epidemics as major public health concerns. The five strategic directions, in the present draft strategy for the period 2016–2021, include: • Strategic direction 1: Information for focused action – Focuses on the need to understand the sexually transmitted infection epidemic and response as a basis for advocacy, political commitment, national planning, resource mobilization and allocation, implementation, and programme improvement. • Strategic direction 2: Interventions for impact – Addresses the first dimension of universal health coverage by describing the essential package of high-impact interventions that need to be delivered along the continuum of services to reach country and global targets, and which should be considered for inclusion in national health benefit packages. • Strategic direction 3: Delivering for equity – Addresses the second dimension of universal health coverage by identifying the best methods and approaches for delivering services to different populations and in different locations, so as to achieve equity, maximize impact and ensure quality. It includes a critical focus on interventions and approaches focused on human rights, gender equality, and addressing barriers that undermine equitable access to services for different populations and in different settings and locations.
9
EB138/31
Annex
• Strategic direction 4: Financing for sustainability – Addresses the third dimension of universal health coverage by identifying sustainable and innovative models for the financing of responses and approaches for reducing costs so that people can access the necessary services without incurring financial hardship. • Strategic direction 5: Innovation for acceleration – Identifies those areas where there are major gaps in knowledge and technologies, where innovation is required to shift the trajectory of the sexually transmitted infection response towards and beyond the 2020 milestones. 14. The five strategic directions and the priority actions are informed by the progress report presented to the Sixty-eighth World Health Assembly,1 and the evaluation of the implementation of the 2006–2015 sexually transmitted infections global strategy.2 The evaluation emphasized a need to: strengthen surveillance and improve knowledge of prevalence, etiology and antimicrobial resistance; scale up sexually transmitted infection interventions, in particular for vulnerable and key populations, including through a focus on ensuring an appropriate enabling environment; increase access to services by integrating the prevention and management of sexually transmitted infections into the broader agendas of HIV, sexual and reproductive health and other key platforms; strengthen financing mechanisms for relevant services and strengthening human resource capacity; accelerate access to innovations through the development of point-of-care diagnostic tests and new preventive interventions, such as vaccines, microbicides, suppressive therapy for the herpes simplex virus, and HIV prevention and health promotion methods.
STRATEGY IMPLEMENTATION 15. Effective implementation of the strategy depends on concerted action from all stakeholders in the health sector response. Strong partnerships are required with bilateral donor and development agencies and initiatives, funds and foundations, civil society, technical institutions and networks, the commercial private sector and partnership networks. 16. The draft strategy calls for greater integration and linking of sexually transmitted infection services and programmes with those for other relevant health areas including for: HIV; family planning; maternal and neonatal care; health promotion, including sexual health; immunization; noncommunicable diseases; and mental health. And in addition to ensuring appropriate coverage through comprehensive primary health care, other sectors such as school health education programmes targeting adolescents, and occupational health can be leveraged to help reduce costs, improve efficiency and lead to better outcomes. 17. Implementation of the strategy will be monitored using existing mechanisms: monitoring and reporting progress towards global goals and targets; monitoring and evaluating the response at regional and country levels; and applying WHO’s framework for results-based management.
1
Document A68/36 progress report G.
2 The progress report of the implementation of the global strategy for the prevention and control of sexually transmitted infections: 2006–2015 is available at: http://www.who.int/reproductivehealth/publications/rtis/STIprogress.pdf?ua=1 (8 December 2015).
10
Annex
EB138/31
18. Full achievement of the global health sector strategy on sexually transmitted infections, 2016 – 2021 will cost an estimated US$ 18 100 million for the five years, of which 99.9% is for implementing priority interventions in 117 low- and middle-income countries, and almost US$ 13 million (0.1%) is for global-level technical support, research and advocacy by WHO and partners. 19. Clinical sexually transmitted infection management is estimated to cost an overall US$ 3000 million, of which service delivery makes up US$ 818 million, and diagnostic testing for gonorrhoea and chlamydia US$ 1400 million.
=
=
=
11