MEETING REPORT

ACCELERATING THE
GLOBAL SEXUALLY
TRANSMITTED
INFECTIONS RESPONSE
REPORT ON THE FIRST INFORMAL THINK-TANK
MEETING

JUNE 2020
ACCELERATING THE
GLOBAL SEXUALLY
TRANSMITTED
INFECTIONS RESPONSE
REPORT ON THE FIRST INFORMAL THINK-TANK
MEETING

JUNE 2020
Accelerating the global Sexually Transmitted Infections response: report on the first informal Think-Tank meeting

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 iii

CONTENTS
ACKNOWLEDGEMENTS iv
ABBREVIATIONS AND ACRONYMS v
I. BACKGROUND 1
II. THE CONTEXT 3
A. Burden of Sexually Transmitted Infections 3
B. The Sexually Transmitted Infection strategy 6
C. WHO transformation 6
D. Progress in the implementation of Sexually Transmitted Infection interventions 10
E. Challenges in Sexually Transmitted Infection control programmes 12

III. DISCUSSION 13
1 Sexually Transmitted Infection strategy: governance and leadership 13
2 Sexually Transmitted Infection surveillance 13
3 Sexually Transmitted Infection testing: innovation and access 14
4 Sexually Transmitted Infection treatment: innovation and access 15
5 Sexually Transmitted Infection service delivery 16
6 Sexually Transmitted Infection prevention: advocacy and community activities 17
7 Reducing stigma and discrimination 18

IV. POLLS AND RESULTS 19

V. CONCLUSIONS 21

REFERENCES22

ANNEX 1: AGENDA OF THE MEETING 24

ANNEX 2: LIST OF PARTICIPANTS 25

iv

ACKNOWLEDGEMENTS
The Global HIV, Hepatitis and Sexually Transmitted Infections Global HIV, Hepatitis and Sexually Transmitted Infections
Programmes (HHS) at the World Health Organization (WHO), Programmes gave overall technical leadership and direction
Geneva, are grateful and would like to thank all individuals to the process. Other Secretariat staff who worked closely on
and organisations that contributed to the development of this organising and conducting the meeting and documenting the
document to make it relevant and responsive to the global public outcomes are Teodora Wi, Andy Seale, Melanie Taylor and
health needs in the area of sexually transmitted infections. Yamuna Mundade. WHO is grateful for the technical review,
expert comments and edits provided by Francis Ndowa, expert
We appreciate the overall support of representatives of peer-reviewer who provided support in editing this report.
ministry of health, partners, donors, experts, community
representatives, and staff members from regional offices who
participated in the meeting. Meg Doherty, Director, WHO
 v

ABBREVIATIONS AND ACRONYMS

AMR antimicrobial resistance

ANC antenatal care
COVID coronavirus disease
EMTCT elimination of mother-to-child transmission
GAM Global AIDS Monitoring
Gavi The Vaccine Alliance
The Global Fund The Global Fund for AIDS, Tuberculosis and Malaria
GHSS Global Health Sector Strategy
GLASS Global Antimicrobial Surveillance System
GPHG Global Public Health Goods
GPW General Programme of Work
HHS Global HIV, Viral hepatitis and STIs programme
HIV human immunodeficiency virus
HPV human papillomavirus
HSV herpes simplex virus
HTLV human T-cell lymphotropic virus
LMIC low- and middle-income countries
MNCH maternal, neonatal, child and adolescent health
MSM men who have sex with men
NSP National Strategic Plan
PADO Paediatric AIDS Drug Optimization
POCT point-of-care test
PrEP pre-exposure prophylaxis
SDGs Sustainable Development Goals
SRH sexual and reproductive health
SRHR sexual and reproductive health and human rights
STI sexually transmitted infection
UCN Division of communicable and noncommunicable diseases
UHC universal health coverage
UN United Nations
UNAIDS Joint United Nations Programme on HIV/AIDS
WHO World Health Organization
 1

I. BACKGROUND
According to estimates by WHO in 2016, about 1 million WHO’s 2019 progress report on HIV, viral hepatitis and
new sexually transmitted infections (STIs) are acquired STIs acknowledges that, “The global response to sexually
every day for the four commonest curable STIs – Treponema transmitted infections is in crisis after years of neglect.
pallidum, Chlamydia trachomatis, Neisseria gonorrhoeae and Opportunities to link with HIV and broader sexual and
Trichomonas vaginalis. Ninety per cent of them occur in low- reproductive health services must be seized to resume
and middle-income countries (LMICs) (1). If not detected and progress” (16). The strategy on STIs has set ambitous targets
treated in good time, these STIs cause severe complications, that include reductions in the incidence of T. pallidum and
such as pelvic inflammatory disease, infertility and adverse N. gonorrhoeae by 90% by 2030, and STI services, or links
pregnancy outcomes. to services, in all primary, HIV, reproductive health, family
planning, and antenatal and postnatal care services by
Of the two commonest viral STIs other than the human 2020 (17). Globally, adult STI incidence is not declining (1).
immunodeficiency virus (HIV), the human papillomavirus There are large gaps in domestic budgets and international
(HPV) is responsible for high morbidity, especially the high- funding for STI prevention and care, leading to limited and
risk genotypes of HPV, which are the main cause of cancers underresourced STI prevention and clinical care services,
of the cervix, anus and penis, resulting in over 300 000 and surveillance.
cervical cancer deaths globally per year (2). The other is the
human herpes simplex virus (HSV), with an estimated adult On account of its high mortality, HIV has been one of the
population of 500 million living with the infection globally foremost global political priorities, but the other STIs have,
in 2016 (3). over the years, lost such traction for resources. However, as
the HIV and STI syndemics become better understood, and the
Many STIs, both ulcerative and inflammatory, increase the risk burden of STIs more evident, more effort and opportunities
of HIV acquisition and transmission. Failure to prevent and must be harnessed to increase attention and identify
adequately treat STIs undermines efforts to end HIV globally resources to strengthen STI prevention and control. First,
(4–8). Expanded use of antiretroviral medicines for treatment global estimates of STIs indicate sustained high incidence and
and prevention of HIV transmission and acquisition, including recent country-level data demonstrate high STI prevalence
pre-exposure prophylaxis (PrEP), has implications for the among general populations such as pregnant women (18–
motivation to use condoms, with an observed increase in 19) and women attending family planning services in some
some STIs, such as syphilis and gonorrhoea in some settings, settings (20). Meanwhile, antenatal screening programmes
especially among men who have sex with men (MSM) (9–13). are only slowing declines in congenital syphilis (21). Second,
Added to this is the global spread of antimicrobial resistance the alarming threat of untreatable gonorrhoea should (14–15)
(AMR) in some sexually transmitted pathogens, especially drive efforts at formulating policies to mitigate the global
N. gonorrhoeae, with the threat of untreatable gonococcal threat of AMR (22). Third, a recent review has highlighted a
infection in view of the limited choices and classes of high STI prevalence at baseline screening and high incidence
antibiotics available (14–15). while taking PrEP for HIV (10). This suggests that PrEP could
be an important gateway to and opportunity for improved STI
testing and treatment in some key populations, including in
2

LMICs (9). Fourth, research in new technologies, including The meeting had the following objectives:
vaccines (23) and point-of-care diagnostic tests (POCT) (24)
for STIs, such as the dual HIV–syphilis rapid POCT (recently 1. Strategize and identify a clear way forward to revitalize
recommended by WHO as the first test in antenatal care STI programming at the country level.
settings (ANC) (25) offers progress for new prevention 2. Identify opportunities to accelerate country-level
and diagnostic technologies. Fifth, the increasing rates of implementation of the current and future Global Health
well-known STIs as well the emergence of newer outbreak- Sector Strategy (GHSS) on Sexually Transmitted Infections.
associated and neglected but re-emerging STIs such as human
T-cell lymphotropic virus (HTLV)-1, and Zika and Ebola viruses 3. Explore challenges and gaps that could form the basis for
demonstrate the need for aggressive prevention interventions collaboration, including through global-level support and
(26). Finally, global initiatives to incorporate disease-specific facilitation for achieving STI control in priority countries.
care into a framework of universal health coverage (UHC) (27)
offer opportunities to align STI interventions, such as partner 4. Present an update of the global epidemiology, the
services, for both HIV and STIs (24), within broader priorities implementation of the current GHSS on STIs and plans for
for comprehensive health care. developing the next strategy for 2022–2030.

WHO has undergone a process of organizational change during 5. Share ideas and themes for a global STI stakeholders’
2020, during which time the STI components of programming, meeting scheduled for later in 2021, which could inform
STI surveillance, normative guidance and mitigation of AMR the 2022–2030 global STI strategy.
in STI pathogens is now part of the WHO Department of HIV, The agenda of the meeting and list of participants are in
Hepatitis and STI (HHS) in order to better operationalize Annexes 1 and 2, respectively.
opportunities for an integrated approach and link STIs with
HIV and hepatitis. WHO HHS has now embarked on focused
meetings with select STI partners to review and discuss the
current epidemiology of STIs and a public health approach to
STI service delivery at global and national levels.

HSS convened this informal consultation with partners to

seek input on strengthening the global STI response. The
meeting discussed the strengthening of political commitment,
financing and delivery of STI services at the country level. It
laid the groundwork for wider engagement of partners for
global investment in STI control and forms the basis for a
larger global STI stakeholder meeting projected for the end
of 2020.
 3

II. THE CONTEXT

A. Burden of Sexually Transmitted Infections Africa. Additionally, STIs, such as syphilis, gonorrhoea,
genital herpes simplex virus infection, greatly increase the
Based on the 2016 global estimates of 376 million new cases risk of acquiring or transmitting HIV infection, by two- to
of curable STIs, WHO estimates that more than 1 million threefold in some populations (4–8). Furthermore, the
curable STIs comprising chlamydia, gonorrhoea, syphilis and physical, psychological and social consequences of STIs
trichomoniasis are acquired every day among those aged 15– have not been fully quantified, but severely compromise
45 years (Fig. 1) (1). Addressing such an enormous burden of the quality of life of those infected and affected.
STIs will contribute significantly towards improving the health
The emerging AMR in Neisseria gonorrhoeae and
of billions of people to attain one of the goals of WHO’s Global
other organisms causing STIs is a major threat for the
Programme of Work 13 (GPW13) (28 ). Information from the
management and control of STIs. Many of the commonly
six WHO regions for three of the curable STIs – gonorrhoea,
used antibiotics have been rendered largely ineffective
chlamydia and trichomoniasis – show that there is a paucity
by AMR in N. gonorrhoeae. There is high-level resistance
of data to make accurate and more meaningful estimates as
to fluoroquinolones, increasing resistance to azithromycin
a limited number of countries report their data. Improving
and emerging resistance to ceftriaxone and cefixime, the
surveillance for STIs will be a priority to make data more
last class of recommended antibiotics for the treatment of
reliable for countries to allocate commensurate resources for
gonorrhoea (14,15). High-level resistance is also reported in
national impact.
Mycoplasma genitalium, which complicates the treatment of
STIs cause immense morbidity and mortality, particularly urethral and cervical infections (29).
in the developing world. It is estimated that syphilis in
Future work will focus on strengthening gonococcal AMR
pregnancy leads to over 230 000 fetal and neonatal deaths
surveillance, conserving the effectiveness of cephalosporins
each year and, in 2016, placed an additional 400 000
and potential new treatment options, increasing the pipeline
infants at increased risk of early death (21). HPV infection
of new antibiotics and facilitating the development of low-cost
is responsible for an estimated 530 000 cases of cervical
POCTs to identify gonorrhoea and chlamydial infections, AMR/
cancer and 275 000 cervical cancer deaths each year (2).
susceptibility testing and advocating for the development of
N. gonorrhoeae and C. trachomatis infections are important
gonococcal vaccines.
causes of preventable infertility, especially in sub-Saharan

Fig. 1: Estimated 376 million new cases of curable STIs in 2016

(chlamydia, gonorrhoea, syphilis, trichomoniasis)

23
million
75
million

51 108
million
34 million
million

86
million

WHO Region of the Americas WHO African Region WHO South-East Asia Region

WHO Western Pacific Region WHO Eastern Mediterranean Region WHO European Region

Source: Rowley et al. https://www.who.int/bulletin/volumes/97/8/18-228486.pdf?ua=1

4

Global estimates of herpesvirus infections were released in Although the estimated total number of cases of congenital
May 2020 and estimates of HPV prevalence among men and syphilis globally fell from 748 000 in 2012 to 661 000 in 2016,
women are under way. Both the prevalence and incidence and cases of congenital syphilis per 100 000 live births fell
of these infections are based on modelling and projections. from 539 to 473, global rates of congenital syphilis by region
There are approximately 500 million people living with in 2012 and 2016 show that progress was rather limited
genital herpes [3] and one in seven women are estimated to in controlling transmission during these years. The rates
have prevalent HPV infection (30). If all the herpes and HPV of congenital syphilis were highest in the African Region
infections are added to the estimated number of curable STIs, and lowest in the European Region, reflecting variations
there is a huge and widespread burden of STIs. in the respective regions’ maternal prevalence and service
coverages (Fig. 2) (21). Of the 661 000 cases of congenital
The Spectrum-STI module was developed to generate country syphilis in 2016, over 350 000 occurred as adverse birth
estimates of prevalence levels and time trends for active outcomes, including stillbirths and neonatal deaths (21).
syphilis, gonorrhoea and chlamydia to support country-level
estimation of these infections. Progress has been made in WHO seeks to improve and increase the frequency of national
generating country-level syphilis estimates. The elimination and global estimates of the curable STIs, mainly chlamydia,
of mother-to-child transmission (EMTCT) of syphilis and HIV gonorrhoea and trichomoniasis through promotion of
have bolstered data availability around syphilis. Almost 1000 prevalence surveys for these infections among general
data points have been achieved between 2009 and 2016 for populations and improvement in case reporting through
syphilis. The majority of countries provided maternal syphilis sentinel surveillance.
screening and treatment data from integration with maternal
health. Currently, it takes four years to update global data for A more recent observation of concern is the increased incidence
STIs. This needs to be thought through to see if STI data can be and prevalence of STIs among users of PrEP for prevention of
compiled as frequently as HIV data. Current reporting systems HIV infection. The burden of STIs ranged from 10% to 20%
are inadequate and limited general population prevalence for infections such as gonorrhoea, chlamydia, trichomoniasis
surveys are conducted to provide data for the Spectrum-STI and that caused by Mycoplasma genitalium, with an equally
model to generate national-level estimates. increased incidence of infections. The pooled incidence
from studies reporting the composite outcome of chlamydia,

Fig. 2. Estimated global congenital syphilis rates by WHO region

1200
Congenital Syphilis cases per 100,000 live births

1000

800

600

400

200

0
2012 2016 2012 2016 2012 2016 2012 2016 2012 2016 2012 2016
AFR AMR EMR EUR SEAR WPR

Non-clinical CS Stillbirth due to CS Neonatal death due to CS Prematurity or LBW due to CS Liveborn with clinical CS

Source: Korenromp et al. PLoS One. 2019

 5

gonorrhoea and early syphilis was 72.2 per 100 person-years than the prevalence, which demonstrated that PrEP users have
(10). Of the 3325 citations identified, 88 articles were included multiple instances of these infections per year (Table 1) (10).
(71 published, 17 unpublished). Data were from 26 countries Therefore, it is essential to provide STI care in PrEP interventions
– 70% were from high-income countries and 66% were from to reduce the acquisition and transmission of STIs (9).
MSM-only programmes. In studies reporting a composite
outcome of chlamydia, gonorrhoea and early syphilis, the pooled In addition to key populations, several PrEP studies in young
prevalence was 23.9% before starting PrEP. The prevalence African women have also shown a high prevalence and
of the STI pathogen by anatomical site showed that it was incidence of STIs, with the majority of those asked about
highest in the rectum (C. trachomatis: 8.5%, N. gonorrhoeae: symptoms being asymptomatic (Table 2) (11–13). With
9.3%) compared to the genital tract (C. trachomatis: 4.0%, N. undiagnosed and untreated STIs, these young women are
gonorrhoeae: 2.1%) and oropharyngeal sites (C. trachomatis: at a higher risk of developing adverse reproductive health
2.4%, N. gonorrhoeae: 4.9%) [10]. The incidence was higher consequences, including pelvic inflammatory disease, ectopic
pregnancy and infertility (11–13).

Table 1. High Sexually Transmitted Infection incidence and prevalence of Sexually Transmitted Infections among
PrEP users (10)

Prevalence Incidence

Pathogen Number of studies Total sample size Prevalence Number of studies Total sample size Incidence per
pooled (95% CI) pooled 100PY (95% CI)

C. trachomatis (any site) 12 4918 10.8 14 6756 21.5

(6.4-16.1) (17.9-25.8)

N. gonorrhoeae (any site) 14 6340 11.6 13 6462 37.1

(7.6-16.2) (18.3-25.5)

T. pallidum* 22 9757 5.0 23 12459 11.6

(3.1-7.4) (9.2-14.6)

Hepatitis B virus 4 4370 1.3 2 1353 1.2

(0.1-3.5) (0.6-2.6)

Hepatitis C virus 4 2555 2.0 8 3786 0.3

(0.8-3.7) (0.1-0.9)

M. genitalium 1 198 17.2 - - -

(12.2-23.2)

Trichomonas vaginalis 2 1379 5.9 1 50 0

(4.7-7.2)
Source: Ong JJ et.al. JAMA Netw Open. 2019
Any C. trachomatis, N. gonorrhoeae 16 8431 23.9 11 6301 72.2
or T. pallidum (18.6-29.6) (60.5-86.2)

Source: Ong et al. JAMA Netw Open. 2019

Table 2. Sexually Transmitted Infection prevalence and incidence in young African women using PrEP (11–13)

CT prevalence (%) CT incidence (Per 100PY) GC prevalence (%) GC incidence (Per 100PY)

VOICE 12 27 4 11
(South Africa, Uganda, Zimbabwe) N=5029

MTN-020/ASPIRE 12 27 4 11
(Malawi, South Africa, Uganda, Zimbabwe) N=2629

Plus Pills 48 NA 6 NA
(Cape Town) N=150

HPTN 082 29 33 8 14
(Cape Town, Johannesburg, Harare) N=427

POWER 26 53 10 20
(Cape Town, Johannesburg, Kisumu) N=1504

3P project 25 42 11 14
(Cape Town) N=200
6

B. The Sexually Transmitted Infection Strategy targets. Achieving the Triple Billion targets requires novel
ways of working, not only within WHO but also alongside
The Department of HHS aims to achieve the targets of the our partners for harnessing the capacities and potential of
GHSS for HIV, Hepatitis and STIs through GPW13, which the whole UN system, leveraging civil society and the private
includes promoting health around HIV and viral hepatitis, and sector, and mobilizing new technologies to address complex
control of STI to achieve the Sustainable Development Goals global health issues.
(SDGs). HHS is working towards country impact to achieve
GPW13 2019−2023 sets out WHO’s 5-year strategic plan with
these targets.
the overarching goal of ensuring healthy lives and promoting
well-being for all, at all ages, and a concrete and ambitious
The SDGs, GPW13 and the Triple Billion goals Triple Billion target (28). It is firmly based on the 2030 Agenda
for Sustainable Development and aligned with the principles
The SDGs recognize health as a precondition for, and an and purpose of UN reform, including the reinforcing of national
outcome and indicator of, sustainable development and, ownership, development of responses specific to country
thus, position global health as a political priority (31). GPW13 contexts, and ensuring the effective delivery of results on the
is clearly committed to supporting United Nations (UN) ground (Fig. 3).
reform and the UN Secretary General’s proposal to work as
“One UN”(28). The UN reform is an opportunity to position GPW13 also sets out how WHO will achieve these goals by
health in the centre of the UN system’s work at country level making some important strategic shifts, namely, stepping
for achieving the SDGs. At the “Leading Health through UN up leadership, driving impact in every country and focusing
Reform” meeting held on the sidelines of the WHO Global global public goods on impact. It places WHO’s country offices
Management meeting in Nairobi, Kenya, 10–12 December and their leaders at the forefront of ensuring that WHO and
2018, WHO committed to leading a transformative agenda Member States together can achieve the Triple Billion targets
that supports countries in reaching all health-related SDG by 2023.

Fig. 3 . Overview of WHO’s Thirteenth General Programme of Work 2019−2023: strategic priorities and shifts (28)

MISSION PROMOTE HEALTH – KEEP THE WORLD SAFE – SERVE THE VULNERABLE

STRATEGIC
PRIORITIES ENSURING HEALTHY LIVES AND PROMOTING WELL-BEING FOR ALL AT ALL AGES BY:
(AND GOALS)
ACHIEVING UNIVERSAL ADDRESSING HEALTH PROMOTING HEALTHIER
HEALTH COVERAGE EMERGENCIES POPULATIONS

1 BILLION 1 BILLION 1 BILLION

more people benefitting from more people better protected more people enjoying better
universal health coverage from health emergencies health and well-being

STRATEGIC DRIVING PUBLIC HEALTH IMPACT IN EVERY COUNTRY

SHIFTS differentiated approach based on capacity and vulnerability
STEPPING UP LEADERSHIP FOCUSING GLOBAL
Policy Strategic Technical Service
diplomacy and advocacy; PUBLIC GOODS ON
dialogue support assistance delivery
gender equality, health IMPACT
to develop to build high to build to fill critical
equity and human rights; normative guidance and
systems of performing national gaps in
multisectoral action; finance the future systems institutions emergencies agreements; data, research
and innovation

Mature health system Fragile health system

Source: Thirteenth Global Programme of Work 2019–2023. Geneva: WHO; 2019 (https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP-18.1-eng.pdf, accessed 13 October 2020).
 7

The Global Health Sector Strategies for HIV, WHO’s current GHSS is till the end of 2021, but work is under
way to develop a new strategy covering the period to the end
Hepatitis and Sexually Transmitted Infections of 2030. Thus, in the upcoming period, the department will
undertake a broad consultative process for the development
Three interlinked GHSS were developed by WHO with the
of the next strategy, as previously, but may need to be more
intention of addressing three major public health issues – HIV,
streamlined during the period of the COVID-19 pandemic.
viral hepatitis and STIs – for the period 2016 to 2021 (17).
Commentaries and publications are being produced on how
All three strategies contribute to the attainment of the post-
to address the political and programmatic contexts to be able
2015 health goal, SDG 3, towards ensuring financial security,
to address barriers and explore opportunities.
health equity and UHC. In 2016, the World Health Assembly
approved the joint WHO GHSS on HIV, Hepatitis and STIs An assessment was conducted in 2018 to evaluate the mid-
(WHA69.22) (17). term progress in implementing the GHSS 2016–2021 (16).
The assessment identified that the global response to STIs
The GHSS on STIs aligns its goals, targets and objectives
is in crisis after many years of suboptimal activities. STIs are
to the HIV and hepatitis strategies and to the 2030 Agenda
not declining globally, except for slow declines in congenital
for Sustainable Development. Its focus on ensuring financial
syphilis. In several countries, STIs are increasing. The report
security and health equity through a commitment to UHC
warned that a complete reversal in trend would be required to
links to the 2030 Agenda for Sustainable Development for
achieve the targets by 2030. There were opportunities to link
the eradication of poverty and reduction of inequality. The STI
with HIV services and with broader efforts at sexual health
Strategy aims to end STIs as a public health threat by 2030,
services, which need to be capitalized on to achieve progress
within the context of ensuring healthy lives and promoting
in controlling STIs.
well-being for all, at all ages. The STI Strategy was developed
around five pillars: (1) strategic information, (2) intervention
for impact, including WHO’s global public health goods,
(3) delivery for equity, (4) financing, and (5) innovation for
acceleration (Fig. 4).

Fig. 4. Global Health Sector Strategy on Sexually Transmitted Infections (STIs) 2016–2021 (17)

VISION, GOAL AND TARGETS

Frameworks for action: Universal health coverage; the continuum of services; and a public health approach

Strategic Strategic Strategic Strategic Strategic

Direction 1: Direction 2: Direction 3: Direction 4: Direction 5:

Information for Interventions Delivering Financing for Innovation for

focused action for impact for equity sustainability acceleration

The who and The what The how The financing The future
the where

Strategy Implementation: Leadership, Partnership, Accountability, Monitoring & Evaluation

8

C. WHO transformation of prioritization, leadership and governance. These collective

efforts, well-coordinated and mutually supportive across the
WHO has undergone a process of organizational change various WHO divisions at headquarters in Geneva and at all
during 2020, referred to as Transformation (32). With this three levels of the Organization, should allow for greater
transformation, the STI programmatic agenda (surveillance, effectiveness and efficiency of the HHS department’s work,
normative guidance, country support and programming) is delivered both individually and collectively. It is also expected
now part of the WHO Department of HHS in order to better to bring greater synergies at country level. By reshaping
operationalize opportunities for integration with and linkages its organizational framework, it is expected that WHO will
between STI, HIV, hepatitis and provision of country support , stimulate similar cross-pollination of efforts across multiple
while increasing synergies with maternal, neonatal, child and teams in the health departments and related ministries at
adolescent health (MNCH). country level (Fig. 5).

HHS will leverage the WHO transformation as a process to WHO is now looking to reduce morbidities due to STIs under
increase coherence, reduce fragmentation and improve the the UHC framework, in alignment with strategic shifts globally,
overall efficiency of HIV–STI programmes and all joint work so as to drive impact at the country level. While WHO focuses
and collaborative efforts at country level. Reorganization on leadership and excellent research and completion of global
of STI programmes at country level would also increase the public health goods (GPHGs), it will simultaneously look to
chances of improved resource mobilization, better monitoring, translate all outputs to diverse settings at the country level.
better reporting and evaluation, and overall improved levels

Fig. 5. Strategic framework for WHO HHS under GPW13 (28)

Mission & Goal • Eliminate HIV, Viral Hepatitis and control STIs GPW 13 mission:
• Promote health – Keep the world Safe – Serve the vulnerable

Strategic • WHO 13th General Programme of Work • Global health sector strategies on
• Agenda for Sustainable Development HIV and Viral Hepatitis
frameworks
• Universal health coverage

Strategic • Reduce HIV and hepatitis deaths • Deliver integrated response • Promote healthier populations
• Prevent new HIV and hepatitis infections • Achieve UHC
priorities
• Reduce new STIs and morbidity • Address health emergencies

Strategic shifts Global leadership Drive impact at country-level Focus global goods
regarding service to achieve HIV
Policy Strategic Technical
delivery efficiencies dialogue Service and viral hepatitis
support – assistance
and greater – to develop delivery – to impact – policy and
to build high – to build
integration in support systems fill critical guidance for priority
performing national
of UHC for the future gaps interventions and
systems institutions
services

Operational • Deliver coordinated and quality support in countries • Transform and expand partnerships
• Emphasize operational and programmatic guidance • Drive innovation
shifts
• Promote strong and vibrant synergies within WHO • Foster cultural change
 9

Following the transition and incorporation of STI programming This should consider new areas of focus, reprioritize
into HHS, WHO is working with partners to identify opportunities interventions and increase the use of the voice and support of
to accelerate the global STI response. Although WHO started key stakeholders for increasing advocacy and efforts towards
to address STIs within MNCH and sexual and reproductive the prevention and control of STIs. WHO has been using
health (SRH) programmes, including family planning, maternal innovative approaches to leveraging HIV and AMR systems
health and infertility, these need to be further strengthened for STI surveillance, and collecting data and information
and integration operationalized. Targeting persons at high risk with limited resources. Existing standard protocols for STI
for STIs, including key populations, is expected to increase the surveillance, prevalence surveys and systems, such as the
impact. There is now an enormous opportunity to bring STI Global Antimicrobial Surveillance System (GLASS), the
services within HIV prevention and care, and an even greater Joint United Nations Programme on HIV/AIDS (UNAIDS)’
opportunity to prevent STIs within the newly initiated PrEP Global AIDS Monitoring (GAM) and Spectrum-STI model
to prevent HIV infection among people who do not have HIV for estimating national STI rates have resulted in increased
but are at very high risk of getting HIV. Within the framework implementation and availability of some data, but more
of the WHO Antimicrobial Stewardship, work is ongoing on countries need to develop national strategic plans (NSPs) for
AMR in pathogens that are sexually transmitted, especially STIs. Many of the service delivery opportunities at country
monitoring and reporting on resistant N. gonorrhoeae, along level are yet to see full utilization, and more efforts are
with partners working on the creation of treatment options needed in these areas.
and new molecules for the treatment of gonorrhoea and
syphilis. WHO is also facilitating the development of low-cost There are more than 30 pathogens that are sexually transmitted,
POC STI diagnostics and exploring STI vaccines. Within the STI but priority STIs have been identified following certain criteria,
strategic approach, previous work on emerging STIs, such as including high incidence and prevalence, serious adverse
Zika and Ebola virus diseases, will be integrated. Significant outcomes and existence of available tools to address these
headway has been made around global initiatives such as the pathogens. Consequently, WHO has prioritized the following
EMTCT of HIV and syphilis, and WHO is now taking up EMTCT microorganisms as they cause curable STIs – Neisseria
of hepatitis B and cervical cancer to the elimination goals gonorrhoeae, Chlamydia trachomatis, Treponema pallidum and
as well. Lastly, WHO is also looking into innovations around Trichomonas vaginalis. There are plans to add Mycoplasma
multiplex HIV and syphilis testing. genitalium to the list. Among the viral STIs, the priority
pathogens are HIV, genital HSV, HPV and viral hepatitis (Fig.
As HHS is preparing to update the GHSS on STIs, it is an 6). Collaboration with the Cervical Cancer Elimination Initiative
opportune time now to plan for the acceleration of prevention will be essential. HTLV-1 has been newly added because it is a
and control of STIs in the upcoming GHSS, 2022–2030. cause of increasing concern in certain populations.

Fig. 6. Priority sexually transmitted pathogens (selection criteria)

Curable STIs Viral infections

Neisseria gonorrhoeae
HIV
(antimicrobial resistance)

Chlamydia trachomatis Genital herpes simplex virus

(adolescent burden & infertility) (high prevalence)

Treponema pallidum Human papillomavirus

(EMTCT – congenital syphilis) (cervical cancer)

Trichomonas vaginalis
Hepatitis B
(highest prevalence)

Mycoplasma genitalium HTLV-1

(increasing rates; AMR) (increasing concern)
10

D. Progress in the implementation of Some recent data from national strategic plans were reviewed
to assess whether countries are on track for implementing
Sexually Transmitted Infection interventions and achieving the targets of the GHSS on STIs. Overall, the
assessment revealed that countries are a long way from
The GHSS on STIs 2016–2021 has a series of milestones and achieving the targets and that intensive and focused country
targets that should be met by 2020 and 2030. Compared to support is required. Across the six WHO regions, the following
the baseline in 2016, a 90% reduction in syphilis incidence, were assessed: the presence of NSPs for STIs, the presence
a 90% reduction in gonorrhoea incidence, and less than 50 of a national EMTCT strategy, availability of STI treatment
cases of congenital syphilis per 100 000 live births should be guidelines, active surveillance under way for AMR of
reached by 2030. It is recognized that more data are needed gonorrhoea, and HPV vaccination under national vaccination
to ensure reliable estimates to inform progress in achieving programmes. Only 112 out of 191 (58%) countries responded
the milestones and targets. Effective responses at the right to the survey. In the future, more rigorous follow up with
coverage are expected over the next year to make sure that countries will be required. This assessment identified priority
the targets will be met by 2030 (Table 3 ). areas of the GHSS on STIs where more efforts are needed and
While surveillance for syphilis has progressed well, substantive ensure that this is reflected in NSPs, including in the HIV, SRH
work is needed around the other STIs for which there is no and MNCH strategic plans of countries.
established or reliable reporting system.

Table 3. Global Health Sector Strategy (GHSS) on Sexually Transmitted Infections: interventions, indicators and targets (17)

2030 targets Baseline 2016 Status – 2019/2020

Impact Indicators 90% reduction in syphilis incidence 6.3 M

90% reduction in gonorrhoea incidence 86.9 M

≤ 50 cases/100,000 live births in 80 countries 473 (385-561) congenital syphilis cases /

100 000 live births

Service coverage 70% of countries with STI surveillance system 135 /185 countries reporting syphilis data 97/ 110 countries
by 2020 STI surveillance

70% of countries have 95% of pregnant women 18 (9%) countries screened and treated at 103/ 111 (93%) with policies for ANC
screened and treated for HIV/syphilis least 95% of pregnant women screen and treat

70% of key population have full access to HIV/STI No data No data

services including condoms

70% of countries provide STI services or link to PHC, Major gaps exist PHC: 88%; HIV: 91%
HIV, FP, ANC On track: Only global surveillance of RHS: 84%; FP: 77%
antimicrobial resistance and momentum ANC: 89%
on tackling cervical cancer

70% of countries report on AMR in gonorrhoea 60 (31%) countries monitor AMR in 57/89 countries monitor AMR gonorrhoea
gonorrhoea , 2017 2019
 11

A majority of countries have prioritized the EMTCT of HIV and management, STI prevention, surveillance and monitoring,
syphilis. This is followed by interventions such as STI screening provision of STI services for adolescents, and monitoring for
among people with HIV, STI screening among high-risk groups AMR are at a lower priority than expected and need to be
such as MSM and sex workers, and condom distribution. paid more attention (Fig. 7).
Other interventions such as HPV vaccination, STI syndromic

Fig. 7: Prioritization of opportunities for accelerating the Sexually Transmitted Infection response

Address STIs in SRH

Attention to AMR
– adolescents, FP and Increasing STIs in PrEP
maternal health – Improved surveillance, new
– STI services for KP S
treatment and diagnosis U
– Scale up and coverage
R
V
E
Global initiatives – EMTCT Tools and innovations I
Emerging outbreaks of HIV, syphilis, cervical L
– Zika, Ebola cancer, Universal Health – HPV vaccine, dual HIV L
Coverage, syphilis A
– address prevention N
– Leverage resources – STI diagnostics
C
E

Cross-cutting engagement: gender and human rights, stigma and discrimination,

behavioural and social factors, wellness and wellbeing
12

E. Challenges in Sexually Transmitted However, despite the existence of such tools, minimal
achievements have been made in the provision of technical
Infection control programmes support to countries to ensure implementation. Building on
the GPW13 strategic shift and WHO core function, there needs
The prevention and control of STIs is made difficult by many to be advocacy for policy options that countries can adapt
issues, among which are the following. through the GHSS on STIs. WHO already has some tools to
• Most STIs are asymptomatic. assess implementation of the GHSS on STIs. Furthermore, WHO
needs to emphasize the issues of gender, equity and human
• Surveillance for STIs is limited. rights in all its programmes, and facilitate access for all who
need STI services, including young women, young men, sex
• There are limited tools for effective interventions such as workers and MSM. Value for money to guide investments in
affordable STI POCT resulting in syndromic management prevention and control of STIs needs to be integrated into the
approaches in many countries and settings. UHC framework, with more understanding and commitment
• Effective interventions are not implemented to scale by countries to pay for services. Additionally, more advocacy
to make an impact, mostly due to limited financial and is needed for countries to support funding for STI services
human resources. within international funding mechanisms, such as the Global
Fund to Fights AIDS, Tuberculosis and Malaria (Global Fund)
• AMR has emerged in some sexually transmitted pathogens and work towards a sustainable approach to controlling STIs.
over the years, thus limiting the range of affordable, These multiple strategic shifts and functions should come
effective antibiotics. together to achieve a better impact at country level.

• There are limited activities to control and mitigate the WHO will work across the three levels of the Organization –
emergence of AMR in Neisseria gonorrhoeae and other headquarters, regional offices and WHO country offices – to
organisms that cause STIs. achieve impact at the country level. If cross-cutting areas of
work at WHO headquarters are examined, it will be evident that
• Numerous human behavioural factors that increase the STIs are enmeshed in several of the programmes, such as AMR,
risk of STIs, including multiple sex partners, inadequate primary health care, MNCH, SRH, essential medicines (MHT)
use of condoms, are difficult to change. and vaccines (IVB). It is imperative that HHS programmes and
the core STI team strengthen interdepartmental collaboration
• Stigma and discrimination against persons with STIs
to integrate the STI workplan across all these cross-cutting
impact on the provision of STI services by governments,
areas.
resulting in limited access to health care for many persons,
including adolescents, sex workers, MSM and other key The immediate undertaking in this regard will be to develop
populations. a global action plan to accelerate the STI response within the
following priority areas of work.
• Competing priorities with other equally important public
health infections and diseases, and emerging infections • Strengthen surveillance to generate data for advocacy
such as COVID-19, mean that funding for STIs is not a and programming.
priority most of the time.
• Advocate for support to STI prevention and control.
To refine and refocus its leadership in the area of STI
prevention and control, WHO needs partner inputs as it moves • Identify opportunities for, and increase engagement with,
the agenda to 2030. There are GPHGs, including guidelines community partners for a sustained STI response.
for the prevention and control of STIs, surveillance of STIs
and diagnostic approaches to the detection of STIs, and some • Mobilize resources to support implementation of the
more are being updated and consolidated. These will require GHSS on STIs.
to be readily available to countries for implementation. • Strengthen support to countries.
 13

III. DISCUSSION

1. Sexually Transmitted Infection strategy: negligible, but morbidity and its scale at which it occurs are
comparatively large. There is also the risk of complications and
governance and leadership sequelae. There is a need to develop new cost–effectiveness
models, where the assumptions are focused on morbidity and
There is a need to develop a compelling message and strategy prevention of complications and disabling sequelae instead of
to advocate for STI support. There are multiple issues to be mortality reduction.
addressed. STI case management should be strengthened by
moving from syndromic to etiological management of STIs.
This will require affordable and accessible diagnostic tests. 2. Sexually Transmitted Infection
Additional leadership from WHO is needed to integrate STI
management at many levels of care – at ANC, at PrEP centres,
surveillance
fertility centres, etc. There needs to be a change in the framing 2.1 Currently, STI surveillance faces the following challenges:
of STIs to elevate this area of work within the country and
global agenda. It may not be ideal to equate STIs with HIV i. difficulty in conducting robust surveillance when
as HIV programmes have existed for many decades and have laboratory testing is not available to understand the
been fairly successful. However, lessons learned from the HIV etiology of these infections;
response can inform efforts to accelerate the STI response.
ii. some of the infections are asymptomatic; therefore,
Strengthening leadership and governance within WHO is the a significant burden of the disease is missed without
first step in elevating STI work in the developmental agenda. the tools to conduct diagnostic testing;
Policy-makers at the country level look to WHO’s level of
prioritization of public health problems to guide their priorities iii. there is limited linking of laboratory data to epidemiological
and actions. Donor partners look to WHO for identifying public data; and
health priorities to direct their funding allocations. If STIs are iv. the representativeness of data can be challenged as
not prioritized by WHO, it would be difficult for managers at reach and access to screening and diagnosis is poor.
the country level to provide leadership for STI control. In many It is yet to be figured out how some of the estimates
HIV programmes in the African Region, STIs are an essential can be validated with real data to see what the actual
component of HIV programmes. This is an opportune time to burden of STIs is by undertaking sentinel approaches
improve governance of STI programmes by better planning, in appropriate sentinel areas.
programming, monitoring and reporting.
2.2 Surveillance is the backbone of public health. There is a
From a wide spectrum of STIs caused by multiple pathogens, need to strengthen ongoing STI surveillance. The need for
for efficiency, it is important to focus on high-burden STIs. surveillance has been highlighted during the work done in
WHO and countries should prioritize curable STIs and ensure countries to create disease burden estimates. Surveillance
that treatment and diagnostics are available and accessible. improves when surveillance data are utilized. Countries
Targeted STI interventions are crucial for greater impact. Key should use surveillance data for planning and programming,
populations with the greatest risk should be reached for STI but this is not being done. Instead of periodic STI estimations,
interventions. Work on the next GHSS has been initiated. WHO/ a move should be made towards the generation of regular
HHS is exploring approaches for inclusion of STI activities into annual estimates to inform programming.
the Global Fund concept notes of countries, using experience 2.3 There are ways to get national data on a sentinel-site basis
from hepatitis programmes, which have no vertical funding. without setting up a completely new surveillance programme
There is a need to work with countries to integrate STIs as an (which may not be feasible in some countries). The etiology
essential package in primary care and UHC frameworks. of STIs has changed from bacterial to predominantly viral
Building an investment case for STIs remains a challenge over the past few decades, especially in the past 10–15 years.
because mortality rates attributable to STIs are minimal. Genital herpes is the commonest cause of genital ulcers
Traditionally, global health aid effectiveness has been centred and not syphilis and chancroid as earlier, based on studies
around the concept of preventing mortality. Specifically, in Africa, Europe and the United States of America (34–36)
crafted impact indicators such as “years of life saved” have Had such studies not been conducted, it would not have
been highlighted when donors evaluate disease programmes been possible to capture this epidemiological shift in causes
for aid effectiveness. Current cost–effectiveness models of genital ulcers. Therefore, it is imperative that sentinel
and investment cases are centred on mortality reduction site studies be conducted on a regular basis to document
as a central assumption. In the case of STIs, mortality is the prevailing causative pathogens of STIs, including the
detection of emerging and re-emerging infections.
14

2.4 The complications of STIs are another component that ii. The development of another management approach
adds to the disease burden. Routine STI surveillance should via the use of POCT will make AMR programmes
incorporate monitoring of STI complications within STI more cost effective, as only those who test positive
management reporting. STI surveillance in key populations for gonorrhoea will be further followed up and tested
remains fundamental, as the STI prevalence in these for AMR.
populations remains a major driver of the STI epidemic. For
this, the collaboration of nongovernmental organizations 2.8 For syphilis, given that there is routine maternal screening
(NGOs) is essential. Routine surveillance based on systematic and trend estimation at country level, the Spectrum-STI model
surveillance and screening of key populations would be more may now be used more frequently. Systems and processes for
relevant in key populations than occasional surveillance that country STI estimates are established using maternal syphilis
rarely results in any intervention. trend estimates (from the Spectrum-STI model) and, with
the WHO congenital syphilis estimation tool to estimate the
2.5 Capacity-building is required for surveillance and incidence of congenital syphilis as a basis for EMTCT validation.
monitoring and evaluation at regional and national levels. It These need to be strengthened and scaled up, linked with STI
is suggested to take data frameworks, data capture and data workshops that are often conducted by UNAIDS for regional
collection to subregional levels to build new STI estimates for HIV estimation. Other curable STIs lack routine prevalence
countries. This will enable a better understanding of disease data to make more frequent estimation productive.
epidemiology and will encourage countries to become more
proactive as they will be empowered to own their national 2.9 A new syphilis impact modelling tool was developed
data and take responsibility for these. Capacity at the Regional by WHO (Region of the Americas, Western Pacific Region,
Office is limited. Better data monitoring systems and capacity- headquarters) in 2019, in collaboration with Avenir Health,
building for staff are needed at the regional level. to assist countries in prioritizing syphilis interventions, such
as screening key populations, treating symptomatic infection,
2.6 The syndromic approach is widely used in STI country and partner management to support the elimination of syphilis
programmes. STI surveillance was originally intended to be an beyond EMTCT. Country STI NSPs, investment cases and the
integral part of the syndromic approach but, over the course GHSS could benefit from this model. Early results highlight the
of many years, most country programmes have become importance of sex partner tracing, and of understanding and
restricted to the use of only the syndromic approach and have reaching key populations with screening. Combining clinical
lost the element of concomitant surveillance on the etiology treatment, sex partner tracing with targeted screening and
of syndromes, due to the lack of financial resources. Currently, behavioural risk reduction in key populations is required to
the only ongoing surveillance taking place with the syndromic eliminate syphilis. This model is being piloted in Papua New
approach is the reporting on case notification. However, the Guinea and Peru. At the regional level, the syphilis impact
data generated under notification have shortcomings due to modelling tool may be used to explore scenarios of what is
under- or over-notification and non-compliance with case required to accelerate declines in the incidence and prevalence
definitions. It is not possible to know which microbe is the of syphilis and achieve a 90% reduction by 2030.
cause of a given syndrome if prescribed therapeutic protocols
are not adhered to and ongoing surveillance of drug resistance
is not conducted. 3. Sexually Transmitted Infection testing:
innovation and access
Gonococcal antimicrobial sentinel surveillance may have
failed in some countries due to non-compliance of health 3.1 One of the bottlenecks in STI programmes is the lack
professionals. of access to diagnostic tests for STIs. Partners such as the
Foundation for Innovative New Diagnostics (FIND) are trying
2.7 Going forward, there could be two potential solutions for
to work on feedback from countries on what is needed to get
ongoing surveillance of AMR.
countries to take up easy-to-use, cheap POCT for gonorrhoea
i. Maintain the syndromic approach and simultaneously and chlamydia when the tests become available. The finding
conduct periodic etiological studies of syndromes. from countries is that they struggle to implement STI activities
Conduct ongoing monitoring for gonococcal AMR. if such activities are not already in the existing funding plans
For this, countries need funds and resources. or in upcoming Global Fund concept notes. Inclusion of new
diagnostic tests for STIs in future STI or HIV plans to scale up
these health products will be a good way forward.
 15

3.2 Due to limited access to and high cost of existing diagnostic 4. Sexually Transmitted Infection treatment:
tests for STIs, especially for gonococcal and chlamydial
infections, and in the absence of rapid STI diagnostic tests to innovation and access
carry out etiological diagnoses for STIs, innovative STI testing
approaches should explored before universal STI screening 4.1 Developing new antibiotics is an extremely long and costly
can be implemented. STI testing could be implemented process. It takes over ten years to get a drug on the market
initially in sentinel clinics to provide data for surveillance and and there are significant risks, such as attrition of drugs from
in services providing STI care for key populations. Through the time they are discovered to the time the drug is registered.
such approaches, background information on asymptomatic It is not a matter of looking in isolation at the new STI drug
infection would be captured. Moreover, countries with being developed, but about how that newly developed drug
limited resources and those still implementing syndromic can be integrated into a much broader public health framework.
case management should conduct periodic surveys of the As it is, big pharmaceutical companies have withdrawn from
etiology of prevailing STI syndromes at least every two years. research into new antibiotics. A few small companies develop
These surveys will inform country-specific syndromic case antibiotics and even fewer focus on antibiotics for STIs such as
management algorithms as well as give some insight into the gonorrhoea. Therefore, partnerships are needed to make sure
burden of STIs. that any antibiotics that come out of this dry pipeline are taken
3.3 In order to have a more efficient approach to up and made accessible in order to impact on STI control.
implementing STI testing, the use of the same diagnostic 4.2 The spectre of the threat of shortage of benzathine
platform and the same samples should be an important benzylpenicillin calls for the need for collaboration and
consideration. The sample type used for testing can be a judicious planning. In 2015, at the launch of the GHSS
decisive factor in increasing access to STI testing. Although 2016–2021, there was a call by Member States to address
focusing on developing POCT is important, test samples that the shortage of penicillin, but the problem has continued.
can be collected non-invasively, such as urine and saliva, are Planning for a global mechanism to minimize shortage and
important to ensure increased uptake of testing, particularly ensure quality is required.
among asymptomatic clients.
Work is under way with the Access to Medicines and Health
3.4 In the context of COVID-19, it is expected that after a Products (MHP) and AMR divisions of WHO to ensure the
few months, there will be a vaccine against COVID-19 and availability of quality benzathine benzylpenicillin through
there might be a once-in-a-lifetime opportunity where health prequalifying companies manufacturing the active product
systems will test and vaccinate a large portion of the human ingredients. Reintegrating a focus on this in the new STI and
population. If a relatively simple STI test is ready and available HIV strategy is needed.
at that point, it would be a great opportunity to test for STIs.
Other diseases that can be eliminated can be included in such 4.3 Surveillance brings a lot of understanding about the
an effort. disease burden and development of resistance. This knowledge
is important while developing new antibiotics.
3.5 In the background of COVID-19, there has been a lot
of expansion of testing technologies in the US. In several 4.4 Conservation of antibiotics is important, but the primary
other high-income countries, self-collection of specimens agenda should be to look at how technologies such as newly
and sending specimens by courier for STI testing are being developed drugs can be preferably combined with diagnostic
implemented. Several PrEP and sexual health clinics for key approaches. Contradictions or conflicts around this needs to
populations are implementing these approaches. Lessons be resolved. The challenge for product development partners is
learnt from these interventions can be adapted in resource- on funding – how is this really going to function on resources
constrained settings. and prioritization. On the technology side, more effort could put
into increasing collaboration in the development of diagnostics,
3.6 Collaboration and discussions with the private sector to drive therapeutics and vaccines, given that all these elements can
down the prices of diagnostic tests and other new products is one benefit from basic science as well as modelling studies to shape
of the issues for WHO to put into operation as it seeks to increase the implementation and marketing of these products that relate
access to diagnostic tests for STIs in countries. to STIs and other conditions.

4.5 Another important milestone in terms of HIV prevention is

the potential use of the injectable PrEP that can be given every
eight weeks. The time when patients come for medication may
also be an opportune time to screen for STIs.
16

5. Sexually Transmitted Infection service 5.6 If access to private sector care is included under public
sector systems, such as health insurance, there is good
delivery evidence that such an approach would begin to introduce
non-equity into the system immediately, especially related to
5.1 Delivery of services for the management of STIs should SRH, gender and income equity. If this meeting is expecting
be context specific. Ideas around integration of STI services to give positive recommendations for collaboration with non-
into other health programmes may not apply in all settings. universal systems such as the private sector, then surveillance
In some countries, STI programmes do not exist as separate to monitor issues of equity in outcomes in terms of these
programmes, but STI control activities are part of national diseases should be an associated strong recommendation,
HIV programmes. akin to a precondition.
5.2 For the way forward for GHSS, one should consider 5.7 As part of the development of new products, such as
complementary interventions that are needed to improve biologicals and vaccines, investment cases are needed for
STI programmes or delivery of STI services in the context future funding, positioning and roll-out. In relation to the
of integrating STIs into HIV programmes. The populations development of investment cases, the major challenges are
that HIV programmes are trying to reach are the same as measurement of the impact of STIs on mortality, which is
other health programmes. It would be important to explore often minimal, although morbidity can be considerable.
how HIV and other programmes can work together to
accomplish shared goals, and not just how STIs can fit into 5.8 Participants belonging to different ministries of health
HIV and other programmes. It will be useful to consider how mentioned that STIs were already part of their country HIV
other programmes can carry the STI niche and integrate STI programmes. Countries have focused on EMTCT of syphilis
surveillance and prevention into their programmes, especially and HIV. Countries are exploring the implementation of STI
SRH interventions. programmes under the UHC framework. They are looking
to improve STI surveillance and have participated in rapid
5.3 The term “collaboration” could be expanded to include assessments by WHO.
involvement, engagement, accountability and integration
in the delivery of services for the management of STIs. 5.9 Colleagues from the Global Fund informed the meeting
The principle of working together is needed in order to be that among new applications, several grants focused
accountable to the populations being served. Community- on integration with sexual and reproductive health and
level engagement fits within the term collaboration, which rights (SRHR) and HIV and tuberculosis (TB) services. It
encompasses engagement with every partner and every was also noted that in countries with women, child and
community. Many patients with STIs as well as those requiring adolescent health activities, funding STI activities can be
ANC, SRH and MNCH services seek care in the private sector. easily rationalized. It was reported that the Global Fund is
Community engagement could help to connect and enhance in the middle of a proposal development phase and a few
private sector engagement. countries have included STI activities in their proposals. This
does not mean that there will not be another opportunity for
5.4 Community engagement is important to effectively engagement, because funding applications are at a high level
increase coverage for both HIV and STIs, and ensure a and details can still be reviewed. Focusing on the design of
continuum of services and linkages to prevention and the grant is an essential first step.
treatment. Collaborative approaches are also seen in efforts
to mobilize resources at the international and national 5.10 Key areas for WHO leadership should be developing
levels. Funds from large donors such as the Global Fund and innovative approaches: upstream for products and downstream
other international donors can be mobilized and used more for delivery approaches. In the HIV space, WHO has started
profitably through integrated approaches to services for STIs a meeting called Paediatric AIDS Drug Optimization (PADO),
and HIV. which sets priorities for research and product development. A
forum such as PADO will also drive targeted product profiles
5.5 Collaboration is needed for product development. New (TPPs) and a target service profile (priorities may be different
POCT and treatment will require that the private sector support in different countries based on different disease burdens).
the roll-out of these products as well as delivery channels.
 17

Consequently, it is important to ensure that the perspective of 6. Sexually Transmitted Infection prevention:
patients and health-care providers are taken into consideration
in the area of research and development of STI products. It is advocacy and community activities
also essential to consider the role of the private sector in the
delivery of these new STI products. 6.1 While expanding access to PrEP programmes, it has been
found that the pressure to prevent STIs in girls and young
5.11 Measuring access to STI services, in addition to women is not so pressing as the need to prevent HIV. This
measuring the burden, could be essential to refocus could be addressed with counselling so that girls and young
measurement indices. Policy-makers will focus on access women also prioritize STI prevention, given that these are
issues rather than on the quantum of disease burden. Instead more common.
of measuring who has an infection, it might make more sense
to measure who gets access to services to fit in with SDG 6.2 There are several methods and tools available for
5.6. It would address some of the additional concerns such prevention of STIs. They include male and female condoms,
as gender, equity and rights. Some thinking is required into vaccines (e.g. HPV vaccines, hepatitis B vaccine), post-
where STIs fit under the SDGs agenda. Since there is a lack of exposure-prophylaxis (PEP) for STIs and male circumcision.
prioritization, STIs seem to be left off the SDG agenda, but if In order to maximize coverage for populations that need these
that is addressed, there is also the matter of where they fit. services, adequate planning, integration and collaboration
There could be more creative thinking on entry points for STIs with existing programmes will be required.
in the existing global agenda. In the background documents, 6.3 Community engagement for STIs is an area that the
much thought has been given on how STIs might be linked Global Fund and other donors could support, leveraging on
with HIV, but the linkages, particularly to prevention, are also current community engagement support for HIV. The synergy
relevant within SRH services. between HIV and STI advocacy and community mobilization
5.12 Donor partners are interested in participating in the would have an impact on accelerating the STI response. More
development of an investment case for STIs. Creating work is needed to explore factors that would motivate donor
investment cases is a top priority for donors, not only at the partners to support STI interventions. Some of the donor
country level, but more so at the global level. In the case of openings for funding proposals should actively promote
infectious diseases, so far, aid-effectiveness models look at STIs. Nuanced advocacy approaches should be developed by
mortality reduction as the most compelling case for justifying shifting some money to community voices and partners to
investments. However, in the case of STIs, outcomes that highlight engagement.
focus on morbidity reduction, reduction of complications and 6.4 The Vaccine Alliance (Gavi) supports two vaccines – HPV
sequelae, and on preventing the emergence of AMR could be and hepatitis C vaccines and Ebola vaccine as well. There are
highlighted. two vaccines in the pipeline, one against HSV and the other
5.13 The SDGs mission statement is about leaving no one against N. gonorrhoeae. Every five years, Gavi runs a process
behind. At this point, PHC service delivery and global funding to identify new vaccines that they might support. The next
are divorced. In trying to understand what integration at the process is coming up in 2022. Since mortality is used as a
PHC level looks like in countries, different ministries must measurable health impact indicator, there is a need to explore
be brought together, particularly when coverage is under how an investment case for vaccines in STIs that does not
assessment. Programming around the SDGs works very well have a high mortality can be developed to make a compelling
with vertical programmes such as HIV. When bringing in case for Gavi support.
horizontal programmes, such as PHC, it becomes challenging
to support service delivery at the point of initial contact and
at the global level.
18

6.5 Training is important for building the skills and competencies 7.2 It was highlighted that, compared to HIV and partly to
of health-care providers. This is particularly important with hepatitis and TB, there is very little advocacy for STIs. It is a highly
regard to training for the delivery of services for STI prevention stigmatized area and a big taboo in many parts of the world
and care, as it requires culturally appropriate, competency- where it is politically incorrect to talk about sexual education.
based training. There is an increasing body of evidence for the Collaborative efforts should focus on bringing in champions and
effectiveness of such approaches in training. WHO can play a celebrities who can address the taboos and stigma.
key role by collating best practices and developing them for
use in countries. Context provides experience for quality-of- 7.3 One objective to diminish stigma and discrimination is to
care improvement. The Extension for Community Healthcare develop culturally acceptable messages for the community on
Outcomes (ECHO) model is a good model that uses remote STI control. In some communities, stigma and discrimination
training experience by organizing one to two conferences against MSM are the main barriers to accessing services for
weekly. These involve didactic lectures and case presentations. STI care. It will be essential to develop culturally accepted
This can be done across cities, countries and continents. sexual health promotion messages, especially for condom
promotion. Some of the stigma could be addressed by
6.6 On behavioural studies, an analysis of sexual behaviour improving services for key populations and adolescents.
in the time of the COVID-19 pandemic among PLHIV showed
that 10% of participants said they had more partners in the 7.4 Engagement of the media is not prioritized as much as
background of social distancing. The social distancing norms it should be in addressing stigma and discrimination. There
with the ongoing pandemic offered an opportunity for HIV- is a need to improve the ability of programmes to get across
infected persons to start antiretroviral therapy (ART) and messages on STI prevention and care to communities. To
achieve suppression of viral load as this is a time when people be able to engage donors, the language of global health
could be easily persuaded to abstain. However, participants needs to be spoken at important forums. Instead of focusing
also noted that modelling and assumptions may not always on delivery of services, there should be a focus on ensuring
reflect real-life scenarios accurately (36). that people have their right to access enabled and rectify
the structural injustices in all of society. There is a need to
open our vistas to a larger range of partners than the STI
7. Reducing stigma and discrimination community is presently doing. Partnerships that can make
change happen at the level of civil society and policy-makers
7.1 Equity considerations, such as stigma and discrimination, are essential.
limit affected people’s reach of STI interventions, including
delivery of vaccines. For instance, HPV vaccinations are being 7.5 Experts in communication need to be engaged, and
provided during the early adolescent period. Approaches messages should not be grouped but be crafted for diverse
are needed to increase the reach and coverage of HPV stakeholders, such as young girls and young boys, MSM, sex
vaccination through integration with other adolescent workers, policy-makers and health-care providers. There is a
health programmes so that people in need can also access need to also communicate effectively to product developers
them. It is not enough to just achieve high vaccine efficacy and regulatory agencies about the commodities required to
in studies; there is also a need to achieve high coverage and facilitate the implementation of quality STI prevention and
high implementation of vaccines by programmes. care services. Conversations with communication experts
are important for getting the messaging right, giving the
right spin to each story and building the STI narrative.
 19

IV. POLLS AND RESULTS

Five rounds of polls were conducted to understand how partners Poll Question number 2:
tend to prioritize issues in STI control and how solutions were
being identified. There were five poll questions: What should countries prioritize to accelerate their STI response?
Choose three options:
1. Which of the following global-level actions should (n=21)
be prioritized to accelerate country-level STI control? a. National strategic planning 62%
(Choose three options.)
b. Integration with other clinical care platforms 57%
2. What should countries prioritize to accelerate their STI family planning, ANC, adolescent health, and
response? (Choose three options.) primary care services.

c. Improving access to STI services 52%

3. Why is there a lack of advocacy for and prioritization of
STI control despite the large global burden and adverse d. Increase focus on HIV prevention (including 33%
health consequences associated with infection? Please PrEP) to introduce STI testing and treatment
in key populations
choose up to three of the following proposed reasons.
e. Prevention interventions (condoms, STI screening) 33%
4. As countries revisit health plans and Universal Health
Coverage commitments considering COVID-19, which f. Antimicrobial resistance monitoring 29%
opportunities to raise the profile of STIs should be
g. Innovative STI case management 19%
prioritized? Choose two.

5. Please suggest high-impact opportunities for collaboration

Participants highlighted national strategic planning as the
between WHO and stakeholders to improve STI response
highest priority (62%), followed by integration with other
globally and nationally. Please select up to four.
clinical care platforms (57%) and improving access to services
The following are the poll results and ranked distribution (52%).
of how meeting participants chose to prioritize issues and
Poll Question number 3:
solutions:

Poll Question number 1: Why is there a lack of advocacy and prioritization of STI control despite
the large global burden and adverse health consequences associated with
infection? Please choose up to three of the following proposed reasons:
Which of the following global level actions should be prioritized to (n=26)
accelerate country-level STI control? Choose three:
(n=22) a. Competing sources for funding/limited 65%
financing opportunities
a. Improve STI data and surveillance monitoring 82%
b. Lack of effective tools for STI control 42%
b. Improve costs and availability of point of care 55% (e.g. affordable point of care tests)
STI diagnostics
c. Limited surveillance to demonstrate global 35%
c. Support policy development, advocacy, and 50% need and demand for services
national prioritization
d. Asymptomatic nature of infections, limiting 35%
d. Facilitate access to funding sources 36% health care seeking behavior and reducing
demand
e. Stimulate community involvement 36% e. Low relative mortality 31%

f. Inclusion of STI services in UHC framework 18% f. Stigma and discrimination 31%

g. Reduce stigma and discrimination 9% g. Lack of a dedicated community affected by 27%

STI to support advocacy
h. Technical support 9%
h. Assumptions that STI prevention was covered 19%
through HIV prevention, adolescent health,
ANC, and family planning messaging
When asked about global actions, 82% of participants said
that improving STI data and surveillance monitoring is to be
prioritized, compared to 55% who suggested improving costs Sixty-five per cent of respondents felt that limited financing
and availability of STI diagnostics. Other proposed global opportunities is the main reason for lack of advocacy on STIs.
actions ranked lower. Only 42% thought that lack of effective tools is a reason for
the low priority of STIs.
20

Poll Question number 4: Poll Question number 5:

As countries revisit health plans and Universal Health Coverage Please suggest high impact opportunities for collaboration between
commitments considering COVID-19 which opportunities to raise the WHO and stakeholders to improve STI response globally and nationally.
profile and prioritization of STIs should be prioritized? Choose two: Please select up to four:
(n=26) (n=26)

a. Integration of STIs into global initiatives and/ 73% a. Highlighting opportunities to bring STI 83%
or platforms (Global Fund, PHC, PMNCH, UHC programming into Global Fund Concept Notes 
2030, adolescent health etc.) b. Develop regional and country partner 69%
b. A clear STI investment case 46% networks for STI advocacy

c. White Paper with partners/stakeholders to 52%

c. The development of a clear set of costed STI 42% share revitalized vision of the public health
interventions approach for STIs
d. Support for inclusion of STI services in 19% d. Joint missions to high burden countries to 45%
insurance packages engage high level country commitment
e. Updated WHO STI clinical and service delivery 12% e. Joint meetings at high profile international 41%
guidelines conferences

f. Side events at the World Health Assembly 28%

In the context of COVID-19, integration of STIs into global
initiatives such as the Global Fund or UHC 2030 were g. Media campaign to raise awareness 21%
identified as the most popular for countries to include in their
h. Other 0%
UHC commitments.

When ranking high-impact opportunities for collaboration

between WHO and stakeholders, 83% of poll respondents
ranked Global Fund concept notes as the most popular.
Developing regional and country partner networks was
ranked second at 69%.
 21

V. CONCLUSIONS
At the end of the meeting, WHO thanked participants for community view that drives access, is where WHO is hoping
their valued contributions and informed them that this was to go. The amount of brain power and innovation that has
the first informal meeting that sets the agenda for future happened during the time of the COVID-19 pandemic is
partnership and narrative-building meetings. The next larger dramatic and amazing. There are many exciting models, such
meeting of STI partners is planned in October–November as market-shaping the pipeline and modelling private sector
2021 and scheduling may be affected by the next session of inputs for finding the missing millions. Incorporating STIs
the World Health Assembly. WHO is focused on dispelling the into the SDGs agenda is a critical area of work, and could
non-coherence and tardiness around STI service delivery at be accomplished by improving surveillance and having better-
the country level. WHO wants to stimulate and unleash the refined indicators. It is definitely comforting to not be starting
drive that moves political commitment. Speaking the global from scratch, and a big advantage is that these infections are
health language, getting civil society oversight and having a treatable and some are curable.
22

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24

ANNEX 1: AGENDA OF THE MEETING

CONTEXT
14:00–14:10 Welcome, meeting objectives and Ren Minghui
introductions Assistant Director-General, Universal Health Coverage Communicable and Non-communicable Diseases (UCN) Division
Meg Doherty
Director, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes
14:10–14:15 Overview of meeting methodology: Andy Seale
Zoom functioning and participant Strategy & Policy, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes
input, SLI.DO polling, reporting
Chatham House; role of WHO observers; declarations of interest; meeting report (no attribution
of ideas to individual participants or organizations); use of chat box function; muting/video, etc.
14:15–14:25 Introduction of external participants All external participants with an active role in the meeting self-introduce
14:25–14:45 WHO’s STI Context: Scene-setting presentation
WHO’s mandate, role and context; Presenters:
the global STI disease burden; the Meg Doherty, Director, Global HIV, Hepatitis and STI programmes
Global Health Sector Strategy;
Melanie Taylor, Medical Officer, STIs
disease programmes in the time of
COVID-19 Teodora Wi, Medical Officer, STIs
14:45–15:00 Q&A/Discussion in response to context presentation
Andy Seale to moderate and summarize any key comments shared in the chat function
SLI.DO: Set 1 (3 polling questions)
https://app.sli.do/event/ms3kbzex - #53077
OPPORTUNITIES
SLI.DO: Set 2 (2 polling questions)
https://app.sli.do/event/ldvkmckc - #22142
15:00–16:00 Key partner perspectives on Moderator: Andy Seale
opportunities and gaps in the STI Each external participant is asked to speak for 1–2 minutes, without slides, around one of the following nine themes:
response which would benefit from
1. STI surveillance; 5. STI drug resistance;
accelerated action
2. STI prevention (vaccines, behavioural interventions); 6. access to medicines and commodities;
3. STI management (testing, treatment and partner 7. community engagement;
notification); 8. STI service delivery; and
4. STI treatment; 9. STI advocacy and activism.
Break 16:00-16:15
SLI.DO: Set 3 (1 polling question)
https://app.sli.do/event/5p3mukpd - #63753
COLLABORATION
16:15–17:00 Moderator: Andy Seale
Building on the ideas proposed in the previous “opportunities” session, this session will move to identify key actors, sectors and partnerships that
could collaborate in support of accelerating STI implementation and impact in countries.
Discussion/Rapid chat box exchange in response to the following guiding questions (40 minutes)
• What would a collaboration exploring STIs in the context of community service delivery, PHC and UHC involve?
• What are the resource and capacity gaps that would benefit from a collaborative approach?
• What would a collaboration based on innovation prioritize for focus and who would be involved?
• What would a collaborative approach to resource mobilization for STIs involve?
Emerging themes:
How would we best define success for collaboration on STIs? (5 minutes)
PARTNERSHIPS & NEXT STEPS
17:00–17:40 STI stakeholder engagement: Moderator: Andy Seale
identifying champions, partners and Participants are invited to:
participants
• suggest ideas, themes and format options for STI stakeholder engagement;
• share any key issues that should be raised at the combined WHO Strategic and Technical
Advisory Committee for HIV, Viral Hepatitis and STIs;
• offer other ideas for engaging stakeholders and identifying champions.
Discussion/Rapid chat box exchange in response to above items.
17:40–18:00 Final word Participants asked to share final suggestions for WHO consideration, including any issues not covered in the agenda.
Concluding remarks.
 25

ANNEX 2: LIST OF PARTICIPANTS

PARTNERS & ADVISORS Heather Doyle
Senior Technical Coordinator, Community, Rights
Emilie Alirol and Gender Investment Support
Project Leader, STI The Global Fund to Fight AIDS, TB and Malaria
Global Antibiotic R&D Partnership (GARDP) Email: [email protected]
Email: [email protected]
Cecilia Ferreyra
Manica Balasegaram AMR Medical Officer
Director Foundation for Innovative New Diagnostics
Global Antibiotic R&D Partnership (GARDP) Email: [email protected]
Email: [email protected]
Geoff Garnet
Taryn Barker The Bill and Melinda Gates Foundation
Children’s Investment Fund Foundation Email: [email protected]
Email: [email protected]
Katerina Galluzzo
Linda Gail Bekker Technical Manager
International AIDS Society Unitaid
Email: [email protected] Email: [email protected]

Gail Bolan Sarah Hawkes

US Centers for Disease Control, Department of STD Prevention University College of London
Atlanta, GA, USA Email: [email protected]
Email: [email protected]
David Rippen
Luiz Pizzaro Chief Science Officer
Team Lead CHAI
Unitaid Email: [email protected]
Email: [email protected]
Cassandra Kelly
Carmen Perez Casas FIND
Technical Manager Email: [email protected]
Unitaid
Eline Korenromp
Email: [email protected]
Senior Modeler & Advisor
Alexandra Maeg Cameron Avenir Health
Technical Manager Email: [email protected]
Unitaid
Nicola Low
Email: [email protected]
University of Bern
Cassandra Kelly-Cirino Bern, Switzerland
Director of Emerging Threats Email: [email protected]
Foundation for Innovative New Diagnostics
Siobhan Malone
Email: [email protected]
The Bill and Melinda Gates Foundation
Carolyn Deal Email: [email protected]
Chief, Enterics and Sexually Transmitted Diseases Branch
Daniel McCartney
Division of Microbiology and Infectious Diseases
Head of SRHR Connect (ACCESS)
National Institute of Allergy and Infectious Diseases, NIH
International Planned Parenthood Federation
Email: [email protected]
Email: [email protected]
Philippe Duneton
Kenneth Mayer
Executive Director A.i.
The Fenway Institute, Harvard Medical School
Unitaid, Geneva
Email: [email protected]
Email: [email protected]
26

Lucy Stackpool Moore Nguyen Trong Khoa

Director, HIV Programmes and Advocacy Vice Director General of Viet Nam Administration for Medical
International AIDS Society Services, Ministry of Health, Viet Nam
Email: [email protected] [email protected]

Francis Ndowa Amina el Kettani

Skin and GU Medicine Clinic, Harare Morocco
Zimbabwe Email: [email protected]
Email: [email protected]

Deepali Patel WHO REGIONAL OFFICES

Senior Manager, Policy
GAVI Masoud Dara
Email: [email protected] Coordinator – Joint Tuberculosis, HIV/AIDS & Hepatitis Programme
WHO Europe
Mael Redard Email: [email protected]
FIND
Email: [email protected] Massimo Ghidinelli
Unit Chief, HIV, Hepatitis, TB, and Sexually Transmitted diseases
Frederic Seghers Pan American Health Organization
Director Email: [email protected]
CHAI
Email: [email protected] Ahmed Sabry Alaama
Technical Officer, Hepatitis, AIDS & STDs
Andrew Storey WHO Eastern Mediterranean Region
Senior Director, New Initiatives Email: [email protected]
CHAI
Email : [email protected] Fabian Ndenzako
Who African Region – IST ESA
John Stover Email: [email protected]
Avenir Health
Email: [email protected] Christine Kisia
NPO, WHO/Kenya
Email: [email protected]
NATIONAL PROGRAM REPRESENTATIVES
Ndoungou Salla Ba
Ludmila Derevyanko Medical Officer, HIV/AIDS, WHO African Region
Ukraine Email: [email protected]
Email: [email protected]
Frank John Lule
Sabin Nasanzimana Medical Officer, HIV/AIDS Treatment and Care, WHO African
Rwanda Region
Email: [email protected] Email: [email protected]

Patricia Garcia Naoko Ishikawa

Peru Coordinator HIV, Hepatitis and STI
Email: [email protected] WHO Western Pacific Region
Email: [email protected]
Catherine Ngugi
Kenya Hugues Lago
Email: [email protected] Team Leader HIV, TB and Hepatitis (UCN)
WHO African Region
Rasanjali Hettiarachchi Email: [email protected]
Sri Lanka
Email: [email protected]
 27

BB Rewari Annette Vester

Medical Officer, HIV/STI/Hepatitis Technical Officer, Headquarters/HHS
WHO South-East Asia Region Email: [email protected]
Email: [email protected]
Magdalena Barr-Dichiara
Anne Brink Consultant, Headquarters/HHS
WP/HSI HIV, Hepatitis and STI Email: [email protected]
WHO Western Pacific Region
Email: [email protected] Marco Vitorio
Medical Officer, Headquarters/HHS
Bridget Mugisa Email: [email protected]
Technical Officer, HIV & Hepatitis
WHO Eastern Mediterranean Region Rachel Baggaley
Email: [email protected] Coordinator, Testing, Prevention and Populations,
Headquarters/HHS
Kouadio Yeboue Email: [email protected]
Medical Officer, HIV/AIDS Treatment and Care, WHO African
Region Daniel Low-Beer
Email: [email protected] Coordinator Strategic Information Headquarters/HHS
Email: [email protected]

WHO SECRETARIAT Mazuwa Banda

Technical Officer, Headquarters/HHS
Meg Doherty Email: [email protected]
Director Global HIV, Hepatitis and STIs Programmes,
Headquarters/HHS Andrew Seale
Email: [email protected] Technical officer, Headquarters/HSS
Email: [email protected]
Teodora Wi
Medical Officer, STI, Headquarters/HHS Morkor Newman
Email: [email protected] Medical Officer, Headquarters/HHS
Email: [email protected]
Andrew Ball
Senior Adviser, Headquarters/HHS Sami Gottlieb
Email: [email protected] Medical Officer, Headquarters/SRH
Email: [email protected]
Melanie Taylor
Medical Officer, Headquarters/HHS Yamuna Mundade
Email: [email protected] Programme Manager, Headquarters/UTD
Email: [email protected]
Nathalie Broutet
Medical Officer, Headquarters/SRH Virginia MacDonald
Email: [email protected] Technical Officer, Headquarters/HHS
Email: [email protected]
Igor Toskin
Scientist, Headquarters/SRH Michele Rodolf
Email: [email protected] Technical Officer, Headquarters/HHS

Mayada Youseff Niklas Luhmann

Technical Officer, Headquarters/HHS Technical Officer, HeadquartersQ/HHS
Email: [email protected] Email: [email protected]
For more information, contact:

World Health Organization

Department of Global HIV,
Hepatitis and STI Programme
20, avenue Appia
1211 Geneva 27
Switzerland

E-mail: [email protected]

https://www.who.int/teams/global-hiv-
hepatitis-and-stis-programmes/stis/overview