There were an estimated 17.8 million women aged 15 and older living with HIV in 2015, constituting 51% of all adults living with HIV. Adolescent girls and young women are particularly affected; in 2015 they constituted 60% of young people aged 15-24 years who were living with HIV, and they also accounted for 58% of newly acquired HIV infections among young persons in that age group. In many countries, women living with HIV do not have equitable access to good-quality health services and are also faced with multiple and intersecting forms of stigma and discrimination. Furthermore, women living with HIV are disproportionately vulnerable to violence, including violations of their sexual and reproductive rights. Many significant changes in HIV-related policies, research and practice have occurred in the 10 years since the World Health Organization (WHO) published Sexual and reproductive health of women living with HIV/AIDS: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resourceconstrained settings in 2006. These changes include the rapid expansion of antiretroviral therapy (ART) and the release in 2015 of WHO recommendations to offer immediate ART to all individuals living with HIV and to offer pre-exposure prophylaxis (PrEP) to individuals at substantial risk of HIV infection as an additional prevention choice. Given the significant difference in scope, this guideline was viewed as a new submission by the WHO Guidelines Review Committee, rather than an update of the 2006 guidelines. This guideline responds to requests from organizations, institutions and individuals for guidance which consolidates existing recommendations specific to women living with HIV along with new recommendations and good practice statements. It is expected to support frontline health-care providers, programme managers and public health policy-makers around the world to better address the sexual and reproductive health and rights (SRHR) of women living with HIV.
The starting point for this guideline is the point at which a woman has learnt that she is living with HIV, and it therefore covers key issues for providing comprehensive SRHR-related services and support for women living with HIV. As women living with HIV face unique challenges and human rights violations related to their sexuality and reproduction within their families and communities, as well as from the health-care institutions where they seek care, particular emphasis is placed on the creation of an enabling environment to support more effective health interventions and better health outcomes.
An integrated approach to health and human rights lies at the heart of ensuring the dignity and well-being of women living with HIV.
HIV is not only driven by gender inequality, but it also entrenches gender inequality, leaving women more vulnerable to its impact. Providing sexual and reproductive health interventions for women living with HIV that are grounded in principles of gender equality and human rights can have a positive impact on their quality of life; it is also a step towards long-term improved health status and equity.
This guideline is meant to help countries to more effectively and efficiently plan, develop and monitor programmes and services that promote gender equality and human rights and hence are more acceptable and appropriate for women living with HIV, taking into account the national and local epidemiological context. It discusses implementation issues that health interventions and service delivery must address to achieve gender equality and support human rights.

# This guideline aims to provide:
n Evidence-based recommendations for the SRHR of women living with HIV in all of their diversity, with a particular focus on settings where the health system has limited capacity and resources; and
n Good practice statements on key operational and service delivery issues that need to be addressed to (i) increase access to, uptake of, and the quality of outcomes of sexual reproductive health (SRH) services, (ii) improve human rights and (iii) promote gender equality for women living with HIV.

# A woman-centred approach
Woman-centred health services involve an approach to health care that consciously adopts the perspectives of women, their families and communities. This means that health services see women as active participants in, as well as beneficiaries of, trusted health systems that respond to women's needs, rights and preferences in humane and holistic ways. Care is provided in ways that respect women's autonomy in decision-making about their health, and services must include provision of information and options to enable women to make informed choices. The needs and perspectives of women, their families and communities are central to provision of care, and to the design and implementation of programmes and services. A woman-centred approach is underpinned by two guiding principles: promotion of human rights and gender equality.

# Guiding principles
Human rights: An integrated approach to health and human rights lies at the heart of ensuring the dignity and well-being of women living with HIV. This includes, but is not limited to, the right to the highest attainable standard of health; the right to life and physical integrity, including freedom from violence; the right to equality and non-discrimination on the basis of sex; and the right to freedom from torture or cruel, inhuman or degrading treatment. The right to SRH is an integral part of the right to health, enshrined in article 12 of the International Covenant on Economic, Social and Cultural Rights.

# Gender equality:
The promotion of gender equality is central to the achievement of SRHR of all women, including women living with HIV in all their diversity. This means recognizing and taking into account how unequal power in women's intimate relationships, harmful gender norms and women's lack of access to and control over resources affect their access to and experiences with health services.

# Guideline development methods
The recommendations or good practice statements: psychosocial support, ageing and healthy sexuality, economic empowerment and resource access (including food security), integration of SRHR and HIV services, empowerment and self-efficacy around safer sex and reproductive decision-making, facilitating safe disclosure for women living with HIV who fear or experience violence, modes of delivery for best maternal and perinatal outcomes (specifically caesarean section), and safe medical and surgical abortion. Development of the new recommendations and good practice statements to respond to these eight topic areas began with systematic and narrative reviews of the evidence. The Guideline Development Group (GDG) assessed the quality of the available evidence for the new recommendations and considered the benefits and risks, values and preferences, human rights, equity, costs and feasibility of implementation to determine the strength of each recommendation.

# Creating an enabling environment
Implementing comprehensive and integrated SRHR and HIV programmes to meet the health needs and rights of the diverse group of women living with HIV requires that interventions be put into place to overcome barriers to service uptake, use and continued engagement. In all epidemic contexts, these barriers occur at the individual, interpersonal, community and societal levels. They may include challenges such as social exclusion and marginalization, criminalization, stigma, genderbased violence and gender inequality, among others. Strategies are needed across health system building blocks to improve the accessibility, acceptability, affordability, uptake, equitable coverage, quality, effectiveness and efficiency of services for women living with HIV. If left unaddressed, such barriers undermine health interventions and the SRHR of women living with HIV.

# Implementation and updating of the guideline
Action on the recommendations in this guideline requires a strategy that is informed by evidence, appropriate to the local context, and responsive to the needs and rights of women living with HIV. In addition, programmes should aim to achieve equitable health outcomes, promote gender equality, and deliver the highest-quality care efficiently at all times. Effective implementation of the recommendations and good practice statements in this guideline will likely require reorganization of care and redistribution of health-care resources, particularly in low-and middle-income countries.
Potential barriers are noted and a phased approach to adoption, adaptation and implementation of the guideline recommendations is advised.
During the guideline development process, the GDG identified important knowledge gaps that need to be addressed through primary research. This guideline will be updated five years after publication unless significant new evidence emerges that necessitates earlier revision.
Tables 1 and 2 present the new and existing recommendations and good practice statements, respectively. Figure 1 presents a visual framework that brings together all the elements of the guideline, with women living with HIV (and their expressed values and preferences) at the core.

# Violence against women services REC B.4 (NEW):
WHO recommends that policy-makers and service providers who support women living with HIV who are considering voluntary HIV disclosure should recognize that many fear, or are experiencing, or are at risk of intimate partner violence.

# REC B.5 (NEW):
WHO recommends that interventions and services supporting women living with HIV who are considering voluntary HIV disclosure should include discussions about the challenges of their current situation, the potential associated risk of violence, and actions to disclose more safely, and facilitate links to available violence prevention and care services.

# Strong recommendation, lowquality evidence
Strong recommendation, lowquality evidence REC B.6: Adolescents should be counselled about the potential benefits and risks of disclosure of their HIV status to others and empowered and supported to determine if, when, how and to whom to disclose. 7 REC B.7: HIV testing services for couples and partners, with support for mutual disclosure, should be offered to individuals with known HIV status and their partners. 8 REC B.8: Initiatives should be put in place to enforce privacy protection and institute policy, laws and norms that prevent discrimination and promote tolerance and acceptance of people living with HIV. This can help create environments where disclosure of HIV status is easier. 9 REC B.9: Children of school age should be told their HIV positive status; younger children should be told their status incrementally to accommodate their cognitive skills and emotional maturity, in preparation for full disclosure. 10 REC B.10: Children of school age should be told the HIV status of their parents or caregivers; younger children should be told this incrementally to accommodate their cognitive skills and emotional maturity. 11  In the document, school-age children are defined as those with the cognitive skills and emotional maturity of a normally developing child of 6-12 years. 1: A condition for which there is no restriction for the use of the contraceptive method 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method 4: A condition which represents an unacceptable health risk if the contraceptive method is used. Conditional recommendation, very low-quality evidence REC B.33: WHO recommends the human papillomavirus (HPV) vaccine for girls in the age group of 9-13 years. Girls receiving a first dose of HPV vaccine before the age of 15 years can use a two-dose schedule.
The interval between the two doses should be six months. There is no maximum interval between the two doses; however, an interval of no greater than 12-15 months is suggested. If the interval between doses is shorter than five months, then a third dose should be given at least six months after the first dose. Immunocompromised individuals, including those who are living with HIV, and females aged 15 years and older should also receive the vaccine and need three doses (at 0, 1-2, and 6 months) to be fully protected. 25 No details on strength or quality found, but recommendation is based on the GRADE approach Note: Where good practice statements apply to "key populations" this includes women living with HIV and therefore these have been included in these guidelines.

# A. Creating an enabling environment: Good practice statements (GPS)
Psychosocial support GPS A.1 (NEW): Psychosocial support interventions, such as support groups and peer support, provided by, with, and for women living with HIV, should be included in HIV care.

# Healthy sexuality across the life course GPS A.2 (NEW):
Women living with HIV in all their diversity should be supported in their choice to have safe and fulfilling sexual relationships and sexual pleasure as they age. Women living with HIV who choose not to be sexually active should also be supported in their choice.

# Economic empowerment and resource access GPS A.3 (NEW):
Comprehensive assessment of food security with linkage to appropriate services is an integral component of the care of women living with HIV.

# Integration of SRHR and HIV services GPS A.4 (NEW):
Women living with HIV should have access to integrated and tailored comprehensive sexual and reproductive health (SRH) and HIV services.

# GPS A.5 (NEW):
Women living with HIV should be included in the design and delivery of these services.

# As defined in the WHO Global Reproductive Health Strategy, 2004 26
Protection from violence and creating safety GPS A.6: Violence against people from key populations should be prevented and addressed in partnership with key population-led organizations. All violence against people from key populations should be monitored and reported, and redress mechanisms should be established to provide justice. 27 GPS A.7: Health and other support services should be provided to all persons from key populations who experience violence. In particular, persons experiencing sexual violence should have timely access to comprehensive post-rape care in accordance with WHO guidelines. GPS A.8: Law enforcement officials and health-and social-care providers need to be trained to recognize and uphold the human rights of key populations and to be held accountable if they violate these rights, including perpetration of violence.

# Social inclusion and acceptance
GPS A.9: Policy-makers, parliamentarians and other public health leaders should work together with civil society organizations in their efforts to monitor stigma, confront discrimination against key populations and change punitive legal and social norms.

# GPS A.10:
Health-care workers should receive appropriate recurrent training and sensitization to ensure that they have the skills, knowledge and understanding to provide services for adults and adolescents from key populations based on all persons' right to health, confidentiality and non-discrimination.

# GPS A.11:
It is recommended to make contraceptives affordable to all, including adolescents, and that law and policy support access to contraception for disadvantaged and marginalized populations. Community empowerment GPS A.12: Programmes should be put in place to provide legal literacy and legal services to key populations so that they know their rights and applicable laws and can receive support from the justice system when aggrieved.

# Supportive laws and policies and access to justice

# Prevention of perinatal transmission of HIV GPS B.3:
Mothers living with HIV and health-care workers can be reassured that ART reduces the risk of postnatal HIV transmission in the context of mixed feeding. Although exclusive breastfeeding is recommended, practising mixed feeding is not a reason to stop breastfeeding in the presence of ARV drugs. This framework illustrates the essential structure of this consolidated guideline and points the reader to specific topics and relevant WHO recommendations (REC) and good practice statements (GPS). The values and preferences of women living with HIV, as expressed by respondents in the Global Values and Preferences Survey, are at the core of this guideline, which is grounded in and advocates for a comprehensive, woman-centred approach to SRHR, and is underpinned by the guiding principles of gender equality and human rights (represented in the pink circle). With this as a foundation, the framework then shows: (A) the encompassing enabling environment (outer purple circle), with all the eight topics as presented in Chapter 3 of the full guideline document (starting at the top and running clockwise); and (B) the health interventions (central teal segments), with all six topics as presented in Chapter 4 of the full guideline document (also clockwise from the top) -in all cases, these topics are accompanied by information on the relevant numbered RECs and GPSs, which are also listed in Tables 1 and 2, respectively.