Consolidated guideline on sexual and reproductive health and rights of women living with HIV.# Introduction
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 resource-constrained 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 front-line 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. 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.
x 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 WHO Department of Reproductive Health and Research (RHR) led the development of this consolidated guideline, following WHO procedures and reporting standards laid out in the 2014 WHO handbook for guideline development. To help ensure that the guidance appropriately reflects the concerns of women living with HIV in all their diversity, WHO commissioned a global survey on the SRHR priorities of women living with HIV -the Global Values and Preferences Survey (GVPS) 1. This process was placed at the heart of the development of this guideline and the findings of the survey are included throughout the guideline.
To develop the scope of this guideline, the WHO Guideline Steering Group (SG) mapped all existing WHO SRHR guidance for women living with HIV, then reviewed these documents to determine the relevance of existing recommendations that have undergone the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) for inclusion in this consolidated guideline. The SG identified the following eight topic areas for new 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.
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 2.1, at the end of Chapter 2, presents a visual framework that brings together all the elements of the guideline, with women living with HIV at the core.
Table 1: Summary list of WHO recommendations for the sexual and reproductive health and rights (SRHR) of women living with HIV (or other family member) or sexual assault by any perpetrator should be offered immediate support. Health-care providers should, as a minimum, offer first-line support when women disclose violence. If health-care providers are unable to provide first line support, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to do so. 2 REC A.12: Health-care providers should ask about exposure to intimate partner violence when assessing conditions that may be caused or complicated by intimate partner violence, in order to improve diagnosis/identification and subsequent care.

# Strong recommendation, indirect evidence
Strong recommendation, indirect evidence 1. Reference for this and all the existing recommendations in the next section on integration of services: Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, second edition. Geneva: World Health Organization; 2016 ( eng.pdf). 2. Reference for this and all the rest of the existing recommendations in this section on violence and safety: Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013 ().
REC A.13: In-service training and training at pre-qualification level and in first-line support for women who have experienced intimate partner violence and sexual assault should be provided to health-care providers (in particular doctors, nurses and midwives).
REC A.14: Pregnant women who disclose intimate partner violence should be offered brief to medium-duration empowerment counselling (up to 12 sessions) and advocacy/support, including a safety component, offered by trained service providers where health-care systems can support this. The extent to which this may apply to settings outside of antenatal care, or its feasibility in low-or middleincome countries, is uncertain.
REC A.15: Care for women experiencing intimate partner violence and sexual assault should, as much as possible, be integrated into existing health services rather than as a stand-alone service.
REC A. 16: Mandatory reporting of intimate partner violence to the police by the health-care provider is not recommended. However, health-care providers should offer to report the incident to the appropriate authorities (including the police) if the woman wants this and is aware of her rights.

# Strong recommendation, very low-quality evidence

# Conditional recommendation, low-quality evidence
Strong recommendation, very low-quality evidence

# Strong recommendation, very low-quality evidence
Community empowerment REC A.17: Provide free HIV and tuberculosis (TB) treatment for health workers in need facilitating the delivery of these services in a non-stigmatizing, gendersensitive, confidential, and convenient setting when there is no staff clinic and/ or their own facility does not offer ART, or where health workers prefer services off-site. 3 REC A.18: Introduce new, or reinforce existing, policies that prevent discrimination against health workers with HIV or TB, and adopt interventions aimed at stigma reduction among colleagues and supervisors. 4 Strong recommendation, weak evidence Strong recommendation, moderate-quality evidence

# B. Health interventions Recommendation (REC) Strength of recommendation, quality of evidence
Sexual health counselling and support REC B.1 (NEW): WHO recommends that for women living with HIV, interventions on self-efficacy and empowerment around sexual and reproductive health and rights should be provided to maximize their health and fulfil their rights.
Strong recommendation, lowquality evidence REC B.2: Brief sexuality-related communication (BSC) is recommended for the prevention of sexually transmitted infections among adults and adolescents in primary health services. 5

# REC B.3:
Training of health-care providers in sexual health knowledge and in the skills of BSC is recommended. 6 Strong recommendation, low-to moderate-quality evidence Strong recommendation, low-to very low-quality evidence 3. Joint WHO/ILO policy guidelines on improving health worker access to prevention, treatment and care services for HIV and TB. Geneva: World Health Organization; 2010 (). 4. Ibid. 5. Brief sexuality-related communication: recommendations for a public health approach. Geneva: World Health Organization; 2015 (). 6. Ibid.
xiv 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 Conditional recommendation, very low-quality evidence Strong recommendation, lowquality evidence for all people with HIV in all epidemic settings; conditional recommendation, lowquality evidence for HIV-negative people depending on the countryspecific HIV prevalence Strong recommendation, lowquality evidence

# Strong recommendation, lowquality evidence

# Conditional recommendation, low-quality evidence
Family planning and infertility services REC B.11: In countries where HIV transmission occurs among serodiscordant couples, where discordant couples can be identified and where additional HIV prevention choices for them are needed, daily oral PrEP (specifically tenofovir or the combination of tenofovir and emtricitabine) may be considered as a possible additional intervention for the uninfected partner. 12 REC B.12: ART should be initiated in all adults living with HIV, regardless of WHO clinical stage and at any CD4 cell count. 13 Conditional recommendation, high-quality evidence Strong recommendation, moderate-quality evidence 7. HIV and adolescents: guidance for HIV testing and counselling and care for adolescents living with HIV: recommendations for a public health approach and considerations for policy-makers and managers. Geneva: World Health Organization; 2013 (http:// apps.who.int/iris/bitstream/10665/94334/1/9789241506168_eng.pdf). 8. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach. Geneva: World Health Organization; 2012 (/ bitstream/10665/44646/1/9789241501972_eng.pdf). 9. Guideline on HIV disclosure counselling for children up to 12 years of age. Geneva: World Health Organization; 2011 (http:// apps.who.int/iris/bitstream/10665/44777/1/9789241502863_eng.pdf). 10. Ibid. 11. Ibid. 12. Guidance on oral pre-exposure prophylaxis (PrEP) for serodiscordant couples, men and transgender women who have sex with men at high risk of HIV: recommendations for use in the context of demonstration projects. Geneva: World Health Organization; 2012 (/). 13. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, second edition. Geneva: World Health Organization; 2016 (/ bitstream/10665/208825/1/9789241549684_eng.pdf).
xv Executive summary 14. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations -2016 update. Geneva: World Health Organization; 2016 (). 15. Reference for this and all the rest of the existing recommendations in this section on contraception, and for the next footnote:
Medical eligibility criteria for contraceptive use, fifth edition. Geneva: World Health Organization; 2015 (/ bitstream/10665/181468/1/9789241549158_eng.pdf). 16. MEC categories (Medical eligibility criteria for contraceptive use, fifth edition, WHO, 2015):
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.
REC B.13: The correct and consistent use of condoms with condom-compatible lubricants is recommended for all key populations to prevent sexual transmission of HIV and sexually transmitted infections (STIs). 14 Strong recommendation, moderate-quality evidence REC B.14: Women living with asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) can use the following hormonal contraceptive methods without restriction: combined oral contraceptive pills (COCs), combined injectable contraceptives (CICs), contraceptive patches and rings, progestogen-only pills (POPs), progestogen-only injectables (POIs; depot medroxyprogesterone acetate  and norethisterone enanthate, and levonorgestrel (LNG) and etonogestrel (ETG) implants (MEC Category 1). Women living with asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) can generally use the LNG-IUD (MEC Category 2) (Part I, section 12b). 15 REC B.15: Women living with severe or advanced HIV clinical disease (WHO stage 3 or 4) can use the following hormonal contraceptive methods without restriction: COCs, CICs, contraceptive patches and rings, POPs, POIs (DMPA and NET-EN), and LNG and ETG implants (MEC Category 1). Women living with severe or advanced HIV clinical disease (WHO stage 3 or 4) should generally not initiate use of the LNG-IUD (MEC Category 3 for initiation) until their illness has improved to asymptomatic or mild HIV clinical disease (WHO stage 1 or 2). However, women who already have an LNG-IUD inserted and who develop severe or advanced HIV clinical disease need not have their IUD removed (MEC Category 2 for continuation). LNG-IUD users with severe or advanced HIV clinical disease should be closely monitored for pelvic infection (Part I, section 12c).

# REC B.16:
Women taking any nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) can use all hormonal contraceptive methods without restriction: COCs, contraceptive patches and rings, CICs, POPs, POIs (DMPA and NET-EN), and LNG and ETG implants (MEC Category 1) (Part I, section 12d).
REC B.17: Women using ART containing either efavirenz or nevirapine can generally use COCs, patches, rings, CICs, POPs, NET-EN and implants (MEC Category 2). However, women using efavirenz or nevirapine can use DMPA without restriction (MEC Category 1) (Part I, section 12d).
Strength of recommendation is indicated by MEC category, which is noted in text. 16 Moderate-to very low-quality evidence

# Moderate-to very low-quality evidence
Low-to very low-quality evidence REC B.21: Intrauterine device (IUD): Women using ARV medication can generally use LNG-IUDs (MEC Category 2), provided that their HIV clinical disease is asymptomatic or mild (WHO stage 1 or 2). Women living with severe or advanced HIV clinical disease (WHO stage 3 or 4) should generally not initiate use of the LNG-IUD (MEC Category 3 for initiation) until their illness has improved to asymptomatic or mild HIV clinical disease. However, women who already have an LNG-IUD inserted and who develop severe or advanced HIV clinical disease need not have their IUD removed (MEC Category 2 for continuation). LNG-IUD users with severe or advanced HIV clinical disease should be closely monitored for pelvic infection (Part I, section 12d).

# Low-to very low-quality evidence
Low-to very low-quality evidence Low-to very low-quality evidence Low-to very low-quality evidence
xvi Antenatal care and maternal health services REC B.22 (NEW): WHO recommends that elective caesarean section (C-section) should not be routinely recommended to women living with HIV.
Strong recommendation, lowquality evidence REC B.23: Late cord clamping (performed approximately 1-3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care. 17 Strong recommendation, moderate-quality evidence REC B.24: ART should be initiated in all adolescents living with HIV, regardless of WHO clinical stage and at any CD4 cell count. 18 REC B.25: As a priority, ART should be initiated in all adolescents with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and adolescents with a CD4 count  350 cells/mm 3. 19 REC B.26: ART should be initiated in all pregnant and breastfeeding women living with HIV, regardless of WHO clinical stage and at any CD4 cell count, and continued lifelong. 20 REC B.27: Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer (similar to the general population) while being fully supported for ART adherence. 21 Conditional recommendation, low-quality evidence Strong recommendation, moderate-quality evidence Strong recommendation, moderate-quality evidence Strong recommendation, lowquality evidence for 12 months, very low-quality evidence for 24 months REC B.28: The use of amniotomy alone for prevention of delay in labour is not recommended. 22 REC B.29: The use of amniotomy and oxytocin for treatment of confirmed delay in labour is recommended. 23 Weak recommendation, very lowquality evidence

# Weak recommendation, very lowquality evidence
Safe abortion services REC B.30 (NEW): WHO recommends that safe abortion services should be the same for women living with HIV who want a voluntary abortion as for all women.
REC B.31 (NEW): WHO suggests that women living with HIV who want a voluntary abortion can be offered a choice of medical or surgical abortion, as for all women.
Strong recommendation, very low-quality evidence

# Conditional recommendation, very low-quality evidence
Sexually transmitted infection and cervical cancer services REC B.32: Sexually transmitted infection (STI) and family planning services can be integrated within HIV care settings. 24 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 17. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization; 2012 (). 18. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, second edition. Geneva: World Health Organization; 2016 (/ bitstream/10665/208825/1/9789241549684_eng.pdf). 19. Ibid. 20. Ibid. 21. Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva: World Health Organization; 2016 ( am/10665/246260/1/9789241549707-eng.pdf). 22. WHO recommendations for augmentation of labour. Geneva: World Health Organization; 2014 (/ books/NBK258875/pdf/Bookshelf_NBK258875.pdf). 23. Ibid. 24. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, second edition. Geneva: World Health Organization; 2016 (/ bitstream/10665/208825/1/9789241549684_eng.pdf). 25. Comprehensive cervical cancer control: a guide to essential practice. Geneva: World Health Organization; 2014 (. who.int/iris/bitstream/10665/144785/1/9789241548953_eng.pdf).
xvii Executive summary 26. Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Global Strategy adopted by the 57th World Health Assembly. Geneva: World Health Organization; 2004 (/ iris/bitstream/10665/68754/1/WHO_RHR_04.8.pdf). 27. Reference for this and all the rest of the existing good practice statements in section A of this table: Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations -2016 update. Geneva: World Health Organization; 2016 ().
Table 2: Summary list of WHO good practice statements for the sexual and reproductive health and rights (SRHR) of women living with HIV 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.
Chapter 1. Introduction
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 (1). 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 (1). 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 (2), including violations of their sexual and reproductive rights (3).
In 2016, the United Nations (UN) Committee on Economic, Social and Cultural Rights (CESCR) defined the right to sexual and reproductive health (SRH) as an "integral part of the right to health" (4). To ensure the sexual and reproductive health and rights (SRHR) of women and girls living with HIV, attention must be paid to the following critical dimensions (5):
n Human rights and gender equality must be placed at the centre of a comprehensive approach to health programming, in particular in relation to sexuality and sexual health.
n Health systems must be responsive to the inequalities in access to health care and quality of care, which negatively affect women living with HIV.
n Women living with HIV should be empowered and engaged in the development of policies and programmes that affect them.
n Monitoring, evaluation and accountability procedures must be strengthened to provide good-quality data, and to ensure remedies for violations of the rights of women living with HIV.  (6).
Many significant changes in HIV-related policies, research and practice have occurred in the 10 years since the publication of the 2006 guidelines. 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 (7). These changes in turn have contributed to advancing the SRHR of women living with HIV (8). Consequently, this guideline was considered by the Guidelines Review Committee (GRC) as a new guideline.
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 SRH services, (ii) improve human rights and (iii) promote gender equality for women living with HIV.
WHO guidance exists on several specific aspects of SRHR and of HIV, but not all include considerations specific to the SRHR of women living with HIV. This consolidated guideline seeks to bring together both new and existing recommendations and good practice statements related to the SRHR of women living with HIV into one document. Where current WHO guidance applies to all women, including women living with HIV, this document refers readers to these other publications for further information, as well as to other relevant WHO tools and documents on programme activities.
The recommendations and good practice statements presented in this guideline relate to either creating and maintaining an enabling environment for SRHR of women living with HIV (Chapter 3), or to specific healthrelated interventions relevant to the SRHR of women living with HIV (Chapter 4). All of the new and existing WHO recommendations presented in this guideline (and summarized in Table 1 in the Executive summary) have been developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (9).
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. This guideline also includes discussion of implementation issues that managers of health interventions and service delivery must address to achieve gender equality and uphold human rights.

# Target audience
This new guideline is expected to support front-line health-care providers, programme managers and public health policy-makers around the world to better address the SRHR of women living with HIV. It is primarily designed for national-level programme managers, policy-makers and other decision-makers within the ministry of health. Acknowledging that the woman-centred approach of this guideline (see section 1.4.1) may require multisectoral engagement, the guideline will also be useful for national-level programme managers from other ministries, such as the ministries of education, gender, family and social welfare, who can be partners in delivering interventions that support a holistic approach to SRHR.
Health services and programmes in low-resource settings will benefit most from the guidance presented here, as they face the greatest challenges in providing services tailored to women living with HIV in all their diversity. However, this guideline is relevant for all settings regardless of the situation of the HIV epidemic or the economic context, and should, therefore, be considered as global guidance. In implementing these global recommendations, WHO regions and countries can adapt them to the local context, taking into account the HIV epidemic, economic conditions, and existing health services and facilities.
The users of this guideline, including health-care providers, programme managers and public health policy-makers, are urged to: (i) implement a woman-centred, gender-sensitive approach to addressing the SRH needs, aspirations and rights of women living with HIV, and to (ii) meet the health needs and support the aspirations of all women living with HIV throughout all stages of the life course, including the post-menopausal years.

# Population of interest
With reference to the 2015 WHO Consolidated guidelines on HIV testing services (11), this guideline will not include HIV testing, but is relevant for women from the point when they already know they are living with HIV.
Women living with HIV who are not aware that they have HIV must first be reached by safe, voluntary, noncoercive HIV testing and counselling, and follow-on services, which need to be expanded and strengthened.
In addition, although this guideline focuses on women who have been tested and know their positive HIV serostatus, it is acknowledged that the SRHR issues highlighted are, in many cases, similar for all women.
This guideline focuses on the SRHR of women living with HIV; while the SRHR of men living with HIV must also be addressed, this is not within the scope of this guideline. HIV is not only driven by gender inequality, but it also entrenches gender inequality, leaving women more vulnerable to its impact. The focus on women living with HIV is justified because many face unique and particular challenges and rights violations in relation to their gender, sexuality and reproductive roles within their families and communities, as well as from the health-care institutions where they seek services.

# Creating and maintaining an enabling environment
The SRHR of women living with HIV is strongly influenced by a range of social, cultural, political and economic factors. Factors that can impede SRHR include, but are not limited to: inequitable gender norms; genderbased and intimate partner violence (GBV and IPV); stigma and discrimination; lack of empowerment among women and girls; violations of human rights; and restrictive and often punitive laws and policies that increase the vulnerability of women living with HIV and limit their health, well-being, and realization of their rights. These factors also pose significant barriers to accessing and utilizing high-quality SRH and HIV services. Policies, programmes and interventions to improve the SRHR of women living with HIV exist in some places, but these alone will not bring about improved health outcomes in the absence of a safe and supportive enabling environment. For this reason, issues related to creating and maintaining an enabling environment, and specific relevant recommendations and good practice statements, including five new good practice statements (GPSs A.1-A.5), are included in the scope of this new consolidated guideline. These are presented in Chapter 3 under the following eight topic areas: psychosocial support; healthy sexuality across the life course; economic empowerment and resource access; integration of SRHR and HIV services; protection from violence and creating safety; social inclusion and acceptance; community empowerment; and supportive laws and policies as well as access to justice (see also section A of Tables 1 and 2 in the Executive summary, and Figure 2.1 at the end of Chapter 2).

# Priority questions and outcomes of interest for health interventions

# Approach and guiding principles
This guideline is grounded in and advocates for a strengthened, comprehensive, woman-centred approach to SRHR, with the assumption that if access to quality services is improved for all women, this will also benefit women living with HIV, and vice versa. This approach is underpinned by the guiding principles of gender equality and human rights.

# Woman-centred approach
Woman-centred health services involve an approach to health care that consciously adopts the perspectives of women, their families and communities (12).
A woman-centred approach:
n sees women as active participants in, as well as beneficiaries of, trusted health systems that respond to their needs, rights and preferences in humane and holistic ways;
n emphasizes the promotion of gender equality as central to the achievement of SRHR of all women, including women living with HIV, and promotes gender-transformative health services which examine critical gender norms and support gender equality;
n requires that women are empowered -through education and support -to make and enact decisions in all aspects of their lives, including in relation to sexuality and reproduction;
n calls for strategies that promote women's participation in their own health care; n recognizes the strengths of women living with HIV as active agents in relation to SRHR, and not merely passive recipients of health services; and n is organized around the health needs and priorities of the women themselves rather than disease management and control.
This guideline is intended to address women living with HIV in all their diversity, including, but not limited to: women who are heterosexual, lesbian, bisexual, transgender or intersex; women who use or have used drugs; women who are or have been involved in sex work; women who are single, married or in stable relationships, separated, divorced or widowed; women who are and are not sexually active; women and girls who have undergone female genital mutilation (FGM); women who have tuberculosis (TB), malaria, hepatitis B or C and/ or other co-morbidities; women who are currently or have previously been incarcerated, detained or homeless; women who are economic or political migrants; women who are indigenous; women living with disabilities; as well as adolescent girls who have acquired HIV perinatally, in childhood or during adolescence. This guideline recognizes that in all countries, but especially in areas with high HIV prevalence, some health workers are, themselves, women living with HIV who have their own priorities, needs and aspirations that require special consideration. The guideline captures diversity across age groups, emphasizing that health services that promote SRHR are important for women throughout all stages of the life course, including the postmenopausal years.
Many women living with HIV face multiple and intersecting forms of inequality and discrimination, depending on the local context. Each country should therefore understand and identify specific populations of women living with HIV that are particularly vulnerable and also those groups that are most relevant to the local epidemic, and should develop their response based on this local epidemiological and social context.
This guideline makes every effort to use language that is respectful of women living with HIV. It also promotes positive messages around health, instead of focusing exclusively on health problems. This woman-centred, rather than disease-centred, orientation can reduce stigma and support a life-enhancing, positive approach to SRHR (13).

# Guiding principles: human rights and gender equality
An integrated approach to health and human rights lies at the heart of ensuring the dignity and well-being of women living with HIV. The protection of human rights for all women living with HIV is therefore fundamental to this guideline. This includes a variety of human rights, namely: the right to the highest attainable standard of physical and mental health (14); the right to life and physical integrity, including freedom from violence (15); the right to equality and non-discrimination on the basis of sex (15); and the right to freedom from torture or cruel, inhuman or degrading treatment or punishment (16). Furthermore, article 27 of the Universal Declaration of Human Rights states that everyone has the right freely to share in scientific advancement and its benefits (16).
Recently, in its General Comment No. 22 (2016) on the right to sexual and reproductive health, the UN Committee on Economic, Social and Cultural Rights (CESCR) defined the right to SRH as an "integral part of the right to health enshrined in article 12 of the International Covenant on Economic, Social and Cultural Rights" (4).
The Programme of Action of the International Conference on Population and Development (ICPD) in 1994 highlighted reproductive and sexual health issues within a human rights framework (17). Since then, international and regional human rights standards and jurisprudence related to the right to SRH have evolved considerably. Most recently, the 2030 Agenda for Sustainable Development includes Sustainable Development Goals (SDGs) and targets to be achieved in the area of SRH (18), as does the Global Strategy on Women's, Children's and Adolescents' Health 2016-2030 (19).
The ICPD Programme of Action defines reproductive health as: "a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes" (17, para 7.2). The Programme of Action also refers to sexual health, "the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases". It further defines reproductive rights as follows:
eproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents (17, para 7.3).
Importantly, the CESCR's recent General Comment No. 22 recognizes that "people living with HIV/AIDS are more likely to experience multiple discrimination" and that "States must reform laws that impede the exercise of the right to sexual and reproductive health, including in relation to HIV status and transmission", and recommends adoption of "appropriate legislative, administrative, budgetary, judicial, promotional and other measures to ensure the full realization of the right to sexual and reproductive health" (4, para 45).
In the course of developing this guideline, two literature reviews were conducted to support the rights-based case for strengthened services that meet the needs and aspirations of women living with HIV. These reviews included a special focus on: (i) the challenges of ensuring that human rights considerations are highlighted by normative bodies (20); and (ii) analysis of human rights within policies and programmes affecting women living with HIV (21). The reviews highlighted key gaps in jurisprudence among international, regional and national bodies. The guidance from these bodies reflects only a few health and human rights considerations related to women living with HIV and SRH. The approach of these bodies has been largely ad hoc and lacks a systematic integration of the human rights concerns of women living with HIV in relation to their SRH. Of the articles and documents reviewed, not a single peer-reviewed article described the explicit implementation of human rights in SRH programming, and only two documents from the grey literature did so. With one possible exception, no articles or documents were found that addressed human rights comprehensively, or addressed the majority of relevant rights. As the two literature reviews were explicitly about the SRHR of women living with HIV, and they reviewed articles that implicitly dealt with these issues and built upon the nine agreed-upon human rights dimensions that are the foundation to good SRHR (see Table 1.1), this highlights a significant gap. In addition, in the articles included in the reviews, the language of rights was used most often to describe the apparent neglect or violation of human rights, as opposed to describing efforts to protect, promote or fulfil rights. When rights-related language was used, it primarily addressed only a few rights (most commonly the rights to access and non-discrimination) in the context of a few areas within SRH, while the issues of STIs, violence and ageing, for instance, were largely neglected.
The two reviews also highlighted the need for Member States to establish and enforce antidiscrimination and protective laws, derived from international human rights standards, in order to eliminate stigma, discrimination and violence faced by women living with HIV (20,21).
Such laws and policies should also address gender inequalities, including harmful gender norms and stereotypes, unequal power in intimate relationships, and women's relative lack of access to and control over resources. All of these inequalities exacerbate the vulnerability of women living with HIV, affect their access to and experience of health services, and create barriers that prevent them from fully exercising their rights to health, including SRH. The promotion of gender equality is central to the achievement of SRHR of all women, including women living with HIV in all their diversity.

# Applying the woman-centred approach and guiding principles
In recognition of all the issues and gaps that have been identified and mentioned here, this guideline aims to propose a comprehensive package of SRH services for women living with HIV, emphasizing that attention must be paid to adopting a woman-centred approach and applying the principles of human rights and gender equality, with reference to the guidance presented in Box 1.2. Box 1.3 provides a list of key WHO resources on human rights and SRH in general and in relation to specific health interventions and stakeholders. While the focus in this guideline is on human rights as they pertain to SRH, it is acknowledged that all aspects of human rights are important.
Box 1.2: Guidance on the application of a woman-centred approach based on principles of human rights and gender equality for SRHR of women living with HIV 1. Uphold and foster human rights and gender equality to address power imbalances, GBV, stigma, discrimination and rights-related barriers to SRH at all levels.
- Strengthen health systems to increase programme effectiveness and efficiency to facilitate improved delivery of a holistic range of high-quality woman-centred health services.
- Engage and empower women living with HIV in the development of policies and programmes that affect them, to ensure these address their lived realities.
- Promote or advocate for a conducive legal and policy environment which safeguards and promotes SRHR of women living with HIV.
- Support access to, and affordability and utilization of, quality health services for prevention and treatment of SRH concerns.
- Ensure acceptability of services to women living with HIV in all their diversity to overcome barriers based on exclusion, isolation, criminalization and poor understanding of women's strengths and needs.
- Promote women's agency and empowerment, including through health literacy and education, and support them to make informed choices and enact decisions that promote their own, their families' and their communities' health.

# Values and preferences of women living with HIV
Unique to the development of this WHO guideline, a global survey was conducted to assess the SRHR priorities of women living with HIV so that their values and preferences could be placed at the heart of the guideline. This global survey, hereafter referred to as the Global Values and Preferences Survey (GVPS), is the largest survey to date on the SRHR of women living with HIV. It was conducted by and for women living with HIV in 2014 to capture their perspectives in their own voices. The report of findings, Building a safe house on firm ground: key findings from a global values and preferences survey regarding the sexual and reproductive health and human rights of women living with HIV (37), and a related article published in the Bulletin of the World Health Organization, include detailed descriptions of the methods and limitations of the survey (37,38).
The limitations included the fact that the survey was most likely to reach women living with HIV globally who were (i) actively involved in networks of people living with HIV; (ii) aware of and potentially more open about their HIV status; and (iii) able to access an online survey using the Internet or participate in the focus group discussions.
A total of 945 women living with HIV participated in the survey, including 832 (from 94 countries) who responded to the quantitative survey, and another 113 (from 7 countries) who participated in focus group discussions. Respondents ranged in age from 15 to 72 years and came from a diverse range of backgrounds and experiences, including: women identifying as heterosexual, lesbian, bisexual, transgender or intersex; women who reported that they use or have used drugs; women involved in sex work; women who reported being single, married or in stable relationships; women who had undergone FGM; women who had TB, malaria, hepatitis B or C and/or other co-morbidities; women who had been incarcerated, detained or homeless; women who reported being economic or political migrants; women identifying as indigenous; women living with disabilities; and women who work as health-care providers.
The GVPS results were presented at a stakeholder consultation on SRHR of women living with HIV at the WHO headquarters in Geneva, in January 2015. The WHO Department of RHR continues to work with the community of women living with HIV, including representatives from key constituencies and different regions of the world. A special supplement in the Journal of the International AIDS Society (JIAS), published in December 2015, highlighted a few of the key issues that have emerged from the discussions and collaboration, in particular related to violence against women living with HIV, and mental health issues (8). In addition, several activities have taken place as a result of the survey, including the development of further peer-reviewed publications and webinars, led by the community of women living with HIV.
The findings of the GVPS (summarized in Box 1.4) informed the development of this guideline as a whole. The Guideline Development Group (GDG) took the findings of the GVPS into account when drafting the PICO (population, intervention, comparison, outcome) questions for the development of new recommendations (see Chapter 2, section 2.5 and Table 2.2) and when drafting the questions that formed the starting point for the new good practice statements. The GVPS also informed the GDG in writing and finalizing the recommendations, the good practices statements and the full guideline document. In particular, relevant survey findings are included in each topic area addressed throughout Chapters 3 and 4.
This symbol representing the values and preferences of women living with HIV is used to alert the reader wherever results from the GVPS are reported.
Box 1.4: Key findings of the Global Values and Preferences Survey (GVPS)
- For women living with HIV, safety was considered paramount. Most survey respondents had experienced violence or fear of violence, before, since or because of their HIV diagnosis, and they called for measures to ensure safety for women living with HIV within health services, at home and in the community.
- Respondents highlighted the need to redress human rights violations, including mandatory testing, involuntary disclosure, and coerced or forced sterilization and abortion.
- Women living with HIV reported gaps in clinical care, practice, policy and research for girls and women outside the reproductive years and for women who do not have children. A holistic, woman-centred con(tra) ception-to-old-age approach to SRH care, with a comprehensive package of age-and stage-appropriate services, was consequently felt to be essential.
- Respect for women living with HIV in all their diversity, including respectful provision of health services and respect for their ability to make informed decisions about their own SRH care, was considered indispensable, particularly given the reported difficulty and considerable lack of empowerment in decision-making around when, how and with whom to have sex, and whether and when to have children.
- Women living with HIV sought further acknowledgement of the importance of peer support and meaningful involvement in decisions that affect their own lives.
- Widespread concerns about punitive and repressive laws were reported, with these laws viewed as barriers to their achievement of health and human rights.
- Many reported challenges to achieving a pleasurable and satisfying sex life, including lack/loss of sexual desire and fear of onward HIV transmission, pregnancy and STIs, linked with difficulties around condom availability, negotiation and use, as well as fears of the impact and consequences of HIV disclosure (including violence).
- Fear of onward transmission of HIV to a child or partner was often compounded by stigmatizing attitudes from health workers.
- Many respondents reported being on HIV treatment and experiencing side-effects that they felt affected their sexual health and overall well-being.
- Respondents also emphasized the challenges of poverty and financial insecurity, which could be a barrier to accessing services and realizing human rights, as well as the associated strain on mental, physical and sexual health. In particular, the wide range and high prevalence of mental health difficulties cited by women living with HIV highlighted the complex implications of an HIV-positive diagnosis.
- Finally, women wanted support for interactions with their children, partners and communities Source: The Salamander Trust, 2016 (37).

# Chapter 2. Methodology and process for development of the guideline
The WHO Department of Reproductive Health and Research (RHR) led the development of this consolidated guideline, following WHO procedures and reporting standards laid out in the WHO handbook for guideline development (39). Given the significant difference in scope to the 2006 guidelines (6), a new title was proposed by the WHO Guideline Steering Group: Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Consequently, this guideline was presented and viewed as a new submission by the WHO Guidelines Review Committee (GRC) and not considered an update of the 2006 document.

# Guideline development working groups
The RHR Department set up three working groups to perform specific guideline development functions: the WHO Guideline Steering Group (SG), the Guideline Development Group (GDG) and the External Review Group (ERG). Members of the groups were selected so as to ensure a range of expertise and experience, including appropriate representation in terms of geography, gender and the community of people living with HIV. The three working groups are described in the following subsections and the names and institutional affiliations of the participants of each group are listed in Annex 1.

# The WHO Guideline Steering Group (SG)
The SG, chaired by the RHR Department, led the guideline development process. The SG included participants from three departments within the WHO Family, Women's and Children's Health Cluster (FWC)the RHR Department, the Department of Maternal, Newborn, Child and Adolescent Health (MCA) and the Department of Ageing and Life Course (ALC) -as well as from the Gender, Equity and Human Rights Team (GER), and from other WHO departments including the Department of HIV/AIDS and the Department for Mental Health and Substance Abuse (MSD), along with representatives from the WHO Regional Offices for Africa, the Americas, Europe, the Eastern Mediterranean and South-East Asia. The SG drafted the initial scope of the guideline and drafted the priority questions in PICO format (population, intervention, comparator, outcome), identified individuals to participate as guideline methodologists and as members of the systematic review teams, the Guideline Development Group (GDG) and the External Review Group (ERG). The SG also finalized and published the guideline document, and will oversee dissemination of the guideline and be involved in the development of implementation tools.

# The Guideline Development Group (GDG)
The SG identified and invited external experts and stakeholders from the six WHO regions to form the GDG, ensuring geographic representation and gender balance. The members of the GDG had expertise in a wide range of SRHR and HIV issues covered in this guideline; they included clinicians, researchers, policy-makers, programme managers and representatives of communities of people living with HIV. The GDG members were involved in reviewing and finalizing key PICO questions and reviewing evidence summaries from the commissioned systematic reviews. They were also responsible for formulating new WHO recommendations and good practice statements, as well as for achieving consensus on the final content.

# The External Review Group (ERG)
The ERG included peer reviewers with a broad range of expertise in issues related to SRHR and HIV, drawn from the community of people living with HIV, clinicians, researchers, policy-makers and programme managers. The group ensured that the guideline decision-making processes had considered and incorporated the contextual values and preferences of persons affected by the recommendations. The ERG members provided their feedback and comments on the draft of the guideline that was shared with them after being drafted, reviewed and revised by the SG and GDG. It was not within the ERG's remit to change the recommendations that had been formulated by the GDG.

# Additional key contributors 2.2.1 External partners
In accordance with guidance in the WHO handbook for guideline development (39), funders, donors and representatives of UN agencies were invited to attend the GDG meeting as observers. These external partners represented the following agencies:

# Women living with HIV
Crucial to the development of this guideline at all stages of the process has been the partnership and engagement with -and the meaningful involvement of -women living with HIV, both as members of the GDG and ERG and as partners in leading and developing the Global Values and Preferences Survey (GVPS), including the investigation methodology, analysis and conclusions (see Chapter 1, section 1.5) (40).
Community engagement in the guideline process was assured through participation in:
n the GVPS, conducted in 2014, and dissemination of the report of the survey findings in 2014-2015 (37); n the stakeholder meeting in January 2015, to share results and key outcomes of the GVPS; and n the GDG and the ERG, which both included women living with HIV as members.

# Declaration of interests by external contributors
In accordance with WHO rules for transparency, prior to issuing formal invitations for individuals to become members of the GDG and ERG, brief biographies of the selected individuals (approximately 350 words) were made available to the public on the Department's website for three weeks (February 2016). In accordance with the WHO handbook for guideline development (39), all prospective members of the GDG and ERG and the other selected external collaborators were asked to declare in writing any academic, financial or other competing interests at the time of the invitation to participate in the development of the guideline. The standard WHO form for declaration of interests (DOI) was completed and signed by each expert and sent electronically, along with their curriculum vitae, to the responsible technical officer. This officer collated the signed DOI forms and curriculum vitae and, together with members of the SG, reviewed the information and determined whether a conflict of interest existed before granting final approval for the experts' invitations to participate. Where any conflict of interest was declared, the SG determined whether it was serious enough to affect the individual's ability to make objective judgements about the evidence or recommendations. To ensure consistency, the SG applied the criteria for assessing the severity of a conflict of interest in the WHO handbook for guideline development (39).
All findings from the received DOI statements were managed in accordance with the WHO DOI guidelines on a case-by-case basis. Where a conflict of interest was not considered significant enough to pose any risk to the guideline development process or reduce its credibility, the expert was only required to declare such conflict at the GDG meeting (also called the Technical Consultation) and no further action was taken. There were no cases of conflicts of interest that warranted management of DOI and assessment of potential conflicts of interest by the WHO Office of Compliance, Risk Management and Ethics (CRE). On confirmation of their invitations to participate, all experts were instructed to notify the responsible technical officer of any change in relevant interests during the course of the guideline development process, in order to update and review any conflicts of interest accordingly. At both the scoping meeting in January 2015 and again at the GDG meeting in April 2016 (both held in Geneva, Switzerland), members were required to state any conflicts of interest openly to the entire group, and were required to submit a signed and updated DOI form. A summary of the DOI statements and information on how conflicts of interest were managed are included in Annex 2.
- 4 Defining the scope and topic areas for new recommendations and good practice statements
Working within the general scope of the guideline as presented in Chapter 1, section 1.3 -the population of interest and the intention of addressing both an enabling environment and specific relevant health interventions -the SG first mapped all existing WHO SRHR guidance with relevance for women living with HIV. The SG then reviewed these and other materials to identify gaps, overlaps and inconsistencies and to determine the relevance of existing recommendations for inclusion in this consolidated guideline. The SG identified the following eight topic areas where new recommendations or good practice statements needed to be developed for this guideline: 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. The outcome of the mapping exercise was presented at the scoping meeting in January 2015.
- 5 Review of the evidence and formulation of recommendations The full details on the population, intervention, comparator and outcomes for each of the four PICO questions are presented in Annex 3, while the summaries of the methods for each of those four systematic reviews, including the search strategies and flow charts for inclusion of studies, are included along with the evidence base (the GRADE tables) in the Web supplement to this guideline. 1 A list of all 13 systematic and literature reviews conducted for the development of this guideline -including the four systematic reviews on the topics of the six new recommendations, five systematic reviews on the topics of the five new good practice statements (GPSs A.1-A.5; see Table 2 in the Executive summary, and Chapter 3), and another four literature reviews on other related topics -is presented in Annex 4.

# Interpretation of the quality of the evidence for recommendations
In accordance with the WHO guideline development process, the GDG formulated the recommendations guided by the quality of available evidence (39). WHO has adopted the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to recommendation development, which defines the quality of evidence as the extent to which one can be confident that the reported estimates of effect (desirable or undesirable) available from the evidence are close to the actual effects of interest (41,42,43). The GRADE approach specifies four levels of quality of evidence, which should be interpreted as detailed in Table 2.1. The GRADE approach (9) to appraising the quality of quantitative evidence was used for all the critical outcomes identified in the PICO questions, and a GRADE profile was prepared for each quantitative outcome within each PICO. The GRADE tables are presented in the Web supplement.

# Determining the strength of a recommendation
The strength of a recommendation -assigned as either "strong" or "conditional" -reflects the degree of confidence of the GDG that the desirable effects of the recommendation outweigh the undesirable effects.
Desirable effects (i.e. potential benefits) may include beneficial health outcomes for individuals (e.g. reduced morbidity and mortality), reduced burden on the individual and/or the health services, and cost-savings for the individual, the community, the programme and/or the health system. Undesirable effects (i.e. potential harms) include adverse health outcomes for individuals (e.g. increased morbidity and mortality) and increased burden on the individual, the family, the community, the programme and/or the health system. This may include, for example, the resource use and cost implications of implementing the recommendations -which programmes, health-care providers or clients would have to bear -as well as potential legal ramifications where certain practices are criminalized.
A strong recommendation (for or against the intervention) is one for which there is confidence that the desirable effects of adherence to the recommendation clearly outweigh the undesirable effects. The higher the quality of the scientific evidence base, the more likely that a strong recommendation can be made. New strong recommendations in this guideline are worded as "WHO recommends...".
A conditional recommendation (for or against the intervention) is one for which the quality of the scientific evidence base may be low or may apply only to specific groups or settings; or it may be assigned in cases where the GDG concludes that the desirable effects of adherence to the recommendation probably outweigh the undesirable effects or are closely balanced, but the GDG is not confident about these trade-offs in all situations. New conditional recommendations in this guideline are worded as "WHO suggests...".
If implemented, an intervention that received only a conditional recommendation should be monitored closely and evaluated rigorously. Further research will be required to address the uncertainties and this may provide new evidence that may change the calculation of the balance of trade-offs.
The values and preferences of the end-users (women living with HIV), as well as consideration of the relevant feasibility, cost and equity issues, all contribute to determining the strength of a recommendation.

# Benefits and risks
When a new recommendation is developed, desirable effects (benefits) need to be weighed against undesirable effects (risks), considering any previous recommendation or another alternative. The larger the gap or gradient in favour of the benefits over the risks, the more likely that a strong recommendation will be made.

# Values and preferences (acceptability)
If the recommendation is likely to be widely accepted or valued highly, it is likely that a strong recommendation will be made. If there is a great deal of variability or strong reasons that the recommended course of action is unlikely to be accepted, it is more likely that a conditional recommendation will be made.

# Costs/financial implications
Lower costs (monetary, infrastructure, equipment or human resources) or greater costeffectiveness are more likely to support a strong recommendation.
The greater the feasibility of an intervention to all stakeholders, the greater the likelihood of a strong recommendation.
If an intervention will reduce inequities, improve equity or contribute to the realization of human rights, the greater the likelihood of a strong recommendation.
Source: Schunemann et al., 2013 (45).

# Decision-making by the GDG during guideline development
The GDG members were guided by a clear protocol for WHO guideline development (39). The GDG reviewed the evidence and discussed the topics under consideration, led by the guideline methodologist. The GDG meeting or Technical Consultation in April 2016, in Geneva, Switzerland, was designed to allow participants to draft and consider each of the recommendations through a process of group discussion and revision. In order to gain an initial indication of GDG members' views on the direction of each recommendation (to recommend for or against an intervention), and on the strength of each recommendation (strong or conditional) as drafted, the methodologist asked participants to raise their hands in support of each separate option. This was not a formal vote, but a decision-making aid to allow the methodologist and chairs to gauge the distribution of opinion and subsequently work towards consensus through further discussion. The final adoption of each recommendation, including its direction and strength, was confirmed by unanimous consensus among all GDG members. The GDG also determined the context of recommendations by the same process of consensus, based on discussions around the balance of evidence on the potential benefits and disadvantages of the interventions across the domains evaluated. The judgements made by the GDG related to each recommendation are noted in Annex 5.

# Compilation and presentation of guideline content
Following the GDG meeting, members of the SG prepared a draft of the full guideline document, including revisions to the recommendations to accurately reflect the deliberations and decisions of the GDG participants.
The draft guideline was then sent electronically to the GDG participants for further comment, and their feedback was integrated into the document before it was sent to the External Review Group (ERG) for their input. The SG then carefully evaluated the input of the ERG members for inclusion in the guideline document. After the GDG meeting and the external peer-review process, any further modifications made to the guideline by the SG were limited to correction of factual errors and improvement in language to address any lack of clarity. The revised final version was returned electronically to the participants of the GDG for their final approval.
This guideline presents WHO recommendations that have been newly developed and published for the first time in this guideline in 2017 (indicated by the label of "NEW" after the recommendation number) and existing recommendations that have been previously published in other WHO guidelines that applied the GRADE approach (all the recommendations not labelled as "NEW"), as well as new and existing good practice statements (again the former are labelled as "NEW").
The five new good practice statements (GPSs) apply to the creation and maintenance of the enabling environment required for successful achievement of optimal SRHR of women living with HIV. These new good practice statements are presented in Chapter 3: Creating an enabling environment. Each new good practice statement is presented in a shaded box along with remarks on key implementation considerations highlighted by the GDG. Additional information relating to each of the eight topics in Chapter 3 is presented in the following order after the box or boxes presenting new or existing recommendations and/or good practice statements: (i) background information about the topic; (ii) barriers to SRHR; (iii) components of an enabling environment that will address the barriers and support SRHR; and, only in the case of the NEW GPSs, (iv) a summary of evidence and considerations of the GDG, including any additional implementation considerations, to support optimal understanding, implementation and outcomes. Each new recommendation is presented in a shaded box, including information about the strength of the recommendation and the quality of the evidence it is based on (assessed using the GRADE method, as previously described in section 2.5.2), followed by a list of remarks, including key considerations for implementation highlighted by the GDG. Additional information relating to each of the six types of services in Chapter 4 is presented in the following order after the box or boxes presenting new or existing recommendations and/or good practice statements (if any): (i) background information; and, only in the case of the NEW RECs, (ii) a summary of evidence and considerations of the GDG, including results and explanations about the quality of the evidence and the strength of the recommendation, and any additional implementation considerations, including feasibility and costs, if any information is available.
For each topic area in this guideline, in both Chapters 3 and 4, there is also an icon referencing the GVPS which is placed to clearly indicate to readers the presentation of information on the values and preferences of women living with HIV, which has been drawn from the findings of the GVPS (37).
The SG also consolidated existing recommendations (only those based on the GRADE approach) and existing good practice statements into this guideline from other recent, GRC-approved WHO guidelines if they were relevant to the SRHR of women living with HIV. In all instances, these existing recommendations and good practice statements are worded exactly as in the separate guidelines where they were previously published. For existing recommendations, the strength of each recommendation and the quality of the evidence as determined by the respective GDGs for those guidelines have also been noted. These existing recommendations have not been reviewed or changed during the guideline development process in 2016 and they remain valid. The evidence base for these recommendations is not included in the supplementary material for this new consolidated guideline since it was already presented at the time of publication of the original guidance. For all existing recommendations and good practice statements, the title and web link for the existing WHO guidance is also provided in the lists of remarks, for easy access to further information from the original source.
In all, this consolidated guideline includes 52 recommendations (including six new ones) and 22 good practice statements (including five new ones) relevant to SRHR of women living with HIV. All the recommendations (RECs) and good practice statements (GPSs) related to creating an enabling environment are presented in Chapter 3 (and summarized in section A in Tables 1 and 2 in the Executive summary, and in Figure 2.1) and they are labelled as REC A.1, REC A.2, etc. and GPS A.1, GPS A.2, etc., respectively, and all those relating to health interventions are presented in Chapter 4 (and summarized in section B in Tables 1 and 2 in the Executive summary, and in Figure 2.1) and they are labelled as REC B.1, REC B.2, etc. and GPS B.1, GPS B.2, etc., respectively, grouped into subsections according to the topic area and type of service.
Chapter 5 on guideline implementation and service delivery presents a discussion of key issues that would guide implementation of the recommendations to support realization of the maximum possible benefits, based on GDG discussions. Chapter 6 of the guideline presents a list of research gaps and priorities, as identified by the GDG, which require further study, and discusses the elements of a recommended inclusive approach for expanding the evidence base on SRHR of women living with HIV. Chapter 7 describes the plans for dissemination, application, monitoring and evaluation, and updating of the guideline and recommendations.
Evidence derived from the four systematic reviews in support of the six new recommendations (see Annex 4) was summarized in GRADE tables to provide the evidence base on effectiveness that informed the new recommendations in this guideline. These GRADE tables, along with the systematic review search strategies and flow charts, are presented separately in the Web supplement.
The framework presented in Figure 2.1 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 GVPS, 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 (starting at the top and running clockwise); and (B) the health interventions (central teal segments), with all six topics as presented in Chapter 4 (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 (in the Executive summary).  This enabling environment can be characterized as follows:

# S T I a n d c e r v i
n Attitudes and behaviours of health workers need to be inclusive, non-stigmatizing, and promote safety and equality. Health-care providers and managers of health-care facilities should be held accountable when they do not deliver services appropriately or fail to meet standards based on professional ethics and internationally agreed human rights principles. Delivery of care and treatment services should be accomplished in a people-centred and non-judgemental way, allowing women living with HIV to lead the decision-making about their own care in an informed, supported fashion.
n Necessary medical products and technologies must be made available to allow health workers to deliver services, implement interventions and to create and maintain the enabling environment.
n Health management information should be produced, analysed, disseminated and used in a timely manner, and should capture the wide range of determinants of good SRH for women living with HIV. This information should be available to and used by health workers, women living with HIV and others in the community to address clinical and non-clinical aspects of SRHR. Information gaps should be identified and filled through appropriate research, including community-driven research. Information should be reliable and accurate and it needs to be trusted by patients, who rely on it to support their informed decisionmaking about their personal health and well-being and about their interactions with health systems.
n Health interventions must be available and accessible at the time and place they are needed, and they must also be acceptable and of high quality.
n Budgetary allocations and financing strategies need to be recognized as playing a critical role in creating the enabling environment to achieve good health outcomes, universal health coverage and costeffectiveness of service delivery.
n Policies, regulations and operational incentives must take into consideration and must support an enabling environment for SRHR of all women living with HIV, including those who are themselves health workers. Due to the range of determinants of SRHR, creating a supportive environment requires leadership and coalition-building across a range of sectors -including collaboration with and meaningful engagement of the community of women living with HIV. The health system should lead these efforts to ensure a comprehensive approach. Creating an enabling environment for the SRHR of women living with HIV should embrace the following strategies:
- Take a holistic approach: Making the environment more enabling requires working at multiple levels across the social ecological framework (see section 3.1), including the individual, relationship, community and institutional levels. Some examples of this approach:
n supporting women's psychosocial health can decrease internalized stigma on the individual level; n continuing HIV education in communities and supporting social protections for all people can decrease stigma in the social settings of women living with HIV;
n ensuring that health-care facilities do not allow discriminatory practices can reduce institutional stigma; n promoting policies and enacting laws that prevent stigma and discrimination can begin to address stigma at its roots.
These are all pieces of a comprehensive approach to an enabling environment for good SRH and realization of the rights of women living with HIV.
- Invest in long-term programming: Examples of this approach include creating SRH and HIV programme plans with a 10-15 year horizon, investing in capacity-building, and working to change destructive social norms, instead of short-term crisis-response activities. Even if plans are concretized in five-year phases, the use of long-term planning strategies and indicators can support long-term goals. Capacity-building among local managers and health-care personnel, along with the training and meaningful engagement of people living with HIV, will support locally owned and locally appropriate, sustainable programmes (48).
- Focus on positive messages: If needs and deficiencies lead the conversation, interventions will not identify or build on strengths that exist among women living with HIV and within the health system. Techniques such as appreciative inquiry (38) allow for the identification of achievements that can serve as a foundation for future progress. Also, an exclusive focus on negative experiences may lead to retraumatization of women who have had negative experiences, without supporting them to consider ways to move forward, towards recovery, healing and resilience.