The World Health Organization guidelines recommend HIV treatment for all The World Health Organization (WHO) has released updated guidelines calling for universal antiretroviral therapy for everyone diagnosed with HIV, regardless of CD4 T-cell count, and pre-exposure prophylaxis (PrEP) for people at risk of infection. The organization estimates that the recommendations, if widely adopted, could avert 21 million deaths and prevent 28 million new infections worldwide by 2030. David Rowlands examines the views of the HIV community on these new guidelines, based on responses to his latest online poll.
International HIV treatment guidelines agree on when to start treatment The new European AIDS Clinical Society (EACS) Guidelines, were recently launched at the 15th European AIDS Conference in Barcelona, which brings Europe into line with the rest of the world by recommending HIV treatment upon diagnosis for all patients. This is the first time since 2006 that all international guidelines have agreed on their “when to start” recommendations. Now, in line with all other guidelines, EACS recommends that treatment should be offered to all people diagnosed with HIV, though they still reserve a category of “strong recommendation” for people diagnosed with CD4 counts below 350 cells/mm3. This is a major step forward in the global fight against HIV. They have the potential to dramatically reduce transmission of HIV worldwide, increase the widespread use of PrEP among those who need it most, and help those living with HIV live longer, healthier lives.
“These new recommendations will have tremendous impact on peoples’ lives, if rapidly implemented,” said Gottfried Hirnschall, director of WHO’s Department of HIV/AIDS. “So we must work together to support countries to translate them into action and results.” Comorbidities and Ageing Another change is not so much in specific recommendations as emphasis. The section on the prevention and treatment of co-morbidities in people with HIV now includes a specific statement:
“We recommend multidisciplinary care for ageing HIV patients with multiple co-morbidities and chronic immune activation to preserve good quality of life and prevent frailty.” This is because as the HIV-positive population ages, it is becoming clearer that certain conditions that arise with age can be more frequent or more severe in people with HIV. More “aggressive” © DiseaseSpotlight.com 2016
David Rowlands – blogger and director of Design-Redefined.co.uk
Treatment for All The new WHO guidelines state that, “Antiretroviral therapy should be initiated in all adults living with HIV at any CD4 cell count.” The same recommendation applies to infants, children, adolescents, and pregnant women. People with advanced immune suppression or clinical symptoms of AIDS should be prioritised for treatment. START trial provides evidence of benefits of early HIV treatment People who start antiretroviral therapy (ART) immediately after an HIV diagnosis — while their CD4 T-cell count is still high — rather than waiting until it falls below 350 cells/ mm3 have a significantly lower risk of illness and death. Findings suggest that HIV Antiretroviral therapy should be provided for everyone regardless of CD4 count. Now we have evidence that aligns individual benefit and prevention benefit without evidence of harm. The recommendation for universal treatment for everyone who tests HIV-positive was informed by the large START trial, which showed the benefits of early antiretroviral therapy. The WHO guidelines team had advance access to these study findings after a data monitoring committee stopped the trial ahead of schedule because there was enough evidence to show an advantage of early treatment. Previous results from a study of heterosexual couples in Africa (HPTN 052), showing that HIV-positive people who start treatment immediately instead of waiting until their CD4 count drops had a 93% lower risk of transmitting HIV to their partners. When transmission did occur, it was usually soon after starting treatment before viral load became undetectable. PrEP Other changes in the new guidelines include a positive recommendation for pre-exposure prophylaxis (PrEP), which brings them into line with the U.S. DHHS and Centres for Disease Control and Prevention (CDC), WHO, and BHIVA. PrEP is “recommended” for “men who have sex with men and transgender individuals, who are inconsistent in their use of condoms with casual partners or with HIV‑positive partners who are not on treatment,” and “may