Breaking: WHO issues new guidance for discordant couples

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The World Health Organization released its new “Guidance on couples HIV testing and counselling, including antiretroviral therapy (ART) for treatment and prevention in serodiscordant couples: Recommendations for a public health approach” on Wednesday. Discordant couples are those where one partner is HIV-infected and the other is not, where a couple is defined as two persons in an ongoing sexual relationship and each of these persons is referred to as a “partner” in the relationship.
 
According to the executive summary, the new guidance states: 
  1. Couples and partners should be offered voluntary HIV testing and counseling with support for mutual disclosure.
    Strong recommendation, low-quality evidence.
  2. Couples and partners in antenatal care settings should be offered voluntary HIV testing and counseling with support for mutual disclosure.
    Strong recommendation, low-quality evidence.
  3. Couples and partner voluntary HIV testing and counseling with support for mutual disclosure should be offered to individuals with known HIV status and their partners.
    Strong recommendation, low-quality evidence for all people with HIV in all epidemic settings / Conditional recommendation, low-quality evidence for HIV-negative people depending on country specific HIV prevalence.
  4. People with HIV in serodiscordant couples and who are started on antiretroviral therapy (ART) for their own health should be advised that ART is also recommended to reduce HIV transmission to the uninfected partner.
    Strong recommendation, high-quality evidence.
  5. HIV-positive partners with a CD4 count >350 in serodiscordant couples should be offered ART to reduce HIV transmission to uninfected partners.
    Strong recommendation, high-quality evidence.

Intended for national policymakers and relevant health program managers  in low- and middle-income countries with generalized HIV epidemics, the guidelines were set to be released at the International AIDS Conference in Rome last July, but delayed in order to consider results from two clinical trials looking at ART use as pre-exposure prophylaxis (PrEP) that showed a strong prevention benefit, as well as the relevance of couples counseling and testing among pairs who are men who have sex with men (MSM) and/or inject drugs.  Yet the  guidelines state that they did not review the evidence of the prevention effect of ART in same-sex couples or other populations, including injection drug users, sex workers, and transgendered people outside of the couples context. “However, international scientific consensus is emerging that ART significantly reduces the risk of sexual transmission of HIV regardless of the population or setting,” according to the executive summary.

The 54-page document also touches on recent evidence that pre-exposure prophylaxis (PrEP) with some antiretrovirals taken in discordant couples can help to prevent sexual acquisition of HIV, and notes that the WHO is reviewing this data and hopes to have a “rapid advice” document on PrEP available sometime this year to help guide programs in discordant couples and in MSM communities.

 “We realise that in making a global recommendation on a health intervention, there is always the understanding that there will be issues of cost and feasibility that vary with context,” said Dr. Gottfried Hirnschall, director of the HIV/AIDS Department at the WHO, in an email disseminating the new guidelines. “Countries and programmes will often have to make difficult choices when resources are limited. In situations of limited or inadequate resources, the guidelines recommend that individuals who require ART for their own health should always be given priority,” Gottfried said, adding that countries should make every effort to expand services, including offering earlier treatment to HIV-infected persons in discordant couples, when possible.

 

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