New WHO guidelines for HIV treatment would begin to narrow care gap between rich and poor countries

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WHOguidelinesWHO: Comprehensive guidelines to start treatment earlier in illness and, for some, immediately, would make 26 million people eligible for medicine, avert 3 million deaths, prevent more than 3 million infections

Calling for more widespread access to antiretroviral medicine worldwide in updated HIV treatment guidelines released Sunday, the World Health Organization acknowledged the changes will demand new investments, but added that acting on the guidelines could lead to the “irreversible decline” of the global HIV epidemic.

The guidelines call for starting treatment before patients’ immune, or CD4, cell counts fall below 500 per cubic millimeter of blood, and call for treatment upon diagnosis for all children with HIV under 5 years of age, all pregnant and breastfeeding women with HIV, and “to all HIV-positive partners where one partner in the relationship is uninfected.” The WHO’s last general guidelines for treatment issued in 2010 recommended starting treatment before patients’ CD4 counts fell below 350. The new guidelines cite the importance of protecting the health of people living with HIV before their immune systems are severely damaged, improvements in antiretroviral medicines, and the proven role of treatment in preventing transmission of the virus.

In recent years studies have shown that early antiretroviral treatment reduces the risk of transmission from an infected partner to an uninfected partner in a relationship, that widespread access to treatment lowers community incidence of HIV and tuberculosis, and increases life expectancy.

The new guidelines also recommend specific antiretroviral medicines, simplifying treatment regimens, and eliminating use of stavudine, a toxic, relatively inexpensive drug with lasting and debilitating side effects.

The WHO has issued guidelines on treating HIV since 2002, with the first set calling for antiretroviral treatment initiation when patients’ CD4 cell counts have dropped to 200 or below, signifying a drastically compromised immune system. The latest guidelines follow a series of updated guidances for specific populations including for couples among whom one partner has HIV and the other does not, as well as for people with TB. They are the first guidelines to encompass programmatic as well as clinical concerns, suggesting steps to facilitate greater treatment access. Among changes, the guidelines urge widening the scope not only of who is eligible to receive antiretroviral treatment, but who is eligible to administer it, calling for an expanded role for community health workers, and suggest using mobile phone messaging reminders to help patients adhere to treatment and clinic visits. The guidelines also recommend that measuring viral load, rather than immune cell count be the preferred method for monitoring treatment failure.

HIV response advocates welcomed the guidelines on Sunday, but emphasized how they are acted upon, and how widely, will determine their success. Criticisms included that the guidelines still do not promote the standard of care, and immediate access to medicine that patients in wealthy countries can receive. In addition, treatment advocates questioned the definition of “couples” “relationships” and  “partners” and how those terms will be applied to determining eligibility for immediate treatment to reduce risks of transmission.

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