In a long anticipated move, the World Health Organization released new recommendations on the treatment and prevention of HIV/AIDS today. The WHO announced that it is now recommending antiretroviral therapy (ART) be initiated at a CD4 threshold of 350 cells/mm3 for “all HIV-positive patients, including pregnant women, regardless of symptoms.”
The WHO called for prolonged use of antiretroviral (ARVs) drugs among pregnant women to reduce the risk of mother-to-child transmission of HIV and said HIV-positive mothers and their babies should take ARVs during breastfeeding. The WHO also said countries should phase out the use of Stavudine, or d4T, “because of its long-term, irreversible side-effects,” according to a news release from the WHO.
These decisions—coming on the eve of World AIDS Day–are very significant, even if widely expected. For starters, they add fuel to the argument that more money is urgently needed for global AIDS programs; with these new recommendations, more HIV-positive patients in poor countries will become eligible for HIV therapy, and treating those patients will become more expensive if the low-cost Stavudine is not an option.
“These new recommendations are based on the most up to date, available data,” said Dr Hiroki Nakatani, Assistant Director General for HIV/AIDS, TB, Malaria and Neglected Tropical Diseases at the WHO. “Their widespread adoption will enable many more people in high-burden areas to live longer and healthier lives.”
The WHO’s decisions also come just before top Obama Administration officials are set to discuss its vision for the US global AIDS program, PEPFAR. At 2:30 today, Secretary of State Hillary Clinton, Global AIDS Coordinator Eric P. Goosby, MD, and others will discuss the Administration’s efforts on HIV, domestically and internationally.
It’s unclear just how much news Clinton, Dr. Goosby, and others will make. No funding levels are expected to be announced, but there may be a few new policy tidbits.
One key question is how Dr. Goosby will react to the WHO news. During a presentation at the IDSA Annual Meeting last month, Dr. Goosby estimated that a change in the WHO treatment threshold would mean 2.5 to 3 times as many people eligible for treatment. At that session, he advocated access to ARVs at 350 for pregnant women and for those who are HIV-TB co-infected.
And in a recent Q&A posted on the Global Health Council’s blog, Goosby said: “I think that if countries go to 350 (CD4 count), there will have to be rationing because they do not have enough resources to cover people below 200 or people below 150. If they now say anybody 350 and down are eligible, they are going to have to figure out a way responsibly to put those people who are most ill on drugs first.”
Another key barometer for Monday’s news conference is whether the Administration announces a new treatment target for PEPFAR. If Goosby and other officials do not articulate a clear treatment goal, that could be a signal of wavering commitment to robust scale up of US efforts to combat the HIV/AIDS pandemic. (The White House event can be viewed live at www.whitehouse.gov/live.)
The WHO, in its news release, noted that its decisions are based on well-established scientific evidence showing that earlier initiation of ART “reduces rates of death and disease.”
“An earlier start to antiretroviral treatment boosts the immune system and reduces the risks of HIV-related death and disease. It also lowers the risk of HIV and TB transmission,” the release says.
The WHO acknowledged that the new recommendations would increase the number of patients needing treatment. But “the associated costs of earlier treatment may be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections,” the WHO noted.