WHO sets new HIV treatment guidelines | New HIV treatment | Hiv prevention treatment
WHO sets new HIV treatment guidelines | New HIV treatment | Hiv prevention treatment
The World Health Organization (WHO) issued a new set of guidelines for the treatment of HIV and prevention of mother-to-child transmission (PMTCT) on 30 November.
The recommendations are intended to provide a reference for countries in setting their own national standards for HIV/AIDS treatment and PMTCT. Implementation will depend on local capacity and budgets, but the guidelines could potentially have a tremendous impact on the lives of the 33.4 million people living with HIV/AIDS.
“The widespread adoption of the recommendations will enable many more people in high-burden areas to live longer and healthier lives,” said Dr Hiroki Nakatani, Assistant Director General for HIV/AIDS, TB, Malaria and Neglected Tropical Diseases at WHO.
The revised guidelines, based on new scientific evidence, raise the threshold for starting antiretroviral therapy (ART) from a CD4 count (a measure of immune system strength) of less than 200 cells per cubic millilitre – as recommended by the guidelines issued in 2006 – to a CD4 count of 350 or less, regardless of whether or not the patient is displaying symptoms.
Studies have shown that starting ART earlier reduces mortality rates, but earlier treatment will mean an average additional one to two years on antiretroviral (ARV) drugs, raising concerns about the costs for governments already struggling to meet targets set according to the previous guidelines.
The 2009 guidelines suggest greater use of laboratory monitoring, including CD4 counts and viral load testing (measuring the amount of HIV in the blood), to better manage HIV treatment and care.
WHO also advises the use of first-line ARV drugs – Zidovudine (AZT) or Tenofovir (TDF) – rather than Stavudine (d4T), which has been widely used in developing countries because of its lower cost, but produces more serious side effects.
In line with several recent clinical studies that have demonstrated the efficacy of ARVs in preventing HIV transmission from mother to child during breastfeeding, the new guidelines call on all HIV-positive pregnant women to begin ARV treatment at 14 weeks of pregnancy and continue until they stop breastfeeding.
Previous guidelines recommended that ARVs be provided to HIV-positive pregnant women only in the third trimester (beginning at 28 weeks). The new guidelines encourage HIV-positive mothers to exclusively breastfeed their infants for the first six months of life. Other foods should be introduced at that point, but WHO suggests mothers continue breastfeeding up until 12 months.
“We are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers when they have access to ARVs,” said Daisy Mafubelu, WHO’s Assistant Director General for Family and Community Health.
WHO is working with UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US President’s Emergency Plan for AIDS Relief (PEPFAR), to provide detailed costings for implementing the new recommendations.
Saira Stewart, from WHO’s HIV/AIDS Department, told IRIN/PlusNews that treatment costs would initially rise, but then decline as starting ART earlier would prevent new HIV infections and opportunistic diseases like tuberculosis.
In some good news in the fight against HIV, fresh data by the UNAIDS shows that new HIV infections have been reduced by 17% and the number of people succumbing to the disease has decreased by 10%.
According to new data in the 2009 AIDS epidemic update, new HIV infections have been reduced by 17% over the past eight years.
Since 2001, the number of new infections in sub-Saharan Africa is approximately 15% lower, which is about 400,000 fewer infections in 2008.
In East Asia, new HIV infections declined by nearly 25% and in South and South East Asia by 10% in the same time period.The number of AIDS-related deaths has declined by over 10% over the past five years as more people gained access to the life saving treatment.
UNAIDS and WHO estimate that since the availability of effective treatment in 1996, some 2.9 million lives have been saved.Around 2,00,000 new infections among children have been prevented since 2001.
One of the significant findings of the report is that the impact of the AIDS response is high where HIV prevention and treatment programmes have been integrated with other health and social welfare services.
Early evidence shows that HIV may be a significant factor in maternal mortality. Research models using South African data estimate that about 50,000 maternal deaths were associated with HIV in 2008.
Benefits and challenges
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 new prevention of mother to child transmission (PMTCT) recommendations have the potential to reduce mother-to-child HIV transmission risk to 5% or lower. Combined with improved infant feeding practices, the recommendations can help to improve child survival.
The main challenge lies in increasing the availability of treatment in resource-limited countries. The expansion of ART and PMTCT services is currently hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV-specific interventions within broader maternal and child health services.
The recommendations, if adopted, will result in a greater number of people needing treatment. 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.
Another challenge lies in encouraging more people to receive voluntary HIV testing and counselling before they have symptoms. Currently, many HIV-positive people are waiting too long to seek treatment, usually when their CD4 count falls below 200 cells/mm3. However, the benefits of earlier treatment may also encourage more people to undergo HIV testing and counselling and learn their HIV status.
WHO, in collaboration with key partners, will provide technical support to countries to adapt, adopt and implement the revised guidelines. Implemented at a wide scale, WHO’s new recommendations will improve the health of people living with HIV, reduce the number of new HIV infections and save lives.
New treatment recommendations
In 2006, WHO recommended that all patients start ART when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of symptoms.
WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long-term, irreversible side-effects. Stavudine is still widely used in first-line therapy in developing countries due to its low cost and widespread availability. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives.
The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.
