WHO Guidelines: Everyone With HIV Should Receive ART

Beth Skwarecki

October 02, 2015

All people infected with HIV should receive antiretroviral therapy (ART) as soon as possible, and those at "substantial" risk should be offered pre-exposure prophylaxis (PrEP), according to new guidelines published September 30 by the World Health Organization.

"These recommendations are 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," the Centers for Disease Control and Prevention stated in a news release lauding the new WHO recommendations. The Infectious Diseases Society of America and the HIV Medicine Association also announced their support for the guideline.

In the previous WHO guidelines, ART was recommended for people who met a threshold for CD4 cell count and for vulnerable groups such as those with tuberculosis and pregnant women. Those limitations have now been removed, which the World Health Organization estimates will increase the number of people eligible for treatment from 28 million to all 37 million living with the virus globally. They also project that the new measures will prevent 21 million deaths and 28 million new infections by 2030.

The new recommendations, based on evidence available through June 2015, are being released early. They are part of a guideline update scheduled to be published in 2016.

Evidence informing the new recommendations includes the Benefits and Risks of Early Antiretroviral Therapy in HIV-infected Adults in Abidjan, Côte d'Ivoire (ANRS 12136 TEMPRANO) clinical trial, which found that initiating treatment while CD4 counts are still high reduces death, AIDS incidence, and severe non-AIDS diseases. People with CD4 counts below 350 cells/mm3 are considered high priority for initiating treatment.

To fully implement the new recommendations, the report says, countries need to ensure that testing and treatment are available and to provide good linkage to care and support to make sure people adhere to treatment.

PrEP, including with tenofovir, is now recommended for everyone at substantial risk of contracting HIV; previously it was only recommended for certain groups, including men who have sex with men and people whose partners had HIV. Substantial risk is defined as at least three per 100 person-years; the forthcoming guideline will include information about identifying people most at risk.

PrEP "should be promoted as a positive choice among people for whom it is suitable and their communities," the authors write, emphasizing that it should not "displace or threaten" other preventative programs, such as those promoting condom use.

The authors have disclosed no relevant financial relationships.

"Guideline on When to Start Antiretroviral Therapy and on Pre-exposure Prophylaxis for HIV." WHO. Published online September 30, 2015. Full text

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