Unusually, there was something to celebrate on World AIDS Day in 2009, even if it was only on paper. The World Health Organization (WHO) updated its antiretroviral treatment (ART) guidelines for adults, adolescents, pregnant women, mother-to-child transmission, and breastfeeding. These guidelines were issued in late November 2009.1 The new WHO guidelines are progressive and reflect changes in knowledge and practice which have also been reflected over the past year in revised ART guidelines in Europe, South Africa, the United Kingdom, and the United States, among others. TAGline will cover the new WHO ART guidelines for adults and adolescents here; future articles will examine issues related to children, pregnancy, breastfeeding, and evolving ART guidelines in specific countries.
The new WHO ART guidelines are the first to be released since 2006. Among the key changes in the new guidelines are a higher CD4 cell level for initiating ART from ≤200 to ≤350 CD4 cells, including pregnant women and people with tuberculosis (TB). This move brings the WHO guidelines more in synch with the most recent ART recommendations in developed nations. The panel addressed several other key issues with this update:
The new WHO guidelines do not change the recommended first-line ART anchor NNRTI agent -- either efavirenz or nevirapine -- with a background of tenofovir (TDF) or zidovudine (AZT) with 3TC or FTC. This presents new complications when starting treatment at higher CD4 counts. Nevirapine is not safe to initiate in women with over 250 CD4 cells (or in men with over 400) due to a higher risk of liver toxicity, while efavirenz is contraindicated in the first trimester of pregnancy due to concerns of neural tube defects in the fetus. Since many women do not know they are pregnant during their first trimester, this complicates the selection of the safest treatment choice when starting ART at a CD4 count of over 250. Data from the antiretroviral pregnancy registry do not suggest that there is an excess of such defects in babies born to mothers taking efavirenz. However, new options that lack either danger would be welcome in this situation.
In the next five years, over 10 million people will die of AIDS unless treatment scale-up -- enrollment of new ART participants -- continues and those on current programs stay enrolled. There is an AIDS funding backlash which claims that treating people with ART is too expensive. It is necessary to point out, however, that for every increase in the proportion of HIV-positive people put on therapy, there is in fact a certain (but not yet precisely measured) decrease in the likelihood of onward transmission of HIV. If applied widely enough, this approach (treating HIV earlier) has the potential, when combined with other effective prevention methods, to reverse the spread of HIV and even perhaps to bring the epidemic under control, though it is unlikely that in the absence of a vaccine that the HIV pandemic can ever be fully eliminated.
The WHO's new HIV treatment guidelines offer plenty of promise in a time of uncertainty about the future of the fight against HIV. Recommendations call for better, safer, and more effective drug combinations to be made available earlier and much more widely for all people with HIV; scale-up of better monitoring technology including viral load is recommended; and the potential for quantifying the effect of expanding HIV treatment to limit HIV transmission thus changing the dynamics of the pandemic is emerging. A tipping point for the pandemic appears to be coming into focus. It would be tragic if world leaders decide now is the time to stop scaling up the fight against HIV.
World Health Organization. Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. November 2009.
World Health Organization. Rapid advice: revised WHO principles and recommendations on infant feeding in the context of HIV. November 2009.
For updates see the WHO ARV guidelines site.