New Progress and Guidance on HIV Treatment

Update on People Receiving HIV Treatment

Read the 2010 guidelines Antiretroviral Treatment for HIV Infection in Adults and Adolescents (PDF).

The number of people receiving lifesaving antiretroviral treatment (ART) reached 5.2 million at the end of 2009, up from 4 million in 2008. The addition of 1.2 million people starting on HIV treatment during 2009 was the biggest increase ever seen in a single year. Between 2003-2010, the number of people receiving HIV treatment increased twelve-fold resulting in millions of lives saved.

2010 Guidelines: "Antiretroviral Treatment for HIV Infection in Adults and Adolescents"

The Guidelines present significant evidence and experience on when to initiate ART and what drug regimens to use have accumulated since the 2006 revision of the guidelines. WHO is now launching new guidance on ART for adults and adolescents. The 2010 guidelines recommend:

• Earlier diagnosis and treatment of HIV in the interest of a prolonged and healthier life.
• Greater use of more patient-friendly treatment regimens.
• Expanded laboratory testing to improve the quality of HIV treatment and care while recognizing that access to laboratory tests should not be a prerequisite for treatment.

Key Recommendations

Eligibility for Treatment

• The best time to start ART is before patients become unwell or develop their first opportunistic infection. The best method to determine when to start treatment is through CD4 testing, which measures the strength of the immune system.
• The 2006 guidelines recommended that ART be started for all patients with advanced clinical disease and/or a CD4 count of 200 cells/mm³ or less.
• The 2010 guidelines promote earlier treatment for all patients, when their CD4 count falls to 350 cells/mm³ or less, regardless of symptoms.
• The 2010 guidelines promote earlier treatment for all patients with TB and Hepatitis B regardless of their CD4 count.

Treatment Regimens

• Stavudine has long-term, cumulative and non reversible toxicities such as peripheral neuropathy (disorder of peripheral nerves characterized by numbness, weakness and burning pain of hands and feet) and lipoatrophy (the loss of fat from specific parts of the body).
• The 2006 guidelines recognized the critical role of stavudine-containing regimens due to its low cost, limited need for laboratory monitoring, initial tolerability and widespread availability.
• However, they recommended that countries plan to move away from stavudine.
• The 2010 guidelines propose that countries progressively phase out the use of stavudine as a preferred firstline therapy option and move to lesstoxic alternatives such as zidovudine (AZT) and tenofovir (TDF).

Role of Laboratory Testing

• There are well recognized limitations to relying only on clinical monitoring to determine when people need to start ART and when they are beginning to fail to respond to their treatment regimen.
• The 2010 guidelines outline an expanded role for laboratory monitoring, including both CD4 testing and viral load monitoring, to improve the quality of HIV treatment and care.
• They promote greater access to CD4 testing and the strategic introduction of viral load monitoring. Access to ART must not be denied if these monitoring tests are not yet available.

Benefits and Challenges

The new guidelines are based on a solid body of evidence indicating that rates of death, morbidity and HIV and TB transmission are all reduced by starting treatment earlier.

An earlier start to treatment reduces a person's viral load much earlier in the course of their HIV infection, and thereby reduces the risk of onward HIV transmission and could potentially avert a significant number of new HIV infections.

By choosing a limited number of treatment regimens that suit the majority of people in need of ART, as recommended by the new guidelines, governments can achieve economies of scale through the purchase of larger quantities of a smaller number of drugs.

The new guidelines will increase the number of people eligible for HIV treatment from 10 to 15 million. However, the additional costs associated with earlier treatment will very likely be offset by decreased hospital and death costs, increased productivity due to fewer days sick, fewer children orphaned by AIDS, and a drop in new HIV infections.

The main challenge is to increase access to treatment in low- and middle-income countries and to encourage people to receive voluntary HIV testing and counselling before they have any symptoms.

Currently, many HIV positive people are waiting too long before they seek treatment, usually when their CD4 threshold falls below 200 cells/mm³.

Broadening the criteria for treatment may result in some persons in urgent need of treatment being displaced by persons for whom treatment would be beneficial but not as urgent.

In recommending a higher CD4 count threshold for initiation, a guiding principle is that those most in need of treatment should retain priority access.