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WHO Updates HIV Treatment Recommendations

New WHO recommendations endorse earlier ART initiation for HIV-infected adolescents and adults and an even more-aggressive approach for those coinfected with TB or HBV.

Almost simultaneously, the WHO and the U.S. Department of Health and Human Services (DHHS) released updated guidelines for HIV treatment. Both raised the CD4-cell–count threshold for starting treatment, and both refined their preferences for first-line regimens. The new WHO recommendations, outlined below, were published online in three rapid-advice documents, with the full set of guidelines expected in February 2010. (A complete review of the DHHS guidelines, by Dr. Abigail Zuger, is available here.)

• All adolescents and adults with HIV infection and CD4 counts 350 cells/mm³, including pregnant women, should be started on antiretroviral therapy (ART) immediately, regardless of whether they have clinical symptoms. (The previous set of guidelines, published in 2006, recommended starting ART at CD4 counts 200 cells/mm³.)
  
• First-line therapy should consist of an NNRTI + two NRTIs, one of which should be AZT or tenofovir. Countries using d4T in first-line regimens should start phasing it out because of its toxicity.
  
• All patients should have access to CD4-cell–count testing. Routine viral-load testing is recommended to monitor for virologic failure.
  
• Pregnant women who do not need ART for their own health should start taking antiretroviral prophylaxis in the second trimester to reduce the risk of mother-to-child HIV transmission. Continuation of ART throughout breast-feeding is encouraged.
  
• Regardless of their CD4-cell counts, patients coinfected with HIV and tuberculosis (TB) should be started on ART as soon as possible after starting TB treatment.
  
• Patients who require treatment for hepatitis B virus coinfection should start ART immediately, regardless of CD4-cell count or WHO clinical stage. First-line regimens for this group should contain tenofovir and either FTC or 3TC.
  
• Second-line ART should consist of a ritonavir-boosted PI plus two NRTIs. Ritonavir-boosted atazanavir and lopinavir/ritonavir are the preferred PIs.
  

Comment: Previous WHO guidelines have taken a cautious approach to HIV treatment because of the lack of resources and clinical infrastructure in many of the most severely affected countries. These new recommendations are much more aggressive, reflecting not only the latest evidence on the benefits of early treatment but also the fact that implementation might now be more feasible, given funding from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR); the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and others. Still, in many resource-constrained settings, practitioners have not yet been able to widely adopt the standards set by the WHO in 2006 and will therefore find it challenging to implement the new recommendations. Clearly, a progressive approach will be needed, with incremental implementation according to the availability of resources and the potential impact of individual strategies on morbidity and mortality.

— Salim S. Abdool Karim, MD, PhD

Published in Journal Watch HIV/AIDS Clinical Care December 7, 2009

Citation(s):

World Health Organization. Rapid advice: Antiretroviral therapy for HIV infection in adults and adolescents. Nov 30 , 2009. (http://www.who.int/hiv/pub/arv/rapid_advice_art.pdf)

World Health Organization. Rapid advice: Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. Nov 30 , 2009. (http://www.who.int/hiv/pub/mtct/rapid_advice_mtct.pdf)

World Health Organization. Rapid advice: HIV and infant feeding — Revised principles and recommendations. Nov 30 , 2009. (http://www.who.int/child_adolescent_health/documents/hiv_if_principles_recommendations_112009.pdf)

Reader Remarks:

Review and add to remarks on this article

• art and hiv
  saka venkata satya prasad, govt, 17 Dec 2009 11:36 AM EST
  The WHO has taken the right desicion to statrt ARTY for all HIV and TB co Infected patients. What has... [more]

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