New HIV/AIDS Treatment guidelines issued by WHO

The WHO on Monday issued new recommendations on the eve of World AIDS Day that patients living with HIV/AIDS begin receiving antiretrovirals (ARVs) earlier than current HIV treatment.

The recommendations – an update to 2006 treatment guidelines – come after several studies showed "people with HIV who start drugs earlier than recommended have a better chance of surviving.

There are 3 Key Recommendations for ART as per the revised guidelines

1. Earlier diagnosis and treatment of HIV in the interest of a prolonged and healthier life.

2. Greater use of more patient-friendly treatment regimens.

3. Expanded laboratory testing to improve the quality of HIV treatment and care. However, access to laboratory tests should not be a prerequisite for treatment.

REVISIONS:

I. 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 2009 recommendations promote earlier treatment for all patients, when their CD4 count falls to 350 cells/mm3 or less, regardless of symptoms.

II.TREATMENT REGIMENS

The 2006 guidelines recognized the critical role of Stavudine (d4T)-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 d4T.

The 2009 recommendations propose that countries progressively phase out the use of Stavudine as a preferred first-line therapy option and move to less toxic alternatives such as Zidovudine (AZT) and Tenofovir (TDF).

III.ROLE OF LABORATORY TESTING

There are well recognized limitations to relying only on clinical monitoring1 to determine when people need to start ART and when they are beginning to fail to respond to their treatment regimen.

The 2009 recommendations outline an expanded role for laboratory monitoring, including both CD4 testing and viral load monitoring2, 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.

Clinical monitoring: The monitoring of a patient’s health by a trained health professional. This typically involves taking a patient’s medical history on a regular basis and conducting routine clinical examinations.

Viral load monitoring: Measuring the concentration of HIV in the bloodstream.

BENEFITS

The new recommendations 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. This prolongs and improves quality of life.

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.

Earlier treatment would boost the immune system, making it less likely that the patient falls sick with TB and other opportunistic diseases which prey on weakened immune systems. This would benefit both the individual concerned and help protect the wider community against the risk of infectious TB.

The prospect of earlier treatment could also act as an incentive for more people to undergo voluntary counselling and testing without waiting to develop symptoms and fall sick.

The incremental costs due to an additional one to two years on ART may be partly 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 phasing out of Stavudine would enable new and existing patients to avoid disabling and disfiguring side effects and reduce the costs of managing these toxicities.

Expanding CD4 testing will enable people to access earlier treatment, before they become unwell, and it is critical to identifying pregnant women who need ART. Wide-scale access to CD4 testing among HIV-positive pregnant women would help to prevent the bulk of mother-to-child transmission of HIV (see also Rapid advice on PMTCT). The introduction of targeted and/or routine viral load testing may reduce premature switching to costly second-line regimens.

CHALLENGES

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

Raising the CD4 threshold to 350 cells/mm3 may mean an average 1–2 years’ additional exposure to ART, prompting some concern about the risk of ART toxicity.

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

It is unclear if HIV-positive patients who feel well will be willing start ART and whether they will have more difficulty adhering to treatment than those who are showing symptoms. However, the prospect of a prolonged and healthier life could act as inducement for earlier treatment.

The WHO ART guidelines committee concluded that the benefits of adopting these new treatment recommendations outweighed the potential risks.