New HIV treatment guidelines by WHO recommend offering antiretroviral therapy (ART) earlier. Recent evidence indicates that earlier ART will help people with HIV to live longer, healthier lives, and substantially reduce the risk of transmitting HIV to others. The move could avert an additional 3 million deaths and prevent 3.5 million more new HIV infections between now and 2025.
The new recommendations are presented in WHO's "Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection", as new data reveal a total of 9.7 million people were taking these lifesaving drugs at the end of 2012.
"These guidelines represent another leap ahead in a trend of ever-higher goals and ever-greater achievements," says WHO Director-General Dr Margaret Chan. "With nearly 10 million people now on antiretroviral therapy, we see that such prospects - unthinkable just a few years ago - can now fuel the momentum needed to push the HIV epidemic into irreversible decline."
Call to initiate treatment at 500 CD4 cells/mm³ or less
The new recommendations encourage all countries to initiate treatment in adults living with HIV when their CD4 cell count falls to 500 cells/mm³ or less - when their immune systems are still strong. The previous WHO recommendation, set in 2010, was to offer treatment at 350 CD4 cells/mm³ or less. 90% of all countries have adopted the 2010 recommendation. A few, such as Algeria, Argentina and Brazil, are already offering treatment at 500 cells/mm3.
WHO has based its recommendation on evidence that treating people with HIV earlier, with safe, affordable, and easier-to-manage medicines can both keep them healthy and lower the amount of virus in the blood, which reduces the risk of passing it to someone else. If countries can integrate these changes within their national HIV policies, and back them up with the necessary resources, they will see significant health benefits at the public health and individual level, the report notes.
The new recommendations also include providing antiretroviral therapy - irrespective of their CD4 count - to all children with HIV under 5 years of age, all pregnant and breastfeeding women with HIV, and to all HIV-positive partners where one partner in the relationship is uninfected. The Organization continues to recommend that all people with HIV with active tuberculosis or with hepatitis B disease receive antiretroviral therapy.
Another new recommendation is to offer all adults starting to take ART the same daily single fixed-dose combination pill. This combination is easier to take and safer than alternative combinations previously recommended and can be used in adults, pregnant women, adolescents and older children.
"Advances like these allow children and pregnant women to access treatment earlier and more safely, and move us closer to our goal of an AIDS-free generation," said UNICEF Executive Director, Anthony Lake. "Now, we must accelerate our efforts, investing in innovations that allow us to test new born babies faster and giving them the appropriate treatment so that they enjoy the best possible start in life."
The Organization is further encouraging countries to enhance the ways they deliver HIV services, for example by linking them more closely with other health services, such as those for tuberculosis, maternal and child health, sexual and reproductive health, and treatment for drug dependence.
"The new WHO guidelines are very timely in view of the rapid progress we have made in expanding programmes for prevention and treatment," says Dr Mark Dybul, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. "This is an example of how the Global Fund and the WHO work together to support countries as we move towards removing HIV as a threat to public health." Since its creation in 2002, the Global Fund has supported more than 1,000 programmes in 151 countries, providing HIV treatment for 4.2 million people.
Challenges still remain. Alongside the new treatment guidelines, a treatment progress update by WHO, UNAIDS, UNICEF identified areas in need of attention.
While the number of all eligible children on ART has increased by 10% between 2011 and 2012, this is still too slow compared to the 20% increase in adults. A further complication is that many key populations such as people who inject drugs, men who have sex with men, transgender people and sex workers, continue to face legal and cultural barriers that prevent them getting treatment that otherwise would be more easily available. Another factor that needs to be addressed is the significant proportion of people who, for many reasons, 'drop out' of treatment.
Data reinforces feasibility of recommendations
Despite this, the Global update on HIV treatment: results, impact and opportunities contains encouraging data that reinforces the feasibility of the new WHO recommendation on earlier ART, which would expand the global number of people eligible for antiretroviral therapy to 26 million.
Between 2011 and 2012, the largest acceleration ever of people enrolled on ART was achieved, with an extra 1.6 million people benefitting from antiretroviral therapy, increasing the total to 9.7 million people. Furthermore, increased coverage of treatment occurred in every region of the world, with Africa leading. Four out of 5 people who started treatment in 2012 were living in sub-Saharan Africa.
"Today nearly 10 million people have access to lifesaving treatment. This is a true development triumph," says Michel Sidibé, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS). "But we now have a new challenge - ensuring that all 26 million people eligible for treatment have access - not one person less. Any new HIV infection or AIDS-related death due to lack of access to antiretroviral therapy is unacceptable."
Today's recommendations were released by WHO on the opening day of the International AIDS Society 2013 conference in Kuala Lumpur. Among those endorsing the recommendations at the launch were representatives from countries, where such earlier ART intervention is already national policy, along with development agencies who are providing technical and financial support.
The International AIDS Society conference is held every two years and attracts leading scientists, clinicians, public health experts and community leaders to examine the latest developments in HIV-related research, and to explore how scientific advances can inform the global response to HIV/AIDS.