Changes in the WHO Guidelines for treatment of HIV

The WHO has released early its revised guidelines on the treatment of those infected with HIV (WHO early release guideline; WHO press release).  There are two important changes.  First, ART is recommended to all HIV infected individuals regardless of their CD4+ count.  Second, PrEP is recommended for people at ‘substantial’ risk of HIV infection as part of a comprehensive package of services.

The first of these revisions comes in the train of repeated rises over recent years in the recommended treatment threshold: first (2010), to350 CD4 per mm3; then (2013), from 350 to 500.  The latest revision is doubtless based on the results of randomized controlled trials (RCT) such as the START (Strategic Timing of Anti-Retroviral Therapy) trial (A Case for Immediate ART Initiation (STI/blog)).  The second builds on a WHO 2014 guideline which already recommended PrEP for MSM populations.  Here again recent RCTs demonstrating the effectiveness of PrEP, such as PROUD and IPERGAY (PrEP highly effective for HIV in MSM (STIs/blog)) will have played their part.

The removal of the threshold has resource implications that will pose a serious challenge in resource poor settings.  Writing in 2010 Hamilton and Crowley (STIs) estimated that setting the threshold for ART initiation at 250 CD4+ would by 2012 increase the need for treatment by a median of 15%, whereas setting at 350 CD4+ would increase it by 42% and 500 CD4+ by 84%. Contributors like Hallett & Garnett (STIs) (Zimbabwe) and Zwahlen (STIs) have sought to develop projections for individual countries.

Also, it has been argued that late diagnosis (even by current standards), and poor retention in care are significant factors in suboptimal health outcomes (Mubezi & Shuha (STIs)Hussey (STIs).  What the revised guidelines will deliver in real terms no doubt depends on the context of implementation.  Yet, even in the relatively more affluent settings (US), some recent research has argued for the reallocation of resources from linkage to retention in HIV care, in order to optimize utilization of scarce resources (Retention in Care (STI/blogs)Sherer (STIs). This could prove hard to square with the prioritization of ever lower thresholds for linkage to care – even if the recommended policy is in the interests of improving individual outcomes.