Statement from Jhpiego HIV experts on the World Health Organization’s new HIV treatment and prevention guidelines:
Research demonstrates that immediately starting antiretroviral therapy (ART) for HIV upon diagnosis is better for an HIV-infected person’s own health and also reduces their risk of transmitting HIV to others. Furthermore, HIV-negative individuals who are at increased risk of contracting the virus may reduce their risk by taking a specific form of ART called pre-exposure prophylaxis (PrEP). WHO’s swift translation of these latest research into global guidance for policymakers is commendable. Specifically, their new recommendation for ART for all people infected with HIV—without a need for further testing to determine eligibility—is a paradigm shift in HIV disease management and HIV prevention strategies.
Before release of the new WHO guidelines on Tuesday, a person testing HIV positive routinely needed an additional blood test (called a CD4 test) before their health care providers could determine whether she or he was eligible for ART. Only those with compromised immune systems, as demonstrated by the CD4 test, were prescribed treatment. Countless were lost to follow-up amid complex and inconvenient health systems trying to clear eligibility hurdles, only to return for medical care years later after falling ill. In the interim, without the benefits of ART, such individuals suffered consequences to their own health and were also at increased risk of transmitting the virus to others.
With the new ART guidelines, there are now clear recommendations from WHO that all 37 million people on Earth infected with HIV should be treated, for their health and the health of their partners. With eligibility hurdles created by health systems and policies removed, “treatment rationing” and long delays between diagnosis and treatment may be a thing of the past.
To complement the new HIV treatment guidelines, WHO also endorsed PrEP, recommending that all HIV-negative individuals at substantial risk of infection be offered the once-daily pill. HIV programs now have an additional prevention tool in their armamentarium. Notably, women have a prevention option that they may better control, as opposed to other prevention modalities that are often directly controlled or heavily influenced by men, such as condom use and voluntary medical male circumcision (VMMC).
With so many good options for keeping HIV-positive people healthy and preventing new infections—immediate ART, VMMC, PrEP—the obvious question is which of these is most important. As usual, there is no single best answer. Tailored combinations of the interventions will likely work differently according to the country and epidemic dynamics in play; some better than others for some people and places. However, because all of the options work well, they all warrant investment. Given that current resources allocated for global health were insufficient prior to the new WHO guidelines, the good news is tempered by the reality that evidence-based policies are only the start. Translating WHO guidance into practice, and finding the resources to do so, may be the greatest challenge of all. New investments to match this last mile in the fight against HIV through treatment as well as intensified prevention of new infections are needed to galvanize the commitment to achieving the AIDS-Free generation.
Tigistu A Ashengo, MD, MPH, Associate Medical Director
Jason Reed, MD, MPH, Senior Voluntary Medical Male Circumcision Technical Advisor