HIV: WHO Calls for Immediate Antiretroviral Therapy and Expanded Pre-Exposure Prophylaxis

New guidelines based on overwhelming clinical evidence that ART is effective.

The World Health Organization today revised its HIV treatment guidelines and is calling for physicians to start antiretroviral therapy (ART) as soon as a patient’s HIV test comes back positive.

It has also expanded its guidelines for offering pre-exposure prophylaxis (PrEP) treatment with antiretrovirals.The WHO now says they should be offered to anyone with “substantial risk” of acquiring HIV.

The announcement of the changes was supposed to be made later this year but the WHO decided to release it early “because of [the guidelines’] potential for public health impact.”

The new guidelines estimate that with the change, the number of HIV-positive people eligible for ART would increase from the current 28 million people 37 million people, globally.

The organization did not provide estimates on how many HIV-negative but at-risk people would be recommended for PrEP.

Previous WHO guidelines on ART called for monitoring CD4 T lymphocyte counts and starting it when they dropped to a dangerous level.

The US Centers for Disease Control and Prevention in 2012 made a similar recommendation for immediate initiation of ART, but there have been concerns over whether all people with HIV are getting the therapy.

The new WHO guidelines are based on overwhelming clinical evidence that ART is effective.

“The expanded use of antiretroviral treatment is supported by recent findings from clinical trials confirming that early use of ART keeps people living with HIV alive, healthier and reduces the risk of transmitting the virus to partners,” WHO said in a news release announcing the change.

In the section on PrEP in the 78-page guideline, the organization summarized numerous studies on PrEP but said a detailed account of how to determine whether a patient is at significant risk of getting HIV would be provided in a guideline next year.

It also noted there are controversies surrounding PrEP. Those include a need to make sure patients on PrEP are not stigmatized. From a behavior and epidemiological standpoint, the organization is also concerned that people on PrEP would abandon safe sex practices, and stressed that education about condom use should always be part of PrEP.

“There are significant concerns about implementing PrEP, especially in legal environments in which the rights of people at substantial risk of HIV are violated. PrEP should not displace or threaten the implementation of effective and well established HIV prevention interventions, such as condom programming and harm reduction. Stigma is a driver of HIV and could be decreased or increased depending on the how PrEP is implemented. PrEP should be promoted as a positive choice among people for whom it is suitable and their communities, in conjunction with other appropriate prevention interventions,” the organization noted.

The WHO estimates that if the new guidelines are widely followed, 21 million AIDS-related deaths and 28 million new infections could be averted.