WHO’s 2013 antiretroviral therapy (ART) guidelines will recommend earlier initiation of ART (at CD4 counts below 500 cells) but will “still prioritise treating patients who are symptomatic as well as those with CD4 cell counts less than 350,” according to Dr Meg Doherty, of WHO’s HIV Department who presented the yet-to-be-finalised 2013 Antiretroviral (ART) guidelines at the 3rd International HIV Treatment as Prevention Workshop in Vancouver, Tuesday April 23, 2013.
In addition, the guidelines will include recommendations for starting treatment in more situations independent of CD4 cell counts: such as in HIV+ people with TB or hepatitis B, pregnant women (option B and B+), sero-discordant couples and children under 5 years of age.
“We will not have a recommendation of initiating at any CD4 count for Hep C, HIV-2, and key populations – just that these should follow general adult recommendations for less than 500,” she said.
Anticipation for new ART guidelines at TasP Workshop
The Treatment as Prevention Workshop is an annual meeting that brings together academic, policy, industry, and community representatives to review new data and to identify priority areas for research and action related to the impact of antiretroviral therapy (ART) use among HIV-infected individuals both to improve health outcomes for people living with HIV and to help them protect their partners and children from becoming HIV infected. Many of the meeting participants favour initiating treatment as soon after testing HIV-positive as possible — a much more aggressive approach than what WHO has historically recommended.
However, over the last several years, WHO’s normative guidance has shifted incrementally towards earlier treatment. Since the HPTN 052 study — which showed that earlier treatment significantly reduces HIV transmission among sero-discordant couples and reduces clinical progression — it has been widely expected that Geneva will relax the CD4 threshold criteria limiting the number of HIV-positive people who can access ART. What has not been so clear is how strong the recommendations will be — whether they might be weakened because of the upfront costs of earlier treatment and/or theoretical fears that healthier patients won’t adhere to treatment and develop drug resistance. Some participant’s have voiced concerns that WHO will wind up giving earlier ‘treatment as prevention’ a tepid endorsement at best.
“Tomorrow you will hear from the World Health Organization,” Stephen Lewis, co-director of AIDS-Free World, said the previous evening. “I’m not sure what they will say, and I’m certainly not one of those people whose privy to the Guidelines, which will emerge in the middle of this year, but I would bet that [the CD4 threshold] will be 500 or 550 or something of the kind, surrounded as always by the World Health Organization with caveats which serve to liberate and strangle simultaneously.”
And indeed, WHO appears to be hedging its bets…
More on the new guidelines and other presentations at the TasP workshop to come.