The number of people eligible for antiretroviral treatment will grow by around six million as a result of recent World Health Organization
recommendations on the use of antiretroviral drugs to prevent HIV transmission,
Dr Gottfried Hirnschall, head of the WHO’s HIV department told the IAPAC Controlling the HIV Pandemic with Antiretrovirals:Treatment as Prevention and Pre-Exposure Prophylaxis Evidence
Summit in London.
The new recommendations almost double the number of people judged to be in need of antiretroviral therapy
– calculated at 7.4 million people with CD4 counts below 350 and therefore in need of treatment at the end of 2010. In 2010, antiretroviral coverage reached 47% of those eligible, he said.
His remarks coincided with the release by WHO of a
Programmatic Update on Antiretroviral Treatment for Prevention of HIV and TB, which
sets out the organisation’s plans to galvanise greater use of antiretroviral
treatment in order to limit new infections.
The summit, organised by the International Association of
Physicians in AIDS Care, is designed to review recent advances in the use of
antiretroviral drugs as a means of preventing HIV transmission, and to discuss
the practical implications of the new data for treatment and prevention
Speaking on the first day of the two-day summit, Dr
Hirnschall pointed out that, for every person placed on treatment, 2.5 people
are still becoming infected every year, amounting to approximately 2.7 million
infections a year in 2010.
Scale-up of a combination of effective prevention
interventions remains urgent, and antiretroviral treatment must play a central
role in the prevention of new infections, he said, following last year’s
release of the results of the HPTN 052 study, which showed that early
antiretroviral therapy for the HIV-positive partner reduced the risk of HIV
transmission by 96% in serodiscordant partnerships.
Similarly, evidence from the South African province of
KwaZulu-Natal demonstrates that, at the population level, antiretroviral therapy
is already having an impact on one of the most severe epidemics in sub-Saharan
Africa. Every 1% increase in antiretroviral coverage among adults
in rural communities between 2004 and 2011 was associated with a 1.7% reduction in the risk of HIV
acquisition, suggesting the potential for large reductions in HIV incidence if
greater progress towards universal access to antiretroviral treatment can be
However, Dr Hirnschall noted that current coverage in low-
and middle-income countries – 47% in 2010 – “is not giving us the prevention
gain we want to see”.
WHO issued guidance on HIV counselling and testing for
serodiscordant couples in April 2012. It recommended antiretroviral therapy for
all HIV-positive people in a serodiscordant partnership, irrespective of CD4
Thirteen countries already make recommendations for
serodiscordant couples on the use of antiretrovirals for prevention of HIV
transmission, including the United Kingdom, the United States, Canada, Italy,
Nigeria, Zambia, Thailand and France. The Chinese Center for Disease Control
and Prevention has begun providing ART for the HIV-positive partner in
serodiscordant couples, regardless of CD4 count, and plans to reach an
estimated 30,000 couples as part of a national strategy for the use of
antiretroviral therapy for prevention.
Several African countries with a high burden of HIV
infection, including Mozambique, Zambia and Rwanda, are already taking steps to
maximise the prevention impact of antiretroviral treatment. Zambia’s national
programme already provides antiretrovirals to the HIV-positive partner in a
serodiscordant partnership, irrespective of CD4 cell count. Mozambique and
Rwanda are in the process of revising national treatment guidelines to the same
Together with recommendations for antiretroviral therapy for
all TB patients diagnosed with HIV, and all pregnant women irrespective of CD4
counts, the impact of the new guidance is to add around six million people to
the number in need of antiretroviral treatment in low- and middle-income
countries, even without a formal recommendation to use antiretroviral treatment (ART) at CD4 counts above the current treatment initiation threshold of 350 cells.
WHO is already incorporating treatment as prevention into
normative guidance through a sequence of incremental updates:
However, WHO is working towards the release of consolidated
guidance addressing the use of antiretrovirals across all age groups and populations
in July 2013. As part of that process, WHO's guidelines panel will review the question of whether the treatment eligibility threshold should be raised to a CD4 cell count of 500 for all adults, Dr Hirnschall told the summit.
In the meantime, WHO is working with countries to identify
opportunities for expansion of treatment in line with its 2010 guidelines,
which recommended treatment for all people living with HIV with CD4 cell counts
below 350, all infants below the age of two, and for everyone with TB and HIV or
hepatitis B and HIV co-infection.
WHO is also working with countries to identify additional
opportunities for treatment as prevention, in particular through implementation
of its new guidance on couples counselling and testing, and ART for prevention
in serodiscordant couples.
Country-level decision-making will require attention to the
likely impact of different recommendations on the local epidemic. In which
settings and populations will early treatment achieve the greatest impact on
the overall national epidemic, and what is the best mix of interventions to
achieve this impact? What are the best ways of delivering treatment to larger
numbers of people, and keeping them in care?
Research studies that set out to answer some of these questions
are already underway or in the design phase, and will be discussed in a
separate report from the evidence summit.
For more news from the summit visit our conference news pages.