WHO Guideline Modules (2007)

The WHO has created simplified, standardised guidelines for ARV therapy within the context of primary health care, based at first-level health facilities or in district clinics.

The modules cover acute and chronic care of adults and adolescents with HIV. As is stated at the website, “These are interim guidelines released for country adaptation and use to help with the emergency scale-up of antiretroviral therapy (ART) in resource-limited settings.”

Below is information on the guideline modules taken directly from the WHO website and accessed 15 September 2007 at: http://www.who.int/hiv/capacity/modules/en/index.html 

IMAI/IMCI (Integrated Management of Adolescent and Adult Illness/Integrated Management of Childhood Illness) guideline modules.  Full text

Acute care (including opportunistic infections, when to suspect and test for HIV, prevention).Acute care presents a syndromic approach to the most common adult illnesses including most opportunistic infections. Clear instructions are provided so the health worker knows which patients can be managed at the first-level facility and which require referral to the district hospital or further assessment by a more senior clinician. Preparing first-level facility health workers to treat the common, less severe opportunistic infections will allow them to stabilise many clinical stage 3 and 4 patients prior to ARV therapy without referral to the district. English [pdf 1.75Mb]French [pdf 1.94Mb]

IMAI/IMCI Chronic HIV Care with ARV Therapy and Prevention. This guideline module includes patient education, psychosocial support, prevention for positives, clinical staging, prophylaxis (INH, cotrimoxazole, fluconazole), preparation for ARV treatment then clinical monitoring, response to side-effects, adherence preparation and support, management of chronic problems, and data collection based on a simple treatment card. The Chronic HIV Care with ARV Therapy effectively integrates HIV care and prevention, increasing the potential for preventive interventions. The broader uptake of preventive interventions is essential for HIV control. English [pdf 2.26Mb]  French [pdf 770kb]

WHO on clinical and laboratory monitoring (2002)

In April 2002, the World Health Organization (WHO) published guidelines for scaling up antiretroviral therapy in resource-limited settings. These guidelines cover critical issues such as when to start therapy and recommended first-line regimens, as well as practical issues, such as the clinical and laboratory monitoring of antiretroviral use. The guidelines were updated in 2003 and are available at the WHO website: http://www.who.int/hiv/pub/prev_care/en/arvrevision2003en.pdf

WHO recommends that in resource-limited settings the basic clinical assessment prior to the initiation of ART includes: documentation of past medical history, identification of current and past HIV-related illnesses, identification of co-existing medical conditions that may influence choice of therapy (such as TB or pregnancy) as well as current symptoms and physical signs.

In order to facilitate the scale up of ARV use in resource-limited settings, WHO prioritised currently available testing into four categories:

• Absolute minimum tests.
• Basic tests.
• Desirable tests.
• Optional tests.

Absolute minimum tests are prerequisites for introduction of ARV therapy in a national programme.

Basic tests are commonly used in the clinical setting and are needed to provide effective monitoring of most ARV regimens. In light of the urgency to provide potentially life-prolonging care to millions of people, the WHO wants to minimise the impediments to care. As such, the basic laboratory tests were not considered to be absolutely essential for programme implementation, although they need to be made available where resources allow.

Desirable tests would make monitoring and evaluation of programme effectiveness much more effective, while optional tests can be used in resource-rich settings.

The absolute minimum laboratory tests to have before initiating antiretroviral therapy are an HIV antibody test and a haemoglobin or haematocrit level. The rationale is that proof of HIV infection is needed prior to starting antiretroviral therapy in the first instance, and screening for anaemia is essential prior to starting AZT (zidovudine, Retrovir) containing regimens.

Basic testing should include a white blood cell count and differential (to permit assessment of neutropenic side-effects and the total lymphocyte count), serum alanine or aspartate aminotransferase level (to assess the possibility of hepatitis co-infection and to monitor for hepatotoxicity), serum creatinine and/or blood urea nitrogen (to assess baseline renal function), a serum glucose, and pregnancy tests for women.

While these tests are not absolutely essential, they are highly recommended in order to be able to provide monitoring for safe use of these agents and inform decisions about switching between regimens.

Desirable supplemental tests include bilirubin, amylase and serum lipids and CD4 cell testing. These tests, while not absolutely essential, are felt to provide significant information that would be beneficial for deciding whether therapy is required and for monitoring the effects of antiretroviral therapy in resource-limited settings.

CD4 cell counts in particular need to be made more widely available in these settings, because they are the best indicator for when to start treatment and to assess immunologic response to treatment.

Viral load testing is currently considered optional because of resource constraints.

Clinical monitoring is essential for the provision of safe and effective antiretroviral therapy. Where laboratory monitoring is limited, close clinical monitoring becomes even more crucial.