The World Health Organization (WHO) has issued new recommendations on how to organise services in order to promote linkage to care and retention in care as part of its new guidelines recommending antiretroviral treatment for all adults and adolescents.
The recommendations on antiretroviral treatment and for pre-exposure prophylaxis for people at substantial risk of HIV infection were announced in September 2015. This week the World Health Organization makes a series of new recommendations on service delivery. These are designed to maximise linkage to care and retention in care as part of efforts to expand access to antiretroviral treatment to ensure that 90% of people diagnosed with HIV infection are on treatment by 2020.
HIV programmes should provide people-centred services that are organised around the health needs and preferences of people living with HIV, WHO says. In practice this means following the evidence regarding how to optimise linkage and retention in care, through decentralisation of care, reduction in clinic visits and clinic waiting times, and “upholding individual dignity and respect, especially for vulnerable populations.”
The new recommendations, based on moderate quality evidence from randomised studies and review of the scientific literature include:
- Routine viral load testing should be carried out 6 months and 12 months after starting antiretroviral treatment, and if the patient is stable on ART, every 12 months thereafter.
- Less frequent clinic visits and medication pick-ups are recommended for people on stable ART: every 3-6 months is sufficient.
- ARVs can be distributed by trained and supervised lay providers; lay people and other trained and supervised non-laboratory staff can also undertake blood finger prick sampling for collection of blood for treatment monitoring.
- Testing sites should have in place a package of support interventions to ensure linkage to care, such as linkage to case management or peer support and navigation. Data should be used to identify how the quality of linkage can be improved.
- Programmes should provide community support intervention such as adherence clubs to encourage retention in care, and programmes should promote adherence through the use of interventions such as peer counsellors, mobile phone text messages, reminder devices, medication adherence training and the use of fixed-dose combinations and once-daily therapy.
- Adolescent-friendly services should be implemented within HIV services to improve engagement and outcomes.
In a response to the new guidelines the International Treatment Preparedness Coalition called for the international community “to ensure that adequate, community-led treatment education is an integral part of treatment scale up.” They also urged government to ensure the rapid adoption of the recommendation on viral load testing, and to ensure that any charges to patients for viral load testing should not be a barrier to care.
The new guidelines also recommend the use of the integrase inhibitor dolutegravir as an alternative first-line treatment adult option for the first time. Dolutegravir was licensed to the Medicines Patent Pool by ViiV Healthcare in 2014, allowing the drug to be used in fixed-dose combinations by generic manufacturers supplying lower-income countries. The International Treatment Preparedness Coalition has called on ViiV to extend the eligibility criteria for its license to the Medicines Patent Pool to allow middle-income countries to obtain the drug more cheaply.
Aurobindo, an Indian manufacturer, announced this week that it will make its generic version of dolutegravir available at $44 a year, matching the price of efavirenz for lower-income countries.
The guidelines also recommend the use of a 400mg efavirenz dose as an alternative first-line option for adults and adolescents in order to improve the tolerability of efavirenz, following the finding that a 400mg dose was just as effective as a 600mg dose, but with fewer side effects. The Indian manufacturer Cipla announced this week that it is preparing to launch fixed-dose combinations containing efavirenz 400mg. Mylan Laboratories will also launch its own fixed-dose combinations in early 2016 at a price of $99. UNITAID says that switching to a 400mg dose of efavirenz could result in savings of US$80 to 100 million globally by 2020.