Delays in updating HIV treatment guidelines in Africa blocking early treatment for millions

Delays in adopting the World Health Organization (WHO) 2015 recommendation of HIV treatment for all threaten the achievement of the 90-90-90 targets for HIV diagnosis and viral suppression by 2020, research carried out by the International Association of Physicians in Aids Care (IAPAC) indicates.

The findings, published last month in the South African Journal of HIV Medicine, show that only three countries in sub-Saharan Africa had adopted the 2015 recommendations by August 2016, with an average delay of eight months to incorporate the WHO recommendations into national guidelines.

Eleven countries in the region, accounting for just over a quarter of the continent’s total burden of HIV infection, are still recommending that people with HIV should wait to start treatment until their CD4 cell counts fall below 350 cells/mm3, according to the survey, despite evidence from two large clinical trials showing that earlier treatment reduces the risk of death and illness. Those trials reported their findings in 2015, leading to a rapid update of the WHO guidelines for antiretroviral treatment.


90-90-90 target

A target set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) for 90% of people with HIV to be diagnosed, 90% of diagnosed people to be taking treatment, and 90% of people on treatment to have an undetectable viral load. 

standard of care

Treatment that experts agree is appropriate, accepted, and widely used for a given disease or condition. In a clinical trial, one group may receive the experimental intervention and another group may receive the standard of care.

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

IAPAC’s findings come from a regular survey of HIV treatment guidelines, which found 59 sets of guidelines from 33 countries in sub-Saharan Africa updated since 2009. The study found persistent delays in updating national guidelines after WHO made new recommendations on when to start treatment. In the case of the 2009 WHO guidelines, it took countries an average of two years to update their own guidelines to follow WHO recommendations. In the case of the 2013 WHO guidelines, which recommended treatment for everyone with CD4 cell counts below 500, it took an average of ten months for countries to update their own guidelines – and eleven countries in the region still haven’t adopted this standard of care, the survey found.

Among the countries still to adopt the 2015 treat-all recommendation, Nigeria faces the biggest treatment gap. Approximately 800,000 people are receiving antiretroviral therapy in Nigeria, out of an estimated 3.4 million people living with HIV, and national treatment guidelines haven’t been updated since 2010. National guidelines still recommend treatment for people with HIV with CD4 cell counts below 350, three years after WHO said this policy was out of date.

“Considering ways to shorten the time lag from science to guideline adoption to delivery of HIV services is essential to more rapidly expand access to treatment […] and achieving the 90-90-90 targets,” the authors conclude.

“Guideline revisions can be complex and often involve consensus building around technical and operational issues and negotiations with internal and external stakeholders regrading budget prioritisation,” the authors note. They draw attention to the mismatch between spending on HIV care and treatment in sub-Saharan Africa – many countries are spending less than half their HIV budgets on treatment – and the new recommendation to treat all designed to maximise the preventive impact of treatment investments.

“There is an urgent need to move away from the traditional 'one step at a time, business as usual' approach to guidelines production, dissemination and revision,” the authors conclude.

The World Health Organization says that many countries will have moved to recommend treatment for all by the end of 2016. Speaking at the 21st International AIDS Conference in Durban in July, Dr Meg Doherty of WHO’s HIV department said that 80% of 'fast-track' countries (those with a high prevalence of HIV or a large population of people living with HIV) are expected to have switched to treating everyone with HIV by the end of the year.

Outside sub-Saharan Africa two countries with large populations of people living with HIV – Russia and India –  have not yet indicated when they plan to implement the WHO 'treat all' recommendation. Ukraine is the only country in Eastern Europe and Central Asia to have adopted the WHO guidance, according to WHO data presented at the conference.


Gupta S & Granich R. When will sub-Saharan Africa adopt treatment for all? South Afr J HIV Med 17(1): a459, 2016.

A database of national treatment guidelines is available at