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Everyone diagnosed with HIV infection should start treatment when their CD4 count falls below 350 cells/mm3, the World Health Organization announced in new recommendations published on November 30th 2009.The recommendation replaces previous guidelines for low and middle-income countries, which recommended treatment for people with advanced symptoms of HIV disease, or a CD4 count below 200 without symptoms. |
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The new guidance also recommends antiretroviral treatment with an efavirenz-based regimen for everyone with TB, regardless of CD4 count, with antiretroviral therapy to be initiated soon after TB treatment. |
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People with HIV and hepatitis B co infection who have hepatitis B infection that requires treatment should also receive antiretroviral treatment with a regimen containing tenofovir and either 3TC or FTC, regardless of CD4 count.
The new guidance aims to bring treatment practice in low and middle-income countries into line with recommendations in Europe, North America and Australia, where earlier treatment has been the norm for several years. |
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The new guidelines also recommend that all countries should develop plans to phase out the use of d4T (stavudine) in first-line treatment due to the high frequency of serious toxicities caused by the drug. These toxicities, such as peripheral neuropathy (nerve damage) and lipoatrophy (fat loss) are often irreversible. According to WHO d4T is still used by more than half of treatment programs in low and middle-income countries. |
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The new recommendations are accompanied by new guidance on treatment for women to prevent mother to child transmission of HIV, and on infant feeding. Women who do not need ART for their own health will now be eligible to receive antiretroviral drugs throughout pregnancy and for the entire duration of breastfeeding. |
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All pregnant women with CD4 counts below 350, or WHO stage 3 or 4 HIV disease, should start ART without delay, for life. Pregnant women who don't need ART for their own health should start taking prophylaxis as soon as possible after week 14 of their pregnancy. |
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HIV-positive women will no longer be encouraged to wean their infants early. Instead, WHO is now recommending 12 months of breastfeeding for HIV-negative or of unknown status infants, in order to ensure that infants have a greater opportunity to benefit from breastfeeding. HIV-positive mothers should breastfeed for at least two years if their child is also HIV-positive, in order to maximize the benefits of breastfeeding. |
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Although formula feeding is not ruled out, it will be left to individual countries to promote one policy for all women, depending on local circumstances. |
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The new recommendations, released in advance of publication of the full adult treatment guidelines in early 2010, emphasize the use of CD4 counts in order to determine eligibility for treatment, in place of the previous model.
Although the recommendation of earlier treatment has the potential to greatly increase the numbers in need of treatment, uptake of earlier treatment will be dependent on increasing the Uptake of voluntary counseling and testing |
