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Access to HIV drugs should be widened, says WHO

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4172 (Published 01 July 2013) Cite this as: BMJ 2013;347:f4172
  1. Anne Gulland
  1. 1London

Antiretrovirals to treat adults with HIV should be given earlier and to more people, new guidelines from the World Health Organization have said.

The guidelines, which are aimed at low and middle income countries, state that all countries should start treatment in adults with HIV when their CD4 cell count falls to 500 cells/mm3 or fewer, even if they are not sick or showing any symptoms.1 The previous recommendation, published in 2010, was to offer treatment at 350 CD4 cells/mm3 or fewer.

For the first time the guidelines also state that regardless of the stage of the disease all HIV positive children aged under 5 years, all HIV positive pregnant and breastfeeding women, and all HIV positive patients with an HIV negative partner should have access to antiretrovirals.

WHO believes that if the guidelines are implemented in full an additional three million deaths and 3.5 million new HIV infections could be averted by 2025.

Speaking at a press conference in London to launch the guidelines, which include recommendations on service delivery and organisation, Gottfried Hirnschall, director of the HIV department at WHO, described them as “an important step forward in the global response to HIV.”

“They will have a major impact on the development and evolution of the epidemic. We are confident that [increasing the number of people on treatment] can be done because of what we have seen over the last few years in terms of scaling up the response,” he said.

WHO is also now recommending the use of a single dose combination pill containing tenofovir, lamivudine (or emtricitabine), and efavirenz to be given once daily to HIV positive adults, pregnant and breastfeeding women, and children over the age of 3. Five manufacturers are currently making three different drug combinations, and yearly treatment costs $120 (£80; €92) to $140 per patient.

Philippa Easterbrook, a scientist at WHO’s department of HIV at WHO, said that because one of the drugs in the combined pill had an effect on bone growth and metabolism it was not being recommended for children under the age of 3.

“One of the main considerations in starting treatment earlier is that we will be exposing patients to treatment for far longer. We have set up a number of monitoring studies to look at the long term impact of using these drugs,” she said.

Hirnschall said that the new guidelines would add about 10% to the estimated annual global spend on HIV of $22bn to $24bn. WHO has predicted that 2025 will be when spending peaks—as fewer people become infected, costs will decrease.

“If countries think about the long term trend and trajectory of the disease, making the investment now will pay off,” he said.

WHO figures show that at the end of 2012 there were 9.7 million people in low and middle income countries taking antiretrovirals, up from less than 300 000 people 10 years ago. The drugs have saved some 4.2 million lives in the past decade, and about 800 000 childhood infections have been avoided through the prevention of mother to child transmission of HIV.

Easterbrook said that the guidelines were based on a number of studies, including a significant trial showing that giving HIV positive patients antiretrovirals prevented their HIV negative partners from contracting the virus.2

She said, “We have also been able to pull together 24 studies that all consistently pointed in the same direction, showing that use of antiretrovirals earlier was associated with improved survival rates.”

But Hirnschall said that increased access to treatment alone would not eradicate AIDS. “The new guidelines will take us a long way in reducing new infections, but we know that unless a vaccine kicks in we will not be able to [eradicate] AIDS.”

Notes

Cite this as: BMJ 2013;346:f4172

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