Author: David Rowlands
The guidelines emphasize that PrEP is a medical intervention that may have side effects, does not protect against other sexually transmitted infections, "may not provide full protection against acquiring HIV," and should be prescribed and supervised by a doctor experienced in sexual health.
EACS has also changed its recommendations for post-exposure prophylaxis (PEP). They no longer recommend PEP if the source partner is HIV-positive with an undetectable viral load, a change that finally brings them into line with BHIVA,
Access to treatment
Under the new recommendation, the number of people eligible for treatment will increase from 28 million to 37 million worldwide, according to WHO. UNAIDS estimated that 15 million people were on treatments from March 2015, representing 41% of adults and 32% of children living with HIV.
The new guidelines stress that in order to effectively implement the recommendations, countries will need to ensure that testing and treatment for HIV infection are readily available and that people on treatment are given support to stay in care and maintain good adherence.
Expanded access to treatment and PrEP are key tools to reach the UNAIDS 90-90-90 targets, which include 90% of people living with HIV being aware of their status, 90% of those receiving antiretroviral therapy, and 90% of those having undetectable viral load.
"Everybody living with HIV has the right to life-saving treatment," said UNAIDS executive director Michel Sidibé. "The new guidelines are a very important step towards ensuring that all people living with HIV have immediate access to antiretroviral treatment."
Community views on the EACS guidelines
Alex, 30, from Salford living with HIV for 6 years: “These recommendations should be implemented across Europe as soon as possible. We cannot afford to delay any further necessary steps to help end this epidemic”
Keeks, 41, from Taunton, living with HIV for 3 years: “They make sense but I don't think anyone should be pressured to go on medication if they aren't ready”
Mark, 49, from Kent, living with HIV for 13 years: “I would rather any clinical decisions about my personal health are based upon my personal needs with my consultant rather than implementing generalist guidelines that coerce me in to starting treatment before it is necessary in order to protect the wider public under the banner of treatment as Prevention (TasP)”
UNAIDS proposes new strategy to end AIDS epidemic by 2030
The UNAIDS programme coordinating board has adopted a new strategy for the next 5 years at its recent annual meeting, saying the initiative could "end the AIDS epidemic as a public health threat" by 2030. UNAIDS aims to accelerate the global response to the epidemic with the goal of getting most people living with HIV tested, treated, and virally suppressed, as well as ending AIDS-related stigma and discrimination.
British HIV Association (BHIVA) new guidelines for the treatment of HIV positive adults with antiretroviral therapy 2015
The guidelines are aimed at clinical professionals directly involved with and responsible for the care of adults with HIV infection, and at community advocates responsible for promoting the best interests and care of HIV-positive adults.
The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of adults with HIV infection on antiretroviral therapy (ART). The scope includes: guidance on the initiation of ART in those previously naïve to therapy; support of people living with HIV (PLWH) on treatment; management of individuals experiencing virological failure; and recommendations in specific populations where other factors need to be taken into consideration.
The community was asked for views on the new EACS Guidelines. There were 96 respondents between 27 October and 17 November 2015, with views collected via online hosting at www.Design-Redefined.co.uk and social networking sites. Thanks to the members of the community for sharing their views.
The World Health Organization (WHO) has released updated guidelines calling for universal antiretroviral therapy for everyone diagnosed with HIV, regardless of CD4 T-cell count, and pre-exposure prophylaxis (PrEP) for people at risk of infection. The organization estimates that the recommendations, if widely adopted, could avert 21 million deaths and prevent 28 million new infections worldwide by 2030. David Rowlands examines the views of the HIV community on these new guidelines, based on responses to his latest online poll.
International HIV treatment guidelines agree on when to start treatment
The new European AIDS Clinical Society (EACS) Guidelines, were recently launched at the 15th European AIDS Conference in Barcelona, which brings Europe into line with the rest of the world by recommending HIV treatment upon diagnosis for all patients. This is the first time since 2006 that all international guidelines have agreed on their "when to start" recommendations.
Now, in line with all other guidelines, EACS recommends that treatment should be offered to all people diagnosed with HIV, though they still reserve a category of "strong recommendation" for people diagnosed with CD4 counts below 350 cells/mm3.
This is a major step forward in the global fight against HIV. They have the potential to dramatically reduce transmission of HIV worldwide, increase the widespread use of PrEP among those who need it most, and help those living with HIV live longer, healthier lives.
"These new recommendations will have tremendous impact on peoples’ lives, if rapidly implemented," said Gottfried Hirnschall, director of WHO's Department of HIV/AIDS. "So we must work together to support countries to translate them into action and results."
Comorbidities and Ageing
Another change is not so much in specific recommendations as emphasis. The section on the prevention and treatment of co-morbidities in people with HIV now includes a specific statement:
"We recommend multidisciplinary care for aging HIV patients with multiple co-morbidities and chronic immune activation to preserve good quality of life and prevent frailty."
This is because as the HIV-positive population ages, it is becoming clearer that certain conditions that arise with age can be more frequent or more severe in people with HIV. More "aggressive"
Treatment for All
The new WHO guidelines state that, "Antiretroviral therapy should be initiated in all adults living with HIV at any CD4 cell count." The same recommendation applies to infants, children, adolescents, and pregnant women. People with advanced immune suppression or clinical symptoms of AIDS should be prioritized for treatment.
START trial provides evidence of benefits of early HIV treatment
People who start antiretroviral therapy (ART) immediately after an HIV diagnosis -- while their CD4 T-cell count is still high -- rather than waiting until it falls below 350 cells/mm3 have a significantly lower risk of illness and death. Findings suggest that HIV Antiretroviral therapy should be provided for everyone regardless of CD4 count. Now we have evidence that aligns individual benefit and prevention benefit without evidence of harm.
The recommendation for universal treatment for everyone who tests HIV-positive was informed by the large START trial, which showed the benefits of early antiretroviral therapy. The WHO guidelines team had advance access to these study findings after a data monitoring committee stopped the trial ahead of schedule because there was enough evidence to show an advantage of early treatment.
Previous results from a study of heterosexual couples in Africa (HPTN 052), showing that HIV-positive people who start treatment immediately instead of waiting until their CD4 count drops had a 93% lower risk of transmitting HIV to their partners. When transmission did occur, it was usually soon after starting treatment before viral load became undetectable.
Other changes in the new guidelines include a positive recommendation for pre-exposure prophylaxis (PrEP), which brings them into line with the U.S. DHHS and Centres for Disease Control and Prevention (CDC), WHO, and BHIVA. PrEP is "recommended" for "men who have sex with men and transgender individuals, who are inconsistent in their use of condoms with casual partners or with HIV-positive partners who are not on treatment," and "may be considered" for "heterosexual men and women who are inconsistent in their use of condoms and are likely to have HIV-positive partners who are not on treatment."