The new guidelines recommend that people living with HIV should be offered ART when their CD4 cell* count falls below 500 cells/mm3, compared with the current threshold of less than 350 cells/mm3. This change in the threshold means that people living with HIV can have access to ART much earlier. Starting treatment when the CD4 count is higher – and the immune system is stronger – has shown to slow clinical progression, reduce the chance of life-threatening conditions such as tuberculosis (TB), and reduce the risk of HIV transmission.
Dr Gitau Mburu, senior advisor on health systems and services at the Alliance, said “We are pleased to see the emphasis in the guidelines on earlier and inclusive access to safer ART delivered in a patient-centred manner. If implemented correctly, these guidelines have the potential to offer an earlier lifeline to millions more around the world.”
The recommendations also include offering treatment regardless of CD4 count (i.e. immediate treatment after HIV diagnosis) to pregnant women living with HIV, people living with HIV and TB or Hepatitis B, children under five years old living with HIV, and people in relationships where one partner is living with HIV and the other is not (serodiscordant couples).
Civil society consultation to inform the new guidelines
Between November and December 2012, the Global Network of People Living with HIV (GNP+) and the Alliance, in collaboration with WHO, conducted a civil society consultation in order to inform the above guidelines. Communities living with and most affected by HIV and civil society organisations supporting community action on AIDS were surveyed in-order to ensure that their values, preferences and recommendations were considered in the process of guideline development. Respondents emphasised the need for meaningful community engagement at all levels once countries begin adapting and implementing the 2013 ART guidelines in order to be able to achieve global HIV targets.
Whilst the new guidelines are welcome, we do not underestimate the challenges ahead.
Millions are still not getting the life-saving treatment they are entitled to and at the same time, there is a significant withdrawal of international aid from many of the middle-income countries with large HIV epidemics.
Anja Teltschik said “Whilst recent biomedical developments have proved the benefits of starting ART earlier, i.e. below 500 cells/mm3, both in terms of treatment and prevention, this comes at a time when HIV programmes face funding challenges which threaten universal access to HIV treatment and services. In addition, social, structural and political barriers continue to hamper the HIV response that need to be addressed urgently to pave the way for greater effectiveness of interventions and inclusive access.”
To mitigate against these risks, GNP+, the Alliance and Dutch NGO, STOP AIDS NOW! are working together to develop a ‘Community Guide’ for use by networks, community-based organisations, and other civil society organisations supporting community action on AIDS. The Guide aims to support communities to position themselves in discussions at regional and national levels about policy-making, programming, implementation and evaluation of programmes that use treatment. Download our joint statement in response to the guidelines.
Access to treatment – what progress?
The rapid expansion of antiretroviral therapy is one of the most remarkable achievements in recent public health history. The scaling up of ART in low- and middle-income countries has transformed national HIV responses and generated broad-based health gains. According to UNAIDS, ART has saved 14 million life-years in low- and middle- income countries, including 9 million in sub-Saharan Africa, since 1995.
Before the new guidelines, close to 17 million people living with HIV in low- and middle-income countries were eligible for ART. With the change in threshold, an estimated 26 million will now be eligible. However, in 2011 only 8 million people had access to the drugs.
There is still insufficient linkage between HIV testing and counselling, and a high drop-out of people enrolled in HIV care and treatment. There is an urgent need to improve retention rates. We know that community engagement has the potential to generate robust, sustainable demand for HIV testing and counselling and treatment services and to improve treatment adherence and other treatment-related outcomes. This is a programming priority for the Alliance in our global strategy, HIV, health and rights: sustaining community action.
* HIV most often infects CD4 cells which are in important part of the immune system. When someone is infected with HIV but has not started treatment, the number of CD4 cells they have goes down. This is a sign that the immune system is being weakened. The lower the CD4 cell count, the more likely the person will get sick.