There is an urgent need to shorten the time lag in adopting and implementing the new WHO guidelines recommending ‘treatment for all’ to achieve the 90-90-90 targets.
When the World Health Organisation issued an early update to its HIV treatment guidelines in September 2015, the new recommendations drew on years of mounting evidence that immediate antiretroviral treatment for people diagnosed with the virus saves lives, prevents transmission, averts serious illnesses, and is essential to control of the pandemic. In fact, by then, 18 high- and middle income countries that include the US already had adopted policies that reflected their recognition of the benefits early treatment offers individual and public health.
Nearly a year after the release of the WHO update, however, only three countries in sub-Saharan Africa have adopted the latest guidelines as their criteria for treatment access. That lag reflects a trend that has slowed treatment access and progress against HIV in countries with the greatest numbers of people living with the virus, say authors of a recently study.
Their study examined the amount of time between the issuance of WHO’s 2009, 2013 and 2015 guidelines, and national policies adopting them across 33 sub-Saharan African countries. Although each change in WHO guidelines reflected an accumulated consensus of best practices that had been evaluated by experts and supported by evidence, adoption of the guidelines has been slow, authors found.
Countries took an average of two years to adopt 2009 guidelines recommending people with HIV start treatment when their CD4 – or immune cell – counts dropped to 350 per cubic millimetre of blood, rather than waiting until their immune systems were more damaged, as previous guidelines had indicated, with counts of 200 or below. Three years after the release of 2013 guidelines that treatment should start earlier, when immune cell counts dropped to 500 or below, 11 countries, including some with the highest rates of infection, have yet to incorporate the recommendations into their national policies.
By comparison, adoption of WHO 2015 guidelines to treat all people diagnosed with HIV may move faster, if public announcements of intention are an indication, the authors say. But actually putting the guidelines into practice – including by allocating resources and adjusting service delivery and supply chains – also will entail further delays.
In the meantime, the authors note, the benefits of the guidelines will be denied where they are needed most. “With nearly 2200 Aids-related deaths and 3,800 new infections each day,” they conclude, “translating the new science into action more quickly needs to become a major public health priority for the sub-Saharan African region.”
Investments in efficient care systems, including through reduced reliance on CD4 testing, treatment initiation by nurses, community-based testing and medicine distribution will help, they say, as will recognition by countries of the necessity to commit funding to the recommended standards of care and treatment.
The study, by Somya Gupta of the International Association of Providers of Aids Care, New Delhi, India and Reuben Granich of the International Providers of Aids Care, Washington, DC, drew on the most recent national treatment guidelines collected at HIVpolicywatch.org.
Background: The World Health Organization (WHO) HIV treatment guidelines have been used by various countries to revise their national guidelines. Our study discusses the national policy response to the HIV epidemic in sub-Saharan Africa and quantifies delays in adopting the WHO guidelines published in 2009, 2013 and 2015.
Methods: From the Internet, health authorities and experts, and community members, we collected 59 published HIV guidelines from 33 countries in the sub-Saharan African region, and abstracted dates of publication and antiretroviral therapy (ART) eligibility criteria. For these 33 countries, representing 97% regional HIV burden in 2015, the number of months taken to adopt the WHO 2009, 2013 and/or 2015 guidelines were calculated to determine the average delay in months needed to publish revised national guidelines.
Findings: Of the 33 countries, 3 (6% regional burden) are recommending ART according to the WHO 2015 guidelines (irrespective of CD4 count); 19 (65% regional burden) are recommending ART according to the WHO 2013 guidelines (CD4 count ≤ 500 cells/mm3); and 11 (26% regional burden) according to the WHO 2009 guidelines (CD4 count ≤ 350 cells/mm3). The average time lag to WHO 2009 guidelines adoption in 33 countries was 24 (range 3–56) months. The 22 that have adopted the WHO 2013 guidelines took an average of 10 (range 0–36) months, whilst the three countries that adopted the WHO 2015 guidelines took an average of 8 (range 7–9) months.
Conclusion: There is an urgent need to shorten the time lag in adopting and implementing the new WHO guidelines recommending ‘treatment for all’ to achieve the 90-90-90 targets.
Somya Gupta, Reuben Granich