More strategic use of antiretroviral HIV medications can significantly reduce the transmission of the virus according to WHO proposals that will be presented at the XIX International AIDS Conference in Washington, DC on Sunday.

“Every year, more than a million more people in low- and middle-income countries start taking antiretroviral drugs,” said Dr Margaret Chan, Director-General, WHO. “But for every person who starts treatment, another two are newly infected. Further scale-up and strategic use of the medicines could radically change this. We now have evidence that the same medicines we use to save lives and keep people healthy can also stop people from transmitting the virus and reduce the chance they will pass it to another person.”

Antiretrovirals reduce transmission of HIV

In 2011, a large multi-country study by the HIV Prevention Trials Network showed that antiretrovirals (ARVs) cut transmission of HIV by 96% within couples where one partner is HIV-positive and the other is not infected. A later study in South Africa reinforced these findings.

“When people take antiretrovirals, the amount of HIV in their body is decreased, making them much less likely to pass the virus to others,” says Dr Gottfried Hirnschall, Director of the HIV Department at WHO. “If we can get, and keep, more people on treatment, and reduce their virus levels, we can reduce the number of new people who are infected.”

Strategic use of antiretrovirals

On the basis of this evidence, WHO advice for more strategic use of antiretrovirals includes:

• new guidelines for treating people with HIV who have uninfected partners (‘serodiscordant’ couples), recommending that antiretroviral therapy be offered to the HIV-positive partner, regardless of the strength of his or her immune system, to reduce the likelihood of HIV transmission to the uninfected partner. Up to 50% of HIV-positive people in on-going relationships are estimated to have HIV-negative partners. Rwanda and Zambia are already implementing this new policy. More than a dozen other countries say they plan to join them.
• a recommendation to consider modifying current practices to prevent mother-to-child transmission of HIV (PMTCT). Malawi, for example, now offers ARVs to all HIV positive pregnant women, regardless of the strength of their immune system, and has them continue taking the medicines for life. This not only treats HIV infected women and prevents transmission to their infants, it can also protect their partners.
• WHO currently recommends that people diagnosed with HIV start taking ARVs when the strength of their immune system drops to a CD4+ count of 350 cells/mm3 or lower. There is increasing evidence that HIV infection causes chronic inflammation, increasing the risk of other health problems, including certain types of cancers, heart disease and diabetes. The Organization is now reviewing recent studies that point to the potential health benefits of giving ARVs earlier, before the immune system starts to weaken.

Increased coverage and early treatment cost-effective

Providing ARVs to people living with HIV who have HIV-negative partners, pregnant women and high risk populations, regardless of their immune status, would increase the number of people eligible for treatment in low- and middle-income countries from the current figure of 15 million to 23 million. While this will increase the cost of providing treatment in the short term, studies predict that the economic benefits of early treatment will substantially offset, and likely exceed, programme costs within 10 years of investment. This economic benefit derives from the fact that the workforce is healthier and more productive and that costs of treatment and orphan care are reduced.

In addition to more targeted treatment approaches recent studies suggest ARVs can also be used to protect people who are currently HIV-negative, but are at high risk of becoming infected. WHO is working with a number of countries where epidemics are concentrated around communities at particularly high risk of being infected with HIV such as men who have sex with men and transgender people.

New WHO recommendations

Over the next 12 months, WHO will compile a new, consolidated set of recommendations related to the use of ARVs for both HIV treatment and prevention. The document will provide countries with clinical, programmatic and operational guidance so they can make the most effective and strategic use of ARVs.

“The new guidance builds on science and experience from countries. It will inform what ARVs to use and when to use them, how to best deliver them and how to make strategic choices that have maximum benefit for people, and maximum impact on the epidemic,” adds Hirnschall.

In addition, at the International AIDS Conference, WHO will release new guidance on a range of issues, including guidelines on HIV services for sex workers, new recommendations on using ARVs in particular circumstances for pre-exposure prophylaxis (PrEP) and the prevention of HIV and hepatitis among people who inject drugs.