Treatment Guidelines for HIV Infection

The World Health Organization has eight key recommendations for treatment of HIV infection.

Recommendation 1: When to start antiretroviral treatment

1.    Any patient with HIV infection and a CD4 count less than 350, regardless of clinical symptoms, should start treatment.

2.    Any patient with HIV infection and a WHO clinical stage 1 or 2 disease should have CD4 testing done to see whether #1 applies.

3.    Any patient with HIV infection and a WHO clinical stage 3 or 4 disease should start treatment, no matter the CD4 count.

Recommendation 2: What treatment to start

·      AZT + 3TC + EFV
(zidovudine, lamivudine, efavirenz)

·      AZT + 3TC + NVP
(zidovudine, lamivudine, nevirapine)

·      TDF + 3TC or FTC + EFV
(tenofovir disoproxil fumarate + lamivudine or emtricitabine + efavirenz)

·      TDF + 3TC or FTC + NVP
(tenofovir disoproxil fumarate + lamivudine or emtricitabine + nevirapine)

Recommendation 3: How to use ART in HIV/TB co-infection

1.    Initiate ART in all patients with HIV and active TB, no matter the CD4 count.

2.    Start with TB treatment, follow closely with ART.

3.    Use one of the above drug combinations that includes EFV (efavirenz).

Recommendation 4: How to use ART in HIV/HBV co-infection

1.    Initiate ART in all patients with HIV and HBV requiring treatment, no matter the CD4 count or WHO clinical stage.

2.    Use one of the above drug combinations that includes TDF (tenofovir).

Recommendation 5: How to use ART in pregnant women

1.    Initiate ART in all pregnant women with HIV infection and a CD4 count less than 350, regardless of clinical symptoms.

2.    Any pregnant women with HIV infection and a WHO clinical stage 1 or 2 disease  should have CD4 testing done to see whether #1 applies.

3.    Any pregnant woman with HIV infection and a WHO clinical stage 3 or 4 disease should start treatment, no matter the CD4 count.

4.    Use one of the regimens listed in Recommendation 1.

5.    Do not use EFV during the first trimester of pregnancy.

Recommendation 6: When to switch ART

1.    Use viral load measure to confirm treatment failure.

2.    Use viral load measure every six months to detect viral replication.

3.    Treatment failure is confirmed at a persistent viral load > 5000.

4.    If viral load measure is not available, use immunological criteria instead.

Recommendation 7: Second-line ART

1.    Use a boosted protease inhibitor (PI/r) plus two nucleoside analogues (NRTIs).

2.    The preferred boosted PIs are ATV/r (atazanavir) and LPV (lopinavir).

3.    Use simplified NRTI options:

·      If d4T (stavudine) or AZT was used first-line, use TDF + 3TC or FTC in their place.

·      If TDF was used first-line, use AZT + 3TC in its place.

Recommendation 8: Third-line ART

1.    Policies should be determined by national agencies according to funding, sustainability, and equitable access.

2.    Use new drugs such as integrase inhibitors and second-generation NNRTIs and PIs.

3.    A patient who fails a second-line regimen and has no new drug options should continue with a tolerable regimen.

Source: World Health Organization (2009). Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. Retrieved November 2011 from: www.who.int/hiv/pub/arv/advice/en/index.html