Scaling up antiretroviral therapy in resource-limited settings:
Adapting guidance to meet the challenges
Purpose of review
This review describes the evolution of WHO guidelines for antiretroviral therapy (ART) in HIV-infected individuals, considering the key epidemiological, scientific, programmatic, and political changes over the last decade, and highlights the major trends for the management of the HIV disease in future guidelines revisions.
In the last few years, new evidence has emerged supporting the potential preventive benefit of ART in reducing HIV transmission. This, together with the potential clinical benefits of earlier initiation of therapy, has led to the consideration of the broader strategic use of ART, taking into account the clinical and public health benefit, and programmatic feasibility.
If implemented as recommended by the World Health Organization, options A, B and B+ are equivalent in preventing new infant infections, yielding cost effectiveness ratios between US$ 37 and US$ 69 per disability adjusted life year averted in children. However, when the three options are compared to the current practice, the provision of antiretroviral therapy to all mothers (Option B+) not only prevents infant infections, but also improves the ten-year survival in mothers more than four-fold.
This translates into saving more than 250 000 maternal life years, as compared to mothers receiving only Option A or B, with savings of 153 000 and 172 000 life years respectively. Option B+ also yields favourable incremental cost effectiveness ratios (ICER) of US$ 455 per life year gained over the current practice.
In 2002, WHO established its first guidelines for ART use, primarily focused on a public health approach for resource-limited settings. These recommendations were updated in 2003, 2006, and 2010, incorporating progressive changes reflecting progressive increase in the knowledge of HIV pathogenesis, development of new drugs and diagnostics, and increased experience of HIV treatment and prevention programs.
The impact of several international political commitments and scale-up initiatives such as the 3 by 5 Initiative, Universal Access targets, and the Treatment 2.0 Strategy were also important drivers of the global response, increasing the treatment coverage and catalyzing the necessary environment for the establishment of operational and programmatic components for an expanded and sustainable global response to HIV/AIDS.