Aid organizations such as the U.S. President's Emergency Plan for AIDS Relief, or PEPFAR, have not committed to increasing their financial support. But, Crowley says, PEPFAR workers did offer advice as the panel developed the guidelines. PEPFAR and the United Nations Joint Programme on HIV/AIDS Uniﬁed Budget and Workplan (UNAIDS UBW) funded the panel's work.
Along with raising the bar for treatment overall, the new WHO guidelines shift the advice for treating pregnant women and infants. As with the general population, the organization recommends that all HIV-positive pregnant women begin antiretroviral therapy in their first trimester if their CD4 counts drop to 350 (instead of the previous threshold of 200), and by the second trimester regardless of CD4 count. The current practice in countries in Africa and Asia is to administer HIV treatment in pregnant women several weeks before their delivery date.
"The policies in Africa right now were designed for one purpose and one purpose only—to prevent transmission, but the mother was not part of the equation," says Dr. Aditya Kaul, who is a professor in the Department of Pediatric Infectious Disease at the New York University Langone Medical Center.
The new guidelines also recommend that HIV-positive mothers breastfeed their newborn babies but that the mother or infant be on antiretroviral therapies to prevent the transmission of virus in the milk. As Kaul points out, doctors realized that infants in Africa are healthier on their mother's breast milk even if their mothers are HIV-positive because the milk helps protect babies from other infections. In contrast, the U.S. guidelines, issued by the National Institutes of Health, recommend against HIV-positive women breastfeeding.
When it comes to which antiretroviral drugs it recommends, the WHO guidelines are consistent from 2006 to 2009. The panel continues to recommend a three-part therapy that contains AZT, or the HIV inhibitor called TDF, in the place of stavudine, which can alter fat metabolism and cause nerve damage. Crowley says that the therapy offered will be a country-based decision, taking availability and affordability into account. AZT and TDF are more expensive than stavudine.
In the scheme of what can be a multi-decade treatment regime, Ross (of the London School of Hygiene and Tropical Medicine) says that treating one or two years earlier should not make a big difference in terms of side effects or drug resistant viruses risks. The long-term side effects of HIV drug treatment, such as increased cholesterol and heart disease, that crop up after 10 or 15 years will still occur. But, Kaul points out, these side effects can often be countered by treatment with other medicines, such as statins, or by making lifestyle changes.
Kaul, like Ross, thinks that the change in guidelines is a step in the right direction, and it sends the right message about HIV treatment for people in Africa and Asia. "Unless we put these [new guidelines] in place we will not get to the point that we expect the same care for them as [for people] in the U.S.," Kaul says.