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Delays in updating HIV treatment guidelines in Africa blocking early treatment for millions
Keith Alcorn, 2016-09-12 16:40:00
Delays in adopting the World Health Organization’s 2015
recommendation of HIV treatment for all threaten the achievement of the
90-90-90 targets for HIV diagnosis and viral suppression by 2020, research carried out
by the International Association of Physicians in Aids Care (IAPAC) indicates.
The findings, published last month in the South African Journal of HIV Medicine,
show that only three countries in sub-Saharan Africa had adopted the 2015
recommendations by August 2016, with an average delay of eight months to
incorporate the WHO recommendations into national guidelines.
Eleven countries in the region, accounting for just over a
quarter of the continent’s total burden of HIV infection, are still
recommending that people with HIV should wait to start treatment until their CD4
cell counts fall below 350 cells/mm3, according to the survey,
despite evidence from two large clinical trials showing that earlier treatment
reduces the risk of death and illness. Those trials reported their findings in
2015, leading to a rapid update of the WHO guidelines for antiretroviral
IAPAC’s findings come from a regular survey of HIV treatment
guidelines, which found 59 sets of guidelines from 33 countries in sub-Saharan
Africa updated since 2009. The study found persistent delays in updating national
guidelines after WHO made new recommendations on when to start treatment. In
the case of the 2009 WHO guidelines, it took countries an average of two years
to update their own guidelines to follow WHO recommendations. In the case of
the 2013 WHO guidelines, which recommended treatment for everyone with CD4 cell
counts below 500, it took an average of ten months for countries to update
their own guidelines – and 11 countries in the region still haven’t adopted
this standard of care, the survey found.
Among the countries still to adopt the 2015 treat-all
recommendation, Nigeria faces the biggest treatment gap. Approximately 800,000
people are receiving antiretroviral therapy in Nigeria, out of an estimated 3.4
million people living with HIV, and national treatment guidelines haven’t been
updated since 2010. National guidelines still recommend treatment for people
with HIV with CD4 cell counts below 350, three years after WHO said this policy
was out of date.
“Considering ways to shorten the time lag from science to
guideline adoption to delivery of HIV services is essential to more rapidly
expand access to treatment […] and achieving the 90-90-90 targets,” the authors
“Guideline revisions can be complex and often involve
consensus building around technical and operational issues and negotiations
with internal and external stakeholders regrading budget prioritisation,” the
authors note. They draw attention to the mismatch between spending on HIV care
and treatment in sub-Saharan Africa – many countries are spending less than
half their HIV budgets on treatment – and the new recommendation to treat all
designed to maximise the preventive impact of treatment investments.
“There is an urgent need to move away from the traditional
`one step at a time, business as usual` approach to guidelines production,
dissemination and revision,” the authors conclude.
The World Health Organization says that many countries will
have moved to recommend treatment for all by the end of 2016. Speaking at the
21st International AIDS Conference in Durban in July, Dr Meg Doherty
of WHO’s HIV department said that 80% of `fast-track` countries (those with a
high prevalence of HIV or a large population of people living with HIV) are
expected to have switched to treating everyone with HIV by the end of the year.
Outside sub-Saharan Africa two countries with large
populations of people living with HIV – Russia and India – have not yet indicated when they plan to
implement the WHO `treat all` recommendation. Ukraine is the only country in
Eastern Europe and Central Asia to have adopted the WHO guidance, according to
WHO data presented at the conference.