Guideline

Antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings : towards universal access : recommendations for a public health approach

Year of Publication

2006

Issuing Institution

World Health Organization

Links

WHO IRIS

Recommendations

25 included recommendations

It is recommended to treat all patients with CD4 counts of ≤350 cells/mm3 irrespective of the WHO clinical stage.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

High

It is recommended that all patients with WHO clinical stage 1 and 2 should have access to CD4 testing to decide when to initiate treatment.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

It is recommended to treat all patients with WHO clinical stage 3 and 4 irrespective of CD4 count.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Low

Start one of the following regimens in ART-naive individuals eligible for treatment. • zidovudine (AZT) + lamivudine (3TC) + efavirenz (EFV) • zidovudine (AZT) + 3TC + nevirapine (NVP) • tenofovir disoproxil fumarate (TDF) + 3TC or emtricitabine (FTC) + EFV • TDF + 3TC (or FTC) + nevirapine (NVP)

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

It is recommended that the triple nucleoside regimens zidovudine (AZT) + lamivudine (3TC) + abacavir (ABC) or AZT + 3TC + tenofovir disoproxil fumarate (TDF) should be used for individuals who are unable to tolerate or have contraindications to non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimens, particularly in the following situations: • HIV/TB coinfection; • pregnant women; • chronic viral hepatitis B; • HIV-2 infection.

Status

Retired

Recommended in favor

Conditional

Certainty of evidence

Low

Start ART in all pregnant women with HIV and a CD4 count of ≤350 cells/mm3, irrespective of clinical symptoms.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

CD4 testing is required to determine if pregnant women with HIV and WHO clinical stage 1 or 2 disease need to start ARV treatment or ARV prophylaxis for PMTCT.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Low

Start ART in all pregnant women with HIV and WHO clinical stage 3 or 4, irrespective of CD4 count.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Start one the following regimens in ART-naive pregnant women eligible for treatment: • zidovudine (AZT) + lamivudine (3TC) + efavirenz (EFV); • AZT + 3TC + nevirapine (NVP) • tenofovir disoproxil fumarate (TDF) + 3TC or emtricitabine (FTC) + EFV; • TDF + 3TC (or FTC) + NVP.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Do not initiate efavirenz (EFV) during the first trimester of pregnancy

Status

Retired

Recommended against

Strong

Certainty of evidence

Low

Start ART in all HIV/HBV-coinfected individuals who require treatment for their HBV infection, (chronic active hepatitis), irrespective of the CD4 cell count or the WHO clinical stage.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Low

Start tenofovir disoproxil fumarate (TDF) and lamivudine (3TC) or emtricitabine (FTC)-containing antiretroviral regimens in all HIV/HBV coinfected individuals needing treatment.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

ART should be started in all TB patients living with HIV regardless of CD4 count

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

TB treatment should be initiated first, followed by ART as soon as possible within the first 8 weeks of treatment

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Efavirenz should be used as the preferred non-nucleoside reverse transcriptase inhibitor in patients starting ART while on antituberculosis treatment

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Where available, use viral load (VL) to confirm treatment failure.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Low

Where routinely available, use viral load (VL) every 6 months to detect viral replication

Status

New

Recommended in favor

Conditional

Certainty of evidence

Low

A persistent viral load (VL) of >5000 copies/ml confirms treatment failure.

Status

New

Recommended in favor

Conditional

Certainty of evidence

Low

When viral load (VL) is not available, use immunological criteria to confirm clinical failure.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

A boosted protease inhibitor (bPI) plus two nucleoside analogues (NRTIs) are recommended for second-line ART.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Atazanavir/r (ATV/r) and lopinavir/r are the preferred bPIs for second-line ART.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Simplification of second nucleoside reverse transcriptase inhibitor (NRTI) options is recommended.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

If stavudine (d4T) or zidovudine (AZT) has been used in first-line therapy, use tenofovir disoproxil fumarate (TDF) + (3TC) or emtricitabine (FTC) as the nucleoside reverse transcriptase inhibitor (NRTI) backbone in second- line therapy

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

If tenofovir disoproxil fumarate (TDF) has been used in first-line therapy, use zidovudine (AZT) + lamivudine (3TC) as the nucleoside reverse transcriptase inhibitor (NRTI) backbone in second- line theapy

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

National programmes should develop policies for third-line ART

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low