HTB South

WHO guidelines for testing, counselling and treatment in serodifferent couples: ART at CD4 >350 to reduce transmission

Nathan Geffen, TAC

In April 2012 the WHO released new guidelines for HIV testing and treatment in couples. This document is important because it includes the broad recommendation that ART be used to prevent transmission at any CD4 count. [1]

These guidelines were originally planned to be distributed at the International AIDS Society meeting in Rome in July 2011. [2] However, for reasons that have never been publicly clarified, publication was withheld and activist organisations, including i-Base, responded with a letter to the WHO. [3]

While much of the text has been reedited, the summary recommendations are essentially unchanged (including the option to use ART at CD4 counts >350 to reduce the risk of transmission), see Table 1. The final document now benefits from a more considered discussion on PEP, PrEP and treatment as prevention.

Although all the recommendations are graded strong, only recommendations 4 and 5 are based on high-quality evidence, primarily HPTN 052. [4]

Table 1: Summary recommendations and level of evidence
Recommendation Level of evidence
1. Couples and partners should be offered voluntary HIV testing and counselling with support for mutual disclosure. Strong recommendation, low-quality evidence.
2. Couples and partners in antenatal care settings should be offered voluntary HIV testing and counselling with support for mutual disclosure. Strong recommendation, low-quality evidence.
3. Couples and partners voluntary HIV testing and counselling with support for mutual disclosure should be offered to individuals with known HIV status and their partners. Strong recommendation, low – quality evidence for all people with HIV in all epidemic settings / Conditional recommendation, low-quality evidence for HIV-negative people depending on country specific HIV prevalence.
4. People with HIV in serodiscordant couples and who are started on antiretroviral therapy (ART) for their own health should be advised that ART is also recommended to reduce HIV transmission to the uninfected partner. Strong recommendation, high-quality evidence.
5. HIV-positive partners with >350 CD4 cells/mm3 in serodiscordant couples should be offered ART to reduce HIV transmission to uninfected partners. Strong recommendation, high-quality evidence.

References:

  1. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: Recommendations for a public health approach. WHO, April 2012
    http://whqlibdoc.who.int/publications/2012/9789241501972_eng.pdf
  2. World Health Organisation. (Unpublished). Couples HIV testing and counselling and antiretroviral therapy for treatment and prevention in serodiscordant couples. Recommendations for a public health approach.
    http://dl.dropbox.com/u/193052/PrimaryDocuments/WHO/
    WHOguidelinesForSeroDiscordantCouples-2011.pdf
    (PDF)
  3. ARASA et al. 2011. Open letter to WHO on delayed testing and treatment guidelines for discordant couples.
    http://www.tac.org.za/community/node/3110
  4. Cohen MS. 2011.Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493-505.
    http://www.ncbi.nlm.nih.gov/pubmed/21767103

Links to other websites are current at date of posting but not maintained.