WHO guidelines for when to start ART and use of PrEP (September 2015)
Simon Collins, HIV i-Base
On 30 September 2015, the World Health Organization (WHO) issued a new 78-page guideline document on two important changes to current treatment and prevention recommendations. [1, 2]
The first change is that antiretroviral treatment (ART) is to now be recommended for all HIV positive people. Previous guidelines included the option to monitor people in early infection until their CD4 count dropped to 500 cells/mm3.
The second change is that pre-exposure prophylaxis against HIV infection (PrEP) should be widely available to HIV negative people who are at substantial risk of infection, in order to reduce their risk of infection.
Currently, PrEP is most widely used as a daily pill that contains two HIV drugs (tenofovir DF plus emtricitabine).
These recommendations have been announced ahead of the full guidelines which are still in press and expected to be released by 1 December 2015. 
Both recommendations are significant for their impact on global health to reduce HIV-related illnesses and deaths and to reduce new infections.
The recommendations are also controversial in being aspirational goals to increase access to both ART and PrEP, which is still limited for many people and in many countries.
The lead shown by WHO is based on evidence from clinical studies that show the both benefits of earlier ART and the effectiveness of PrEP.
In practice, current access to both ART and PrEP means that these goals are unlikely to be immediately achieved in many country, however well resourced.
Both changes, together with the publicity that the news will generate, are likely to contribute to both reducing late and undiagnosed HIV and to normalise HIV by reducing stigma and fear that currently remains high.
In the UK, 40% of the 6250 people diagnosed in 2013 were late – defined as having a CD4 count had already dropped to less than 350 cells/mm3.
UK BHIVA 2015 guidelines now include the recommendation for all HIV positive people to be treated, including at higher CD4 counts.
UK availability of PrEP on the NHS is in the late stages of review, and will be based on the results of the UK PROUD study, that reported PrEP dramatically reduced the risk of HIV infection in gay men and transgender women who were at high risk of HIV infection.
WHO-approved generic formulations of PrEP are easy to buy online at greatly reduced prices compared to the current in- patent version used for HIV treatment. It is legal in the UK to buy online medication for personal use (defined as a three month supply). A recent Q&A on the i-Base website includes further information. 
People in the UK are increasingly busing these sites to buy generic medicines. This shows the importance for the NHS to provide a setting where the essential monitoring can be easily provided.
- World Health Organization (WHO). Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV, (September 2015).
http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en (web page)
http://apps.who.int/iris/bitstream/10665/186275/1/9789241509565_eng.pdf (PDF download)
- WHO press release. Treat all people living with HIV, offer antiretrovirals as additional prevention choice for people at ‘substantial’ risk. (30 September 2015).
- World Health Organization (WHO). WHO consolidated guidelines on the use of antiretroviral drugs for preventing and treating HIV infection. (In press, expected publication by 01 December 2015).
- i-Base Q&A. Where can I buy PrEP or HCV meds online and is it legal in the UK?