Q&A: WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
Q: What do the new guidelines cover and why is WHO issuing them?
A: The guidelines consolidate WHO’s HIV advice for five “key population” groups: men who have sex with men, injecting drug users, sex workers, transgender people and people in prisons. Despite overall progress in HIV prevention, rates of HIV infection among these groups remain high. For example, recent data indicates that men who have sex with men are up to 19 times more likely to have HIV than the general population – transgender women are almost 50 times more likely. Recent UNAIDS analysis suggests that up to 50% of all new infections globally are among these population groups. But these groups are among the least likely to access care, often because they are stigmatized, face discrimination or because their behaviour is criminalized.
In 2013, WHO issued consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. The 2014 guidelines address additional issues relevant to key populations, and are designed to help policymakers and health officials plan and implement HIV services for these groups. As well as consolidating existing advice, the guidelines make two specific new recommendations, one aimed at reducing new HIV infections among men who have sex with men, and one at preventing people who use drugs from dying of heroin overdose.
Q: How does WHO recommend reducing new infections among men who have sex with men?
Rates of HIV infection among men who have sex with men remain high almost everywhere and an increased focus on comprehensive HIV services is urgently needed. It is important that men who have sex with men can access the entire range of HIV services, including antiretroviral therapy for those with HIV, and a full package of prevention options, including condoms and lubricants. WHO also recommends men who have sex with men consider taking antiretroviral medicines as an additional option to prevent HIV infection (“pre-exposure prophylaxis” or PrEP) alongside the use of condoms. WHO recognizes that PrEP will not be an appropriate choice for all men who have sex with men and supports offering men who have sex with men the full range of prevention options to suit their circumstances, taking into account their risks and preferences. WHO will continue to work with countries to review and support HIV programmes for key populations including those that offer PrEP. Finding ways to provide and increase access to quality services that are acceptable and effective for key populations remains a priority to overcome the current inequity.
Q. How does WHO recommend reducing deaths from opioid overdose?
WHO recommends making naloxone available to people who are likely to witness an opioid overdose in a friend or relative. Naloxone is a medication which blocks the effects of opioids such as heroin and enables a person who has overdosed to wake up and resume breathing normally. Among people with HIV who inject drugs, the most common cause of death globally is opioid overdose, followed by HIV. WHO recommends that people likely to witness an opioid overdose should be able to access naloxone and be instructed how to administer it. The same recommendation applies to people living with and without HIV.
Q: What progress has there been in treating HIV recently?
A: There has been major progress in the last 3 to 4 years:
- More people had HIV tests in 2013 than in previous years.
- There was a sharp decline in HIV-related deaths: 1.5 million people in 2013, 25% fewer than in 2009.
- Access to antiretroviral therapy (ART) continued to expand: 12.9 million people globally were on ART at the end of 2013 –around 11.7 million of whom were in low- and middle-income countries.
- In 2013, more then two out of three pregnant women with HIV received antiretroviral (ARV) drugs to prevent mother-to-child transmission.
But there are still big challenges:
- Too many people remain unaware of their HIV status.
- Not enough people are receiving ART who are eligible for it according to WHO treatment criteria (when their CD4 cell count falls to 500 cells/mm3 or less – i.e. when their immune systems are still strong). Only slightly more than 1 in 3 adults living with HIV in low- and middle-income countries are on ART, while only 1 in 4 children aged 0-14 years with HIV are getting it.
- Adolescents generally are not accessing HIV services sufficiently - HIV is the second cause of death globally for adolescents.
- Young women under 24 years of age in Africa are still at disproportionate risk of being infected.
Q: Are antiretroviral drugs getting cheaper?
A: In general, yes. The average price for a WHO-recommended combination of first line antiretroviral drugs is now US$ 115 per patient per year, compared with US$ 147 in 2004. This reduction is due to greater predictability of demand, economies of scale, increased competition among manufacturers, and, above all, generic drugs. In 2013, generic manufacturers supplied 98% of all ARV drugs in low- and middle-income countries.
But upper middle-income countries, including China, Brazil, Mexico, Russia, Thailand and Ukraine pay higher prices. In most cases this is because patents are in force in their countries so they are unable to access generic products.
Treating HIV requires lifelong medication. But over time a person may need newer and stronger medicines to combat drug resistance. The prices of what are known as second-line drug regimens are still higher, but they have also fallen significantly to cost approximately US$ 330 per patient a year. The cost of third-line treatment has decreased for low-income countries, but it is still around US$ 1500 per patient per year, with middle-income countries paying considerably more.
Q: What is the situation regarding HIV and co-infections with other diseases?
A: People living with HIV tend to be more vulnerable than the general population to other infections and diseases. Tuberculosis (TB) remains a leading cause of death among people living with HIV and viral hepatitis is a major problem. An estimated 5% to 20% of people with HIV are infected with hepatitis B and 5% to 15% with hepatitis C.
HIV and TB services are increasingly managed jointly, which is having a big impact. In 2013, half of people with TB had an HIV test, and the number of people living with HIV screened for TB has tripled since 2009. The number of people dying from HIV-associated TB has dropped by 36% since 2004; yet one in five of HIV-related deaths is still due to TB. All opportunities need to be taken to screen TB patients for HIV and start them on ARVs as early as possible.
As ART enables many people with HIV to live longer, they then have an increased risk of developing noncommunicable diseases (NCDs) like heart disease, diabetes, liver, kidney and lung diseases, as well as some types of cancer. People who are being treated for HIV should be offered testing and care for NCDs and mental health disorders. This includes nutritional advice, promoting nutrition and support in stopping tobacco use. Needle and syringe programmes substantially and cost-effectively reduce HIV transmission among people who inject drugs, and also reduce the transmission of other bloodborne infections, such as viral hepatitis B and C.