30 November 2009 On the eve of World AIDS Day, the United Nations today issued new recommendations for fighting the pandemic, calling for an earlier start to treatment for adults and adolescents, as well as urging HIV-positive mothers and their infants to take antiretroviral drugs (ARVs) while breastfeeding to prevent transmission.
“These new recommendations are based on the most up to date, available data,” said Hiroki Nakatani, Assistant Director General for HIV/AIDS, TB, Malaria and Neglected Tropical Diseases at the UN World Health Organization (WHO). “Their widespread adoption will enable many more people in high-burden areas to live longer and healthier lives.”
But the main challenge lies in increasing treatment in resource-limited countries, where expansion of antiretroviral therapy (ART) is hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV-specific care within broader maternal and child health services.
An estimated 33.4 million people are living with HIV/AIDS, and there are some 2.7 million new infections each year. Globally, HIV/AIDS is the leading cause of mortality among women of reproductive age.
In 2006, WHO recommended that all patients start ART when their CD4 count (a measure of immune system strength) fell to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV.
But with trials showing that starting ART earlier reduces rates of death and disease, WHO now recommends a higher threshold of 350 cells/mm3 for starting ART for all HIV-positive patients, including pregnant women, regardless of symptoms.
WHO also recommends that countries phase out the use of Stavudine, or d4T, still widely used in first-line therapy in developing countries due to its low cost and widespread availability, because of long-term irreversible side-effects. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives.
The new recommendations for women and infants contrast with the guidelines of 2006, when WHO called for ARVs to be provided to HIV-positive pregnant women in the third trimester (starting at 28 weeks) to prevent mother-to-child transmission. Now, after trials, it urges starting ARVs at 14 weeks of pregnancy and continuing through the end of breastfeeding, which should last 12 months, thus reducing the risk of transmission.
“In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers, when they have access to ARVs,” WHO’s Assistant Director General for Family and Community Health. Daisy Mafu said.
WHO noted that the recommendations will result in a greater number of people needing treatment, but said the associated costs of earlier treatment might be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections.
The publications of the new guidelines coincided with the release of a UN report showing that national efforts to combat AIDS, particularly by preventing mother-to-child transmission, are showing positive results, but that many HIV and AIDS affected children still struggle to have their basic needs met.
The report – Children and AIDS: The Fourth Stocktaking Report, 2009 – published jointly by WHO, the Joint UN Programme on HIV/AIDS (UNAIDS), the UN Population Fund (UNFPA) and the UN Children’s Fund (UNICEF) and the World Health Organization (WHO), shows significant progress in some countries in both treatment to avoid mother-to-child transmission and testing of pregnant women for HIV.
Treatment to prevent mother-to-child transmission is now provided to 95 per cent of those in need in Botswana, 91 per cent in Namibia and 73 per cent in South Africa, all countries with high HIV prevalence. Progress is particularly evident in South Africa, where coverage was risen from just 15 per cent in 2004.
“Globally, 45 per cent of HIV-positive pregnant women are now receiving treatment to prevent them passing HIV on to their children, an increase of nearly 200 per cent since 2005,” UNICEF Executive Director Ann M. Veneman said. “The challenge is to scale up treatment in countries such as Nigeria,” home to 15 per cent of the world’s pregnant women living with HIV, of whom 90 per cent are not accessing treatment.
Globally paediatric treatment for HIV positive children, while still lagging behind adult treatment, has increased to cover 38 per cent, an improvement of nearly 40 per cent in just one year. Recent evidence indicates that diagnosis in the first two months of life and early ART can lead to significant reductions in mortality, but globally only 15 per cent of children born to HIV-positive mothers are being tested in the first two months.
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