The Best of Times, the Worst of Times: Do WHO's New ARV Guidelines Serve the Needs of Key Populations?

Published: July 16, 2013

One of the highlights of the recently concluded 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention in Kuala Lumpur, Malaysia, was the launch by World Health Organization (WHO) of new Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.
Announced on 30 June 2013 at a satellite session, the new guidelines, if implemented at scale, could help avert an additional 3 million deaths and prevent 3.5 million more new HIV infections between now and 2025. At their core is the idea that earlier initiation of anti-retroviral (ARV) drugs will help people living with HIV (PLHIV) live longer and healthier lives.
The new guidelines recommend initiation of anti-retroviral treatment (ART) in all adults who have a CD4 count of 500 cells/mm3 or less, and priority should be given to individuals who have CD4 counts less of 350 cells/mm3 or less. Additionally the new guidelines also recommend that ART should be initiated immediately for PLHIV coinfected with TB or Hepatitis B and for those in serodiscordant couples. It also calls for Initiation of ART in all children infected with HIV below five years of age, regardless of WHO clinical state.
Soon after the launch, one of the conference participants, a self-identified MSM living with HIV, aptly described the new recommendations to me: ‘It was the best of times, it was the worst of times.’ One of the guiding principles behind the new recommendations is ‘promoting human rights and health equity,’ and for the first time WHO clinical ARV guidelines acknowledge the distinct challenges faced by key populations affected by the epidemic—men who have sex with men, transgenders, people who inject drugs, and female sex workers.
This is great progress for many reasons. The failure of the global HIV response to adequately acknowledge and address the barriers that prevent key populations from accessing treatment and related clinical services continues to be a gap of significant proportions. Structural, legal, institutional, and social forces keep key populations from entering into the continuum of care. For example, Alliance India conducted operations research in 2012 to assess the quality of HIV-related services for MSM and transgender populations in India. The research identified specific issues such as lack of confidentiality, lack of privacy, overall unfriendly environment at the service centre, and insensitivity amongst health-care providers at this country’s ART centres.

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