Today’s World Health Organization (WHO) “Early Release Guideline” on antiretroviral therapy (ART) for HIV treatment and pre-exposure prophylaxis (PrEP) for HIV prevention has the potential to change the world and help begin to end the AIDS epidemic – if the guidance is swiftly and comprehensively funded and implemented. The new guideline recommends providing ART to all adults living with HIV, regardless of CD4 cell count, and offering oral PrEP as an additional prevention option to all people at substantial risk of acquiring HIV.
“This is a cause for celebration,” said Mitchell Warren, AVAC Executive Director. “WHO is paving the way for a fundamental shift in the world’s response to HIV – abandoning the partial or piecemeal use of antiretroviral medicines in favor of full access for men and women in need. Both science and conscience demand that we put these recommendations into effect as quickly as possible.
“If fully funded and implemented, the recommendations will greatly simplify ART for people living with HIV and revolutionize prevention for people at risk. But there is much work ahead to translate them into practice, from securing resources to revamping HIV guidelines in country after country to implementing comprehensive treatment and prevention programs. These new recommendations will contribute to achieving the #GlobalGoals agreed by the UN last week; now global leaders like PEPFAR and the Global Fund and national governments must begin rallying resources and laying out a vision for action.”
ART “on demand” is a wholly new concept in many parts of the world, where people have long been told to wait until they were sick or approaching low CD4 cell counts to begin treatment. Much work will need to be done to ensure that this guidance is understood and implemented.
The recommendation of PrEP for all people at substantial risk replaces prior WHO guidance focusing on men who have sex with men and on heterosexual couples in which one partner is HIV positive and the other negative. Importantly, it vastly expands the likelihood that oral PrEP will be offered to young women, offering them a long-needed prevention option that they can use discretely, not at the time of sex—a profoundly important development.
AVAC works in coalition with advocates, activists and scientists on advancing an effective AIDS response, and many partners welcome the news and call for immediate action.
“We are hoping that the WHO guidelines push governments in the right direction and finally policy makers will move to making both treatment and PrEP available to those who desperately need it,” said Yvette Raphael, a human rights activist who recently completed a year-long project focused on addressing the HIV prevention, treatment, and sexual and reproductive health needs of young South African women. “In South Africa, many young women have expressed the need for PrEP to be available as an option that will work for them. PrEP can help young women and girls take more control of their sexual and reproductive health rights and be more empowered to control their own sex lives. As a woman who has been living with HIV for 15 years, I know the importance of taking control of all aspects of your life and health.”
“Women living with HIV have been on the frontlines of demanding access,” said Lillian Mworeko, Director of ICW EA. “Now we are on the frontlines of demanding programs that include and prioritize peer support, civil society partners, and a rights-based, treatment-literacy oriented approach to the offer of ART to all.”
“A revolution in HIV prevention is now underway,” said Tom Craig, who participated in the IPERGAY trial, and advocates for improved HIV treatment and prevention. “The concept of combination prevention is now widely accepted, and now PrEP is a part of that revolution. The problem is that few people know about it, especially those in key populations, where the rate of new infections are at an all time high. When will we have access to it? Why is it taking so long? How many more people need to be infected before our governments take action?”
“As a sex worker and prevention advocate from Kenya, I have traveled my country speaking about PrEP,” said Carol Njoroge, a rights activist with the Kenya Sex Worker Alliance and a 2015 AVAC Fellow focused on expanding PrEP access. “I see that most of the people at high risk of HIV who know about PrEP and how effective it is, want it. There is demand from male, female and transgender sex workers and others at high risk for HIV, and we have PrEP demonstration studies looking at how best to provide PrEP in the real world. And in Kenya we have a “Prevention Revolution Roadmap.” But there’s still a lot more needed: clear clinical guidelines, regulatory approval, civil society partnership and funding commitments to make PrEP a reality in Kenya. These recommendations from WHO at this time - can help Kenya move towards PrEP rollout.”
AVAC is committed to working with these and other partners around the world to ensure that the new treatment and PrEP recommendations are put into practice as part of comprehensive programs that address and protect human rights, minimize gender inequities and include tailored packages of proven strategies including harm reduction, male and female condoms and voluntary medical male circumcision—a critical intervention to bring to scale in any epidemic driven by heterosexual transmission.
“We can’t let these groundbreaking guidelines sit on a shelf,” said Warren. “If taken seriously, they can help ensure that millions of people with HIV live long and healthy lives, and that millions more women and men at high risk can remain uninfected.”
At the same time, continued research into additional prevention options is critical. Two efficacy trials of a monthly vaginal ring with a different ARV called dapivirine; phase II trials of two different injectable ARVs, used every two or three months; a phase II daily rectal microbicide gel; ongoing HIV vaccine trials and new passive antibody studies may eventually provide additional options for young people and others at high risk of HIV.
“These guidelines are also an important reminder of the essential work of crafting, funding and implementing a truly comprehensive, integrated and sustained response that links rights-based prevention, treatment and research to end the epidemic,” said Warren.