The World Health Organization (WHO) has issued new recommendations for the clinical management of HIV, focusing on enhancing antiretroviral therapy, preventing vertical transmission of the virus, and improving tuberculosis (TB) prevention strategies for those living with HIV. This updated guidance aims to provide a comprehensive and evidence-based approach, reducing HIV-related mortality and expediting efforts to eliminate AIDS as a public health threat.
These revised guidelines reflect significant advancements in HIV treatment since the last comprehensive WHO guidelines were published in 2021. They respond to emerging evidence regarding optimized antiretroviral regimens and simplified approaches to TB preventive treatment.
Optimizing Antiretroviral Therapy
The recommendations reaffirm dolutegravir-based regimens as the preferred choice for both initial and subsequent HIV treatment. For patients whose current regimen is ineffective, the updated guidelines now recommend darunavir/ritonavir as the first-line option when a protease inhibitor (PI) is necessary, replacing earlier preferences for atazanavir/ritonavir or lopinavir/ritonavir.
Additionally, the updated guidelines endorse the reuse of tenofovir and abacavir in subsequent treatment regimens due to improved outcomes, programmatic advantages, and potential cost savings. Long-acting injectable antiretroviral therapy is recommended in specific situations for adults and adolescents struggling to adhere to daily oral regimens. For clinically stable individuals, oral two-drug regimens are also suggested as simplified treatment options.
Strengthening Prevention of Vertical HIV Transmission
Despite significant progress in reducing vertical transmission, new cases of infant HIV infections persist, particularly during breastfeeding. The updated recommendations advocate for a person-centred public health approach that prioritizes maternal choice and the well-being of infants. WHO continues to recommend exclusive breastfeeding for the first six months for mothers living with HIV, with continued breastfeeding possible for up to 24 months, combined with effective maternal antiretroviral therapy and appropriate complementary feeding.
All infants exposed to HIV should receive six weeks of postnatal prophylaxis, ideally with nevirapine. Infants considered at higher risk may be prescribed enhanced triple-drug prophylaxis, which can be extended until maternal viral suppression is achieved or breastfeeding is discontinued.
Prioritizing TB Prevention in People Living with HIV
Tuberculosis remains one of the leading causes of mortality among individuals living with HIV. To increase the uptake and adherence to TB preventive therapy, WHO now recommends a regimen of three months of weekly isoniazid plus rifapentine (3HP) as the preferred TB preventive treatment for adults and adolescents living with HIV. Other regimens previously recommended by WHO remain viable options based on clinical and programmatic needs.
The integration of mainstreamed interventions aims to improve service delivery and reduce TB-related deaths among people living with HIV.
In response to the updated guidelines, Dr. Tereza Kasaeva, Director of the Department of HIV, TB, Viral Hepatitis, and STIs at WHO Headquarters in Geneva, stated, “These updated recommendations reflect WHO’s commitment to ensuring that people living with HIV benefit from the most effective, safe and practical treatment options available.” She highlighted the importance of simplifying treatment to improve adherence and address gaps in prevention, ultimately aiding countries in strengthening their HIV programmes and saving lives.
The updated recommendations will be included in the forthcoming edition of the consolidated WHO guidelines on HIV. They are designed to inform national HIV programmes, clinicians, partners, and communities worldwide, reinforcing a global commitment to combatting HIV and related health challenges.
