Challenges in initiating antiretroviral therapy for all HIV-infected people regardless of CD4 cell count.
BACKGROUND
Recently published large randomized controlled trials, START, TEMPRANO and HPTN 052 show the clinical benefit of early initiation of antiretroviral treatment (ART) in HIV-infected persons and in reducing HIV transmission. The trials influenced the World Health Organization (WHO) decision to issue updated recommendations to prescribe ART to all individuals living with HIV, irrespective of age and CD4 cell count.


CONCLUSIONS
It is clear that the new 2015 WHO recommendations if followed, will change the face of the HIV epidemic and probably curb its burden over time. Implementation however, requires that health systems, especially those in low and middle-income settings, be ready to face this challenge on a large scale. HIV prevention and treatment are easy in theory yet hard in practice. The new WHO guidelines for initiation of ART regardless of CD4 cell count will lead to upfront increases in the costs of healthcare delivery as the goal is to treat all those now newly eligible for ART. Around 22 million people living with HIV qualify and will therefore require ART. Related challenges immediately follow: firstly, that everyone must be tested for HIV; secondly, that anyone who has had an HIV test should know their result and understand its significance; and, thirdly, that every person identified as HIV-positive should receive and remain on ART. The emergence of HIV drug resistant strains when treatment is started at higher CD4 cell count thresholds is a further concern as persons on HIV treatment for longer periods of time are at increased risk of intermittent medication adherence.


CONCLUSIONS
The new WHO recommendations for ART are welcome, but lacking as they fail to consider meaningful solutions to the challenges inherent to implementation. They fail to incorporate actual strategies on how to disseminate and adopt these far-reaching guidelines, especially in sub-Saharan Africa, an area with weak healthcare infrastructures. Well-designed, high-quality research is needed to assess the feasibility, safety, acceptability, impact, and cost of innovations such as the universal voluntary testing and immediate treatment approaches, and broad consultation must address community, human rights, ethical, and political concerns.
Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, 451, Rue 2005, P.O. Box 1274, Yaounde, Cameroon. bignarimjj@yahoo.fr.|Bordeaux School of Public Health, University of Bordeaux, Bordeaux, France. bignarimjj@yahoo.fr.
Jean Joel R
JJ
Bigna
Department of Medicine, Division of Translational Medicine, New York University Langone Medical Center, New York, NY, USA.
Claudia S
CS
Plottel
Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaoundé, Cameroon.|Infectious Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon.
Sinata
S
Koulla-Shiro
D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology; D006801:Humans; D014944:World Health Organization
D044966:Anti-Retroviral Agents
Antiretroviral; CD4 count; Challenges; Early initiation; HIV; Immediate initiation; Resource limited setting; Universal access; WHO guidelines