New WHO Guidelines on ART and PrEP Can Put the World on Track to End AIDS

On September 30, the World Health Organization announced their "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."

Advocates like Warren say that, 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.

This sentiment was echoed by the Gay Men's Health Crisis, who urged that the global health community ensure there is sufficient funding to implement these guidelines across the globe. �

"The WHO guidelines confirm what GMHC has known and seen firsthand -- providing early antiretroviral treatment to those infected by HIV and using new prophylactic tools like PrEP that can prevent HIV's spread will save innumerable lives, and will help us begin to end the AIDS epidemic worldwide," said GMHC CEO Kelsey Louie.

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."

"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?"

In New York, community activists were heartened that Governor Andrew Cuomo's plan to end the epidemic by 2020 already calls for the aggressive approach recommended by the WHO.�
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"As the world's first AIDS service organization, we have seen firsthand at GMHC's David Geffen testing center in New York City the impact of providing early antiretroviral treatment to those infected by HIV because it can help suppress the virus and saves lives," said Louie.
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When�someone�tests positive for HIV at a GMHC's testing center, they�are able to get them a same-day appointment to see an HIV-specialist through their unique partnership with Mt. Sinai Hospital. Following their doctor's appointments, they accompany�clients�to get their prescriptions immediately filled out at GMHC's�on-site Duane Reade pharmacy, and provide them with case management and other support services to help them maintain their doctor's appointments�moving forward, get treated early, and stay connected to the care they need�to stay healthy.
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"Our comprehensive service delivery model is how we're able to achieve the 90 percent viral suppression rate for clients who test positive at�GMHC's testing center, over twice the viral suppression rate statewide, and over 3.5 times the viral suppression rate nationwide," added Louie.
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AVAC is also committed to working with 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.

"We have a long and hard road ahead to turn these guidelines into everyday practice," echoed Louie. "We must sort out not only funding and logistic barriers, but also the significant challenge of spreading accurate and timely information. We have seen awareness of PrEP edging up, but many are still unaware or simply don't have accurate information on how PrEP can help protect against HIV infections. Today, we can celebrate hard fought advances in both treating and preventing HIV and AIDS, but tomorrow we must get to work on how to make these guidelines a reality."