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WHO Guidelines for treatment monitoring. Nathan Ford Dept of HIV/AIDS World Health Organization. WHO ART guidelines evolution. Vitoria M, et al, Current Opinions HIV/AIDS, 2013. WHO ART guidelines evolution. Earlier initiation. Simpler treatment. Less toxic, more robust regimens. - PowerPoint PPT Presentation
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WHO Guidelines for treatment monitoring
Nathan FordDept of HIV/AIDS
World Health Organization
WHO ART guidelines evolution
Topic 2002 2003 2006 2010 2013
When to start
CD4 ≤200 CD4 ≤ 200 CD4 ≤ 200- Consider 350 - CD4 ≤ 350 for TB
CD4 ≤ 350-Irrespective CD4 for TB and HBV
CD4 ≤ 500-Irrespective CD4 for TB, HBV, PW and SDC- CD4 ≤ 350 as priority
1st Line 8 options- AZT preferred
4 options- AZT preferred
8 options- AZT or TDFpreferred- d4T dose reduction
6 options &FDCs- AZT or TDF preferred- d4T phase out
2 options & FDCs- TDF and EFV preferred
across all populations
2nd Line Boosted and non-boosted PIs
Boosted PIs-IDV/r LPV/r, SQV/r
Boosted PI- ATV/r, DRV/r, FPV/r LPV/r, SQV/r
Boosted PI - Heat stable FDC: ATV/r, LPV/r
Boosted PIs - Heat stable FDC: ATV/r, LPV/r
3rd Line None None None DRV/r, RAL, ETV DRV/r, RAL, ETV
Viral LoadTesting
No No (Desirable)
Yes(Tertiary centers)
Yes(Phase in)
Yes(preferred)
Vitoria M, et al, Current Opinions HIV/AIDS, 2013
WHO ART guidelines evolution
Topic 2002 2003 2006 2010 2013
When to start
CD4 ≤200 CD4 ≤ 200 CD4 ≤ 200- Consider 350 - CD4 ≤ 350 for TB
CD4 ≤ 350-Irrespective CD4 for TB and HBV
CD4 ≤ 500-Irrespective CD4 for TB, HBV, PW and SDC- CD4 ≤ 350 as priority
1st Line 8 options- AZT preferred
4 options- AZT preferred
8 options- AZT or TDFpreferred- d4T dose reduction
6 options &FDCs- AZT or TDF preferred- d4T phase out
2 options & FDCs- TDF and EFV preferred
across all populations
2nd Line Boosted and non-boosted PIs
Boosted PIs-IDV/r LPV/r, SQV/r
Boosted PI- ATV/r, DRV/r, FPV/r LPV/r, SQV/r
Boosted PI - Heat stable FDC: ATV/r, LPV/r
Boosted PIs - Heat stable FDC: ATV/r, LPV/r
3rd Line None None None DRV/r, RAL, ETV DRV/r, RAL, ETV
Viral LoadTesting
No No (Desirable)
Yes(Tertiary centers)
Yes(Phase in approach)
Yes(preferred for monitoring, use of PoC, DBS)
Earlier initiation
Simpler treatment
Less toxic, more robust regimens
Better monitoringVitoria M, et al, Current Opinions HIV/AIDS, 2013
Recommendations on ART Monitoring
Viral load is recommended as the preferred monitoring approach to diagnose and confirm ARV treatment failure
(strong recommendation, low-quality evidence)
If viral load is not routinely available, CD4 count and clinical monitoring should be used to diagnose treatment failure
(strong recommendation, moderate-quality evidence)
Definition of virological failure: plasma viral load above 1000 copies/ml based on two consecutive viral load measurements after 3 months, with adherence support (6 months post ART)
Higher threshold for DBS and point-of-care technologies
Implementation considerations• ART access should be the first priority: Lack of
laboratory tests for monitoring treatment response should not be a barrier to initiating ART
• Prioritization: If viral load availability is limited, it should be phased in using a targeted approach to confirm treatment failure.
• This may be particularly relevant in populations receiving ARVs to reduce HIV transmission, such as pregnant and breastfeeding women and in sero-discordant couples.
Implementation considerations• Feasibility of phasing in VL capacity (DBS)• PoC viral load on horizon• Enables monitoring of treatment for
prevention • Equity• Cost-effectiveness influenced by monitoring
approach (frequency, additive or as replacement to CD4)