The Global Forum on MSM & HIV Welcomes New WHO Antiretroviral Guidelines

July 1, 2013 - On June 30th, the World Health Organization (WHO) released the 2013 Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection at a satellite session of the 7th International AIDS Conference on HIV Pathogenesis, Treatment, and Prevention.

The new guidelines represent an attempt to combine and harmonize recommendations from other WHO guidance documents, while integrating the latest data on the use of antiretroviral drugs (ARVs) to treat and prevent HIV. The new guidelines have numerous important implications for people living with HIV (PLHIV) and men who have sex with men (MSM) in resource-limited settings.

Some of the new key clinical recommendations for treating PLHIV contained in the 2013 WHO Consolidated ARV Guidelines include:

  • Starting ARV treatment at a CD4 count of 500 or less for adults, earlier for adolescents and older children, and giving priority to PLHIV with a CD4 count of 350 or below;
  • Starting ARV treatment at any CD4 count for some populations living with HIV, including those with certain co-infections, serodiscordant couples, pregnant and breastfeeding women, and young children;
  • Using a new preferred first-line ART regimen; and
  • Using viral load testing as the preferred approach to monitor ARV treatment and identify treatment failure.

“We are pleased that the new guidelines have responded to evidence on the health benefits of early treatment for PLHIV, as well as its potential to prevent forward transmission,” said Dr. George Ayala, Executive Director of the Global Forum on MSM & HIV (MSMGF). “However, we are concerned that the guidelines fall short of recommending earlier ARV initiation for all people, including key populations, who wish to gain the benefits of early treatment and reduce the risk of transmitting HIV. The health benefits of early treatment for PLHIV are well supported in the research literature. For MSM specifically, biological vulnerabilities coupled with structural barriers, discrimination, and violence greatly increase the risk for HIV infection and forward transmission. Early treatment for MSM and other key populations must be prioritized and delivered in a manner that respects our rights and dignity.”

“We recognize that the global community has not been successful in achieving its existing treatment targets, with an estimated 7 million people eligible for treatment under previous guidelines still awaiting ARVs,” said Cornelius Baker, MSMGF Steering Committee Member and Technical Advisor, AIDS and Community Health at FHI 360. “As new evidence emerges on the importance of early treatment both for the health of PLHIV and for the prevention of forward transmission, we must increase investments in ARV access on behalf of all people who are in need. We must not allow barriers that patents and other intellectual property rights may impose on our ability to access affordable, quality ARVs in low and middle income countries. Science and human rights must dictate our collective funding decisions, not the other way around.”

In addition to general treatment guidance, several recommendations address key populations explicitly, highlighting the importance of community-based services and community involvement in strategic planning:

  • Community-based HIV testing and counseling for key populations, with immediate linkage to prevention, treatment, and care services;
  • HIV testing and counseling, with linkages to prevention, treatment, and care for adolescents from key populations in all settings (generalized, low, and concentrated epidemics); and
  • Implementation of the new guidelines by national authorities using transparent, open, and informed processes with broad stakeholder engagement and meaningful participation of affected communities.

“It is especially noteworthy that the new guidance focuses on the entire service continuum, including HIV testing, linkage to care, and treatment monitoring,” said Noah Metheny, Director of Policy at the MSMGF. “Too many MSM are lost in the treatment cascade, facing ignorance, stigma, and discrimination at every step of the continuum - from testing to treatment to maintenance. It is essential to address these challenges with a comprehensive, community-based approach if we are to ensure that MSM initiate treatment at the appropriate time and are retained in care.”

The MSMGF’s 2012 Global Men’s Health and Rights survey (GMHR) of more than 5000 MSM from over 160 countries revealed that 57% of participants living with HIV did not find ARV treatment to be easily accessible. Examining young MSM (age 30 and below), the study showed that nearly half (44%) of YMSM with a CD4 count below 350 were not engaged in treatment. Among all MSM surveyed, access to treatment was negatively associated with homophobia and positively associated with comfort with health service providers.

“Homophobia is rampant in health service settings, keeping many MSM living with HIV from initiating treatment and staying linked to care,” said Dr. Ayala. “While the 2012 GMHR showed that homophobia can block access to treatment, it also showed that connection to the gay community can increase access to a wide variety of services, with community-based organizations providing safe spaces to receive respectful and knowledgeable healthcare. By emphasizing the integration of community-based services, the new guidelines highlight the critical role played by community-based organizations in the delivery of sensitized and competent care, tailored to the specific needs of MSM.”

The MSMGF also commends the 2013 WHO Consolidated ARV Guidelines for including the promotion of human rights and health equity among its guiding principles, stressing that access to HIV prevention, treatment, care, and support should be recognized as fundamental to realizing the universal right to health.

“Implementation of the recommendations contained in these guidelines must incorporate a deeper and more nuanced understanding of the drivers of HIV vulnerability, including the role of political, social, economic, and legal factors in stopping key populations from seeking out and accessing health services,” said Mr. Metheny. “All too often, we have seen recommendations addressing key populations quietly fall off the agenda as decisions are made behind closed doors in the halls of power. It is incumbent upon grassroots advocates and organizations focused on key populations to hold policymakers accountable to these recommendations, including meaningful involvement of key populations in a transparent implementation planning process. We must have our proper seat at the table and ensure that our right to health is upheld.”