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Review of Global HIV Treatment Guidelines from 149 countries

This review compares national HIV treatment guidelines for 149 countries with the WHO 2013 guidelines. It includes information on ART initiation criteria and monitoring for different target populations.

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Review of Global HIV Treatment Guidelines from 149 countries

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  1. Review of Global HIV Treatment Guidelines from 149 countries Please note that this is “under construction” and is a dynamic area — policies are changing and we do not have written policies for some countries — let us know if you see errors and/or there are newly published policies for the database

  2. Objectives and methodology: “wiki strategy” Objective: Compare national ART guidelines for 149 countries with WHO 2013 guidelines Recommendation on ART initiation criteria and monitoring for different target population abstracted Search end date: July 2015

  3. ART initiation for asymptomatic people Source: published policy

  4. Irrespective of CD4 count US Netherlands Irrespective of CD4 count Spain Thailand Papua (Indonesia) Mexico Consider at ≤500 and >500 Guyana Irrespective of CD4 count Australia France Brazil Korea Irrespective of CD4 count Maldives Irrespective of CD4 count BC Canada Consider for >500 Italy Consider at >500 Argentina Austria Germany ≤350 Burkina Faso Sweden Djibouti, Croatia Moldova, Niger, PNG, Nicaragua Portugal Sierra Leone ≤500 Algeria Consider at ≤500 Guinea Consider at >500 Hong Kong Consider at >500 Greece Consider at ≤500 Belize ≤ 200 (200-350) ≤ 350 ≤ 500 ≤ 200 ≤500 Bolivia Chile Colombia DRC, Fiji Haiti Ecuador Ethiopia Honduras Madagascar Mali, Oman Rwanda Tunisia Uganda Zambia Zimbabwe ≤500 Bangladesh, Bhutan, Burundi, Cameroon, El Salvador, Gabon, Kenya, Malawi, Nepal, Lesotho, Sudan, Uruguay Mauritania, Poland, Myanmar Namibia, South Africa, South Sudan, Sri Lanka, Tanzania Venezuela ≤350 Ghana Morocco Nigeria Ukraine ≤ 350 Angola Jamaica Kazakhstan Malaysia Panama Switzerland ≤350 Botswana Benin China Guatemala Peru ≤500 Cambodia Swaziland Viet Nam ≤200 (200-350) Afghanistan Belarus Cuba Russia ≤200 (200-350) Cape Verde Estonia ≤200 Pakistan Senegal ≤300 Macedonia ≤200 Comoros Lao PDR Liberia Philippines Consider at ≤500 Costa Rica Finland ≤350 Britain, India Dominican Republic, Paraguay, Canada Cote d’Ivoire ≤350 Mozambique Indonesia Norway Source: published policy

  5. ART initiation for asymptomatic people 2013 WHO Recommendation : CD4 count ≤ 500 cells/mm3 <200, <250 or <300 <350 <500 >500 Irrespective of CD4 count Source: published policy

  6. ART initiation criteria in Africa 2013 WHO Recommendation : CD4 count ≤ 500 cells/mm3 <200 <350 <500 >500 Irrespective of CD4 count Source: published policy

  7. Reported ART initiation criteria in 53 countries (missing written policy document)

  8. ART initiation for asymptomatic people Source: published policy + reported

  9. ART initiation for asymptomatic people 2013 WHO Recommendation : CD4 count ≤ 500 cells/mm3 <200, <250 or <300 <350 <500 >500 Irrespective of CD4 count Source: published policy + reported

  10. ART initiation criteria in Africa 2013 WHO Recommendation : CD4 count ≤ 500 cells/mm3 <200 <350 <500 >500 Irrespective of CD4 count Source: published and reported policy

  11. Changes in ART policy following June 2013 WHO guidelines

  12. ART eligibility criteria: before 2010 <500 <350 <250 <200 Not available Source: published policy + reported

  13. ART : mid-2013 eligibility criteria <500 <350 <250 <200 Not available Source: published policy + reported

  14. ART eligibility criteria: After July, 2013 <500 <350 <250 <200 Not available Source: published policy + reported

  15. GDP per capita and ART coverage Low and middle-income countries

  16. National policy on task shifting Nurses can initiate ART and lay workers can provide ART adherence counselling Neither nurses can initiate ART nor lay workers can provide ART adherence counselling Lay workers can provide ART adherence counselling Nurses can initiate ART Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner

  17. National policy on ARV drug dispensing Nurses can initiate ART and lay workers can provide ART adherence counselling Neither nurses can initiate ART nor lay workers can provide ART adherence counselling Lay workers can provide ART adherence counselling Nurses can initiate ART Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner

  18. Task shifting and ARV drug dispensing Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner

  19. ART eligibility criteria for children below age of 5 2013 WHO Recommendation : Irrespective of CD4 count • Of the 110 countries with guidelines, 79 countries (96% burden) have recommendations on paediatric ART • ART initiation criteria for children <5 vary considerably • Of the 79 countries, 33 (57% global paediatric burden) are consistent with WHO 2013 guidelines • Afghanistan, Angola and India reported guideline change to provide ART to all children below 5

  20. ART eligibility criteria for children <5 years WHO 2013 Guidelines: ART irrespective of CD4 count Source: published policy

  21. ART eligibility criteria for children <5 years WHO 2013 Guidelines: ART irrespective of CD4 count Clinical prerequisites ART for all children <1 ART for all children <2 ART for all children <5 ART for all children <10 ART for all children <15 Source: published policy

  22. ART eligibility criteria for children <5 years Children <2 Guyana Children <15 Zambia Uganda Children <15 Namibia Children <15 Tanzania Children <1 Brazil Burkina Faso Sweden Children <5 Rwanda Children <10 Kenya Children <5 China <5 years Pre-requisites <2 years Children <5 Bangladesh Bhutan, Sudan Burundi Cameroon El Salvador Indonesia Gabon, Malawi Lesotho, Nepal Mauritania Mozambique Myanmar South Sudan Children <2 Kazakhstan Panama Viet Nam Children <2 Argentina Benin Botswana Papua New Guinea Tanzania Children <2 Algeria Ghana Morocco Nigeria Children <5 Colombia DRC Fiji Honduras Mali Oman South Africa Zimbabwe Pre-requisites Afghanistan Comoros Djibouti Lao PDR Liberia Malaysia Peru Sierra Leone Ukraine Children <5 Cambodia Maldives Swaziland Pre-requisites Cape Verde Children <2 Cote d’Ivoire, Haiti, India Children <2 Venezuela Children <1 Angola Paraguay Children <1 Ethiopia Guatemala Children <1 Costa Rica Finland Mexico Sri Lanka Thailand US, Uruguay Children <1 Chile Dominican Republic Hong Kong Madagascar Tunisia Pre-requisites Guinea Source: published policy

  23. ART initiation for people with HIV and TB 2013 WHO Recommendation : Irrespective of CD4 count Source: published policy

  24. ART initiation for pregnant women 2013 WHO Recommendation : Irrespective of CD4 count Source: published policy

  25. ART initiation for serodiscordant couples 2013 WHO Recommendation : Irrespective of CD4 count Source: published policy

  26. ART initiation for people with Hepatitis B 2013 WHO Recommendation : Irrespective of CD4 count Source: published policy

  27. ART initiation criteria for key populations 2013 WHO Recommendation : CD4 count <500 cells/mm3 Source: published policy

  28. ART initiation criteria for key populations No recommendation specific for KP Irrespective of CD4 count for KP Irrespective of CD4 count for all, including KP Source: published policy KP: Key populations

  29. Frequency of CD4 monitoring (55 countries) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring?

  30. Viral Load for ART monitoring (55 countries) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring?

  31. Frequency of VL monitoring (47 countries) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring?

  32. Viral Load for ART monitoring (55 countries) Recommended and widely available Recommended (availability unknown) Recommended with limited availability Recommended only for monitoring treatment failure Not recommended No recommendation (limited availability) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring?

  33. Early Infant Diagnosis (within 2 months of birth) Colombia, South Africa Mexico Chile Morocco Argentina, Malaysia Guatemala, Ukraine, Thailand Rwanda, Swaziland, Zambia Angola, Botswana, Cambodia, Democratic Republic of Congo, Indonesia, Mali, Myanmar, Peru, Tanzania, South Sudan, Viet Nam (WHO recommendation) Brazil, Haiti, Mozambique, Venezuela Benin, Burkina Faso, Burundi, Cameroon, China, Dominican Republic, Ethiopia, Ghana, Guinea, India, Kenya, Lesotho, Malawi, Namibia, Nepal, Papua New Guinea, Uganda, Zimbabwe Weeks 5 4 7 8 2 6 0 3 1 In 2013, the % of HIV-exposed infants receiving a virological test within 2 months of birth was <30% in countries in red and >70% in countries in bold (source: UNAIDS GARPR 2014).

  34. Limitations • Guidelines may be outdated and/or in the process of being updated • Written policies may not reflect programme implementation or clinical practice • Other guidelines covering ART, task shifting, drug dispensing may exist

  35. Conclusion • Guidelines from 6 countries released before 2013 recommend ART for asymptomatic people at CD4 ≤ 500 or earlier • USA, Netherlands, France, Brazil, Australia, Korea, Spain, Maldives, Mexico and Thailand recommend test and treat • Only 33 countries are consistent with WHO paediatric ART recommendation • Post 2013 WHO guidelines, countries are revising/ planning to revise national guidelines

  36. IAPAC Global ART guidelines database Link: http://www.hivpolicywatch.org/ http://www.globalhivpolicywatch.org/ Please send new and/or updated guidelines to: Reuben Granich MD MPH Vice President and Chief Technical Advisor, IAPAC E-mail: rgranich@iapac.org

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