Everyone diagnosed with HIV infection should start treatment when their CD4 count falls below 350 cells/mm3, the World Health Organization announced in new recommendations published on November 30th 2009.

The recommendation replaces previous guidelines for low and middle-income countries, which recommended treatment for people with advanced symptoms of HIV disease, or a CD4 count below 200 without symptoms.

The new guidance also recommends antiretroviral treatment with an efavirenz-based regimen for everyone with TB regardless of CD4 count, with antiretroviral therapy to be initiated soon after TB treatment.

People with HIV and hepatitis B coinfection who have hepatitis B infection that requires treatment should also receive antiretroviral treatment with a regimen containing tenofovir and either 3TC or FTC, regardless of CD4 count.

The new guidance aims to bring treatment practice in low and middle-income countries into line with recommendations in Europe, North America and Australia, where earlier treatment has been the norm for several years.

The new guidelines also recommend that all countries should develop plans to phase out the use of d4T (stavudine) in first-line treatment due to the high frequency of serious toxicities caused by the drug. These toxicities, such as peripheral neuropathy (nerve damage) and lipoatrophy (fat loss) are often irreversible. According to WHO d4T is still used by more than half of treatment programmes in low and middle-income countries.

The new recommendations are accompanied by new guidance on treatment for women to prevent mother to child transmission of HIV, and on infant feeding. Women who do not need ART for their own health will now be eligible to receive antiretroviral drugs throughout pregnancy and for the entire duration of breastfeeding.

HIV-positive women will no longer be encouraged to wean their infants early. Instead, WHO is now recommending 12 months of breastfeeding for HIV-negative infants, in order to ensure that infants have a greater opportunity to benefit from breast feeding. Although formula feeding is not ruled out, it will be left to individual countries to promote one policy for all women, depending on local circumstances.

http://www.who.int/hiv/pub/arv/rapid_advice_art.pdf