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The WHO has issued new HIV recommendations based on the latest research.

Released yesterday (30 November), on the eve of World AIDS Day, the recommendations cover HIV treatment, prevention and infant feeding.

The WHO now advocates starting antiretroviral therapy (ART) when the number of CD4 immune cells in a patient's blood — an indicator of immune system strength — falls to 350 cells per millilitre.

In 2006, when the last set of recommendations was issued, the WHO advised starting ART at 200 CD4 cells per millilitre or lower, the point when patients start to exhibit disease symptoms. But research in the past three years has shown that early ART can reduce death rates.

"We now have significant evidence and experience on when to start treatment, what drugs to use [in adults and adolescents] and what drugs to use for the prevention of mother–child transmission," Teguest Guerma, head of the WHO's HIV department, told SciDev.Net. "We have gathered a lot of evidence since 2006."

For the first time, the WHO is recommending that HIV-positive mothers have ART during breastfeeding to prevent disease transmission. Additionally, HIV-positive expectant mothers should start using antiretrovirals earlier in pregnancy, at 14 weeks as opposed to the 2006 recommendation of 28 weeks.

The recommendations present big challenges, particularly for developing countries. For example, Guerma admits that starting treatment early will raise costs and increase the number of people requiring treatment by 3–5 million worldwide. But the WHO "knows that this is the best clinical practice", she said, and countries can set their own workable targets.

"We know that countries will not change their policies immediately," said Guerma. "Each country will adapt [the recommendations] according to their own local context." She added that the WHO will help individual countries with this.

Other recommendations include the phasing out of stavudine, or d4T — a first-line antiretroviral with irreversible side effects that is used in developing countries because of its low cost and widespread availability. The WHO says the drug should be replaced with less harmful alternatives such as tenofovir or zidovudine.

The WHO also recommends increased access to laboratory tests such as viral load monitoring — which measures the amount of HIV in the blood — and tests to assess CD4 cell levels. But it stresses that patients must not be denied ART if such testing is not available.

Tido von Schoen-Angerer, executive director of Médecins Sans Frontières' Campaign for Access to Essential Medicines, welcomed the guidelines, describing them as a call to action for donors.

"The challenge for countries and donors is to step up and continue increasing the scale-up for treatment," von Schoen-Angerer said. "It is a clear call for donors that have been waning in their support for AIDS treatment that this is not a time to be complacent."

Drug affordability is crucial, von Schoen-Angerer added. "For example, with first-line tenofovir, there are some generic first-line options coming out but prices have not come down enough."