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Review of Global HIV Treatment Guidelines from 157 countries

This review examines the HIV treatment guidelines from 157 countries, comparing them to the WHO 2015 guidelines. It includes information on ART initiation criteria for asymptomatic individuals. Please note that some countries may have outdated or unavailable policies.

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Review of Global HIV Treatment Guidelines from 157 countries

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  1. Review of Global HIV Treatment Guidelines from 157 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 Last updated: July 2016

  2. Objectives and methodology: “wiki strategy” Objective: Compare national ART guidelines for 157 countries with WHO 2015 guidelines Recommendation on ART initiation criteria and monitoring for different target population abstracted Search end date: July 2016

  3. ART initiation for asymptomatic people Source: published policy

  4. ALL Italy, Mexico, Romania, Spain, Thailand ALL Argentina, Austria, UK, Germany, Maldives, Montenegro ALL Netherlands United States ALL Australia, Brazil, France, South Korea, Turkey Consider for >500 Guyana Consider for >500 Greece, Norway <500 Algeria Consider for <500 Guinea Consider for <500 Belize Consider for >500 Hong Kong Consider for <350 Cape Verde, Estonia <350 Burkina Faso, Croatia, Djibouti, Ghana, Nicaragua, Niger, PNG, Portugal, Sierra Leone, Sweden, Macedonia* <200 Senegal <200 (200-350) Belarus, Cuba, Russia <350 Morocco, Nigeria <350 AfghanistanJamaica, Kazakhstan Panama, Switzerland Timor-Leste <350 Benin, China, Guatemala, Peru <500 Bolivia, Chile, Colombia, DRC, Haiti, Ecuador, Ethiopia, Fiji, Honduras, Madagascar, Mali, Oman, Rwanda, Tunisia, Zambia, Uganda, Zimbabwe All Botswana, Japan, Lesotho, Malawi <500 Bangladesh, Bhutan, Burundi, Cameroon, El Salvador, Gabon, Kenya, Mauritania, Moldova,Myanmar, Namibia, Nepal, Poland, South Africa, South Sudan, Sri Lanka, Sudan, Tanzania, Uruguay, Venezuela <500 Cambodia, Pakistan, Swaziland, Ukraine, Viet Nam <350 Canada, Cote d’Ivoire,India, Dominican Rep., Marshall Islands, Paraguay, Samoa, Tuvalu, Vanuatu <350 Angola, Costa Rica, Finland, Indonesia, Latvia, Malaysia, Mozambique <200 Comoros, Lao PDR, Liberia, Philippines

  5. ART initiation for asymptomatic people 2015 WHO Recommendation : Irrespective of CD4 count <200, <250 or <300 <350 <500 >500 Irrespective of CD4 count Source: published policy

  6. ART initiation criteria in Africa 2015 WHO Recommendation : Irrespective of CD4 count <200 <350 <500 >500 Irrespective of CD4 count Source: published policy

  7. Policy Lag in Sub-Saharan Africa – Methods IDENTIFICATION (92) 92 guidelines from 37 countries identified from the Internet, Ministries of Health, WHO, UNAIDS, CDC, USAID, PEPFAR, NGOs, HIV experts and members of the community Excluded 4 countries that have reported move to CD4 <350 or earlier but latest guidelines are not available (an old version recommending ART at CD4 <200 available for each country) SCREENING (88) 88 guidelines from 33 countries (2001-2016) screened Excluded 29 guidelines from 16 countries that did not contribute to calculating the time to adoption of the WHO 2009, 2013, or 2015 guidelines (countries published multiple guidelines before 2009) DATA COLLECTED (59) From 59 guidelines from 33 countries, data were collected on month and year of publication, and ART eligibility criteria DATA ANALYSIS Average time lag in adoption of the WHO 2009, 2013 and 2015 guidelines calculated and analyzed Source: Gupta, Granich (2016)

  8. Policy Lag in Sub-Saharan Africa (33 countries) Source: Gupta, Granich (2016) * Assumption: 11 remaining countries move to CD4 <500 or earlier in July 2016

  9. Timeline showing release of WHO guidelines and guidelines from 33 countries in Sub-Saharan Africa June 2013 Oct 2009 Sep 2015 JANUARY Swaziland 2006 Sierra Leone JUNE Niger FEBRUARY Angola JANUARY Mozambique JUNE Cote d’Ivoire JANUARY Namibia Sudan JANUARY Swaziland APRIL Lesotho APRIL Botswana South Africa Tanzania MAY Zimbabwe JUNE Guinea Uganda MAY Malawi MARCH South Sudan 2007 Lesotho Rwanda JUNE Ethiopia Madagascar JUNE Zambia JUNE Botswana JULY Malawi JULY Democratic Republic of the Congo 2008 Mali Djibouti Ghana Burkina Faso APRIL Lesotho Malawi JULY Namibia JUNE Benin WHO 2013 guidelines (CD4 <500 cells/mm3) WHO 2009 guidelines (CD4 <350 cells/mm3) NOVEMBER Kenya WHO 2015 guidelines (Irrespective of CD4 count) OCTOBER Ethiopia JUNE Cameroon Gabon Kenya Tanzania AUGUST Democratic Republic of the Congo NOVEMBER Mali DECEMBER Rwanda Uganda Zambia Zimbabwe OCTOBER Burundi Nigeria AUGUST Burundi Mauritania DECEMBER South Africa Note: Red box denotes move to the WHO 2009 guidelines [CD4 count <350 cells/mm3], green box denotes move to the WHO 2013 guidelines [CD4 count <500 cells/mm3], and blue box denotes move to the WHO 2015 guidelines [irrespective of CD4 count].

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

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

  12. ART initiation for asymptomatic people 2015 WHO Recommendation : Irrespective of CD4 count <200, <250 or <300 <350 <500 >500 Irrespective of CD4 count Source: published policy + reported

  13. ART initiation criteria in Africa 2015 WHO Recommendation : Irrespective of CD4 count <200 <350 <500 >500 Irrespective of CD4 count Source: published and reported policy

  14. GDP per capita and ART coverage

  15. 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

  16. 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

  17. 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

  18. ART eligibility criteria for children below age of 15 2015 WHO Recommendation : Irrespective of CD4 count • Of the 120 countries with guidelines, 86 countries (91% burden) have recommendations on paediatric ART • ART initiation criteria for children <15 vary considerably • Of the 86 countries, 7 (21.5% global paediatric burden) are consistent with WHO 2015 guidelines • India reported guideline change to provide ART to all children below 5

  19. ART eligibility criteria for children <15 years WHO 2015 Guidelines: ART irrespective of CD4 count Source: published policy

  20. ART eligibility criteria for children <15 years WHO 2015 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

  21. <15 years Tanzania <15 years Uganda, Zambia <15 years Namibia <2 years Guyana <5 years Rwanda <5 years China <10 years Kenya <1 year Brazil, Burkina Faso, Sweden Pre-requisites Cape Verde Pre-requisites Comoros, Djibouti, Lao People’s Democratic Republic, Liberia, Malaysia, Peru, Philippines, Sierra Leone, Ukraine <2 years Algeria, Ghana, Morocco, Nigeria <2 years Afghanistan Kazakhstan Panama, Timor-Leste <2 years Argentina, Benin, Papua New Guinea <5 years Colombia, Democratic Republic of Congo, Fiji, Honduras,Mali, Oman, South Africa, Zimbabwe <15 years Botswana, Lesotho, Malawi <5 years Angola, Bangladesh, Bhutan, Burundi, Cameroon, El Salvador, Gabon, Indonesia, Mauritania, Mozambique, Myanmar, Nepal, South Sudan, Sudan <5 years Cambodia, Maldives, Pakistan, Swaziland, Viet Nam <2 years Cote d’Ivoire,Haiti, India, Marshall Islands, Samoa, Tuvalu, Vanuatu <2 years Venezuela <1 year Paraguay <1 year Ethiopia, Guatemala <1 year Costa Rica, Finland, Mexico, Sri Lanka, Thailand, United States, Uruguay Pre-requisites Guinea <1 year Chile, Dominican Republic, Hong Kong, Madagascar, Romania, Tunisia

  22. ART initiation for people with HIV and TB Source: published policy

  23. ART initiation for pregnant women 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

  24. ART initiation for serodiscordant couples 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

  25. ART initiation for people with Hepatitis B 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

  26. ART initiation criteria for key populations 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

  27. ART initiation criteria for key populations 2015 WHO Recommendation : Irrespective of CD4 count Earlier ART for KPs 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

  28. Frequency of CD4 monitoring (55 countries)

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

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

  31. 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?

  32. 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

  33. Conclusion • Guidelines from 15 countries released before 2015 recommend ART for asymptomatic people irrespective of CD4 count • Twenty-two countries (14% burden) recommend test and treat • Only seven countries are consistent with the 2015 WHO paediatric ART recommendation • Post 2015 WHO guidelines, countries are revising/ planning to revise national guidelines

  34. 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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