Earlier initiation of ART
On the basis of the available evidence the panel recommended ART initiation for all PLHIV with a CD4 count of ≤350 cells/mm3 and for those with WHO clinical stage 3 or 4 if CD4 testing is not available.
Simplified, less toxic antiretroviral drugs for use in first-line and second-line therapy
While current options have permitted rapid ART scale-up, the cost in terms of side-effects has been considerable. There is a clear demand both from PLHIV and health-care providers to phase in less toxic ARVs while maintaining simplified fixed-dose combinations. The available evidence indicates that initial ART should contain an NNRTI (either NVP or EFV) plus two NRTIs one of which should be 3TC or FTC and the other AZT or TDF. Countries are advised to choose one second-line regimen for individuals with first-line failure.
Promoting the initiation of ART for all those with HIV/TB coinfection
While recognizing that this recommendation will be challenging for many countries with a significant HIV and TB burden, the panel placed high value on reducing the impact of TB on societies and on the data demonstrating a reduction in all-cause mortality among individuals provided with TB therapy and ART.
Promoting improved HBV diagnosis and more effective treatment of HIV/HBV coinfection
Evidence supports the initiation of ART, irrespective of WHO disease stage or CD4 cell count, for all those with HIV/HBV coinfection and chronic active hepatitis B when treatment is indicated for hepatitis B. However, there is no agreed definition of chronic active hepatitis in resource-limited settings. Despite this, the panel felt that it was necessary to include the principles of optimum care for those with HIV/HBV coinfection and bring these into alignment with recommendations in well-resourced settings. There is an urgent need to develop diagnostic criteria to identify individuals with HIV/HBV coinfection who need treatment in situations where HBV DNA and liver biopsy are not routinely available.
More strategic monitoring for antiretroviral efficacy and toxicity
While laboratory monitoring should not be a barrier to initiating ART, the newly recommended ARV regimens may require more laboratory monitoring than current regimens, especially in individuals at higher risk for adverse events. A phased-in approach to the use of viral load testing, if feasible, will improve the identification of treatment failure.