WHO normative guidelines are developed for a global audience and it is expected that each country will adapt the recommendations to suit its own circumstances. WHO endorses the use of a national technical or advisory treatment working group to direct the adaptation process. It is recognized that the implementation of some recommendations may be challenging in some settings in view of the differing prevalence of HIV and of limited available and promised resources. It is recognized that the new recommendations have the potential to increase substantially the number of people eligible for ART and to increase the cost of delivering ART as part of comprehensive care. Immediate and full implementation of these recommendations may not be practicable, feasible or affordable. However, country-level strategic planning should be directed towards eventually implementing these recommendations and achieving national universal access to HIV care and treatment. It is recommended that national ART advisory committees consider the following six guiding principles to direct decision-making when introducing the revised recommendations.

1. Do no harm
   Seek to maintain current progress of treatment programmes without disrupting the care of those on treatment or compromising PLHIV at highest risk for poor outcomes.
2. Accessibility
   Ensure that all clinically eligible people infected with HIV are able to enter treatment services.
3. Quality of care
   Ensure that care achieves the highest standards possible.
4. Equity of access
   Ensure fairness and justice in access to treatment services.
5. Efficiency in resource use
   Aim to achieve the greatest health impact with the optimal use of available human and financial resources.
6. Sustainability
   Understand the long-term consequences of changes and have the vision to provide continued, lifelong access to ART for those in need.

While the six guiding principles should be used to direct decision-making, contextual issues must also be taken into consideration, and it is not expected that all national ART advisory committees will come to the same decisions. It is important to engage stakeholders, including PLHIV, civil society and health-care workers, in open discussions about how to make choices and implement changes.

In addition, the following points should be considered.

1. Strengthen health systems
   In making decisions, priority should be given to interventions that will directly or indirectly strengthen health systems.
2. Implement in phases
   It may not be possible to implement every new recommendation in every setting. A phased approach may be necessary if only some recommendations can be implemented.
3. Understand the perspectives of PLHIV
   The toxicity of d4T is of concern to the majority of PLHIV and its continuing use may undermine confidence in ART. If d4T has to be included in ongoing regimens, strategies should be devised to allow for substituting an alternative drug in cases of toxicity. There should be a plan to eventually avoid the routine use of this drug.
4. Be forward-looking
   The WHO guideline Antiretroviral therapy for HIV infection in adults and adolescents will next be updated in 2012. Member States should strive to adopt the 2010 recommendations before that date.

An adaptation guide has been written to accompany these guidelines. WHO recognizes that the new recommendations will promote significant benefits to HIV-infected individuals, and also that they have the potential to substantially increase the number of people in need of ART and the cost of delivering it. Depending on how the new guidelines are implemented or interpreted, they could also lead to unintended consequences, such as reduced access to those most in need or the undermining of existing ART coverage or impending ongoing or planned research. The purpose of the adaptation guide is to assist Member States and programme managers to choose and prioritize the recommendations, especially where resources are limited. In addition, the guide is intended to serve as an advocacy tool for policy-makers and to provide a basis for difficult choices and decisions in Member States. The adaptation guide is available at: http://www.who.int/hiv/topics/treatment/guide_for_adaptation.pdf.

To further assist countries, programme managers, academic institutions and national ART advisory committees to adapt these new recommendations to their local circumstances, the following materials are available on the WHO main evidence map web page. http://www.who.int/hiv/topics/treatment/evidence3/en/index.html.