19.1. Guiding principles

1. Countries should establish a package of care interventions, in addition to ART, to reduce HIV transmission, prevent illness and improve the quality of life.
2. A key component of the package of care interventions is the promotion of early HIV diagnosis and early assessment of ART eligibility by CD4 testing, in order to minimize late initiation of ART and maximize HIV prevention.
3. WHO continues to advocate for wider access to monitoring tools, including CD4 and viral load testing.
4. The package of care interventions should be aligned with the WHO Essential prevention and care interventions for adults and adolescents living with HIV in resource-limited settings.(193)

Not all PLHIV are eligible for ART. However, it is imperative that as many PLHIV as possible enter care before they become ill with their first opportunistic infection (OI) or before they develop advanced immunosuppression (CD4 cell count <200 cells/mm³), which puts them at higher risk of developing opportunistic disease. Expanded access to HIV testing and counselling, especially provider-initiated but also client-initiated, is critical to identifying people who need to enter care. The pre-ART period in care provides a setting for interventions to prevent further transmission of HIV, to treat and prevent other illnesses, to prepare for the time when ART will be necessary and to maximize long-term retention in care.

19.2. Voluntary counselling and testing and provider-initiated testing and counselling

Client-initiated voluntary counselling and testing (VCT) is the process whereby the client requests a test. However, attendance at any health facility offers an opportunity to integrate discussion of HIV and HIV testing into routine medical care through provider-initiated testing and counselling (PITC).(22) PITC facilitates early HIV diagnosis, partner diagnosis and enrolment into pre-ART care, and minimizes late initiation of ART.

19.3. Preventing further transmission of HIV

From a public health perspective, PLHIV make up the most important group to address with HIV prevention strategies.(194) A change in the risk behaviour of a person with HIV has a greater impact on the transmission of HIV than the same behavioural change in a person without HIV. (195) Enrolment into care facilitates the identification of PLHIV with behavioural risk factors and interventions to reduce risk, and facilitates the identification of clinical risk factors, such as sexually transmitted infections and treatment, and interventions to reduce unplanned pregnancies and mother-to-child transmission of HIV.(196)

Pre-ART care includes harm reduction for people who inject drugs (supportive environment, opioid substitution therapy and the provision of clean needles and syringes). This not only reduces HIV transmission but has the potential to stabilize the persons' lifestyles by limiting active drug use in preparation for ART initiation.

Positive prevention strategies, at group and individual levels, have demonstrated a reduction in HIV risk behaviours among people with HIV. They include support to improve the consistency of condom use, a reduction of needle-sharing and unprotected sex among people who inject drugs, and a reduction in the number of sexual partners.(197–199)

19.4. The Three I's for HIV/TB

Among people living with HIV, TB is the most frequent life-threatening opportunistic infection and a leading cause of death. Pre-ART care provides a setting for implementation of the WHO Three I's strategy: isoniazid preventive treatment (IPT) where indicated, intensified case finding (ICF) for active TB, and TB infection control (IC) at all clinical encounters, which are key public health strategies to decrease the impact of TB among individuals and the community. The Three I's should be a central part of HIV care and treatment and are critical for the continued success of ART scale-up.(200) TB infection control is essential to keep vulnerable patients, health-care workers and their communities safe from becoming infected with TB.(200) Information about TB should be provided to all people with HIV. Counselling should include information about the risk of acquiring TB, strategies for reducing exposure, clinical manifestations of TB disease, and the risk of transmitting TB to others.

19.5. Cotrimoxazole prophylaxis

Cotrimoxazole prophylaxis is recommended for all symptomatic individuals (WHO clinical stages 2, 3 or 4) including pregnant women. Where CD4 testing is available, cotrimoxazole prophylaxis is recommended for individuals with a CD4 cell count of <350 cells/mm³, particularly in resource-limited settings where bacterial infection and malaria are prevalent among PLHIV. If the main targets for cotrimoxazole prophylaxis are Pneumocystis jiroveci pneumonia and toxoplasmosis infection, a CD4 threshold of <200 cells/mm³ may be chosen. Data from an observational analysis in the DART trial showed that the use of cotrimoxazole prophylaxis reduced mortality by 50% in severely immune-suppressed HIV-infected adults initiating ART, with benefits continuing for at least 72 weeks. Furthermore, cotrimoxazole prophylaxis reduced malaria incidence in these patients.(201)

19.6. Sexually transmitted infections

Pre-ART (and on-ART) care is an opportunity to provide comprehensive STI services, which should include correct diagnosis by syndrome or laboratory test, provision of effective treatment at the first encounter, notification and treatment of partners, reduction of further risk behaviour and transmission through education, counselling and the provision of condoms. Laboratory screening should include a serological test for syphilis, especially in pregnant women, and HIV testing for all individuals diagnosed with an STI.(196)

19.7. Treatment preparedness

There is evidence that some PLHIV do not have access to accurate knowledge about HIV, the effectiveness of ART and the challenges of adherence.(202) In resource-limited settings, major factors contributing to good adherence are free ARVS, ease of use, and preparedness for use. (203) Modelling studies suggest that treatment readiness is associated with improved adherence once ART has commenced.(204) Enrolment into care before the time of initiation of ART provides an opportunity for PLHIV to learn, understand and prepare for successful lifelong ART.

19.8. Early initiation of ART

Enrolment into pre-ART care is critical for the early initiation of ART, maximizing treatment response and minimizing treatment complication such as immune reconstitution inflammatory syndrome (IRIS).(205,206) In reality, most people do not receive any pre-ART care, presenting with advanced HIV disease, and this results in delayed initiation of ART. Mortality rates during the first year of ART are high (3-26%), most deaths occurring in the first few months, largely because of late presentation.(207) The fundamental need is for earlier HIV diagnosis, enrolment into care, ideally with CD4 count monitoring to determine eligibility for ART, and the initiation of ART before sickness occurs.(208)

19.9. ART as prevention

Studies continue to support the benefits of ART for prevention.(209) There is evidence that individuals on fully suppressive ART who are adherent to the therapy are less likely to transmit HIV to sexual partners. Conversely, those with unrecognized HIV infection contribute significantly to onward sexual transmission. At an individual level, ART reduces viral load and infectiousness. (210) The use of ARV drugs has been proved to reduce MTCT of HIV.