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WHO Issues Recommendations on Linkage to Care, Retention to Help Bring HIV Treatment to All


The World Health Organization (WHO) has issued new recommendations on how to organize services in order to promote linkage to care and retention in care as part of its new guidelines recommending antiretroviral treatment for all adults and adolescents diagnosed with HIV.

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The WHO recommendations on antiretroviral therapy and pre-exposure prophylaxis (PrEP) for people at substantial risk of HIV infection were announced in September 2015. This week, in conjunction with World AIDS Day, the organization made a series of new recommendations on service delivery. These are designed to maximize linkage to care and retention in care as part of efforts to expand access to antiretroviral treatment to ensure that 90% of people diagnosed with HIV infection are on treatment by 2020.

HIV programs should provide people-centered services that are organized around the health needs and preferences of people living with HIV, WHO says. In practice, this means following the evidence regarding how to optimize linkage and retention in care, through decentralization of care, reduction in clinic visits and clinic waiting times, and "upholding individual dignity and respect, especially for vulnerable populations."

The new recommendations, based on moderate quality evidence from randomized studies and review of the scientific literature include:

  • Routine HIV viral load testing should be carried out 6 months and 12 months after starting antiretroviral treatment, and if the patient is stable on ART, every 12 months thereafter.
  • Less frequent clinic visits and medication pick-ups are recommended for people on stable ART; every 3-6 months is sufficient.
  • Antiretrovirals can be distributed by trained and supervised lay providers; lay people and other trained and supervised non-laboratory staff can also undertake finger prick blood sampling for collection of blood for treatment monitoring.
  • Testing sites should have in place a package of support interventions to ensure linkage to care, such as case management or peer support and navigation. Data should be used to identify how the quality of linkage can be improved.
  • Programs should provide community support intervention such as adherence clubs to encourage retention in care, and should promote adherence through the use of interventions such as peer counselors, mobile phone text messages, reminder devices, medication adherence training, and the use of fixed-dose combination pills and once-daily therapy.
  • Adolescent-friendly services should be implemented within HIV services to improve engagement and outcomes.

In a response to the new guidelines, the International Treatment Preparedness Coalition and allies called for the international community "to ensure that adequate, community-led treatment education is an integral part of treatment scale up." They also urged governments to ensure the rapid adoption of the recommendation on viral load testing, and to ensure that any charges to patients for viral load testing should not be a barrier to care.

The new guidelines also recommend the use of the integrase inhibitor dolutegravir (Tivicay) as an alternative first-line treatment option for adults for the first time.

Dolutegravir was licensed to the Medicines Patent Pool by ViiV Healthcare in 2014, allowing the drug to be used in fixed-dose combinations by generic manufacturers supplying lower-income countries. The International Treatment Preparedness Coalition has called on ViiV to extend the eligibility criteria for its license to the Medicines Patent Pool to allow middle-income countries to obtain the drug more cheaply.

Aurobindo, an Indian manufacturer, announced this week that it will make its generic version of dolutegravir available at $44 a year, matching the price of efavirenz (Sustiva or Stocrin) for lower-income countries.

The guidelines also recommend the use of a 400 mg efavirenz dose as an alternative first-line option for adults and adolescents in order to improve the tolerability of efavirenz, following the finding that a 400 mg dose was just as effective as a 600 mg dose, but with fewer side effects.

The Indian drug manufacturer Cipla announced this week that it is preparing to launch fixed-dose combinations containing 400 mg efavirenz. Mylan Laboratories will also launch its own fixed-dose combinations in early 2016 at a price of $99 a year. UNITAID says that switching to a 400 mg dose of efavirenz could result in savings of $80-100 million globally by 2020.



World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: what’s new. November 2015.

International Treatment Preparedness Coalition et al. Barriers to progress --Treatment activists’ response to WHO HIV treatment guidelines 2015. Press release. December 1, 2015.