Bibliographic Info
GuidelineGuidelines: updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring
Year of Publication2021
Issuing InstitutionWHO
Recommendation
Status
Updated
Treatment monitoring; People living with HIV who are initiating or receiving ART: Revised treatment monitoring algorithm
Notes and Remarks
- 1.The treatment monitoring algorithm was revised based on additional data available since 2016 and new optimized treatment options recommended by WHO. 2. Treatment algoritm based management, Fig 1 at page 51 of the Guidelines 3. The 2016 treatment monitoring algorithm suggests that the first viral load test be performed six months after initiating ART; however, experience has shown that for many people living with HIV, sample collection, testing and result delivery occur beyond that time period. The updated treatment monitoring algorithm therefore encourages that the first viral load result be more urgently available and reviewed by six months after initiating ART. 4. In many settings, reliance on dried blood spot, point-of-care technologies or other alternative specimen type or technology is necessary to expand access to viral load testing. The diagnostic accuracy, sensitivity and specificity of dried blood spots and point-of-care viral load technologies to detect treatment failure at theoretically lower treatment failure thresholds was variable (Table 1) (41,69). Several technologies could perform to lower treatment failure thresholds; however, others had considerably poorer performance. Most technologies were unable to achieve sensitivity and/or specificity greater than 90% when the treatment failure threshold of undetectable versus detectable was used. For some, the confidence intervals are wide, and additional studies are necessary to better understand potential performance. Experts noted the value of distinguishing viral suppression or undetectable from treatment failure that requires switching therapy. Further, the significant transition efforts towards DTGbased regimens across countries should be recognized. The Guideline Development Group determined that the treatment failure threshold should remain at 1000 copies/ml. Viral suppression and undetectability, however, are defined as viral load equal to or less than 50 copies/ml. 5. . Implementation considerations for treatment monitoring of pregnant and breastfeeding women
- Whenever possible, use same-day point-of-care testing for viral load testing of pregnant and breastfeeding women to expedite the return of results and clinical decision-making. If this is not available, viral load specimens and results for pregnant and breastfeeding women should be given priority across the laboratory referral process (including specimen collection, testing and return of results).
- Adherence counselling should be provided at all antenatal care and postnatal visits to ensure that viral suppression is maintained throughout pregnancy and breastfeeding.
- For all pregnant women, regardless of ART initiation timing: conduct viral load testing at 34–36 weeks of gestation (or at the latest at delivery) to identify women who may be at risk of treatment failure and/or may deliver infants at higher risk of perinatal transmission. Action: if viral load >1000 copies/ml, follow the treatment monitoring algorithmª and provide enhanced postnatal prophylaxisb for the infant. Where available, consider infant nucleic acid testing at birth.b In addition: a) For pregnant women receiving ART before conception: conduct a viral load test at the first antenatal care visit (or when first presenting) to identify women at increased risk of in utero transmission. Action: If viral load >1000 copies/ml, follow treatment monitoring algorithmª and consider infant nucleic acid testing at birth,b where available. b) For pregnant women starting ART during pregnancy: conduct a viral load by three months after ART initiation to ensure that there has been rapid viral suppression.c Action: If viral load >1000 copies/ml,a follow the treatment monitoring algorithm.a Regardless of the maternal viral load, the infants of mothers starting ART at any time during pregnancy could be considered for birth testing,b where available.
- For all breastfeeding women, regardless of when ART was initiated: conduct a viral load test three months after delivery and every six months thereafter to detect viraemic episodes during the postnatal period. Action: if viral load >1000 copies/ml,a follow the treatment monitoring algorithm,a conduct infant HIV testing immediatelyd and consider reinitiating enhanced postnatal prophylaxis for the infant