- Introduction 1.5 scope and components 1.5.4 Guidance for programme managers Chapter 10: Aims to assist countries in decision-making and programme planning. Implementation will involve various policy mixes based on local context, including the prevalence and dynamics of HIV infection; modes of transmission; the organization and capacity of health systems; relative income; and the current coverage of interventions. The chapter proposes steps to ensure fair, inclusive and transparent decision-making processes at the country level; discusses parameters to consider in assessing and adapting the global recommendations in countries; and suggests tools for costing and planning. Considerations for implementation across the health system and for specific, key recommendations in the guidelines are also discussed.

# monitoring and evaluation
Chapter 11: Provides guidance on the implications for monitoring of key new recommendations in these guidelines. It proposes a range of indicators that may be used to track the implementation of new recommendations and indicators to monitor the performance of programmes across the continuum of care. Chapter 11 also highlights opportunities provided by new recommendations to review and strengthen monitoring and evaluation systems. - Strengthening monitoring and evaluation systems

# Contribution to global health goals
Implementing these guidelines will contribute to achieving universal access to HIV prevention, treatment, care and support in accordance with the goals and targets articulated in the 2006 Political Declaration on HIV/AIDS (1) and the 2011 Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS (2). These guidelines will also contribute to attaining specific health sector goals in the Global Health Sector Strategy on HIV/AIDS 2011-2015 (3) and the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive (4). Major targets for 2015 include reducing by half the percentage of young people 15-25 years who are infected with HIV compared with 2009; reducing the number of children newly infected with HIV by 90% compared with 2009; reducing the number of people dying from HIV-related causes by 25% compared with 2009; reducing by half the number of HIV-related maternal deaths compared with 2009; reducing by half the number of people dying from TB compared with 2004; and having 15 million people on ArT in low-and middle-income countries. In the longer term, the guidelines will contribute to and inform efforts to achieve universal health coverage, a key pillar of the post-2015 development agenda.

# Public health approach
In accordance with WHO guidance on HIV since 2002, these guidelines are based on a public health approach to scaling up the use of ArV drugs for HIV treatment and prevention (5).
The public health approach seeks to ensure the widest possible access to high-quality services at the population level, based on simplified and standardized approaches, and to strike a balance between implementing the best-proven standard of care and what is feasible on a large scale in resource-limited settings.

# strengthening health systems through innovation and learning
The recommendations and innovations in service delivery described in these guidelines should be implemented with a view to strengthening the continuum of HIV care and broader health systems, especially primary care and chronic care.
HIV services are already being integrated at lower-level health facilities in many settings with a high burden of HIV infection, while services for PMTCT are increasingly becoming core elements of maternal and child health services. HIV, TB, hepatitis, drug dependence and harm reduction services are being integrated to varying degrees. As people receiving ArT begin to age and HIV infection becomes a chronic, manageable condition, improving the integration of HIV services with care for noncommunicable diseases will also become more important. In accordance with these trends, the guidelines promote the adaptation of service delivery models that strengthen the continuum of HIV care and enable the timely initiation of ArT in a variety of settings, ensuring that people are appropriately referred to services and are retained in and adhere to lifelong treatment.
National HIV programmes should consider undertaking implementation research to determine how best to adopt and adapt these guidelines to their local context and bringing to scale more efficient and effective services.
2 Guiding principles

# Increasing the effectiveness and efficiency of programmes
In the context of limited financial resources, competing priorities and health system constraints, countries may face difficult choices among an expanding range of options for using ArV drugs to reduce HIV morbidity, mortality and transmission. These guidelines are based on the principle that countries should further scale up and optimize the effectiveness and efficiency of HIV programmes through a strategic approach to using ArV drugs that involves:
giving priority to providing ArV drugs to people living with HIV who are eligible for treatment and most in need; exploring opportunities to enhance the impact of ArV drugs on HIV prevention by starting treatment earlier in certain populations;
increasing the effectiveness and reach of ArV programmes across the continuum of care through a strategic mix of quality-assured HIV testing approaches, improving adherence and retention, innovative service delivery, integrating ArT in a wider range of settings and strengthening links between services; and engaging in both short-and longer-term efforts to optimize and harmonize drug regimens and increase their affordability and to develop and implement simpler and more affordable point-of-care diagnostics and laboratory services.

# Promoting human rights and health equity
Access to HIV prevention, treatment, care and support should be recognized as fundamental to realizing the universal right to health, and these guidelines should be implemented based on core human rights and ethical principles. In general, HIV programmes need to ensure that ArV drugs and related interventions are accessible to the people who need them most, including pregnant women, children and key populations, and that they are provided in an environment that minimizes stigma and discrimination. Informed consent -notably for HIV testing but also for initiating ArT -should always be obtained. Adequate safeguards must be in place to ensure confidentiality. Some countries may face significant ethical challenges as they seek to implement these guidelines in the context of constraints on resources and health systems. A key challenge may involve the need to give priority to ensuring ArT for the people who are most ill and those already receiving treatment, while also striving to implement expanded eligibility criteria. Each country will need to plan its own approach to ensuring that current ArV programmes are not disrupted and that expanded access is fair and equitable.

# Implementation based on local context
Implementation of the recommendations in these guidelines should be informed by local context, including HIV epidemiology, availability of resources, the organization and capacity of the health system and anticipated cost-effectiveness. A strong recommendation for a specific approach to service delivery should not necessarily be viewed as an endorsement of that model over an effective service delivery model already in place in a country.
The 2013 consolidated guidelines compile new recommendations, existing recommendations and other guidance across the continuum of HIV care. This includes guidance on HIV diagnosis, general HIV care and the strategic use of ArV drugs for treating and preventing HIV infection, based on a public health approach. New clinical and operational recommendations were developed in accordance with procedures outlined by the WHO Guidelines review Committee (1) and are based on the GrADE (Grading of recommendations, Assessment, Development and Evaluation) system (2)(3)(4)(5)(6)(7)(8)(9)(10)(11). Most recommendations cited from existing guidance were developed using the GrADE system. In a few cases where GrADE was not used, the text notes this. Chapter 10 did not use the GrADE approach, since the programmatic guidance does not contain any formal recommendations.

# Information sources
The following sources of information were used in developing new recommendations.

# methoDs AND PRoCess foR DeVeLoPING the GuIDeLINes 3 methods and process for developing the guidelines
Two global community and civil society consultations on service delivery across the continuum of care in generalized and concentrated epidemic settings.
Consultations with health workers working with adults and with children on the values and preferences related to priority areas in the guidelines were conducted through an e-survey (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).

# The sixth annual survey in 2012 of the WHO AIDS Medicines and Diagnostics
Service on the use of ArV drugs and diagnostics in 80 low-and low-middle-income countries (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
Mathematical modelling on the impact and cost-effectiveness of earlier ArT in various populations and settings, based on data from countries with both generalized and concentrated epidemics (India, Kenya, South Africa, Viet Nam and Zambia), together with modelling of various treatment monitoring strategies were undertaken by the HIV Modelling Consortium (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
An impact assessment using the Spectrum model to estimate the increased number of adults and children eligible for ArT based on various eligibility criteria (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
Reports on country implementation experiences were provided on using option B+ for PMTCT in Malawi; introducing TDF in first-line ArV regimens in Zambia; phasing out d4T in Zimbabwe; and scaling up viral load monitoring in Medecins Sans Frontieres programmes in southern Africa.
An electronic e-survey of country-level end-users was undertaken of WHO guidelines on ArV drugs to identify areas for improvement in format, presentation and dissemination (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).

# external participation

# Guideline Development Groups and peer review process
The process was supported by four, separate, external Guideline Development Groups (Adult; Maternal and Child Health; Operational and Service Delivery; and Programmatic, comprising 108 individuals) and an external peer review group of over 100 individuals. The acknowledgements list the members of these Groups. The composition of the Groups was in accordance with WHO procedures for developing guidelines (1) and included HIV experts, researchers, programme managers, guideline methodologists, epidemiologists, human rights experts, development agencies, United Nations partners, civil society representatives and representatives from networks of people living with HIV. Appropriate representation by geography and sex was considered. Community group members were selected following an open call for nominations. A full draft of the guidelines was circulated for comment to members of the Guideline Development Groups and the external peer review group.

# Conflicts of interest
All members of the Guideline Development Groups and peer review group completed WHO declaration of interest forms (including participation in consulting and advisory panels, research support and financial investment). A total of 21 Guideline Development Group members and 12 peer reviewers declared membership of pharmaceutical industry or other advisory panels or receipt of consulting fees, and 23 Guideline Development Group members and 13 peer reviewers declared pharmaceutical industry financial support through grants for research.
The focus of the 2013 guidelines was on the development of new or updated recommendations on the use of ArV drugs in adults, adolescents, children and pregnant women. The WHO secretariat and co-chairs of each Guideline Development Group considered that important areas for potential conflict of interest would be evidence for exclusive engagement with one pharmaceutical company, or a major role within completed, ongoing or planned trials on either the timing of ArT, or evaluation of specific ArV regimens. The WHO Guideline Steering Group reviewed all declarations, and found no case where there was exclusive membership of an advisory group panel, receipt of consulting fees or financial support through research grants from only one pharmaceutical company. There was also a further declaration at the Guideline Development Group meeting of the involvement of members as investigators in key trials and studies. Overall, the WHO Guideline Steering Group and co-chairs of each Guideline Development Group were satisfied that there had been a transparent declaration of interests, and that no case necessitated exclusion from the deliberations. The broad range of constituencies represented on the different Guideline Development Group panels was also noted, and that the majority of members had no declared interests. All individuals with declared interests therefore proceeded to participate fully in the Guideline Development Group meetings or to act as peer reviewers.

# Process of formulating recommendations
Four Guideline Development Group meetings were held in Geneva, Switzerland between November 2012 and January 2013 (Operational and Service Delivery Guideline Development Group, November 2012; Adult Guideline Development Group and Maternal and Child Health Guideline Development Group, December 2012; and Programmatic Guideline Development Group, January 2013). The systematic reviews, evidence tables prepared in accordance with GrADE and other relevant information described in section 3.2 were presented and discussed at these meetings and made available through a password-protected web site. The proposed recommendations were then considered, informed by a standardized decision-making table for each topic (Box 3.1) encompassing the following elements: existing and proposed recommendations; summary of the evidence; benefits and risks; community and health care worker values and preferences; costs and resource implications; cost-effectiveness; feasibility and barriers to implementation; equity, ethics and human rights implications; the suggested rating of the strength of recommendations (strong or conditional) and quality of the evidence; research gaps and needs; and the overall rationale for the recommendations.
The Guideline Development Groups discussed both the proposed wording of the recommendations and the rating of its strength (strong or conditional). All decisions were reached by discussion and consensus on the recommendations, including their strength and, where appropriate, the conditions to be attached to the recommendations. Disagreements were resolved through e-mail discussions, teleconferences and redrafting recommendations and rationale. Early drafts of sections of the guidelines were circulated to Guideline Development Group members, and a full draft of the guidelines was circulated to Guideline Development Group members and peer reviewers for comment. The extensive comments from more than 100 reviewers were addressed where possible and incorporated into the revised guidelines.

# Process of formulating recommendations

# Box 3.1 Approach to rating the quality of evidence and strength of recommendations using the GRADE system
Since 2008, WHO has followed the GrADE system. GrADE separates the rating of the quality of evidence from the rating of the strength of the recommendation.
The quality of evidence is defined as the confidence that the reported estimates of effect are adequate to support a specific recommendation. The GrADE system classifies the quality of evidence as high, moderate, low and very low (Table 3.1) (4-10). randomized controlled trials are initially rated as high-quality evidence but may be downgraded for several reasons, including the risk of bias, inconsistency of results across studies, indirectness of evidence, imprecision and publication bias.
Observational studies are initially rated as low-quality evidence but may be upgraded if the magnitude of the treatment effect is very large, if multiple studies show the same effect, if evidence indicates a dose-response relationship or if all plausible biases would underestimate the effect (10). The higher the quality of evidence, the more likely a strong recommendation can be made.
The strength of a recommendation reflects the extent to which the Guideline Development Group was confident that the desirable effects of following a recommendation outweigh the potential undesirable effects. The strength is influenced by the following factors: the quality of the evidence, the balance of benefits and harms, values and preferences, resource use and the feasibility of the intervention (Table 3.2).
The GrADE system classifies the strength of a recommendation in two ways: "strong" and "conditional" (11). A strong recommendation is one for which the Guideline Development Group was confident that the desirable effects of adhering to the recommendation outweigh the undesirable effects. A conditional recommendation is one for which the Guideline Development Group concluded that the desirable effects of adhering to the recommendation probably outweigh the undesirable effects but the Guideline Development Group is not confident about these trade-offs. Table 3.3 summarizes the implications of a strong or conditional recommendation for individuals, clinicians and policy-makers.
The reasons for making a conditional recommendation include the absence of highquality evidence; imprecision in outcome estimates; variability in the values and preferences of individuals regarding the outcomes of interventions; small benefits; applicability in all settings versus specific settings; and benefits that may not be worth the costs (including the costs of implementing the recommendation).

# Benefits and risks
Desirable effects (benefits) need to be weighed against undesirable effects (risks). The more that the benefits outweigh the risks, the more likely that a strong recommendation will be made.

# Values and preferences (acceptability)
If the recommendation is likely to be widely accepted or highly valued, a strong recommendation will probably be made. If there are strong reasons that the recommended course of action is unlikely to be accepted, a conditional recommendation is more likely to be made.

# Costs and financial implications (resource use)
Lower costs (monetary, infrastructure, equipment or human resources) or greater cost-effectiveness will more likely result in a strong recommendation.
If an intervention is achievable in a setting where the greatest impact is expected, a strong recommendation is more probable.

# Table 3.3 Implications for strong and conditional recommendations for individuals, clinicians and policy-makers

# Strong recommendation Conditional recommendation
Most people in your situation would want the recommended course of action and only a small proportion would not
The majority of people in your situation would want the recommended course of action, but many would not

# Most individuals should receive the recommended course of action
Be prepared to help individuals to make a decision that is consistent with their own values
The recommendation can be adapted as a policy in most situations
There is a need for substantial debate and involvement of stakeholders 3.6 Dissemination

# other methods
Recommendations from existing guidelines. In addition to new recommendations based on the GrADE system, the guidelines summarize existing relevant recommendations from other WHO guidelines). Most of these recommendations were developed using the GrADE system or an alternative grading used prior to 2008 (A (strongly recommended) to C (optional)) and I-IV (level of evidence) (Web Annex www.who.int/hiv/pub/guidelines/ arv2013/annexes). For these existing recommendations, no new evidence reviews were undertaken. recommendations that require updating are noted, and it is clearly stated where updated guidelines are planned.
Where systematic reviews and GrADE assessment of quality of evidence to support new recommendations were not possible or appropriate, qualitative reviews of the literature were undertaken and presented. This applies to specific topics in Chapter 9, including retention across the continuum of care, but this did not lead to formal recommendations.
Guidance for programme managers on programmatic decision-making. Chapter 10 and Chapter 11 did not involve formulating recommendations or rating of the quality of evidence and therefore did not follow the GrADE system. The process involved a narrative review of literature on both the process and criteria for evidence-based ethical decisionmaking, a review of relevant WHO policies and World Health Assembly resolutions, and results from mathematical modelling on the impact and cost-effectiveness of earlier ArT in various populations and settings. Structured discussions were held among Guideline Development Group members regarding setting priorities for key clinical recommendations in various epidemic scenarios (settings with generalized and concentrated epidemics and with low, moderate and high ArT coverage).
The guidelines will be disseminated as a printed publication and electronically on the WHO web site in the six official United Nations languages. The web version will include all annexes. A short version will summarize key new and existing recommendations for easy reference. A library of all supporting documentation and evidence will also be made available on the web site. WHO headquarters will work closely with regional and country offices and implementing partners to ensure their wide dissemination through regional and subregional meetings. Assistance will be provided to Member States to adapt the guidelines to their national contexts.
An evaluation of how users have implemented the guidelines has been developed to assess the uptake of the recommendations and the barriers to effective implementation. A review of the guidelines is planned for 2015. Interim technical and programmatic updates may be developed if important new evidence becomes available.

# Existing recommendation(s).
The recommendations and the strength of the recommendation, and quality of the evidence assessed using the GrADE system (or an alternative method) are stated.
4 organization of the guidelines

# how to use the guidelines for specific populations
These guidelines include recommendations for adults, pregnant and breastfeeding women, adolescents, children, and key populations. The populations relevant to each recommendation are clearly specified and also marked by an appropriate symbol for quick reference.

# Adults Children
Pregnant women Key populations Adolescents Tables 4.1-4.4 also summarize the chapter and section number of key recommendations and guidance for specific populations: pregnant and breastfeeding women, adolescents, children and infants, and key populations. The tables highlight selected topics that are particularly relevant to the respective populations. However, the topics listed are not exhaustive and many of the recommendations and other guidance are relevant across different populations.

# Pregnant and breastfeeding women
The location of the most important guidance and recommendations specific to children (younger than 10 years) is summarized in Table 4.3.

# key populations
In these guidelines, key populations include both vulnerable and most-at-risk populations. Most-at-risk populations include men who have sex with men, transgender people, people who inject drugs and sex workers.
The use of ArT in key populations should follow the same general principles and recommendations as for adults. There is one recommendation on community-based HIV testing, that is specific to key populations.
The location of the most important guidance and recommendations specific to key populations is summarized in Table 4.4.

# Goal of this chapter
To provide a summary of existing and new evidence-based clinical recommendations outlining a public health approach to diagnosing HIV infection and providing ARV drugs for prevention in the context of the broad continuum of HIV care, with a focus on settings with limited health system capacity and resources.

# hIV testing and counselling
People access HIV treatment, care and prevention through the gateway of HIV testing and counselling. It is currently estimated globally that about half of the people living with HIV do not know their HIV status. The people who do know often test late, and poor linkages from HIV testing and counselling to care -including failure to assess rapidly for ArT eligibility -mean that many people start treatment when they are already significantly immunocompromised, resulting in poor health outcomes and ongoing HIV transmission. The overall HIV testing and counselling goal for a national HIV programme should be to identify as many people living with HIV as early as possible after acquiring HIV infection, and link them appropriately and in a timely manner to prevention, care and treatment services. The people tested who are not infected should be linked to appropriate prevention services, such as voluntary male medical circumcision in the priority countries in sub-Saharan Africa, or harm reduction services for those who use drugs, and encouraged to retest at a later time.
Diverse models of HIV testing and counselling services are available to increase access to HIV diagnosis, including testing services in health care facilities, freestanding sites and a wide range of community-based approaches. These are described in detail in the WHO 2012 strategic HIV testing and counselling framework (1). The use of rapid HIV diagnostic tests that can be used at point of care has become an important strategy to expand access, increase the return of same-day results and enable appropriate referral and follow-up. Countries should choose a strategic mix of service delivery models to achieve equitable access to HIV testing and counselling, based on the local context, the nature of the epidemic, cost-effectiveness and available resources. The mix should facilitate diagnosing as many people living with HIV as early as possible to enable timely linkage to ArT. Strategies should be able to reach the people who are most vulnerable, most-at-risk and marginalized (Box 5.1).
The use of a single HIV test to diagnose HIV infection is not sufficient; it must be confirmed by following the steps outlined in the updated WHO 2012 HIV testing strategies (algorithms) (1). Quality assurance systems should be put in place to minimize false-positive and false-negative results. Failure to do this will lead to people being given incorrect test results, with potential serious adverse long-term consequences. Quality assurance and quality improvement measures are also important for the counselling process to ensure that HIV testing and counselling is always conducted in an acceptable and effective manner.
- Clinical guidelines across the continuum of care: HIV diagnosis and ARV drugs for HIV prevention

# hIV testing and counselling in health facilities
WHO recommends routinely offering HIV testing and counselling in clinical settings (known as provider-initiated testing and counselling) as an efficient and effective way to identify people with HIV who could benefit from treatment. Mandatory or coerced testing is never appropriate, whether that coercion comes from a health care provider or from a partner or family member.

# Source for recommendations
The following key principles apply to all models of HIV testing and counselling and in all circumstances.
People receiving HIV testing and counselling must give informed consent (verbal consent is sufficient and written consent is not required) to be tested and counselled.
They should be informed of the process for HIV testing and counselling and their right to decline testing.
HIV testing and counselling services are confidential, meaning that what the HIV testing and counselling provider and the person discuss will not be disclosed to anyone else without the expressed consent of the person being tested. Although confidentiality should be respected, it should not be allowed to reinforce secrecy, stigma or shame. Counsellors should raise, among other issues, whom else the person may wish to inform and how they would like this to be done. Shared confidentiality with a partner or family members and trusted others and with health care providers is often highly beneficial.
HIV testing and counselling services must be accompanied by appropriate and highquality pre-test information (which can be provided as group pre-test information in some settings) and post-test counselling. Quality assurance mechanisms and supportive supervision and mentoring systems should be in place to ensure the provision of high-quality counselling.
HIV testing and counselling providers should strive to provide high-quality testing services, and quality assurance mechanisms should be in place to ensure the provision of correct test results. Quality assurance may include both internal and external measures and should include support from the national reference laboratory as needed.
Connections to prevention, care and treatment services should include the provision of effective referral to appropriate follow-up services as indicated, including longterm prevention and treatment support.
Quality assurance of both testing and counselling is essential in all approaches used.

# Community-based hIV testing and counselling
In addition to providing HIV testing and counselling in clinical settings, HIV testing and counselling can be offered in a variety of settings in the community.
Existing recommendations (2) In generalized epidemics, provider-initiated testing and counselling should be recommended to everyone (adults, adolescents and children) attending all health facilities, including medical and surgical services; sexually transmitted infection, hepatitis and TB clinics; public and private facilities; inpatient and outpatient settings; mobile or outreach medical services; services for pregnant women (antenatal care, family planning and maternal and child health settings); services for key populations; services for infants and children; and reproductive health services.
In concentrated and low-level epidemics, provider-initiated testing and counselling should be recommended in all health facilities for:
adults, adolescents or children who present in clinical settings with signs and symptoms or medical conditions that could indicate HIV infection, including TB; and HIV-exposed children, children born to women living with HIV and symptomatic infants and children.
Provider-initiated testing and counselling should be considered in sexually transmitted infection, hepatitis and TB services, antenatal care settings and services for key populations (notably men who have sex with men, transgender people, sex workers and people who inject drugs).

# New recommendations (2013)
In generalized HIV epidemics, community-based HIV testing and counselling with linkage to prevention, care and treatment services is recommended, in addition to provider-initiated testing and counselling (strong recommendation, low-quality evidence).
In all HIV epidemic settings, community-based HIV testing and counselling for key populations, with linkage to prevention, care and treatment services is recommended, in addition to provider-initiated testing and counselling (strong recommendation, low-quality evidence).
These guidelines include expanded criteria for eligibility for ArT for children, adolescents, adults and pregnant and breastfeeding women living with HIV. To maximize the individual and public health benefits of these recommendations, people living with HIV must be diagnosed and linked to care early in the course of HIV infection. Although facility-based testing is a key approach, people living with HIV are often identified late in the course of HIV disease in clinical settings, and some populations, including men and adolescents, and especially key populations, have low utilization of health care services. Community-based

# hIV testing and counselling
testing approaches may reach people with HIV earlier in the course of HIV disease than provider-initiated testing and counselling, as well as reaching populations that may not normally attend health services.
The use of rapid HIV diagnostic tests using blood from a finger-prick sample taken by trained lay counsellors and community health workers has facilitated the expansion of HIV testing and counselling in community settings including homes, transport stations, religious facilities, schools, universities, workplaces and venues frequented by key populations. Continued expansion of community-based testing to complement facilitybased testing is an important consideration in achieving universal knowledge of HIV status and earlier diagnosis linked to care and treatment. Community-based HIV testing and counselling includes using mobile, door-to-door, index, campaign, workplace and schoolbased HIV testing and counselling approaches (1).

# Rationale and supporting evidence
The recommendations are based on evidence and on operational and programmatic considerations. The systematic review identified four randomized studies (3,4) and eight observational studies (5-10) comparing community-based testing to facility-based testing in generalized epidemics (Web Annex: www.who.int/hiv/pub/guidelines/arv2013/ annexes). Overall, community-based approaches had increased rates of people testing for the first time and adults diagnosed with CD4 counts exceeding 350 cells/mm 3. However, the frequency of positive test results was higher in health facility-based testing than in many community settings. The systematic review found that HIV testing and counselling coverage at the district level increased as a result of offering community-based HIV testing and counselling (using either door-to-door or mobile approaches) in combination with facility-based HIV testing and counselling.
An additional review covering key populations identified three studies comparing community-based testing to facility-based testing in key populations (11)(12)(13). Although increased uptake was observed in community-based approaches, the rate of participants receiving their first HIV test was comparable in both the community-and facility-based approaches.
Fifteen studies examined potential negative consequences of community-based testing (10,(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25). These studies discussed both the clients' positive testing experiences and their fears. Eight articles reported that a minority of participants refused HIV testing and counselling because of fear of status disclosure or stigma (10,(14)(15)(16)(17)21,23,25). The studies did not demonstrate that community-based approaches either reduced stigma or fear or increased them or other harms.
The few studies comparing the cost per person tested using facility-and community-based testing found that the cost per person tested was similar in both approaches (Web Annex: www.who.int/hiv/pub/guidelines/arv2013/annexes).
Although the review provided low-quality evidence overall, there was consensus that the critical programmatic advantages of community-based HIV testing and counselling and an assessment of values, preferences, costs and feasibilities provided sufficient basis for the Guideline Development Group to propose strong recommendations.
Community-based testing should be implemented in addition to provider-initiated testing and counselling. Multiple approaches are needed, which may include standalone sites, home-based testing, mobile outreach (including in workplaces, schools, universities, special testing campaigns and events) and multi-disease campaigns tailored to epidemiological and social contexts.

# Existing recommendations (2)

# Generalized epidemics
Provider-initiated testing and counselling is recommended for women as a routine component of the package of care in all antenatal, childbirth, postpartum and paediatric care settings.
re-testing is recommended in the third trimester, or during labour or shortly after delivery, because of the high risk of acquiring HIV infection during pregnancy.

# Low-level and concentrated epidemics
Provider-initiated testing and counselling should be considered for pregnant women. Many countries prioritize provider-initiated testing and counselling in antenatal care as a key component of their effort to eliminate the mother-to-child transmission of HIV and are effectively bundling HIV testing with syphilis screening, hepatitis testing or other key tests relevant to the setting as well as prioritizing the strengthening of underlying maternal and child health system.  Existing recommendations (27) It is strongly recommended that all infants with unknown or uncertain HIV exposure being seen in health care facilities at or around birth or at the first postnatal visit (usually 4-6 weeks), or other child health visit, have their HIV exposure status ascertained (strong recommendation, high-quality evidence).
It is strongly recommended that all HIV-exposed infants have HIV virological testing at four to six weeks of age or at the earliest opportunity thereafter (strong recommendation, high-quality evidence).
For infants with an initial positive virological test result, it is strongly recommended that ArT be started without delay and, at the same time, a second specimen be collected to confirm the initial positive virological test result. Existing recommendation (28) Children of school age should be told their HIV-positive status and their parents or caregiver's status; younger children should be told their status incrementally to accommodate their cognitive skills and emotional maturity, in preparation for full disclosure (strong recommendation, low-quality evidence).
Adolescents are often underserved and given insufficient priority in many HIV programmes, with poor access to and uptake of HIV testing and counselling and linkage to prevention and care. Adolescents with HIV include those surviving perinatal infection and those newly acquiring infection as they become sexually active or are exposed through injecting drug use, other unsafe injections and blood transfusions. In generalized epidemic settings, many vertically infected infants are not diagnosed through programmes for PMTCT and would benefit from earlier HIV diagnosis and treatment. In many settings, adolescent girls and adolescents from key populations are also vulnerable to HIV infection and would benefit from access to acceptable and effective HIV services, including HIV testing and counselling. Consent issues may pose a barrier to access for adolescents in some settings and are discussed in detail in the WHO 2013 guidelines for adolescents (29).

# Source for recommendations
Guidance on HIV testing and counselling for adolescents and care for adolescents living with HIV. Geneva, World Health Organization, 2013, in press (29).
New recommendations (2013) (29) HIV testing and counselling, with linkages to prevention, treatment and care, is recommended for adolescents from key populations in all settings (generalized, low and concentrated epidemics) (strong recommendation, very-low-quality evidence).
HIV testing and counselling with linkage to prevention, treatment and care is recommended for all adolescents in generalized epidemics (strong recommendation, very-low-quality evidence).
We suggest that HIV testing and counselling with linkage to prevention, treatment and care be accessible to all adolescents in low and concentrated epidemics (conditional recommendation, very-low-quality evidence).
We suggest that adolescents be counselled about the potential benefits and risks of disclosure of their HIV status and empowered and supported to determine if, when, how and to whom to disclose (conditional recommendation, very-lowquality evidence).

# hIV testing and counselling in specific populations

# Rationale and supporting evidence
These recommendations were developed as part of new HIV guidelines for adolescents from WHO, UNESCO, UNFPA, UNICEF and GNP+ published in 2013 and are based on systematic reviews of the evidence, community consultations to assess values and preferences of adolescents and health providers and consideration by the respective Guideline Development Group. For the most part, published evidence for adolescent-specific recommendations is lacking; for these guidelines, considerable weight is given to expert opinion, values and preferences of adolescents and their health care providers, and to the field experience of practitioners. Further details are provided in the summary of evidence in the full Guidance on HIV testing and counselling for adolescents and care for adolescents living with HIV (29).

# key populations
Background HIV testing and counselling has been provided to key populations since HIV tests were first developed. WHO produced guidance for testing people who inject drugs in 2006, for prisoners and refugees in 2009, for men who have sex with men and for transgender people in 2011 and for sex workers in 2012.
For key populations, especially those who are criminalized, HIV testing and counselling services are sometimes used in punitive or coercive ways. Both existing and new recommendations for HIV testing and counselling for these most-at-risk and vulnerable groups therefore emphasize consent and confidentiality as well as ensuring that HIV testing and counselling is part of a comprehensive prevention, care and treatment programme.
The 2012 WHO HIV testing and counselling strategic framework (1) summarizes HIV testing and counselling guidance for all of these groups and populations (Tables 5.2 and 5.3).    Existing recommendations (38) Existing WHO recommendations (38) are for the use of oral PrEP in demonstration projects for serodiscordant couples and men and transgender women who have sex with men.

# Additional guidance
Serodiscordant couples. When serodiscordant couples are identified and where additional HIV prevention choices for them are needed, daily oral PrEP (either TDF or the combination of TDF + FTC) may be considered as a possible additional intervention for the uninfected partner (conditional recommendation, high-quality evidence).
If oral PrEP is to be provided for the HIV-negative partner in same-sex, male serodiscordant couples, the combination of TDF + FTC should be used, as evidence of effectiveness and safety in male-to-male penetrative sex is available for this regimen only.
Men and transgender women. Where HIV transmission occurs among men and transgender women who have sex with men and additional HIV prevention choices for them are needed, daily oral PrEP (specifically the combination of TDF + FTC) may be considered as a possible additional intervention (conditional recommendation, high-quality evidence).

# hIV prevention based on ARV drugs ii

# oral pre-exposure prophylaxis
Oral pre-exposure prophylaxis of HIV (PrEP) is the daily use of ArV drugs by HIV-uninfected people to block the acquisition of HIV. Clinical trials of daily oral PrEP have shown evidence of effectiveness with serodiscordant heterosexual couples (34), men and transgender women who have sex with men (35), high risk heterosexual couples (36), people who inject drugs (37).  (38).

# Source for recommendations
ii Chapter 7 covers other aspects of ArV drugs as prevention, including PMTCT.

# hIV prevention based on ARV drugs
Existing recommendations (26) People with HIV in serodiscordant couples who start ArT for their own health should be advised that ArT is also recommended to reduce HIV transmission to the uninfected partner (strong recommendation, high-quality evidence).
HIV-positive partners with a CD4 count 350 cells/mm 3 in serodiscordant couples should be offered ArT to reduce HIV transmission to uninfected partners (strong recommendation, high-quality evidence).

# ARt for prevention among serodiscordant couples

# Source for recommendations
Couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples. Geneva, World Health Organization, 2012 (http:// whqlibdoc.who.int/publications/2012/9789241501972_eng.pdf) (26).
Existing recommendation (2013) (39) Consider HIV post-exposure prophylaxis for women presenting within 72 hours of a sexual assault. Use shared decision-making with the survivor to determine whether HIV post-exposure prophylaxis is appropriate (strong recommendation, very-low-quality evidence).

# Post-exposure prophylaxis for occupational and non-occupational exposure to hIV
Post-exposure prophylaxis is short-term ArT to reduce the likelihood of acquiring HIV infection after potential exposure either occupationally or through sexual intercourse.
Within the health sector, post-exposure prophylaxis should be provided as part of a comprehensive package of universal precautions that reduces the exposure of personnel to infectious hazards at work. WHO post-exposure prophylaxis guidelines for occupational exposure have not been reviewed since 2006 and will be updated by 2014. The current recommended duration of post-exposure prophylaxis for HIV infection is 28 days, and the first dose should be offered as soon as possible within 72 hours after exposure. The choice of post-exposure prophylaxis drugs should be based on the country's first-line ArV regimen for HIV. A recent recommendation (39) relates specifically to post-exposure prophylaxis in the case of sexual assault.

# Source for recommendation
Responding to intimate partner violence and sexual violence against women: clinical and policy guidelines. Geneva, World Health Organization, in press (39).

# Combination hIV prevention
People's HIV prevention needs change during their lifetime, and a combination approach helps people to access the types of interventions that best suit their needs at different times.
Combining approaches may also result in synergies that have greater impact than single interventions alone. Although ArV drugs play a key role in HIV prevention, they should be used in combination with an appropriate mix of the following.
Other biomedical interventions that reduce HIV risk practices and/or the probability of HIV transmission per contact event, including the following.
- Male and female condoms. Male condoms reduce heterosexual transmission by at least 80% and offer 64% protection in anal sex among men who have sex with men (40), if used consistently and correctly. Fewer data are available for the efficacy of female condoms, but evidence suggests they can have a similar prevention effect (41).
- Needle and syringe programmes are highly associated with a reduction in HIV transmission through injecting drug use (42).
- Opioid substitution therapy with methadone or buprenorphine is the most effective form of treatment for opioid dependence and has the additional benefit of effectively reducing HIV risk behaviour and transmission through injecting drug use. Opioid substitution therapy also provides adherence support to people on ArT (43)(44).
- Voluntary medical male circumcision reduces the risk of acquisition of HIV for men by up to 66% and offers significant lifelong protection (45).
Behavioural interventions reduce the frequency of potential transmission events, including the following.
- Targeted information and education. Programmes that use various communication approaches -for example, school-based sex education, peer counselling and community-level and interpersonal counselling -to disseminate behavioural messages designed to encourage people to reduce behaviour that increases the risk of HIV and increase the behaviour that is protective (such as safer drug use, delaying sexual debut, reducing the frequency of unprotected sex with multiple partners, using male and female condoms correctly and consistently and knowing your and your partner's HIV status).

# Goal of this chapter
To provide an overview of issues and interventions related to general HIV care for individuals from the time that they are diagnosed with HIV infection to the time that they are initiated on ART, including practices for linking people diagnosed with HIV infection to HIV care and treatment, the components of a general care package, and preparing individuals for starting ART.
It is critical for people living with HIV to enrol in care as early as possible. This enables both early assessment of their eligibility for ArT and timely initiation of ArT as well as access to interventions to prevent the further transmission of HIV, prevent other infections and comorbidities and thereby to minimize loss to follow-up. The 2012 WHO strategic HIV testing and counselling programme framework (1) especially emphasizes the importance of ensuring linkage between HIV testing and counselling programmes and prevention, treatment, care and support services.

# Good practices for linkage to care
Interventions to improve linkage to care need to be more rigorously evaluated. However, several systematic reviews and observational studies suggest that several good practices can improve linkage to care (2)(3)(4). These include integrating HIV testing and counselling and care services; providing on-site or immediate CD4 testing with same-day results; assisting with transport if the ArT site is far from the HIV testing and counselling site; involving community outreach workers to identify the people lost to follow-up; ensuring support from peers or expert patients; and using new technologies, such as mobile phone text messaging.

# General care for people living with hIV
Countries should establish a package of general HIV care interventions, in addition to ArT, for people living with HIV to reduce HIV transmission, prevent illness and improve their quality of life. Not all people living with HIV are eligible for ArT and, of those eligible, not all will be able to access ArT immediately. Others may choose to defer ArT to later. Enrolment in care provides an opportunity for close clinical and laboratory monitoring and early assessment of eligibility for ArT and timely initiation, and aims to minimize loss to follow-up. Many care interventions are relevant across the full continuum of care, including HIV-exposed individuals and people living with HIV before initiating, and during ArT.
General care includes basic HIV prevention, promoting the health of people living with HIV and the screening, prophylaxis and management of HIV-related coinfections and comorbidities. WHO has produced summary guidance on general care and prevention interventions (5)(6)(7) A general care package will vary according to the epidemic type, populations affected and prevalence of coinfections, other comorbidities and health conditions. Table 6.1 provides an overview of elements of a general care package for people living with HIV. Section 8.1 summarizes key recommendations from existing WHO guidelines on the screening, prophylaxis and timing of ArT with the most common coinfections, comorbid conditions and other health conditions.

# Preparing people living with hIV for ARt
Before people start ArT, it is important to have a detailed discussion with them about their willingness and readiness to initiate ArT, the ArV regimen, dosage and scheduling, the likely benefits and possible adverse effects and the required follow-up and monitoring visits. For children with HIV, this conversation should directly involve the carer and include discussion about disclosing their HIV status (see Chapter 5). retesting all people living with HIV before initiating ArT is good practice to ensure correct diagnosis of HIV infection. Initiation of ArT should always consider nutritional status, any comorbidities and potentially interacting medications for possible contraindications or dose adjustment.
The choice to accept or decline ArT ultimately lies with the individual person or his or her caretaker, and if they choose to defer initiation, ArT can be offered again at subsequent visits. If there are mental health, substance use or other problems that are major barriers to adherence, appropriate support should be provided, and readiness to initiate ArT should be reassessed at regular intervals. A wide range of patient information materials as well as community and peer support can help the person's readiness and decision to start therapy.
People starting treatment and carers should understand that the first ArV regimen offers the best opportunity for effective virological suppression and immune recovery, and that successful ArT requires them to take the medications exactly as prescribed. They should be advised that many adverse effects are temporary or may be treated, or that substitutions can often be made for problematic ArV drugs. (See section 9.2 for strategies to support adherence to an ArV regimen). People receiving ArT and carers should also be asked regularly about any other medications that are taken, including herbal remedies and nutritional supplements.
People receiving ArT should understand that, while the ArV drugs reduce the risk of HIV transmission, they cannot be relied on to prevent other people from acquiring infection. They should be given advice on safer sex (including condom use) and avoidance of other high-risk activities, such as sharing of injecting equipment, to prevent transmitting HIV to other people.

# what to expect in the first months of ARt
Although taking ArT is a lifelong commitment, the first six months of therapy are especially important. Clinical and immunological improvement and virological suppression are expected when individuals adhere to ArT, but opportunistic infections and/or immune reconstitution inflammatory syndrome (IrIS) may develop, as well as early adverse drug reactions, such as drug hypersensitivity, especially in the first three months of ArT. ArT significantly decreases mortality overall, but death rates are also highest in the first three months of ArT. These complications are commonest when the people starting ArT already have advanced HIV disease with severe immunodeficiency and existing coinfections and/or comorbidities, severely low haemoglobin, low body mass index and very low CD4 counts or are severely malnourished (8,9).

# CD4 recovery
In most adults and children, CD4 cell counts rise when ArT is initiated and immune recovery starts. Generally, this increase occurs during the first year of treatment, plateaus, and then continues to rise further during the second year (10). However, severe immunosuppression may persist in some individuals who do not experience a significant rise in CD4 cell count with treatment, especially those with a very low CD4 cell count when initiating ArT. Failure to achieve some CD4 recovery should alert the health care provider to potential adherence problems or primary non-response to ArT, and consideration should be given to continue prophylaxis for opportunistic infections such as co-trimoxazole preventive therapy.

# Immune reconstitution inflammatory syndrome (IRIS)
IrIS is a spectrum of clinical signs and symptoms thought to be associated with immune recovery brought about by a response to ArT. It is a widely recognized phenomenon that occurs among 10-30% of the people initiating ArT, usually within the first 4-8 weeks after initiating therapy (11,12). It may present in two different ways: paradoxical IRIS, when an opportunistic infection or tumour diagnosed before ArT initially responds to treatment but then deteriorates after ArT starts; or unmasking IRIS, in which initiating ArT triggers disease that is not clinically apparent before ArT. It should be considered only when the presentation cannot be explained by a new infection, expected course of a known infection or drug toxicity.
The clinical spectrum is diverse, and IrIS has been reported for many different infections, tumours and non-infectious conditions (11,12). The most serious and life-threatening forms of paradoxical IrIS are for TB, cryptococcosis, Kaposi's sarcoma and herpes zoster. BCG vaccine-associated IrIS (localized and systemic) may occur in infants infected with HIV in settings where BCG immunization is routine. A low CD4 + cell count (<50 cells/mm 3 at ArT initiation, disseminated opportunistic infections or tumours and a shorter duration of therapy for opportunistic infections before ArT starts are the main risk factors (11,12). IrIS is generally self-limiting, and interruption of ArT is rarely indicated, but people may need to be reassured in the face of protracted symptoms to prevent discontinuation of or poor adherence to ArT.
The most important steps to reduce the development of IrIS include: earlier HIV diagnosis and initiation of ArT before a decline to below 200 CD4 cells/mm 3 ; improved screening for opportunistic infections before ArT, especially TB and Cryptococcus; and optimal management of opportunistic infections before initiating ArT. Timing of ArT in people with opportunistic infections requires balancing a greater risk of IrIS after early initiation against continuing high mortality if ArT is delayed. Chapter 8 summarizes existing WHO recommendations for the optimal timing of ArT among people with TB (see section 8.1.2) and cryptococcal disease (see section 8.1.3) based on evidence from randomized clinical trials.
To provide updated, evidence-based clinical recommendations outlining a public health approach to ART in the context of the continuum of HIV care, with a focus on resource and capacity limited settings. Early treatment initiation is associated with clinical and HIV prevention benefits, improving survival and reducing the incidence of HIV infection at the community level. The Guidelines Development Group recommends that national HIV programmes provide ART to all people with a confirmed HIV diagnosis with a CD4 count of 500 cells/mm or less, giving priority to initiating ART among those with severe/advanced HIV disease (see Annex 1) or a CD4 count of 350 cells/mm 3 or less. It is also recommended to initiate ART in people with active TB disease and HBV coinfection with severe chronic liver disease, all pregnant and breastfeeding women with HIV, all children younger than five years living with HIV and all individuals with HIV in serodiscordant relationships, regardless of CD4 cell count (Table 7.1).

# When to start art
a There is insufficient evidence and /or favourable risk-benefit profile to support initiating ART at a CD4 cell count >500 cells/mm 3 or regardless of CD4 cell count or WHO clinical stage in the following situations: individuals with HIV older than 50 years, individuals with HIV-1 infected or coinfected with HIV-2, individuals with HIV coinfected with HCV and key populations with HIV with a high risk of transmission (such as people who inject drugs, men who have sex with men, transgender people and sex workers). ART initiation in these populations should therefore follow the same principles and recommendations as for other adults with HIV. b There is insufficient evidence and /or favourable risk-benefit profile to support initiating ART in everyone coinfected with HIV and HBV with a CD4 count >500 cells/mm3 or regardless of CD4 cell count or WHO clinical stage. Initiating ART regardlessof CD4 count is therefore recommended among people with evidence of severe chronic liver disease, who are at greatest risk of progression of liver disease and mortality from liver disease. For people without evidence of severe chronic liver disease, ART initiation should follow the same principles and recommendations as for other adults.

# When to start art in adults and adolescents

# New recommendations neW neW neW
As a priority, ART should be initiated in all individuals with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and individuals with CD4 count 350 cells/mm 3 (strong recommendation, moderate-quality evidence).
ART should be initiated in all individuals with HIV with a CD4 count >350 cells and 500/mm 3 regardless of WHO clinical stage (strong recommendation, moderate-quality evidence). a ART should be initiated in all individuals with HIV regardless of WHO clinical stage or CD4 cell count in the following situations:
- Individuals with HIV and active TB disease (strong recommendation, low-quality evidence).
- Individuals coinfected with HIV and HBV with evidence of severe chronic liver disease b (strong recommendation, low-quality evidence).
- Partners with HIV in serodiscordant couples should be offered ART to reduce HIV transmission to uninfected partners (strong recommendation, high-quality evidence).
- Pregnant and breastfeeding women with HIV (see section 7.1.2 for recommendations).

# neW neW
Since 2002, WHO guidelines on ART have evolved as the body of evidence to support the earlier initiation of ART has progressively increased (1). The 2010 WHO guidelines for adults and adolescents (2) recommended initiating ART for all individuals (including pregnant women) with a CD4 count 350 cells/mm 3 regardless of WHO clinical stage and for those with severe or advanced HIV disease (WHO clinical stages 3 or 4) regardless of CD4 count. This strong recommendation was based on moderate-quality evidence from randomized controlled trials (3,4) and observational studies (5)(6)(7)(8) showing that initiating ART at or below this CD4 threshold reduced mortality, disease progression (including TB), vertical HIV transmission and serious adverse events. Mathematical modelling simulations also suggested that initiating ART earlier could impact on both sexual and vertical HIV transmission if there is high treatment coverage and full adherence (9). For people with active TB disease or HBV coinfection requiring HBV treatment, the 2010 guidelines (2) recommended initiating ART regardless of CD4 cell count.
Global ART coverage for those eligible according to the 2010 recommendations (CD4 350 cells/mm 3 had reached 54% -or more than 8 million people -by the end of 2011 (10), but coverage varies across regions, ranging from 15% to 68% (11)

# Hepatitis B coinfection
Initiate in all individuals with CD4 500 cells/mm 3 and regardless of CD4 cell count in the presence of severe chronic liver disease b

# HIV-serodiscordant couples
Provide ART to all partners infected with HIV regardless of CD4 cell count (to reduce the risk of HIV transmission to the negative partner) (Existing 2012 recommendation ( 49))
a TB treatment should be initiated first, followed by ART as soon as possible afterwards (and within the first eight weeks of initiating TB treatment). For those with a CD4 count less than 50 cells/mm 3 ART should be provided within two weeks of starting TB treatment (see section 8.1.2). b Severe chronic liver disease includes cirrhosis and end-stage liver disease and is categorized into compensated and decompensated stages. Decompensated cirrhosis is defined by the development of clinically evident complications of portal hypertension (ascites, variceal haemorrhage and hepatic encephalopathy) or liver insufficiency (jaundice).
Table 7.2. Summary of when to initiate ART in adults and adolescents annexes) showed that more than 90% had adopted the CD4 threshold for initiating ART of 350 cells/mm 3 or less, and several other countries have moved their CD4 threshold above 350 cells/mm 3. The median CD4 count at the time ART is initiated, although increasing, has been far lower than 350 cells/mm 3 in almost all settings, including high-income countries (12,13), and late presentation for treatment is associated with high early mortality rates and poor retention in care (6,14). Increasing knowledge of HIV status, strengthening links between testing and care and ensuring optimal long-term retention and adherence remain significant challenges in many settings.

# Rationale and supporting evidence
Since 2010, evidence and programmatic experience have continued to shift the riskbenefit ratio towards initiating ART earlier. Increasing evidence also indicates that untreated HIV may be associated with the development of several non-AIDS-defining conditions (including cardiovascular disease, kidney disease, liver disease, several types of cancer and neurocognitive disorders) (15)(16)(17) and that initiating ART earlier reduces such events and improves survival. Recent evidence (18) also show that ART substantially reduces sexual transmission in HIV-serodiscordant couples, but not all studies have reported survival benefits. At the same time, more convenient and less toxic regimens have become more widely available, and ARV costs have continued to fall. How early ART should be started is still debated, and the Guidelines Development Group paid close attention to evaluating the potential benefits and harms to the individual and community in developing these new recommendations.

# Initiating ART in individuals with symptomatic and asymptomatic HIV disease at a CD4 count 350 cells/mm 3 as a priority
The benefits of initiating ART are greatest among individuals with symptomatic HIV disease or those with lower CD4 counts. The 2013 Guidelines Development Group did not change the strength and quality of evidence for this recommendation established in the 2010 ART guidelines (2). Moderate-quality evidence from two randomized controlled trials and several observational studies shows that initiating ART at CD4 350 cells/mm 3 significantly reduces mortality, disease progression and the incidence of opportunistic diseases, especially TB and non-AIDS-defining conditions (2).

# Initiating ART at a CD4 count between 350 and 500 cells/mm 3
The risk-benefit analysis of the rationale for ART initiation between 350 and 500 CD4 cells/mm 3 in these guidelines was debated. The Guidelines Development Group agreed that impact on HIV transmission is strongly supported by the evidence. The quality of evidence for clinical benefit of earlier ART initiation was rated as moderate using the GRADE system, as it mostly relies on observational data mainly from high-income countries. The Guidelines Development Group strongly recommended earlier ART as a public health approach. In settings where feasibility of implementation is a concern, the Guidelines Development Group suggested conducting operational research during implementation to assess context-specific factors such as feasibility, linkage to and retention in care, adherence and resource allocation.
The recommendation for initiating ART at CD4 counts between 350 and 500 cells/mm 3 is based on a systematic review with GRADE evidence profiles (Web Annex www.who. int/hiv/pub/guidelines/arv2013/annexes) that assessed the quality and strength of the evidence from 21 observational studies (8, and three randomized controlled trials (3,18,40) reporting morbidity, mortality and immunological and virological outcomes. They showed that initiating ART at a CD4 count >350 cells/mm 3 compared with treatment at a CD4 count 350 cells/mm 3 reduced the risk of progression to AIDS and/or death, TB, development of a non-AIDS-defining illness and increased the likelihood of immune recovery. Although no studies suggest that earlier ART causes individual harm, these studies were of limited duration.
The pooled analysis of the observational studies found a consistent decreased risk of death with earlier initiation of ART in 13 studies (21)(22)(23)26,(29)(30)(31)(34)(35)(36)(37)(38)(39) and a decreased risk of progression to AIDS or death in 9 studies (21,23,26,27,30,33,34,36,39) and 3 randomized controlled trials (3,18,40), with a low level of heterogeneity, supporting moderate-quality evidence for earlier treatment. A further subgroup analysis showed a reduced risk of mortality with a CD4 threshold for initiating ART of 500 cell/mm 3. The impact on immune recovery was inconsistent and rated as low-to very-low-quality evidence (20,24,28). Two studies found no significant difference in the likelihood of virological suppression (<500 copies/ml), risk of virological failure and viral rebound when treatment is initiated at higher or lower CD4 cell counts (20,36).
In the pooled analysis of two randomized controlled trials (3,18) there was low-quality evidence supporting ART initiation at higher CD4 thresholds for reducing mortality, disease progression or the combined outcome of death and/or progression and, in one trial, the risk of non-AIDS-defining illnesses. The risk of severe adverse events did not differ significantly, but the risk of Grade 3 or 4 laboratory abnormalities iii was increased in one randomized controlled trial (40). Since treatment in the delayed arm of the SMART trial (3) was initiated when the CD4 count fell below 250 cells/mm 3 (rather than 350 cells/mm 3, the quality of the evidence for clinical benefit was graded as low because of imprecision and indirectness.
A separate systematic review (41) identified one randomized clinical trial (18) and two observational studies (42,43) reporting a decreased risk of TB when individuals initiated ART with CD4 counts exceeding 350 cells/mm 3. ART also reduces recurrent TB by about 50% (44). Dynamic models have suggested ART initiation above 350 cells/mm 3 could lead to a more substantial reduction in population tuberculosis incidence (45).
Finally, there is high-quality evidence from one randomized controlled trial (18) indicating that earlier ART can markedly reduce the risk of sexual transmission to HIV-negative sexual partners. This is supported by the secondary outcomes of a trial that also found a 92% reduction in HIV sexual transmission from partners with HIV taking ART (46).

# Cost and cost-effectiveness
The Guidelines Development Group reviewed mathematical simulations of the costs and epidemiological benefits of initiating ART at a CD4 count 350 cells/mm 3 CD4 count 500 cells/mm 3 and for all adults with HIV regardless of CD4 cell count. These models suggest that expanding the ART eligibility criteria to 500 cells/mm 3 could lead to substantial health benefits and be cost-effective in both generalized and concentrated epidemic settings; the increased cost of earlier ART would be partly offset by subsequent reduced costs (such as decreased hospitalization and increased productivity) and preventing
iii Grade 3 and 4 laboratory abnormalities are considered as severe drug adverse reactions and usually requires discontinuation of ARV drugs until the patient is stabilized and substitution for an alternative drug (See Web Annex www.who.int/hiv/pub/ guidelines/arv2013/annexes)

# When to start art
new HIV infections (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes). However, these benefits depend on a high testing uptake, high treatment coverage, sustained adherence and high rates of retention in care. The models also show that, because the greatest costs are associated with full implementation of the 2010 ART guidelines (2) (initiating ART at CD4 count 350 cells/mm, the incremental cost of moving the ART initiation criterion from a CD4 count 350 cells/mm 3 to 500 cells/ mm 3 is relatively small, especially if countries already have a substantial number of people with HIV with a CD4 cell count less than 350 cells/mm 3 already receiving ART. These modelling findings support the recommendation to initiate ART in adults and adolescents with HIV with a CD4 count 350 cells/mm 3 as a priority. However, the cost implications at the regional and country levels should be explored further, since countries have different levels of treatment coverage and local cost considerations depending on their context and resources.

# Potential harms
Not all observational studies have consistently demonstrated the beneficial impact of initiating ART earlier on mortality and the incidence of non-AIDS events associated with chronic inflammation and ongoing viral replication, and longer follow-up is needed to evaluate potential harms and benefits. The long-term safety profile of ART and the implications of earlier initiation on drug resistance and toxicity will also need to be closely monitored.
According to cohort and national programme data, the number of people needing treatment could increase by up to 25% if eligibility is based on CD4 counts increasing from 350 cells/mm 3 to 500 cells/mm 3 (47,48) (Web Annex www.who.int/hiv/pub/ guidelines/arv2013/annexes). However, country experience has also shown that moving to a higher CD4 threshold for ART initiation may not necessarily lead to a significant immediate increase in the numbers of people who actually access treatment in the absence of increased uptake of HIV testing and counselling, stronger linkages to care, adequate treatment monitoring and sustained adherence support.
Implementing the recommendation to initiate ART in individuals with HIV with CD4 counts between 350 and 500 cells/mm 3 may involve additional human, infrastructure and financial resources. Chapter 10 discusses these issues in further detail.

# Initiating ART regardless of CD4 cell count

# HIV-positive partners in HIV-serodiscordant couples iv
The results of the HPTN052 study (18) strongly support the use of ART to prevent HIV transmission among HIV-serodiscordant couples. The Guidelines Development Group therefore endorsed the recommendations established in the 2012 WHO guidance on HIV testing and counselling including ART for treatment and prevention in serodiscordant couples (49) that the sexual partner with HIV in such a couple should be offered ART regardless of CD4 count.
iv An HIV-serodiscordant couple is a couple in which one of the sexual partners is HIV-positive and one is HIV-negative. Although one partner is currently HIV-negative, this does not mean that this partner is immunized or protected against getting HIV in the future.
v Active TB disease refers to TB infection where the person has symptoms and clinical disease. Latent TB infection refers to TB infection where the person does not have symptoms or clinical disease. Not all persons with latent TB infection will develop TB disease, but the risk of progressing to disease is very high in people with HIV. vi Severe chronic liver disease includes cirrhosis and end-stage liver disease and is categorized into compensated and decompensated stages. Decompensated cirrhosis is defined by the development of clinically evident complications of portal hypertension (ascites, variceal haemorrhage and hepatic encephalopathy) or liver insufficiency (jaundice).

# Treating active TB disease v
In 2010, WHO recommended starting ART in all people with HIV and active TB regardless of CD4 cell count, and that TB treatment should be started first, followed by ART, as soon as possible afterwards (and within the first eight weeks). The Guidelines Development Group reviewed evidence from three randomized clinical trials that showed for people with TB and severe immunodeficiency (CD4 count 50 cells/mm 3, starting ART before eight weeks has a clinical benefit compared with deferring treatment to later than eight weeks (50)(51)(52), and endorsed the 2010 recommendations. Implementation of the recommendations on HIV and TB management may be facilitated by integration of services (Chapter 9).
HIV and HBV coinfection with evidence of severe chronic liver disease vi HIV coinfection affects almost every aspect of the natural history of HBV infection.
The consequences include higher rates of chronicity; less spontaneous HBV clearance; accelerated liver fibrosis progression with increased risk of cirrhosis and hepatocellular carcinoma; higher liver-related mortality and decreased ARV response (53)(54)(55)(56). Liver disease has emerged as a leading cause of death in people coinfected with HIV and HBV (57,58).
The 2010 WHO ART guidelines (2) recommended initiating ART among all individuals coinfected with HIV and HBV who require treatment for their HBV infection (defined as chronic active hepatitis), regardless of CD4 cell count or WHO clinical stage. However, in the absence of routine screening for HBV, most people are unaware of their HBV status.
In addition, there is limited access to costly diagnostic tools for staging liver disease (liver biopsy, transient elastography, HBV-DNA and serum biomarkers) needed to establish the presence of chronic active liver disease and eligibility for HBV treatment.
A meta-analysis (59) and a subgroup analysis of a randomized controlled trial (60) provide low-quality evidence of the overall impact of ART on liver-related morbidity and mortality among individuals coinfected with HIV and HBV, but these studies did not examine the benefit of initiating ART at higher CD4 counts.
Overall, the Guidelines Development Group considered that there was not sufficient evidence and/or a favourable risk-benefit profile to support initiating ART among all people coinfected with HIV and HBV with a CD4 count >500 cells/mm 3 or regardless of CD4 count or stage of liver disease. There are also risks associated with initiating ART earlier (hepatotoxicity, immune reconstitution inflammatory syndrome and hepatic flares).
However, the Guidelines Development Group does recommend providing ART to all people coinfected with HIV and HBV regardless of CD4 count in people with evidence of severe chronic liver disease, who are at greatest risk of liver disease progression and mortality. The term severe chronic liver disease was used instead of chronic active hepatitis (as in the 2010 guidelines), as this is a term that is more widely understood and applicable using clinical criteria alone. In settings where ART cannot be provided to all individuals with HIV with CD4 counts 500 cells/mm 3 giving priority to diagnosing and treating individuals coinfected with HIV and HBV should be considered.
As reported in the 2010 WHO ART guidelines (2), data from one randomized controlled trial support the use of at least two agents with activity against HBV (TDF + 3TC or FTC) in terms of improved viral load response and reduced development of HBV drug resistance (61,62).
Critical research gaps in this area include the need for more data on the impact of ART on liver-related outcomes in HBV-coinfected people in resource-limited settings and on the relative impact of ART in people with CD4 cell counts >500 cells/mm 3 and early-stage liver disease.

# Populations for which no specific new recommendation is made
The Guidelines Development Group did not find evidence and/or favourable risk-benefit profiles to support recommendations for initiating ART at CD4 cell count >500 cells/mm 3 or regardless of CD4 cell count or WHO clinical stage in the following populations.

# Individuals with HIV who are 50 years of age and older
A pooled analysis of data from 13 cohorts from Europe and North America showed increased risk of death and disease progression in people with HIV older than 50 years of age (26). However, these data were not stratified by CD4 cell count and do not support initiating ART at CD4 counts > 500 cells/mm 3 for this group.

# Individuals with HIV-2
The lack of randomized treatment studies in individuals with HIV-2 makes it difficult to determine the optimal timing of ART initiation in this population. A systematic review (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes) evaluated observational data from 15 studies and showed no significant differences between initiating ART at a CD4 count 350 cells/mm 3 and >350 cells/mm 3 considering the outcomes of mortality, disease progression, increase in CD4 cell count, virological response and risk of drug resistance. The quality of evidence was rated as low to very low, with serious risk of bias and imprecision (few events) for all these outcomes.

# Individuals coinfected with HIV and HCV
Observational studies have shown that coinfection with HIV and HCV accelerates HCVrelated progression of liver fibrosis and leads to a higher rate of end-stage liver disease (63) and mortality (63)(64)(65).
There is consistent but low-quality observational data about the overall benefit of ART on mortality and progression of liver disease in individuals coinfected with HIV and HCV based on evidence from a meta-analysis (66), and a review of nine cohort studies that examined the relationship between ART and hepatic fibrosis showing that ART was associated with a decreased rate of liver fibrosis progression, although this was not evaluated by the level of CD4 count (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes). The Guidelines Development Group endorsed the special note in the 2010 guidelines (2) that initiating ART among people coinfected with HCV should follow the same principles as in HIV monoinfection. Initiating ART regardless of CD4 cell count was not recommended because of lack of evidence.
There are challenges in diagnosing and treating active HCV infection in settings with limited access to HCV antibody and RNA assays, diagnostic tools for staging of liver disease (such as biopsy) and HCV therapy and in certain populations such as people who inject drugs. However, limited access to HCV testing or treatment and/or high rates of HCV infection should not be barriers to initiating ART.
WHO hepatitis guidelines forthcoming in 2014 will provide detailed guidance on HCV screening, treatment and care. People coinfected with HIV and HCV receiving ART and HCV drugs require close monitoring because of potential drug interactions and increased risk for drug toxicity between HCV drugs (such as interferon, ribavirin and newer directly acting agents) and ARV drugs.

# Key populations
The scale-up of ARV drugs for preventing HIV infection or reducing HIV incidence in key populations has been evaluated in community-wide and ecological studies and mathematical models (67)(68)(69)(70)(71)(72)(73)(74)(75)(76)(77)(78)(79). Some of these studies showed a reduction in the community viral load, with and without an associated decline in HIV incidence, invariably where ART coverage is high or access to ART is expanding rapidly. However, the Guidelines Development Group concluded that there is insufficient evidence to recommend earlier initiation of ART in key populations regardless of CD4 cell count. The initiation of ART in key populations should follow the same general principles and recommendations as in other adults and adolescents with HIV.

# Clinical considerations
Section 10.6 (Checklist 10.3) discusses implementation considerations for moving the CD4 threshold from 350 cells/mm 3 to 500 cells/mm 3 of relevance to programme managers.

# Key research gaps
Further research is required to determine more fully the clinical benefits and disadvantages of earlier ART initiation. Two large randomized trials are examining the optimal timing for initiating ART, with results expected in 2014 to 2015. The Strategic Timing of Antiretroviral Therapy (START) trial in ARV-naive adults aged 18 years and older is comparing immediate ART in those with CD4 cell counts above 500 cells/mm 3 to ART deferred until the CD4 count falls below 350 cells/mm 3 or an AIDS event develops (80). The TEMPRANO trial (Early Antiretroviral Treatment and/or Early Isoniazid Prophylaxis against Tuberculosis in HIV-infected Adults -ANRS 12136) is comparing the benefits and risks of initiating ART according to the 2010 WHO guidelines (350 cells/mm 3 (2) to the benefits and risks of initiating ART immediately among adults with CD4 counts >350 cells/mm 3 in Cote d'Ivoire (81). These studies will inform future WHO recommendations.
Other research priorities include assessing the incidence of severe adverse events as a result of increased exposure to ART and assessing ART acceptability, uptake, adherence and long-term retention in care for people who initiate ART at higher CD4 counts, and the magnitude of the prevention benefit of immediately initiating ART in key populations.

# When to start art in pregnant and breastfeeding women

# New recommendations
All pregnant and breastfeeding women with HIV should initiate triple ARVs (ART), which should be maintained at least for the duration of mother-to-child transmission risk. Women meeting treatment eligibility criteria should continue lifelong ART (strong recommendation, moderate-quality evidence).
For programmatic and operational reasons, particularly in generalized epidemics, all pregnant and breastfeeding women with HIV should initiate ART as lifelong treatment (conditional recommendation, low-quality evidence).
In some countries, for women who are not eligible for ART for their own health, consideration can be given to stopping the ARV regimen after the period of mother-to-child transmission risk has ceased (conditional recommendation, low-quality evidence).  Initiate ART and stop after delivery and cessation of breastfeeding b c a CD4 count 500 cells/mm 3 or clinical stage 3 or 4 disease at the time of ART initiation or in accordance with national guidelines. b Patients who develop clinical or laboratory criteria indicating failure during pregnancy or the breastfeeding period should be assessed for second-line therapy. c In the case of breastfeeding stop ART one week after breastfeeding ends. In the case of replacement feeding stop ART after delivery.
ARV drugs are used for pregnant and breastfeeding women with HIV primarily for the mother's health and to prevent the exposed child from becoming infected. It may also offer benefits for preventing the sexual transmission of HIV. The 2010 WHO PMTCT guidelines (82) recommended lifelong ART for women eligible for treatment (based on the 2010 eligibility criteria of CD4 counts 350 cells/mm 3 or presence of WHO clinical stage 3 or 4 disease) and ARV prophylaxis for PMTCT for women with HIV not eligible for treatment. For those not eligible for treatment, two prophylaxis regimens were recommended: "Option A", AZT for the mother during pregnancy, single-dose NVP (sd-NVP) plus AZT and 3TC for the mother at delivery and continued for a week postpartum; and "Option B", triple ARV drugs for the mother during pregnancy and throughout breastfeeding. Prophylaxis was recommended to start as early as 14 weeks of gestation, and both prophylaxis options included four to six weeks of peripartum NVP or AZT for the infant, regardless of whether the mother was breastfeeding. Countries were advised to choose a national approach for their ARV option for PMTCT based on operational considerations.
To accelerate the rapid global scaling up of ART and PMTCT in resource-limited settings, ensure equitable access to ART for pregnant women and achieve the global goal of eliminating new paediatric infections and keeping mothers alive (83), recommendations need to be further simplified, standardized and harmonized. In 2011, Malawi implemented a new approach of lifelong ART for all pregnant and breastfeeding women with HIV regardless of CD4 count or clinical stage, commonly referred to as "Option B+" (84)(85)(86). WHO issued a programmatic update in April 2012 (87) outlining some of the operational advantages of Option B and the emerging strategy of Option B+.
These 2013 guidelines recommend ART (one simplified triple regimen) for all pregnant and breastfeeding women with HIV during the period of risk of mother-to-child HIV transmission and continuing lifelong ART either for all women or for the women meeting eligibility criteria for their own health. Option A is no longer recommended.

# Rationale and supporting evidence
Advantages of a standardized ARV regimen for all pregnant and breastfeeding women with HIV Although available data continue to show that the Option A and B prophylaxis regimens have similar efficacy in clinical trial settings (88)(89)(90)(91)(92), the complexities of Option A have been an impediment to scaling up PMTCT in many countries. These complexities include different treatment and prophylaxis regimens; the requirement for CD4 measurement to determine treatment eligibility and type of regimen; changing antepartum-intrapartumpostpartum regimens; the need for an additional postpartum ARV "tail" in mothers; and extended NVP prophylaxis in infants.
By contrast, providing an optimized, fixed-dose combination first-line ARV regimen of TDF + 3TC (or FTC) + EFV (see section 7.2.2) to all pregnant and breastfeeding women with HIV provides important programmatic and clinical benefits, including the following.
Ease of implementation. The same simplified ARV regimen is administered to all pregnant women (regardless of "eligibility" for treatment) and continued during pregnancy and labour and postpartum.
Harmonized regimens. The optimized first-line fixed-dose combination regimen can be harmonized with guidelines for ART in non-pregnant adults.
Increased coverage of ART. This ensures that immunocompromised women who do not have access to CD4 testing receive appropriate ART without delay.
- Vertical transmission benefit. Provides coverage with ART to maximize the prevention of infant infections.
- Maternal health benefit. Will delay disease progression over the course of treatment (93).
Acceptability. Reviews conducted for these guidelines generally indicated strong community preference and acceptability for this approach.
Sexual prevention benefit. ART will reduce sexual transmission of HIV to sexual partners (18).
The Guidelines Development Group also considered the overall evidence from the systematic review of 21 observational studies  and three randomized controlled trials (3,18,40) used in the evaluation of when to start ART in adults (Web Annex www. who.int/hiv/pub/guidelines/arv2013/annexes; see section 7.1.1). The recommendation to increase the use of ART in pregnant and breastfeeding women is made with the understanding that there are limited ARV drug options in resource-limited countries.
It also recognizes the need to balance the benefits of starting ART in pregnant and breastfeeding women with the possible risks of ARV drug toxicity to the mother and fetus and infant during pregnancy and breastfeeding. Other issues the Guidelines Development Group considered included costs; cost-effectiveness and health system burden (94,95); issues related to adherence and retention (96), HIV drug resistance, ART failure and the availability of future treatment options; and ensuring treatment access for all people who meet current guidelines on eligibility for treatment.

# When to start art
Lifelong ART versus stopping ART after the risk of mother-to-child HIV transmission ends The recommendation to provide lifelong ART to all pregnant and breastfeeding women with HIV or to continue ART only for those meeting treatment eligibility criteria for the woman's health is conditional, based on the epidemic setting and country programme, and because of the lack of conclusive evidence on the impact and efficacy of fully implementing lifelong ART for all pregnant and breastfeeding women.
In generalized epidemic settings and in settings with limited access to CD4 testing, limited partner testing, long duration of breastfeeding or high rates of fertility, the benefits of lifelong ART for all pregnant and breastfeeding women with HIV are clear. It will assure maximum coverage for those needing treatment for their own health, avoid stopping and starting drugs with repeat pregnancies, provide early protection against mother-to-child transmission in future pregnancies, reduce the risk of HIV transmission to HIV-serodiscordant partners and improve maternal health. With the new treatment eligibility threshold of CD4 500 cells/mm 3 approximately 60% of HIV-infected pregnant women will meet treatment eligibility criteria for their own health (97). Although not well quantified, it is likely that at least an additional 10-20% of women would become eligible for treatment over the subsequent two years after birth.
In countries with concentrated epidemics that have high access to CD4 testing, adequate capacity to provide ART to the pregnant and breastfeeding women eligible for treatment, low fertility rates and/or where breastfeeding for mothers with HIV is not recommended, consideration can be given to stopping the ARV drugs in women not eligible for ART after the period of mother-to-child transmission risk has ended. Regardless of the approach, special effort and supportive initiatives are needed to optimize adherence, especially during breastfeeding, where many programmes currently have poor follow-up, and to assure effective linkages to long-term treatment. Chapter 10 provides additional guidance for national programmes on making the decision between lifelong ART and stopping ART (Box 10.4).
Enhanced ARV toxicity surveillance for exposure throughout pregnancy and the breastfeeding period is critical to evaluate the safety of this approach for women, the fetus and the child. This is especially true as an increasing number of women already receiving ART become pregnant, resulting in much higher levels of ARV drug exposure during early gestation (see Sections 7.2.2 on "What ARV regimen to start with" and 7.4 on "Monitoring and substitutions for ARV drug toxicities"). In addition, implementation research is important to ensure that the many gaps in knowledge associated with lifelong ART are addressed.

# Transition from the 2010 guidelines to the 2013 guidelines
The new 2013 guidelines recommend that countries currently implementing Option A based on the 2010 guidelines (82) should transition, with appropriate planning, to initiating ART for all pregnant and breastfeeding women with HIV; the 2013 guidelines no longer recommend Option A. Countries moving towards Option B and those currently implementing Option B should consider the advantages and disadvantages of implementing lifelong ART for all pregnant and breastfeeding women in their setting.

# Clinical considerations
Section 10.6 (Implementation considerations for key recommendations, Box 10.4) discusses clinical and implementation considerations relevant to programme managers for moving towards lifelong ART for all pregnant and breastfeeding women. A toolkit for managing the transition to lifelong ART for pregnant and breastfeeding women has been developed (98), including a readiness assessment checklist (Annex 6).
ARV toxicity surveillance. Additional research is needed on the safety and acceptability of lifelong ART for pregnant and breastfeeding women, and their infants, especially in lowresource settings, where malnutrition and comorbidities are more common than in resourcerich countries and monitoring capacity is limited. Better data are needed on mothers' health outcomes, pregnancy outcomes (such as stillbirth, low birth weight and prematurity) birth defects and health outcomes for infants and young children (see Box 7.2).

# Maternal and child health outcomes.
Research is needed to better define the long-term outcomes in terms of both mother-to-child transmission at the end of breastfeeding and maternal health. In addition to short-term outcomes (such as impact on early mother-tochild transmission rates, which are now commonly measured at six weeks), assessments of long-term outcomes with maternal ART are critical to measure final transmission rates at the end of breastfeeding and HIV-free survival; the health of the mother and children infected or uninfected with HIV; retention in care (for those with both low and high CD4 counts); the longterm success of first-line ART; and HIV drug resistance.

# Adherence and retention.
Research is needed to determine how to optimize acceptability, adherence and retention on ART in pregnant and breastfeeding women, including among the women initiating lifelong ART who do not meet current eligibility criteria for their own health.
Research is also needed on health systems and community interventions to optimize lifelong ART for pregnant and breastfeeding women with HIV, and the potential impact of different ART initiation strategies in different populations.

# arv drugs and duration of breastfeeding
The key principles and recommendations established in 2010 remain, including:
National or subnational health authorities should decide whether health services will mainly counsel and support mothers known to be infected with HIV to either breastfeed and receive ARV interventions or avoid all breastfeeding given their particular context.
In settings where national authorities have decided that maternal and child health services will mainly promote and support breastfeeding and ARV interventions as the strategy that will most likely give infants born to mothers known to be infected with HIV the greatest chance of HIV-free survival.
Mothers known to be infected with HIV (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast-milk can be provided (strong recommendation, high-quality evidence for the first 6 months; lowquality evidence for the recommendation of 12 months).

# arv drugs and duration of breastfeeding
The primary aim of WHO recommendations regarding HIV and infant feeding is to improve the HIV-free survival of HIV-exposed infants. This includes reducing the risk of HIV transmission through breast-milk, primarily by providing ARV drugs, while avoiding malnutrition and the increased risk of serious infections in infants and children through unsafe feeding practices.
In 2010, WHO recommended that ARV drugs be provided either to the mother or the infant throughout breastfeeding to reduce the risk of postnatal HIV transmission (82,99). In countries that recommended breastfeeding with ARV drugs, it was recommended that women with HIV should "continue breastfeeding for the first 12 months of life" and "only stop once a nutritionally adequate and safe diet without breast-milk can be provided" (99). This recommendation was based on evidence that the maximum benefit of breastfeeding in preventing mortality from diarrhoea, pneumonia and malnutrition is in the first 12 months of life and that the risk of transmitting HIV to infants through breastfeeding is low in the presence of ARV drugs (100,101). At that time, there was uncertainty about the mothers' adherence to ARV drugs as prophylaxis and their ability to give ARV drugs to their breastfeeding infants over longer periods of time up to 18 or 24 months of age. Consequently, there was uncertainty about the level of protection against HIV transmission for children breastfeeding beyond 12 months. Finally, there were limited data on potential adverse events among infants exposed to prolonged -though low-dose -ARV drugs through breast-milk (102)(103)(104).
Since 2010, country-level recommendations on the appropriate duration of breastfeeding for women with HIV and their infants (where breastfeeding is recommended) have varied from 12 to 24 months; in some cases, the duration is not specified. Data on ARV drug coverage and adherence during breastfeeding and effective postpartum follow-up of mother-infant pairs remain limited. With increasing antenatal coverage of ARV drugs in PMTCT programmes, the relative proportion of infants infected during breastfeeding may be increasing because of inadequate ARV drug coverage during breastfeeding, emphasizing the importance of an effective postpartum prevention strategy.
The option of providing lifelong ART to all pregnant women with HIV, regardless of CD4 count or clinical stage (section 7.1.2), raises the question of whether these mothers need to limit the duration of breastfeeding.
The Guidelines Development Group therefore considered whether, in the context of pregnant women with HIV receiving lifelong ART regardless of CD4 count or clinical stage, to maintain the recommendation on the duration of breastfeeding as continued breastfeeding for the first 12 months of life or whether to recommend unrestricted duration of breastfeeding. The Guidelines Development Group considered a revision because of the potential operational advantages of extending the breastfeeding period, including:
simplifying the recommendations for mothers with HIV and their infants and harmonizing them with those for mothers without HIV would likely simplify public health messaging and improve infant-feeding practices in the entire community; and decreasing stigma and possible increasing acceptability by mothers and communities.
Ultimately, the Guidelines Development Group decided not to change the 2010 recommendations on HIV and infant feeding.

# Rationale for not changing the 2010 WHO recommendations on HIV and infant feeding
Overall, there is no new evidence to support changing the 2010 recommendation.
The main concern about promoting unrestricted breastfeeding among mothers with HIV is that mothers may not adhere to ART throughout breastfeeding, placing their infants at risk of HIV transmission. Although this is important at any time when the infant is breastfeeding, it is of particular concern after the infant reaches 12 months of age. Before 12 months of age, breastfeeding provides major protection to the infant against death from diarrhoea, pneumonia and malnutrition. Although breastfeeding continues to provide a range of benefits to the child after 12 months of age, reductions in mortality from these conditions become less significant.
WHO recommendations acknowledge that some mothers may not be able to provide a safe and adequate diet to children beyond 12 months of age without breastfeeding and, in these situations, suggest that breastfeeding should continue. However, evidence to support this as a general approach, including the additional risk of HIV transmission and ARV toxicity surveillance data to exclude possible ARV-related adverse health outcomes for the infant, is not currently available.

# Clinical considerations for supporting mothers with HIV to breastfeed
Key clinical and implementation considerations for using ARV drugs during breastfeeding include:
postnatal prophylaxis for infants remains critical: infants of mothers who are receiving ART and are breastfeeding should receive six weeks of infant prophylaxis with daily NVP (section 7.2.2); specific interventions (such as integrated follow-up with immunization and other wellchild services) should be considered to improve postpartum follow-up of mother-infant pairs, which is often weak in most programmes; and communicating clearly and effectively with the community and users the value of breastfeeding with ARV drugs and local considerations regarding the duration of breastfeeding.
In addition, the Guidelines Development Group emphasized the need to support enhanced monitoring for potential toxicities from prolonged exposure to ARV drugs (such as sentinel site monitoring of infant cohorts during the first two years of life), for the next three to five years, and to continue monitoring as new drugs are introduced, to assess the effects of ARVs especially on neurodevelopmental outcomes and renal and bone health.

# Key research gaps
the risk of postpartum transmission in the context of ART, with variable duration of breastfeeding and different programme settings;
short-and long-term infant health outcomes related to prolonged, low-dose exposure to ARV drugs (especially EFV and TDF) through breast-milk, including neurodevelopmental outcomes, nutritional status (including micronutrients), bone metabolism and growth; and interventions to improve adherence to postnatal ARV drugs during breastfeeding and whether initiating lifelong ART in all pregnant and postpartum women enhances adherence to ARV drugs during breastfeeding, which would enable women with HIV to breastfeed without any time restriction.

# General guidance
Pregnant women with HIV should receive at least the minimum package of recommended antenatal visits and pregnancy care, and additional interventions such as screening for sexually transmitted infections, nutritional support and infant feeding and family planning counselling should be considered.
There is a high risk of HIV transmission during labour and delivery. This risk can be minimized by following several key principles and practices, including reinforcing recommended antenatal clinic visits, especially high-risk management in the late third trimester; promoting facility-based delivery by trained skilled birth attendants; avoiding unnecessary instrumentation and premature rupture of membranes by using a partograph to monitor stages of labour; and non-invasive suction of nasogastric secretions and washing away blood in the newborn.

# Additional measures to reduce HIV transmission include the following:
The early identification of mothers with HIV and providing ARV drugs to both the mother and the newborn baby are essential.
For mothers presenting at labour with unknown HIV status, rapid HIV testing should be done during labour or immediately postpartum.
For women testing positive, ARV drugs should be provided to both the mother and child in accordance with current treatment recommendations and with consideration of extended prophylaxis to the infant (see section 7.2.2).
Health care workers should follow universal precautions for all deliveries, including those involving mothers with HIV.
Special efforts should be made to ensure that delivery care is provided in a nonstigmatizing and supportive manner.
Although Caesarean section has been shown to protect against HIV transmission, especially in the absence of ARV drugs or in the case of high viral load, WHO does not recommend it in resource-limited settings specifically for HIV infection; rather it is recommended for obstetric and other medical indications.
Women with HIV and women of unknown HIV status who deliver outside health facilities should be encouraged to be medically assessed at a maternal and child health facility as soon as possible after delivery and to begin or continue appropriate HIV interventions.
Providing follow-up, linkages to care and treatment and postpartum care are especially important for women with HIV and their HIV-exposed infants. Initial care of the child is usually scheduled at the first immunization visit at four to six weeks, including reinforcement of safe feeding practices, review of ARV coverage and early infant diagnosis testing. Follow-up care for the mother should ideally be scheduled at the same time and should include a postpartum check, family planning counselling, review of ARV regimen and adherence support.

# When to start art in children
a This recommendation is conditional because of the lack of evidence supporting earlier initiation in this age group, but this approach is expected to provide significant programmatic advantages in settings with limited access to immunological testing, high burden of paediatric HIV disease and low ART coverage among children, since simplifying eligibility criteria for initiating ART is likely to increase ART coverage in children infected with HIV and improve their health outcomes. Priority for ART initiation should be given to children younger than two years of age, regardless of WHO clinical stage or CD4 cell count, because of higher mortality risk, and to children between two and five years of age with advanced disease (WHO HIV clinical stages 3 and 4) or with CD4 count 750 cells/mm 3 or <25%, whichever is lower, regardless of WHO clinical stage (strong recommendation, verylow-quality evidence) (105). b This recommendation is conditional because of the lack of evidence in this population for individual benefit as a result of initiating ART earlier; however, this approach is expected to provide significant programmatic advantages in settings with high coverage of paediatric ART and a programmatic need to align with ARV drug recommendations for adults.
Infants and young children have an exceptionally high risk of poor outcomes from HIV infection. Up to 52% of children die before the age of two years in the absence of any intervention (106). By five years of age, the risk of mortality and disease progression in the absence of treatment falls to rates similar to those of young adults (107,108).
The scaling up of early infant diagnosis programmes has increased the identification of infants infected with HIV, but initiating ART early for those who have been found to be infected remains poor. Most HIV-infected children who are eligible for ART are still not being treated, and ART coverage among children lags significantly behind that among adults (28% versus 57% globally in 2011) (11).
Diagnosing and retaining children exposed to HIV and children infected with HIV in care also presents unique challenges because of their dependence on a caregiver. Loss to follow-up has been particularly high along the continuum of care (109), with retention especially challenging for children who are in HIV care but not yet eligible for ART.
Some countries are already introducing immediate ART for children younger than five years based on operational and programmatic grounds (110,111).
The 2010 WHO guidelines aligned clinical and immunological criteria for ART eligibility for children older than five years with those for adults (that is, treat for WHO clinical stage 3 or 4 disease or CD4 350 cells/mm 3 (105). They also recommended treating all children infected with HIV younger than two years of age regardless of clinical or immunological status. For children between two and five years of age, it was recommended that those with WHO stage 3 or 4, clinical disease or CD4 <25% or 750 cells/mm 3 be treated (105).
The review of evidence in 2013, together with operational considerations and values and preferences expressed by care providers, has led to revised recommendations to simplify and expand treatment in children, including initiating ART in all children up to five years and to increase the CD4 count threshold for ART initiation to 500 cells/mm3 in children 5 years and older, aligning with the new threshold in adults.

# Rationale and supporting evidence
These recommendations are based on strong operational and programmatic advantages resulting from simplification of criteria for initiating ART, despite the lack of clinical benefits to support treatment regardless of CD4 or clinical stage beyond infancy. Similarly, for programmatic purposes and given that disease progression in children five years and older is comparable to that of young adults, alignment with ART initiation criteria for adults was considered of high value.
Evidence for increasing the age threshold for early ART to five years CD4 count and WHO clinical stage can identify children at increased risk of disease progression and death. Previous recommendations were based on observational studies demonstrating that untreated children in the second year of life continue to experience high rates of death and illness compared with children without HIV (106). Child-survival curves suggest that the mortality for children older than two years of age and with CD4 exceeding 25% is about 1-2% per year (107,108).
A systematic review identified only one randomized clinical trial, PREDICT (112), informing this issue (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes). The trial enrolled 300 children (1-12 years old, median age 6.4 years) with CD4 counts above 15% and without CDC clinical stage C disease, randomizing them to either immediate treatment or deferred treatment until the CD4 count fell below 15%. AIDS-free survival, neurodevelopmental outcomes and growth parameters did not differ between groups (113).
A causal modelling study was also undertaken using prospective data collected by the IeDEA-Southern Africa network on 5732 ART-naive children 24-59 months old (median age 3.3 years) who had CD4 counts above the existing eligibility thresholds of 25% or 750 cells/mm 3 (114) (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes). The study did not show any survival benefit from early treatment in this population, but a large proportion of children in this age range would rapidly become eligible under the existing criteria, since most children with CD4 count of 750 cells/mm 3 or higher at enrolment into care reached the CD4 treatment threshold within three years. More specifically, 32% of this subset of the cohort fell below the thresholds for eligibility after one year and 60% after two years.

# Operational and programmatic advantages
Despite the lower risk of progression in children 2-5 years old compared with children younger than two years and the low quality of evidence, the Guidelines Development Group emphasized the operational and programmatic advantages of removing the CD4 barrier to treatment for children under 5 years of age. Treating all children younger than five years of age is expected to simplify paediatric treatment and facilitate a significant expansion of ART coverage for young children. Although this has not been assessed as an outcome, programmatic data suggest that retention is better among children on ART than among those in care but not started on ART (109). Increasing ART coverage and targeting these children for HIV care may also facilitate the treatment of other preventable causes of under-five mortality. This approach will likely represent a small increased burden on current systems (115). Note that late diagnosis is still occurring, and a large proportion of the children identified as infected with HIV would already be eligible for ART based on the 2010 recommendations.

# Community values and preferences
Expanding ART to every child younger than five years of age is expected to be well accepted.
Assessment of the values and preferences of people living with HIV, caregivers and health care providers of children with HIV showed that earlier initiation is preferable because it is believed to facilitate family-based care, prevent loss to follow-up and improve adherence (116).
Nevertheless, there is a risk of resistance if treatment is initiated early in young children and adherence is poor or drug supplies are suboptimal; this is particularly the case for the youngest children, among whom harmonizing the formulations for children and adults is most difficult. However, the benefits of treatment are likely to outweigh these risks.
Where access to immunological testing is limited, the burden of paediatric HIV disease is high and paediatric ART coverage is low, simplifying the eligibility criteria for initiating ART may significantly improve the overall health outcomes for children with HIV (117). National programmes need to determine how best to implement this recommendation and whether to recommend universal treatment for all children younger than five years or to focus on universal treatment for infants younger than one year and apply clinical or immunological criteria for children one to five years old. When ART initiation is expanded regardless of clinical or immunological status beyond infancy to all children younger than five years, treatment of children younger than two years should be given priority because of their higher risk of death and rapid disease progression. In addition, expanding ART services will require ensuring retention in care and should be matched with concomitant expansion of interventions to support adherence.
Evidence for increasing the CD4 threshold to 500 cells/mm 3 The criteria for initiating ART in children five years of age and older are the same as for adults.
Although there are limited data to assess the clinical impact of treating children with a CD4 count between 350 and 500 cells/mm 3 and the benefits of ARV drugs in preventing sexual transmission are not a factor for this population, this approach has programmatic advantages resulting from harmonizing the criteria with those for adults. It may be most feasible in settings with high ART coverage. As in the case of adults, treating children with CD4 counts 350 cells/ mm 3 should be a high priority since they have the highest risk of disease progression.

# Coinfection with HIV and HBV
Small cohort studies in which both HIV and HBV are endemic report rates of chronic HBV among children with HIV between 1% and 49% (118). HBV is often acquired in infancy or early childhood and, unlike among adults, may have an immunotolerant phase that lasts throughout childhood and adolescence. Unfortunately, the natural history of the disease among children with HIV is still poorly known, and the benefits from initiating ART earlier in these children remain to be assessed.

# Clinical considerations for scaling up ART among children
Section 10.6 discusses implementation considerations relevant to programme managers (see Box 10.6). An additional important implementation consideration for clinicians and other health care providers is that expanding the initiation of ART regardless of clinical or immunological status to children younger than five years eliminates the need for determining the CD4 count to initiate treatment in this age group and avoids delaying ART in settings without access to CD4 testing. However, the availability of CD4 testing, including determining the baseline CD4 count and percentage, remains important to ensure appropriate treatment monitoring in the absence of viral load monitoring.

# Key research gaps
More data are needed to define potential clinical benefits and the impact of initiating ART early on morbidity for children younger than five years as well as immunological response and virological response over time. The impact of initiating ART earlier on retention, adherence and potential HIV drug resistance among children with less advanced disease needs to be investigated further. Data are also needed to inform the optimal approach to initiating ART in children coinfected with HBV.

# What arv regimen to start with (first-line art)
Using simplified, less toxic and more convenient regimens as fixed-dose combinations is recommended for first-line ART. Once-daily regimens comprising a non-thymidine NRTI backbone (TDF + FTC or TDF + 3TC) and one NNRTI (EFV) are maintained as the preferred choices in adults, adolescents and children older than three years. For children younger than three years, a PI-based regimen is the preferred approach (Table 7.5).

# First-line ART

# New recommendations
First-line ART should consist of two nucleoside reverse-transcriptase inhibitors (NRTIs) plus a non-nucleoside reverse-transcriptase inhibitor (NNRTI)
- TDF + 3TC (or FTC) + EFV as a fixed-dose combination is recommended as the preferred option to initiate ART (strong recommendation, moderate-quality evidence).
- Countries should discontinue d4T use in first-line regimens because of its wellrecognized metabolic toxicities (strong recommendation, moderate-quality evidence). neW a For adolescents, see section 7.2.4 on first-line ART for children three years and older which includes adolescents infected with HIV (10 years and older). b Using d4T as an option in first-line treatment should be discontinued and restricted to special cases in which other ARV drugs cannot be used. The duration of therapy with this drug should be limited to the shortest time possible and include close monitoring. c Special circumstances may include situations where preferred or alternative regimens may not be available or suitable because of significant toxicities, anticipated drug-drug interactions, drug procurement and supply management issues, or for other reasons.
The 2010 WHO ART guidelines (2) recommended that ART in treatment-naive adults should initially consist of an NNRTI (either NVP or EFV) plus two NRTIs, one of which should be 3TC (or FTC) and the other AZT or TDF. The guidelines emphasized the importance of avoiding d4T as a preferred option in first-line regimens because of its well-known mitochondrial toxicity, using regimens that are potentially less toxic and more suitable for most people, preferably as fixed-dose combinations given the clinical, operational and programmatic benefits. The recommended regimens had better toxicity profiles than d4T but were considered comparable in terms of efficacy, since there was no evidence that AZT is virologically superior to d4T, AZT superior to TDF, TDF superior to d4T or ABC, or EFV superior to NVP.
The phasing out of d4T as a preferred option in first-line ART has been variable. Some countries have made rapid and substantial progress, whereas others have taken a gradual approach, such as avoiding d4T only for people starting ART or not using d4T in pregnant women (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
WHO (119,120) promotes a more affordable and efficient approach to treatment, including simpler, single-pill, once-daily ARV regimens. The 2013 guidelines promote further simplification of ART delivery by reducing the number of preferred first-line regimens and focusing on regimens that may be used across a range of populations.

# Rationale and supporting evidence
The move to TDF + 3TC (or FTC) + EFV as the preferred first-line option A systematic review comparing six regimens showed moderate-quality evidence indicating that a once-daily combination of TDF + 3TC (or FTC) + EFV is less frequently associated with severe adverse events and has a better virological and treatment response compared with other once-or twice-daily regimens (Web Annex www.who.int/hiv/pub/guidelines/ arv2013/annexes). An additional systematic review showed people receiving NVP are twice as likely as those receiving EFV to discontinue treatment because of adverse events (121).
The Guideline Development Group also reviewed a published meta-analysis and a further updated analysis (122,123) that showed no increased risk of birth defects with EFV compared with other ARV drugs used during the first trimester of pregnancy (122)

# NVP in pregnant women
There are continued concerns about the higher risk of adverse events with NVP compared with EFV, and about the use of NVP in women with HIV with CD4 cell counts above 250 cells/mm 3 with some studies showing an increased relative risk for severe hepatic and skin reactions in pregnant women using NVP at higher CD4 cell counts (124)(125)(126). A systematic review (127), updated in 2013 (134) of the risk of NVP-associated toxicity in pregnant women suggests that the frequency of adverse events is elevated but no higher than that observed in the general adult population. The evidence supporting the theory that pregnant women with HIV who have high CD4 counts are at increased risk of adverse events compared with the general population with HIV is weak. The need for lead-in dosing for initial use of NVP and the fact that it is not available as a fixed-dose combination with TDF + 3TC (or FTC) are important considerations. NVP should therefore be used with caution in pregnant women and women who might be pregnant and only after considering the risk and benefits and available alternatives (see section 7.3.2).

# What arv regimen to start with (first-line art)
Alternatives to NVP, such as ABC and boosted PIs, are acceptable but should only be used when NVP is not available.

# Using alternative regimens and phasing out d4T
The currently recommended alternative regimens such as AZT instead of TDF or NVP instead of EFV (Table 7.5) are comparable in therapeutic efficacy but have potential clinical and programmatic disadvantages compared with the preferred options. Individuals who are already clinically stable on an alternative regimen with no contraindications can consider continuing that regimen based on national guidance or switch to the preferred options to simplify treatment management, reduce cost, improve tolerability, enhance adherence and promote better regimen sequencing. In special circumstances, ABC and boosted PIs are acceptable but should only be used when other options are not available.
Use of d4T-containing regimens should be discontinued and restricted to cases in which other ARV drugs cannot be used, and the duration of therapy with this drug should be limited to the shortest time possible and include close monitoring. In settings in which d4T regimens are still used as a preferred option for initiating ART, a plan for phasing out d4T should be implemented, preferably towards using TDF-based first-line regimens (2,128,129). Section 10.6 (Box 10.7) further discusses the issue of phasing out d4T.

# TDF toxicity
A systematic review on TDF toxicity (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes) indicates that TDF has a low rate of renal toxicity in the short to medium term, especially among people with pre-existing, or risk factors for, renal disease. Prospective cohort data show that TDF is associated with modest reduction in renal function (measured by the decrease in the estimated glomerular filtration rate) (130,131) and reduction in bone mineral density, but the clinical significance and magnitude of these side effects, especially with prolonged therapy, need to be investigated further. Further research is also needed to determine whether laboratory screening and monitoring of TDF toxicity should be routine or undertaken only in high-risk populations, such as people with hypertension or diabetes or those using boosted PIs. Since TDF renal toxicity is usually tubular, glomerular function tests do not provide a direct measure, and no other simple test can detect renal tubular toxicity. Section 7.4 discusses this issue further.
Evidence suggests that the overall improvement in renal function resulting from ART can offset the risk of TDF toxicity among people with HIV who do not have secondary renal disease.

# HIV-2 infection
A systematic review of treatment options for individuals with HIV-2 (Web Annex www. who.int/hiv/pub/guidelines/arv2013/annexes) rated the evidence in all observational studies as being of very low quality, with serious risk of bias, inconsistency and imprecision. Since HIV-2 is naturally resistant to NNRTIs, treatment-naive people coinfected with HIV-1 and HIV-2 should be treated with a regimen containing three NRTIs (TDF + 3TC (or FTC) + AZT or AZT + 3TC + ABC) or a ritonavir-boosted PI plus two NRTIs. If a PI-based regimen is used, the preferred option for first-line therapy should be LPV/r, since this will be procured in low-income settings for both second-line treatment for adults and for first-line treatment for children. SQV/r and DRV/r are alternative boosted-PI options, but they are not available as heat-stable fixed-dose combinations.

# first-line art for pregnant and breastfeeding women and arv drugs for their infants
The 2010 WHO guidelines on PMTCT (82) recommended a choice of four different regimens for pregnant and breastfeeding women with HIV who required ART for their own health: AZT + 3TC or TDF + 3TC (or FTC) plus either NVP or EFV. Because of concerns about the increased risk of toxicity of NVP among pregnant women with higher CD4 counts (132)(133)(134), the recommended regimens for pregnant women who did not require treatment for their own health and who were receiving triple ARV regimens for PMTCT were AZT + 3TC or TDF + 3TC (or FTC) + EFV as the preferred NNRTI regimens. Alternative regimens were AZT + 3TC plus either LPV/r or ABC, rather than NVP. Although TDF and EFV were recommended, there were limited safety data on their use during pregnancy and breastfeeding.
The 2010 WHO guidelines (82) also recommended four to six weeks of infant NVP (or AZT) as post-exposure prophylaxis for all infants born to mothers who were receiving triple ARV regimens for treatment or prevention. Daily NVP infant prophylaxis throughout breastfeeding was recommended if the mother was not receiving a triple ARV regimen.
In clinical trials, infant prophylaxis has been shown to be especially important for PMTCT when the mother has received limited or no antepartum ARV drugs and when virological suppression has not yet been achieved (135)(136)(137). This continues to be a recommended component of PMTCT regimens in resource-rich countries as added protection against exposure to HIV during labour, even when mothers receive ART during pregnancy and when the mother is not breastfeeding (138). The data informing this recommendation have not changed since 2010.
A once-daily fixed-dose combination of TDF + 3TC (or FTC) + EFV is recommended as first-line ART in pregnant and breastfeeding women, including pregnant women in the first trimester of pregnancy and women of childbearing age. The recommendation applies both to lifelong treatment and to ART initiated for PMTCT and then stopped (strong recommendation, low-to moderate-quality evidence: moderate-quality evidence for adults in general but low-quality evidence for the specific population of pregnant and breastfeeding women and infants).
Infants of mothers who are receiving ART and are breastfeeding should receive six weeks of infant prophylaxis with daily NVP. If infants are receiving replacement feeding, they should be given four to six weeks of infant prophylaxis with daily NVP (or twice-daily AZT). Infant prophylaxis should begin at birth or when HIV exposure is recognized postpartum (strong recommendation, moderate-quality evidence for breastfeeding infants; strong recommendation, low-quality evidence for infants receiving only replacement feeding).
Note: For the recommendations on infant prophylaxis, the GRADE ratings and recommendations shown are from the 2010 guidelines and were not reviewed by the Guidelines Development Group for the current guidelines.

# Rationale and supporting evidence
The 2013 guidelines emphasize simplifying and harmonizing first-line therapy. A once-daily fixed-dose combination regimen is recommended, with TDF as the preferred NRTI and EFV as the preferred NNRTI, in combination with 3TC or FTC for all adults -including pregnant and breastfeeding womenas the preferred regimen to improve health outcomes and facilitate adherence and drug procurement (see section 7.2.1 and Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
The ideal first-line regimen for pregnant and breastfeeding women with HIV has low cost; is available as a fixed-dose combination; is safe for both pregnant and breastfeeding women and their infants; is well tolerated; has low monitoring requirements and a low drug-resistance profile; is compatible with other drugs used in clinical care; and is harmonized with the recommendations for non-pregnant adults. The regimen of TDF + 3TC (or FTC) + EFV is available as a once-daily fixed-dose combination and is the recommended first-line regimen for adults because of simplicity, affordability (the cost has declined significantly since 2010) and efficacy against HBV.
Safety is a critical issue for pregnant and breastfeeding women and their infants as well as women who might become pregnant. Although data on EFV and TDF use in pregnant women remain limited, more data have become available since 2010 and provide increased reassurance for recommending TDF + 3TC (or FTC) + EFV as the first-line ARV regimen for pregnant and breastfeeding women (122,139,140). Sections 7.3.1 and 7.5.2 provide more detail on the overall rationale for the recommended first-line regimen, including toxicity and monitoring issues.

# Safety of EFV in pregnancy
Early data suggesting birth defects, including anencephaly, microphthalmia and cleft palate among primates with EFV exposure in utero (141) and some isolated case reports and retrospective clinical data on neural tube defects among humans (142) have led to concern about using EFV in the first trimester of pregnancy or in non-pregnant women with childbearing potential. The United States Food and Drug Administration and European Medicines Agency advise against using EFV in the first trimester and in women of childbearing potential unless the potential benefits outweigh the potential risks; however, the British HIV Association recently changed its recommendation to allow EFV to be used in the first trimester (143).
Because the risk of neural tube defects is limited to the first five to six weeks of pregnancy and because pregnancy is rarely recognized this early, especially in resource-limited settings, any potential risk of neural tube defects with the use of EFV would be primarily in women who become pregnant while already receiving EFV. Evaluation of prospectively collected data in humans is reassuring; an updated systematic review and meta-analysis, including the Antiretroviral Pregnancy Registry (47,134), reported outcomes for 1502 live births to women receiving EFV in the first trimester and found no increase in overall birth defects and no elevated signal for EFV compared with other ARV exposure in pregnancy (140). With one identified neural tube defect, the estimated prevalence from the systematic review continues to be about 7 per 10 000 population (0.07%), which is comparable to the estimates of 0.02-0.2% in the general population in the USA (138).
Because neural tube defects are relatively rare events and there are limited exposures in the Antiretroviral Pregnancy Registry and in the meta-analyses, current available data are sufficient to rule out a potential increased risk greater than three-fold or up to 0.21% (the more limited data available for the 2010 guidelines were sufficient to rule out a 10-fold increased risk). Although the Guidelines Development Group emphasized that better data on birth defects are needed, it felt confident that this potential low risk should be balanced against the programmatic advantages and the clinical benefit of EFV in preventing HIV infection in infants and for the mother's health.
neW Safety of NVP in pregnancy: (see section 7.2.1)

# Safety of TDF in pregnancy and during breastfeeding
Potential concerns about the safety of TDF include renal toxicity (see section 7.4.3), adverse birth outcomes and effects on bone density. A systematic review assessed the toxicity of fetal exposure to TDF in pregnancy (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
In the Antiretroviral Pregnancy Registry, the prevalence of overall birth defects with exposure to TDF in the first trimester was 2.4% of 1612 live births and did not differ from the background rate in the USA. A limited number of studies showed no difference in fetal growth between infants exposed or not exposed to TDF (144,145). TDF has limited penetration into breast-milk, which would limit potential toxicity for the breastfeeding infant. However, there have been no studies of TDF among lactating women, who normally have bone loss during breastfeeding that stabilizes after lactation. More extensive studies are ongoing of TDF bone and renal safety in pregnancy and breastfeeding for both the mother and child.
The once-daily TDF + 3TC (or FTC) + EFV fixed-dose regimen is simple and convenient, and harmonizing the recommendations for pregnant and non-pregnant women simplifies supply chain management. Based on available data and experience, the Guidelines Development Group felt that the clear benefits of this regimen for pregnant and breastfeeding women (and women of childbearing potential) outweigh the potential risks (see section 7.5.2). a Infants weighing 100 ng/ml with the least dose changes.

# Infant prophylaxis

# What arv regimen to start with (first-line art)
No new data inform any change in the recommendations on infant prophylaxis. For breastfeeding infants, six weeks of infant NVP is recommended; for infants receiving replacement feeding, four to six weeks of infant NVP or AZT continues to be recommended.
If toxicity from infant NVP requires discontinuing the drug or if infant NVP is not available, infant 3TC can be substituted. Several studies (146,147) have safely used infant prophylaxis during breastfeeding with 3TC.
Although the Guidelines Development Group did not formally review this, it considered several scenarios in which longer infant prophylaxis might be appropriate. Because several weeks or months are required for maternal ART to achieve virological suppression and a breastfeeding infant may not be protected against postnatal transmission during that period, or when a breastfeeding mother initiates ART very late in pregnancy (such as less than four weeks prior to delivery) during labour or postpartum, increasing the duration of infant NVP prophylaxis to 12 weeks can be considered.
Infant prophylaxis is also important when a breastfeeding mother interrupts ART during breastfeeding, as this places her infant at increased risk of postnatal transmission. In such situations, providing daily infant NVP during the period of maternal ART interruption should be considered, and this could be stopped six weeks after maternal ART is restarted (or one week after breastfeeding ends, whichever comes first). Table 7.8 summarizes the range of scenarios for maternal and infant prophylaxis.
a Infants weighing <2000 g should receive mg/kg dosing; the suggested starting dose is 2 mg/kg twice daily.

# Infant age Daily dosing
Birth  Ideally, obtain the mother's CD4 cell count at the time of initiating or soon after initiating ART; country guidelines should be used to determine whether ART is lifelong or is stopped after the risk for transmission has ended. b If infant NVP causes toxicity or NVP is not available, 3TC can be substituted. c If the mother is using replacement feeding, infant AZT can be substituted for infant NVP; if there is documented maternal virological suppression near delivery for a mother receiving ART and using replacement feeding, four weeks of infant ARV prophylaxis may be considered. d If it is known that the mother has initiated ART less than 4 weeks before delivery, consider extending infant NVP for infants who are breastfeeding to 12 weeks.

# What arv regimen to start with (first-line art)
Alternative regimens: for toxicity, intolerance or lack of availability of recommended regimens AZT is recommended as the alternative NRTI for non-pregnant women who cannot tolerate or receive TDF. Given the extensive safety and efficacy data on AZT in pregnant and breastfeeding women, AZT is also the recommended alternative NRTI for pregnant and breastfeeding women.
For non-pregnant women who cannot tolerate or receive EFV, the recommended alternative NNRTI is NVP. However, because ART (triple ARV drugs) is now recommended for pregnant and breastfeeding women regardless of CD4 cell count, concerns remain regarding the use of NVP in women with higher CD4 counts. Although the 2010 guidelines (2,82) stated that the benefit of NVP outweighed the risk for women with CD4 counts of 250 to 350 cells/ mm 3 data on safety in women with CD4 counts 350 cells/mm 3 are limited, and the finding of life-threatening hepatic toxicity when NVP was used for occupational post-exposure prophylaxis in individuals without HIV infection raises concerns regarding its use for individuals with higher CD4 count. However, a recent systematic review of the risk of NVP-associated toxicity in pregnant women (134) (Web Annex www.who.int/hiv/pub/guidelines/arv2013/ annexes) suggests that the frequency of adverse events is no higher than that in the general adult population. Further, data on the association between NVP toxicity and elevated CD4 cell counts are conflicting, and the risk of significant hepatic toxicity in most studies is about 3% (121). Data suggest that switching to NVP for individuals who have been treated and had virological suppression is not associated with elevated toxicity even where the immune system has reconstituted. Finally, the alternative to substituting NVP for EFV toxicity would be a PI, which is the recommended second-line therapy and is more expensive than NNRTI drugs. On balance, the Guidelines Development Group held that the overall benefit of substituting NVP for pregnant or breastfeeding women in the rare circumstances that EFV is not tolerated outweighs the potential risks.

# Clinical considerations
Maintaining the drug supply chain and ensuring uninterrupted delivery of maternal ART and infant ARV drugs during pregnancy and breastfeeding are critical for PMTCT. All antenatal care and maternal and child health sites providing PMTCT services should have the capacity to initiate, support and monitor ongoing maternal ART and infant ARV drugs.

# Key research gaps
Surveillance of ARV drug toxicity. Research is needed to continue to evaluate both the short-and long-term effects of EFV, TDF and other ARV drugs on pregnant and breastfeeding women, fetuses and children, including monitoring for birth defects and other adverse pregnancy outcomes and evaluating the renal and bone effects of TDF on both the woman and HIV-exposed infant.

# Acceptability of EFV as first-line ART.
The level of intolerance to EFV and whether switching to an alternative first-line regimen is necessary needs to be studied further, as do ways to support alternative first-line regimens in programme settings for pregnant and breastfeeding women.

# Infant prophylaxis.
Better data are needed on the optimal duration of infant prophylaxis when mothers receive ART, especially if the mother starts ART late in pregnancy or during the postpartum period and hence is not virally suppressed at the time of delivery or when breastfeeding begins. NVP formulations that are improved and easier to administer are needed to facilitate drug administration to neonates and infants.

# Optimal management of infants identified as HIV exposed during breastfeeding.
It is important to determine the extent to which perinatal HIV exposure is missed antenatally and the extent of maternal seroconversion, appropriate strategies for postpartum screening of infants for HIV exposure and optimal testing and prophylaxis strategies.
Stopping NNRTI-based ART (use of a "tail"). Because of the prolonged half-life of EFV (and NVP), suddenly stopping an NNRTI-based regimen risks developing NNRTI resistance. For women who choose to or must stop EFV-based ART because of toxicity or other conditions, more data are needed to determine whether an NRTI "tail" coverage is needed to reduce this risk. Pharmacokinetic modelling reviewed for the guidelines suggests that, if the NRTI backbone included TDF, such a tail may not be needed, but if the NRTI backbone included AZT, a two-week tail is advisable (EFV has a longer half-life than NVP).

# first-line art for children younger than three years of age
A LPV/r-based regimen should be used as first-line ART for all children infected with HIV younger than three years (36 months) of age, regardless of NNRTI exposure. If LPV/r is not feasible, treatment should be initiated with a NVP-based regimen (strong recommendation, moderate-quality evidence).
Where viral load monitoring is available, consideration can be given to substituting LPV/r with an NNRTI after virological suppression is sustained (conditional recommendation, low-quality evidence).
Special note: The randomized control trial supporting the use of this approach (148,161) defined virological suppression as a viral load 400 copies/mm 3 with the goal of identifying the children who are more likely to be able to safely substitute LPV/r with NVP. The use of a higher viral load cut-off for determining virological suppression has not been studied in the context of this strategy.
For infants and children infected with HIV younger than three years, ABC + 3TC + AZT is recommended as an option for children who develop TB while on an ARV regimen containing NVP or LPV/r. Once TB therapy has been completed, this regimen should be stopped and the initial regimen should be restarted (strong recommendation, moderate-quality evidence).
For infants and children infected with HIV younger than three years, the NRTI backbone for an ARV regimen should be ABC or AZT + 3TC (strong recommendation, low-quality evidence). 14 days of age. Dosing for children younger than 6 weeks should be calculated based on body surface area (Annex 3). c During the finalization of these guidelines, the United States Food and Drug Administration approved the use of EFV in children 3 months to 3 years old weighing more than 3.5 kg. Due to the limited data to inform the best use of this drug in this age group, the Guidelines Development Group agreed to maintain NVP as the recommended NNRTI for children under 3 years. WHO will provide further guidance as soon as the additional data become available. d Because of the limited options available for children younger than three years, d4T is still included among the recommended NRTIs, but its use should be restricted to the situations in which toxicity to AZT is suspected or confirmed and ABC cannot be used. The duration of therapy with this drug should be limited to the shortest time possible. Box 10.7 provides guidance on phasing out d4T. e Special circumstances may include situations where preferred or alternative regimens may not be available or suitable because of significant toxicities, anticipated drug-drug interactions, drug procurement and supply management issues, or for other reasons.

# New recommendations neW
Optimizing first-line ART in children younger than three years is critical to achieving effective and rapid control of viral replication in the context of high viral load and rapid infant growth.
Considerations that may require alternative therapeutic approaches include the limited availability of drugs in appropriate formulations, the long-term toxicities of ARV drugs, difficulty with adherence and the possibility of pre-existing viral resistance because of ARV drug exposure for PMTCT.
Young children with HIV who are exposed to NNRTIs used for PMTCT may have demonstrable viral resistance (150), which compromises the response to NVP-containing first-line ART (151,152). For this reason, the 2010 WHO guidelines (105) recommended the use of LPV/r-based treatment in children younger than 24 months of age previously exposed to NNRTIs. For young children not exposed to NNRTIs or whose status was unknown, an NVP-based regimen was recommended (105).
New evidence has become available for this age group suggesting the superiority of a LPV/r-based regimen regardless of PMTCT exposure (153,154). Several strategies have also been tested to overcome the challenges of using LPV/r-based regimens or to provide potent alternatives in settings in which using LPV/r is not feasible or is problematic because of the high prevalence of TB. (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).

# Rationale and supporting evidence
This recommendation is based on evidence of the superiority of a LPV/r-based regimen for young children balanced against feasibility considerations.

# Efficacy of a LPV/r-based regimen for infants and young children
A systematic review of two randomized trials (153,154) shows that children younger than 36 months have a reduced risk of discontinuing treatment and virological failure or death if they are started on a LPV/r-based regimen instead of a NVP-based regimen. At 24 weeks, LPV/r was demonstrated to be superior to NVP regardless of NNRTI exposure for PMTCT (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes). In addition, surveillance of drug resistance among children younger than 18 months (149,155) provides further evidence of detectable NNRTI resistance even among children without any history of exposure to ARV drugs for PMTCT or whose exposure status is unknown, suggesting that a history of exposure for PMTCT may not be an accurate marker for identifying children at higher risk of HIV resistance to NNRTI.
LPV/r is known to have a better resistance profile that protects against the selection of NRTI resistance without compromising the use of other PIs in second-line regimens (156,(157)(158)(159).
In addition, a potential advantage is offered by the considerable reduction in the incidence of malaria among children receiving LPV/r-based regimens, as recently demonstrated in a randomized trial comparing the use of LPV/r versus NVP or EFV among children in Uganda receiving an artemether + lumefantrine combination for treating malaria episodes (160).

# Feasibility of LPV/r in resource-limited settings
Providing an LPV/r-based regimen to infants and children younger than three years in some resource-limited settings may be challenging. The current LPV/r syrup formulation has coldchain requirements until the point of dispensing. The syrup is unpalatable, with the potential for suboptimal adherence, as highlighted in the values and preferences survey among health workers, and the risk of metabolic complications among children who initiate LPV/r early in life is unknown. Further, LPV/r is costly and administering this with TB treatment is complex. Alternative approaches are proposed to overcome these challenges.
A recent randomized clinical trial (148,161) and an ongoing randomized clinical trial (162) have evaluated a strategy in which LPV/r is started and later substituted with an NNRTI (NVP or EFV). Such PI-sparing strategies aim to reduce exposure to LPV/r, offer an easier approach to maintaining treatment and preserve PI-based therapy for second-line ART. This approach has been shown to be safe and effective in the trial setting for children with sustained virological suppression achieved after receiving LPV/r-based first-line therapy, especially in the absence of HIV resistance to NNRTI before initiating ART (148,161). However, this approach may also add complexity to treatment programmes and may require access to virological monitoring. This strategy may therefore only be viable in settings in which viral load and/or genotype testing are available.
In settings in which none of these approaches is feasible or affordable, an NVP-based regimen provides an effective alternative, especially given the availability of two-and three-drug fixed-dose combinations. As observed in a recent randomized controlled trial, good virological outcomes (83% had a viral load less than 400 copies per ml for 3.7 years irrespective of age) can be achieved by starting children on ABC, 3TC and an NNRTI (163). EFV has not been used in this age group, however during the finalization of these guidelines the United States Food and Drug Administration approved this drug for children 3 months to 3 years old weighing more than 3.5 kg. Dosing for this population is provided in Annex 7 and further guidance on how best to use this drug as an alternative to LPV/r or NVP will be provided when additional data are available.

# Choice of NRTIs
The choice of NRTIs should aim to construct a robust and durable backbone that balances minimizing toxicity, minimizing cost and maximizing feasibility. Only limited evidence (164) from head-to-head comparisons informs the selection of NRTIs (AZT or ABC) combined with 3TC in a triple ARV regimen. However, the choice of first-line NRTIs affects second-line ART, and failure of AZT is known to result in the accumulation of thymidine analogue mutations, reducing susceptibility to ABC or TDF in a subsequent regimen (if two or more thymidine analogue mutations are present). The risk of this occurring is greater with an NNRTI-based regimen; using AZT in the context of an LPV/r-based regimen may therefore not be as problematic. By contrast, HIV resistance to ABC does not lead to resistance to thymidine analogues and preserves or even increases the susceptibility of HIV to AZT and d4T for second-line use (159).
Although ABC may be preferable in the interest of ART sequencing (159,165) and harmonizing with the regimens for older children, availability is limited in resource-limited settings. In addition, the cost of ABC may be a significant barrier to adopting it in many countries, especially when combined with LPV/r. Definitive data on the comparative efficacy of ABC and AZT are expected from ongoing studies (166).
Since 2010, WHO has recommended that d4T be phased out because of its known long-term toxicity. However, in settings in which using AZT may not be advisable because of the high risk of anaemia (such as malaria-endemic settings) and in which ABC is not available, d4T remains an option within the limited treatment options for this specific age group. d4T also remains important in the situation in which toxicity to AZT is suspected or confirmed and ABC cannot be used. However, the duration of therapy with this drug should be limited to the shortest time possible. Box 10.7 provides guidance on phasing out d4T.
In developing these recommendations, the Guidelines Development Group emphasized: the importance of potent, first-line regimens for which there is evidence of better virological response as indicated by randomized controlled trials in this age group; the need to address the increasing evidence of HIV resistance to NNRTI among children younger than 18 months, especially in the context of the recommendation to treat pregnant women with EFV-based regimens for PMTCT;
the desirability of having one preferred regimen for children younger than three years while providing alternative strategies that remain less costly, preserve second-line options and address feasibility concerns;
anticipating the availability of new formulations during the next few years (sprinkles or sachets containing LPV/r); using non-thymidine analogues in first-line regimens to preserve the response to AZT in second-line regimens and to harmonize the regimens for older children and adults, while also recognizing the additional expense;
identifying a subset of children who can benefit from alternative strategies to preserve PIs for use in second-line ART as indicated by a randomized trial; and identifying a manageable regimen, such as ABC + 3TC + AZT, for use in the context of TB co-treatment that can maintain good clinical and immunological response after virological suppression on standard ART.

# Clinical considerations
Section 10.6 (Implementations considerations for key recommendations, Box 10.6) discusses implementation considerations relevant to programme managers. An important consideration for clinicians and other health care providers relates to the challenges of providing LPV/r for young children. When clinicians anticipate significant difficulties in dealing with storing or administering LPV/r, using NVP (especially an NVP-based fixed-dose combination) can be considered. In addition, using LPV/r oral liquid should be avoided in premature babies or in full-term babies younger than 14 days (167). Dosing for children younger than six weeks should be calculated based on body surface area (Annex 3).

# Key research gaps
The extent to which new approaches to PMTCT influence the resistance pattern of children becoming infected with HIV despite exposure to ARV drugs for PMTCT still needs to be fully explored outside trial settings. In addition, more evidence is needed to inform the optimal choice of NRTIs and to confirm the safety of EFV-containing regimens, as a first-line option or within PI-sparing strategies in the absence of viral load or genotyping. Studies to fully address the long-term metabolic implications of using LPV/r-based regimens for infants and young children are also needed. For children infected with HIV three years and older (including adolescents), EFV is the preferred NNRTI for first-line treatment and NVP is the alternative (strong recommendation, low-quality evidence).
Special note: In determining the choice of NNRTI for first-line therapy, national programmes should consider the dosing characteristics of EFV (once-daily) and NVP (twice-daily) and how this aligns with the NRTI backbone. For example, NVP may be a better choice if the recommended regimen is a twice-daily option using a fixed-dose combination.
For children infected with HIV three years to less than 10 years old (or adolescents less than 35 kg), the NRTI backbone for an ARV regimen should be one of the following, in preferential order:
- ABC + 3TC - AZT or TDF + 3TC (or FTC) (Conditional

# recommendation, low-quality evidence).
Special note: Consideration should be given to the relative merits of ABC versus TDF versus AZT for this population. There is no definitive evidence to make a preferred recommendation, and each option has its respective risks and benefits. ABC can be used once daily, is available across age groups as a fixed-dose combination with 3TC and harmonizes with TDF from a resistance perspective (168). AZT has been widely used and is available as dual and triple fixed-dose combinations with NVP but is dosed twice daily and can cause severe anaemia. TDF has recently been approved for use in children (169), and the advantages include once-daily dosing. However, paediatric TDF formulations are not widely available, experience with TDF in children is limited and there are concerns about the long-term effects of bone toxicity (170,171). Considerations that support the adoption of TDF as the national recommendation include: the national programme uses TDF for adults and pregnant women and a suitable TDF fixed-dose combination formulation for children is available.
For adolescents infected with HIV (10 to 19 years old) weighing 35 kg or more, the NRTI backbone for an ARV regimen should align with that of adults and be one of the following, in preferential order: Children and adolescents who are on d4T-containing regimens without evidence of treatment failure can safely substitute ABC or TDF for d4T. Despite a lack of direct evidence, consideration can also be given to substituting ABC or TDF for AZT with the goal of simplifying and harmonizing treatment regimens across age groups. Including TDF in initial ARV regimens for children with HBV coinfection offers the potential advantage of reducing the selection of HIV resistance to 3TC that may compromise future options for HBV treatment. b d4T use should be restricted to situations in which toxicity to AZT is suspected or confirmed and access to ABC or TDF is lacking. The duration of therapy with this drug should be limited to the shortest time possible. See Box 10.7 for guidance on phasing out d4T. c Special circumstances may include situations where preferred or alternative regimens may not be available or suitable because of significant toxicities, anticipated drug-drug interactions, drug procurement and supply management issues, or for other reasons.
Despite increased access to early infant diagnosis and the widespread availability of several child-friendly fixed-dose combinations, ART coverage among children lags significantly behind that of adults. Treatment recommendations for children should be easy to implement at all levels of the health system, including the primary care level, and by all ART service providers, rather than paediatric specialists alone.

# Rationale and supporting evidence
The United States Food and Drug Administration (172) and European Medicines Agency (173) approved using TDF for children older than two years of age, providing an opportunity to offer the same regimen to both adults and children. Harmonizing treatment recommendations with adult regimens could improve children's access to ART. Other benefits of TDF include the ability to combine it with 3TC and EFV to create a potent once-daily regimen for children (169). In addition, the fact that HIV resistance to TDFspecifically K65R -can enhance the antiviral effect of AZT may make TDF a good choice for first-line therapy in terms of sequencing NRTIs from first-to second-line regimens (165,(174)(175)(176). However, experience with TDF in young children is limited, and although TDF is known to reduce bone mineral density, it is not clear whether this is permanent and how it might affect future patterns of growth and fracture risk, as highlighted in the values and preferences survey among health workers. In addition, TDF formulations for younger children are not widely available and to date there are no TDF-containing paediatric fixed-dose combinations. ABC shares many of the benefits of TDF (once-daily dosage and a favourable resistance profile) but, in contrast to TDF, ABC has been more thoroughly studied in children and is generally well tolerated. ABC is also available in paediatric fixed-dose combination formulations but is significantly more costly. Further, among people with HLA-B5701, it can cause potentially fatal hypersensitivity; although this is very rare among African children, it can affect up to 3-4% of Caucasian and Asian children (177).
A systematic review based on observational data indicates that EFV has a better shortterm toxicity profile and is associated with better virological response than NVP (121,178).
Most children currently receiving ART are treated with regimens that contain NVP, whereas in adults, EFV is increasingly being selected as the preferred NNRTI. The primary reason for this discrepancy relates to the relative availability of NVP or EFV in fixed-dose combinations for children or adults. Children who are well controlled and stable on NVPcontaining regimens do not need to substitute EFV for NVP, but EFV would be a better choice for those initiating ART with other once-daily drugs.
In developing these recommendations, the Guidelines Development Group emphasized: using potent first-line regimens;
the convenience of once-daily dosing and the use of fixed-dose combinations whenever possible;
using non-thymidine analogues -either ABC or TDF -in first-line regimens to maximize the response to AZT in second-line ART; and providing treatment recommendations for older children and adolescents that are aligned with those for adults.  - Aligned with adult regimens a Defined based on the criteria for treatment failure adopted nationally.

# Clinical considerations for scaling up ART for children
The long-term efficacy and safety of TDF, ABC and EFV and the recommended combination need further investigation. More data are needed on the bone, growth and renal toxicity profiles of TDF in children and adolescents, especially in the context of malnutrition and stunting. Similarly, adverse events associated with EFV during adolescence, such as central nervous system effects, require investigation to ensure safe harmonization with adult treatment regimens. Toxicity surveillance systems implemented alongside ART at sentinel sites can provide data to better understand the frequency and clinical relevance of these toxicities.

# tB co-treatment in children with hiv
TB is one of the most common opportunistic infections affecting children with HIV.
Selecting regimens that are compatible with TB therapy is therefore essential. Interactions between rifampicin and LPV/r or NVP mean that co-treatment in children under three years is challenging, but a recent large randomized controlled trial (163) of ART in children has generated preliminary evidence on the efficacy of triple nucleoside therapy which, despite limited data in the context of TB co-treatment, offers a suitable option for children who require TB treatment while already receiving ART (Table 7.12).
The recommended regimens for children diagnosed with TB and starting ART are consistent with the 2010 recommendations and are summarized in Table 7.12, together with broader guidance on choosing regimens for co-treatment of HIV and TB.  (163), this regimen should be considered as the preferred option for children younger than three years who are receiving a LPV/r-based regimen when starting TB treatment. The United States Food and Drug Administration approval for the use of EFV in children 3 months to 3 years old weighing more than 3.5 kg offers a potential alternative to the triple NRTI approach. An EFV-based regimen in children under 3 years is still not recommended as pharmacokinetics data are needed to ensure that the co-administration of rifampicin does not decrease drug levels below the therapeutic level. Triple NRTI should also be considered as the preferred regimen for children older than 3 years with a history of failure on a NNRTI-based regimen. d Increase RTV until it reaches the same dose as LPV in mg, in a ratio of 1:1. e Substitution with EFV should be considered as the preferred option (179), and EFV could be maintained after TB treatment ends to enable simplification and harmonization with the ARV drug regimens used for older children. If feasible, HBsAg testing should be performed to identify people with HIV and HBV coinfection and who therefore should initiate TDF-containing ART. b Can be considered only in settings with a high prevalence of cryptococcal antigenaemia (>3%) (180). c Consider assessing the presence of chronic conditions that can influence ART management such as hypertension and other cardiovascular diseases, diabetes and TB. d Among children and adults with a high risk of adverse events associated with AZT (low CD4 or low BMI). e Among people with a high risk of adverse events associated with TDF: underlying renal disease, older age group, low BMI, diabetes, hypertension and concomitant use of a boosted PI or potential nephrotoxic drugs. f Among people with a high risk of adverse events associated with NVP, such as being ART-naive, women with HIV with a CD4 count >250 cells/mm 3 and HCV coinfection. However, liver enzymes have low predictive value for monitoring NVP toxicity.
Clinical assessment and laboratory tests play a key role in assessing individuals before ART is initiated and then monitoring their treatment response and possible toxicity of ARV drugs. Table 7.13 summarizes recommended laboratory tests for HIV screening and monitoring, as well as approaches to screen for coinfections and noncommunicable diseases.

# New recommendations
Viral load is recommended as the preferred monitoring approach to diagnose and confirm ARV treatment failure (strong recommendation, low-quality evidence).
If viral load is not routinely available, CD4 count and clinical monitoring should be used to diagnose treatment failure (strong recommendation, moderate-quality evidence).
Special notes: Treatment failure is defined by a persistently detectable viral load exceeding 1000 copies/ml (that is, two consecutive viral load measurements within a three-month interval, with adherence support between measurements) after at least six months of using ARV drugs. Viral load testing is usually performed in plasma; however, certain technologies that use whole blood as a sample type, such as laboratory-based tests using dried blood spots and point-of-care tests, are unreliable at this lower threshold, and where these are used a higher threshold should be adopted.
Viral load should be tested early after initiating ART (at 6 months) and then at least every 12 months to detect treatment failure. If viral load testing is not routinely available, CD4 count and clinical monitoring should be used to diagnose treatment failure, with targeted viral load testing to confirm virological failure where possible.
Monitoring individuals receiving ART is important to ensure successful treatment, identify adherence problems and determine whether and which ARV regimens should be switched in case of treatment failure. Before 2010, WHO guidelines on ARV recommended using clinical outcomes and CD4 count for routinely monitoring the response to ARV drugs. However, the value of viral load testing as a more sensitive and early indicator of treatment failure is increasingly recognized and is the gold standard for monitoring the response to ARV drugs in high-income settings.
The 2010 WHO guidelines recommended that countries consider phasing in viral load testing to monitor the response to ART and use a viral load threshold above 5000 copies/ml in an adherent person with no other reasons for an elevated viral load (such as drug interactions, poor absorption and intercurrent illness). However, most ARV programmes in resource-limited settings still do not have access to viral load testing and continue to rely on clinical and immunological monitoring. This limited use of viral load monitoring has been identified as a key reason for the lower than expected rates for switching ARV regimens in resource-limited settings.

# Rationale and supporting evidence
Although evidence from clinical trials for a survival benefit of viral load testing is limited, it can provide an early indication of treatment failure, and the 2013 guidelines strongly recommend using it for detecting virological failure and/or confirming treatment failure among people with evidence of clinical and/or immunological failure (Table 7.14). Since several clinical and epidemiological studies show that the risk of HIV transmission is very low when the viral load is lower than 1000 copies/ml (181), the Guidelines Development Group also recommended reducing the viral load threshold for treatment failure from 5000 copies/ml to 1000 copies/ml. neW

# Virological failure
Plasma viral load above 1000 copies/ ml based on two consecutive viral load measurements after 3 months, with adherence support
The optimal threshold for defining virological failure and the need for switching ARV regimen has not been determined
An individual must be taking ART for at least 6 months before it can be determined that a regimen has failed Assessment of viral load using DBS and point-of-care technologies should use a higher threshold a See the list of clinical conditions associated with advanced or severe HIV disease in Annex 1. b Section 6.1 discusses immune reconstitution inflammatory syndrome.

# monitoring response to art and the d iagnosis of treatment failure

# Virological monitoring (viral load) versus immunological (CD4) and clinical monitoring (WHO clinical staging)
The main rationale for recommending viral load monitoring as the preferred approach compared with immunological and clinical monitoring is to provide an early and more accurate indication of treatment failure and the need to switch to second-line drugs, reducing the accumulation of drug-resistance mutations and improving clinical outcomes. Measuring viral load can also help to discriminate between treatment failure and non-adherence (183) and can serve as a proxy for the risk of transmission at the population level (76).
There is still limited evidence to support any additional survival benefit of viral load monitoring over CD4 and/or clinical monitoring among individuals with HIV receiving ART. A systematic review identified three randomized clinical trials on virological versus immunological and clinical monitoring (184-186) (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
Compared with immunological and/or clinical monitoring, adding viral load monitoring has not been associated with reduced mortality. In one of these trials (185), no significant difference in the incidence of clinical failure, switching to second-line regimens and resistance mutations was found. One cohort modelling study among adults also found that adding virological monitoring to clinical and/or immunological criteria made no difference in mortality or new AIDS-defining illnesses (187). Although randomized controlled trials have not yet shown that viral load monitoring translates into survival gains, follow-up has been limited (less than five years) and longer follow-up is required to examine the longer-term impact on survival, resistance profile and HIV transmission.
A systematic review provided moderate-quality evidence that current WHO guidelines on immunological and clinical monitoring for treatment failure have poor sensitivity and lower positive predictive value for identifying virological failure in adults (187)(188)(189)(190)(191)(192)(193)(194)(195)(196)(197)(198)(199)(200) (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes). This means that many of the people who are identified with immunological failure in fact have adequate virological suppression and risk being misclassified as having treatment failure and switched unnecessarily to second-line therapy. A further systematic review using data in children also provided moderate-quality evidence that immunological criteria (201)(202)(203)(204) have low sensitivity and positive predictive value for identifying children with virological failure.

# Immunological monitoring versus clinical monitoring
Where viral load monitoring is unavailable, clinical monitoring and CD4 monitoring are recommended (205). Although a systematic review of two randomized controlled trials (184,206) provide moderate-quality evidence of mortality and morbidity benefits with CD4 and clinical monitoring compared with routine clinical monitoring in adults receiving ART, these trials largely focused on CD4 and clinical monitoring in people who initiated ART at CD4 counts below 200 cells/mm 3 (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
Existing immunological and clinical criteria may have decreased sensitivity and specificity to detect treatment failure in people who initiate ART at higher CD4 counts, and more accurate immunological criteria for these people remain to be identified.

# Routine versus targeted viral load monitoring to detect treatment failure
Viral load should be monitored routinely (every 6-12 months) to enable treatment failure to be detected earlier and more accurately. In settings with limited access to viral load testing, a targeted viral load strategy to confirm failure suspected based on immunological or clinical criteria (Table 7.14) should be used to avoid unnecessary switching to second-line ART. Targeted viral load monitoring is less costly than routine viral load testing, but as with clinical and immunological monitoring, has the potential to delay switching to second-line ART and may subsequently increase the risk of disease progression, selection of ARV drug resistance and HIV transmission.

# Threshold for defining virological failure
The optimal threshold for defining virological failure and for switching ARV regimens has not been established. The rationale for the threshold of 1000 copies/ml was based on two main sources of evidence. First, viral blips or intermittent low-level viraemia (50-1000 copies/ml) can occur during effective treatment but have not been associated with an increased risk of treatment failure unless low-level viraemia is sustained (207). Second, clinical and epidemiological studies show that the risk of HIV transmission and disease progression is very low when the viral load is lower than 1000 copies/ml (181,208,209).
Most standard blood and plasma viral load platforms available and being developed have good diagnostic accuracy at this lower threshold. However, the sensitivity of dried blood spots for viral load determination at this threshold may be reduced (210,211). Programmes relying on dried blood spot technology for viral load assessment may therefore consider retaining the higher threshold (3000-5000 copies/ml) until sensitivity at lower thresholds is established (212)(213)(214).

# Special considerations for children
These guidelines aim to harmonize monitoring approaches for children with those recommended for adults. As more children start ART earlier and at higher CD4 counts, viral load monitoring to detect treatment failure and lack of adherence will be increasingly beneficial. In addition, viral load may be instrumental for implementing treatment strategies to preserve second-line options as children age (such as switching from LPV/r to an NNRTI once virological suppression is sustained) (see section 7.2.3).
Evidence from one randomized controlled trial conducted in several countries (including the United States of America, European countries, Brazil and Thailand) PENPACT1 (158), suggests that switching treatment at lower viral load thresholds does not lead to better clinical and virological outcomes but does minimize the development of HIV drug resistance, especially for NRTIs when an NNRTI-based regimen is used. In this context, alignment with the viral load thresholds recommended for adults is advisable. However, viral load results in the first six months after initiating ART should be interpreted carefully, as infants and young children may require longer to achieve virological suppression because of high baseline viral load.
The recommendation to initiate ART for all children younger than five years of age regardless of clinical and immunological criteria means that CD4 cell count testing at baseline is not required for initiating ART. However, where viral load monitoring capacity is limited or unavailable, CD4 monitoring -including baseline measurement and CD4 percentage for children younger than five years of age -will still be important for monitoring treatment response.
As in the case of adults, lack of viral load or CD4 capacity should not prevent children from starting ART. The results from a recently completed trial show that mortality and disease progression are comparable between clinical monitoring and laboratory monitoring, especially in the first year of treatment (163). Access to ART should be the first priority. Lack of laboratory tests for monitoring treatment response should not be a barrier to initiating ART.

# Clinical considerations for scaling up viral load testing

# Setting priorities.
If viral load testing is limited, it should be phased in using a targeted approach to confirm treatment failure. This may be especially relevant in populations receiving ARVs to reduce HIV transmission, such as pregnant and breastfeeding women and among serodiscordant couples, for whom sustained viral load suppression is critical to the efficacy of the strategy.

# monitoring and substitutions for arv drug toxicities 7.4.1 Guiding principles
The availability of laboratory monitoring is not required for initiating ART.
Symptom-directed laboratory monitoring for safety and toxicity can be used for those receiving ART.

# major types of arv toxicities
The 2010 WHO ART guidelines recommended a symptom-directed approach to laboratory monitoring of the safety and toxicity of ARV regimens. At the same time, several laboratory tests for monitoring ARV toxicity were advised (but not required) for specific high-risk people using certain drugs. Table 7.15 lists key types of toxicity and associated risk factors for the major ARV drugs.
Monitoring drug toxicity using a symptom-directed approach needs to be investigated further to optimize treatment. More data are needed on whether routine or periodic laboratory monitoring for specific types of toxicity (such as renal function monitoring among TDF users) is required for all individuals or only people at higher risk.

# monitoring tdf toxicity
TDF nephrotoxicity is characterized by proximal tubular cell dysfunction that may be associated with acute kidney injury or chronic kidney disease (130).
According to a systematic review (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes), no studies have properly compared monitoring strategies for people receiving TDF, such as routine toxicity monitoring versus care with no monitoring or incidental monitoring in case of perceived clinical need. One clinical trial (the DART trial) comparing laboratory with clinical monitoring showed that individuals receiving TDF have an increased risk of reduced estimated glomerular filtration rate but no increased risk of renal failure over a median five years of follow-up (low-quality evidence). A few observational cohort studies reported that using TDF was associated with an increased risk of chronic kidney disease. However, the exposure time to TDF in all these studies was considered too short to indicate a long-term increased risk for renal failure, the occurrence of bone fractures or changes in fat distribution.
The best parameter for TDF-related renal toxicity monitoring needs to be evaluated; meanwhile, laboratory monitoring using a creatinine test is not mandatory to initiate treatment with TDF. However, it is advisable for high-risk people (those who are older or have underlying renal disease, long-term diabetes or uncontrolled hypertension concomitant with boosted PIs or nephrotoxic drugs) to detect and limit further progression of renal impairment. High frequency of glycosuria has also been found in people without diabetes biopsied for TDF nephrotoxicity with increased serum creatinine compared with TDF-treated people with a normal glomerular filtration rate, suggesting that dipstick glycosuria may be a cost-effective screening test for serious TDF-induced kidney injury (215).  TDF-related decreases in bone mineral density have been observed in children, although it is unclear how reducing bone mineral density might impact future growth patterns or the risk of bone fracture. In addition, an accurate and feasible method to measure bone mineral density still needs to be identified, and significant uncertainty remains around how best to monitor TDF-related bone toxicity among children. Dual-energy X-ray absorptiometry testing is not possible in most settings, but careful growth monitoring is recommended while children are receiving treatment with TDF (169).

# Clinical considerations
Laboratory monitoring is not mandatory to initiate treatment with TDF.
Routine blood pressure monitoring may be used to assess for hypertension.
Urine dipsticks may be used to detect glycosuria or severe TDF nephrotoxicity in individuals without diabetes using TDF-containing regimens.
If the creatinine test is routinely available, use the estimated glomerular filtration rate a at baseline before initiating TDF regimens.
Do not initiate TDF when the estimated glomerular filtration rate is <50 ml/min, or in longterm diabetes, uncontrolled hypertension and renal failure.
Monitor growth in children using TDF.

# Key research gaps
More data are needed on how to best monitor renal function in people using TDF-containing regimens (whether toxicity monitoring should be routine or targeted in high-risk groups, with alternative drugs for high-risk people). In addition, more data are needed to understand the frequency and clinical relevance of reduced bone mineral density in children. More accurate and affordable methods to monitor bone toxicity should be identified for this specific population.

# toxicity monitoring for other arv drugs AZT
AZT is associated with a risk of haematological toxicity, and measuring haemoglobin is recommended before initiating ART, mainly among adults and children with low body weight, low CD4 counts and advanced HIV disease. People with HIV with severe anaemia at baseline (haemoglobin <7.0 g/dl) should avoid AZT as first-line therapy.
The laboratory measurement of liver enzymes has very low predictive value for NVP-containing regimens. However, monitoring hepatic enzymes is recommended if feasible, especially for women with HIV who have CD4 cell counts >250 cells/mm 3 and individuals with HIV who are coinfected with HBV or HCV. Section 7.2.1 provides more information on the safety of NVP among individuals with high CD4 cell counts.

# monitoring and substitutions for arv drug toxicities
The main type of toxicity of EFV is central nervous system side effects, which typically resolve after a few weeks. However, in some cases, they can persist for months or not resolve at all. Despite concerns about the potential risk of teratogenicity associated with using EFV during pregnancy, a recent meta-analysis found no overall increase in the incidence of birth defects for first-trimester EFV exposure compared with other ARV drugs (122). Section 7.3.2 provides more information on the safety of EFV among pregnant women.

# drug substitutions for arv drug toxicity
Drug regimen or single agent substitutions may be required for drug toxicity and to avoid drug interactions. Section 7.4.3 and 7.4.4 provides guidance on monitoring specific types of ARV drug toxicity.

# Clinical considerations
Delaying substitutions or switches when there are severe adverse drug effects may cause harm and may affect adherence, leading to drug resistance and treatment failure.
When drug interruptions are required, such as for severe and life-threatening adverse events related to toxicity, it is important to consider the various half-lives of ARV drugs. For example, when a NNRTI needs to be discontinued, a staggered approach should be used by prolonging the use of the NRTI backbone for two to three weeks. Alternatively, the NNRTI could be temporarily substituted with a boosted PI.

# Key arv drug interactions
Providers should be aware of all drugs that people with HIV are taking when ART is initiated and new drugs that are added during treatment maintenance. There are several key drug interactions (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
WHO TB treatment guidelines review key considerations for managing coinfection with TB and HIV (216). A key contraindicated drug combination includes rifampicin and PIs. When people coinfected with TB and HIV are receiving a boosted PI, rifampicin may need to be substituted with rifabutin. If rifabutin is not available, LPV/r and SQV/r can be used for the duration of TB treatment, if the boosting dose of RTV is increased or double the standard dose of LPV/r is used (see section 7.6.1). For children, using a triple NRTI regimen (such as AZT + 3TC + ABC) should also be considered.
Ribavirin and peginterferon alpha-2a are often used for treating HCV. Administration of these agents with AZT has been associated with an increased risk of anaemia and hepatic decompensation. People coinfected with HCV and HIV and receiving AZT may need to be switched to TDF.
Substitute NVP with EFV

# Itraconazole and ketoconazole
Use an alternative antifungal agent (for example fluconazole)
WHO recommends methadone and buprenorphine for treating opioid dependence (218).
Co-administering EFV decreases methadone concentrations. This could subsequently cause withdrawal symptoms and increase the risk of relapse to opioid use. People receiving methadone and EFV should be monitored closely, and those experiencing opioid withdrawal may need to adjust their methadone dose.
ARV drugs have the potential to either decrease or increase the bioavailability of steroid hormones in hormonal contraceptives (219). Limited data suggest potential drug interactions between many ARV drugs (especially some NNRTIs and RTV-boosted PIs) and estrogen-based hormonal contraceptives. These interactions may alter the safety and effectiveness of both the hormonal contraceptive and the ARV drug. If women receiving ART decide to initiate or continue using hormonal contraceptives, consistently using condoms and other contraceptive methods is recommended both to prevent HIV transmission and to compensate for any possible reduction in the effectiveness of the hormonal contraception.
Concomitant use of boosted PIs and NNRTI with some antihistamine agents (such as astemizole and terfenadine) has been associated with severe and life-threatening reactions, such as cardiac arrhythmia. Alternative antihistamine agents include loratidine and cetirizine.
WHO recommends using statins for people with a 10-year cardiovascular risk exceeding 30% (220). Boosted PIs may lead to increased concentrations of lovastatin and simvastatin. Increased concentrations may increase the risk of developing serious adverse events such as myopathy (including rhabdomyolysis). Alternative dyslipidaemia agents should be used to prevent severe toxicity among people with HIV.
a This table was developed using the University of Liverpool's drug interaction charts, a resource which can be found online at www.hiv-druginteractions.org. A more comprehensive table of ARV drug interactions is available on the Web Annex (www.who. int/hiv/pub/guidelines/arv2013/annexes).

# monitoring and substitutions for arv drug toxicities

# Box 7.2 Surveillance of ARV drug toxicity
WHO commissioned systematic reviews on specific types of toxicities associated with key ARV drugs and laboratory monitoring strategies to consolidate and update technical guidance (140,169). The reviews highlighted remaining evidence gaps in the potential increased risk of toxicity associated with the long-term use of ARV drugs, the use of ARV drugs during pregnancy and in breastfeeding mothers, children and adolescents and populations with associated risk factors and in laboratory monitoring for toxicity.
The available evidence is limited to studies with limited sample size or short duration.
It is essential to monitor the use of ARV drugs in resource-limited countries where toxicities may present a different pattern in association with environmental or behavioural factors, the prevalence of other conditions and where ARV drugs are used in association with other medicines. Implementing toxicity surveillance will provide the opportunity to produce evidence on specific types of toxicity, increase confidence in the use of the drugs, identify populations with risk factors and plan preventive strategies.
The Guidelines Development Group encouraged WHO to strengthen toxicity surveillance activities to increase evidence on toxicity in key areas. These areas cover a potential increased risk of toxicity associated with the long-term use of ARV drugs, renal and bone toxicity associated with using TDF among adults and children, the safety of using EFV-and TDF-containing regimens during pregnancy and in breastfeeding mothers and using TDF among children, adolescents and populations with associated risk factors. Developing laboratory markers to monitor renal function among people using TDF is another important area for research.
Several toxicity surveillance activities have already started with WHO support, using standardized approaches at sentinel sites in resource-limited settings. Targeted and systematic surveillance is being conducted in Cote d'Ivoire to monitor renal toxicity associated with TDF in first-and second-line regimens, with an assessment of laboratory monitoring needs in three sentinel sites. A similar approach is being implemented in Viet Nam to assess renal toxicity associated with TDF and central nervous system toxicity associated with EFV in people who use ARV drugs to prevent HIV infection, such as in serodiscordant couples. In the Lao People's Democratic Republic, anaemia associated with AZT and hypersensitivity associated with NVP are monitored using a targeted and systematic surveillance approach. In Malawi, a surveillance programme will monitor infant growth, following mothers who are breastfeeding and receiving TDF.
The implementation of a pregnancy registry, including a surveillance programme for birth defects, is recommended where feasible to assess the safety of ARV drugs and any other medicines during pregnancy and risk factors for adverse pregnancy outcomes, including maternal health outcomes, premature births, stillbirths, low birth weight and congenital abnormalities. WHO, the United States President's Emergency Plan for AIDS Relief, the United States Centers for Disease Control and Prevention and the United States National Institutes of Health support the establishment of ARV pregnancy registries and birth defect surveillance in sentinel sites in Malawi, South Africa and Uganda to assess the use of EFV-containing regimens at large scale among pregnant women.
Surveillance of ARV drug toxicity will help to better understand the long-term risk of ART toxicity and optimize the management of ARV drugs for HIV treatment and prevention in all populations. a DRV/r can be used as an alternative PI and SQV/r in special situations; neither is currently available as a heatstable fixed-dose combination, but a DRV + RTV heat-stable fixed-dose combination is currently in development. b ATV/r can be used as an alternative to LPV/r for children older than six years. c Unless failure is caused by lack of adherence resulting from poor palatability of LPV/r.

# What arv regimen to switch to (second-line art)
Using a boosted PI + two NRTI combination is recommended as the preferred strategy for second-line ART for adults, adolescents and also for children when NNRTI-containing regimens were used in first-line ART. In children using a PI-based regimen for first-line ART, switching to NNRTI or maintaining the PI regimen is recommended according with age (Table 7.17).

# second-line art for adults and adolescents

# New recommendations
Second-line ART for adults should consist of two nucleoside reverse-transcriptase inhibitors (NRTIs) + a ritonavir-boosted protease inhibitor (PI).
- The following sequence of second-line NRTI options is recommended:
- After failure on a TDF + 3TC (or FTC)-based first-line regimen, use AZT + 3TC as the NRTI backbone in second-line regimens.
- After failure on an AZT or d4T + 3TC-based first-line regimen, use TDF + 3TC (or FTC) as the NRTI backbone in second-line regimens.
- Use of NRTI backbones as a fixed-dose combination is recommended as the preferred approach (strong recommendation, moderate-quality evidence).
Heat-stable fixed-dose combinations of ATV/r and LPV/r are the preferred boosted PI options for second-line ART (strong recommendation, moderate-quality evidence).

# HIV and TB coinfection
If rifabutin is available Standard PI-containing regimens as recommended for adults and adolescents If rifabutin is not available Same NRTI backbones as recommended for adults and adolescents plus double-dose LPV/r (that is, LPV/r 800 mg/200 mg twice daily) or standard LPV dose with an adjusted dose of RTV (that is, LPV/r 400 mg/400 mg twice daily)

# HIV and HBV coinfection
AZT + TDF + 3TC (or FTC) + (ATV/r or LPV/r) a ABC and ddI can be used as NRTI backup options but add complexity and cost without clinical advantages. DRV/r can be used as an alternative PI and SQV/r in special situations, but neither is currently available as a heat-stable fixed-dose combination, but a DRV + RTV heat-stable fixed-dose combination is in development.
The 2010 WHO ART guidelines recommended that second-line adult regimens include a boosted-PI plus two NRTIs (determined by the drug used in first-line therapy). Those guidelines placed a high value on using simpler second-line regimens, ideally heat-stable formulations and fixed-dose combinations (once-daily formulations when possible).
Except for the recommendation for people with HIV and TB, the recommendations in 2013 remain unchanged from the 2010 recommendations.

# Rationale and supporting evidence PI options for second-line ART
Since first-line ART should preferably be based on an NNRTI, PI-based regimens are recommended for second-line therapy. Of the PI options, ATV/r and LPV/r are preferred. DRV/r is an alternative but is currently not available as a fixed-dose combination, although one is in development. The other PIs (FPV/r, IDV/r and SQV/r) are not available as heat-stable fixed-dose combinations and/or are associated with high pill burden and higher frequency of side effects.
The Guidelines Development Group emphasized the importance of simplifying second-line ART by reducing the pill burden and limiting the number of preferred second-line regimens that could be used across populations (adults, adolescents, children, pregnant women and people coinfected with TB, HBV and HCV). The use of less toxic, more convenient and more efficacious heat-stable fixed-dose combinations was also considered critical.
A systematic review (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes) of data from six clinical trials comparing drugs used for second-line ART (ATV/r, LPV/r and DRV/r) concluded that there was no evidence to support changing the recommendation in the 2010 neW guidelines (221)(222)(223)(224)(225)(226). These studies showed low-to very-low-quality evidence (downgraded in the GRADE evaluation primarily for indirectness and imprecision) for using ATV/r or DRV/r (once-daily) over LPV/r (twice-daily) or vice versa as preferred boosted PI options. ATV/r was considered to be comparable to LPV/r in one trial among ART-experienced individuals (221).
In a trial among ART-naive individuals, ATV/r showed a better virological response and better retention in care when compared with LPV/r (224). In two studies, people receiving DRV/rcontaining regimens also showed better virological response and retention in care than people receiving LPV/r, both in treatment-naive and experienced people (222,226). DRV/r has been used for second-line therapy in high-income settings. However, two key factors currently preclude DRV/r as a preferred option in these guidelines. These include the high cost and it not being available as a heat-stable fixed-dose combination. Additional research is required to better understand sequencing strategies for PIs in second-and third-line therapy. The different drug toxicity profiles of ATV/r and LPV/r, the contraindication of ATV/r with rifampicin and the lack of WHO approval for the use of ATV/r in children younger than six years provide additional grounds for maintaining both PIs as equal options (Table 7.

# 19). The Guidelines Development
Group recommended that DRV/r should be maintained as a preferred third-line drug. However, using it as an alternative option to LPV/r or ATV/r for second-line therapy can be considered, especially when competitively priced fixed-dose combinations are available.

# NRTI backbone
The Guidelines Development Group maintained the rationale adopted in 2010, recommending drug sequencing consistent with ART-optimizing principles (in particular, availability as fixeddose combinations and tolerability) and resistance mutation risk, based on the NRTIs used in the first-line regimen. If a thymidine analogue NRTI (AZT or d4T) was used in the failing firstline regimen, TDF should be used in the second-line regimen. If a non-thymidine analogue NRTI was used in first-line ART (that is, TDF), AZT should be used in second-line ART. Other NRTI drugs such as ABC and ddI are acceptable as potential back-up options in special situations but are not recommended as preferred alternatives, since they have no specific advantage and add complexity and cost.
For individuals coinfected with HIV and HBV whose first-line regimen contained TDF + 3TC (or FTC), these NRTIs should be continued in the second-line regimen for the anti-HBV activity and to reduce the risk of hepatic flares, regardless of the selected second-line regimen, which should be AZT + TDF + 3TC (or FTC) + a boosted PI.
For people with active TB disease receiving rifampicin, all boosted PIs in standard doses are contraindicated because of drug interactions and significant reductions in PI plasma concentrations (227)(228)(229)(230). In this situation, LPV/r and SQV/r may be used with an adjusted, superboosted dose of RTV (LPV/r 400 mg/400 mg twice daily or SQV/r 400 mg/400 mg twice daily) or doubling the LPV/r daily dose (LPV/r 800 mg/200 mg twice daily), but this is associated with high levels of toxicity and requires close clinical and laboratory monitoring. The recommendation to use LPV/r 800 mg/200 mg twice daily is based on evidence graded as low-quality, and it is associated with a similar level of toxicity as LPV/r 400 mg/400 mg twice daily (230,231). However, this option may be less complex and more feasible, since LPV/r is widely available as a single formulation, whereas RTV is not. However, when rifabutin is used in place of rifampicin, all boosted PIs can be concomitantly administered in their standard doses (Table 7. 19).

# Clinical considerations
Clinical and programmatic simplification can be promoted in the sequencing from first-to second-line ART. If AZT-or d4T-based regimens are failing, a second-line regimen with oncedaily dosing for boosted PI and NRTI components (such as TDF + 3TC (or FTC) + ATV/r) should be adopted. If a TDF-based regimen is failing, twice-daily dosing for boosted PI and NRTI components (such as AZT + 3TC + LPV/r) should be adopted.

# Key research gaps
Several ongoing studies comparing various drugs and ARV classes (232-236) will provide more data on appropriate second-line regimens, including NRTI-sparing and NRTI-limiting approaches (the results are expected after 2014). Further investigation is needed of the role of DRV in second-and third-line regimens (optimal dosing in adults and children, once versus twice daily, fixed-dose combinations with other boosting agents and integrase inhibitors and sequencing strategies). Several trials are underway that are examining induction and maintenance using PI/r monotherapy in maintenance. The potential of including rifabutin as part of fixed-dose combinations for TB treatment also needs to be explored.

# second-line art for children (including adolescents)

# Summary of recommended first-and second-line ARV regimens for children (including adolescents)
a No change is recommended unless in the presence of advanced clinical disease progression or lack of adherence specifically because of poor palatability of LPV/r. In this case, switching to a second-line NVP-based regimen should be considered. Based on the recent approval of the use of EFV in children less than 3 years, an EFV-based regimen could be considered as an alternative. However, more data are needed to inform how best to use EFV in this population. b TDF may only be given to children >2 years. c ATV/r can be used as an alternative to LPV/r in children older than 6 years.

# Children (including adolescents)

# First-line ARV regimen
Second-line ARV regimen
Recommending potent and effective second-line regimens for infants and children is especially difficult because of the current lack of experience in resource-limited settings and the limited formulations available. This highlights the importance of choosing potent and effective first-line regimens and ensuring their durability and effectiveness by optimizing adherence.
The 2010 WHO guidelines recommended a regimen based on a PI boosted with RTV and combined with two NRTIs as the second-line treatment for children who fail a regimen of two NRTIs plus an NNRTI (105). For infants and young children exposed to an NNRTI as part of PMTCT interventions and starting a PI-based regimen in first-line ART, the recommendation for second-line was to use two new NRTIs and an NNRTI, as this was the only new drug class available.
The recommendations are now better informed by paediatric clinical trial data (156,158,237) and observational data (157). The Guidelines Development Group also considered operational and programmatic issues including the availability of heat-stable formulations and fixed-dose combinations for children.

# Rationale and supporting evidence
After reviewing data for adults and children and considering factors such as the availability of a heat-stable fixed-dose combination, optimal daily dose, regimen harmonization with adults, high cost and availability of alternatives, the main recommendations established in the 2010 guidelines were maintained.
For children for whom a LPV/r-based first-line regimen has failed, NNRTIs remain the only new drug class that can be introduced. Randomized data among older children (158) provide indirect evidence supporting the safe use of an NNRTI-based second-line regimen, but concerns remain about this approach for infants and young children. Based on the suboptimal performance of NVP-based regimens (and the limited data available to inform the use of EFV) in children younger than three years (153,154) and the potential rapid re-emergence of archived NNRTI-resistant HIV, second-line NNRTI-based regimens are expected to have limited durability in this age group (238).
Increasing evidence suggests that, in young children for whom LPV/r-based regimens have failed, selection of major mutations to PI is rare and accumulation of thymidine analogue mutations is very limited (156,237,239,240). In this context and in the absence of robust second-line alternatives such as DRV/r-containing regimens, the Guidelines Development Group recommended that children younger than three years of age should be maintained on LPV/r until the age of three years, despite treatment failure. However, a more rapid switch should be considered in situations in which failure results from poor adherence because of the poor palatability of LPV/r or in cases of advanced HIV disease. In such cases, children younger than three years should be switched to a NVP-based regimen, and close monitoring should be provided to ensure adequate adherence.
For children starting first-line ART with an NNRTI-based regimen, PI-based regimens remain the recommended choice for second-line therapy. LPV/r is the preferred option, but ATV/r and DRV/r may be considered if more appropriate formulations become available.
Despite its toxicity profile and limited role in TB and HIV coinfection, ATV/r is a promising alternative to LPV/r for children older than six years of age. ATV/r has some advantages over LPV/r, including lower cost and the potential for once-daily dosing. DRV/r is the PI of choice following LPV/r or ATV/r treatment failure and would be valuable as a third-line drug or as second-line therapy in young children for whom first-line ART with LPV/r has neW failed. However, ATV/r is currently only licensed for use among children older than six years and DRV/r in children older than three years. Neither ATV/r nor DRV/r is currently available as a co-formulated fixed-dose combination for children. The Paediatric ARVs Working Group identified appropriate doses of both drugs using current WHO weight bands with scaling down from the current adult fixed-dose combination tablets. Validation studies are urgently needed to develop adequate paediatric formulations.
Unboosted PIs (such as fosamprenavir (FPV), DRV and ATV) and other PIs (such as IDV/r, SQV/r, FPV/r and TPV/r) are associated with reduced virological suppression, high pill burden and/or a higher frequency of side effects and are therefore discouraged (241).
Notably, liquid RTV requires cold storage, is unpalatable, has significant gastrointestinal intolerance and is poorly tolerated by infants and children. The heat-stable 100-mg fixeddose combination tablet formulation of LPV/r for children is better tolerated but cannot be cut or crushed; many children have difficulty in swallowing this tablet whole. Data on whether LPV/r can be given once daily are expected soon from an ongoing randomized trial (242). New heat-stable paediatric sprinkle formulations appear to be a suitable alternative and will be available in the near future (243).
The sequencing of NRTI was determined based on optimizing principles for ARV drugs and the need to maximize antiviral activity despite the selection of resistance mutations. If a thymidine analogue NRTI drug (AZT or d4T) was used in the failing first-line regimen, ABC or TDF should be used in the second-line regimen. If a non-thymidine analogue NRTI drug (ABC or TDF) was used in the failing first-line regimen, AZT should be used in the second-line regimen. The added value of ddI in second-line regimens is unclear; continuing 3TC despite the likely presence of 3TC resistance is the preferred option. HIV harbouring 3TC resistance with the M184V mutation may have reduced viral replication and may also induce some degree of resensitization to AZT or TDF, although this is based on in vitro data (165,244).

# Key research gaps
More evidence is needed to inform the choice of second-line regimens for young children for whom an LPV/r-based first-line regimen has failed. Validation studies to assess simplified dosing for ATV/r and DRV/r fixed-dose combinations are critical to ensure future effective alternatives. Innovative second-line strategies such as PI + integrase inhibitors or induction and maintenance using PI/r monotherapy among children should also be investigated.

# third-line art
In 2010, WHO made recommendations on third-line ART in the context of limited evidence to guide third-line strategies. Although there were few studies of newer agents, cohort data showed high mortality among people for whom second-line ART had failed (245).

# Rationale and supporting evidence
The Guidelines Development Group maintained the recommendations established in the 2010 WHO guidelines. In so doing, the Guidelines Development Group emphasized balancing the need to develop policies for third-line ART with the need to expand access to first-line and second-line ART. It also recognized that many countries have financial constraints that limit the adoption of third-line regimens.
Data from randomized controlled trials are available for DRV/r, etravirine (ETV) and raltegravir (RAL), but most studies have been conducted in well-resourced or middle-to high-income countries. Taken together, these data support the efficacy of these agents in highly ART-experienced patients. In a published pooled subgroup analysis, DRV/r plus an optimized background regimen (OBR) chosen by genotyping and phenotyping was shown to be superior to the control group (boosted PI + OBR where the investigator selected the boosted PI) among highly treatment-experienced individuals (222). DRV/r was also shown to be non-inferior to LPV/r among treatment-experienced people after 96 weeks (223). Among individuals with limited treatment options, RAL + OBR provided better virological suppression than the OBR alone for at least 96 weeks (246,247). Similarly, ETV + OBR provided better virological suppression and improved immunological response than the optimized background regimen alone after 96 weeks (248). In people with multidrugresistant HIV who have few remaining treatment options, the combination of RAL, ETV and DRV/r was well tolerated and was associated with a rate of virological suppression similar to that expected among treatment-naive people (249,250).
Evidence from post-marketing reports indicates higher rates of hypersensitivity to ETV than previously reported (251). ETV + RAL is not approved for use in individuals younger than 16 years of age. There are limited data on the use of these newer drugs in infants, children and pregnancy, including very limited pharmacokinetic and safety data.

# third-line art

# New recommendations
National programmes should develop policies for third-line ART (conditional recommendation, low-quality evidence).
Third-line regimens should include new drugs with minimal risk of cross-resistance to previously used regimens, such as integrase inhibitors and second-generation NNRTIs and PIs (conditional recommendation, low-quality evidence).
Patients on a failing second-line regimen with no new ARV options should continue with a tolerated regimen (conditional recommendation, very low-quality evidence).

# neW neW

# Special considerations for children
Strategies that balance the benefits and risks for children need to be explored when second-line treatment fails. For older children and adolescents who have more therapeutic options available to them, constructing third-line ARV regimens with novel drugs used in treating adults such as ETV, DRV and RAL may be possible (for details on using these drugs in children, see Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes).
Children on a second-line regimen that is failing with no new ARV drug options should continue with a tolerated regimen. If ART is stopped, opportunistic infections still need to be prevented, symptoms relieved and pain managed.

# Clinical considerations
The criteria for diagnosing the failure of second-line ART are the same as those used for diagnosing the failure of first-line ART. The demand for second-and third-line regimens will increase as access to viral load monitoring improves and first-line ART continues to be scaled up. Although developing a policy on access to third-line ART is desirable, it should not compromise access to initiation of first-line ART. The costs of potential third-line drugs, such as DRV, ETV and RAL, are not well established in resource-limited settings but are expected to be higher than those of first-and second-line regimens.

# Key research gaps
Many areas require more information to guide second-and third-line ART for resourcelimited settings, including monitoring critical outcomes for people receiving secondline ART, studying once-daily dosing for DRV/r and RAL as an alternative to NRTIbased regimens in second-line ART, and developing heat-stable formulations of DRV/r. Pharmacovigilance research is needed, including studies on the long-term safety and potential drug-drug interactions with TB, malaria, hepatitis and opioid substitution therapy drugs. As the epidemic matures in low-and middle-income countries, pilot studies are urgently needed on implementing third-line ART in settings with limited capacity and resources in the health system.
Various coinfections, comorbidities and other health conditions are common among people living with HIV and have implications for their treatment and care, including the timing and choice of ARV drugs. This section provides a brief overview of the most common and important conditions. It summarizes selected key recommendations from already existing WHO guidelines and related materials, focusing on the screening, prophylaxis and timing of ART for these conditions; it does not cover their broader management. Sources and links are provided for relevant guidelines, including the evidence base and rationale supporting different recommendations. The strength of recommendations and quality of evidence is rated using either the GRADE system (strong or conditional recommendations and high, moderate, low and very low quality of evidence) or an alternative grading used prior to 2008 (A (strongly recommended) to C (optional)) and I-IV (level of evidence). In some cases, the sources and web links only are provided. These recommendations were not reviewed or discussed during the 2013 guideline development process, but are included as part of the consolidation of guidance related to HIV care and ARV drugs.

# Prevention, screening and management of common coinfections 8.1.1 Co-trimoxazole preventive therapy
Co-trimoxazole preventive therapy (CPT) should be implemented as an integral component of a package of HIV-related services. Existing recommendations cover initiation of CPT among adults, adolescents, pregnant women and children for prevention of Pneumocystis pneumonia, toxoplasmosis and bacterial infections, as well as benefits for malaria prophylaxis and discontinuation of CPT.  b In all regardless of CD4 percentage or clinical stage in settings with high HIV prevalence, high infant mortality due to infectious diseases and limited health infrastructure. c If initiated primarily for Pneumocystis pneumonia or toxoplasmosis prophylaxis. d Some countries may choose to adopt a CD4 threshold of <200 cells/mm 3. e In settings with high prevalence of bacterial infections or malaria.

# Source for recommendations

# Guidelines on co-trimoxazole prophylaxis for HIV-related infection among children

# Key selected existing recommendations

# Additional guidance
Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource-constrained settings. Geneva, World Health Organization, 2011 (www.who.int/tb/challenges/hiv/ICF_IPTguidelines/en/index. html). Improving the diagnosis of and treatment of smear-negative pulmonary and extrapulmonary TB among adults and adolescents: recommendations for HIV prevalent and resource-constrained settings. Geneva, World Health Organization, 2007 (www.who.int/hiv/pub/tb/pulmonary/en/).

# WHO policy on TB infection control in health-

# Recommendations for investigating contact of persons with infectious tuberculosis in low-and middle-income countries.
Geneva World Health Organization, 2012 (http:// apps.who.int/iris/bitstream/10665/77741/1/9789241504492_eng.pdf).

# Guidelines for the programmatic management of drug-resistant tuberculosis.
Geneva World Health Organization, 2011 (/ publications/2011/9789241501583_eng.pdf).

# Childhood tuberculosis guidelines. Geneva, World Health Organization, forthcoming (expected 2013).

# Prevention, screening and management of common coinfections

# Key selected existing recommendations TB case-finding and antituberculosis treatment
Adults and adolescents living with HIV should be screened for TB with a clinical algorithm; those who report any one of the symptoms of current cough, fever, weight loss or night sweats may have active TB and should be evaluated for TB and other diseases (Fig. 8.1) (strong recommendation, moderate-quality evidence) (2).
Children living with HIV who have any of the following symptoms of poor weight gain, fever or current cough or contact history with a TB case may have TB and should be evaluated for TB and other conditions. If the evaluation shows no TB, children should be offered isoniazid preventive therapy regardless of their age (Fig. 8.

# 2) (strong recommendation, lowquality evidence) (2).
TB patients with known positive HIV status and TB patients living in HIV-prevalent settings should receive at least six months of rifampicin treatment regimen (strong recommendation, high-quality evidence).

# The optimal dosing frequency is daily during the intensive and continuation phases (strong recommendation, high-quality evidence) (2).
Xpert MTB/RIF should be used as the initial diagnostic test in individuals suspected of having HIV-associated TB or multidrug-resistant TB (strong recommendation) (21).

# Key selected existing recommendations

# Isoniazid preventive therapy (IPT) (2)
Adults and adolescents living with HIV should be screened with a clinical algorithm; those who do not report any one of the symptoms of current cough, fever, weight loss or night sweats are unlikely to have active TB and should be offered IPT (strong recommendation, moderate-quality evidence).

# Duration of IPT 
Adults and adolescents who are living with HIV, have unknown or positive tuberculin skin test (TST) status and are unlikely to have active TB should receive at least six months of IPT as part of a comprehensive package of HIV care. IPT should be given to such individuals irrespective of the degree of immunosuppression, and also to those on ART, those who have previously been treated for TB and pregnant women (strong recommendation, high-quality evidence).
- Adults and adolescents living with HIV who have an unknown or positive TST status and who are unlikely to have active TB should receive at least 36 months of IPT. IPT should be given to such individuals irrespective of the degree of immunosuppression, and also those on ART, those who have previously been treated for TB and pregnant women (conditional recommendation, moderate-quality evidence).
A TST is not a requirement for initiating IPT in people living with HIV (strong recommendation, moderate-quality evidence).
People living with HIV who have a positive TST benefit more from IPT; TST can be used where feasible to identify such individuals (strong recommendation, high-quality evidence).
Providing IPT to people living with HIV does not increase the risk of developing isoniazid-resistant TB. Therefore, concerns regarding the development of INH resistance should not be a barrier to providing IPT (strong recommendation, moderate-quality evidence).
Children living with HIV who do not have poor weight gain, fever or current cough are unlikely to have active TB (strong recommendation, low-quality evidence).
Children living with HIV who are more than 12 months of age and who are unlikely to have active TB on symptom-based screening and have no contact with a TB case should receive six months of IPT (10 mg/kg/day) as part of a comprehensive package of HIV prevention and care services (strong recommendation, moderate-quality evidence).
In children living with HIV who are less than 12 months of age, only those who have contact with a TB case and who are evaluated for TB (using investigations) should receive six months of IPT if the evaluation shows no TB disease (strong recommendation, low-quality evidence).
All children living with HIV, after successful completion of treatment for TB disease, should receive isoniazid for an additional six months (conditional recommendation, low-quality evidence).
a Every adult and adolescent should be evaluated for eligibility to receive antiretroviral therapy. Infection control measures should be given priority to reduce Mycobacterium tuberculosis transmission in all settings that provide care. b Chest radiography can be done if available but is not required to classify people into TB and non-TB groups. In settings with high HIV prevalence and a high TB prevalence among people living with HIV (such as exceeding 10%), strong consideration must be given to adding other sensitive investigations. c Contraindications include: active hepatitis (acute or chronic), regular and heavy alcohol consumption and symptoms of peripheral neuropathy. Past history of TB and current pregnancy should not be contraindications for starting IPT. Although not a requirement for initiating IPT, tuberculin skin testing may be performed as a part of eligibility screening in some settings. d Investigations for TB should be performed in accordance with existing national guidelines.   b Poor weight gain is defined as (1) reported weight loss or very low weight (weight for age less than -3 z-score), (2) underweight (weight for age less than -2 z-score), (3) confirmed weight loss (>5%) since the last visit or (4) growth curve flattening. c Contraindications include: active hepatitis (acute or chronic) and symptoms of peripheral neuropathy. A past history of TB should not be a contraindication to starting IPT. Although not a requirement for initiating IPT, tuberculin skin testing may be performed as part of eligibility screening in some settings. d Investigations for TB must be performed in accordance with existing national guidelines.

# Prevention, screening and management of common coinfections

# Infection control
People living with HIV are at high risk of acquiring TB in health care facilities and congregate settings. National TB programmes and national HIV programmes should provide managerial direction for implementing TB infection control programmes. Each health care facility should have a TB infection control plan for the facility that includes administrative, environmental and personal protection measures to reduce the transmission of TB in health care and congregate settings and surveillance of TB disease among workers (Box 8.1). Health care workers with HIV should be provided with ART and IPT if they are eligible.

# Sources for recommendations

# WHO policy on TB infection control in health-

# Box 8.1. Summary of recommendations for key actions for infection control (3)

# Administrative (facility-level infection control committee and protocols)

# Key selected existing recommendations

# Timing of ART for adults and children with TB
ART should be started in all TB patients, including those with drug-resistant TB, irrespective of the CD4 count (strong recommendation, low-quality evidence) (4).
Antituberculosis treatment should be initiated first, followed by ART as soon as possible within the first 8 weeks of treatment (strong recommendation, moderatequality evidence). The HIV-positive TB patients with profound immunosuppression (such as CD4 counts less than 50 cells/mm 3 should receive ART immediately within the first two weeks of initiating TB treatment (2).
ART should be started in any child with active TB disease as soon as possible and within eight weeks following the initiation of antituberculosis treatment irrespective of the CD4 count and clinical stage (strong recommendation, low-quality evidence) (5).
Efavirenz should be used as the preferred NNRTI in patients starting ART while on antituberculosis treatment (strong recommendation, high-quality evidence) (2).
Section 7.2 provides more detailed information and recommendations on the co-treatment of TB and HIV.
More detailed information and recommendations on drug interactions between ARV drugs and TB drugs are available in the Web Annex (www.who.int/hiv/pub/ guidelines/arv2013/annexes).

# Multidrug-resistant TB and HIV Background
Multidrug-resistant TB (MDR-TB) is defined as TB that is resistant to at least isoniazid and rifampicin. Patients with both HIV and MDR-TB face complicated clinical management, fewer treatment options and poorer treatment outcomes. Limited information is available about the association between HIV and MDR-TB at the population level, especially because only 40% of the people with active TB are tested for HIV (6). Outbreaks of MDR-TB among people with HIV have been documented in hospital and other settings, especially in eastern Europe and in southern African countries with a high HIV prevalence (7).
People with HIV with suspected drug-resistant TB should be tested using Xpert MTB/RIF where possible, since this test is more sensitive for detecting TB among people with HIV and rapidly detects rifampicin resistance, thus greatly shortening the time to diagnosing and treating MDR-TB.
The burden of MDR-TB should be reduced by strengthening HIV prevention, improving infection control and improving collaboration between HIV and TB control activities, with special attention to the groups at the highest risk of MDR-TB and HIV infection, such as people who inject drugs and those exposed in congregate settings.

# Prevention, screening and management of common coinfections

# Cryptococcal infection
Cryptococcal meningitis is one of the most important opportunistic infections and a major contributor to high mortality before and after ART is initiated. WHO 2011 Rapid Advice covers diagnosis, screening and prevention of cryptococcal infection, induction, consolidation and maintenance regimens, monitoring and managing toxicities, timing of ART and discontinuing maintenance regimens. Full guidelines will be published at the end of 2013.

# Source for recommendations
Rapid advice: diagnosis, prevention and management of cryptococcal disease in HIVinfected adults, adolescents and children. Geneva, World Health Organization, 2011 (www.who.int/hiv/pub/cryptococcal_disease2011) (8).

# Key selected existing recommendation (4)
WHO recommends ART for all patients with HIV and drug-resistant TB, requiring second-line anti-tuberculosis drugs irrespective of CD4 cell count, as early as possible (within the first eight weeks) following initiation of anti-tuberculosis treatment (strong recommendation, very-low-quality evidence).

# Source for recommendation

# Key selected existing recommendations Screening and prophylaxis (8)
Use of routine serum or plasma Cryptococcus neoformans antigen (CrAg) screening in ART-naive adults, followed by pre-emptive antifungal therapy if CrAg-positive and asymptomatic, to reduce the development of cryptococcal disease, may be considered prior to ART initiation in patients with a CD4 count of less than 100 cells/mm 3 and where this population also has a high prevalence of cryptococcal antigenaemia (conditional recommendation, low-quality evidence).
Routine use of antifungal primary prophylaxis for cryptococcal disease in people living with HIV with a CD4 count of less than 100 cells/mm 3 and who are CrAg-negative or where CrAg status is unknown is not recommended prior to ART initiation (strong recommendation, high-quality evidence).
The use of routine CrAg screening and pre-emptive antifungal therapy in ART-naive adolescents and children with a CD4 count of less than 100 cells/mm 3 prior to ART initiation is not recommended (conditional recommendation, low-quality evidence).

# hepatitis B and C
Background Chronic hepatitis B virus infection affects 5-20% of the 33 million people living with HIV worldwide, and hepatitis C affects 5-15%, although this may be up to 90% among people who inject drugs (9,10). The burden of coinfection is greatest in low-and middle-income countries, particularly in South-East Asia and sub-Saharan Africa for hepatitis B. Viral hepatitis is an increasing cause of morbidity and mortality among people living with HIV, including those on ART. A comprehensive approach includes prevention, hepatitis B and hepatitis C screening, hepatitis B vaccination and treatment and care for people with HIV coinfected with hepatitis B and/or hepatitis C.  The WHO guidelines for the management of hepatitis C are scheduled to be published in 2014.

# Additional guidance

# Guidance on timing of ART in hepatitis B and C
They will provide detailed guidance on hepatitis C screening, hepatitis C-specific treatment and general hepatitis C care.
See the source above for recommendations on discontinuing secondary prophylaxis.

# Timing of ART (8)
Immediate ART initiation is not recommended in patients with cryptococcal meningitis due to the high risk of immune reconstitution inflammatory syndrome (IRIS) with central nervous system disease, which may be life-threatening (conditional recommendation, low-quality evidence).
Among people living with HIV with a recent diagnosis of cryptococcal meningitis, ART initiation should be deferred until there is evidence of a sustained clinical response to antifungal therapy and - after two to four weeks of induction and consolidation treatment with amphotericin containing regimens combined with flucytosine or fluconazole; or - after four to six weeks of induction and consolidation treatment with a high-dose oral fluconazole regimen (conditional recommendation, low-quality evidence).

# Prevention, screening and management of common coinfections
People with HIV with immunosuppression living in malaria-endemic areas are at high risk of complications of malaria, and all infants and children under five years of age and pregnant women are at particular risk of severe malaria and its complications.
Key interventions to control malaria include prompt and effective treatment with artemisinin-based combination therapies and using insecticide-treated nets and indoor residual spraying with insecticide to control the vector mosquitoes. An additional intervention recommended in areas of high transmission for specific high-risk groups is intermittent preventive treatment during pregnancy and seasonal malaria chemoprophylaxis.
People living with HIV who develop malaria should receive prompt, effective antimalarial treatment regimens. Parasitological confirmation should be undertaken for all suspected malaria cases using either microscopy or a rapid diagnostic test.
The drugs used to treat malaria and ARV drugs may share toxicities (particularly sulfa-based drugs) and may have clinically important pharmacokinetic interactions (especially artemesinins, lumefantrine, NNRTIs and PIs). For this reason, people receiving treatment for both HIV and malaria should be monitored closely for adverse drug reactions, and people with HIV receiving AZT, or EFV should, if possible, avoid amodiaquine-containing artemisinin-based combination regimens because of increased risk of neutropaenia in combination with AZT, and hepatotoxicity in combination with EFV.

# Source for recommendations

# Key selected existing recommendations (11) a
In areas of stable malaria transmission, people living with HIV (as for the general population) should routinely use insecticide-treated bed-nets or have access to indoor residual spraying to reduce their exposure to malaria infection. (A-I)
Treatment or intermittent preventive treatment with sulfadoxine-pyrimethamine should not be given to patients with HIV receiving co-trimoxazole prophylaxis. (A-III)
a See the Web Annex (www.who.int/hiv/pub/guidelines/arv2013/annexes) for methodology used in rating quality of evidence.

# Prevention, screening and management of common coinfections

# Sexually transmitted infections

# Vaccines for people living with hIV
People living with HIV should be assessed for eligibility for vaccination at all stages of care. HIV-exposed infants and children and young adults with HIV should receive all vaccines under routine vaccination according to recommended national immunization schedules. Those with more severe immunosuppression may be at higher risk of complications from live vaccines. Inactivated vaccines are more effective among people receiving ART and those without immunosuppression, but they are safe and can be used with some efficacy in all groups.

# Mental health
People living with HIV and their carers may have a wide range of mental health needs. The most common mental health comorbidities among people living with HIV include depression, anxiety, dementia and other cognitive disorders and substance use disorders. HIV care settings provide an opportunity to ensure the detection and management of mental disorders among people living with HIV. Treatment or lack of treatment for these conditions can affect adherence to ARV drugs, retention in care and may involve potential side effects and drug interactions.
WHO has no specific recommendations on screening and treatment for mental disorders among people living with HIV. The Mental Health Gap Action Programme (mhGAP) intervention guide for mental, neurological and substance use disorders in non-specialized health settings makes recommendations related to general mental health that can be relevant to people living with HIV. Additional guidance on management of mental health conditions in people living with HIV is planned for 2014.

# Additional guidance

# Drug use and drug use disorders
People living with HIV who use drugs may experience a range of disorders related to their drug use, including drug dependence, intoxication, withdrawal and overdose. Injecting drug use is associated with a range of bloodborne and local infections, including viral hepatitis, septicaemia and bacterial endocarditis, in addition to HIV.
WHO has developed guidance for the treatment of opioid dependence and prevention of hepatitis B and C among people who inject drugs.
WHO, UNODC and UNAIDS recommend a comprehensive package of nine interventions for HIV prevention, treatment and care for people who inject drugs, including needle and syringe programmes, opioid substitution therapy, HIV testing and counselling, ART, preventing and treating sexually transmitted infections, condom programmes, targeted behaviour change communication, preventing and treating viral hepatitis and preventing and treating TB.

# Among adolescents and adults living with hIV
Low energy intake combined with increased energy demands because of HIV infection (14)(15)(16)(17) and related infections may lead to HIV-related weight loss and wasting. In addition, an altered metabolism, reduced appetite and higher incidence of diarrhoea may lower nutrient intake and absorption and also lead to nutrient losses. These effects may all be compounded in low income, food insecure contexts. Low body mass in adults (body mass index vii less than 18.5kg/m 2, weight loss and wasting in children are all independent risk factors for HIV disease progression and mortality (18,19). Nutritional assessment (anthropometry, clinical and dietary assessment), counselling and support should be an integral component of HIV care and conducted at enrolment in care and monitored during all HIV care and treatment. Malnourished HIV patients, especially in food insecure contexts, may require food supplements, in addition to ART, to ensure appropriate foods are consumed to support nutritional recovery. Weight loss or failure to regain or maintain a healthy weight at any stage of HIV infection or ART should trigger further assessment and appropriate interventions.
WHO is currently revising recommendations for nutritional care and support of adolescents and adults living with HIV, including pregnant and lactating women.

# Among children living with hIV
Nutritional assessment is essential to identify malnutrition and growth faltering early.
Infants and children should undergo initial nutritional assessment (evaluation of nutritional status, diet and symptoms) and then be weighed and have height measured at each visit and monitored with reference to WHO or national growth curves. Growth monitoring should also be integrated into the assessment of ART response (20). If poor growth is identified, then further assessment should be performed to determine the cause, and plan appropriate response. The 2009 guidelines for an integrated approach to the nutritional care of children living with HIV provide details of nutritional interventions.  9.6 Laboratory and diagnostic services 9.6.1 Overview 9.6.2 Implementation considerations and good practices 9.6.3 Strengthening and expanding laboratory and diagnostic services 9.6.4 Supporting a dedicated specimen referral system 9.6.5 Increasing access to HIV viral load testing 9.6.6 Expanding diagnostic services to point-of-care settings 9.6.7 Providing guidance for developing health workers' capacity including staff training and certification 9.6.8 Implementing comprehensive quality management systems 9.7 Procurement and supply management systems 9.7.1 Overview 9.7.2 Rationale and supporting evidence 9.7.3 Implementation considerations and good practices

# Additional guidance

# Goal of this chapter
To provide guidance on key issues related to operations and service delivery that need to be addressed to strengthen the continuum of HIV care and further integrate the provision of ARV drugs into health systems.

# OPERATIONS AND SERVICE DElIVERy 9 GuIDANCE ON OPERATIONS AND SERVICE DElIVERy
ARV drugs and related services need to be delivered as effectively, equitably and efficiently as possible by optimizing available human and financial resources, ensuring appropriate links between care settings and services, supporting adherence to lifelong treatment and maximizing retention of patients across the continuum of care. This chapter provides broad guidance in six operational and service delivery areas in which action is essential to ensure the long-term effectiveness and sustainability of ARV programmes. These areas are: adherence to ART; retention across the continuum of care; service delivery, comprising service integration and linkage and decentralization of HIV care and treatment; human resources, including task shifting; laboratory and diagnostic services; and procurement and supply management systems.
New recommendations, developed through the GRADE process, are found in the sections on adherence and service delivery and human resources and include: text messages to promote adherence; ART integration into and linkage with maternal and child health, TB and opioid substitution therapy services; decentralization of ART; and task shifting.

# Adherence to ART 9.2.1 Barriers to adherence
WHO defines treatment adherence as "the extent to which a person's behaviour -taking medications, following a diet and/or executing lifestyle changes -corresponds with agreed recommendations from a health care provider" (1). For ART, a high level of sustained adherence is necessary to (1) suppress viral replication and improve immunological and clinical outcomes; (2) decrease the risk of developing ARV drug resistance; and (3) reduce the risk of transmitting HIV.
Multiple factors related to health care delivery systems, the medication and the person taking ARV drugs may affect adherence to ART. The individual factors may include forgetting doses; being away from home; changes in daily routines; depression or other illness; a lack of interest or desire to take the medicines; and substance or alcohol use. Medication-related factors may include adverse events; the complexity of dosing regimens; the pill burden; and dietary restrictions. Health system factors may include requiring people with HIV to visit health services frequently to receive care and obtain refills; travelling long distances to reach health services; and bearing the direct and indirect costs of care. Lack of clear information or instruction on medication, limited knowledge on the course of HIV infection and treatment and adverse effects can all be barriers to adherence to ART. Moreover, uninterrupted ARV drug supply and continuity of care are essential for people to adhere to their medication. Lack of continuity of care is a strong predictor of non-adherence in the longer term. Adherence to ART may also be challenging in the absence of supportive environments for people living with HIV and due to HIV-related stigma and discrimination (2,3).

# Pregnant and postpartum women
The pregnancy and postpartum period presents significant biological, social and economic challenges that may affect treatment adherence. Pregnancy-related conditions such as nausea and vomiting may negatively affect treatment adherence. Other challenges during this period may include dealing with the diagnosis of HIV infection (many women learn about their HIV infection during routine screening during pregnancy); concerns about how ART affects the health of the fetus; pill burden; the number of clinic visits during pregnancy; fear of disclosure of HIV status to partners; long waiting times at clinics; and lack of follow-up and transfer to other clinics after delivery (4,5).
Adherence challenges faced by adolescents include a potentially large pill burden if they are treatment-experienced; stigma and fear of disclosure; concerns about safety of medications; adverse effects; peer pressure and perceived need to conform; not remembering to take medications; and inconsistent daily routine. The transition from paediatric to adolescent care presents several challenges that may affect treatment adherence in adolescents. These include assuming increased responsibility for their own care (which may lead to treatment interruptions because of forgetfulness); an inability to navigate the health care system; lack of links between adult and paediatric services; lack of health insurance; and inadequately skilled health care providers (6,7). Depression and substance use have also been shown to present challenges in adolescents.

# Infants and children
Adherence among children is a special challenge. The limited choice of paediatric formulations, poor palatability of liquid formulations, high pill or liquid volume burden, large pill size, frequent dosing requirements, dietary restrictions, loss of primary caregiver, difficulties in swallowing tablets and adverse effects may all affect adherence (3,8,9). Successfully treating a child requires the commitment and involvement of a responsible caregiver. Parents and other family members of children living with HIV may themselves be living with HIV; suboptimal HIV care and treatment for family members could result in suboptimal care for the child.

# Mental health disorders
Adherence to ART is known to be complicated by mental health comorbidity that results in forgetfulness, poor organization and poor comprehension of treatment plans. Studies have linked uncontrolled depressive symptoms with low levels of adherence to ART and poor treatment outcomes. As a result, several treatment strategies target depression and psychosocial stress to improve adherence to ART, ranging from co-counselling for HIV and depression to appropriate medical therapies for individuals with mental disorders (10)(11)(12)(13).

# Substance use disorders
Individuals with substance use disorders may have poor adherence to ART. Alcohol and other drug use could be associated with forgetfulness, poor organization and diversion of monetary and time priorities (10,(14)(15)(16).
Most-at-risk populations (including sex workers, men who have sex with men, transgender people and people who inject drugs)
In several settings, most-at-risk populations face multiple challenges to accessing health services. Service delivery approaches to improve longitudinal care and maintain adherence for most-at-risk populations remains a critical gap in many settings. Experience indicates encouraging results with peer-based interventions that include strong social support such as outreach teams, peer educators and health workers providing multidisciplinary, nonjudgemental and respectful care.
Incarceration may negatively affect continuity of care, diminish trust and predispose individuals to poor financial and social support both during and after incarceration. Substance use disorders may also be an additional challenge for this population. People who are incarcerated have the additional risk of acquiring TB, resulting in high morbidity and mortality rates in the absence of efficacious HIV and TB treatment (17). However, excellent outcomes can be achieved with adequate support and structured treatment programmes within the prison setting.

# Interventions to optimize adherence to ART
No single adherence intervention or package of interventions is effective for all populations and all settings. People's needs and circumstances may also change over time, and programmes and care providers therefore need to tailor a combination of feasible interventions to maximize adherence to ART based on individual barriers and opportunities.
Programme-level interventions for improving adherence to ART include: (1) avoiding imposing out-of-pocket payments at the point of care, (2) using fixed-dose combination regimens for ART and (3) strengthening drug supply management systems to reliably forecast, procure, and deliver ARV drugs and prevent stock-outs.
The individual-level adherence intervention recommendation in this section relates to the use of mobile phone text messages. There have been simple and robust trials to demonstrate its importance as one of many adherence tools. Adherence interventions, such as text messaging, should clearly be provided as part of a total package of several interventions. Many individuallevel adherence interventions are indicated for reasons in addition to improving adherence to ART. For example, nutritional support, peer support, management of depression and substance use disorders and patient education are vital components of routine health and HIV care.
Efforts to support and maximize adherence should begin before ART is initiated. Developing an adherence plan and education are important first steps. Initial patient education should cover basic information about HIV, the ARV drugs themselves, expected adverse effects, preparing for treatment and adherence to ART. Adherence preparation should not delay treatment initiation, when prompt action is necessary.

# Patient education and counselling and peer support
Patient education and counselling are essential both when ART is initiated and throughout the course of treatment. Informing and encouraging people receiving ART and their families and peers are essential components of chronic HIV care. Studies show that counselling improves adherence to ART, and in some settings there is an association between peer support and high rates of adherence and retention (18-23).

# Adherence to ART

# Reminder and engagement tools

# Substance use and mental health interventions
Studies indicate that improving well-being by treating depression and managing substance use disorders improves HIV treatment outcomes. The systematic review identified verylow-quality evidence from one observational study evaluating opioid substitution therapy for improving adherence. After 12 months, the rates of unsuppressed viral loads were comparable among people who inject drugs using opioid substitution therapy and people who inject drugs without opioid substitution therapy (24). The systematic review also identified very-low-quality evidence from one randomized trial evaluating the treatment of depression for improving adherence. After 12 months, the risk of non-adherence was similar among those who received depression treatment and those who did not (25). WHO recommends co-treatment of depression and substance use disorders irrespective of HIV status, and concurrent treatment should be evaluated in relation to adherence to ART. Other services for people living with HIV who use drugs, such as needle and syringe programmes, drug dependence treatment and peer outreach, provide opportunities for supporting treatment adherence.

# Nutritional support
Nutrition assessment, care and support are essential components of HIV care. HIV programmes should ensure that existing national policies on nutritional support are observed when it is necessary and feasible to maximize adherence to ART and achieve optimal health outcomes in food-insecure settings.
Nutritional support could include nutritional counselling, cash transfers and subsidizing food costs and/or food vouchers. ART in conjunction with nutritional support could accelerate recovery. The systematic review identified one study from low-and middle-income countries with low-quality evidence showing that nutritional support provided by community health workers to people receiving ART reduces the risk of non-adherence after one year among food-insecure individuals relative to the standard of care (26).

# Financial support
Financial support may include reimbursement for the costs of receiving HIV care (including drugs, diagnostics, clinical services and transport vouchers) and may potentially mitigate the burden of HIV in disadvantaged settings. The systematic review identified very-low-quality evidence that financial support reduces the risk of non-adherence one year post-intervention relative to the standard of care (27). Programmes and care providers should consider a broader programmatic approach for reducing the costs of care for people living with HIV that would include avoiding out-of-pocket payments at the point of care, decentralizing and coordinating care and exploring opportunities to minimize health facility visits. Programmes need to consider ethical implications and equity in providing food and financial support or other similar interventions for people living with HIV and not others. Standardized criteria for supporting people receiving ART may need to be developed based on national poverty levels.

# New recommendation
Mobile phone text messages could be considered as a reminder tool for promoting adherence to ART as part of a package of adherence interventions (strong recommendation, moderate-quality evidence).
Forgetfulness and changes in daily routines are often cited as the main reasons for poor adherence to ART in most settings, although the specific reasons for forgetting to take medication could vary. Reminders and communication that engage people in taking ARV drugs could be an important intervention to improve adherence through behavioural change.
The use of mobile text messages for supporting adherence and in health care delivery in general has increased as access to phone technology expands (28). Using this, however, requires adequate national regulations to protect the privacy of the people receiving text messages (29,30). Programmes may explore public-private partnerships to accelerate the scaling up of mobile phone-based interventions.

# Rationale and supporting evidence
Mobile phone technology may be a convenient reminder mechanism to engage people living with HIV in care. Moreover, since mobile phones are widely used globally, using them may not require major changes to people's daily routines. Mobile phone text messaging is also relatively inexpensive or without marginal cost, is a succinct way of sending a message without the need to talk and offers a record of messages.
The systematic review identified five randomized trials and two observational studies on mobile phone text messaging for improving adherence to ART. High-quality evidence from two randomized trials found that text messages contributed to reduced unsuppressed viral loads after one year (31,32). This finding was consistent with high-quality evidence from three randomized trials that found reduced non-adherence levels after one year (31,33,34).
Four observational studies evaluated the use of text messaging for less than one year. Verylow-quality evidence from one observational study found reduced unsuppressed viral loads after nine months (35). Although moderate-quality evidence from two randomized trials showed similar non-adherence levels after 4-6 months (36,37), very-low-quality evidence from two observational studies suggests reduced non-adherence levels after 6-9 months (35,38). Overall, the systematic review supports the use of text message reminders, although the quality of the data was variable and duration of follow-up short (up to one year).

# Other patient reminders
Other patient reminder tools include alarms, phone calls, electronic diaries and calendars and are used to send brief reminders about the timing of ARV drugs, drug dosage and appointments. The evidence does not demonstrate that these interventions support treatment adherence better than the standard of care.
The systematic review identified four randomized trials. Moderate-quality evidence from one randomized trial found that the risk of unsuppressed viral loads was similar after 18 months of follow-up using alarms versus the standard of care (19). Low-quality evidence from one randomized trial also found that rates of non-adherence and unsuppressed viral loads were similar after three months using phone calls compared with the standard of care (39). Very-low-quality evidence from one randomized trial further found that the risk of unsuppressed viral load and non-adherence was similar after 15 months using diaries relative to the standard of care (40). Finally, low-quality evidence from one randomized trial found that non-adherence was similar using calendars relative to the standard of care after one year of follow-up (41). Using these interventions requires further exploration among different populations and settings.

# Monitoring adherence to ART in routine programme and care settings
Objective monitoring of adherence to ARV drugs is necessary for effective and efficient treatment planning and ongoing support. Each facility visit brings opportunity for assessing and supporting treatment adherence. Effectively monitoring adherence requires a combination of approaches based on human and financial resource capacity, acceptability to people living with HIV and to health workers and the local context.

# Viral load monitoring
These guidelines recommend viral load monitoring to diagnose and confirm treatment response and failure. Although treatment failure is often caused by lapses in adherence to ART, it may also result from other factors (such as drug stock-outs, drug interactions or malabsorption). However, viral load monitoring does not provide an opportunity for care providers to monitor non-adherence in real time and prevent progression to treatment failure. Viral load monitoring must therefore be combined with other approaches to monitoring adherence.

# Pharmacy refill records
Pharmacy refill records provide information on when people living with HIV pick up their ARV drugs (42,43). When people obtain pharmacy refills at irregular intervals, this may indicate non-adherence to ART; however, in many routine care settings, people may pick up their medications when receiving care irrespective of their adherence level. This behaviour could lead health care providers to overestimate adherence by solely using pharmacy refill records. A recent validation study to assess the usefulness of various adherence monitoring approaches found pharmacy records to be more reliable than self-report (44). In many settings, pharmacy refill records are already a part of national monitoring and evaluation frameworks and can also provide additional information on adherence to ART when used in combination with other tools.
Asking people living with HIV or their caregivers how many doses of medication they have missed since the last visit (or within a specified number of days in the past) can help to estimate non-adherence. However, although this method is commonly used, people may not remember missed doses accurately or may not report missed doses because they want to be perceived as being adherent and to avoid criticism. Counselling on the importance of remembering and/or documenting ARV drug doses and an environment that promotes and enables honest reporting of non-adherence are critical components of monitoring adherence to ART in routine care settings (45).

# Pill counts
Counting the remaining pills in bottles may help to assess adherence. Pill counts usually take place at routine health care visits. However, some people may throw away tablets prior to health care visits, leading to overestimated adherence (45,46). Although unannounced visits at people's homes could lead to more accurate estimates, this approach poses financial, logistical and ethical challenges. Counting pills also requires health care personnel to invest significant time and may not be feasible in routine care settings.

# Retention across the continuum of care 9.3.1 Background
Retaining people living with HIV across the continuum of care is essential for optimal health outcomes. Among those who do not have immediate indications for ART, care visits provide opportunities for screening, prevention and treatment of other conditions and comorbid illnesses, including providing co-trimoxazole prophylaxis, PMTCT, isoniazid preventive therapy and regular screening for TB and clinical and laboratory monitoring to allow timely initiation of ART once the indications arise. For people who are eligible for ART at the time they test HIV-positive, rapid linkage to care is critical; delays of days or weeks with people already being ill with TB or other opportunistic infections increases the risk of mortality (47,48). For people living with HIV who are receiving treatment, uninterrupted ART and continual monitoring are essential for sustained viral suppression and optimal treatment outcomes.
Retaining people living with HIV in care, especially people who are not yet eligible for ART and those who are eligible but have not yet initiated treatment, poses a great challenge. Synthesis of available literature from sub-Saharan Africa showed that 54% of those who are not yet eligible for ART were lost to follow-up before becoming eligible, while 32% of the people living with HIV who were eligible for ART were lost before initiating treatment (49,50). Outcomes among those lost to follow-up may vary, as loss to follow-up reported at the health facility level can include people who have self-transferred to another facility, unascertained deaths and true losses to follow-up. People who discontinue care -especially those who are not eligible for ART at initial assessment -frequently return to care only after they become ill with advanced HIV disease, when early mortality after initiating ART is significant (51,52). Data on the proportion of people who remain on ART over time in low-and middle-income countries show that most discontinued care occurs within the first year of starting therapy. In some settings, many people living with HIV who are lost to follow-up in the first months after initiating ART have died (53). In 2011, the average retention rate at 12 months after initiating ART was 81% (92 reporting countries), 75% at 24 months (73 reporting countries) and 67% at 60 months (46 reporting countries) (53).
Multiple factors relating to the health care delivery systems and patients could facilitate or hinder retention in HIV care. Interventions to improve linkage to and retention in HIV care, from diagnosis and across the continuum of care, need to address issues reported by the people receiving care and related to the health system and require a more targeted evaluation in different settings and populations (54-57).

# Good practices for retention across the continuum of care NEw
Optimizing retention in HIV care requires interventions at multiple levels of the health care system as well as implementation research. Given the broad array of challenges and heterogeneity of barriers across settings, no single approach is likely to work for everyone in all settings. Improving the understanding of barriers and innovative strategies to address them are important priorities in implementation research and public health.
Studies show that the direct and indirect costs of care affect the ability of people living with HIV to remain in care. They consistently report that the distance from health care facilities is a barrier to retention in diverse settings and along the continuum of HIV care. Related transport costs and loss of income while seeking care serve as disincentives when health facilities are located far from the person's home. Bringing services closer to communities, where feasible, reduces the indirect costs of care for the people living with HIV and their families and improves retention.
Waiting times at the facility during consultation are frequently high, especially in settings with a high burden of HIV infection (58,59). Reorganizing services, such as systems for appointment, triage, separating clinical consultation visits from visits to pick up medicine, integrating and linking services and family-focused care may reduce waiting times at the health facility (59,60).
Many people living with HIV who are not yet eligible for ART may not attend clinic appointments and may not return to care until they are symptomatic. Regularly following up these individuals is important to ensure continual monitoring and timely initiation of ART. Countries have used approaches and achieved positive outcomes, including providing co-trimoxazole prophylaxis free of user charges, on-site or immediate CD4 testing with same-day results and peer support to improve retention in care (22,61,62).
Key populations generally experience more barriers to accessing health services.
Interventions harnessing social support have emerged as a promising approach to counteract the structural, economic, service delivery and psychosocial constraints that affect retention in care.
Table 9.1 summarizes the factors related to the health system and people receiving ART influencing retention and adherence and potential interventions.   (63) In many countries, health services are organized primarily to provide episodic acute care.
As HIV begins to become a manageable, chronic condition, programme managers and care providers need to consider how current health delivery systems can be reorganized to provide chronic care.
Once people are diagnosed and enrolled in chronic care, follow-up visits should be scheduled and planned. Waiting until people present with symptoms or preventable complications is costly and inefficient. People living with HIV require care that anticipates their needs at different stages of the care continuum. Compared with the acute care model, planned chronic care models provide opportunities for prevention, early identification of issues and timely intervention.
Chronic care requires broad support for people living with HIV from their communities and health care teams to stay in care, adhere to treatment and cope with stigma. People living with HIV and their families need to be informed about HIV infection and the anticipated side effects of medicines and supported to adhere to treatment. Health care teams play an important role in linking people living with HIV with community-level interventions, resources and support.
A system to keep information on the people receiving care at health facilities is critical for ensuring the continuity of chronic care. A patient registry serves a reminder function for follow-up services. Health care teams can use it to identify people's needs, to follow-up and plan care, to monitor responses to treatment and to assess outcomes for both individuals and for the overall treatment cohort. Information systems can be paper-based or based on an electronic registry, depending on local context. Programmes should develop a systematic strategy for collecting and aggregating key information that supports better management of the patient and ensures high-quality care. A robust patient information system is also critical for high-quality monitoring and evaluation of programmes and for supply management systems.
When effective operational solutions such as successful service delivery models and processes of care are identified in existing systems, programmes need to consider scaling up such models of care.

# Integrating and linking services
Chronic care requires integrating and linking related services to ensure comprehensive and consistent patient management over time, including providing related services in single settings, systems to share information and effective referrals across settings and providers.
Integrating and linking services are likely to reduce missed opportunities for initiating ART, enhance long-term adherence support and optimize patient retention in care. Programmes for HIV, sexual and reproductive health, maternal and child health, TB and drug dependence need to collaborate to successfully implement ART and related services at different levels of the health system. Issues to be considered include mobilizing and allocating resources; training, mentoring and supervising health workers; procuring and managing drugs and other medical supplies; and monitoring and evaluation.

# Delivering ART in antenatal care and maternal and child health settings
In 2011, coverage of effective ARV drug regimens for PMTCT reached 57% in low-and middle-income countries. However, in the same year, only 30% of pregnant women who needed ART for their own health received it, compared with 54% ART coverage for all eligible adults in low-and middle-income countries (53). Ensuring access to ART for pregnant women with HIV who are eligible for treatment continues to be a challenge, as does provision of ARVs for PMTCT among pregnant adolescent girls living with HIV, female sex workers and women who inject drugs.
Because many women living with HIV only access health services at the time of pregnancy, maternal and child health settings provide a key opportunity to expand access to ART for those who need treatment (56,57). In most generalized epidemic settings, maternal and child health services are provided at the primary care level, where pregnant women and children predominantly access health services. Existing WHO guidance recommends that provider-initiated HIV testing and counselling be implemented in all antenatal and maternal and child health care settings in generalized epidemics and that it should be considered in antenatal and maternal and child health settings for key populations in concentrated and low-level epidemics (64).
These 2013 guidelines recommend that triple-drug ART or ARV prophylaxis be initiated among all pregnant and breastfeeding women living with HIV, regardless of CD4 count, and that countries decide whether to continue this for all pregnant and breastfeeding women or just those who are eligible for treatment for their own health. Therefore, ART should be available in maternal and child health clinics or easily accessible in a linked clinic approach. Countries with generalized epidemics may consider a phased approach to providing ART in maternal and child health settings and effectively transforming such settings into ART sites, giving priority to facilities with the largest burden of HIV and building health systems to ensure uninterrupted ART, adherence and retention.
A challenge is to continue ART beyond the mother-to-child transmission risk period. Not all maternal and child health settings will have capacity to provide long-term HIV care and treatment for women, their partners and infants. These settings will need to assess the best time for referring and linking mothers and their infants to chronic HIV care. This assessment may include the women's progress in treatment and the capacity and quality of HIV care in the maternal and child health setting as well as the acceptability and proximity of alternative HIV care settings.

# New recommendation
In generalized epidemic settings, ART should be initiated and maintained in eligible pregnant and postpartum women and in infants at maternal and child health care settings, with linkage and referral to ongoing HIV care and ART, where appropriate (strong recommendation, very-low-quality evidence).

# NEw 9.4 Service delivery

# Rationale and supporting evidence
The systematic review evaluated the effect of delivering HIV care and treatment in antenatal care and maternal and child health settings on access to ART, mortality, morbidity and retention on ART in generalized epidemic settings. One clusterrandomized trial and three observational studies assessed the impact of delivering ART in antenatal care and maternal and child health settings compared with referring people to HIV care clinics for ART. This positively influenced adherence to ART during pregnancy, enrolment in care and the uptake of ART among women living with HIV. Comparable outcomes were observed for maternal mortality, morbidity, immune response, infant HIV testing uptake, mother-to-child transmission and satisfaction with care. The quality of some of these studies was downgraded because of relatively few events (65)(66)(67)(68)(69)(70).
The alternative to providing ART in antenatal care and maternal and child health settings is to refer eligible women and infants to HIV facilities to receive HIV treatment. Referral systems may contribute to the low ART coverage among pregnant and breastfeeding women and infants (57). Referral-based models may further require women and infants to receive care at separate service delivery points that may require pregnant women to travel and wait in queues to receive HIV care and treatment. Studies from Malawi (55), Uganda (56) and Zimbabwe (57) have found that long queues at HIV clinics and the cost of transport from homes to clinics were among the main reasons for loss to follow-up for pregnant and breastfeeding women.
Although HIV programmes may invest to expand access and reduce health facility waiting times, delivering ART in settings where pregnant and breastfeeding women are already receiving care could improve access and provide opportunities for a continuum of care from providing HIV testing to ART at a single site that is also providing antenatal and postnatal care.
In a recent study, women had positive experiences in antenatal care clinics providing ART. They reported that the personnel had "treated them" well and "given them helpful counselling" and that their babies had received "good care" and were free from HIV infection because of this. Other research has explored the operational feasibility of providing ART in maternal and child health care settings and its acceptability to health care personnel in antenatal care clinics. Providers felt that integration increased efficiency, decreased the time people spent in clinics, improved relationships with providers and adherence to ART because of decreased stigma and increased confidentiality. All these factors increased the satisfaction of the people receiving care and may have contributed to improving the quality of care (66,71
In 2011, 79% and 48% of the people with TB who were known to be living with HIV received co-trimoxazole prophylaxis and ART, respectively (72). The percentage of people with TB with a documented HIV-positive test result who received ART exceeded 75% in only 6 of the 41 countries with the highest burden of HIV and TB, globally.
Since 2010, WHO has recommended ART for everyone with TB who is living with HIV, regardless of their CD4 count. TB treatment should be initiated first, followed by ART as soon as possible within the first eight weeks of starting TB treatment. Co-trimoxazole prophylaxis is also recommended for all TB patients with HIV. These service delivery recommendations are intended to facilitate expanded ART coverage for people with HIV and TB and to support the early diagnosis and treatment of TB among people living with HIV.
Although the treatment of TB has been decentralized to the community level in most settings, HIV treatment remains difficult to access in many places. Data from a WHO survey indicate that the ratios of the number of health facilities providing TB treatment to the number of health facilities providing ART ranged from 1.3 to 30.2 (72). Moreover, despite a high burden of HIV and TB coinfection, services for HIV and TB treatment may be offered at geographically different sites. Although HIV and TB programmes may invest financial and human resources to improve access and reduce the time associated with receiving care, offering ART and TB treatment at a single point could improve access and adherence to HIV and TB treatment by providing a continuum from HIV testing to HIV and TB co-treatment at a single site.
Implementing TB infection control measures is crucial in HIV care settings to minimize the risk of nosocomial (occurring in a health care setting) transmission of TB. See section 8.1.2 for WHO recommendations on TB infection control in health care settings.

# Rationale and supporting evidence
Since people with HIV and TB who do not initiate ART and co-trimoxazole prophylaxis have high mortality and since the combination of ART and co-trimoxazole improves survival (73)(74)(75), increasing ART and co-trimoxazole coverage is probably paramount in reducing the large number of people who die from having HIV and TB globally. The systematic review evaluating the effectiveness of delivering ART in TB treatment settings identified 19 observational studies, many of which showed increased ART uptake and timeliness of ART initiation. However, data on mortality and TB treatment success were inconsistent. The systematic review evaluating the effect of delivering TB treatment in HIV care settings identified five observational studies: two studies reported decreased mortality

# New recommendations
In settings with a high burden of HIV and TB, ART should be initiated for an individual living with HIV in TB treatment settings, with linkage to ongoing HIV care and ART (strong recommendation, very-low-quality evidence).
In settings with a high burden of HIV and TB, TB treatment may be provided for an individual living with HIV in HIV care settings where TB diagnosis has also been made (strong recommendation, very-low-quality evidence).
- 4 Service delivery and another showed comparable mortality rates. TB treatment success rates and ART uptake were comparable across studies. The quality of evidence was weighed along with programmatic risks and benefits; acceptability; values; preferences; cost implications; feasibility; critical contextual constraints; and contextual relevance. There was consensus that, although the quality of evidence was not high using the GRADE method, there was sufficient rationale to proceed with strong recommendations.
Data from 49 countries indicate that injecting drug use increases the risk of acquiring HIV infection 22-fold relative to the general population, and in countries in eastern Europe up to 40% of the people acquiring HIV infection are people who inject drugs and their sexual partners (97). Existing WHO guidance states that consideration should be given to recommending HIV testing and counselling to all people attending drug dependence treatment services in generalized, concentrated and low-level epidemics when this is socially acceptable and epidemiologically appropriate. Plans for provider-initiated testing and counselling in such settings should emphasize supportive social, policy and legal frameworks (64).
These guidelines recommend the same criteria for eligibility for ART for all adults regardless of drug use behaviour. Limited global data are available on ART coverage among key populations; however, where data are available, there are often gaps between the coverage among people who inject drugs relative to that of the general population. In 2010, a report including 19 low-and middle-income countries in Europe and central Asia indicated that only 22% of people living with HIV who inject drugs and are eligible for ART received it (53).
For treating opioid dependence, WHO recommends opioid substitution therapy (with methadone or buprenorphine) combined with psychosocial assistance (98). Where there are many opioid-dependent people living with HIV, treatment of opioid dependence should be integrated with and administered in conjunction with HIV treatment. Although ART outcomes improve among people living with HIV who inject drugs and are also accessing opioid substitution therapy, enrolment in settings providing opioid substitution therapy should not be a prerequisite for initiating or maintaining ART for people who use opioids.
Nevertheless, providing ART in settings providing opioid substitution therapy may expand access to ART for people who inject drugs.
Common comorbidities such as alcohol use disorders, mental health disorders, TB and viral hepatitis also need to be addressed as part of a comprehensive package of harm reduction interventions, requiring a multi-skilled workforce and close collaboration within the health sector.

# ART in settings providing opioid substitution therapy

# New recommendation
ART should be initiated and maintained in eligible people living with HIV at care settings where opioid substitution therapy (OST) is provided (strong recommendation, very-low-quality evidence).

# NEw NEw
Given the high incarceration rates of people who inject drugs, efforts should be made to ensure that ART is available as part of prison health services and continuity of HIV care and ART when people transition from incarceration to the community.

# Rationale and supporting evidence
In many countries, people who inject drugs are a marginalized population with limited access to and utilization of health care services. Drug overdose and AIDS are leading causes of death in this population (99). Randomized trials found that opioid substitution therapy decreases illicit drug use and increases retention in care relative to placebo (98).
Observational studies found that opioid substitution therapy decreases mortality relative to not being in care (100). ART outcomes also improved among people with HIV who inject drugs and are accessing opioid substitution therapy (16). The systematic review found one randomized trial and three observational studies evaluating the effect of delivering ART in settings providing opioid substitution therapy. Most of these studies had small sample sizes that limited the statistical power. Some studies observed trends for improved viral suppression and reduced mortality, whereas others found comparable rates of viral suppression and mortality (101)(102)(103).
This recommendation focuses on expanding access to ART by delivering the service in settings providing opioid substitution therapy. Coverage of opioid substitution therapy also remains low in many settings, and policy-makers should evaluate whether providing opioid substitution therapy in settings providing HIV care and treatment is feasible.
Where health authorities or the health sector do not manage drug-dependence services, HIV programmes need to collaborate closely with social welfare departments and community and nongovernmental organizations that provide these services.

# Decentralizing hIV treatment and care

# New recommendations
The following options should be considered for decentralization of ART initiation and maintenance.
Initiation of ART in hospitals with maintenance of ART in peripheral health facilities (strong recommendation, low-quality evidence).
Initiation and maintenance of ART in peripheral health facilities (strong recommendation, low-quality evidence).
Initiation of ART at peripheral health facilities with maintenance at the community level (that is outside health facilities in settings such as outreach sites, health posts, home-based services or community-based organizations) between regular clinical visits (strong recommendation, moderate-quality evidence).

# Service delivery
Although rapidly scaling up HIV programmes has significantly improved access to ART and increased the health and survival of people living with HIV, it also poses significant challenges to health systems. Decentralizing ART to primary care settings may ease the burden of routine management on other parts of the health system and may improve equity by promoting access to ART in rural areas. In several settings, transport cost is a significant barrier to access and retention in care. In many settings with a high burden of HIV infection, hospitals have long waiting times because of a large flow of patients needing care. Decentralizing HIV care and treatment could reduce the workload for health care personnel, thereby reducing waiting times for people with HIV and people receiving care at hospitals for other conditions and bring HIV services closer to people's homes. HIV-related services such as TB care and maternal and child health services are decentralized to primary care in several settings.

# Rationale and supporting evidence
The systematic review identified two observational studies evaluating how decentralization of initiating and maintaining ART in peripheral health facilities affects patient attrition (patient death and losses to follow-up). Attrition declined after 12 months, resulting largely from significantly reduced losses to follow-up. The systematic review identified four observational studies evaluating how maintaining ART at peripheral health facilities affected patient attrition. In this further review, attrition declined after 12 months, due to losses to both follow-up and death. The systematic review also identified two cluster-randomized trials evaluating how community-based maintenance of ART affects attrition. Comparable rates of attrition were observed after 12 months (104)(105)(106)(107)(108)(109)(110)(111)(112)(113)(114)(115).
When deciding which decentralization option to implement, programme managers may consider (1) the number of people living with HIV likely to attend decentralized settings;
(2) whether decentralization brings services closer to people who would otherwise travel long distances to receive ART; and (3) whether decentralizing ART reduces the workload at centralized facilities. This recommendation calls for links to the supply of diagnostics and medicines, services, training and supervision of health workers to maintain the quality of care. In addition, in several settings, decentralizing ART will involve task shifting to ensure an appropriate mix of health care personnel at peripheral facilities.
A WHO operations manual for delivering HIV care and treatment at primary health centres in high-prevalence, resource-limited settings (116) provides additional guidance.

# Implementation considerations for decentralizing ART
Box 10.5 discusses implementation considerations relevant to programme managers.
- 5 human resources

# Building human resource capacity
Within the past decade, in the context of the rapid scaling up of HIV care and treatment, in-service training has assumed a key role in rapidly upgrading the competencies of health practitioners.
All health workers, including community health workers, need to be regularly trained, mentored and supervised to ensure high-quality care and the implementation of updated national recommendations. Given the rapidly evolving knowledge on HIV care and treatment, countries need to consider a system for supporting health workers' continuing education, including clinical mentoring and regular supportive supervision. The use of new technologies such as computer-based self-learning, distance education, online courses and phone-based consultation may supplement classroom in-service training and support the efficient use of health workers' time and other resources (116,117).
It is, however, equally important to fully embrace and strengthen HIV care and treatment in existing pre-service courses leading to health workers graduating and being certified in various disciplines. Health workers also need to be equipped to manage HIV as a chronic condition, and to work in a team and need to be familiar with the national guidelines and care protocol. In several countries, people living with HIV, other community workers and volunteers are already involved in delivering HIV testing, counselling, care, treatment and social support services. In addition, people living with HIV are involved in training health workers as expert trainers. Involving people living with HIV in both training health workers and delivering HIV services may have the additional benefit of overcoming HIV-related stigma.
Countries should consider long-term reform that could support human resource strategies related to task shifting and introducing new types of health workers (such as for HIV testing or peer counsellors) on a sustainable basis within a comprehensive and nationally endorsed regulatory framework (laws and proclamations, rules and regulations, policies and guidelines). Although volunteers can make a valuable contribution on a short-term or parttime basis, all trained health workers who are providing essential health services, including community health workers, should receive adequate wages and/or other appropriate and commensurate incentives (116).

# Task shifting for hIV treatment and care

# New recommendations
Trained non-physician clinicians, midwives and nurses can initiate first-line ART (strong recommendation, moderate-quality evidence).
Trained non-physician clinicians, midwives and nurses can maintain ART (strong recommendation, moderate-quality evidence).
Trained and supervised community health workers can dispense ART between regular clinical visits (strong recommendation, moderate-quality evidence).

# human resources
Reorganizing, integrating and decentralizing HIV treatment and care will require reexamining the roles and tasks of teams of health care providers involved in delivering chronic HIV care. Task shifting involves the rational redistribution of tasks among health workforce teams. With this approach, specific tasks are reassigned, where appropriate, from highly qualified health workers to health workers with shorter training and fewer complementary qualifications to more efficiently and effectively use the available human resources. Task shifting should be implemented alongside other strategies designed to increase the total numbers and capacity of all types of health workers.
Health care personnel remain insufficient in many settings with a high burden of HIV.
Although increasing the capacity of countries to train more health care personnel is crucial, clinical tasks need to be shared and shifted to ensure that enough health workers are available to care for people with HIV. Task shifting improves access to ART at sites without physicians (such as rural health facilities, TB services and maternal and child health services). Task shifting also allows physicians to spend more time managing more complex clinical conditions such as coinfection and other comorbidities, toxicity of ART or treatment failure.
WHO guidance in 2008 (118) recommended that nurses and non-physician clinicians may initiate and maintain first-line ART and that community health workers may monitor people receiving ART during long-term follow-up. Since these recommendations were largely based on programme review and good practices, the evidence related to task shifting for ART was reviewed when developing these consolidated guidelines.
In this guideline, initiation of ART includes assessment for ART eligibility (based on clinical and/or immunological criteria); assessment for opportunistic infections; adherence counselling; and the prescribing of first-line ART. Maintenance of ART includes ongoing clinical assessment; monitoring for toxicity, treatment failure (clinical, immunological and virological) and opportunistic and other coinfections; adherence counselling; and the further prescribing of ART. Dispensing ART includes assessment for any new signs and symptoms, adherence monitoring and support and dispensing medication to patients who are already on ART between regular clinic visits.

# Rationale and supporting evidence
The systematic review identified three randomized trials and six observational studies addressing task shifting. Overall, the data showed no difference in mortality and losses to care when nurses or non-physician clinicians initiate or maintain people on ART or when community health workers maintain people on ART, relative to physicians providing this care. The quality of care in these studies was ensured by (1) providing training, mentoring, supervision and support for nurses, non-physician clinicians and community health workers;
(2) ensuring clear indications for patient referral; (3) implementing referral systems and (4) implementing monitoring and evaluation systems. Patient education could help people and their families understand that care provided by nurses and community health workers is not of lower quality than that provided by physicians (106)(107)(108)111,113,114,(119)(120)(121).
Shifting the initiation and maintenance of ART to adequately trained and supervised nurses and community health workers may enable substantial cost savings through (1) the ability to decentralize care to primary care facilities; (2) lower overhead costs for delivering quality care (with comparable or better outcomes) by nurses, non-physician clinicians and community health workers compared with physicians; and (3) decreased facility and utility costs (if care is being delivered in health facilities complemented with community-level services).
- 6 laboratory and diagnostic services
These guideline recommendations support increased access to HIV care and treatment, which will also require increased access to laboratory and diagnostic services. To ensure that testing services are accurate and reliable, relevant quality assurance systems need to be developed and strengthened.
Within a country, a multiplicity of testing settings may exist, such as laboratories, maternal and child health clinics, HIV testing and counselling sites, community-based testing and thus a multipronged and networked approach to selecting diagnostics and laboratory systems should be planned and adopted. Since an increasing number of new diagnostic tests and point-of-care systems is entering the market, the use of only high-quality diagnostics and equipment needs to be ensured. Strategic planning for properly placing and harmonizing testing platforms should be carried out to ensure appropriate use and cost-effectiveness.

# Implementation considerations and good practices
This guidance to strengthen laboratory and diagnostic services emphasizes the importance of leadership and governance, high-quality laboratory services, expanding testing services and developing the health workforce:
to strengthen and expand laboratory and diagnostic services;
to support a dedicated specimen referral system;
to increase access to HIV viral load testing;
to support the expansion of diagnostic services to include testing at the point of care;
to train and certify health workers who perform the testing; and to ensure high-quality diagnostics and plans for implementation, including quality assurance.

# Strengthening and expanding laboratory and diagnostic services
The following areas are important to strengthen the network of laboratory and diagnostic services for implementing the guideline recommendations:
standardizing testing methods to streamline procurement, quality assurance and training;
incorporating new testing approaches and systems into national laboratory strategic plans and policies; evaluating diagnostics for their performance and operational characteristics to validate testing algorithms (with back-up options) before introduction; carrying out strategic planning for properly placing and harmonizing testing platforms to ensure appropriate use and cost-effectiveness;
expanding current laboratory networks to support and monitor the decentralization and integration of testing services or to provide access to testing when diagnostic services are unavailable at service delivery sites; and allocating appropriate resources to ensure the availability of testing services, including human and financial resources.
- 6 laboratory and diagnostic services 9.6.4 Supporting a dedicated specimen referral system Laboratory referral systems and procedures for collecting and processing specimens need to be strengthened to increase access to viral load testing and other testing (for example, CD4 and early infant diagnosis). Providing for and strengthening a dedicated, efficient, safe and cost-effective specimen referral system requires reliable specimen transport with adequate conditions for whole blood, plasma and dried blood spot (DBS) specimens and rapidly and dependably reporting test results back to the referring site with linkage to care. Rapidly reporting results is essential for timely care.

# Increasing access to hIV viral load testing
The guidelines call for monitoring the response to treatment and diagnosing and confirming treatment failure with viral load testing. This will require strengthening the existing laboratory services and phased expansion of monitoring services into peripheral facilities and can include:
strengthening and leveraging existing CD4 and early infant diagnosis networks;
ensuring that laboratories have adequate infrastructure, technical testing expertise and quality assurance and quality improvement programmes;
ensuring an appropriate mix of high-volume centralized laboratory testing and testing at the point of care for facilities in remote locations; and the use of dried blood spots as a tool to increase access to viral load testing.

# Expanding diagnostic services to point-of-care settings
Decentralizing laboratory and diagnostic services requires that all aspects of laboratory tests be in place before implementing services, including: using only high-quality, evaluated and reliable diagnostic tests;
supervising and monitoring point-of-care tests for quality and reliability; implementing a strategy for managing supply chain and equipment service; and establishing data management systems for timely identification of quality issues and regional and national data reporting. Table 9.2 provides guidance on organizing testing services at various levels of the health care delivery system. Countries require guidelines for the qualification of personnel who will perform the laboratory tests. The guidelines should include training requirements for specific tests and the process for certification and recertification. All health workers assigned to perform pointof-care tests must be trained and proficient on the testing procedure, specimen collection and quality assurance before implementing these services.

# Implementing comprehensive quality management systems
Developing a comprehensive quality management system including external quality assessment and quality control is essential. The quality management system should:
be implemented within the laboratory network and all remote testing sites;
be incorporated into the routine testing procedures and monitored; ensure that testing sites undertake quality control, as appropriate;
ensure that testing sites are enrolled in an external quality assessment scheme (proficiency testing programme); ensure the use of standard operating procedures for all processes, including specimen collection and processing, test methods, interpreting results and reporting; ensure the use of standardized logbooks or electronic data management and reporting, including identifying errors and potential misclassification; and ensure that equipment and facilities are maintained, both preventive and corrective.

# Procurement and supply management systems 9.7.1 Overview
Ensuring adequate and continuous availability of quality and affordable essential medicines, diagnostics and other consumables at service delivery sites is a critical role of procurement and supply management systems. The increasing number of people who need chronic HIV care, especially in settings with a high burden of HIV infection, necessitates an uninterrupted supply of HIV-related health products. This can be achieved only if the procurement and supply management system is strengthened at all levels of the health system. Moreover, ARV drug regimens and formulations and HIV treatment recommendations need to be regularly updated in response to new developments and emerging evidence. This requires a more efficient and dynamic supply management system to prevent waste and shortages.

# Rationale and supporting evidence
Successful HIV programmes are only possible if all services providing ART are equipped with an uninterrupted and sustained supply of high-quality ARV drugs, preferably WHOprequalified products. Other pharmaceuticals that are needed to support ART services include medicines to prevent or treat opportunistic infections, and laboratory reagents, supplies and equipment to diagnose HIV and opportunistic infections, monitor the progression of HIV infection and treatment response and detect adverse drug reactions. Since a single health facility may not carry out the dispensing of all needed pharmaceuticals, in some settings clients would need to be able to access services through a referral system.

# Implementation considerations and good practices
Management support is integral to each component of the procurement and supply management cycle: selection, procurement, storage and distribution, use and monitoring. It includes a variety of activities at all levels of the health care delivery system: from the national programme level down to where medicines are dispensed and diagnostics are used. The main activities include managing the information system, ensuring timely information flow between stakeholders at different levels and securing financial and other resources, including the medicines and diagnostics needed for the programme. The following provides broad guidance on key activities at each stages of the supply management cycle.

# Selecting pharmaceuticals and diagnostics
Countries adapting these guidelines may need to update national medicine lists to include newly recommended ARV drug regimens and formulations. The advantage of using the essential list concept is to enable a health system to limit other more expensive or WHO-delisted medicines and diagnostics from being purchased and accelerating the registration of WHO-prequalified products to facilitate quality-assured procurement (123).
If a selected fixed-dose combination or other ARV drug regimen is not on the national list or not registered in the country, HIV programme managers need to coordinate with the national drug regulatory authority and request that these drugs be put on the list and registered.
Detailed national ART guidelines, for example, that provide recommendations for managing toxicity or treatment failure and recommended formulations for weight and age can help to standardize prescribing and dispensing practices and facilitate forecasting for ARV drugs.
Synchronized introduction of new guidelines with forecasting, procurement and distribution planning during the phasing in and phasing out of new and old ARV drug products will minimize the waste of products that are being phased out and shortages of newly recommended products.
In several settings, paediatric formulations are not widely available. The national medicine list should be optimized for paediatric ARV drug formulations, to include fixeddose combinations, scored or dispersible products that facilitate adherence and supply management. Countries may consider removing less preferred products and aligning paediatric formulations with those of adults, where possible.
Health workers need to be trained at different levels in managing pharmaceuticals and diagnostics, including forecasting, procurement and distribution and ensuring adequate supervision throughout the supply system.
A uniform and harmonized national procurement system is required for efficiently procuring quality-assured affordable ARV drugs and diagnostics (124,125). Procurement should be based on appropriate selection of products and need-based forecasting, considering consumption, expanding services, phasing in and phasing out formulations and implementing new recommendations. Transparent procedures should be adopted to achieve best-value procurement and a quality assurance system implemented to procure, store and distribute high-quality pharmaceuticals, diagnostics and other health products (124,126).

# Procurement and supply management systems
Procurement systems should: procure the most effective, heat-stable, fixed-dose quality-assured ARV drug formulations in the right quantities, at the lowest possible cost and in a timely manner;
request that the partners supporting the national HIV programme consolidate and harmonize ARV drugs and diagnostics procurement and supply management systems and pool demands for ARV drugs and diagnostics, exploring options for pooling under a common tender system; use a publicly accessible database to facilitate access to information about prices and support competition (127)(128)(129)(130); and follow the principles described in the United Nations interagency guidelines for donated drugs (131).

# Storage and distribution
Appropriate storage and distribution of HIV medicines, diagnostics and other commodities are important components of the supply management system (Table 9.3).
Product integrity and quality need to be maintained during storage and distribution (125,132), and waste from spoilage and expired products should be minimized. Integrated supply systems should be promoted when planning for decentralization, building on what exists and strengthening capacity where required. For example, existing immunization programme infrastructure, including cold chains, could be used to expand the supply of paediatric formulations, such as LPV/r liquid formulations. Facilities should have adequate storage space, trained personnel and the tools to manage supplies effectively. The number of storage levels should be rationalized to reduce the supply pipeline.
Accurate inventory records should be maintained and a system created to track products that enter and leave the supply system. A routine consumption-based reordering cycle at service delivery sites should be established. Flexibility should be introduced in the supply system such as procedures for reporting and redistribution of excess ARV drug supplies, more frequent ordering and filling of non-routine orders to minimize expiry and stockouts. Pharmaceutical and diagnostic products need to be adequately stored, especially if ART delivery is further decentralized and is dispensed from an increasing number of peripheral health facilities. Measures are required during transport and storage to prevent theft and fraud such as vehicle tracking systems, secured storage areas, audits and labelling of ARV drug products procured by HIV programmes.

# use and monitoring
Robust information systems ensure the availability of accurate and timely consumption data on ARV drugs and other information required for effectively monitoring the performance of the entire supply system and for forecasting the ARV drugs and diagnostics needed. Monitoring procurement and supply management through the effective use of early warning indicators prevents stock-outs and overstocks leading to expiry (126).
The recommendations in these guidelines increase the number of people eligible for ART, promote new first-and second-line regimens and propose changes in approaches and strategies to laboratory monitoring to maximize treatment effectiveness. National stakeholders face several important choices on how to optimally translate these recommendations into national practice. For example, although evidence of clinical efficacy supports the uptake of interventions, issues such as cost and costeffectiveness, ethical and human rights considerations, the perceptions of various stakeholders and the legal and regulatory environment must also be taken into account (1).
National HIV programme managers play a unique role in managing the process for adapting and implementing the HIV guideline recommendations in their respective countries. First, convening a broad, inclusive and transparent consultative process can help to define what programme changes are relevant and necessary, such as revising national protocols, guidelines and regulations. Second, in parallel, it is necessary to secure the financial resources and political support required to implement the proposed changes. Third, systems are required to ensure broad accountability for implementation from all partners at all levels and adequately document performance to inform programming decisions and maintain political support. Lastly, implementation and operations research should be supported so that innovative approaches can be assessed and taken to scale.
Human rights and ethical principles should guide the revision of national treatment policies to ensure that they are equitable and meet the specific needs of all beneficiaries. New recommendations should inform the HIV programme's overarching vision, goals and objectives, and existing strategic plans should be adapted accordingly to assure consistency, avoid duplication and leverage potential economies of scale (2).
As HIV programmes mature and increasingly focus on the challenges of long-term prevention, treatment, care and support, national responses need to be considered within the broader health and development contexts. The sustainability and effectiveness of HIV programmes can be greatly enhanced by creating and strengthening linkages with other health and non-health programmes (3). Although national programme managers should oversee the decision-making process, it should also be broadly representative. Broad stakeholder engagement in policy design, implementation, monitoring and evaluation will help to ensure that the national adaptation of global guidelines results in HIV programmes that are legitimate, acceptable, effective and equitable and address community needs (1,5).
The composition of the working group may vary over time and depend on the specific recommendations under discussion. For example, when considering how to improve programmes for PMTCT, joint planning with those responsible for maternal and child health should be undertaken. Checklist 10.1 provides a checklist of key elements to consider in implementing a transparent and inclusive decision-making process.

# Data to support decision-making (5)
Decisions on how to adapt and implement these guidelines should be based on a careful assessment of epidemiological dynamics and programme performance to identify programme strengths and weaknesses and necessary policy changes, consistent with the principles of "know your epidemic, know your response" (Checklist 10.1) (6,7). In some countries, these data may be available from regular monitoring and evaluation activities or from recent programme assessments. Elsewhere, new analyses may be warranted, such as studies of the modes of HIV transmission, to shed light on key epidemiological or response elements. Quantitative and qualitative data should, whenever possible, be disaggregated by gender, age, subnational administrative categories (such as regions and districts) and other relevant stratifications, including key populations, to ensure that new policies address inequities in access and increase the coverage of interventions.
The consolidation of health information systems, including patient record registries, into electronic databases is critical to facilitate the management of increasing amounts of data and improve their robustness and availability for programme decision-making (see section 11.5).

# National and local hIV epidemiology
An epidemiological analysis should describe the prevalence levels among the general population and in specific key populations, the rate at which HIV infection is acquired and among whom, including infants, young children, pregnant women and serodiscordant couples. Both prevalence and incidence measurements should aim to identify populations at higher risk for HIV infection, including in generalized epidemic settings viii and adequate population size estimates for these populations should be available so that results can be interpreted appropriately (9). Data on the prevalence and incidence of key coinfections (such as TB and hepatitis B and C) and other comorbidities should also be gathered to inform decision-making.

# Programme performance and response analysis
Determining whether current ARV programmes are adequate to address the needs that have been identified requires understanding who is currently accessing these services.
Programmes should assess present ARV coverage levels among the general population as well as key populations, the disease stage at which they access care, how well these groups are retained in care and treatment, the ARV regimens used and the impact of ART on viral load suppression, morbidity and mortality. Programmes that are considering raising the CD4 cell count threshold for ART eligibility should ideally have data on the median CD4 cell counts and the stage of HIV disease of people at the time of their HIV diagnosis and at the time of initiating treatment. Disaggregated data for various groups enable assessment of ARV needs and establishment of priorities for delivering services. Data on adherence, retention and viral load suppression are key to assess the quality of the services provided. Surveillance of transmitted and acquired HIV drug resistance can also be instrumental in informing decisions on optimal regimen choices (Box 11.1). Whenever possible, indicators of impact, such as changes in HIV-related incidence, prevalence, morbidity and mortality, should also be reviewed.

# Socioeconomic, policy and legal context
A review of epidemiological and programmatic data is incomplete without a deeper understanding of what drives HIV vulnerability and how various political, social, economic and legal factors affect the ability and willingness of various groups -such as men, women, adolescents, sex workers, men who have sex with men, transgender people and people who inject drugs -to seek and access health services. Stigma, discrimination, poverty, gender inequality, education and migration status are key elements that should be taken into account to inform effective HIV programming.
The legal context can also affect access to interventions, such as laws related to intellectual property rights and those that criminalize homosexuality, HIV exposure and/ or transmission, drug use and sex work. Such laws should be reviewed and reformed to eliminate discriminatory practices, decrease HIV vulnerability, improve access to health services and protect human rights.
viii Incidence estimates by modes of transmission have already been developed for some countries and are available from UNAIDS (8).

# Data to support decision-making
Checklist 10.1 Process and evidence for decision-making Process for decision-making (10,11) 1. Does the process follow principles for sound and appropriate decision-making?

# Can all stakeholders participate effectively, be heard and influence decisionmaking?
Is information accessible to all key stakeholders in written and understandable language? Is the process organized to ensure the meaningful participation of all relevant stakeholders? Have the potential social, cultural, and legal barriers that deter the meaningful participation of historically marginalized stakeholders been identified and addressed?

# Transparency regarding the grounds for decisions
Are the decision-making criteria transparent and is the rationale stated explicitly with reference to: Scientific evidence, including effectiveness and risk? Opportunity costs of interventions, including cost-effectiveness? Equity impact (distribution of health benefits and burdens for different groups)?
Evidence for decision-making

# HIV incidence and prevalence
In what population groups are HIV incidence and prevalence highest? Relevant criteria include gender, location (urban versus rural), age, income, general population and pregnant women, and key populations (such as men who have sex with men, people who inject drugs, sex workers and prisoners)
What is the HIV seroprevalence among the partners of index cases? What is the incidence of HIV infection in serodiscordant couples?

# Programme and response analysis
Has the decision-making process taken into account: the current coverage of HIV testing and counselling disaggregated by relevant stratifiers?
the current coverage of ART disaggregated by relevant stratifiers?
the current coverage of ARV drugs for PMTCT and ART among pregnant women living with HIV?
the median CD4 cell count and HIV disease stage of people initiating ART?
the proportion of people starting ART who are alive and still receiving ART after 12, 24 and 60 months?
the prevalence of viral suppression (and % treatment failure) among people receiving ART after 12 months? the prevalence of HIV drug resistance among people starting first-line ART and among those already receiving treatment?

# Equity in access
Based on a review of epidemiological and programme response data, do the recommendations promote greater access to ARV drugs and other services for people with least access or those most in need, including key populations?

# Alignment between evidence and recommendations
Are the recommendations appropriate for the epidemiological setting in which they will be implemented?
Are the recommendations aligned with and do they support the implementation of the programme's overarching vision, goals and objectives?
Have the recommendations been informed by local and national evidence?

# Contextual issues
Has the decision-making process taken into account how poverty, gender inequality, education, stigma, discrimination and migration status affect HIV vulnerability and access to services?
Are there any punitive laws and practices, at any levels, related to HIV transmission, sex work, drug use or homosexuality?
Has it been determined how such barriers will be dealt with and how the responses will affect programme planning?
Are there legal or regulatory barriers to adolescents being able to have independent access to HIV testing, counselling, treatment and care?  (12,13).
Global and national commitments require providing HIV treatment and prevention to everyone in need, following the human rights principles of non-discrimination, accountability and participation (14)(15)(16). National HIV strategies should be planned and implemented from the outset with the ultimate goal of delivering the full package of services and interventions recommended in these guidelines as soon as possible. Key ethical principles of fairness, equity and urgency should also be observed in the process of reviewing and adapting guidelines. The design of effective and equitable policies implies that strategies should focus comprehensively on addressing barriers to access testing, prevention and treatment services, particularly those faced by key populations. Facility-and community-level reviews may be useful to understand the extent to which services are acceptable and adapted to the specific needs of key populations.

# Impact and cost-effectiveness
Realizing positive impact for a population is an important goal of public health programmes and policies. Examples of the impact of HIV programmes include reduced HIV incidence, prevalence, morbidity and mortality and improved quality of life (17). Impact is often a result of a complex set of factors and a combination of diverse inputs and activities or processes, and it is often not attributable to a single intervention or programme (5).
Cost-effectiveness analysis is one of several economic evaluation tools used to measure the value of delivering particular services. Economic evaluation measures the costs and consequences of alternative programmes, which are then compared to assess how the greatest health benefits can be generated. In cost-effectiveness analysis, impact is often measured using indicators related to a change in health status, such as disability-adjusted life-years (DALYs) gained, which includes the estimated number of deaths and infections averted. As the experience of scaling up ART in low-and middle-income countries demonstrates, the cost-effectiveness of health interventions also changes over time, as costs fall because of gains in scale, improvements in technology or the design of more efficient delivery systems.
During the development of these guidelines, a consortium of research groups independently developed and then compared mathematical models to assess the epidemiological and clinical impact as well as cost-effectiveness ratios of various interventions, notably those related to earlier initiation of ART (Box 10.1). Although evaluating cost-effectiveness and health impact may be useful in systematically comparing various programme interventions, they should be considered in the light of the ethical, equity and human rights implications associated with different courses of action, especially in settings in which not all eligible individuals currently have access to ART. Investments in critical enabler programmes (such as integrated treatment and rights literacy programmes, legal services, stigma and discrimination reduction programmes, training for health care workers and law enforcement) can play a role in overcoming barriers to accessing treatment and other HIV-related services and keeping people connected to care. As such, these programmes can contribute to overall cost-effectiveness, in addition to achieving other important objectives, such as reducing discrimination (18).
Box 10.1 Estimating the impact and cost-effectiveness of selected recommendations using mathematical models: results from the independent HIV Modelling Consortium
As HIV programme managers work to implement these guidelines, they may face complex choices on how to optimally allocate resources for HIV treatment: for example, determining the relative allocation of resources for scaling up HIV testing and linkage to care and for increasing access to ART based on expanded eligibility criteria.
The HIV Modelling Consortium, an independent group of research institutions (www. hivmodelling.org), used multiple independent mathematical models based on data sets from four countries with different types of epidemics and current ART coverage -India, South Africa, Viet Nam and Zambia -to examine the health benefits, costs and cost-effectiveness of various strategies for expanding eligibility for ART as well as testing and access to HIV care (19) (Web Annex www.who.int/hiv/pub/guidelines/arv2013/annexes). In each case, a range of potential options was investigated, including various thresholds for ART eligibility (CD4 cell count 500 cells/mm 3 all people with HIV and specific key populations), assuming current as well as expanded patterns of HIV testing and linkage to care. The costs and both individual and preventive health benefits associated with each intervention were estimated, including changes in HIV incidence, reductions in the loss of healthy life-years and costs over time. These models also considered the relative cost-effectiveness of strategies, highlighting which of them, for a given budget, would be expected to maximize health gains.
Expanding the criterion for ART eligibility to CD4 cell count 500 cells/mm 3 was found to be highly cost-effective in low-and middle-income settings. However, combining expanded eligibility with a large increase in HIV testing and linkage to care produced the greatest benefits, especially in settings with low ART coverage. Expanding ART eligibility to all adults with HIV (irrespective of CD4 count) was less cost-effective than expanding the criterion to 500 cells/mm 3 because of less immediate improvements in health as the CD4 threshold for initiating ART is increased.
The modelling results should be interpreted in light of some important limitations. Many of these conclusions could change substantially depending on cost assumptions, especially those related to testing and counselling and to retaining people in pre-ART care. Moreover, the models did not consider how the estimated impact and cost-effectiveness of the various interventions would change if they were combined or only partly implemented. Models also did not address potential trade-offs with non-antiretroviral interventions, and several important issues were not covered, such as treatment of children.

# Opportunities and risks
The recommendations in these guidelines have the potential to further reduce HIV-related mortality, improve the quality of life, reduce the number of people acquiring HIV infection and enhance treatment effectiveness. The benefits accrued from implementing them are likely to considerably outweigh the upfront investment needed and have the potential to fundamentally change the course of the epidemic. Nevertheless, domestic factors (such as budget cuts, theft of ARV drugs, attrition of trained health workers and emergence of drug resistance) and external contingencies (such as withdrawal of external financial support, political instability and natural disasters) could negatively affect their implementation. It is essential to design strategies to mitigate such events so that continued service delivery can be assured, especially for those most in need (20).

# Implementation considerations across the health system
As countries consider how to optimally implement these guidelines, the budgetary, human resource requirements and other health system implications should be analysed to identify which inputs and systems are currently available and which areas require additional investment. The six building blocks for health systems identified by WHO provide a useful analytical framework (21). Checklist 10.2 provides a checklist of key critical issues in these areas. Such considerations should not determine whether a particular recommendation is included or excluded from national guidelines but can be used as a tool to understand the impact of a recommendation and how best to adapt it and mobilize resources for its implementation. When the relative budget implications of specific recommendations are considered, it is also important to take into account the costs of inaction in terms of increased mortality, morbidity and HIV transmission. An implementation plan should clearly define the set of activities required in a specified period of time to achieve targeted outcomes, with a clear division of labour among all stakeholders involved in implementing programmes.
Robust procurement and supply management systems are needed to ensure the continued availability of all necessary drugs, diagnostics and other commodities across the various levels of the health system. Pooled or joint procurement can be used to secure lower costs through economies of scale, and careful demand forecasting is key to minimizing waste. Fixed-dose combinations and once-daily therapy should be used whenever possible to support adherence and make treatment as convenient as possible for the people receiving therapy and their caregivers. Laboratory capacity must also be reviewed and services should be strengthened to cope with higher demand, and nationally standardized health information systems and patient monitoring tools should be used in all settings. Stronger interventions are also needed to maximize treatment adherence and retention across the continuum of care. Specific interventions may be needed in particular settings, such as postpartum followup of mother-infant pairs.
The quality of health care is a critical dimension to consider in the planning and adaptation process. The rapid scale-up observed during the past decade has left gaps in the quality of service delivery at times that have negatively affected, for example, adherence rates, timely enrolment in care or retention on ART. The implementation of new guidelines provides an opportunity to comprehensively review and address such gaps. Critically, this requires effective monitoring and evaluation systems (see Chapter 11). A key component of sound quality assurance mechanisms is a clear delineation of roles and responsibilities for the delivery of the various functions and inputs (such as leadership, financing, supply chain management, human resources, monitoring and evaluation needed for effectively providing services at the national, regional, district, facility and individual clinician levels).
A quality assurance and improvement framework developed for HIV testing and counselling may inform broader quality assurance and quality improvement interventions across the continuum of care (22).
Effective HIV programming is multisectoral in nature and goes beyond biomedical interventions. It is essential to assess how HIV interventions can be optimally linked with other health programmes and non-health services to increase coverage and optimize resources. Planning should also take into account the variety of providers involved in health service delivery, including public, private and not-for-profit organizations. Community involvement and peer outreach strategies are key to improve programme design, promote its sustainability and maximize coverage. 1. Treat the sickest people first. Individuals with CD4 cell counts of less than 350 cells/mm 3 have a different mortality profile than those with higher CD4 cell counts. What systems will be in place to ensure that the sickest people are adequately given priority, especially in settings with low ART coverage?
- Phase out d4T. Given the long-term toxicity and side effects of d4T, programmes raising the ART initiation threshold to 500 CD4 cells/mm 3 should have significantly progressed in phasing out d4T in adult and adolescent regimens to optimize treatment outcomes.

# Consider task shifting and decentralization.
Human resource plans should be developed or adjusted to support the policy decision to increase the CD4 eligibility threshold, including through task shifting and training new cadres of health workers (see section 9.5.2).

# Reinforce adherence support.
A higher threshold for initiating ART means that more people who feel healthy will become eligible for treatment. What interventions to promote and reinforce adherence will be implemented for these people?
- Provide treatment monitoring. As more people initiate ART earlier and stay on it for longer, monitoring viral suppression becomes increasingly important, as keeping people on failing regimens may lead to higher levels of drug resistance, which might compromise the efficacy of treatment, especially of NNRTIs. How will access to viral load monitoring be scaled up?

# Develop treatment literacy on the use of viral load.
As most programmes in low-and middle-income countries have historically relied on CD4 monitoring, people receiving ARV drugs and health care providers may not be familiar with the concept and importance of viral load. Counselling should be provided so that people receiving ARV drugs and health care providers understand the meaning and implications of having a detectable or undetectable viral load and its relation to adherence.

# Promote adherence and retention.
Adherence to therapy and retention in care of mother-infant pairs may be especially difficult in the postpartum breastfeeding period. What strategies will be put in place to monitor and support adherence and retention and re-engage in care those lost to follow-up, including both the mother and the HIV-exposed children?

# Consider ethical issues.
Initiating lifelong ART for all pregnant and breastfeeding women regardless of CD4 count may result in temporary disparities in access to treatment. For example, a pregnant woman with a high CD4 count may continue to receive ART after delivery, whereas her husband, other family members, neighbours or other women intending to get pregnant with a lower CD4 count may not yet be eligible for treatment. What process and strategies will be put in place at the policy and service delivery levels to address such possible disparities? How can the enrolment of all pregnant and breastfeeding women into lifelong treatment be leveraged to enhance a family approach, including getting partners and other household members tested for HIV and treatment?
- Assure the quality of HIV testing. Developing quality-assurance programmes, including for HIV rapid testing (which in some settings may be the only test used to determine the initiation of lifelong ART) and appropriate use of testing algorithms, will be important to ensure optimal implementation in all areas of the country.
Box 10.4 (continued) 7. Assess laboratory monitoring needs. Although CD4 testing may not be required to initiate ART among pregnant women, toxicity and ART response monitoring, including viral load (which is key for assessing viral suppression), should be available, similar to all people receiving ART. Infant diagnosis is also essential to identify infants infected with HIV and to link them to the necessary treatment and care. Surveillance systems (which can be sentinel sites) should be established to evaluate the impact of ART on birth defects, pregnancy outcomes, safety among infants and young children exposed through breastfeeding as well as transmission outcomes and tolerance of first-line ART.
- Implement adequate monitoring and evaluation frameworks. New strategies are needed to ensure high quality and longitudinal cohort data on the mothers and their HIVexposed infants across a range of service delivery entry points and across the continuum of care. For breastfeeding mothers and infants, the true effectiveness of a PMTCT programme depends on infant infection status and HIV-free survival at the end of the breastfeeding period and not on early infection status at age six weeks.

# Provide infant prophylaxis.
Infant prophylaxis is particularly critical for PMTCT in situations of late HIV diagnosis in the mother, limited or no antepartum maternal ART or if maternal ART is interrupted due to toxicity, intolerance or lack of adherence.
- Assure continuous drug supply. An uninterrupted supply of maternal ART during pregnancy and breastfeeding is critical for PMTCT as well as maternal health. Adequate drug forecasting and drug supply chain is essential.

# Contextual issues to consider for PMTCT options
Although country programmes will define the choice between (1) providing ART to pregnant or breastfeeding women living with HIV for the duration of the risk of mother-to-child transmission or (2) lifelong ART regardless of CD4 cell count based on local circumstances, preferences and values, several contextual features are especially relevant for decision-making.
- Providing lifelong ART ("Option B+") to all pregnant and breastfeeding women is particularly relevant in settings with the following characteristics:
- generalized epidemic;
- high repeat pregnancy rates ix and low family planning coverage;
- low partner testing rates;
- limited access to CD4 testing;
- low existing coverage of ART for pregnant women who meet the treatment eligibility criteria for non-pregnant individuals; and
- long duration of breastfeeding by women living with HIV.
- Providing ART only during the period of risk of mother-to-child transmission ("Option B") with continuing lifelong ART only for those women meeting standard eligibility criteria for the treatment of non-pregnant adults is especially relevant in settings with the following characteristics:
- concentrated epidemics;
- lower repeat pregnancy rates and higher family planning coverage;
- high access to CD4 testing;
- high existing coverage of ART for pregnant women who meet the treatment eligibility criteria for non-pregnant individuals; and
- formula feeding is recommended, available and safe.
ix In settings with high fertility rates, it should be a priority to institute family planning programmes to allow women to avoid unplanned pregnancies. 1. Choose a suitable alternative. WHO recommends TDF as the preferred alternative to d4T in firstline regimens. TDF is also more likely to be effective than AZT among people who have developed resistance while on d4T.
- Design a costed phase-out plan. The overall operational plan for phasing out d4T should be fully costed and should consider any additional investment in laboratory strengthening and capacitybuilding that may be required to support implementation.

# Identify priorities for implementation.
Because of programme constraints, not all countries may be able to promptly switch everyone receiving d4T to new regimens. Priorities should be clearly defined and agreed with all relevant stakeholders.

# Avoid treatment disruption.
Although new d4T orders should be discontinued, adequate and timely forecasting and procurement of the preferred alternative drug are critical to avoid stock-outs and treatment interruption.
Review and compare prices. Substantial reductions in the price of both TDF and its preferred companion drug EFV have been observed in recent years. Countries are encouraged to ensure they are procuring these drugs at the best possible price. WHO's Global Price Reporting Mechanism may be a useful source of price information (23).
- Manage stockpiles. Options include reserving stocks for back-up situations for individuals who may require d4T in the absence of alternative choices.

# Implementing recommendations in different epidemic settings
The guidelines recommend that, in all settings, everyone (adults, adolescents and children) presenting with CD4 cell counts less than 500 cells/mm 3 should be offered ART. People with CD4 cell counts of 350 cells/mm 3 or less should receive ART as a priority. This is a highly cost-effective intervention that can dramatically reduce HIV-related mortality and morbidity, in addition to HIV incidence. ART should also be initiated in all pregnant and breastfeeding women with HIV, regardless of CD4 count, and be provided to all individuals with active TB and HBV coinfection with severe chronic liver disease and for HIV-positive partners in a serodiscordant couple, irrespective of CD4 count. Coverage of ART among children is also often low, and targeted investment is needed to ensure that all eligible children, including all children younger than five years, have timely access. In addition, the guidelines recommend phasing out d4T and increasing the use of fixed-dose combinations of ARV drugs.
In concentrated epidemic settings with low ART coverage, it is critical to identify opportunities to expand access to HIV treatment and care, including testing and counselling, to most-at-risk populations, such as men who have sex with men, transgender people, sex workers, people who inject drugs and prisoners. This requires addressing any structural barriers that may prevent these populations from seeking and accessing care. Integrating HIV services into drug dependence treatment and harm reduction services and TB clinics can be a highly effective approach to reaching these populations (see section 9.4.2). In these settings, given the relatively limited number of pregnant women living with HIV, phasing out option A for PMTCT and providing ART during pregnancy and breastfeeding to reduce the risk of mother-to-child transmission of HIV (option B) are highly effective and relatively low-cost strategies.
In generalized epidemic settings with low ART coverage, ensuring that all individuals with CD4 counts of less than 350 cells/mm 3 are identified and enrolled in care and treatment is a priority and requires greatly increasing HIV testing and counselling rates among the general population. This can be accomplished by scaling up an appropriate mix of approaches to HIV testing and counselling, including provider-initiated HIV testing and counselling for everyone seeking care as well as all pregnant or breastfeeding women, with effective referral systems and links to care and treatment (section 5.1). Identifying individuals with CD4 counts between 350 and 500 cells/mm 3 provides an important opportunity to link them into care and initiate ART early. Other strategies to improve the overall levels of access to and uptake of ART include decentralizing HIV services to the primary health care level and integrating HIV services with TB and antenatal care and maternal and child health services (see section 9.4.2), and offering pregnant and breastfeeding women living with HIV the option of receiving lifelong ART, based on national programme decisions. In addition, as in concentrated epidemics, it important to identify and reach key populations and those with poor access to clinical and community-based services. These may include sex workers, people who inject drugs, men who have sex with men, transgender people or other groups such as adolescent girls, migrants and other mobile populations, older women and certain high-risk occupational groups.
As coverage of ART increases and programmes mature, expanding access to second-line regimens increasingly becomes a programmatic priority. Scaling up viral load monitoring will be important to adequately identify treatment failure and to avoid switching unnecessarily to second-line regimens. Viral load monitoring is also likely to play a central monitoring role in places in which ART is being broadly expanded to reduce HIV incidence.
As people initiate treatment earlier and stay on it for longer, monitoring the quality of service delivery and strengthening service linkages to improve retention throughout the cascade of care are essential to optimize treatment outcomes and long-term programme performance.

# useful tools for costing and planning
Estimating the costs associated with implementing new recommendations is a key step in the roll-out process. Several costing tools and resources are available to assist countries in estimating the costing and budgeting of HIV and related interventions and services.
Spectrum is a suite of models and analytical tools to support decision-making. It comprises several software applications including AIM (AIDS Impact Model) and Goals (Cost and Impact of HIV Interventions). The AIM and Resource Needs modules can be used to estimate the impact of key new recommendations on number of deaths averted by ART, the number of infant infections averted by PMTCT and adult, PMTCT and paediatric treatment needs and costs. The key data needed to generate these estimates are demographic projections, HIV incidence trends, historical data on the numbers of people receiving ART, the numbers of pregnant women receiving PMTCT interventions and the unit costs for ART for adults and for PMTCT. All countries already have AIM files prepared as part of their national epidemiological estimates, so both modules can be rapidly applied.
The Goals module can be used to estimate the number of adult HIV infections averted by ART under different eligibility criteria and rates of scale-up. The key inputs required are the distribution of the adult population by risk group (such as serodiscordant stable couples, those with casual partners, female sex workers, male clients of sex workers, men who have sex with men, transgender people and people who inject drugs); sexual behaviour by risk group (numbers of partners per year, acts per partner and condom use) and needle sharing among people who inject drugs. Goals models already exist for about 25 countries, and other countries have compiled these data in the context of modes of transmission studies.
OneHealth is a software tool designed to strengthen health system analysis and costing and to develop financing scenarios at the country level. It is specifically designed to assess health investment needs in low-and middle-income countries and provides planners with a single framework for planning, costing, impact analysis, budgeting and financing of strategies for all major diseases and health system components. OneHealth can also be downloaded free of charge (24).
WHO and collaborating organizations have recently developed a variety of tools to assist with drug quantification and supply management. Several are available for download, with a description of their main purposes and programmatic focus (25). Guidance on the costing of different PMTCT options has also been developed (26). A flexible tool for costing investments in critical enablers (such as integrated treatment and rights literacy programmes, legal services, stigma and discrimination reduction programmes, training for health care workers and law enforcement) has also been developed and can be downloaded for free, along with a user guide (27,28).

# MONITORING AND EVAluATION
As countries adapt and implement these guidelines, monitoring and evaluation frameworks and systems need to be adapted to collect and analyse information to track the implementation and impact of new recommendations. Monitoring and evaluation will help programme managers to assess the effectiveness of interventions and linkages between services along the cascade of treatment and care for HIV and associated conditions (Fig. 11.1). Such information is essential to detect and respond to bottlenecks or gaps in programme performance and to adequately characterize and respond to patient attrition. As programmes mature, monitoring individual-and population-level outcomes, including toxicity and adverse events, drug resistance, viral suppression, mortality, survival and incidence, is also essential to assess the impact of programmes.

# Fig. 11.1 The HIV treatment and care cascade
Data can be collected in many ways, including routinely reported data from all facilities or sentinel sites; population-based surveys; surveillance data; observations on cohorts of people living with HIV; and periodic evaluation. Programme input and processes can also be monitored through facility surveys or updated lists of service availability; documenting the availability and training of human resources; and monitoring the availability of HIV medicines and diagnostics at various geographical and facility levels. Special studies can be considered where routine monitoring is inappropriate.
In considering how best to collect critical data, efforts should also be made to review monitoring systems, such as better linking the monitoring of services for PMTCT, TB and ART and integrating HIV drug resistance monitoring into routine health information systems. Involving civil society in monitoring and evaluation activities is also critical to better understand successes and failures, especially in assessing the perceptions, values and experiences of people living with HIV, key populations and the broader community in accessing and using services. The community can also play a key role in designing and implementing data collection tools and analysing and interpreting findings.
WHO is developing a consolidated guide on monitoring and evaluation of HIV in the health sector that brings together the various elements of monitoring and evaluation systems for HIV programmes. The guide will consolidate and align existing monitoring and evaluation approaches in relevant programmatic areas (such as HIV testing and counselling, ART, PMTCT and HIV drug resistance) with the recommendations in these guidelines and will also include new guidance in emerging areas for HIV monitoring and evaluation. The publication on three interlinked patient monitoring systems (1) will also be updated to reflect this new monitoring and evaluation guidance.

# Monitoring implications of new recommendations
The monitoring and evaluation strategy should monitor service delivery, including inputs and processes as well as outputs and outcomes, such as the number of people receiving interventions and the impact at the individual and population levels (see section 11.3). The monitoring and evaluation plan should include a framework to track progress in implementing the guidelines to verify whether new policies on ART eligibility and recommendations on and plans for treatment or service delivery are actually implemented. This will enable national programmes to document the effect of the shift in guidelines and can contribute to evaluating the impact of the guidelines. Table 11.1 lists key areas to review when implementing major new recommendations in these guidelines. For each key area, potential topics to monitor and possible implications for revising monitoring systems are provided. Not all information needs to be captured routinely; data needs and the timing of data collection depend on the local context.  (2). In some evolving areas (such as links between HIV diagnosis and ART, retention of pregnant women in using ARV drugs and viral load monitoring), indicators are still being reviewed and evaluated. The forthcoming consolidated monitoring and evaluation guide for HIV in the health sector will provide more detailed guidance.

# Other monitoring considerations
Programmes are increasingly moving beyond coverage indicators to focus on critical outcomes, such as viral load suppression and immune reconstitution, and on the broader impact of HIV treatment, including HIV-related mortality and HIV incidence. However, programmes also need to measure potential unintended outcomes, such as HIV drug resistance and ARV-related toxicities. Periodic evaluations and implementation research are also central to reviewing programmes.

# hIV drug resistance
WHO recommends the use of early warning indicators to help identify deficits in programme performance that favour the emergence of HIV drug resistance (Box 11.1). WHO also recommends that countries undertake surveillance of HIV drug resistance and provides specific guidance on how to do the surveys required.

# Sentinel surveillance for ARV toxicity monitoring
Surveillance of the toxicity of ARV drugs is essential to identify and address preventable adverse events. Various approaches have been developed to monitor the toxicity of ARV drugs, including targeted and systematic surveillance reporting on specific types of toxicity and serious adverse events caused by a specific drug in targeted populations, and the pregnancy exposure registry following a cohort of pregnant women exposed to ART, including birth defect surveillance. WHO technical guidance on implementing toxicity monitoring at sentinel sites will become available in 2013.

# Evaluation, including impact and programme performance, and implementation research
Routine monitoring should be complemented by systematic evaluations and programme reviews to assess the performance and effects of HIV programmes, either comprehensively or with respect to specific priority areas. Social science and implementation research are important to assess perceptions and values of service recipients and communities along with barriers, facilitators and experiences in delivering and receiving services.
Impact indicators, such as incidence, morbidity and mortality, are often difficult to measure. Guidance on the use of assays for recent infection to estimate HIV incidence at the population level has been recently developed (3), and guidance on monitoring mortality, including the cause of death, will be available in 2013. A short guide summarizing five methods to measure the impact of programmes for PMTCT (4) is already available, and detailed guidance that can be adapted to implement each method will become available in 2013.
Mathematical modelling is often undertaken to project various scenarios for programme planning and evaluating impact. Ensuring the availability of robust data is especially important when estimating the prevention impact of ARV drugs at the population level, as multiple sources of information and uncertainty come into play. Specific data collection efforts and models for particular contexts may provide more accurate estimates.

# Box 11.1 Monitoring HIV drug resistance
HIV drug resistance poses a significant threat to the success of national HIV programmes. Drug resistance results in more rapid virological failure among people receiving first-line regimens and increases the need for second-line regimens, which may be associated with greater toxicity, adverse events, poorer adherence and higher costs. Drug resistance may also affect the ability to prevent HIV transmission using ARV-based pre-or post-exposure prophylaxis or topical microbicides.
Surveillance of drug resistance should be an integral component of national HIV programmes. Surveillance data should inform the selection of first-and second-line regimens for ART, as well as ARV drugs for PMTCT, to optimize treatment outcomes within a public health approach.
WHO and its partners have developed a standardized and complementary assessment strategy to be implemented by countries, for both adult and paediatric populations, with the following components.
Monitoring early warning indicators for HIV drug resistance. Early warning indicators use existing clinic and pharmacy records to assess the factors associated with the emergence of HIV drug resistance at the level of ART programmes and clinics. These factors include ART prescribing practices; drug supply continuity; adherence to ARV drug regimens measured by on-time pick-up of ARV drugs; retention in care; and viral load suppression, when available. The monitoring of early warning indicators should be integrated into a country's monitoring and evaluation system and provides the information needed to address practices that may lead to poor outcomes and HIV drug resistance.
Surveys to monitor acquired HIV drug resistance and associated factors in populations receiving ART. The WHO generic protocol for monitoring acquired HIV drug resistance uses a standardized survey methodology to assess population-level virological suppression at the national level and the emergence of HIV drug resistance among populations receiving treatment. Performed regularly at representative sites, these surveys provide evidence for action at the programme and clinic level to minimize HIV drug resistance. They also provide evidence to optimize the selection of first-and second-line ARV regimens.
Surveys to monitor pre-treatment HIV drug resistance. The WHO generic protocol for surveillance of pre-treatment HIV drug resistance provides a nationally representative estimate of HIV drug resistance in populations initiating therapy. Performed regularly at representative ART clinics, these surveys support national, regional and global decision-making regarding the choice of first-line regimens.
Surveillance of transmitted HIV drug resistance among individuals recently infected with HIV. The WHO generic protocol for surveillance of transmitted HIV drug resistance provides estimates of transmitted HIV drug resistance in recently infected populations, and the results should contribute to ART policy decisions, including guidelines on ARV regimens and HIV prophylaxis.
Surveillance of HIV drug resistance among children under 18 months of age. The WHO generic protocol for surveillance of HIV drug resistance among children under 18 months of age can provide estimates of national prevalence of HIV drug resistance among infants diagnosed with HIV infection through early infant diagnosis testing. The results assess differences in HIV drug resistance prevalence between populations exposed to ARV drugs for PMTCT and those with unknown exposure to support the selection of optimal first-line ART for this population.
National strategies for assessing HIV drug resistance should be developed and routinely implemented as part of comprehensive HIV treatment programmes.
- 5 Reviewing and strengthening monitoring and evaluation systems

# Reviewing and strengthening monitoring and evaluation systems
The recommendations in these guidelines may require certain adaptations to the monitoring and evaluation system. Guidance is available on the 12 components of a monitoring and evaluation system and tools to review and strengthen national HIV monitoring and evaluation systems (5). Table 11.3 highlights some specific areas to review to ensure that monitoring and evaluation systems are aligned to the new ARV guidelines.     b For children younger than 5 years, moderate malnutrition is defined as weight-for-height <-2 z-score or mid-upper arm circumference 115 mm to <125 mm. c Some additional specific conditions can be included in regional classifications, such as penicilliosis in Asia, HIV-associated rectovaginal fistula in southern Africa and reactivation of trypanosomiasis in Latin America. d For children younger than 5 years of age, severe wasting is defined as weight-for-height <-3 z-score; stunting is defined as length-for-age/height-for-age <-2 z-score; and severe acute malnutrition is defined as either weight for height <-3 z-score or mid-upper arm circumference <115 mm or the presence of oedema.

# Annex 2. Algorithm for the 2013 recommendations for adults and adolescents
a Annex 1 lists the WHO clinical staging for HIV disease. b ART initiation in individuals with severe or advanced symptomatic disease (WHO clinical stage 3 or 4), regardless of CD4 cell count, or with CD4 count 350 cells/mm 3 regardless of clinical symptoms, should be prioritized. c Active TB disease refers to the time when TB breaks out of latency and causes disease. Latent TB infection refers to the period of time when the immune system has been successful in containing the Mycobacterium tuberculosis and preventing disease. d Severe chronic liver disease includes cirrhosis and end-stage liver disease and is categorized into compensated and decompensated stages. Decompensated cirrhosis is defined by the development of clinically evident complications of portal hypertension (ascites, variceal haemorrhage and hepatic encephalopathy) or liver insufficiency (jaundice). e For details on ARVs for pregnant and breastfeeding women with HIV (Option B and Option B+), see Annex 3 and sections 7.1.2, 7.1.3 and 7.2.2. f A HIV-serodiscordant couple is a couple in which one of the sexual partners is HIV-positive and one is HIV-negative. Although one partner is currently HIV-negative, this does not mean that this partner is immunized or protected against getting HIV in the future. g For adolescents weighing less than 35 kg, refer to the algorithm for children in annex 4 which indicates the appropriate first-line ARV regimen options. The 2013 consolidated guidelines recommend that all pregnant and breastfeeding women with HIV should initiate ART and, based on national programme decisions, that either all women continue ART as lifelong treatment or women not eligible for ART for their own health stop after the mother-to-child transmission risk period. Countries planning for this transition, and those working to expand and strengthen their programme, may find it useful to refer to this readiness assessment checklist, which addresses a range of issues from national policy to facility readiness.

# Weight-based dosing for antiretroviral formulations for children

# Prescribing information and weight-based dosing of available ARV formulations for infants and children
This annex contains information on antiretroviral drugs for which there are paediatric indications, formulations or sufficient information and evidence to provide guidance on prescribing and dosing. The work to develop and update simplified guidance on antiretroviral drugs for use in children has been undertaken by WHO through the Paediatric Antiretroviral Working Group. x For simplification and ease of implementation, doses are expressed per weight-band rather than per kilogram or per square metre of body surface area. When this simplified weight-band dosing was developed, careful consideration was given to the usual body surface area of children from low-and middle-income countries in that weight band. The primary source of information for the guidance provided is the manufacturer's package insert. This was supplemented with data from other clinical studies as well as expert paediatric pharmacology consultations. For fixeddose combinations, a dose-modelling tool (www.who.int/hiv/paediatric/generictool/en/index. html) was used to predict the dose delivered for each component drug against the recommended dosing schedule. In some cases the dose for a component in a particular weight band may be somewhat above or below the target dose recommended by the manufacturer. This is inevitable given the limitations imposed by a fixed-dose combination, but care was taken to ensure that in no case would a child receive more than 25% above the maximum target dose or more than 5% below the minimum target dose. For simplification, Antiretroviral drugs that are no longer considered preferred or alternative options for children such as didanosine and saquinavir are no longer included in the dosing guidance. In addition, dosing for postnatal prophylaxis for HIVexposed infants is not provided here but can be found in Chapter 7, Table 7.7.
During the finalisation of these Guidelines the United States Food and Drug Administration approval was granted for the use of EFV in children 3 months to 3 years old weighing at least 3.5 kg. While recognizing the opportunity to provide an additional option to children and allow further harmonisation across age groups, the Guideline Development Group highlighted the need for further data prior to recommending EFV as a treatment option in children less than 3 years. This dosing annex and the simplified dosing schedule will be regularly reviewed and updated as further data or newer formulations become available, but national programmes are advised to consider the most recent product labelling for up-to-date information. Additional information can also be found in specific drug information sheets in the Web Annex at www.who.int/hiv/pub/ guidelines/antiretroviral2013/annexes. Antiretroviral drugs and formulations are available from several companies, and the dose strengths of tablets, capsules and liquid formulations may vary from the information given here. In addition, the listing of a formulation in this annex does not equate to quality assurance of that formulation. National programme managers should ensure that any product procured for use is approved and of appropriate quality and stability. For guidance on the quality assurance of medicines, see the WHO medicines web site (www.who.int/medicines/areas/quality_safety/ quality_assurance/about/en/index.html) and the Access to HIV/AIDS drugs and diagnostics of acceptable quality, which is available and updated at www.who.int/hiv/amds/selection/ en/index.html. The current list of WHO prequalified drugs is available at / prequal/query/ProductRegistry.aspx. For the current list of antiretroviral drugs approved and tentatively approved by the United States Food and Drug Administration, see www.fda.gov/ internationalprograms/FDAbeyondourbordersforeignoffices/AsiaandAfrica/ucm119231.htm For the policy of the Global Fund to Fight AIDS, Tuberculosis and Malaria on procurement and quality assurance, see www.theglobalfund.org/en/procurement/quality/pharmaceutical.

# General principles
The principles followed in developing the WHO simplified tables include the following:
It is preferable to use an age-appropriate fixed dose combination for any regimen if such a formulation is available.
Oral liquid or syrup formulations should be avoided where possible, especially if volumes are large -such as above 10 ml.
Dispersible tablets (or tablets for oral solution) are the preferred solid oral dosage forms, since each dispersible tablet can be made into liquid at the point of use.
In general, young children should be switched to available solid oral dosage forms as soon as they are tolerated.
Where children have to use adult formulations, care must be taken to avoid underdosing. Adult tablets that are scored are more easily split. For tablets that are not easily split, WHO recommends that this be done in the dispensing pharmacy using appropriate tablet cutters.
Some tablets such as LPV/r heat-stable tablets are made in a special embedded matrix formulation (a proprietary melt extrusion technology that stabilizes drug molecules that are normally heat labile) and should not be cut, split or crushed, since they lose bioavailability.
Different dosing between morning and evening doses should be avoided where possible.
Children have to be weighed at each clinic visit, and dose changes are required as children grow and/or gain weight.  EFV is not recommended for children younger than 3 years and weighing less than 10 kg. FDA approval for use in children less than 3 years weighing more than 3.5 kg was granted during the finalisation of these guidelines (3.5-5 kg two 50 mg capsules; 5-7.5 kg three 50 mg capsules; 7.5-15 kg one 200 mg capsule), however more data are urgently needed to inform recommendations for use of EFV in this age group.
The double-scored tablet has two score lines on one side of the tablet and one score line on the other side, enabling the tablet to be divided into thirds and halves as needed. This formulation is currently awaiting regulatory approval, and a scored junior tablet (480 mg/150 mg/12.5 mg) is also under development.

# Annex 7 Dosages of recommended antiretroviral drugs
Target dose: 8 mg/kg or 200 mg/m 2 (maximum 300 mg). The Paediatric Antiretroviral Working Group developed this guidance to harmonize TDF dosing with WHO weight bands and to reduce the numbers of strengths to be made available. The WHO generic tool was used based on the target dose provided by the manufacturer's package insert. In accordance with the standard Paediatric Antiretroviral Working Group approach, dosing was developed ensuring that a child would not receive more than 25% above the maximum target dose or more than 5% below the minimum target dose.
b 200-mg tablets should be used for weight 25-29.9 kg and 300 mg tablets for 30-34.9 kg.

# Annex 7 Dosages of recommended antiretroviral drugs
The need for new formulations
The work of the Paediatric Antiretroviral Working Group has highlighted the urgent need for formulations, especially fixed-dose combination formulations containing LPV/r in solid forms, suitable for treating younger children, scored tablets of TDF and TDF-based fixed-dose formulations for children. In addition, the availability of ATV/r and DRV/r in heat-stable fixeddose combination formulations is becoming more critical to facilitate treatment sequencing. Access to a heat-stable formulation containing 30 mg of RTV is also important for "superboosting" LPV in the setting of rifampicin-based TB treatment. The table below contains some duplication of formulations. for example, a scored adult fixed-dose combination of TDF + 3TC + EFV is not needed if a formulation for children is available. However, the Paediatric Antiretroviral Working Group recognized that, although a child-specific formulation may be ideal, a scored adult formulation may be easier to develop as a first step.
The recent approval of EFV for use in children 3 months to 3 years old has provided an additional option for young children and offers further opportunity for harmonisation. As more data are obtained to inform the best use of this drug in young children, sprinkles formulation should be made available in resource limited settings.
In moving towards the joint UNAIDS/WHO Treatment 2.0 initiative, WHO will continue to work to simplify prescribing, dispensing and dosing guidance and work with the pharmaceutical industry (originator and generic) and other partners to develop more practical recommendations on the range of formulations required to safely accelerate the scaling up of ART for children.

# Additional guidance
Essential prevention and care interventions for adults and adolescents living with HIV in resource-limited settings. Geneva, World Health Organization, 2008 (www.who.int/hiv/ pubprev_care/OMS_EPP_AFF_en.pdf).
Evaluating household water treatment options: health-based targets and microbiological performance specifications. Geneva, World Health Organization, 2011 (www.who.int/water_sanitation_health/publications/2011/evaluating_water_ treatment.pdf).
Guidelines for drinking-water quality. 4th ed. Geneva, World Health Organization, 2011 ().

# Checklist 10.2 Implementation checklist of key health system issues
The successful implementation of new recommendations depends on several critical decisions in key programme areas.

# Communication, leadership and advocacy
Has it been determined who will be responsible for updating currently existing materials, including service delivery guidelines, protocols, clinical and laboratory standard operating procedures, monitoring and evaluation tools, patient monitoring mechanisms or systems, reference manuals, health worker training materials, job aids, supervisory checklists and materials for public information, education and communication?
Has it been decided how new recommendations will be communicated to (1) local programme managers, including public, not-for-profit and private institutions; (2) health workers; and (3) other relevant stakeholders, such as people living with HIV? Has it been agreed who will take overall responsibility for advocacy with stakeholders such as political leaders, health personnel and the mass media?

# Staffing and human resources
Has it been determined how many additional workers are required to implement new recommendations? Which cadres of health workers (physicians, health officers, nurses, midwifes, community health workers and laboratory assistants) are needed and how they can be recruited? Can task shifting and sharing be employed to optimize available human resources and expand service delivery? (see section 9.5.2) 1. Consider the appropriate approach to scaling up. The infrastructure and operational implications of providing lifelong ART to all pregnant and breastfeeding women living with HIV must be carefully reviewed. Countries may consider a phased approach with an early learning phase before full scale-up.

# Drugs and supplies
- Assure linkages to care and patient transfer. The location in which ARV drugs are provided to pregnant and breastfeeding women and the provision of long-term ART should be considered and decided before the programme is implemented. Will women continue to receive ART at the site providing ARV drugs for PMTCT or will they be transferred to an existing ART site? What strategies will be put in place to minimize the risk of women being lost to care as they are transferred to various ART service locations?

# Implementation considerations for key recommendations
Box 10.5 Key implementation considerations for programme managers: decentralizing ART services (section 9.4.3)
- Examine the models and options. Programmes should determine which clinical and laboratory services will be available at what level of the health care delivery system. The optimal model for ART decentralization (partial or full) depends on the local context.
Consider human resources policies and task shifting. All health workers, including community health workers, need to be trained regularly, mentored and supervised to ensure high-quality care and implementation of updated national recommendations. In many settings, decentralizing ART requires task shifting to ensure an appropriate mix of health workers at peripheral facilities. An appropriate regulatory framework (laws, regulations, policies and guidelines) is needed to allow tasks to be performed by different cadres of health workers, in addition to nationally standardized training, mentoring and supervision for all health workers involved in HIV care.

# Implement strategies for retaining staff.
Programme managers should support the development and implementation of policies to create a suitable environment for recruiting, retaining and motivating personnel in rural or remote areas, where health worker turnover and attrition may be considerably higher than in urban settings.

# Strengthen linkages and referral systems.
Although community-based treatment programmes provide an important option for decentralizing ART, they should always be linked with regular care at health facilities and with adequate laboratory, diagnostics, monitoring and evaluation and drug and supply management systems.

# Agree on a division of labour.
An efficient division of responsibilities among levels of the health system (national, provincial or regional and district) is crucial to minimize duplication and to optimize the use of resources. The role of each level should match its capacity, and the lines of authority and accountability should be clear and well understood by all.
- Build partnerships. National regulatory bodies, professional associations and other stakeholders need to be involved when addressing the scope of practice, roles and responsibilities of health workers. 1. Expanding ART coverage should be the first priority. Since all treatment regimen options have been shown to reduce morbidity and mortality, the use of less preferred options is better than leaving children untreated.

# Younger children are at greater risk of poor outcomes.
Children younger than two years living with HIV have higher mortality rates and more rapid disease progression than older children. Early diagnosis and prompt initiation of ART are especially critical for infants and young children.

# Strengthen links between diagnosis and treatment.
Diagnosis and treatment for children are often performed at different facilities, increasing the risk of their being lost to follow-up. Improving links between early infant diagnosis and ART sites is essential to minimize such losses and improve uptake of ART among children. Family-based approaches to HIV testing and provider-initiated testing and counselling are important approaches to increase HIV diagnosis and treatment among children.

# Optimize and improve the choice of ARV formulations available.
It is critical to accelerate regulatory approval of preferred formulations. Scored dispersible fixed-dose combinations for children with dosage based on weight bands can support the scaling up of ART for children in remote areas.

# Goal of this chapter
To provide programmatic guidance for decision-makers and planners at the national level in tracking the implementation of these guidelines and monitoring their impact on HIV programmes and people receiving ART.

# Considerations for individuals receiving TB therapy
In the presence of rifabutin, no dose adjustment required. In the presence of rifampicin, adjusted dose of LPV/r (LPV 800 mg + RTV 200 mg twice daily or LPV 400 mg + RTV 400 mg twice daily) or SQV/r (SQV 400 mg + RTV 400 mg twice daily), with close monitoring.

# Integrase strand transfer inhibitors (INSTIs)
Raltegravir (RAL) 400 mg twice daily a For adolescents weighing less than 35 kg, see the next page for weight-based dosing for ARV formulations for children.