The Strategic Use of Antiretrovirals To Prevent HIV Infection: A Converging Agenda

SUPPLEMENT ARTICLE
The Strategic Use of Antiretrovirals to Prevent

HIV Infection: A Converging Agenda
Rachel Baggaley, Meg Doherty, Andrew Ball, Nathan Ford, and Gottfried Hirnschall
Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
There is a clear convergence toward an overarching strategic use of antiretroviral drugs to prevent human im-
munodeciency virus (HIV) infection. Four interventionsimmediate antiretroviral therapy (ART) for the in-
fected partner in a serodiscordant couple, preexposure prophylaxis (PrEP), prevention of mother-to-child
transmission (PMTCT), and postexposure prophylaxis (PEP)are all strongly recommended by the World
Health Organization as effective ways to prevent HIV infection. For HIV-infected individuals, ART to protect
an HIV-uninfected partner and PMTCT are both part of an expanding list of recommendations for starting
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ART immediately to both treat and prevent HIV infection. For HIV-uninfected individuals, PrEP and PEP
are increasingly being seen as related interventions, and there are compelling reasons to consider the provision
of PEP as a potential gateway to PrEP. The effectiveness of each of these interventions depends on overcoming
barriers to seeking services, adequate community understanding and engagement, high levels of access and up-
take of services including HIV testing and counselling, and high levels of adherence.
Keywords. antiretroviral therapy; HIV/AIDS; postexposure prophylaxis; preexposure prophylaxis; PMTCT.
Global efforts to scale up access to antiretroviral drugs These 4 interventionsimmediate ART for the in-
have largely focused on the life-saving benets of treat- fected partner in a serodiscordant couple, PrEP, PMTCT,
ment, and over the last decade these efforts are estimat- and PEPare all strongly recommended by the World
ed to have saved >4 million lives [1]. Health Organization (WHO) as effective ways to pre-
More recently, increased attention has been given to vent HIV infection; these ART-based interventions
the use of antiretroviral drugs to prevent human immu- are recommended as part of a comprehensive HIV pre-
nodeciency virus (HIV) infection, following the results vention package of evidence-based interventions that
of several large randomized trials providing clear evi- include male and female condoms, male medical cir-
dence of reduced HIV transmission and acquisition cumcision, and needle and syringe programs [57]. In
when antiretroviral drugs are provided immediately to the formulation of global guidance, an important prin-
HIV-infected individuals in serodiscordant relationships ciple for WHO has been to harmonize, as far as possi-
[2], or when taken by HIV-uninfected individuals as pre- ble, recommendations for treatment and prevention, to
exposure prophylaxis (PrEP) [3, 4]. These interventions simplify procurement and prescribing and improve up-
add to the well-established antiretroviral-based prevention take. Consistent with this approach, the same 2 nucleo-
interventions to prevent mother-to-child transmission of side reverse transcriptase inhibitor (NRTI) antiretroviral
HIV (PMTCT) [5] and to prevent the establishment of drugstenofovir combined with either lamivudine or
HIV infection following occupational or nonoccupational emtricibineare recommended for all 4 interventions.
exposure using postexposure prophylaxis (PEP) [6]. For early treatment and for PMTCT, this 2-drug NRTI
backbone is combined with a third antiretroviral drug,
efavirenz, whereas for the revised PEP recommenda-
Correspondence: Rachel Baggaley, MBBS, Department of HIV/AIDS, World Health
Organization, 20 Avenue Appia, 1211 Geneva, Switzerland (baggaleyr@who.int).
tion, this NRTI backbone is combined with lopinavir/
Clinical Infectious Diseases 2015;60(S3):S15960 ritonavir. For PrEP, trials thus far have used a single or
The Author 2015. Published by Oxford University Press on behalf of the Infectious dual antiretroviral regimen of tenofovir or tenofovir/
Diseases Society of America. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com.
emtricitabine, respectively, and WHO recommendations
DOI: 10.1093/cid/civ091 reect this choice.
Antiretrovirals to Prevent HIV Infection CID 2015:60 (Suppl 3) S159

Traditionally, each of these 4 interventions has been consid- WHO remains committed to responding to new evidence with
ered separately, with recommendations provided in different new recommendations, and supporting countries to translate
guidelines and directed at different audiences. These distinc- recommendations into further declines in mortality due to
tions have become less meaningful, and there is a clear conver- HIV and incidence of new infections.
gence toward an overarching strategic use of antiretroviral drugs
to both treat and prevent HIV infection. For HIV-infected indi-
viduals, ART to protect an HIV-uninfected partner and Notes
PMTCT are both part of an expanding list of recommendations Financial support. This work was in part supported by funds from the
for starting ART immediately to both treat and prevent HIV in- Bill & Melinda Gates Foundation.
fection. In 2013, WHO recommended giving HIV-infected Supplement sponsorship. This article appears as part of the supplement
HIV Postexposure Prophylaxis, sponsored by the World Health
pregnant women ART for life irrespective of CD4 cell count, ef- Organization.
fectively bringing pregnant women alongside serodiscordant Potential conicts of interest. All authors: No reported conicts.
couples as populations considered eligible for immediate life- All authors have submitted the ICMJE Form for Disclosure of Potential
Conicts of Interest. Conicts that the editors consider relevant to the con-
long ART [5]; several countries have moved to providing imme- tent of the manuscript have been disclosed.
diate ART irrespective of CD4 cell count to other populations
according to their epidemic situation, and future WHO guidance
will document and reect these country experiences. For HIV- References
uninfected individuals, PrEP and PEP are increasingly being
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S160 CID 2015:60 (Suppl 3) Baggaley et al

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SUPPLEMENT ARTICLE

The Strategic Use of Antiretrovirals to Prevent

Downloaded from http://cid.oxfordjournals.org/ by guest on May 25, 2015

Antiretrovirals to Prevent HIV Infection CID 2015:60 (Suppl 3) S159

Downloaded from http://cid.oxfordjournals.org/ by guest on May 25, 2015

S160 CID 2015:60 (Suppl 3) Baggaley et al

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