The World Health Organization (WHO) has issued updated recommendations concerning HIV clinical management. These guidelines provide new and revised guidance on antiretroviral therapy, the management of vertical HIV transmission, and tuberculosis (TB) prevention for individuals living with HIV.
The recommendations aim to support evidence-based, cost-effective strategies for treatment outcomes, reduction of HIV-related mortality, and progress towards addressing AIDS as a public health concern. These updates reflect developments in HIV treatment since the WHO's 2021 guidelines and incorporate recent evidence on optimized antiretroviral regimens and simplified TB preventive treatment options for people living with HIV.
Antiretroviral Therapy Optimization
The updated recommendations reaffirm dolutegravir-based regimens as the preferred choice for initial and subsequent HIV treatment. They also introduce modifications for individuals whose current treatment regimen is no longer effective. Darunavir/ritonavir is now recommended as the preferred protease inhibitor when required, replacing previous preferences for atazanavir/ritonavir or lopinavir/ritonavir. The guidelines also support the reintroduction of tenofovir and abacavir in subsequent regimens, citing improved outcomes, programmatic efficiencies, and potential cost benefits. Long-acting injectable antiretroviral therapy is recommended under specific conditions, such as for adults and adolescents experiencing challenges with daily oral adherence. Oral two-drug regimens are also suggested as treatment-simplification options for selected clinically stable individuals.
Prevention of Vertical HIV Transmission
Despite advancements in reducing vertical HIV transmission, new infant HIV infections persist, particularly during breastfeeding periods. The updated guideline promotes a person-centred, public health framework that considers maternal choice and infant well-being.
The WHO continues to advise that mothers with HIV exclusively breastfeed for the initial six months, continuing up to 12 months and potentially beyond, concurrent with effective maternal antiretroviral therapy and appropriate complementary feeding. All infants exposed to HIV should receive six weeks of postnatal prophylaxis, with nevirapine being the preferred option. Infants identified as higher risk should receive enhanced triple-drug prophylaxis. Extended infant prophylaxis may be considered until maternal viral suppression is achieved or breastfeeding ceases.
Tuberculosis Prevention in People Living with HIV
Tuberculosis remains a primary cause of death among individuals living with HIV. To enhance the uptake and completion of TB preventive therapy, WHO now recommends three months of weekly isoniazid plus rifapentine (3HP) as the preferred TB preventive treatment regimen for adults and adolescents living with HIV. Other previously recommended WHO regimens remain available options, contingent on clinical and programmatic factors. Integrated interventions are designed to facilitate better service coordination and aim to reduce TB-related mortality in people living with HIV while simplifying service delivery.
Supporting Global Implementation
Dr. Tereza Kasaeva, Director of the Department of HIV, TB, Viral Hepatitis, and STIs at WHO Headquarters in Geneva, stated that these updated recommendations aim to provide people living with HIV with effective, safe, and practical treatment options. The guidelines seek to assist countries in strengthening HIV programs and improving health outcomes by simplifying treatment, enhancing adherence, and addressing prevention gaps.
These recommendations will be incorporated into the forthcoming edition of the WHO consolidated HIV guidelines and are intended to inform national HIV programs, clinicians, partners, and communities globally.