The World Health Organization (WHO) has released updated recommendations on HIV clinical management providing new and revised guidance on antiretroviral therapy, management of vertical HIV transmission, and tuberculosis (TB) prevention for people living with HIV. These recommendations support an evidence-based, cost-effective approach to improving treatment outcomes, reducing HIV-related mortality and accelerating progress towards ending AIDS as a public health threat.
The guideline reflects significant advances in HIV treatment since the last consolidated WHO guidelines published in 2021 and responds to emerging evidence on optimized antiretroviral regimens and simplified options to TB preventive treatment for people living with HIV.
Optimizing antiretroviral therapy
The updated recommendations confirm dolutegravir-based regimens as the preferred option for initial and subsequent HIV treatment and introduce important changes for people whose treatment regimen is no longer effective. When a protease inhibitor (PI) is needed, darunavir/ritonavir is now recommended as the preferred option, replacing earlier preferences for atazanavir/ritonavir or lopinavir/ritonavir. The guideline also supports the reuse of tenofovir and abacavir in subsequent regimens based on improved outcomes, programmatic advantages and potential cost savings. The guideline also recommends the use of long-acting injectable antiretroviral therapy in specific circumstances, such as for adults and adolescents who face challenges adhering to daily oral regimens; oral two-drug regimens are also recommended as treatment-simplification options for selected individuals who are clinically stable.
Strengthening the prevention of vertical HIV transmission
Despite major progress in eliminating vertical transmission, new infant HIV infections continue to occur, particularly during breastfeeding. The updated guideline emphasizes a person-centred, public health approach that supports maternal choice and infant well-being.
WHO continues to recommend that mothers with HIV exclusively breastfeed for the first six months, with continued breastfeeding up to 12 months and possibly up to 24 months or longer, alongside effective maternal antiretroviral therapy and appropriate complementary feeding. All HIV-exposed infants should receive six weeks of postnatal prophylaxis, preferably with nevirapine, while infants at higher risk should receive enhanced triple-drug prophylaxis. Extended infant prophylaxis may be used until maternal viral suppression is achieved or breastfeeding has stopped.
Prioritizing TB prevention in people living with HIV
Tuberculosis remains a leading cause of death among people living with HIV. To improve 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 WHO-recommended regimens remain options based on clinical and programmatic considerations. Mainstreamed interventions will facilitate better integration of services and aim at reducing TB-related mortality in people living with HIV while simplifying service delivery.
Supporting countries to accelerate impact
"These updated recommendations reflect WHO's commitment to ensuring that people living with HIV benefit from the most effective, safe and practical treatment options available," said Dr Tereza Kasaeva, Director, Department of HIV, TB, viral Hepatitis and STIs of WHO Headquarters in Geneva. "By simplifying treatment, improving adherence and addressing persistent gaps in prevention, they will help countries strengthen HIV programmes and save lives."
The recommendations will be integrated into the next edition of the WHO consolidated HIV guidelines and are intended to inform national HIV programmes, clinicians, partners and communities worldwide.
