1. Review of Global Guidelines from 132 countries DRAFT PRESENTATION Please note that this is “under construction” and is a dynamic area—policies are changing and we do not have written policies for some countries — let us know if you see errors and/or there are new policies for the database Review of Global HIV Treatment Guidelines from 151 countries Please note that this is “under construction” and is a dynamic area — policies are changing and we do not have written policies for some countries — let us know if you see errors and/or there are newly published policies for the database Last updated: November 2015

2. Objectives and methodology: “wiki strategy” Objective: Compare national ART guidelines for 151 countries with WHO 2013 guidelines Published guidelines from 114 countries and reported recommendations from 50 countries AIDSTAR-One database UNAIDS regional support team Web search Ministry of Health officials Recommendation on ART initiation criteria and monitoring for different target population abstracted Search end date: November 2015

3. ART initiation for asymptomatic people ART initiation criteria No. of Countries People with HIV (2014) Countries Irrespective of CD4 count 14 3,162,000 (8.5%) Argentina, Australia, Brazil, British Columbia, France, Korea, Maldives, Mexico, the Netherlands, Romania, Spain, Thailand, UK, US, Turkey Consider for >500 7 15,000 (<1%) Austria, Germany, Greece, Guyana, Hong Kong, Italy, Norway ≤500 43 19,580,000 (53%) Algeria, Bangladesh, Bhutan, Bolivia, Burundi, Cambodia, Cameroon, Chile, Colombia, Democratic Republic of Congo, Ecuador, El Salvador, Fiji, Ethiopia, Gabon, Haiti, Honduras, Kenya, Lesotho, Mali, Madagascar, Malawi, Mauritania, Myanmar, Namibia, Nepal, Oman, Pakistan, Poland, Rwanda, South Africa, South Sudan, Sri Lanka, Sudan, Swaziland, Tanzania, Tunisia, Uganda, Uruguay, Venezuela, Viet Nam, Zambia, Zimbabwe ≤350 (consider for CD4 ≤ 500) 4 129,000 (<1%) Belize, Costa Rica, Finland, Guinea ≤350 34 10,934,000 (30%) Angola, Benin, Botswana, Burkina Faso, Canada, China, Cote d’Ivoire, Croatia, Djibouti, Dominican Republic, Ghana, Guatemala, India, Indonesia, Jamaica, Kazakhstan, Latvia, Malaysia, Moldova, Morocco, Mozambique, Nicaragua, Niger, Nigeria, Panama, Papua New Guinea, Paraguay, Peru, Portugal, Sierra Leone, Sweden, Switzerland, Timor- Leste, Ukraine ≤300 1 200 (<1%) Macedonia ≤200 (consider for CD4 ≤ 350) 6 1,456,000 (4%) Afghanistan, Belarus, Cape Verde, Cuba, Estonia, Russia ≤200 5 124,000 (1%) Comoros, Lao PDR, Liberia, Philippines, Senegal Source: published policy

4. 2003-052006-09201020112012201320142015 ≤200 (200-350) Afghanistan Belarus Cuba Russia ≤350 Burkina Faso Djibouti, Croatia, Ghana, Sweden Niger, Moldova, PNG, Nicaragua Portugal, Sierra Leone ≤350 Morocco Nigeria Ukraine ≤ 350 Jamaica Kazakhstan Panama Switzerland Timor-Leste Consider for >500 Italy Consider at ≤500 Guinea Irrespective of CD4 count Australia Brazil France Korea Turkey ≤350 Botswana Benin China Guatemala Peru ≤200 (200-350) Cape Verde Estonia ≤200 Comoros Lao PDR Liberia Philippines ≤200 Senegal ≤350 India Dominican Republic, Paraguay, Canada Cote d’Ivoire Consider at ≤500 Belize ≤500 Algeria ≤500 Bolivia Chile Colombia DRC, Fiji Haiti Ecuador Ethiopia Honduras Madagascar Mali, Oman Rwanda Tunisia Uganda Zambia Zimbabwe Source: published policy Consider at ≤500 and >500 Guyana Irrespective of CD4 count BC Canada Irrespective of CD4 count US Netherlands Consider at >500 Hong Kong ≤500 Bangladesh, Bhutan, Burundi, Cameroon, El Salvador, Gabon, Kenya, Malawi, Nepal, Lesotho, Sudan, Uruguay Mauritania, Poland, Myanmar Namibia, South Africa, South Sudan, Sri Lanka, Tanzania Venezuela Consider at ≤500 Costa Rica Finland ≤500 Cambodia Pakistan Swaziland Viet Nam ≤ 200 ≤ 200 (200-350)≤ 350 ≤ 500 Irrespective of CD4 count Argentina Britain Maldives ≤350 Angola Latvia Malaysia Mozambique Indonesia ≤300 Macedonia Consider at >500 Austria Germany Greece Norway Irrespective of CD4 count Spain Thailand Mexico Romania

5. Source: published policy ART initiation for asymptomatic people 2015 WHO Recommendation : Irrespective of CD4 count <200, <250 or <300 <350 <500 >500 Irrespective of CD4 count

6. <200 <350 <500 >500 Irrespective of CD4 count Source: published policy ART initiation criteria in Africa 2015 WHO Recommendation : Irrespective of CD4 count

7. Reviewed all guidelines for a. Month and year of publication b. ART eligibility criteria for asymptomatic PLHIV Identified 85 national ART guidelines from 37 countries (97% regional HIV burden) Sources: IAPAC database, AIDSTAR-One database, Internet search, and WHO, UNAIDS, CDC and MoH staff No. of months taken to adopt WHO guidelines calculated for a. 19 countries that changed to <350 after WHO 2009 guidelines b. 21 countries that changed to <500 after WHO 2013 guidelines Average time to adopt WHO guidelines = Total months taken to adopt WHO guidelines Total no. of guidelines Policy Lag in Africa - Methodology Source: Gupta, Granich (2015) Unpublished data

8. WHO 2009 guidelines WHO 2013 guidelines Date of publicationOctober, 2009June, 2013 ART eligibility criteria recommended <350 cells/mm 3 <500 cells/mm 3 Countries that adopted the recommendation 33 (99% burden) 21 (71% burden) Average time to adopt the WHO guidelines (Range) 2 years (3 months – 4 years 8 months) 9 months (0 months – 1 year 7 months) Countries yet to adopt the recommendation 4 (<1% burden) 16 (29% burden) Policy Lag in Sub-Saharan Africa

9. 2006 Sierra Leone 2007 Lesotho Rwanda 2008 Mali Djibouti Ghana Burkina Faso JUNE Niger JANUARY Swaziland MAY Zimbabwe JUNE Zambia JULY Namibia AUGUST Democratic Republic of the Congo OCTOBER Burundi Nigeria FEBRUARY Angola JUNE Uganda JULY Malawi NOVEMBER Kenya JANUARY Mozambique APRIL Botswana South Africa Tanzania OCTOBER Ethiopia JUNE Cote d’Ivoire JUNE Ethiopia Madagasca r JULY Democratic Republic of the Congo NOVEMBER Mali DECEMBER Rwanda Uganda Zambia Zimbabwe JANUARY Namibia Sudan MARCH South Sudan APRIL Lesotho Malawi JUNE Cameroon Gabon Kenya Tanzania AUGUST Burundi Mauritania DECEMBER South Africa JANUARY Swaziland Oct 2009 June 2013 Sept 2015 WHO 2009 guidelines (CD4 <350 cells/mm 3 ) WHO 2013 guidelines (CD4 <500 cells/mm 3 ) WHO 2015 guidelines (Irrespective of CD4 count) Timeline showing release of WHO guidelines and guidelines from 31 countries in Sub-Saharan Africa Note: Red box denotes move to WHO 2009 recommendation of CD4 count <350 cells while green box denotes move to WHO 2013 recommendation of CD4 count <500 cells

10. Reported ART initiation criteria in 50 countries (missing written policy document) ART initiation criteria No. of Countries Countries Irrespective of CD4 count 2 Belgium, Panama >5002 Montenegro, New Zealand ≤50019 Afghanistan, Antigua and Barbuda, Belize, Central African Republic, Chad, Costa Rica, Cuba, Dominica, Grenada, Guatemala, India, Liberia, Morocco, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Timor- Leste, Trinidad and Tobago, Yemen ≤35025 Albania, Armenia, Bahamas, Barbados, British Virgin Islands, Bulgaria, Comoros, Cape Verde, Congo, Egypt, Equatorial Guinea, Eritrea, Gambia, Guinea- Bissau, Iran, Kyrgyzstan, Mauritius, Sao Tome, Senegal, Serbia, Seychelles, Somalia, Tajikistan, Togo, Turkmenistan ≤3001 Uzbekistan ≤2001 Suriname

11. ART initiation for asymptomatic people ART criteriaCountriesPLHIV (2014)Countries Irrespective of CD4 count 163,199,000 (9%) Argentina, Australia, Belgium, Brazil, British Columbia, France, Korea, Maldives, Mexico, the Netherlands, Panama, Romania, Spain, Thailand, Turkey, US, UK Consider for CD4 >500 915,500 (<0.1%) Austria, Germany, Greece, Guyana, Hong Kong, Italy, Montenegro, New Zealand, Norway, Europe ≤50062 22,084,000 (60%) Afghanistan, Antigua and Barbuda, Algeria, Bangladesh, Belize, Bhutan, Bolivia, Burundi, Cambodia, Cameroon, Central African Republic, Chad, Chile, Colombia, Costa Rica, Cuba, Democratic Republic of Congo, Dominica, Ecuador, El Salvador, Ethiopia, Fiji, Gabon, Grenada, Guatemala, Haiti, Honduras, India, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Morocco, Myanmar, Namibia, Nepal, Oman, Pakistan, Poland, Rwanda, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Sri Lanka, South Africa, South Sudan, Sudan, Swaziland, Tanzania, Timor-Leste, Trinidad and Tobago, Tunisia, Uganda, Uruguay, Venezuela, Viet Nam, Yemen, Zambia, Zimbabwe ≤350 (consider for CD4 ≤ 500) 2118,000 (0.3%)Finland, Guinea ≤35054 9,348,000 (25%) Albania, Angola, Armenia, Bahamas, Barbados, Benin, Botswana, British Virgin Islands, Bulgaria, Burkina Faso, Canada, Cape Verde, China, Comoros, Congo, Cote d’Ivoire, Croatia, Djibouti, Dominican Republic, Egypt, Equatorial Guinea, Eritrea, Gambia, Ghana, Guinea- Bissau, Indonesia, Iran, Jamaica, Kazakhstan, Kyrgyzstan, Latvia, Malaysia, Mauritius, Moldova, Niger, Mozambique, Nicaragua, Nigeria, Papua New Guinea, Paraguay, Peru, Portugal, Serbia, Sao Tome, Senegal, Seychelles, Sierra Leone, Somalia, Sweden, Switzerland, Tajikistan, Togo, Turkmenistan, Ukraine ≤300232,500 (0.1%) Macedonia, Uzbekistan ≤200 (consider for CD4 ≤ 350) 31,429,000 (4%) Belarus, Estonia, Russia ≤200351,000 (0.1%) Lao PDR, Philippines, Suriname Source: published policy + reported

12. ART initiation for asymptomatic people <200, <250 or <300 <350 <500 >500 Irrespective of CD4 count 2015 WHO Recommendation : Irrespective of CD4 count

13. <200 <350 <500 >500 Irrespective of CD4 count Source: published and reported policy ART initiation criteria in Africa 2015 WHO Recommendation : Irrespective of CD4 count

14. ART eligibility criteria: before 2010 Source: Gupta, Granich (2015) Unpublished data <200 or <250 <350 <500 Irrespective of CD4 count Unknown

15. ART : mid-2013 eligibility criteria <200 or <250 <350 <500 Irrespective of CD4 count Unknown Source: Gupta, Granich (2015) Unpublished data

16. ART eligibility criteria: October, 2015 <200 or <250 <350 <500 Irrespective of CD4 count Unknown Source: Gupta, Granich (2015) Unpublished data

17. GDP per capita and ART coverage

18. National policy on task shifting Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner Nurses can initiate ART and lay workers can provide ART adherence counselling Nurses can initiate ART Lay workers can provide ART adherence counselling Neither nurses can initiate ART nor lay workers can provide ART adherence counselling

19. National policy on ARV drug dispensing Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner Nurses can initiate ART and lay workers can provide ART adherence counselling Nurses can initiate ART Lay workers can provide ART adherence counselling Neither nurses can initiate ART nor lay workers can provide ART adherence counselling

20. Countries Nurses can initiate ART Lay workers can provide adherence counseling 2-3 month routine ARV refills for people in stable condition ARV dispensing at community level ZambiaYES Kenya, Malawi, South Africa, Swaziland YES x Botswana, Central African Republic, Lesotho, Uganda, Zimbabwe YES xx EthiopiaYESx x MozambiqueYESxx India, TanzaniaxYES x GuineaYESxxx Brazil, Cameroon, China, Democratic Republic of Congo, Namibia, Nigeria, Ukraine xYESxx Myanmarxxxx Task shifting and ARV drug dispensing Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner

21. ART eligibility criteria for children below age of 5 Of the 114 countries with guidelines, 82 countries (95% burden) have recommendations on paediatric ART ART initiation criteria for children <5 vary considerably Of the 82 countries, 36 (59% global paediatric burden) are consistent with WHO 2013 guidelines Afghanistan and India reported guideline change to provide ART to all children below 5 2013 WHO Recommendation : Irrespective of CD4 count

22. ART eligibility criteria for children <5 years ART INITIATION CRITERIA NUMBER CHILDREN WITH HIV COUNTRIES Irrespective of CD4 count for children <5 36 1,531,000 (59%) Angola, Bangladesh, Bhutan, Burundi, Cambodia, Cameroon, China, Colombia, Democratic Republic of Congo, El Salvador, Fiji, Gabon, Honduras, Indonesia, Kenya, Lesotho, Mali, Malawi, Maldives, Mauritania, Mozambique, Myanmar, Namibia, Nepal, Oman, Pakistan, Rwanda, South Africa, South Sudan, Sudan, Swaziland, Tanzania, Uganda, Viet Nam, Zambia, Zimbabwe Irrespective of CD4 count for children <2 16 484,000 (19%) Algeria, Argentina, Benin, Botswana, Cote d’Ivoire, Ghana, Guyana, Haiti, India, Kazakhstan, Morocco, Nigeria, Panama, Papua New Guinea, Timor-Leste, Venezuela Irrespective of CD4 count for children <1 19 140,000 (5%) Brazil, Burkina Faso, Chile, Costa Rica, Dominican Republic, Ethiopia, Finland, Guatemala, Hong Kong, Madagascar, Mexico, Paraguay, Romania, Sri Lanka, Sweden, Thailand, Tunisia, United States, Uruguay Conditional (clinical prerequisites) 11 20,200 (1%) Afghanistan, Cape Verde, Comoros, Djibouti, Guinea, Lao PDR, Liberia, Malaysia, Peru, Sierra Leone, Ukraine WHO 2015 Guidelines: ART irrespective of CD4 count Source: published policy

23. ART eligibility criteria for children <5 years WHO 2015 Guidelines: ART irrespective of CD4 count Source: published policy ART for all children <1 Clinical prerequisites ART for all children <2 ART for all children <5 ART for all children <10 ART for all children <15

24. 2004-052006-09201020112012201320142015 Pre-requisites Afghanistan Comoros Djibouti Lao PDR Liberia Malaysia Peru Sierra Leone Ukraine Children <2 Guyana Children <1 Brazil Burkina Faso Sweden Children <2 Algeria Ghana Morocco Nigeria Children <2 Kazakhstan Panama Timor-Leste Children <5 Rwanda Children <15 Zambia Uganda Children <2 Argentina Benin Botswana Papua New Guinea Tanzania Pre-requisites Cape Verde Children <5 Colombia DRC Fiji Honduras Mali Oman South Africa Zimbabwe Children <15 Namibia Children <5 Angola Bangladesh Bhutan, Sudan Burundi Cameroon El Salvador Indonesia Gabon, Malawi Lesotho, Nepal Mauritania Mozambique Myanmar South Sudan Children <10 Kenya Children <2 Venezuela Children <1 Costa Rica Finland Mexico Sri Lanka Thailand US, Uruguay Children <2 Cote d’Ivoire, Haiti, India Children <1 Chile Dominican Republic Hong Kong Madagascar Romania Tunisia Children <1 Ethiopia Guatemala Children <1 Paraguay Pre-requisites Guinea ART eligibility criteria for children <5 years Source: published policy Children <5 Cambodia Maldives Pakistan Swaziland Viet Nam Pre-requisites<2 years <5 years Children <5 China Children <15 Tanzania

25. ART initiation for people with HIV and TB ART INITIATION CRITERIA COUNTRIES Irrespective of CD4 count 89 Algeria, Angola, Argentina, Australia, Bangladesh, Belize, Benin, Bhutan, Bolivia, Botswana, Brazil, Britain, Burundi, Cambodia, Cameroon, Canada, Chile, China, Colombia, Costa Rica, Croatia, Democratic Republic of Congo, Dominican Republic, Ecuador, El Salvador, Ethiopia, France, Fiji, Finland, Gabon, Ghana, Greece, Guatemala, Guyana, Haiti, Honduras, Hong Kong, India, Indonesia, Italy, Jamaica, Kenya, Korea, Latvia, Lesotho, Madagascar, Malawi, Maldives, Mali, Mauritania, Mexico, Morocco, Mozambique, Myanmar, Namibia, Nepal, Netherlands, Nigeria, Norway, Oman, Pakistan, Panama, Papua New Guinea, Paraguay, Peru, Poland, Portugal, Romania, Rwanda, South Africa, Spain, Sri Lanka, South Sudan, Sudan, Swaziland, Switzerland, Tanzania, Timor-Leste, Thailand, Tunisia, Turkey, Uganda, United States, Ukraine, Uruguay, Venezuela, Viet Nam, Zambia, Zimbabwe ≤500 1 Malaysia ≤350 17 Afghanistan, Austria, Burkina Faso, Cote d’Ivoire, Cuba, Djibouti, Germany, Guinea, Kazakhstan, Lao PDR, Liberia, Moldova, Nicaragua, Niger, Philippines, Sierra Leone, Sweden ≤300 1 Macedonia ≤200 6 Belarus, Cape Verde, Comoros, Estonia, Russia, Senegal Source: published policy

26. ART initiation for pregnant women ART INITIATION CRITERIA NO. OF COUNTRIES COUNTRIES Option B+ 77 Algeria, Angola, Argentina, Australia, Austria, Bangladesh, Benin, Bhutan, Bolivia, Brazil, Burundi, Cambodia, Cameroon, Chile, Costa Rica, Croatia, Democratic Republic of Congo, Dominican Republic, Ecuador, El Salvador, Ethiopia, France, Fiji, Finland, Gabon, Germany, Greece, Ghana, Guatemala, Haiti, Honduras, India, Indonesia, Italy, Kenya, Korea, Lesotho, Madagascar, Malawi, Maldives, Mali, Mauritania, Mexico, Morocco, Mozambique, Myanmar, Namibia, Nepal, Netherlands, Nicaragua, Norway, Pakistan, Papua New Guinea, Paraguay, Peru, Poland, Romania, Rwanda, Spain, Sri Lanka, South Africa, South Sudan, Sudan, Swaziland, Switzerland, Uganda, UK, US, Uruguay, Venezuela, Tanzania, Thailand, Tunisia, Turkey, Viet Nam, Zambia, Zimbabwe ≤500 4 Colombia, Hong Kong (China), Malaysia, Oman ≤350 23 Afghanistan, Belize, Botswana, Burkina Faso, Canada, China, Cote d’Ivoire, Djibouti, Guinea, Guyana, Jamaica, Kazakhstan, Latvia, Liberia, Moldova, Niger, Nigeria, Panama, Portugal, Sierra Leone, Sweden, Timor-Leste, Ukraine ≤300 1 Macedonia ≤200 (consider for ≤350) 4 Belarus, Cape Verde, Estonia, Russia ≤200 5 Comoros, Cuba, Lao PDR, Philippines, Senegal 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

27. ART initiation for serodiscordant couples ART INITIATION CRITERIA NO. OF COUNTRIES COUNTRIES Irrespective of CD4 count 62 Algeria, Argentina, Australia, Austria, Bangladesh, Benin, Bhutan, Bolivia, Brazil, Britain, Burundi, Cambodia, Cameroon, Canada, Chile, China, Costa Rica, Democratic Republic of Congo, Ecuador, El Salvador, France, Fiji, Gabon, Germany, Haiti, Honduras, Hong Kong, Indonesia, Italy, Kenya, Korea, Lesotho, Madagascar, Maldives, Mali, Mauritania, Mexico, Myanmar, Namibia, Nepal, Netherlands, Oman, Pakistan, Poland, Rwanda, Spain, Sri Lanka, South Sudan, Sudan, Swaziland, United States, Uganda, Uruguay, Tanzania, Thailand, Tunisia, Turkey, Venezuela, Viet Nam, Zambia, Zimbabwe, Romania >350 3 Angola, Nigeria, Norway 350-500 1 Malaysia HIV+ partner of pregnant or breastfeeding women 1 Mozambique 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

28. ART initiation for people with Hepatitis B ART INITIATION CRITERIA NO. OF COUNTRIES COUNTRIES Irrespective of CD4 count 80 Algeria, Angola, Argentina, Australia, Austria, Bangladesh, Belize, Bhutan, Brazil, Britain, Burundi, Cambodia, Cameroon, Chile, China, Costa Rica, Croatia, Cuba, Democratic Republic of Congo, Dominican Republic, Ecuador, El Salvador, France, Fiji, Finland, Gabon, Germany, Greece, Guatemala, Haiti, Honduras, Hong Kong, India, Indonesia, Italy, Jamaica, Kenya, Latvia, Lesotho, Madagascar, Malawi, Maldives, Mali, Mauritania, Mexico, Morocco, Myanmar, Mozambique, Namibia, Nepal, Netherlands, Nicaragua, Nigeria, Norway, Pakistan, Papua New Guinea, Paraguay, Peru, Poland, Romania, Rwanda, South Korea, Spain, Sri Lanka, South Africa, South Sudan, Sudan, Swaziland, Tanzania, Timor-Leste, Thailand, Tunisia, Turkey, Uganda, Ukraine, United States, Uruguay, Venezuela, Zambia, Zimbabwe <500 3 Malaysia, Portugal, Switzerland Same as eligibility 31 Afghanistan, Belarus, Benin, Bolivia, Botswana, Burkina Faso, Canada, Cape Verde, Colombia, Comoros, Cote d’Ivoire, Djibouti, Ethiopia, Ghana, Guinea, Guyana, Kazakhstan, Lao PDR, Liberia, Macedonia, Moldova, Niger, Oman, Panama, Philippines, Russia, Senegal, Sierra Leone, Sweden, Viet Nam 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

29. ART initiation criteria for key populations COUNTRY TEST AND TREAT (ART IRRESPECTIVE OF CD4 COUNT) FOR KEY POPULATIONS Austria and Germany Men who have sex with men (MSM) Burundi MSM, sex workers Cameroon MSM, sex workers, injecting drug users Indonesia MSM, sex workers, injecting drug users, transgender Myanmar MSM, female sex workers, injecting drug users, transgender Rwanda MSM, sex workers Tanzania MSM, sex workers, injecting drug users, prisoners Sri Lanka MSM, female sex workers, injecting drug users, drug users, beach boys, prisoners Uganda Fisher folks, sex workers, truckers Viet Nam MSM, sex workers, injecting drug users Source: published policy 2015 WHO Recommendation : Irrespective of CD4 count

30. No recommendation specific for KP Irrespective of CD4 count for KP Irrespective of CD4 count for all, including KP Source: published policy KP: Key populations ART initiation criteria for key populations 2015 WHO Recommendation : Irrespective of CD4 count Earlier ART for KPs

31. Frequency of CD4 monitoring (55 countries) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring? FREQUENCYNUMBERCOUNTRIES Month 1; 3-monthly thereafter1Madagascar Every 3 months1Ukraine Every 3-monthly for 1 year; 6- monthly thereafter 1China Every 3-4 months1Sierra Leone Every 3-6 months3Angola, Argentina, Colombia Month 3 and 6; 6-monthly thereafter 2Botswana, Burkina Faso Month 3; 6-monthly thereafter2Nigeria, Pakistan Month 3; every 4-6 months thereafter 1Chile Every 4-6 months3Dominican Republic, Malaysia, Mexico 6-monthly (WHO recommendation) 28 Benin, Brazil, Burundi, Cambodia, Cote d'Ivoire, Democratic Republic of Congo, Ecuador, Ethiopia, Guatemala, Guinea, Haiti, India, Indonesia, Lesotho, Mali, Mozambique, Nepal, Myanmar, Niger, Papua New Guinea, Peru, Rwanda, South Sudan, Sudan, Tanzania, Viet Nam, Zambia, Zimbabwe Every 6-12 months1Venezuela Month 6; yearly thereafter1Ghana No routine CD4 ART monitoring8 Cameroon, Kenya, Malawi, Namibia, South Africa, Swaziland, Thailand, Uganda No recommendation2Morocco, Senegal

32. RECOMMENDATIONNUMBERCOUNTRIES Routine viral load for ART monitoring (WHO recommendation) 47 Angola, Argentina, Benin, Botswana, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Chile, China, Colombia, Cote d'Ivoire, Democratic Republic of Congo, Dominican Republic, Ecuador, Ghana, Guatemala, Guinea, Indonesia, Kenya, Lesotho, Madagascar, Malawi, Malaysia, Mali, Mexico, Mozambique, Namibia, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Peru, Rwanda, Sierra Leone, South Africa, Sudan, Swaziland, Tanzania, Thailand, Uganda, Ukraine, Venezuela, Viet Nam, Zambia Targeted viral load monitoring 6 Haiti, India, Morocco, Myanmar, South Sudan, Zimbabwe Not recommended1Ethiopia No recommendation1Senegal Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring? Viral Load for ART monitoring (55 countries)

33. Frequency of VL monitoring (47 countries) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring? MONTH AFTER ART INITIATION Month 1 Month 3 Month 6 Month 9 Month 12 Month 18 Mont h 24 Post the last VL test Angola, Burundi, Dominican Republic, Ecuador, Guatemala, Malaysia, Mali, Niger, Nigeria, Papua New Guinea, Venezuela, Viet Nam ✔✔✔✔ 6-monthly Argentina, Colombia ✔✔✔✔✔ 3-6 monthly Ukraine ✔✔✔✔✔✔ 6-monthly Botswana, Brazil, Chile, Mexico, Pakistan, Peru, Sierra Leone ✔✔✔✔✔ 6-monthly Thailand ✔✔✔✔ Yearly Benin, Burkina Faso, Cameroon, China, Cote d’Ivoire, Democratic Republic of Congo, Ghana, Kenya, Indonesia, Lesotho, Madagascar, Mozambique, Namibia, Nepal, South Africa, Sudan, Swaziland, Tanzania, Uganda, Zambia ✔✔✔ Yearly Guinea, Rwanda ✔✔ Yearly Malawi ✔✔ Biennially Cambodia ✔ Yearly

34. Viral Load for ART monitoring (55 countries) Recommended and widely available Recommended only for monitoring treatment failureRecommended with limited availability Recommended (availability unknown) No recommendation (limited availability) Not recommended Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring?

35. Early Infant Diagnosis (within 2 months of birth) In 2013, the % of HIV-exposed infants receiving a virological test within 2 months of birth was 70% in countries in bold (source: UNAIDS GARPR 2014). Benin, Burkina Faso, Burundi, Cameroon, China, Dominican Republic, Ethiopia, Ghana, Guinea, India, Kenya, Lesotho, Malawi, Namibia, Nepal, Papua New Guinea, Uganda, Zimbabwe 1 2 3 4 5 6 78 Brazil, Haiti, Mozambique, Venezuela Angola, Botswana, Cambodia, Democratic Republic of Congo, Indonesia, Mali, Myanmar, Pakistan, Peru, Tanzania, South Sudan, Viet Nam (WHO recommendation) Rwanda, Swaziland, Zambia Guatemala, Ukraine, Thailand Argentina, Malaysia Mexico Weeks 0 Morocco Colombia, South Africa Chile

36. Limitations Guidelines may be outdated and/or in the process of being updated Written policies may not reflect programme implementation or clinical practice Other guidelines covering ART, task shifting, drug dispensing may exist

37. Guidelines from 6 countries released before 2013 recommend ART for asymptomatic people at CD4 ≤ 500 or earlier Fourteen countries recommend test and treat Only 36 countries are consistent with WHO paediatric ART recommendation Post 2013 WHO guidelines, countries are revising/ planning to revise national guidelines Conclusion

38. Please send new and/or updated guidelines to: Reuben Granich MD MPH Vice President and Chief Technical Advisor, IAPAC E-mail: rgranich@iapac.orgrgranich@iapac.org IAPAC Global ART guidelines database Link: http://www.hivpolicywatch.org/ http://www.globalhivpolicywatch.org/