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Open Letter to WHO on Delayed Testing and Treatment Guidelines for Discordant Couples

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9 August 2011

Dr. Margaret Chan, Director‐General
World Health Organization
Avenue Appia 20,
1211 Geneva 27, Switzerland
Dear Dr. Chan:
We are writing with alarm following the International AIDS Society conference in Rome, where it seems that the WHO scrapped release of technical guidelines on HIV testing and treatment for discordant couples.  We have obtained a copy of this document, available online: with ISBN number (9789241501972), which appears to be the final version. We understand that many copies of the document had been printed for distribution at the Rome conference and were subsequently destroyed.
This guidelines document was, according to its own description, finalised after wide consultation. It is well written, pays substantial attention to human rights and makes important recommendations. Undoubtedly, as with any complex WHO guidelines document, there are aspects of the report that will draw criticism and that could be improved. However, the WHO, after following its own strict procedures for developing guidelines, is duty-bound to publish.
In particular we welcome recommendation five:
ART for HIV-positive partners with ≥350 CD4 cells/μL in serodiscordant couples is recommended to reduce HIV transmission to uninfected partners.
The evidence for this recommendation came after over a decade of evidence culminating with the HPTN 052 trial, which showed a 96% reduction in HIV transmission through ARV treatment. What was obvious prior to the last few months has now become clear scientific consensus: antiretroviral treatment not only prevents mortality and morbidity, but it prevents infection among discordant couples. WHO is now failing in its responsibility to help implementing countries and program managers translate this science into policy. Importantly, this science directly impacts on practice that can be implemented immediately: the infrastructure, human rights framework, and technologies required for testing and counseling followed by ARV initiation are already in place—what is lacking is policy guidance.
These guidelines are urgently needed by doctors and implementing agencies throughout the world to support people living with HIV and their partners to make informed decisions about their sexual relationships and reproductive choices. In the coming months national governments will be revising their guidelines and major global initiatives will be creating their strategies in the area of discordant couples—all without guidance from WHO. Meanwhile, at the local level clinicians will see patients without any clear indication of how to use one of the most effective prevention tools at their disposal in ARVs.  
In particular, we are disturbed by reports that key donors to WHO including the Bill & Melinda Gates Foundation may have unduly influenced the decision to halt publication of these completed guidelines, fundamentally undermining the legitimate guidelines development process. We believe this is inappropriate—and is resulting in a failure to implement proven life-saving, disease-preventing practice.
These guidelines should be published immediately. Therefore we ask:
1.     WHO release the document Couples HIV Testing and Counseling and Antiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples immediately.  
2.     Can we be sure that when it is released the following paragraph, on page 6, will remain in the document and remain truthful? “All members of the Guidelines Group and peer reviewers were asked to complete a WHO declaration of interest form. Seven people declared potential conflicts of interest. These were discussed by the WHO steering group and then with the Guidelines Group. No one declared a potential conflict of interest that was thought to be significant.”
We note that additional guidelines are also needed regarding PrEP—an ARV-based prevention strategy that could complement early initiation of treatment. We are dismayed that WHO’s actions might be contributing to the unnecessary pitting of PrEP and treatment as prevention against each other.
As you know, we are working in an environment where WHO’s independence, and relevance, is being regularly questioned by policy makers and governments. Your urgent corrective action can help put to rest these questions.
AIDS and Rights Alliance of Southern Africa (ARASA)
Global Network of People Living with HIV/AIDS (GNP+)
Health GAP (Global Access Project)
HIV i-Base
Treatment Action Campaign (TAC)
Treatment Action Group (TAG)
UK Stop AIDS Campaign