Implementing Comprehensive HIV/STI Programmes with Sex Workers Implementing Comprehensive HIV/STI Programmes with | Page 130

5 Clinical and Support Services

5.3.2 Essential definitions and prerequisites of ART services
The 2013 WHO Consolidated guidelines on the use of antiretroviral drugs for treating and preventing
HIV infections outline recommendations on when to start ART and what to use.
• ART should be initiated in all HIV-positive individuals with CD4 count ≤500 cells/mm3 regardless
of WHO clinical stage.
• As a priority, ART should be initiated in HIV-positive individuals with severe or advanced HIV clinical
disease (WHO clinical stage 3 or 4) and HIV-positive individuals with CD4 count ≤350 cells/mm3.
• ART should be offered to all HIV-positive individuals, regardless of WHO clinical stage or CD4 cell
count, in the following situations:
›› individuals co-infected with HIV and active TB disease
›› individuals co-infected with HIV and hepatitis B virus (HBV) with evidence of severe chronic
liver disease
›› pregnant and breastfeeding women with HIV
›› HIV-positive partners in serodiscordant couples, to reduce the risk of HIV transmission to
uninfected partners
›› all HIV-positive children under 5 years old.
The guidelines also recommend:
• use of simplified, less toxic and more convenient antiretroviral regimens for first- and second-line
treatment, preferably as fixed-dose combinations
• integration of ART in TB, antenatal and maternal and child health services, and in settings providing
opioid substitution therapy (OST)
• decentralization of ART services. ART should be provided in peripheral health facilities, initiated by
nurses and with maintenance support from community health workers
• the “Three I’s” for HIV/TB (intensified TB case-finding, isoniazid preventive therapy [IPT] and TB
infection control), as outlined in the WHO policy on collaborative TB/HIV activities: guidelines for
national programmes and other stakeholders.

5.3.3 Specific considerations for sex workers on ART
The principles for ART use, including when to start and what to use, are the same for all people with
HIV. Therefore the clinical management of HIV-positive sex workers should not differ from that of
other populations, and there are no special requirements.
Sex workers in many countries report that they experience stigma, discrimination and a lack of respect
when attending health-care facilities used by the general public. However, experience in some high
HIV-burden countries, including Cambodia, Côte d’Ivoire, Kenya, Thailand and Zambia shows that
ART services designed specifically for sex workers increase treatment uptake and adherence.

108