Transcript Poster presentation - WHO archives

Developing Comprehensive
HIV/AIDS Standard Treatment
Guidelines in a Resource-Poor
Setting
Ndhlovu C E, Latif AS. HIV/AIDS
Quality of Care Initiative(HAQOCI) and
National Drug and Therapeutics Policy
Advisory Committee, University of
Zimbabwe, Harare, Zimbabwe
ABSTRACT
Developing Comprehensive HIV/AIDS Standard Treatment Guidelines in a
Resource -Poor Setting. Ndhlovu C E, Latif AS. HIV/AIDS Quality of Care Initiative and National Drug and
Therapeutics Policy Advisory Committee(NDTPAC), University of Zimbabwe, Harare, Zimbabwe
Problem Statement: Zimbabwe has a huge burden of disease due to HIV/AIDS. The urgent need for a minimum
package of HIV/AIDS care interventions was expressed at a national multi-sectoral stakeholders' meeting convened
in February 2002.
Objective: To produce a national booklet of comprehensive standard treatment guidelines (STGs) for HIV/AIDS
care.
Design: A modified Delphi approach was used.
Study Setting and Population: Experts and healthcare workers experienced in the treatment of HIV-infected
patients in Zimbabwe.
Methods: Topic leaders were endorsed at an Opinion Leaders meeting in September 2002. The participants agreed
on what each guideline would cover. By applying the essential drug concept and the rational use of drugs and above
all evidence-based medicine, guidelines based on the consensus of the topic leaders and their group members were
produced and forwarded to the Coordinator of the project. It had been hoped that as each guideline was produced, it
would be disseminated to the end users for review and criticism prior to the final manual being produced. Due to
time constraints, an editor was identified to review and format all the drafts. In July 2003, the core guideline
development group met to finalize the document.
Results: An A5 sized draft book with 345 pages was produced. (1) There was a shortage of experts or topic leaders
for some of the areas. Applying the modified Delphi approach was not quite successful as some of the groups were
small. (2) There are hardly any locally conducted HIV/AIDS interventions for most of our clinical
recommendations, including those in our current Essential Drug List of Zimbabwe(EDLIZ). (3) The healthcare
delivery system has suffered from brain drain, and hence there are generally fewer human resources to draw from.
Conclusions: A full-time coordinator for standard treatment guideline development is essential. A consensus
methodology to create evidence-based guidelines within a reasonable time limit using part-timers is not feasible.
Use of electronic mail both to develop and to disseminate the guidelines should be encouraged given the lack of
resources to allow people to meet physically.
Study Funding: Zimbabwe- Centre for Disease Control and Prevention (Zim-CDC) Collaboration with the Clinical
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Epidemiology Resource and Training Centre(CERTC), University of Zimbabwe, Harare, Zimbabwe.
Background


Zimbabwe is one of the Sub-Saharan countries hit hardest by
the HIV/AIDS pandemic1. Sub-Saharan countries account for
10% of the global population but contributes 26.6 million(66%)
of PLWHA. Zimbabwe’s population is estimated to be about 13
million(1998 census) and with a overall prevalence of HIV
infection of 24.6% 15-49 years age group, about 2.5 million
people are expected to have HIV/AIDS2. The majority are not
aware of their status which obviously impacts negatively on
attempts to prevent new infections.
The need for a minimum package of HIV/AIDS care guidelines
was expressed at a national multi-sectoral Stakeholders’
meeting convened in February 20023.
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Introduction


Although our famous Essential Drug List of Zimbabwe(EDLIZ)
did have a chapter entitled “HIV Related Disease” which had
references to the management of a few disorders, it was noted
that these were grossly inadequate. Firstly, there was still not
much active treatment being offered for the major opportunistic
infections as the drug treatment was viewed as being too costly
to include in the list and let alone make it available especially in
the public sector. Secondly, the next revised edition of EDLIZ
was only due in 2005 and that date was obviously too far off.
At the time that the Stakeholders’ meeting was convened in
February 2002, the prospect of introducing antiretroviral drugs
nationally was very remote. Hence, one of the strategies
adopted was that of urgently developing a minimal
comprehensive package of HIV/AIDS interventions in the form
of evidence based standard treatment guidelines. These
guidelines would seek to improve the quality of life of those
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infected and affected by HIV/AIDS.
Objectives


To develop, using topics identified by the stakeholders as being
important, simple, credible and valid guidelines for use by
healthcare workers at all levels.
To produce a pocket sized national booklet of comprehensive
standard treatment guidelines(STGs) for HIV/AIDS care.
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Methods



HAQOCI identified the NDTPAC as being the most appropriate
organization to spearhead the development of these guidelines
given NDTPAC’s track record of producing/revising EDLIZ. Thus
the NDTPAC was included naturally in the core guideline
development group and produced the workplan for the project.
Identifying and collecting the potential evidence based
guidelines to be used as reference material was done by a
fulltime HAQOCI Information Officer as well as the rest of the
NDTPAC and HAQOCI members.
In September 2002, the first activity was the convening an
“Opinion Leaders Meeting” whose main objectives were as
follows:
– confirmation of the core guideline development group
– formation of topic specific guideline development groups
and, more critically, identification of the group leaders
– discussion of criteria to be used when assessing evidence
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– the basic guideline outline
Methods



At that initial workshop, the need to apply the essential drug
concept as well as rational use of drugs was emphasized as
being the overall guiding principles of the development of these
new guidelines.
The modified Delphi technique4,5 was adopted. The principle of
consensus was to be applied but still attempting to make the
recommendations as research based as possible within each
group. 15 topic leaders were identified and email connectivity to
enable widespread communication among the group members
was facilitated by setting up a specific email discussion forum
whose email address was as
follows:[email protected]
Just a year after the first workshop, a second workshop was
held to finalize the draft recommendations
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Results




The first workshop was attended by 74 healthcare workers from all
over the country . This group included a multidisciplinary lot of
healthcare workers including academics, provincial medical directors,
pharmacists,nurses and other paramedics.
Within six months of the first workshop, two working groups ,
psychosocial and neuro-psychiatric groups, had already realized that
their recommendations were too long to be communicated via their
email which was served by Healthnet and hence had to hold face to
face consultations on two occasions. In general, most of the groups
had few members e.g. neurology, ear, nose and throat disorders.
It had been hoped that most of the drafts would have been in within
the first 6 months but this was impossible as the period was straddling
the Christmas holidays. Thus an editor was quickly identified to start
editing the drafts and formatting them for the final review process.
In July 2003, about a year after commencing the guideline
development process, a second and final workshop was held. This
was attended by 34 participants who were mainly the core guideline
development i.e. NDTPAC members plus HAQOCI members, group
leaders and their active members. Within 2 months of this final
meeting, the editor had finalized the reviews and handed the draft 8
document to the overall Coordinator.
Results


By early March 2004,
nearly 2 years after the
initial stakeholders’
meeting which had
started this whole
process, the guidelines
were ready for
publication after
endorsement by the
Minister of Health and
Child Welfare.
The draft book is A5
sized and 345 pages
long.
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Results


Is the draft pocket
sized?
It is hoped that by using
a small font in the final
publication, the book
will be about the size of
EDLIZ which is 382
pages long.
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Implications/Conclusions



Two years later, after a national stakeholders’ meeting had recommended that
guidelines be produced urgently, an A5 sized booklet has been produced.
Holding of workshops, with a reduced healthcare staff number and funding, had
to be kept to a minimum. Our modified Delphi methodology depended on the
use of email to allow more widespread consultation at a relatively low cost. This
was facilitated by the setting up of the University intranet at the same time that
their services were needed. However, the “zimguideline” email discussion
forum was rarely used. Perhaps this was a reflection of our people’s reluctance
to use this form of communication i.e people preferring to “lurk” rather that be
active participants. A full time coordinator would have speeded up this process
as they would have also done the editorial work as the drafts were being
received.
There are hardly any locally conducted trials to support our recommendations.
Other evidence based guidelines had to be modified by our experts to suit our
local working conditions.
The next step will be dissemination of the HIV /AIDS STGs with the HAQOCI
offices as “a central guideline information centre”. HAQOCI already has a
website on which these guidelines are posted.Training workshops in provinces
will have to be conducted using the new guidelines. A formal launch of AIDS
manual is needed followed by monitoring,evaluation and reviewing of the
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guidelines.
References
1. Report on the global HIV/AIDS epidemic 2002. Joint United
Nations Programme on HIV/AIDS , UNAIDS
2. Ministry of Health and Child Welfare, June 2003, Harare,
Zimbabwe
3. Report on the National Stakeholders Meeting to Build
Consensus on HIV/AIDS Care Improvement in
Zimbabwe, February,2002, Harare, Zimbabwe.
4. Indicators for Monitoring National Drug Policies,
Department of Essential Drugs and medicines Policy,
WHO/EDM/PAR/99.3
5. Managing Drug Supply: the selection, procurement,
distribution and use of pharmaceuticals. 2nd Edition,
revised and expanded.Management Sciences for Health in
collaboration with the World Health Organization.,1997,
Kumarian Press.USA
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