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Ingold H, Gomez GB, Stuckler D, Vassall A, Gafos M. "Going into the black box": a policy analysis of how the World Health Organization uses evidence to inform guideline recommendations. Front Public Health 2024; 12:1292475. [PMID: 38584925 PMCID: PMC10995388 DOI: 10.3389/fpubh.2024.1292475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/29/2024] [Indexed: 04/09/2024] Open
Abstract
Background The World Health Organization (WHO) plays a crucial role in producing global guidelines. In response to previous criticism, WHO has made efforts to enhance the process of guideline development, aiming for greater systematicity and transparency. However, it remains unclear whether these changes have effectively addressed these earlier critiques. This paper examines the policy process employed by WHO to inform guideline recommendations, using the update of the WHO Consolidated HIV Testing Services (HTS) Guidelines as a case study. Methods We observed guideline development meetings and conducted semi-structured interviews with key participants involved in the WHO guideline-making process. The interviews were recorded, transcribed, and analysed thematically. The data were deductively coded and analysed in line with the main themes from a published conceptual framework for context-based evidence-based decision making: introduction, interpretation, and application of evidence. Results The HTS guideline update was characterized by an inclusive and transparent process, involving a wide range of stakeholders. However, it was noted that not all stakeholders could participate equally due to gaps in training and preparation, particularly regarding the complexity of the Grading Recommendations Assessment Development Evaluation (GRADE) framework. We also found that WHO does not set priorities for which or how many guidelines should be produced each year and does not systematically evaluate the implementation of their recommendations. Our interviews revealed disconnects in the evidence synthesis process, starting from the development of systematic review protocols. While GRADE prioritizes evidence from RCTs, the Guideline Development Group (GDG) heavily emphasized "other" GRADE domains for which little or no evidence was available from the systematic reviews. As a result, expert judgements and opinions played a role in making recommendations. Finally, the role of donors and their presence as observers during GDG meetings was not clearly defined. Conclusion We found a need for a different approach to evidence synthesis due to the diverse range of global guidelines produced by WHO. Ideally, the evidence synthesis should be broad enough to capture evidence from different types of studies for all domains in the GRADE framework. Greater structure is required in formulating GDGs and clarifying the role of donors through the process.
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Affiliation(s)
- Heather Ingold
- Department of Global Health and Development, Faculty of Public Health Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Unitaid, Global Health Campus, Geneva, Switzerland
| | - Gabriela B. Gomez
- Department of Global Health and Development, Faculty of Public Health Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Stuckler
- Department of Social Sciences and Politics, Bocconi University, Milan, Italy
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mitzy Gafos
- Department of Global Health and Development, Faculty of Public Health Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Kinuthia R, Verani A, Gross J, Kiriinya R, Hepburn K, Kioko J, Langat A, Katana A, Waudo A, Rogers M. The development of task sharing policy and guidelines in Kenya. HUMAN RESOURCES FOR HEALTH 2022; 20:61. [PMID: 35906629 PMCID: PMC9336004 DOI: 10.1186/s12960-022-00751-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 05/30/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The global critical shortage of health workers prevents expansion of healthcare services and universal health coverage. Like most countries in sub-Saharan Africa, Kenya's healthcare workforce density of 13.8 health workers per 10,000 population falls below the World Health Organization (WHO) recommendation of at least 44.5 doctors, nurses, and midwives per 10,000 population. In response to the health worker shortage, the WHO recommends task sharing, a strategy that can increase access to quality health services. To improve the utilization of human and financial health resources in Kenya for HIV and other essential health services, the Kenya Ministry of Health (MOH) in collaboration with various institutions developed national task sharing policy and guidelines (TSP). To advance task sharing, this article describes the process of developing, adopting, and implementing the Kenya TSP. CASE PRESENTATION The development and approval of Kenya's TSP occurred from February 2015 to May 2017. The U.S. Centers for Disease Control and Prevention (CDC) allocated funding to Emory University through the United States President's Emergency Plan for AIDS Relief (PEPFAR) Advancing Children's Treatment initiative. After obtaining support from leadership in Kenya's MOH and health professional institutions, the TSP team conducted a desk review of policies, guidelines, scopes of practice, task analyses, grey literature, and peer-reviewed research. Subsequently, a Policy Advisory Committee was established to guide the process and worked collaboratively to form technical working groups that arrived at consensus and drafted the policy. The collaborative, multidisciplinary process led to the identification of gaps in service delivery resulting from health workforce shortages. This facilitated the development of the Kenya TSP, which provides a general orientation of task sharing in Kenya. The guidelines list priority tasks for sharing by various cadres as informed by evidence, such as HIV testing and counseling tasks. The TSP documents were disseminated to all county healthcare facilities in Kenya, yet implementation was stopped by order of the judiciary in 2019 after a legal challenge from an association of medical laboratorians. CONCLUSIONS Task sharing may increase access to healthcare services in resource-limited settings. To advance task sharing, TSP and clinical practice could be harmonized, and necessary adjustments made to other policies that regulate practice (e.g., scopes of practice). Revisions to pre-service training curricula could be conducted to ensure health professionals have the requisite competencies to perform shared tasks. Monitoring and evaluation can help ensure that task sharing is implemented appropriately to ensure quality outcomes.
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Affiliation(s)
- Rosemary Kinuthia
- Department of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA.
| | - Andre Verani
- U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA, 30333, USA
| | - Jessica Gross
- U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA, 30333, USA
| | - Rose Kiriinya
- Emory University Kenya Health Workforce Project, Nairobi, Kenya
| | - Kenneth Hepburn
- Department of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA
| | - Jackson Kioko
- Kenya Ministry of Health, Afya House, Cathedral Road, P.O. Box:30016-00100, Nairobi, Kenya
| | - Agnes Langat
- U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA, 30333, USA
| | - Abraham Katana
- U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA, 30333, USA
| | - Agnes Waudo
- Emory University Kenya Health Workforce Project, Nairobi, Kenya
| | - Martha Rogers
- Department of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA
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Wu Y, Chu L, Yang H, Wang W, Zhang Q, Yang J, Qiao S, Li X, Shen Z, Zhou Y, Liu S, Deng H. Simultaneous Determination of 6 Antiretroviral Drugs in Human Hair Using an LC-ESI+-MS/MS Method: Application to Adherence Assessment. Ther Drug Monit 2021; 43:756-765. [PMID: 33587427 PMCID: PMC8355263 DOI: 10.1097/ftd.0000000000000878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The determination of antiretroviral drugs in hair is receiving considerable research interest to assess long-term adherence to antiretroviral therapy (ART). Currently in China, lamivudine, zidovudine, nevirapine, efavirenz, ritonavir, and lopinavir are combined as first-line and second-line free therapy regimens and are recommended for people living with HIV (PLWH). Simultaneous determination of the 6 antiretroviral drugs in human hair is important for accurately and widely assessing long-term adherence in Chinese PLWH receiving different ART regimens. METHODS Six drugs were extracted from 10-mg hair samples incubated in methanol for 16 hours at 37°C and then analyzed by liquid chromatography with tandem mass spectrometry using a mobile phase of 95% methanol, with an electrospray ionization source in multiple reaction monitoring and positive mode. RESULTS The LC-ESI+-MS/MS method exhibited a linear range (R2 > 0.99) within 6-5000, 10-5000, 6-50,000, 12-50,000, 8-5000, and 8-12,500 pg/mg for lamivudine, zidovudine, nevirapine, efavirenz, ritonavir, and lopinavir. For all 6 drugs, the limits of quantification ranged between 6 and 12 pg/mg. The intraday and interday coefficients of variation were within 15%, and the recoveries ranged from 91.1% to 113.7%. Furthermore, the other validation parameters (ie, selectivity, matrix effect, stability, and carryover) met the acceptance criteria stipulated by guidelines of the US Food and Drug Administration and European Medicines Agency. Significant intergroup differences were observed between high-adherence and low-adherence groups, with high intercorrelations in the hair content of the 6 drugs. CONCLUSIONS The developed method demonstrated good reliability, to comprehensively and accurately assess adherence in PLWH receiving different ART regimens.
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Affiliation(s)
- Yan Wu
- Department of Brain and Learning Science, School of Biological Science and Medical Engineering, Southeast University
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, China
| | - Liuxi Chu
- Department of Brain and Learning Science, School of Biological Science and Medical Engineering, Southeast University
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, China
| | - Haoran Yang
- Department of Brain and Learning Science, School of Biological Science and Medical Engineering, Southeast University
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, China
| | - Wei Wang
- Department of Brain and Learning Science, School of Biological Science and Medical Engineering, Southeast University
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, China
| | - Quan Zhang
- Department of Health Promotion, Education and Behavior, South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
- Institute of Applied Psychology and School of Public Administration, Hohai University
| | - Jin Yang
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, China
- Department of Preventive Medicine, School of Public Health, Southeast University, Nanjing; and
| | - Shan Qiao
- Department of Health Promotion, Education and Behavior, South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Xiaoming Li
- Department of Health Promotion, Education and Behavior, South Carolina SmartState Center for Healthcare Quality (CHQ), Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Zhiyong Shen
- Unit of AIDS Prevention and Control, Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Yuejiao Zhou
- Unit of AIDS Prevention and Control, Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Shuaifeng Liu
- Unit of AIDS Prevention and Control, Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Huihua Deng
- Department of Brain and Learning Science, School of Biological Science and Medical Engineering, Southeast University
- Key Laboratory of Child Development and Learning Science (Southeast University), Ministry of Education
- Institute of Child Development and Education, Research Center for Learning Science, Southeast University, Nanjing, China
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Govere SM, Chimbari MJ. The evolution and adoption of World Health Organization policy guidelines on antiretroviral therapy initiation in sub-Saharan Africa: A scoping review. South Afr J HIV Med 2020; 21:1103. [PMID: 33101722 PMCID: PMC7564818 DOI: 10.4102/sajhivmed.v21i1.1103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/26/2020] [Indexed: 11/05/2022] Open
Abstract
Background Despite past and present global interventions, the human immunodeficiency virus (HIV) pandemic remains a public health problem in low- and middle-income countries (LMICs). The World Health Organization (WHO) has assisted these countries by providing antiretroviral therapy (ART) policies for adoption and adaptation to local needs. Objectives This article describes the response of countries in sub-Saharan Africa (SSA), to the WHO’s changing CD4-threshold ART-initiation recommendations of the past two decades. Methods Relevant articles published in international peer-reviewed journals were accessed via the following search engines: PubMed, Google Scholar, Cochrane, Embase and EBSCOhost. The study’s inclusion criteria were articles published in the English language between 2000 and 2019 that highlighted changes to the CD4 ART-initiation threshold and that focused on the WHO’s ‘commencement of ART’ policy guidelines. Sixteen studies (n = 16) from SSA were identified and included in this review: four are cross-sectional, four deal with cost-effectiveness, four are retrospective, one is a randomised trial and three are observational studies. Only studies conducted in SSA were assessed. Results Four themes emerged: (1) adoption of the WHO CD4-ART-initiation policy by SSA countries, (2) timely implementation of the changing guideline initiation policy in the region, (3) barriers and facilitators encountered in the implementation of the changing guidelines and (4) description of similarities in policy implementation at country level from 2002 to 2019. Regional studies – cross-sectional, observational, retrospective, cost-effectiveness and randomised have described greater access to ART in SSA. However, barriers remain. The most common barriers to the timely implementation of ‘new’ ART-initiation guidelines were economic constraints, drug stock-outs, delays in obtaining baseline blood-test results and staff shortages. Conclusion Although countries in SSA have adopted the WHO-ART-CD4 initiation-threshold policy guidelines, implementation has seldom occurred in a timely manner. Barriers have been identified. Whilst a small number of countries have implemented recommendations promptly, for many, the barriers still require to be overcome.
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Affiliation(s)
- Sabina M Govere
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Moses J Chimbari
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Zhang Q, Qiao S, Yang X, Li X. Antiretroviral Concentration in Hair as a Measure for Antiretroviral Medication Adherence: A Systematic Review of Global Literature. AIDS Behav 2020; 24:311-330. [PMID: 30877582 DOI: 10.1007/s10461-019-02460-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This review aims to validate hair antiretroviral concentration (HAC) as a measure for antiretroviral medication adherence. This review included 31 studies that analyzed a total of 11 ARV drugs in four different drug classes. The associations between HAC and non-pharmacokinetic measures were generally lower than the association between HAC and other pharmacokinetic measures: the correlation coefficients (r) ranged from - 0.20 to 0.38 for self-report or pill counts and 0.20 to 0.85 for electronic drug monitoring; HAC and other pharmacokinetic measures were positively correlated with the correlation coefficients (r) ranging from 0.20 to 0.72, 0.34 to 0.86, 0.50 to 0.85 for antiretroviral concentration in plasma, peripheral blood mononuclear cells, and dried blood spots, respectively. HAC was one of the strongest independent predictors of virologic responses. HAC of tenofovir was significantly associated with renal toxicity in large sample studies. This review suggests that HAC is a valid biomarker of antiretroviral medication adherence.
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Affiliation(s)
- Quan Zhang
- South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Discovery I, 915 Greene Street, Columbia, SC, 29028, USA.
- Institute of Pedagogy and Applied Psychology, School of Public Administration, Hohai University, Nanjing, China.
| | - Shan Qiao
- South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Discovery I, 915 Greene Street, Columbia, SC, 29028, USA
| | - Xueying Yang
- South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Discovery I, 915 Greene Street, Columbia, SC, 29028, USA
| | - Xiaoming Li
- South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Discovery I, 915 Greene Street, Columbia, SC, 29028, USA
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Chahal HS, Capella P, Presto R, Murray JS, Shimer M, Valdez ML, Lurie PG. Impact of the US Food and Drug Administration registration of antiretroviral drugs on global access to HIV treatment. BMJ Glob Health 2018; 3:e000651. [PMID: 29862054 PMCID: PMC5969730 DOI: 10.1136/bmjgh-2017-000651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/28/2018] [Accepted: 03/01/2018] [Indexed: 11/03/2022] Open
Abstract
Background Since 2004, the US Food and Drug Administration's (USFDA) dedicated drug review process in support of President's Emergency Plan for AIDS Relief (PEPFAR) has made safe, effective and quality antiretrovirals (ARVs) available for millions of patients. Furthermore, the WHO and Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) can add the USFDA-reviewed products to their respective formularies, through a novel process of 'one-way reliance'. We assessed the number of ARVs made available through WHO and Global Fund based on the USFDA review. Methods We conducted a cross-sectional study of all the USFDA-reviewed PEPFAR drugs between 1 December 2014 and 20 March 2017 to determine 1) the percentage that are included on the WHO and Global Fund formularies; 2) the number of the USFDA ARVs supporting the WHO HIV treatment guidelines, and their uptake by WHO and Global Fund and 3) time between the USFDA review and WHO review of the same ARVs. Findings Overall, 91% (204/224) of the USFDA products appeared on either the WHO/Prequalification of Medicines Programme (PQP) or the Global Fund ARV lists. Forty-five per cent (100/224) and 83% (184/224) appear on WHO/PQP and Global Fund formularies through one-way reliance, respectively. Forty-one per cent (91/224) of the USFDA products support the WHO-preferred first-line HIV treatment options. Of these 91 products, 38% and 85% of products were adopted by WHO/PQP and Global Fund through one-way reliance, respectively. Sixty-six products that were fully reviewed and registered by WHO (vs one-way reliance) had also undergone the USFDA review; 46 of these were registered by WHO after the USFDA review was complete (median delay of 559 days (IQR 233-798 days)). Conclusions The USFDA's PEPFAR process is making safe and effective ARVs available worldwide, in part because the major global ARV procurement organisations rely on the USFDA registration as proof of quality. There is room for improved information sharing and collaboration to reduce duplication of effort, save resources and further expedite access to ARVs.
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Affiliation(s)
- Harinder Singh Chahal
- Office of Public Health Strategy and Analysis, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA
| | - Peter Capella
- Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ryan Presto
- Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Jeffrey S Murray
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Martin Shimer
- Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Mary Lou Valdez
- Office of International Programs, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA
| | - Peter G Lurie
- Office of Public Health Strategy and Analysis, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA
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Implementation and operational research: the impact of option B+ on the antenatal PMTCT cascade in Lilongwe, Malawi. J Acquir Immune Defic Syndr 2015; 68:e77-83. [PMID: 25585302 PMCID: PMC4359035 DOI: 10.1097/qai.0000000000000517] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In 2011, Malawi implemented Option B+ (B+), lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women. We aimed to describe changes in service uptake and outcomes along the antenatal prevention of mother-to-child transmission (PMTCT) cascade post-B+ implementation. DESIGN Pre/post study using routinely collected program data from 2 large Lilongwe-based health centers. METHODS We compared the testing of HIV-infected pregnant women at antenatal care, enrollment into PMTCT services, receipt of ART, and 6-month ART outcomes pre-B+ (October 2009-March 2011) and post-B+ (October 2011-March 2013). RESULTS A total of 13,926 (pre) and 14,532 (post) women presented to antenatal care. Post-B+, a smaller proportion were HIV-tested (99.3% vs. 87.7% post-B+; P < 0.0001). There were 1654 (pre) and 1535 (post) HIV-infected women identified, with a larger proportion already known to be HIV-infected (18.1% vs. 41.2% post-B+; P < 0.0001) and on ART post-B+ (18.7% vs. 30.2% post-B+; P < 0.0001). A significantly greater proportion enrolled into the PMTCT program (68.3% vs. 92.6% post-B+; P < 0.0001) and was retained through delivery post-B+ (51.1% vs. 65% post-B+; P < 0.0001). Among those not on ART at enrollment, there was no change in the proportion newly initiating ART/antiretrovirals (79% vs. 81.9% post-B+; P = 0.11), although median days to initiation of ART decreased [48 days (19, 130) vs. 0 days (0, 15.5) post-B+; P < 0.0001]. Among those newly initiating ART, a smaller proportion was alive on ART 6 months after initiation (89.3% vs. 78.8% post-B+; P = 0.0004). CONCLUSIONS Although several improvements in PMTCT program performance were noted with implementation of B+, challenges remain at several critical steps along the cascade requiring innovative solutions to ensure an AIDS-free generation.
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