Sunday, 7 July 2013

Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection

This slightly wordy heading refers to Guidelines issued by the WHO this week on treating HIV.  Although really aimed at low and middle-income countries, they contain some useful ideas for everyone.  Apart from the numerous recommendations - the most significant of which is probably starting therapy earlier than is often the case, my take on it is this.

  1. Firstly the idea of consolidated guidelines - rather than having different guidelines for pregnancy; children; adolescents; adults etc..... put them all together.  This makes the transitional arrangements clearer and may help to reduce the barriers that different professional groups have working with each other.
  2. The same goes for hospital - community care.  This is important because something that more developed health care systems are going to have to get to grips with is the change from HIV being an acute disease ending in sickness and death and with a relatively low prevalence; to a chronic disease with less sickness but higher prevalence as people with HIV survive.  There is probably much that we can learn from middle-income countries about how to provide less intense but equally effective services.
  3. Linked to the above is who and how to provide services - do we actually need highly trained doctors and nurses to do all of this?  Yes some people will require that level of expertise, but taking blood; monitoring blood counts.....could this be done in different ways?  One suggestion is to take the principles of the NICE Guidelines for the treatment of fever in children - devise a 'traffic-light' system of signs and symptoms that are associated with low, intermediate and high risk of serious disease.  This needs to be accompanied by high quality 'safety-net' advice but may allow patients to do more of their own monitoring.
  4. GRADE as a way of developing recommendations.  This is not the time or place to explain GRADE, apart from to say that GRADE stands for the Grading of Recommendations Assessment, Development and Evaluation, and is a way of grading the quality of evidence and strength of recommendations.  For anyone who is having difficulty getting to grips with GRADE this may help their understanding
  5. Which brings me back to the opening point.  Rather than assume as an advanced health system that we know everything; we should learn from how others do things, including countries with fewer resources, because necessity is, as they say, the mother of invention.  If I were to make one major criticism of the UK NHS it is this - sometimes money stifles innovation.

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