Excellent healthcare locally delivered OVERVIEW OF CLINICAL
RECOMMENDATIONS FOR ADULTS, PREGNANT WOMEN AND CHILDREN OVERVIEW OF
CLINICAL RECOMMENDATIONS FOR ADULTS, PREGNANT WOMEN AND CHILDREN
Dr. Philippa Easterbrook 2013 Consolidated ARV Guidelines Dr.
Philippa Easterbrook
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30 th June 2013
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Guideline Dissemination Regional Guidelines Workshops
MonthEventDatesLocation JulyStrategic Use of
ARVs23-25/07/2013Yogyakarta, Indonesia JulyAFRO East and Southern
Africa 23-25/07/2013Pretoria, South Africa AugustPPTCT Asia
Regional PMTCT meeting 27-29/08/2013Kathmandu, Nepal AugustPAHO
Regional26-28/08/2013Buenos Aires, Argentina SeptemberEMRO
Regional11-13/09/2013Casablanca, Morocco SeptemberWPRO/SEARO
Consultation16-18/09/2013Beijing, China
OctoberEURO29-31/10/2013Istanbul, Turkey NovemberAFRO East and
Central Africa 11-13/11/2013Accra, Ghana
DecemberICASA7-11/12/2013Cape Town, South Africa
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Objectives of presentation WHO guidelines development and key
features Recommendations for Adults, pregnant women and children
and Overview of Evidence Base and Rationale: When to Start ART What
ART to Start (First-Line) What ART to Switch to (Second-Line) How
to Monitor ART
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30 th June 2013 Find the New 2013 WHO Consolidated ARV
Guidelines on
http://www.who.int/hiv/pub/guidelines/arv2013/en/index.html
http://www.who.int/hiv/pub/guidelines/arv2013/en/index.html
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TOPIC2002200320062010 WHEN TO START CD4 200 - Consider 350 -
CD4 350 for TB CD4 350 -Irrespective CD4 for TB & HBV
PMTCTSince 2001 4 weeks AZT; AZT+ 3TC, or single dose NVP 2004 AZT
from 28 weeks + single dose NVP AZT from 28 weeks + single dose NVP
+AZT/3TC 7days Option A (AZT +infant NVP) Option B (triple ARVs) 1
ST LINE8 options - AZT preferred 4 options - AZT preferred 8
options - AZT or TDF preferred - d4T dose reduction 6 options &
FDCs - AZT or TDF preferred - d4T phase out 2 ND LINEBoosted PI
ATV/r, DRV/r, FPV/r LPV/r, SQV/r Boosted PI Heat stable FDC: LPV/r,
ATV/r VIRAL LOAD TESTING No (Desirable) Yes Tertiary centers Yes
Phase in Evolution of WHO ART Guidelines Vitoria M et al, Curr Opin
HIV/AIDS 2013 Earlier initiation Simpler treatment Less toxic, more
robust regimens Better monitoring Simplified treatment options for
pregnant women
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Guidance for Programme Managers HOW TO DO IT? Service delivery
Diagnostics Drug supply HOW TO DO IT? Service delivery Diagnostics
Drug supply HOW TO DECIDE? Prioritization Equity and ethics
Monitoring & Evaluation HOW TO DECIDE? Prioritization Equity
and ethics Monitoring & Evaluation WHAT TO DO? When to start or
switch Which regimen to use How to monitor Co-infections &
co-morbidities WHAT TO DO? When to start or switch Which regimen to
use How to monitor Co-infections & co-morbidities Operational
WHO 2013 Consolidated ARV Guidelines
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Concept Behind Consolidation Consolidation of new with existing
guidance Consolidation across populations and ages Consolidation
along the continuum of care
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Scoping the document Disclosure and management of secondary
interests Formulation of the recommendations (GRADE) Including
explicit consideration of: Benefits and harms Values and
preferences Resource use Including explicit consideration of:
Benefits and harms Values and preferences Resource use
Dissemination, implementation (adaptation) Dissemination,
implementation (adaptation) Evaluation of impact Plan for updating
1 7 8 9 Formulation of the questions (PICO) and choice of the
relevant outcomes Formulation of the questions (PICO) and choice of
the relevant outcomes Evidence retrieval, assessment and synthesis
(systematic review(s)) Evidence retrieval, assessment and synthesis
(systematic review(s)) GRADE - evidence profile(s) 3 4 5 WHO
Guideline Development PICO: requires specifics of Population,
Intervention, Comparator & Outcomes 6 Setting up Guideline
Development Group and External Review Group 2
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Scoping the document Disclosure and management of secondary
interests Formulation of the recommendations (GRADE) Including
explicit consideration of: Benefits and harms Values and
preferences Resource use Including explicit consideration of:
Benefits and harms Values and preferences Resource use
Dissemination, implementation (adaptation) Dissemination,
implementation (adaptation) Evaluation of impact Plan for updating
1 7 8 9 Setting up Guideline Development Group and External Review
Group 2 3 Guideline Development at WHO PICO: requires specifics of
Population, Intervention, Comparator & Outcomes 6 Formulation
of the questions (PICO) and choice of the relevant outcomes
Formulation of the questions (PICO) and choice of the relevant
outcomes 4 Evidence retrieval, assessment and synthesis (systematic
review(s)) Evidence retrieval, assessment and synthesis (systematic
review(s)) GRADE - evidence profile(s) 5
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G rades of R ecommendation A ssessment, D evelopment and E
valuation
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Scoping the document Disclosure and management of secondary
interests Dissemination, implementation (adaptation) Dissemination,
implementation (adaptation) Evaluation of impact Plan for updating
1 7 8 9 Setting up Guideline Development Group and External Review
Group Formulation of the questions (PICO) and choice of the
relevant outcomes Formulation of the questions (PICO) and choice of
the relevant outcomes Evidence retrieval, assessment and synthesis
(systematic review(s)) Evidence retrieval, assessment and synthesis
(systematic review(s)) GRADE - evidence profile(s) 2 3 4 5
Guideline development at WHO PICO: requires specifics of
Population, Intervention, Comparator & Outcomes Formulation of
the recommendations (GRADE) Including explicit consideration of:
Benefits and harms Values and preferences Resource use Including
explicit consideration of: Benefits and harms Values and
preferences Resource use 6
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Modelling of impact and cost-effectiveness Earlier ART and
different testing strategies Different populations General
population Serodiscordant couples Pregnant women IDUs, sex workers
and MSMs HIV-HBV and HCV Different settings Generalised (South
Africa, Zambia) Concentrated (Vietnam, India)
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Values and Preferences 87 participants Malawi and Uganda Adult
(n=98) & Paediatric (n=342): 9 Global implementers (ANEPA,
ANECA, CHAI, CDC, EGPAF, ICAP, IeDEA, MSF, PATH) Health care worker
consultation Community consultation Option B+ Focus Groups E-survey
(n=1088), E-forums (n=955) 6 UN languages E-survey: 21% LIC, 58%
MIC; 45% PLHIV; Topics Earlier ARV initiation Lifelong ART in
pregnant women Task-shifting and integrated services Role of
communities