WHO's 2010 Recommendations for HIV Treatment: National Guideline Revision Challenges and Lessons Learned

The World Health Organization (WHO) released revised recommendations for adult and adolescent HIV treatment in 2010. The aim of this technical brief from the United States Agency for International Development (USAID)'s AIDSTAR-One (AIDS Support and Technical Assistance Resources, Sector 1, Task Order 1) is to provide HIV policymakers and programme managers with a point of reference as they adapt and implement revised national HIV treatment guidelines. Approaches that worked well, challenges, and lessons learned from three regions of the world - sub-Saharan Africa (South Africa, Tanzania, Zambia, Zimbabwe), Latin America (Guyana, Honduras, and Nicaragua), and Southeast Asia (Cambodia) - are highlighted.

The key messages that emerged from the WHO recommendations are: earlier initiation of antiretrovial therapy (ART), the use of less toxic treatment regimens, and an expanded role for laboratory monitoring, including both cluster of differentiation 4 (CD4) testing and viral load (VL) monitoring. "Although the scientific evidence in support of these recommendations is compelling, national programs in resource-limited settings throughout the world are encountering challenges with their adoption and implementation."

WHO recommends that countries work through a 12-step process for revision of their national treatment guidelines, as described in Table 3 on page 4 of the technical brief. Several approaches helped to expedite and improve the revision process in Tanzania, South Africa, Honduras, and Zambia. These strategies include streamlining the revision process, partial adoption of earlier ART initiation, ensuring strong government leadership of the process, and forecasting and resource mobilisation. For example, in Honduras, "[t]he National AIDS Programme moderated an active, multi-stakeholder process of assessing the feasibility of the new WHO recommendations in the Honduran context. It was an open process of dialogue that included key international partner organizations such as the Pan American Health Organization and WHO, civil society, and PLHIV [people living with HIV]."

Once countries have completed the guideline revision process, the implementation phase is next. Zambia, Guyana, and South Africa provide examples of some successful approaches to addressing challenges presented by implementation of the 2010 WHO recommendations. These approaches include rolling out national training of trainers workshops, mentoring social workers to address patient concerns, and implementing various task-shifting strategies. For example, in Zambia at the end of 2010, the guideline revision committee developed an orientation package highlighting the changes made from previous guidelines. A one- to two-day training of trainers workshop was planned with partner organisations and the Ministry of Health (MOH). Each district has an identified trainer/mentor who will be trained to lead the training workshop in their district for health care workers.

After implementation challenges are outlined, the technical brief offers several recommendations. Examples of communication-related recommendations include:

• "Include an appropriate mix of stakeholders: National health leaders should invite an appropriate mix of stakeholders to participate in the guideline revision process. It should be a forum for collaborative partnership between local and international agencies, including representatives from the government; multilateral, bilateral, and nongovernmental partner organizations; civil society; PLHIV groups; and the private sector. Technical expertise should be drawn from a mix of policymakers, program managers, implementers, clinical personnel, supply chain managers, and costing experts. Early in the revision process, efforts should be made to foster a spirit of inclusion, transparency, and technical expertise."
• "Support health care workers through rapid, standardized in-service training and mentoring: Health care workers must be trained not only to deliver high-quality services according to new treatment guidelines, but also to manage patient concerns associated with changes in drug regimens and dosing. Training workshops should be rolled out nationally immediately following government endorsement of revised treatment guidelines....Standing implementer meetings or a similar mechanism should be established for feedback, questions, and concerns from the health care workers at the facilities to policymakers and program managers at the national level. Plans for on-the-job mentoring of health care workers during the early stages of the implementation phase should be made where possible."
• "Educate patients and the community: Patients need counseling to increase their understanding of the benefits associated with newer, more patient-friendly drug regimens....Communication with patients and the community can be achieved through targeted media messaging using printed literature, public television, and radio broadcasts, as well as through existing community structures, such as patient support groups. Media campaigns should engage and include messages from traditional and religious leaders, civil society, and PLHIV, and should reach the broadest audience possible."

The brief concludes with links to key resources for countries revising guidelines and implementing revisions.