Developing Comprehensive HIV/AIDS Standard Treatment Guidelines in a Resource-Poor Setting

1. 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 PolicyAdvisory Committee, University of Zimbabwe, Harare, Zimbabwe

3. 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.

4. 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 infected and affected by HIV/AIDS.

5. 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.

6. 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 • the basic guideline outline

7. 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:zimguideline@yahoogroups.com • Just a year after the first workshop, a second workshop was held to finalize the draft recommendations

8. 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 document to the overall Coordinator.

9. 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.

10. 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.

11. 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 guidelines.

12. 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