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A number of factors explain why WHO guideline developers make strong recommendations inconsistent with GRADE guidance.
Journal of Clinical Epidemiology. 2016; 70:111-122.Objective: Many strong recommendations issued by the World Health Organization (WHO) are based on low- or very low-quality (low certainty) evidence (discordant recommendations). Many such discordant recommendations are inconsistent with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance. We sought to understand why WHO makes discordant recommendations inconsistent with GRADE guidance. Study Design and Setting: We interviewed panel members involved in guidelines approved by WHO (2007e2012) that included discordant recommendations. Interviews, recorded and transcribed, focused on use of GRADE including the reasoning underlying, and factors contributing to, discordant recommendations. Results: Four themes emerged: strengths of GRADE, challenges and barriers to GRADE, strategies to improve GRADE application, and explanations for discordant recommendations. Reasons for discordant recommendations included skepticism about the value of making conditional recommendations; political considerations; high certainty in benefits (sometimes warranted, sometimes not) despite assessing evidence as low certainty; and concerns that conditional recommendations will be ignored. Conclusion: WHO panelists make discordant recommendations inconsistent with GRADE guidance for reasons that include limitations in their understanding of GRADE. Ensuring optimal application of GRADE at WHO and elsewhere likely requires selecting panelists who have a commitment to GRADE principles, additional training of panelists, and formal processes to maximize adherence to GRADE principles. Copyright: 2016 Elsevier Inc.
Lancet Infectious Diseases. 2008 Feb; 8(2):98-100.Kevin De Cock is director of WHO's HIV/AIDS department. Formerly director of the US Centers for Disease Control and Prevention in Kenya, he is an infectious disease specialist, with expertise in HIV/ AIDS, tuberculosis, liver disease, and tropical diseases such as yellow fever and viral haemorrhagic fevers. TLID: How has your time as WHO's HIV/AIDS director been? KDC: It has been extremely interesting. AIDS policy is always challenging and changing. WHO's HIV efforts up to 2005 were very much oriented around the 3 by 5 initiative. The G8 in 2005 made an announcement about working towards universal access, which became an AIDS rallying cry. So we've had to reorganise ourselves around that as a theme. Some internal reorganisation was necessary to focus not only on treatment, but also on broader issues. We now have five key strategic directions: increasing access to HIV testing and counselling, maximising prevention, accelerating treatment scale-up, strengthening health systems, and investing in strategic information. We have also been working on some important technical areas. One is the issuing of guidance on both provider-initiated testing and male circumcision. In April, 2007, we also issued a report, in response to a request from the World Health Assembly, on the health sector's progress towards universal access. (excerpt)
Geneva, Switzerland, World Health Organization [WHO], Communicable Diseases Programme, Stop TB Department, 2001. 39 p. (WHO/CDS/TB/2001.294)Conclusion and Recommendations: This analysis suggests that TB and HIV/AIDS programmes will need to collaborate to deliver a more effective response to TB/HIV. Consideration of the barriers to, and mechanisms to promote, future collaboration between TB and HIV/AIDS programmes give rise to the following recommendations on how WHO might promote more effective TB control among HIV-infected people: 1) At the international level, promote TB and HIV/AIDS programme collaboration through: a) development and wide dissemination of a strategic framework to decrease the burden of TB/HIV; b) clarification of the roles and responsibilities of, and linkages between, UNAIDS and WHO; c) increased political commitment to TB control among HIV-infected people through increased resources, financial and human; d) promotion of the interdependence of TB and HIV at the highest levels in WHO through administrative links and broad representation by TB and HIV leadership at each other’s meetings. 2) At the national and district level, promote TB and HIV/AIDS programme collaboration through: in-country high level political commitment; b) joint planning meetings; c) involvement of HIV and TB community groups on national interagency coordination committees; d) joint training of programme and general health service staff in the issues common to HIV and TB prevention and care; e) joint TB and HIV/AIDS programme reviews; f) utilisation of existing organisational structures and the sharing of experience; g) a strengthened referral system; h) implementation of care packages in high HIV prevalence populations, including TB prevention and care (such as those piloted in the ProTEST Initiative); i) formulation of joint health education messages. 3) Increase financial and technical assistance to TB and HIV programmes through: a) co-ordinated support from WHO HIV and TB programmes (at country, regional and HQ level); b) joint advocacy with UNAIDS and other international partners for greater international and national commitment to TB control among HIV-infected people; c) dialogue with international development assistance agencies and global financing institutions on funding joint TB and HIV programme collaborative activities. (excerpt)