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• W619494051 abstract "To the Editors: We are pleased to see the shift to evidence-based HIV care and support programming reported by President's Emergency Plan for AIDS Relief.1 Given the magnitude of the epidemic, and the large financial investment by the US Government, the appraisal of available evidence for key interventions is intended to inform decision making and prioritization of finite resources. Such careful evidence-based approaches should be encouraged. The intention of these evidence reviews is that country teams should use the conclusions to inform local prioritization of care and support interventions. Given the importance of the conclusions drawn, we raise a number of methodological issues and reflections on underpinning assumptions. First, the methodological design of the evidence reviews is not stated. Given the intention of the reviews, we would anticipate that a systematic review would be the preferred design. However, this is not stated nor are any of the robust systematic reviews reporting systems (such as Preferred Reporting Items for Systematic Reviews and Meta-Analyses2) provided to ensure transparency of methods, retrieval, and findings. Second, a number of assumptions are made. These include prioritizing but not reporting an intervention because there is an “abundance of information” and “its recognized importance” (ie, tuberculosis screening and treatment). It is not clear how the relative importance and data volumes were appraised with respect to other biomedical interventions reported, such as prevention of cryptococcal meningitis and isoniazid prevention therapy. Third, the lack of transparency of search strategies means the searches are not reproducible. Instead, the lead article outlines “base” and “simple” strategies followed by “more complex” strategies using “variations” of terms. The search descriptions within the individual review reports also lack specificity. Fourth, for retrieval of citations, the inclusion and exclusion criteria lack specificity, rather using terminology that they were included if they “seemed to address the intervention of interest.” Fifth, retained studies were (importantly) subjected to quality assessment using criteria including undefined “quality” of the randomized controlled trial, giving a grade classification could be “modified by other factors such as number of study participants and assessment of internal and external validity.” It is unclear how these criteria were applied across raters. These ratings were then applied to an overall rating of “expected impact” as either high, moderate, low, or uncertain. Again the specific criteria and how reliable this would be between raters are unclear. An example of the complexity of this type of rating approach is exemplified in the review of social services,3 which identified 7 studies that measured quality of life as an outcome, of these “there were significant methodological issues in almost all studies” yet the expected impact is classified as “high.” This highlights the challenges of drawing conclusions in the absence of a substantial body of high-quality evidence. This challenge is also noted in the review of screening and treatment for cervical dysplasia, which concluded that “The major limitation of this review was the paucity of data.” This is likely a finding and a caveat on conclusions drawn, rather than a limitation of the review. Finally, we agree with the authors when they make the important recommendation that Country Teams make planning decisions in light of local epidemiology and health systems. This raises several issues. The review does not take account of need, only of evidence to meet presumed need. Some further assumptions are made in splitting intervention into “critical needs” to be universally provided in all settings, and “contextual” (optional) ones. This division should be more transparent and does not seem to have taken into account President's Emergency Plan for AIDS Relief care and support self-report data (for example) that demonstrated high burden of psychosocial problems4 from diagnosis,5 and the health systems challenges of delivering “Universal” interventions such as laboratory monitoring in President's Emergency Plan for AIDS Relief sites.6 The challenge with the selection (without any clear justification) of laboratory monitoring (which was excluded from this series of reviews but then included as a required “Universal” intervention), tuberculosis screening, cotrimoxazole prophylaxis, and interventions to optimize retention is that they do not address the key challenge of ensuring that services offer holistic care (ie, what patients prioritize and identify as needing) so that people living with HIV wish to attend and remain in care. There is a large body of evidence on the high prevalence and debilitating nature of pain and other symptoms, poor drug availability, depression, mental health burden, and stigma7–117–117–117–117–11 and a growing evidence base on the benefits of social protection12,1312,13 that should place them centrally in packages of integrated care and support. We agree with the conclusion that interventions should be selected because they are “critical to saving lives.” A number of interventions were identified as being “universal” (despite not being reviewed or lacking a clear justification for being elevated to “universal intervention”). We suggest that psychosocial interventions are also required to save lives, enhance biomedical as well as psychosocial outcomes, and to ensure that recipients feel that they have a life that is valued and “worth living.” True integrated care and support is required." @default.
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• W619494051 date "2015-12-15" @default.
• W619494051 modified "2023-09-27" @default.
• W619494051 title "Evidence-Based Programming of HIV Care and Support" @default.
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