Who hiv 2012.26_eng

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Who hiv 2012.26_eng

  1. 1.       WHO/HIV/2012.26     Annex  5.  Decision  Tables     Question  1.   Should  an  accelerated  HBV  vaccination  regimen  versus  a  standard   HBV  vaccination  regimen  be  used  among  PWID?   Recommendation   Using  an  accelerated  HBV  vaccination  regimen  is  suggested  over   using  a  standard  HBV  vaccination  regimen  among  PWID   (Conditional  recommendation,  very  low  quality  evidence)   Key  considerations   - HBV  vaccine  is  already  strongly  recommended  for  PWID  as  per   WHO  guidelines.     - A  higher  dose  HBV  vaccine  should  be  used  with  the  rapid   regimen.     - The  priority  for  any  regimen  is  delivery  of  the  first  vaccine  dose.     - Completion  of  three  doses  is  more  important  than  following  a   specific  schedule.  The  implication  is  that  a  missed  dose  should   be  given  at  the  earliest  opportunity  without  re-­‐initiating  the   regimen.       - Individuals  with  inadequately  treated  HIV  or  with  chronic  HCV   may  have  a  suppressed  immunogenicity  and  may  benefit  more   from  the  standard  regime   Justification   - Evidence  suggests  benefits,  particularly  in  terms  of  vaccination   completion,  may  outweigh  potential  harms.  The   recommendation  is  conditional  given  the  very  low  quality   evidence  and  the  intervention  may  be  resource  intensive.   Implementation   considerations   - More  intensive  regimens  may  increase  workload  and  vaccine   stocks   - High  dose  regimens  require  increased  vaccine  stock   - Both  the  rapid  and  standard  regimens    should  be  offered  to   PWID.   Research  priorities   - RCTs  comparing  the  effectiveness  of  rapid  HBV  vaccine  versus   the  standard  HBV  vaccine  among  PWID     - RCT  comparing  the  effectiveness  of    high  dose  vaccine  to   standard  dose,  regardless  of  delivery  schedule.     - RCTs  comparing  the  effectiveness  of  new  adjuvant   vaccines  versus  the  standard  HBV  vaccine  among  PWID   - RCTs  comparing  intramuscular  versus  intradermal   administration  of  the  HBV  vaccine  among  PWID   - Immunogenicity  studies  of  rapid  and  standard  HBV   vaccination  regimens  among  PWID  co-­‐infected  with  HIV   and  HCV  
  2. 2.   2     Question  2.   Should  incentives  for  HBV  vaccination  completion  versus  no   incentives  be  used  among  PWID?   Recommendation   Offering  incentives  for  completion  of  the  HBV  vaccine  schedule  is   suggested   over   not   offering   incentives   to   PWID.   (Conditional   recommendation,  low  quality  evidence)   Key  considerations   - Vaccinations   should   be   provided   at   a   location   and   time   convenient  for  PWID   - This  recommendation  applies  to  settings  with  lower  vaccination   uptake   among   PWID   and   where   other   efforts   to   increase   vaccination  uptake  are  already  in  place.   - This   recommendation   is   conditional   on   local   acceptability   and   resource  availability   - An   inability   to   provide   incentives   should   not   bar   countries   or   settings  from  offering  HBV  vaccination  to  PWID.   Justification   - Evidence  suggests  benefits,  particularly  in  terms  of  vaccination   completion,  may  outweigh  potential  harms.  The   recommendation  is  conditional  given  the  very  low  to  low   quality  evidence  and  the  intervention  may  be  resource   intensive.   Implementation   considerations   - Vaccinations   should   be   provided   at   a   location   and   time   convenient  for  PWID   - Consider  financial  resources  required  for  provision  of  monetary   incentives..   - Feasibility  varies  dependent  on  setting   Research  priorities   - RCTs  comparing  the  effectiveness  of  providing  incentives   versus   not   providing   incentives   on   the   initiation/completion   of   HBV   vaccination   regimen   among   PWID   - Operational   research   on   the   preferences   of   PWID   and   service   providers   for   the   type   of   incentive   e.g.   cash,   voucher,  other.   - Cost   effectiveness   studies   of   incentives   in   local   settings,   especially  resource  limited  settings   - Study   of   whether   the   provision   of   cash   incentives   for   public   health   interventions   leads   to   decreased   rates   of   participation  in  subsequent  interventions        
  3. 3.   3   Question  3.   Should  low  dead  space-­‐syringes  versus  high  dead  space  syringes  be   provided  to  PWID?   Recommendation   Offering   low   dead   space   syringes   is   suggested   over   offering   high-­‐ dead-­‐space   syringes   to   PWID   at   needle   syringe   programs.   (Conditional  recommendation,  very  low  quality  evidence)   Key  considerations   - Syringe  programs  should  offer  all  types  of  syringes  appropriate   for  local  needs   - LDSS  are  produced  in  a  limited  number  of  sizes.  Larger  syringes   should  also  be  offered  if  appropriate  to  local  needs  regardless   of  dead  space  volume.   - Education   should   be   provided   to   PWID   on   why   LDSS   syringes   are  preferable.   Justification   - Evidence  suggests  benefits,  in  reduction  of  HCV  and  HIV   infection,  may  outweigh  potential  harms.  The  recommendation   is  conditional  given  the  very  low  quality  evidence.   Implementation   considerations   - Switching  from  HDSSs  to  LDSSs  may  incur  cost  differences.    In   general,  the  cost  of  LDSS  and  HDSS  is  the  same.   - LDSSs  are  only  available  in  a  limited  number  of  sizes  and  may   not  be  appropriate  for  all  PWID,  nor  all  drug  types.   Research  priorities   - RCTs  comparing  the  effectiveness  of  LDSS  versus  HDSS  in   decreasing   the   incidence   of   HIV,   HBV   and   HCV   infection   among  PWID   - Operational  research  on  acceptability  and  preferences  for   different   syringe   sizes   with   detachable   needles   among   PWID;   - Studies  modelling  potential  harms  if  preferred  equipment   is  not  available  (e.g.  potential  increases  in  re-­‐use  of  (own)   syringes,   receptive   syringe   sharing,   injecting   related   injuries  and  blood-­‐borne  infections);     - Observational  studies  assessing:   o Impact   of   changes   in   types   of   syringes   distributed   in   different  settings;   o Within   country   variations   in   types   of   equipment   distributed     o Types   of   equipment   distributed   in   high   and   low   HCV   incidence  locations        
  4. 4.   4   Question  4.   Should  psychosocial  interventions  versus  no  psychosocial   interventions  be  used  among  PWID?   Recommendation   Not  offering  psychosocial  interventions  is  suggested  over   offering  psychosocial  interventions  to  PWID,  when  the  goal  is   to  reduce  the  incidence  of  viral  hepatitis.     (Conditional  recommendation,  low  quality  evidence)   Key  considerations   - Psychosocial  interventions  should  not  be  precluded  as  part  of   comprehensive  interventions  with  goals  broader  than  reducing   the   incidence   of   viral   hepatitis.   However,   they   should   not   be   recommended  as  a  standalone  intervention.     - This   recommendation   does   not   address   peer   delivered   interventions   - Referral  to  psychosocial  pharmacotherapy  guidelines1   o PWID   should   be   offered   access   to   needle   and   syringe   programs     o PWID   should   be   offered   access   to   effective   substance   use  treatment  programs.     Justification   - There  is  lack  of  evidence  for  the  effectiveness  of  psychosocial   interventions  and  it’s  uncertain  whether  benefits  outweight   harms.  The  intervention  require  significan  human  and  other   resources.  The  quality  of  evidence  is  low   Implementation   considerations   - When  implemented,  psychosocial  interventions  need  to  be  part   of   a   comprehensive   approach   aiming   at   a   wider   range   of   behavioural   problems   as   recommended   by   the   psychosocial   pharmacotherapy  guidelines2   Research  priority   - RCTS  comparing  the  effects  of  psychosocial  interventions  versus   no  psychosocial  interventions  on  HCV,  HBV,  and  HIV  incidence,   and  on  quality  of  life  among  PWID.                                                                                                                                   1  WHO,  WHO  Guidelines  for  the  psychosocially  assisted  pharmacological  treatment  of  opioid   dependence.  Geneva,  WHO,  2009.   http://whqlibdoc.who.int/publications/2009/9789241547543_eng.pdf   2  WHO,  WHO  Guidelines  for  the  psychosocially  assisted  pharmacological  treatment  of  opioid   dependence.  Geneva,  WHO,  2009.   http://whqlibdoc.who.int/publications/2009/9789241547543_eng.pdf  
  5. 5.   5   Question  5.   Should  peer  based  interventions  versus  no  peer  based   interventions  be  used  among  PWID?   Recommendation   Offering  peer-­‐based  interventions  is  suggested  over  not   offering  peer-­‐based  interventions  to  PWID,  when  the  goal  is     to  reduce  the  incidence  of  viral  hepatitis.     (Conditional  recommendation,  low  quality  evidence)     Key  considerations   - Including  peers  is  an  important  component  of  service  delivery   to  PWID.     - Refer  to  related  WHO  recommendations3   Justification   - Evidence  suggests  benefits,  particulary  needle  sharing  behavior,   may  outweigh  potential  harms.  The  recommendation  is   conditional  given  the  low  quality  evidence.   Implementation   considerations   - Feasibility  depends  on  capacity  and  availability  of  human   resources,  will  vary  by  setting   Research  priorities   - RCTs   comparing   peer   based   interventions   to   other   prevention  interventions  (e.g.  opioid  substitution  therapy   and  needle  syringe  program  coverage)  on  HBV,  HCV  and   HIV  incidence  among  PWID   - RCTs  of  peer-­‐driven  interventions  in  multiple  settings   - Operational  research  in  resource  limited  settings                                                                                                                                     3  WHO,  Mental  Health  Gap  Action  Programme  (mhGAP)  intervention  guide  for  mental,  neurological   and  substance  abuse  disorders  in  non-­‐specialised  health  settings.  Geneva,  WHO,  2010.     http://whqlibdoc.who.int/publications/2010/9789241548069_eng.pdf  
  6. 6.   6   © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.      

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