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
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
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
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
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
