Bridging the gap between researchers and policy makers: GRIPP in Nigeria
GRIPP– Herpes Simplex Virus Type- 2 Treatment and HIV Infection: International Guidelines...
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![Page 1: GRIPP– Herpes Simplex Virus Type- 2 Treatment and HIV Infection: International Guidelines Formulation and the Case of Ghana Burris H 1, Adu-Sarkodie Y.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649cda5503460f949a4c36/html5/thumbnails/1.jpg)
GRIPP– Herpes Simplex Virus Type-2 Treatment and HIV Infection:
International Guidelines Formulation and the Case of Ghana
Burris H1, Adu-Sarkodie Y2, Parkhurst J1, Baafuor KO2, Mayaud P1
1 London School of Hygiene & Tropical Medicine, London, UK
2 Kwame Nkrumah University of Sciences & Technology, Kumasi, Ghana
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Study Aim & Design
• To evaluate the process of incorporating evidence from international or national research into international or national policies/guidelines
• Case study: – incorporating management of Herpes simplex virus (HSV)
into genital ulcer disease (GUD) guidelines;– International level: WHO– National level: Ghana
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International level
National level
Policy
Policy
Practice
Research(multicentre trials, modelling,
CE, reviews, meta-analysis)
GRIPP: from an RPC perspective…
C
C
C C
Communication
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International level
National level
Policy
Policy
Practice
GRIPP: from an RPC perspective…
C
Research(trials, observational, CE)
Research (operational, health systems)
C
C
C
Communication
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Background: GUD & HSV
• GUD proven cofactor of HIV acquisition or transmission (Cameron 1989; Hayes 1995; Gray 2001)
• GUD aetiologies include syphilis, chancroid and herpes simplex virus (HSV)– Relative prevalence has changed over time, with HSV now
dominant aetiology (>40%) (Mayaud 2004)
• Syndromic approach to GUD management promoted by WHO: 1994 vs. 2003
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1994 WHO GUD algorithmPatients complaining
of ulcers
Treat for syphilis and chancroid.
No treatment.Sore or ulcer present?
YES
NO
• Only treats for TP and HD
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Courtesy: D. Mabey
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2003 WHO GUD algorithm• Treats for HSV-2 if ulcer has sign or symptom for
HSV-2 (first arm)• Otherwise treat for TP or HD (second arm)• Includes prevalence threshold for treating
everyone for HSV-2 in second arm
Patients complaining of ulcers
Treat for HSV-2.Treat for syphilis and chancroid. Treat for
HSV-2 if above prevalence threshold?
No treatment.Sign or symptom
for HSV-2 ?Sore or ulcer
present?
YES YES
NONO
First arm of algorithm Second arm of algorithm
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Herpes treatment often not provided because:• Self-limited disease (in HIV negatives)
• Perceived to be ineffective (1-2 days gain in healing rates)
• Does not prevent recurrences (unless provided daily)
• Expensive (US$0.5 per day, but generics could be as cheap as US$0.07)
• Access/availability (private sector, HIV clinics)
• Lack of awareness (among planners, clinicians, patients, community…)
• Lack of epidemiological data (GUD aetiology, seroprevalence)
• Complicated algorithm?
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HSV-HIV and International Policy Context
• HSV-HIV synergies++ • WHO Consultation on HSV Research (London, 2001)
• HSV-HIV trials (2002-09) (ANRS, CDC, Gates, NIH, WT)– Strategies: episodic (5d) vs. suppressive (daily) therapy– Populations: HIV+ and HIV-, men/women, Asia/SSA/LAC/US– Outcomes: HIV acquisition (in HIV-), HIV infectivity (genital shedding in HIV+), HIV
transmission (serodiscordant couples), HIV disease progression
• Global Strategy for the Prevention and Control of STI (2006-15) adopted at WHA (Geneva, June 2006)
• Formation of International HSV-HIV Collaborative group (London, October 2007)
• Acyclovir Access study planned with WHO (2007-08)• Revision of WHO GUD management guidelines + international HIV-HSV
meeting (Montreux, April 2008)
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Ghana• GUD management policy in Ghana
– Based on WHO; last revision guidelines 2000
• ANRS1212 HSV-HIV trial (2002-2006): Ghana+CAR– Multicentre RCT of acyclovir (400mg x3 for 5d) in addition to synd. mx. for
GUD episodes among women– Results:
• 50% of GUD caused by HSV-2; 50% of patients HIV+• small impact of acyclovir on ulcer healing, no impact on HIV genital shedding or
plasma viral load• Impact on healing in subgroups: HIV+ with low CD4, primary herpes
– Dissemination/Communication: • national w’shops in 2002 and 2006 (preceded by w’shop on interpretation of results
with WHO STI and WHO Afro staff… but little “national” representation!)
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Communication with national stakeholdersworkshops, participation of national (+international) stakeholders, researchers, police & army, NGOs, etc, media, press release, RPC newsletter, editorials, ….publications)
C
Daily Graphics, February 2002
“Black Stars To Receive Heroes’ Return”
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Study Methods(1) In-depths interviews in Montreux (n=11)
• Researchers, programme managers, WHO staff
(2) In-depths interviews in Ghana (n=8)• High-level sexual health government officials, policy-
makers, leaders in HIV and reproductive health non-profit community, prominent researchers, practitioners
MSc student with supervision of two LSHTM staff; accompanied by senior researcher in Ghana for stakeholders interviews
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Theoretical frameworks I(1) Evidence into Policy• Linear/rationalist model: change as problem-solving• Enlightenment model: change requires an accumulation of
information (Weiss C, 1977)
• The “two-worlds” model: need “bridging the gap”• RAPID Study: context, evidence, links, external influences
(ODI)
(2) International to National Policy Transfer• “Looped” and “incremental” policy transfer (Cliff et al. 2004)
• HIV/AIDS as a policy window (Lush L, et al. 2003)
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Theoretical frameworks II
(3) Research to National Policy Development• Champions of the cause• Policy change follows practice (Meheus and syndromic
management)
(4) Accounting for context• Health policy triangle: accounting for a complexity of factors
(Walt G & Gilson L, 1994)
• Agenda setting: drivers of change (ODI)
• “Three streams” model: creating a window of opportunity
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Findings: international level
Conscious attempt to incorporate evidence into guidelines: high-level quality research from multitude of formats (RCT, meta-analysis, biological experiments, health economics, modelling, policy); consensus building; grading of the evidence; commissioning of further research
Despite inconclusive evidence, changes in guidelines were recommended: HSV treatment incorporated, and highlighted further research required
Importance of “Intellectual Clubs” to get research onto agenda, then into guidelines
Some disconnect between researchers and programmatic staff (“two worlds”)
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Findings: national levelMechanisms of GRIPP in Ghana:• Response to donor pressure (influenced by international research and
WHO/International guidelines)
• Need a local “Champion” (at MOH/Govt level)
• Importance of “intellectual clubs” (communities of researchers, practitioners and Govt. officials)
• “Policy will follow practice”
Commissioning ResearchHSV trial perceived as too international, no real local scientific
ownership/champion Turnover of programme staff: discontinuity, lack of ownershipMore locally-relevant research would be operational in nature
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Summary
Changes in international GUD guidelines best explained by the ‘Enlightenment framework’
HIV-HSV synergies provided the policy window
Epistemic communities (Haas E, 1990) appear to be a primary internal driver of change in Ghana
Donors are a considerable force shaping national research agenda and set national priorities in Ghana
Importance of WHO Guidelines, particularly as they may tie in into funding/aid
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International level
National level
Policy
Policy
Practice
GRIPP: from an RPC perspective…
C
Research(trials, observational, CE)
Research (operational, health systems)
C
C
C
DONORS
Communication
C C
Research(multicentre trials, modelling,
CE, reviews, meta-analysis)
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Lessons learnt for RPCInternational level: • importance of high quality and multiple forms of evidence• thematic coalitions with international researchers,
WHO/UNAIDS, DFID and others (eg HSV, HPV, POC, microb.) • being responsive to needs or emerging agendas (eg MC) • exploit windows of opportunityNational level: • successful engagement for GRIPP in other contexts for HSV-
HIV (South Africa, Malawi)• development of the maternal/congenital syphilis research
agenda (Ghana)Communication: • investment in multiple formats and channels of communication,
reinforcing the same/incremental messages to different audiences