Elie A. Akl, MD, MPH, PhD, assistant professor of medicine, family medicine and social and preventive medicine at the University at Buffalo School of Medicine and Biomedical Sciences and School of Public Health and Health Professions, was the guideline methodologist for the high-profile guidelines that were issued in June.
The “Global Guidance on Prevention and Treatment of HIV and other STI Among MSM and other Transgender People,” (available at http://www.who.int/hiv/pub/guidelines/msm_guidelines2011/en/index.html) was developed in response to concerns raised by public health organizations and grassroots groups all over the world that the rate of HIV/AIDS among MSM and transgender people recently has started to rise again.
The purpose was to develop clinical practice guidelines to help public health agencies around the world in general, and especially in low- and middle-income countries, in establishing programs for HIV treatment and prevention.
Akl’s role in the process as the guideline methodologist involved applying the GRADE (Grading of Recommendations Assessment Development and Evaluation) approach to the WHO guidelines. The GRADE methodology is increasingly being adopted by national and international organizations, including WHO. Akl is a member of the GRADE working group.
“The GRADE approach starts by defining the questions important to the guideline users,” explains Akl. “It conducts systematic reviews of the literature to evaluate the scientific evidence for those questions and then develops the recommendations, taking into account the values and preferences. “My role was to make sure that the recommendations are based on the best available scientific and medical evidence, while taking into account the values and preferences of the target population.”
Akl is an expert in evidence-based medicine, in which the best available evidence from peer-reviewed scientific data is applied to the clinical care of patients. While WHO guidelines used to be developed based primarily on the opinion of experts in the field, the organization’s guidelines are now being developed according to the standards of evidence-based medicine.
The guidelines panel included members of the global MSM and transgender community. Their participation was essential to the project, Akl adds.
“We also conducted a civil society consultation, where we asked these members of the MSM and transgender communities about their values and preferences in relation to different interventions being considered,” says Akl.
One of the strongest recommendations in the WHO guidelines was that MSM and transgender people use condoms consistently during anal intercourse, to reinforce a behavior that is increasingly being abandoned as a result of what public health experts term ‘safe behavior fatigue’ or ‘condom fatigue.’
“However, while there is some evidence in the literature that circumcision may prevent HIV transmission, the guidelines suggest against circumcision because in certain countries, where same-gender sexual activity is criminalized, a campaign advocating circumcision for MSM might further stigmatize these communities. Also, the civil society consultation found very low acceptance of this intervention.”
The executive summary of the guidelines notes that more than 75 countries currently criminalize same-gender sexual activities; it also points out that in most countries in the world, transgender people lack legal recognition, which forces them to risk criminal sanctions if they reveal their sexual risks to a healthcare provider.
While the WHO guidelines cannot force countries to change the way they provide health care, Akl says that global funding agencies, such as the World Bank or PEPFAR (U.S. President’s Emergency Plan for AIDS Relief) , can make their funding contingent on the adoption of the WHO guidelines.
Akl also is involved as guideline methodologist in other WHO efforts, some of which are funded by PEPFAR, on scaling up transformative medical and nursing education in the developing world, on retention of health workers in underserved and rural areas and on the first global guidelines for HIV/AIDS treatment and prevention among sex workers, which will be issued in the next several months.
The University at Buffalo is a premier research-intensive public university, a flagship institution in the State University of New York system that is its largest and most comprehensive campus. UB’s more than 28,000 students pursue their academic interests through more than 300 undergraduate, graduate and professional degree programs. Founded in 1846, the University at Buffalo is a member of the Association of American Universities.