Academic journal article Bulletin of the World Health Organization

Translating Evidence into Policy in Low-Income Countries: Lessons from Co-Trimoxazole Preventive therapy/Traduire Les Preuves En Politique Dans Les Pays a Faible Revenu: Lecons Tirees De la Therapie Preventive Au cotrimoxazole/Conversion De Datos En Planes De Accion En Los Paises De Ingresos Bajos: El Tratamiento Preventivo Con la Asociacion De Trimetroprim

Academic journal article Bulletin of the World Health Organization

Translating Evidence into Policy in Low-Income Countries: Lessons from Co-Trimoxazole Preventive therapy/Traduire Les Preuves En Politique Dans Les Pays a Faible Revenu: Lecons Tirees De la Therapie Preventive Au cotrimoxazole/Conversion De Datos En Planes De Accion En Los Paises De Ingresos Bajos: El Tratamiento Preventivo Con la Asociacion De Trimetroprim

Article excerpt

Introduction

In recent years, three separate papers in leading medical journals have raised the question of why co-trimoxazole prophylaxis for opportunistic infections in patients living with the human immunodeficiency virus (HIV) has not been more widely scaled up in low-income countries. Published in The Lancet Infectious Diseases, (1) the BMJ (2) and the Bulletin of the World Health Organization, (3) these papers have all expressed the authors' frustration at knowing that an intervention known to be highly efficacious, cost-effective, amply researched and urgently needed has not become widely available, especially in Africa. In the most recent article, Date et al. combined analyses of the development of policy on co-trimoxazole prophylaxis and on isoniazid preventive therapy to raise concerns about the uptake of both interventions. While operationally the need to rule out active disease before initiating treatment creates problems that make isoniazid preventive therapy especially challenging, Date et al. highlight similarities in the frustration generated by the slow scale-up of both co-trimoxazole prophylaxis and isoniazid preventive therapy. They point out that at the national level both the development of co-trimoxazole prophylaxis and the development and implementation of policy on isoniazid preventive therapy have been sluggish, and they argue that "strong advocacy and dissemination of evidence-based information regarding the benefits of co-trimoxazole prophylaxis and isoniazid preventive therapy are urgently required at the national and international level".

Several efforts have been made internationally to improve the way in which research evidence is conveyed to health policy makers and to advocate for the bridging of the gap between evidence and policy. The Evidence Informed Policy Network, launched by the World Health Organization (WHO), is an example of an entity whose purpose is to promote these functions (www.who.int/rpc/evipnet/en/). However, advocacy and dissemination can only go so far in influencing policy change and implementation in practice. As Date et al. explain, evidence-based data on the benefits of both co-trimoxazole prophylaxis and isoniazid preventive therapy has not been lacking internationally. The findings from the first studies conducted on cotrimoxazole prophylaxis were published in the Lancet as early as 19994 (4,5) and subsequent studies showed that co-trimoxazole prophylaxis was beneficial in adults and children in areas of high resistance to co-trimoxazole (6-8), as well as in adults on antiretroviral therapy (ART). (9) Research on the efficacy of isoniazid preventive therapy began even earlier and has already been the subject of three Cochrane reviews, (10-12) Beyond these research findings, the Joint United Nations Programme on HIV/AIDS, WHO and the United Nations Children's Fund have all issued guidelines on the use of co-trimoxazole prophylaxis on three different occasions, (13-15) while isoniazid preventive therapy was the subject of WHO recommendations first published in 1998 and later reaffirmed by the Stop TB partnership in 2007 and 2011. (16-18)

In these examples, research findings were available and in many cases had been clearly disseminated or advocated for by the research and international public health communities. Those who feel frustrated by the lack of uptake of research results and the apparent stalling of policy development must understand the need to move beyond the assumption that the epidemiological and cost-effectiveness data that are available, once communicated, will be automatically integrated into policy. Broader analyses are needed to support researchers as they seek to get clinically effective interventions into place. Such analyses require established methods and frameworks from the field of policy analysis to improve the understanding of the process of health policy development in a given national and international context. …

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