HIV This Week

Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet 2007 Jun 2;369(9576):1883-9.

WHO regulations, dating back to 1951, emphasise the role of expert opinion in the development of recommendations. However, the organisation’s guidelines, approved in 2003, emphasise the use of systematic reviews for evidence of effects, processes that allow for the explicit incorporation of other types of information (including values), and evidence-informed dissemination and implementation strategies. Oxman and colleagues examined the use of evidence, particularly evidence of effects, in recommendations developed by WHO departments. The authors interviewed department directors (or their delegates) at WHO headquarters in Geneva, Switzerland, and reviewed a sample of the recommendation-containing reports that were discussed in the interviews (as well as related background documentation). Two individuals independently analysed the interviews and reviewed key features of the reports and background documentation. The authors found that systematic reviews and concise summaries of findings are rarely used for developing recommendations. Instead, processes usually rely heavily on experts in a particular specialty, rather than representatives of those who will have to live with the recommendations or on experts in particular methodological areas. The authors interpreted in this that progress in the development, adaptation, dissemination, and implementation of recommendations for member states will need leadership, the resources necessary for WHO to undertake these processes in a transparent and defensible way, and close attention to the current and emerging research literature related to these processes.

Editors’ note: This article received a lot of attention in public health circles. Although there are often difficulties in trying to obtain international consensus, it is clear that guidelines from normative agencies such as WHO need to be adapted by countries to their own epidemiological circumstances. For the record, the recommendations from the WHO/UNAIDS convened consultation on male circumcision and HIV in March 2007 were definitely anchored in the results of the three randomised controlled trials in Orange Farm, South Africa; Kisumu, Kenya; and Rakai District, Uganda but other evidence and information also came into play and influenced the recommendations (please see the UNAIDS website or WHO website).