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Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach: 2010 Revision. Geneva: World Health Organization; 2010.

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Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach: 2010 Revision.

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Recommendations contained in the 2006 guidelines were based on levels of evidence from randomized clinical trials (RCTs), scientific studies, observational cohort data and, where insufficient evidence was available, expert opinion. Each recommendation was rated using the criteria described in Table 1, the letters A, B, and C representing the strengths of the recommendations and the numerals I, II, III and IV representing the quality of the evidence. Cost-effectiveness, acceptability and feasibility were not explicitly considered.

Table 1Assessment of evidence as used in the 2006 guidelines

Strength of recommendationLevel of evidence to make for recommendation
  1. Recommended – should be followed
  2. Consider – applicable in most situations
  3. Optional
  1. At least one randomized controlled trial with clinical, laboratory or programmatic end-points
  2. At least one high-quality study or several adequate studies with clinical, laboratory or programmatic end-points
  3. Observational cohort data, one or more case-controlled or analytical studies adequately conducted
  4. Expert opinion based on evaluation of other evidence

In the 2010 guidelines the development of a recommendation remains guided primarily by the quality of evidence using GRADE methodology. However, the GRADE approach includes the additional domains of the balance between risks and benefits, acceptability (values and preferences), cost and feasibility. Values and preferences may differ in regard to desired outcomes or there may be uncertainty about whether an intervention represents a wise use of resources. Furthermore, despite clear benefits, it may not be feasible to implement a proposed recommendation in some settings.

Table 2Assessment of strengths of recommendations as used in the 2010 guidelines

Strength of recommendationRationale
StrongThe panel is confident that the desirable effects of adherence to the recommendation outweigh the undesirable effects.
ConditionalThe panel concludes that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects.


the recommendation is only applicable to a specific group, population or setting OR

new evidence may result in changing the balance of risk to benefit OR

the benefits may not warrant the cost or resource requirements in all settings.
No recommendation possibleFurther research is required before any recommendation can be made.

In the GRADE approach, the quality of a body of evidence is defined as the extent to which one can be confident that the reported estimates of effect (desirable or undesirable) available from the evidence are close to the actual effects of interest. The usefulness of an estimate of the effect of an intervention depends on the level of confidence in that estimate. The higher the quality of evidence, the more likely a strong recommendation can be made. It is not always possible to prepare GRADE profiles for all interventions.

Table 3Assessment of strength of evidence as used in the 2010 guidelines

Evidence levelRationale
HighFurther research is very unlikely to change confidence in the estimate of effect.
ModerateFurther research is likely to have an important impact on confidence in the effect.
LowFurther research is very likely to have an estimate of effect and is likely to change the estimate.
Very lowAny estimate of effect is very uncertain.

Table 4Additional domains considered in developing strengths of recommendations

Benefits and risksWhen developing a new recommendation, desirable effects (benefits) need to be weighed against undesirable effects (risks), considering any previous recommendation or an alternative. The larger the gap or gradient in favour of the benefits compared to the risks, the more likely a strong recommendation will be made.
Values and preferences (acceptability)If the recommendation is likely to be widely accepted or valued more highly, a strong recommendation will probably be made. If there is a great deal of variability or if there are strong reasons that the recommended course of action is unlikely to be accepted, it is more probable that a conditional recommendation will be made.
Costs / financial implications (resource use)Lower costs (monetary, infrastructure, equipment or human resources), or greater cost-effectiveness will more probably result in a strong recommendation.
FeasibilityIf an intervention is achievable in a setting where the greatest impact is expected to be attained, a strong recommendation is more probable. Tools have been developed to assist national ART advisory committees when assessing the feasibility of implementing a new recommendation. These are available at: http://www​​/topics/treatment/evidence3/en/index​.html
Copyright © 2010, World Health Organization.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK138529


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