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EACS Guidelines in 12 new languages
Why the guidelines are so important
Professor Nathan Clumeck, one of the originators of the EACS treatment
guidelines, made this presentation at Crucial Issues in HIV diagnosis
and management in South East Europe, sponsored by the HIV Treatment
and Resource Initiative in Belgrade, Serbia, 25 May 2007 in conjunction with
the formal announcement that the Serbian National Health Ministry had adopted
the European AIDS Clinical Society’s (EACS) HIV treatment guidelines.
Please note this talk is in reference to the 2005 EACS
guidelines, not the newly-released 2007
guidelines.
Hello.
I am Professor Nathan Clumeck, chief of Infectious Diseases at the University
Hospital in Brussels. I am among the founding members of the European AIDS
Clinical Society. Presently I am the treasurer of the society and in charge
of coordinating the guidelines on HIV treatments.
The 2005 EACS guidelines are
recommendations for treatment and care of HIV persons. The aim is to propose
the best type of treatment that could be applied in Europe because there are
many guidelines — the American guidelines,
the British guidelines, the Australian guidelines. But we think that in Europe
we could have a common approach to care and that is why we produce guidelines.
So the guidelines are recommendations for the clinician and our goal is to
improve the quality of care and also to give information for physicians who
do not have access to international meetings.
Who produces the guidelines?
The guidelines have been produced by a panel of European experts, and I think
it is interesting, because of course the way the patient is treated in the
south of Europe, in the north of Europe, in central Europe is not the same,
so it is important to put together all these people coming from parts of Europe
in order to try to find the best common way, the consensus, on how to treat
in Europe, taking into account the European reality, and also the social security
systems, which are quite different from United States for example. Finally
the executive committee of the society approves the guidelines.
The main questions are when to treat
the patient and how to treat the
patient.
For the question when to treat, there have been tremendous differences between
parts of Europe. Now these differences tend to diminish. It is easier now to
reach consensus on when to treat than it was 3 to 5 years ago when we started
to produce the guidelines. For example for the UK, when to treat, the limit
was CD4 level around 200-250. For many other European countries it was around
350-400’s. So this kind of differences, we discussed that and the consensus
was when to treat is when the CD4 level is approaching 350. So now we could
say that in Europe most of the patients will not be treated too late in our
point of view or too early. So to have this kind of recommendation could certainly
help the clinician who face thes question when to treat, when he is alone,
he is in the office and he asks himself when to treat, this is one example.
In
Europe there are also many differences between countries about how to treat
the people who prefer an NNRTI-based regimen or the people who prefer a PI-based
regimen. In the new guidelines, the consensus is that starting with an NNRTI-based
regimen is as good as starting with a PI-based regimen. So we do not push one
or other regimen, we put the regimens on the same level. There are countries
where the recommendation is to start with an NNRTI-based regimen. So here in
Europe, we accept the proposition to start whether with the PI- or NNRTI-based
regimen and among the NNRTIs, the propositions that are made are wider
than it is in some national guidelines in order to take into account access
and cost of the treatments in various European countries.
The guidelines can be a tool to provide
greater access to better drugs
One positive point also that we shall see for the guidelines is that they could
help the clinicians at the national level to convince the health authorities
to give access to some treatments, to allow new treatment in the country, and
I think that is a very important point. The clinician is in a very difficult
position, because he is in between his patient and the health authorities.
So what we really want is to empower the clinician. I think that if the clinician
can go to his health authority and say, “Look, we belong to Europe, in
Europe there are guidelines and any European country can use this guidelines,
so why don’t we use them?” I think it is a question of ethics,
it is a question of what kind of health system is accepted at the national
level, and it also is a question to demonstrate to health authorities that
these guidelines could help them in a cost-effectiveness approach to the disease.
I think it has been largely demonstrated now by the World Bank that it is cost-effective
to treat patients. So even if the treatment could appear to be costly at first
glance, when really you enter into the detail of how to treat and when to treat,
it appears rapidly that it is cost-effective, and the treatment options which
are proposed in these guidelines are wide enough to allow each country to have
the possibility to give access to some new therapeutics particularly for patients
who are resistant to treatment. So that is why I think with the guidelines
are helpful to both the clinicians and also the national medical society, because
the clinician who is isolated might not have much real influence, but the medial
society, which should exist in each country, could have a positive dialog with
the health authorities based on the guidelines.
The guidelines are independent of pharmaceutical companies
An important point is that the guidelines are totally independent from
the pharmaceutical companies. The guidelines are supported by the European
AIDS Clinical Society (EACS), without any financial support of any pharmaceutical
company. We are very attached to that and it is one of our major achievements.
So I would say that if there is a relation with the companies that
it will be as the companies promote the guidelines as a service for the clinicians.
They could buy the copies of the guidelines and distribute these guidelines,
but there is no question that any company could say that they are associated with
the guidelines. So independence is very important.
The guidelines can help you license new drugs in your country
The fact that Serbia has adopted the 2005 European guidelines could certainly
help for licensing of new drugs in that country, because the fact that the
drugs appear in the guidelines means that there is no doubt about the efficacy
and the usefulness of these drugs. So if any drug company needs to be registered
and licensed in this country, the fact that their drug is on the guidelines
is certainly of help.
And finally…
So the 2005 guidelines cover, many areas — the area of primary HIV infection,
the area when to treat, how to treat, when to switch, when we should stop treatment,
what attitude should we have in case of failure of therapy, the first failure,
the second failure, and the multiple failure. The guidelines also give recommendations
for pregnant women and recommendations in case of accidental exposure to HIV.
There
are also guidelines on co-infection with Hepatitis C, Hepatitis B and guidelines
on how to manage metabolic complication of HIV published for the EACS Madrid
Conference (October, 2007). These two parts, coinfection and metabolics, are
new parts of the EACS guidelines, under the responsibility of Jens Lundgren
for the metabolic guidelines and Jurgen Rockstroh for the co-infection. The
updated HIV treatment guidelines will also be published and distributed at
the Madrid conference.
So the guidelines really help clinicians to cover
most of the frequent situations that they could and can face during their practice.
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