Introduction - Dr Andrew Moore

Proceedings of the 5th Bandolier Conference
New horizons in HIV and AIDS
The Wellcome Building, London, 17 December 1997

Bandolier tries to bring to people's attention information about good evidence - the principles and the practice. Evidence-based medicine has been described by Sackett and colleagues as the `conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients'. 1


Because there are so many biomedical journals (perhaps as many as 30,000), the chance of any practitioner being aware of all developments of interest is vanishingly small. We depend on reading reviews and increasingly we want systematic reviews.

But in fast-moving areas there are times when we just can't wait for the systematic review and must make decisions based on complex new information, from a variety of sources, which has to be rapidly assimilated into practice and policy. The recent changes in treatment and diagnosis of HIV/AIDS are a case in point.

Modern scientific techniques
A decade ago all seemed hopeless (and perhaps still does in some parts of the world, as Professor Adler tells us). Yet with application of modern scientific techniques we have new tests and treatments, and newspaper headlines about rapidly decreasing death rates and `problems' of affected people in coming to terms with new situations ( The Times , January 17, 1998). Mr Gerrard MP puts some of the societal problems into perspective.

There are new tests - but which one to use? Dr Pereira demonstrates that viral load tests can misdiagnose some patients, especially at the low end. How do we incorporate the new information on genetics that Professor Gotch discusses into our thinking, especially the gene deletions that apparently make some people immune to HIV?

Most of all there are issues of treatment. Professor Gazzard reviews the treatment choices and the strengths and weaknesses of the evidence on which they are based. The key question is: when to begin therapy? And in making these decisions we have to separate the facts from the conjecture, as he cautions us.

Difficult choices

Mike Youle examines cost-effectiveness issues. Best guesses now are that combination therapies are in the range where they compare favourably with other interventions on a cost per life-year saved basis, which raises questions of equity.

And by no means least is the perspective of the health commissioner, the person who has to purchase services for all of us, who has to make difficult and sometimes painful choices. John James gives a unique viewpoint on the issues for one of the most experienced areas in the UK.
Bandolier conferences have a special flavour and this, focusing on a particularly difficult area, was instructive. We may not, nor may ever, have formal systematic review or meta-analysis. But rules of evidence still count and help inform high-quality care and service provision.

Reference

  1. 1. Sackett DL, Rosenburg WMC, Muir Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: what it is what it isn't. BMJ 1996; 312: 71-72.