Goal is to give every doc an ‘AIDS cookbook’

Standard founded on ‘evidence-based’ medicine

As his last achievement at Kaiser Family Foundation in Menlo Park, CA, Mark Smith, MD, MPH, helped lay the theoretical and financial grounds for creating a gold standard for HIV treatment that will be widely disseminated and have credibility both inside and outside the AIDS community.

"AIDS is simply too complicated to expect everyone to do it on their own," says Smith, former chairman of the CDC’s Advisory Committee on HIV and president of the California Health Care Foundation in Oakland. "The most sophisticated practitioners may be using certain information as a basis for their decisions months before it gets published in mainstream journals. Too many state and federal programs, left to their own devices, would have to come up with their own clinical standards."

In order to formulate the first comprehensive HIV treatment standard in nearly five years, Smith wanted to make sure the standard’s creators weren’t limited to AIDS clinicians and researchers, but included managed care medical directors and others who are attuned to "evidence-based medicine." The result is a well-rounded, diverse group that will have wide credibility, he says.

"Not everyone there is an AIDS specialist, and that was deliberate because we’re trying not to replicate a process in which subspecialists never meet a drug or procedure they didn’t like," he notes. "We needed to have some authoritative source that could incorporate the newest scientific developments quickly and serve as a reference point to which institutions, including managed care organizations, Medicaid agencies, prisons, and the rest could be held accountable."

The panels’ recommendations won’t surprise the nation’s most savvy AIDS specialists, but to managed care directors and Medicaid medical directors who have little contact with AIDS patients, the standard will be a one-stop source for making decisions for everything from viral-load testing to immunizations.

While critics have called the approach "cookbook medicine," Smith doesn’t take offense to the analogy. "It wouldn’t be such a bad thing if every doc in America had an AIDS cookbook essentially edited by John Bartlett and Tony Fauci," he says. "If they cook like that every night, I would give up a little hyper-variability on an individual basis."

Other critics of the standards approach contend that the AIDS field is moving too fast to pin it down with standards that leave no room for the most up-to-date advances. Smith, however, is more concerned that providers are so far behind in keeping up with treatment advances that patients are suffering for it. Indeed, a recent survey from the federal AIDS Drug Assistance Program working group found that more than 10% of its patients were still prescribed monotherapy.

"Some were worried this would put a ceiling on care," he says. "Frankly, I am more worried right now about there being a reasonable floor under people’s care than somehow preventing some eighth-generation protease inhibitor that some wildly rich guy feels he might not get if this panel hasn’t blessed it."