Scientific approaches to program components opportunities challenges and impact
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Scientific Approaches to Program Components: Opportunities Challenges and Impact. Sevgi Aral, PhD. Istanbul, Turkey March 21, 2011. National Center for HIV/AIDS, Viral Hepatitis, STD , and TB Prevention. Why now? So many efficacious STI/HIV interventions – so little impact.

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Scientific approaches to program components opportunities challenges and impact

Scientific Approaches to Program Components: Opportunities Challenges and Impact

Sevgi Aral, PhD

Istanbul, Turkey

March 21, 2011

National Center for HIV/AIDS, Viral Hepatitis, STD , and TB Prevention


Scientific approaches to program components opportunities challenges and impact

  • Why now?

  • So many efficacious STI/HIV interventions – so little impact


Scientific approaches to program components opportunities challenges and impact

Goal: To prevent individual acquisition

To prevent individual transmission

To reduce population incidence


Scientific approaches to program components opportunities challenges and impact

Prevention of individual acquisition and transmission

Reduction of population incidence


Efficacious individual intervention

Efficacious Individual Intervention

distribution of technology

dissemination of knowledge

cost

affordability

side-effects

Access/ acceptability

correct use

consistent use

correct timing

correct dose

long-term maintenance of above

Adherence

changes in risk perception

↑ other risk behaviors

Disinhibition

(risk compensation)

Successful Prevention

Of Individual Acquisition/Transmission


Successful prevention of individual acquisition transmission

Successful Preventionof Individual Acquisition/Transmission

Identification

affected subpopulations

sexual structures

social practices; demographic patterns; migration & turnover

organizational structures

epidemic phase/epidemic trajectory

identified need

organizational capacity/financial resources

synergies and antagonisms among interventions

context XX intervention interactions

Intervention Mix

  • sexual mixing patterns → who are exposed to pathogen

    • who are transmitting pathogen

  • sexual networks → which are central positions and roles

  • Prevention targets

    numbers and social location of persons to prevent acquisition/

    transmission

    pathways for introduction and scale-up of interventions

    Coverage & scale-up

    subpopulations

    sexual structures

    sexual behaviors

    intervention implementation

    POPULATION (SUBPOPULATION) INCIDENCE

    M & E

    Reduction of Population

    Incidence


    Scientific approaches to program components opportunities challenges and impact

    • B

    • B

    • B

    C

    D

    E

    • A

    • B

    • A

    • B

    • B

    • B

    Not only at individual level

    bridge populations

    men


    Scientific approaches to program components opportunities challenges and impact

    Often it seems

    Prevention of acquisition and transmission (in individuals) framework is used when thinking about reducing population incidence

    ?? Is the hidden individualistic biomedical (psychological) model the culprit???


    Opportunities

    Opportunities

    Huge we are not doing an adequate job of: identification; determining intervention mix; determining prevention targets; coverage and scale-up issues; monitoring and evaluation (of population impact)

    assessing the relationships among these

    assessing the interactions

    between context and intervention schemes


    How well do we assess the context

    How well do we assess the context?

    Epidemiology

    distribution and concentration of infection

    emergent clusters

    geographic distribution

    sexual structures → where the epidemic is going?

    epidemic trajectory

    epidemic phase

    Socio-demographic context

    behavior patterns

    sexual mixing patterns

    migration

    turnover in key populations

    key populations – powerful men, police, military


    Scientific approaches to program components opportunities challenges and impact

    Perhaps we do not examine epidemiology sufficiently

    (or we do not respect what we observe sufficiently)


    Scientific approaches to program components opportunities challenges and impact

    Paper # 137Identification of Localized Clusters of High HIV Incidence in a Widely Disseminated Rural South African Epidemic: A Case for Targeted Intervention Strategies

    Frank Tanser*1, T Bärnighausen1,2, and M-L Newell1,3

    1Africa Ctr for Hlth and Population Studies, Univ of KwaZulu-Natal, Durban, South Africa; 2Harvard Sch of PublHlth, Boston, MA, US; and 3Inst of Child Hlth, UnivColl London, UK

    Session 38-Oral Abstracts

    http://www.retroconference.org/2011/Abstracts/41395.htm


    Scientific approaches to program components opportunities challenges and impact

    Paper # 137Identification of Localized Clusters of High HIV Incidence in a Widely Disseminated Rural South African Epidemic: A Case for Targeted Intervention Strategies

    Conclusions:  Targeting efforts at settings where HIV

    transmission is most intense is crucial. Our study

    provides clear empirical evidence for the localized

    clustering of new HIV infections. The results show that

    even in a severely affected rural African community,

    interventions that specifically target, geographically

    defined, high-risk communities could be highly

    effective in reducing the overall rate of new infections.

    Session 38-Oral Abstracts

    http://www.retroconference.org/2011/Abstracts/41395.htm


    Hiv incidence across the study area with high incidence clusters superimposed

    HIV incidence across the study area with high-incidence clusters superimposed

    Session 38-Oral Abstracts

    http://www.retroconference.org/2011/Abstracts/41395.htm


    Distribution of sero conversions

    Distribution of sero-conversions


    Scientific approaches to program components opportunities challenges and impact

    ….and it is not only infections that cluster geographically….

    In the Bagalkot district of Karnataka in South India

    15 % of the villages accounted for 54% of all rural FSW

    Blanchard JF et al. Sex Transm Infect 2007; 83:i30-i36 d oi:10.1136/sti.2006.023572


    Scientific approaches to program components opportunities challenges and impact

    In the UK…Project SIGMA found “….Most individuals (60%) who engage in AI do so only once or twice a month, but there is a long tail of those who do it much more. In terms of the amount of AI acts, one-tenth of the individuals are performing half of the acts of AI. The Gini coefficient of concentration is high (0.55).”

    Coxon PM and McManus TS. The Journal of Sex Research 2000


    In the u s

    In the U.S.

    20% of women

    account for

    60% of vaginal sex acts in past 4 weeks

    and

    24% of men

    account for

    61% of vaginal sex acts in past 4 weeks

    Leichliter JS et al. Sex Transm Infect December 2010; 86(Suppl 3):


    In the u s1

    In the U.S.

    20% of women

    account for

    47% of opposite sex partners in past year

    and

    20% of men

    account for

    57% of opposite sex partners in the past year

    Leichliter JS et al. Sex Transm Infect December2010; 86(Suppl 3)


    In the u s county level analysis

    In the U.S. (county level analysis)

    20% of the population

    accounts for

    39% of Chlamydia

    52% of Gonorrhea

    64% of Primary and Secondary Syphilis

    Chesson HW et al. Sex Transm Infect December 2010; 86(Suppl 3)


    Scientific approaches to program components opportunities challenges and impact

    Perhaps we do not assess “context” sufficiently

    (or we do not respect the context we observe adequately)


    The concurrency debate

    The concurrency debate


    Aral so partner concurrency and the std hiv epidemic curr infect dis rep 2010 12 2 134 139

    Aral SO.  Partner concurrency and the STD/HIV Epidemic.  Curr Infect Dis Rep 2010; 12(2):134-139.


    Scientific approaches to program components opportunities challenges and impact

    Concurrency is more complex than it seemsMirjam Kretzschmar,1,2 Richard G. White,3 and Michel Caraël4

    1Centre for Infectious Disease Control, RIVM, Bilthoven, The Netherlands

    2Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands

    3Infectious Disease Epidemiology Unit, Department of Epidemiology and Population Health and Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK

    4Department of Social Sciences, Free University of Brussels, Belgium

    Corresponding Author: Dr MirjamKretzschmar, Corresponding Author’s Institution: University of Bielefeld

    Keywords: Polygyny, concurrency, HIV transmission

    Published in final edited form as: AIDS. 2010 January 16; 24(2): 313–315.

    doi: 10.1097/QAD.0b013e328333eb9d.


    Scientific approaches to program components opportunities challenges and impact

    Concurrency is more complex than it seemsMirjam Kretzschmar,1,2 Richard G. White,3 and Michel Caraël4

    However, the empirical basis proving that concurrency actually is the

    driving force behind the continuing high prevalence of HIV in sub

    Saharan Africa has been lacking. While some studies investigated the

    impact of concurrent partnerships on the prevalence of HIV in various

    sub-Saharan Africa populations [7-9], they were not able to identify

    concurrency as a strong explanatory factor. Also, epidemiological

    observations like the decrease of HIV prevalence in Uganda following

    the advocacy of the “zero grazing” strategy for HIV prevention [10, 11]

    is not conclusive evidence for the impact of concurrent partnerships on

    HIV transmission, because of the possibility of ecological inference

    fallacy. Now Reniers and Watkins demonstrate in an ecological study of

    HIV prevalence in 34 sub-Saharan Africa countries that concurrency in

    the traditional form of polygyny can even be negatively correlated with

    HIV prevalence [12].

    Published in final edited form as: AIDS. 2010 January 16; 24(2): 313–315.

    doi: 10.1097/QAD.0b013e328333eb9d.


    Scientific approaches to program components opportunities challenges and impact

    Concurrency is more complex than it seemsMirjam Kretzschmar,1,2 Richard G. White,3 and Michel Caraël4

    It clearly shows the need to view concurrent partnerships in

    their social and cultural context. It matters what the

    motivation is for establishing concurrent partnerships, how

    they are distributed among men and women, and in how far

    they are anchored in the culture of a society.

    Published in final edited form as: AIDS. 2010 January 16; 24(2): 313–315.

    doi: 10.1097/QAD.0b013e328333eb9d.


    Scientific approaches to program components opportunities challenges and impact

    It turns out that it is “mutual non-monogamy”

    or “symmetric concurrency” that drives

    STI/HIV spread….

    Polygyny and symmetric concurrency: comparing long-duration sexually transmitted infection prevalence using simulated sexual networks

    ShaliniSanthakumaran, Katie O'Brien, Roel Bakker, Toby Ealden, Leigh Anne Shafer, Rhian M Daniel, Ruth Chapman, Richard J Hayes, Richard G White

    Sex Transm Infect 2010;86:553-558 doi:10.1136/sti.2009.041780

    Non-monogamy: risk factor for STI transmission and acquisition and determinant of STI spread in populations

    Sevgi O. Aral, Jami S. Leichliter

    Sex Transm Infect 2010;86:iii29-iii36 Published Online First: 5 October 2010 doi:10.1136/sti.2010.044149


    The role of sti in hiv spread debate

    ….. “The role of STI in HIV spread” debate

    Differences among

    Mwanza

    Rakai

    Masaka….


    Scientific approaches to program components opportunities challenges and impact

    Perhaps we do not respect sexual structures adequately (or we do not integrate what we know about sexual structures into program design sufficiently)


    Scientific approaches to program components opportunities challenges and impact

    Infections reflect where the epidemic is

    Sexual structures and mixing patterns reflect where the epidemic is going

    St. Petersburg;

    Saratov;

    ?? Tallin


    Scientific approaches to program components opportunities challenges and impact

    Take home message:

    Sexual structures can be assessed through systematic rigorous

    rapid assessments


    Scientific approaches to program components opportunities challenges and impact

    migration and population movements of all kinds

    where the infection is going

    need to be considered in program planning and design


    Scientific approaches to program components opportunities challenges and impact

    • Movement networks and disease transmission

    Networks of movements as explanation for spatio temporal spread of infections

    Matt Keeling et al. PNAS, May 2010


    A study of geographic profile of partnerships

    A study of geographic profile of partnerships

    • Proportionately more long distance partnerships among gc infected compared to those with chlamydia

    • Proportionately more long distance partnerships among co-infected compared to those infected with gc or chlamydia

    • Proportionately more long distance partnerships among chlamydia repeaters compared to non-repeaters.

    • ? Implications for effectiveness of PN

    Hippe and Jolly – In preparation

    Jolly – personal conveersation


    Scientific approaches to program components opportunities challenges and impact

    How well do we plan

    and design prevention programs?


    Scientific approaches to program components opportunities challenges and impact

    Do we determine prevention targets based on a good understanding of sexual structures?


    Scientific approaches to program components opportunities challenges and impact

    Do we determine the intervention mix based on a good understanding of:

    preventiontargets

    affordability

    sustainability

    interactions with context

    synergies and antagonisms among interventions

    cost-effectiveness?


    Scientific approaches to program components opportunities challenges and impact

    In program planning and design – do we consider the required coverage (for population impact)?

    Do we plan adequately for scale-up?

    Do our scale-up plans consider populations and health systems to be CAS’s?


    Scientific approaches to program components opportunities challenges and impact

    • Do we have the correct monitoring and evaluation plans in place?

      • Do we know what needs monitoring?

      • Do we know what can be effectively evaluated?


    Questions

    Questions

    • Effect of an intervention?

  • or

    • Effect of the interaction between context and intervention?


  • Questions con t

    Questions (con’t)

    • Is it possible to tease out

    • the effects of a particular intervention on population incidence?


    Questions con t1

    Questions (con’t)

    • Do Community Randomized Trials provide the best evidence for population impact of community interventions?


    Choices as we delve into our knowledge base

    Choices as we delve into our knowledge base


    Scientific approaches to program components opportunities challenges and impact

    Choices ….. (con’t)


    Population health as complex adaptive system

    Population health as complex adaptive system

    • Location

    • Life course perspective/ path dependence (chains of consequences)

    • Mutual determination

      feedback loops (feedback – feed forward)

    • Dynamic aspects

    • Spatial aspects

    • Multilevel aspects

    • Interactions between levels


    Population health as complex adaptive system con t

    Population health as complex adaptive system (con’t)

    • Interactions between determinants

    • There is heterogeneity and heterogeneity counts

    • Variance is important – it is the distribution (not central tendency) and tail of distribution that plays a real big role

    • Adaptation to feedback

    • Emergence; emergent properties

      Need for agent-based modeling


    Scientific approaches to program components opportunities challenges and impact

    “The reason to look at epidemiology from a complex systems approach is that it does not make sense to try any other approach”

    Carl Simon


    Scientific approaches to program components opportunities challenges and impact

    “Everything should be as simple as it is, but not simpler”

    Albert Einstein


    We do have tools

    We do have tools

    • Systematic rigorous rapid assessments of context

    • Venue mapping – the “place” method

    • Mapping/monitoring of members of key populations

    • Geographic Information Systems (GIS)

    • Distribution analysis – Gini Coefficients and Lorenz Curves

    • Resource allocation decision making tools

    • Cost, cost-benefit, cost effectiveness analyses

    • Mathematical modeling – for targeting and coverage issues

      (• Agent based modeling for emergent properties)

    • CAS based approaches to scale-up

    • New approaches to M&E being developed


    What we need is

    What we needis

    not a paradigm shift

    but a major paradigm enhancement

    An expanded approach to bring “population health”

    and “complexity science” approaches into STI/HIV

    prevention.


    Scientific approaches to program components opportunities challenges and impact

    Thank you!


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