Promoting hiv aids evidence based decision making
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Program. Promoting HIV/AIDS Evidence-based Decision Making. Naomi Rutenberg, PhD Program Director, Horizons, Population Council. Horizons Structure and Organization. Global HIV/AIDS operations research program 10 years, August 1997 – July 2007

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Promoting HIV/AIDS Evidence-based Decision Making

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Promoting HIV/AIDS Evidence-based Decision Making

Naomi Rutenberg, PhD

Program Director, Horizons, Population Council

Horizons Structure and Organization

  • Global HIV/AIDS operations research program

  • 10 years, August 1997 – July 2007

  • Funded by USAID: Office of HIV/AIDS, Bureaus and Missions

  • 25 professional staff in DC, Kenya, Ghana, South Africa, India, and Thailand

Horizons Partners

  • International Center for Research on Women

  • PATH

  • Tulane University

  • International HIV/AIDS Alliance

  • Johns Hopkins

  • Family Health International

Identifyproblems inHIV/AIDSprograms

Field test and evaluateprogram approaches totreatment,prevention, care and support

Disseminate research findings to program managers and policy makers

Promote utilization of findings for program improvement


Field based, program-oriented research

Focus on program solutions under the control of managers

Research to guide program design/ implementation

Collaborate with NGOs, community groups, universities, FBOs, government

Responsive to national HIV/AIDS needs

Rapid review and implementation

Examine cost of interventions

Horizons Approach

Guiding OR Questions

  • WHAT is the program problem?

  • WHICH interventions work best?

  • WHY do they work?

  • WHERE do they work best?

  • WHO do they affect?

  • WHAT do they cost?

  • HOW do they impact on HIV/AIDS?

Diagnostic: Identify program problems

Intervention: Seek program solutions

Evaluative: Measure program impact

Cost: Determine cost of impact

Types of OR Studies

Current HIV/AIDS Focus AreasTreatment, Prevention, Care

  • Increase ARV coverage and adherence

  • Reduce stigma and discrimination

  • Change behavior using ABC approach

  • Involve private sector

  • Prevent mother to child transmission

  • Provide care and support to orphans and PLHA

  • Assess cost and effectiveness of interventions

  • Scale-up successful pilot programs

18 Studies

  • Prevention of mother-to-child transmission of HIV (PMTCT), 9 studies. Naomi Rutenberg, Carolyn Baek

  • Adherence to antiretroviral therapy, 4 studies. Avina Sarna, Susan Cherop-Kaai, Philip Guest

  • Changing gender norms among young men, 2 studies. Julie Pulerwitz, Ravi Verma

  • Health needs of men who have sex with men, 3 studies. Placide Tapsoba, Amadou Moreau, Harriet Birungi, Scott Geibel, Andy Fisher

Why these four areas?

  • Large gaps in our knowledge that prevent us from developing evidence based programs

  • New technology with ARVs but little real world experience delivering the technology

  • Important relationship between gender norms and health risks but how to measure this concept and develop operational programs

  • Health and risk behavior of MSM a neglected topic in Africa


  • Why is topic important to HIV/AIDS

  • Focus of Horizons research

  • Selected findings

  • Impact of research and scale-up

1. PMTCT Programs

  • 630,000 children worldwide infected in 2003

  • 490,000 children died of AIDS-related causes in 2003

  • Short course AZT (1997) and Nevirapine (1999) trials showed that nearly 50% of infant infections could be prevented cheaply

  • Opportunity to integrate PMTCT into ANC/MCH platform

Infection Rates



  • Antiretroviral drugs + extended breastfeeding15-25%

  • Antiretroviral drugs + short breastfeeding10-15%

  • Antiretroviral drugs + no breastfeeding9%

  • Antiretroviral drugs + no breastfeeding + 1-2%cesarean delivery

If You Build It, Will They Come?

  • Multi-site studies to measure use-effectiveness in Kenya and Zambia

  • Strengthening infant feeding practices in Ndola, Zambia

  • Evaluation of UN Pilot PMTCT Programs in 11 countries

    What is the real world “use-effectiveness” of a package of PMTCT services for prevention of vertical transmission?

PMTCT Utilization and Infections Averted in Zambia: Targets and Practice

Why the “cascade”?

  • Demand

    • Do not want to know HIV status

      • Fear, no cure, depression

    • No intervention for mother

    • Concern about stigma

    • Lack of male and community support

    • Difficulty in implementing infant feeding options

  • Supply

    • Human resources and capacity

    • Lack of basic ANC and HIV services

Strengthening Health Systems and Scale-up

  • PMTCT needs assessment methodology developed

  • Patient counseling procedures improved

  • Supplies and equipment needs identified

  • Patient and program monitoring systems developed

  • University-government partnership formed

  • Curriculum for training health workers developed for Kenya study adopted in other countries

  • Kenya study basis for national scale-up

2nd Generation PMTCT Studies

  • Adherence to PMTCT ARVs in Botswana

  • Evaluation of peer psychosocial support in South Africa

  • Community based PMTCT in Nairobi, Kenya

  • Pilot of postnatal services for HIV+ women and infants in Swaziland

  • Linking PMTCT to ARV care for HIV+ women in India

2. ARV Adherence

  • High levels of adherence to ARVs (≥ 95%) required for treatment to be successful

  • Low levels of adherence may increase chances of resistant strains rendering the drug treatment ineffective

Focus of Kenya ARV Adherence Research

  • Randomized controlled two-arm study


    • Twice weekly follow-up at clinic for first 24 weeks

    • Routine monthly follow-up for next 24 weeks


    • Monthly follow-up for 48 weeks

  • 3 treatment sites and 6 observation sites

  • Would DAART strategy result in improved adherence to ARVs?

  • ARV Adherence  95%: Self Reports

    1-6 months: NS difference between groups

    ARV Adherence  95%:Pill Counts

    1-6 months: DAART 93% vs non-DAART 74%, p = .001

    Other measures over 6 months, significant within groups, not between

    • CD4 cell counts more than double in both groups

    • 5 to 6 Kg. weight gain in both groups

    • Depression scores in both groups decreased

    • Quality of life score improve in both groups

    Impact and Scale Up

    • Initial adherence results are encouraging. On basis of pill counts, DAART patients achieved 95% adherence

    • Significant improvements in CD4 counts, weight, depression, and QOL measures in both groups

    • Now examining viral loads in Mombasa

    • An adherence manual for trainers produced, 3,000 copies, widely used in Africa and Asia.

    • Completing studies in Thailand and Zambia that examine adherence and in India looking at paying and non-paying ARV patients.

    3. Gender Equity Programs

    • Increasing awareness that gender role socialization puts women and men at health risk (WHO 2000).

      • e.g. Peer pressure on males for multiple sexual partners

    • But, operationally, how to measure gender norms, and what kind of interventions would be effective to change norms and reduce HIV/STI risk.

    Focus of Brazil Gender Equitable Norms Research

    • Changing inequitable gender norms of young men in Brazil

    • Building relationships based on respect, equality, and intimacy rather than sexual conquest

    • Taking financial and caregiving responsibility for children

    • Being responsible for reproductive health and disease prevention

    • Opposing intimate partner violence

    HIV/STI Risk at Baseline

    Change in Reported STI Symptoms




    *p < 0.05 - Chi-square test, No significant change in control group

    Change in Condom Use at Last Sex


    *p < 0.05 - Chi-square test, No significant change in control group

    “Used to be when I went out with a girl, if we didn’t have sex within two weeks of going out, I would leave her. But now (after the workshops), I think differently. I want to construct something (a relationship) with her.”

    Impact and Scale Up

    • Work in Brazil now replicated in India

    • Moved from the conceptual level to the operational

    • Gender equitable scale developed to measure norms

    • Program interventions can change gender norms

    • Relationship between gender norms and reduced HIV/STI risk

    4. MSM Research in Africa

    • Little information in Africa about MSM behaviors

    • Widespread denial about the existence of MSM in Africa

    • No knowledge about the extent to which MSMbehaviors put men and their partners at risk of HIV infection in Africa

    Focus of First Senegal MSM Study

    • Sociodemographic characteristics of MSM

    • Sexual health risk and prevention behaviors

    • Sexual health problems

    • Stigma and discrimination experiences

    • Health-seeking behavior

    Selected Findings: Risk Factors Among 250 MSM in Senegal

    • 88% ever had sex with a woman

    • 2/3 received money in recent MSM encounter

    • 43% reported being raped at least once

    • 13% raped by policeman

    • 42% experienced genital/anal health problems

    • 23% used condom at last insertive sex, 14% last receptive sex

    Focus of Second Senegal Study:Service Utilization May 2003 – March 2005

    • 5 providers in Dakar, 1 in each of 4 regions

    • 774 MSM reached with clinical consultation

    • 168 requested/referred for VCT

    • 141 returned for results

    • 63 HIV-

    • 78 HIV+ or 10% of all 774 (in a country where the overall prevalence is < 1%)

    • 50 MSM under treatment, including ARVs

    Third MSM Study in Kenya Among 500 MSM

    • 62% reported having sex with at least 1 man in the last week, 90% in last month

    • 61% reported having anal sex at least 1 time in the last week

    • 69% have ever had sex with a woman

    • 59% said they always used condoms

    • 25-35% ever experienced STI symptoms

    • 57% had an HIV test, 98% received results

    Conclusions From Senegal and Kenya

    • MSM exist in both areas, not negligible

    • Sexual behavior of MSM also involves women and has reproductive health implications

    • Condom use is high among MSM in Nairobi, low in Senegal

    • Sex with multiple partners is high

    • Many experience discrimination, stigma, and violence

    • Some receive money or gifts for sex

    • Confidentiality most important in seeking health care

    Impact and Scale Up in Africa

    • Senegal AIDS control commission committed to improving health of MSM and increasing preventive behaviors

    • MSM component in World Bank Programs for Senegal, The Gambia, and Burkina Faso

    • Ghana diagnostic study and service provision by USAID Bilateral

    • Bristol Meyers-Squibb committed to funding MSM interventions in Mali and soon Burkina Faso

    Final Conclusions

    • Multiple studies in multiple sites addressing a single topic can identify issues, constraints, and solutions to program problems that a single study might miss.

    • Impact can be substantial such as influencing an entire country’s scale-up program in Kenya with PMTCT, or focusing donor attention on an important, neglected area such as health and risk behaviors of MSM.

    Final Conclusions

    • Tools developed as part of study implementation are important: training curriculum for PMTCT providers, adherence manual for ARV trainers, valid scale to measure gender equity,

    • Field based studies help shape policies and guide programs on the basis of evidence, not ideology or best guesses.

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