Outsmarting TB using research and collaboration

 
Tags: , ,

Tuberculosis (TB), which in 2016 killed an estimated 1.7 million people, is an ancient disease found in the bones of mummies dug up from Peru. It has evolved with humans, and like other successful organisms, finds ways to avoid death, so it can thrive and spread to the next person. Trying to get ahead of this successful adversary requires pursuing a consistent, aggressive research agenda aided by international collaboration.

Strong leadership advocating for TB research, like the leadership offered by our teams at FHI 360, is making it possible for the hardest hit regions of the world to do the kind of research that will have a major impact locally – and globally. In this blog post, I will describe two of our major TB research endeavors, recently highlighted during the 48th Union World Conference on Lung Health in Guadalajara, Mexico, that focus on the importance and promise of coordinated, collaborative research efforts in high-burden countries.

Increasing HIV detection with incentive-based, peer-referral approach known as Risk Tracing Snowball Approach

 
Tags: , ,

Cambodia has achieved measurable success in its fight against HIV. Prevalence has dropped more than 60% from 1998 to 2015, and the number of new HIV cases fell more than 80% over the same period. However, as in many countries, going the last mile to fully eliminate the AIDS epidemic requires innovative approaches to reach individuals unaware of their HIV status – especially among hard-to-reach key populations – and link them to treatment to achieve viral load suppression.

A consortium comprised of three NGOs – KHANA, FHI 360, and Population Services International (PSI) – working with the HIV/AIDS Flagship Project funded by USAID came up with an intervention study idea. Would we detect more newly identified HIV cases if we asked people that walked-in for HIV testing (presumably high-risk) to refer their peers whom they think are at risk for HIV infection for testing? We hypothesized yes. If we were right, it would be brilliant and we could help Cambodia’s National Centre for HIV/AIDS, Dermatology and STD (NCHADS) scale-up the intervention and avert hundreds of new infections every year. The same Risk Tracing Snowball Approach (RTSA) had proven to be successful among high-risk heterosexuals in the United States, among drug users in Greece, and heterosexual couples in China. We set out to determine if it would work in Cambodia, and I describe our intervention design and evaluation outcomes in this blog post.

From the Red Book to the Blue Book: Advancing HIV surveillance among key populations

 
Tags: , , ,

The World Health Organization (WHO) recently published new global guidelines on how to do biobehavioral surveys related to HIV infection in a document known as the Blue Book. The Blue Book replaces the previous Red Book of guidelines for such surveys. The updated guidance keeps the global health community abreast of the evolving HIV epidemic, which has led to 37 million people currently living with HIV infection. Biobehavioral surveys provide population-level estimates for the burden of HIV disease and HIV-related risk factors, and they allow estimation of the coverage of prevention and treatment services for key populations that are at increased risk for HIV. Advances in available data and changes in the epidemic rendered the survey tools and guidelines in the Red Book out-of-date. In this blog post, we’re going to highlight how the new Blue Book addresses these critical gaps to deliver a manual better suited to the era of ending AIDS.

My tribute to Peter Lamptey’s lifelong contributions to global health

 
Tags: , ,

Known around the world, Prof. Peter Lamptey is a global health champion in any light. Many of you may know him from his early involvement in the global HIV response or from his fight to raise public awareness of noncommunicable diseases (NCDs). I first heard Prof. Lamptey speak about the role of laboratory science in the NCD response at a conference plenary hosted by the African Society for Laboratory Medicine, my former employer. A compelling talk for sure, but notably his plenary was also my first significant introduction to FHI 360’s research.

Fast forward several years. I’m now editor of the very FHI 360 research blog you are reading, and Prof. Lamptey retires from FHI 360 this month. In a selfishly full-circle moment for me, I want to add my tribute to Prof. Lamptey’s immeasurable contributions to global health. Not with a speech or a party (though there have been those too), but with a blog post highlighting a few of his evidence-centered publications. To help celebrate nearly four decades of Prof. Lamptey’s accomplishments, here are three of those publications that I find interesting.

Research improves handwashing programs by uncovering drivers of behavior change

 
Tags: , ,

Evidence on the health and social benefits of handwashing is strong. We know that handwashing can prevent up to 40% of diarrheal diseases, and can lead to fewer school absences and increased economic productivity. However, many people don’t wash their hands at critical times, even when handwashing facilities are available. While research on behavior change has shown examples of approaches that lead to increased rates in handwashing, we’re still seeking to understand why people wash their hands, and how motivation for handwashing can be translated into programs that result in effective behavior change.

In celebration of Global Handwashing Day on October 15, USAID and the Global Handwashing Partnership – an international coalition with a Secretariat hosted by FHI 360 – organized a webinar on drivers for handwashing behavior change. The Partnership’s work focuses on promoting handwashing with soap as key to health and development, with an emphasis on connecting practitioners with research findings to inform their work. Our webinar speakers provided two examples of how research is exploring behavior change from cognitive (how we think about and understand handwashing) and automatic (how we can be unconsciously prompted to wash our hands) standpoints. In this blog post, I’ll summarize how the two examples show different ways of understanding human behavior and discuss how the findings help us understand what drives behavior change for handwashing.

Call for papers: Optimizing the impact of key population programming across the HIV cascade

 
Tags: , ,

Key populations – including men who have sex with men, sex workers, transgender people, and people who inject drugs – shoulder a disproportionate burden of HIV. UNAIDS estimates that between 40 and 50 percent of all new HIV infections among adults worldwide occur in these key populations and among their sex partners. Reaching members of these communities with evidence-based interventions that improve their access to and uptake of services across the HIV prevention, care, and treatment cascade is essential to achieving the UNAIDS 90-90-90 goals. In this post, I highlight a new call for papers that will focus on new evidence and data-driven strategies for improving key population programming across the HIV cascade.

Seizing an opportunity to collect user experience data

 
Tags: , , ,

Contraceptive clinical trials routinely collect vast amounts of data, but what new data can we collect about method acceptability during this research stage? If a method has reached the clinical trial phase, we’d hope formative acceptability research was already conducted to inform its development and to determine if a potential market exists. At this point in the game, few changes can be made to a method based on acceptability findings… so what’s left to learn?

Hypothetically speaking… If we build it, will they come?

 
Tags: , , , ,

Contraceptive product development efforts, to date, have largely been premised on the notion that if we build it, they will come. Primary attention has been paid to making products that work, with the assumption that if women want to avoid pregnancy, they will use them. While the desire to avoid pregnancy is an extremely powerful motivator, it is not enough. For many women, the fear of contraceptive side effects or the challenge associated with accessing and using contraceptives is greater than the burden of another pregnancy.

Some argue that to improve uptake and continuation rates, we need to improve provider counseling around contraceptive side effects and address socio-cultural barriers, such as inequitable gender norms, that prevent women from using contraceptives. These efforts – while essential – are still insufficient. Even the most informed and empowered women can have unintended pregnancies when they don’t have access to acceptable contraceptives – methods that meet their particular needs in their particular life stage and context.

As researchers, how do we shift the model of contraceptive development to focus first on what users want from an ideal contraceptive?

The science of beating HIV and AIDS

 
Tags: , ,

The International AIDS Society (IAS) Conference on HIV Science (IAS 2017) in Paris last week brought together over 6,000 scientists, clinicians, public health practitioners and officials to review the state of the science intended to control and eventually end the HIV/AIDS epidemic. The central thrust of the global effort to control the epidemic is achieving the 90-90-90 targets set by the Joint United Nations Programme on HIV/AIDS (UNAIDS). These targets state that, by 2020, 90% of those living with HIV know their status, 90% of known HIV-positive individuals receive sustained antiretroviral therapy (ART), and 90% of individuals on ART have durable viral suppression. We know that HIV-infected persons with viral suppression, while not cured, do not transmit HIV infection – hence the focus on treatment, which is prevention.

While some countries have made encouraging progress, we are far short of the global 90-90-90 targets, and worse, there were 1.8 million new HIV infections in 2016. We need science to inform the way forward to reach the targets. In this post, I will report on some of the conference presentations around two major themes: 1) generating and applying evidence to optimize the use of current tools, and 2) developing new and improved methods for HIV prevention, care and treatment.

Teasing apart stigma and knowledge as barriers to HIV testing: A study with young Black adults in Durham, North Carolina

 
Tags: , , ,

What experiences do young Black adults in Durham, North Carolina, have with HIV testing? And what influence does stigma play on those experiences? To answer these questions, my co-authors and I recently published the results of a community-based participatory research (CBPR) study: Relationship between HIV knowledge, HIV-related stigma, and HIV testing among young Black adults in a southeastern city. Our cross-sectional survey examined barriers, facilitators and contributors to HIV testing. This blog post summarizes our findings and provides guidance on HIV prevention strategies.

LINKAGES research digest highlights ability of young key populations to access and remain in the HIV care cascade

 
Tags: , ,

On a quarterly basis, the LINKAGES project releases a research digest comprised of the latest peer-reviewed article abstracts related to HIV and key populations (KPs) – sex workers, men who have sex with men (MSM), transgender people, and people who inject drugs. LINKAGES is PEPFAR and USAID’s largest global project dedicated to using evidence-based approaches for reducing HIV transmission among KPs and improving their enrollment and retention in care. KPs have the highest risk of contracting HIV and often face formidable barriers to accessing prevention, care, and treatment services. The research digest keeps implementers and researchers up to date on the rapidly expanding evidence base pertaining to HIV services for KPs on a global scale. So, what did we learn about young KPs and HIV in the past quarter?

Turning lemons into lemonade, and then drinking it: Rigorous evaluation under challenging conditions

 
Tags: , , , ,

In early 2014, USAID came to the ASPIRES project with a challenge. They requested that our research team design and implement a prospective quantitative evaluation of a USAID-funded intervention in Mozambique. The intervention centered on a combined social and economic intervention for girls at high risk of HIV infection. As a research-heavy USAID project focused on the integration of household economic strengthening and HIV prevention/treatment, ASPIRES was prepared for the task.

The challenges, however, came in the particulars of the evaluation scenario. The research team set its mind to identifying the best possible design to fulfill the request. This is to say, we sought out a recipe for lemonade amidst these somewhat lemony conditions.

Improving the evaluation of quality improvement

 
Tags: , , ,

The use of quality improvement approaches (known as “QI”) to improve health care service outcomes has spread rapidly in recent years. Although QI has contributed to the achievement of measurably significant results as diverse as decreasing maternal mortality from post-partum hemorrhage to increasing compliance with HIV standards of care, its evidence base remains questioned by researchers. The scientific community understandably wants rigorously designed evaluations, consistency in results measurement, proof of attribution of results to specific interventions, and generalizability of findings so that evaluation can help to elevate QI to the status of a “science”. However, evaluation of QI remains a challenge and not everyone agrees on the appropriate methodology to evaluate QI efforts.

In this post, we begin by reviewing a generic model of quality improvement and explore relevant evaluation questions for QI efforts. We then look at the arguments made by improvers and researchers for evaluation methods. We conclude by presenting an initial evaluation framework for QI developed at a recent international QI conference.

Applying the power of partnership to evaluation of a long-acting contraceptive

 
Tags: , ,

A long-acting, highly effective contraceptive method called the levonorgestrel intrauterine system (LNG-IUS) was first approved for use almost thirty years ago. Since then, it has become popular and widely used in high-income countries. However, until recently, the high cost of existing products has limited availability of the method in low-resource settings. Now, new and more affordable LNG-IUS products are becoming available. In 2015, USAID convened a new working group comprised of a diverse group of donors, manufacturers, research and service delivery partners to help accelerate introduction of the method. Through this platform, FHI 360 and other members contributed to the development of a global learning agenda – a series of research questions that donors and implementing agencies agreed are priorities to evaluate the potential impact of the LNG-IUS. Working group members then implemented a simple but innovative approach to making limited research dollars go farther in addressing the learning agenda questions.

Academia takes on global health

 
Tags: , ,

The Consortium of Universities for Global Health (CUGH) held their 8th Annual Conference in Washington DC this week. More than 1,700 people from every corner of the globe gathered for three days to explore how the world’s academic institutions can best contribute to improving global health. This year’s meeting was particularly interesting given the contrast between current prospects for financial support for global health and the trajectory of support over the last 15 years. That contrast made several of the key topics discussed at CUGH even more salient to me.

Learning about focus groups from an RCT

 
Tags: , , ,

In my previous job at 3ie I spent a lot of time telling researchers that a randomized controlled trial (RCT) with a few focus groups thrown in for good measure doesn’t count as a mixed methods impact evaluation. In the course of repeatedly saying that focus groups are not enough, I must have developed an unconscious bias against focus groups, because I was pleasantly surprised by what I learned from a recently published article written by some of my FHI 360 colleagues. In their study, Guest, et al. use an RCT to compare the performance of individual interviews against focus groups for collecting certain data.

Mining for development gold: Using survey data for program design

 
Tags: , , , ,

As global health resources become more scarce and the prevalence of international crises increase, it is more important than ever that we design and target development programs to maximize our investments. The complexity of the applicable social, political and physical environments must be taken into consideration. Formative research can help us to understand these environments for program design, but formative research is often skipped due to budgetary, time or safety concerns that constrain the collection of new data. What many overlook is the vast untapped potential of existing household survey data that are rigorously collected, clean and freely available online around the world. By mining existing survey data, we can conduct the formative research necessary to maximize development impact.

Should PEPFAR be renamed the “President’s Epidemiologic Plan for AIDS Relief”?

 
Tags: , ,

The effective use of data within PEPFAR has played a central role in getting us to the point where we can finally talk about controlling the HIV epidemic and creating an AIDS-free generation. PEPFAR’s transition from an emergency approach to one driven by real-time use of granular, site-level data to guide programmatic investments has contributed to achieving epidemic control. In view of this improved use of data, perhaps the “Emergency” in PEPFAR should now be changed to “Epidemiologic.”

Beyond research: Using science to transform women’s lives

 
Tags: , , , ,

It was a warm spring day in 2011, and eight of my colleagues were helping me celebrate the realization of a long-awaited policy change in Uganda by sipping tepid champagne out of kid-sized paper cups. A colleague asked me, amazed, “How did you guys pull this off? What’s your secret to changing national policy?” I offered up some words about patience, doggedness, and committed team work. My somewhat glib response is still true, but since then I’ve thought a lot about what it takes to get a policy changed.