Research Interest Questions:

GENERALLY:

- Development of innovative, cross-faculty means to obtain, understand, and weigh evidence of the outcome of prevention programmes and implementation of the knowledge that can be gained from such better understanding. This entails development of monitoring and evaluation tools for “combination prevention”, i.e. the combination of behavioural, structural and biomedical interventions. These must include interactions from individual, community, environmental and structural levels.

- Development of analytical and theoretical tools to better understand long-wave events and research frameworks tailor-made to repeat surveys to catch and deal with changing trends over time. This entails development of theory and tools for understanding and analysing the socio-economic factors specific to the spread of HIV/AIDS (e.g. poverty, religion, human rights, inequalities and their interactions) or specific to HIV/AIDS prevention. Further research into which drivers other than material and power related ones affect the spread of the epidemics. Does this differ with countries?

- Development and application of sound management principles in relation to running HIV/AIDS programmes

- Development of framework for business-organisation cooperation on applying business theories such as supply chain management, operational analysis and complexity theory to HIV/AIDS related issues and operations

- Research into the mechanisms of scaled-up programmes (scale-ups from functioning community projects). Studies into scale-ups of intervention that has been tested at community level. How do we overcome the gap between the normal approach of RCT’s at community level and the fact that radical changes are needed in a sufficiently large number of people to have any measurable effect. This is needed both for biomedical (including adherence science), behavioural and structural scale-ups.

- Which strategies for combining scientifically derived evidence with local and community level wisdom and ownership have been tried, and which ones have worked?

- Which society changing strategies (structural changes) have been tried as HIV/AIDS prevention? Analysis and understanding of which hindrances there is to this.

- Evidence-based research into available behavioural and structural interventions in specific areas or populations

BIOMEDICAL INTERVENTIONS:

- Assessment of oral and vaginal ARV-drugs used prophylacticly.

- Research into reducing infectiousness for already infected individuals.

- Development of methods of assessment of (possibly marginal) effects, especially to distinguish the effect of one intervention from that of an extensive package, the nature of the control group, and separation of the effect of adherence from the potential of the intervention. Research into how to set standards so that effects that are moderate (e.g. less than 50 %, these could still offer significant protection at individual or population level) do not demonstrate inefficiency.

- Development of rating tools to rate the desirability of an intervention considering both the evidence of biological effectiveness, operational considerations (e.g. long-term adherence), the possibility of harm and sustainability.

- Research into which additional measures should come with male circumcision to avoid risk compensation (feeling more safe leads to more risky behaviour). Identification of which populations or countries are in need of this. Development of indicators for circumcision programmes.

- Establishment of the use of condoms at population level (adherence to consistent condom use).

- Research into whether or not diaphragms used with spermicide (possibly with ARV’s added) are as effective as condoms.

- Research into the effect of full treatment of other STD’s as a preventive measure .

- Research into whether different measures are needed at different stages (ages) of en epidemic.

- Research into whether male circumcision protects female partners by reducing transmission of the virus.

- Research into how to test new biomedical interventions with the combination prevention regime which seems to make RCT’s undesirable.

- Research into both how to measure and how to improve adherence. Which factors is it dependent on (e.g. people who are already infected might be more willing to adhere to treatment than those who’re only at risk).

- Research into which additional information can be gathered from already obtained or routinely obtained data (e.g. from antenatal clinics).

BEHAVIOURAL STRATEGIES:

- More research of development of self-efficacy as prevention method (specifically targeting members of vulnerable groups as opposed to targeting the inequalities making those groups vulnerable at a national or community level). This is a structural approach, too.

- Research into how to change focus from single interventions and individual behaviour to larger scales of intervention and larger population groups.

- Development of new theoretical and programmatic approaches to increase the effects of behavioural strategies. Development of new indicators that measure the effects of a combination of various efforts on various levels and approaches. Development of framework to develop new behavioural strategies in (e.g. LPA for NGO projects) including approaches that have been proven to be effective (e.g. multiple choice in VCT settings, peer education, involvement of community leaders) but also taking into consideration the ownership and involvement of the local communities and people involved the way that LPA doesn’t always do. Similarly, research into integrating and sustaining feelings of ownership, responsibility and commitment in employees or volunteers at all levels of projects is needed.

- Research into seroconcordant negative couples to understand how to prevent infection outside – and thus inside – of the relationship.

- Research into assessment tools of various ways of HIV education, e.g. workplace peer education, community peer education, theatre groups with dramatised messages, local and international media (e.g. local newspapers or radiostations versus MTV’s “Staying Alive”), innovative use of modes of communication (e.g. Swaziland’s “Secret Lover” SMS campaign). This is probably context dependent, too. How to overcome the gap between “Oh, that’s interesting” and “This concerns me and my life”. Research into scale-ups of these strategies (social-cognitive, educational strategies), which have almost always been delivered as some sort of education of individuals or small groups, and expansion of this to national levels have not been tried, tested or assessed (except in terms of secondary school sex education). Research into why myths flourish and some people (and which extend of people) find it easier to believe in myths and e.g. are more willing to violate infants than go for ARV treatment.

- Development of new motivational models that go beyond persuasive communication (financial incitements have been tried, but other methods of motivating people are needed). I.e. how to make the benefits of disclosure stronger than the risks of it.

- More sero-epidemiological and behavioural-epidemiological studies in one country or one area are needed.

- More research into serodiscordant couples in long term relationships and what is needed to keep the seronegative partner negative. Here especially the challenges of controlling viral loads and this infectiousness in environments in which constant monitoring of viral loads and CD4 counts and such are not possible, or the development of other methods to protect the seronegative partner from becoming infected. This is also adherence science.

- Research into risk compensation itself.

-Development of methods to educate clinic staff (and other relevant personnel or people) in continual risk assessment, ongoing information and counselling services, services for STD’s and referral of patients to harm reduction and drug treatment as well as methods for handling people who continue to engage in risky behaviour.

- Research into strategies for programmes to offer available, affordable, useful contraception and protection to all sexually active people (scale-up again).

STRUCTURAL APPROACHES:

- Comparison of success rates of HIV/AIDS programmes that incorporate structural approaches to those that don’t. Indicators for this. Conceptual and technical definition and implementation of structural approaches, development of assessment tools suited to their long-term nature. Taking into account that evaluation requires routine process assessment of interventions. Are different indicators and different assessment tools needed depending on the proximity or distality of the structural intervention? Comparison between projects with a high level of local ownership and those with a high level of top-down leadership. Indicators for this.

- Research into classification systems of structural factors (factors of a social, economic, political or environmental nature that contribute to the risk of and vulnerability to HIV infection). This classification system should acknowledge differences in populations and thus the fact that the same structural approaches might not be equally useful in different populations. Research into specifying and analysing the details of both the people and the settings that make particular programmes or policy inputs relevant end effective.

- Research into which empowerment of women programmes have been implemented (in terms of income generation, redressing gender inequalities, sexual coercion or violence, etc.) and which outcomes they have had, or whether this has been assessed. Is there a correlation with other societal inequalities like lacking democratic control with the government or prevention from voting in elections? Is there a correlation with the Social Development Index? The Gini coefficient (the broader the gap between the richest and the poorest, the higher the prevalence rate)?

- Identification and contextual analyses of how social, political, economical and environmental factors are operating and influencing vulnerability and risk and the causal pathways between the structural factor and the behaviour or behaviours leading to risk in a given community. A structural change will most likely need to be worked on several levels along the causal pathway. Assessment of success or failure of a project must also assess its effect on the elements of the causal pathway. Improving on assessment methods seeing as RCT’s are not well suited to test structural interventions. Analyses of which factors affect the epidemics proximally and which ones affect it distally. Assessment of how best to address these factors. It is highly possible that these should be handled differently depending n both context and proximity or distality.
 
- Identification of the factors averse to change in a society and the drivers of regression or stalled development. Strategies to overcome these in a HIV/AIDS setting.

- Research into the social, economic, political and environmental conditions in which specific HIV/AIDS programmes are implemented and into which influences they have had on the outcomes. Documentation of these differences and exploration of the mechanisms by which an intervention works for a particular group.

- Studies of HIV/AIDS prevention programmes in cooperation with the NGO’s or Governmental Organisations running them (the people implementing them), as these organisations tend to try to redress structural factors in innovative ways but lack the scientific knowledge of assessment tools to make significant analyses of the outcomes. Studies into how many NGO’s or other organisations have data that they cannot process, like the Swazi organisation TASC.
 
MAKING HIV PREVENTION PROGRAMMES WORK:

- Research into how to implement the change from short-term, emergency, “myopic” efforts to long-term, strategic efforts.

- Research into how to improve targeting, selection, and delivery of prevention interventions, and optimisation of funding.

- Development of frameworks in which sufficient data for intervention effectiveness and country specific epidemiology can be gathered by or in cooperation with programme managers.

- Application of optimisation techniques to cost and effectiveness of combinations of interventions.

- Research into how existing data can be used better. Generation of methods to assess effectiveness. Ensuring that the interventions reach those most at risk or those most vulnerable. Which measures can be taken to overcome political or normative reluctance to addressing specific population groups?

- Development of powerful and user-friendly analyses models or software that catch not only the current pattern but also emerging trends. I.e. prediction of where the next 1,000 infections will occur so that those at risk can be targeted. This means understanding the underlying patterns of epidemiology and why and how they change and implementing this into models.
 
- Development of standardised social-science protocols on how to use qualitative and quantitative data collection methods in order to facilitate regular monitoring of contextual factors, determinants of risk behaviour and barriers to prevention. Use of these to feed the models from the above point to improve knowledge of cost-efficiency of different interventions in specific contexts.

- Development of methods to safeguard long-term HIV/AIDS interventions against changes in governments, religious or political issues or priorities and ensure predictability of funding.

- Is there a lot of data around from prevention programmes that have never been systematically assessed or studies discarded because they didn’t meet the minimum design criteria? If so, can it still be used to gain better understanding of the epidemiologies or the methods used?

- Development of methods to assess more modest effects. Exhaustion of methods of assessment so that one can be satisfied that all methods of assessment have been used and nothing has been missed.

- Development of methods to improve the capacity of implementation among programme staff.

- Development of tools and guides to assess HIV/AIDS prevention activities and programmes.

- Development of systems to connect data collection efforts regarding knowledge of the epidemic and measuring specific activities, interventions, or programmes and management information systems to track service delivery, cost per client. Including how to use evidence of effectiveness and cost, and how to interpret the data to guide management and develop management structures that that can effectively translate management decision into action at the point of delivery. Provision of practical guidance for countries in need.

- Research into which project sites work better and into which factors contribute or subtract from effectiveness in context.

- Development of specific strategies to counter brain drain and bottlenecks in terms of finding insufficiently skilled staff.

- Research into how to answer the question of how many millions of dollars are actually needed every year for prevention in a particular country.

- Research into returns to different prevention interventions and programmes to different scales and in different contexts.

- Research into why HIV prevention is and has been so under-funded.

- Research into how to alleviate risk aversion and thus enable willingness to undertake long-term strategies such as prevention with less instant results. Both in terms of managers and donors.

- Development of methods to enable transfer and use of the newest methods and technologies to people working in the field (Logistic Problem).

- Development of new technologies to measure HIV incidence. Identification of which kinds of information need to be included as part of the bulk of evidence needed to design prevention programmes.

- Research into what prevention approaches work best, where, for whom, and why.

COMING TO TERMS WITH COMPLEXITY:

- Establishment of early warning systems of changes in epidemiological trends much like those warning against Tsunamis or earth quakes. This is very narrowly connected with trying to identify where the next 1,000 infections will occur. Research into how the epidemiological patterns change with the age (maturity) of the epidemic.

- Research into what facilitates systematic implementation of prevention programmes, what bottlenecks hold up progress, and what strength of effort will be necessary. E.g. the Avahan Programme or the Three Ones in India, as well as social involvement at community level and building of capacity and community infrastructure. This is a structural approach, too, and linked with trying to identify the change adverse factors in a society.

- Research into the actual role and contribution of concurrency in the spread of HIV, and to which extend it works alone or in concert with other factors such as low rate of male circumcision, mobility, family separation, religion, and other cultural factors. Establishment of recommendations on concurrency for all HIV prevention efforts.

- More studies of sexual education as a preventive measure.

- Frameworks to identify weak links in concerted efforts and to reinforce those so as not to hamper the whole effort.

- Frameworks to make up for the loss of social momentum experienced in the earlier days of the pandemic, where there seemed to be a correlation between recent social movement and effective mass movements for HIV/AIDS treatment and prevention.

- Establishment of which (additional) areas a HIV/AIDS prevention effort must address (e.g. mitigation of the negative consequences of the epidemic). At least HIV prevention as an integral part of a country’s development plan, active engagement of multiple sectors in government and civil society, effort effectively led at state level.

- Development of operational research and systematic evaluation protocols to capture not only the ways in which integrated interventions which tackle social vulnerability can be made more effective, but also measure their effect on HIV related outcomes such as quality of life, mortality, and changes in incidence.

- Research into the development and adaptation of complexity theory techniques to HIV prevention, such as agent based models to predict future infections.

- Establishment of clear and simple criteria for managing performance within countries and between them.

- Ensuring that monitoring will identify areas that show progress so that they can be sustained and built on.

(Quoted from the 6th article’s Call To Action: )

- Creation of agenda for operations research and evaluation and ensuring funding, focused on what strategies work best under what circumstances, and how best to deliver them.

- Research novel approaches to implementation science and interdisciplinary applications to elucidate ways to tackle the structural drivers of the epidemic

- Continue concerted and continuous search for a HIV vaccine

- Invest in research on many potential HIV prevention technologies, including microbicides and ARV as prevention

- Research into combination approaches to the development of new technologies that not only anticipates new needs but addresses known needs, and encompasses the full range of factors which affect the epidemic.