AIDS Alert International
Taking prevention from research to reality is tricky
Investigator offers fresh ideas to make it work
One of the major problems the HIV prevention field has had is translating successful research into success in the real world. This challenge is even more of a hurdle when it comes to sending successful programs designed in the United States to sub-Saharan African and other developing world settings.
"The problem in the AIDS area is the major journals are read primarily by other scientists, but the real users of our work are AIDS service organizations," says Jeffrey A. Kelly, PhD, a professor of psychiatry and behavioral medicine and director of the Center for AIDS Intervention Research at the Medical College of Wisconsin in Milwaukee, WI.
"Those organizations generally don't have access to our journals, or they're written in the wrong language," Kelly says. "Or even if they could access the articles, the description of the program is usually a couple of paragraphs long, and no one could possibly replicate an intervention from that description."
So there's a disconnect between good HIV prevention research and the implementation of that research in the field.
"No matter how good our research is, if it isn't transferred to HIV providers, then the research on its own isn't contributing to public health and preventing the disease," Kelly says.
"I think all of us in the HIV prevention area want to see our intervention used, so we think if it works we want to create a manual so other people will use it," Kelly says. "What the field has not done much of is scientifically study how to transfer what we've learned to providers, and that's the area that interests me."
For the 95 percent of HIV infections occurring outside of the United States, most of the prevention work is carried out by non-governmental organizations (NGOs), Kelly notes.
"Researchers know quite a bit about the principles of behavior change, but good NGOs know much more about their community, their community's needs, their community's culture," Kelly explains. "So we're trying to bring together here two bases of knowledge: one in the scientific arena, and the other is what providers know from their experience."
Investigators approached this transfer of prevention program information with the philosophy that there are core elements common across all effective interventions.
"We wanted to get people to carry out adult community programs with these characteristics," Kelly says. "How they did this and what they wanted to emphasize was up to them."
So researchers tried to train NGOs about these core elements rather than focus solely on the intervention, he says.
"A lot of people say, 'We provide manuals for interventions,'" Kelly says. "But we're among the few groups studying the science of dissemination and faster uptake of interventions, and that's a niche that I think is very important."
Since thousands of the NGOs have little access to evidence-based prevention interventions, Kelly has researched how to bring this information to them in a way they can adopt and adapt for their own purposes.
"We developed a curriculum in the popular opinion leader intervention and community level intervention," Kelly says. "This is the kind of model the NGOs said they'd find useful."
Investigators created an interactive curriculum that can use audio and video streaming to model intervention techniques. It has self-pace segments to guide an organization through planning, carrying out, and then sustaining a program based on the model, Kelly says.
It's relatively simple to create a Web-based program for NGOs, but the challenge is in using advanced communication technology as a training tool, Kelly says.
"One immediate issue was that most of the NGOs don't speak English, so we developed everything for the project in four different languages: English, French, Spanish, and Russian," Kelly says. "It was quite a technical undertaking, developing all of these materials in all of these languages."
Researchers contacted leading NGOs in the capitol or large cities of 78 countries, and these NGOs became the study's participants, he says.
Studying how the NGOs adapted and implemented the prevention programs was very difficult logistically, Kelly notes.
Investigators had to assess how interventions worked in these very different environments: "How did the popular opinion leader intervention work when carried out with drug users in a post-Soviet country?" Kelly says. "How did it work with high school kids in Latin America?"
Designing a trial in this way is the first hurdle. Then there is the issue of control over the intervention. For instance, the NGOs likely will want to make changes, but how many changes are too many for it to be meaningfully studied? And is there anyway of proving that the NGOs implemented the intervention in the way they say they did, he asks
"These trials are logistically very difficult to do," Kelly says. "You have to have lots of providers carrying this out, and you have to have ethics research approvals when there are a lot of messy questions."
One of the bigger issues in technology and information transfer across oceans is that interventions often are developed around what is most important to the researcher, Kelly notes.
"I believe that a part of the technology transfer process is not moving interventions from the research arena to providers, but listening to providers and creating an intervention that is needed in the world," Kelly says. "It's bi-directional."
If investigators are studying interventions that cannot be used practically in the real world, then they're developing the wrong interventions, he says.
"We need better, mutual, reciprocal interventions in which providers inform the research," Kelly says. "We have to remember that if what we're researching is not useful in the field, then we're not really helping and being effective."