Scaling Up Treatment for the Global AIDS Pandemic Challenges and Opportunities (2005) / Chapter Skim
Currently Skimming:
6 The Path Forward
6 The Path Forward
Pages 176-198
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From page 176... ...
To this end, this chapter sets forth critical operations, applied clinical, and behavioral research that will be crucial in a number of key areas. It concludes by emphasizing that even with iterative improvements obtained through solid research, the path forward will require sustained, long-term commitment.
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From page 177... ...
These threats would not necessarily be evident in a pilot program whose relatively modest requirements were, in the grander scheme, absorbable or even resourced external to the underlying health care infrastructure. Various avenues might be pursued to mitigate this risk of collateral negative effects, although scientific evidence would likely be needed to assess the advisability of different options.
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From page 178... ...
· Foster programmatic fiscal security through pooled funding. · May help avert resource imbalances and negative collateral effects that can occur with well-funded vertical programs.
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From page 179... ...
Not infrequently, newly integrated health-sector programs have shown signs of failure due to such factors as lack of capacity among managers to deal with new tasks, inadequate technical supervision as hierarchies are removed, weak logistic support for carrying out necessary procurement, weak monitoring systems, misplaced foci in capacity building, change that was too swift with resultant gaps, and immature planning systems. Sometimes resources to support a particular activity end up reduced as vertical programs are integrated and resources shifted.
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From page 180... ...
Learning by Doing Through Operations Research Regardless of whether specific pilot initiatives prove to be replicable or integrated programs become the favored option, the complexities and challenges of implementing ART programs countrywide and on a much larger scale than that of any pilot initiative conducted thus far highlight the reality, emphasized earlier, that ART scale-up will largely be a learn-by-doing process. By feeding lessons learned back into the treatment and care systems, ART scale-up can be accelerated; become more effective in terms of improving both patient and population health, as well as increasing costeffectiveness; and achieve the success needed to ensure continued donor support.
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From page 181... ...
But as scale-up proceeds and as ART programs expand, so will the need and opportunity to conduct such research in parallel with program implementation. As noted, one of the most critical concerns with regard to operations research pertains to funding and the reality that most medical research worldwide is not linked to the provision of health care.
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From page 182... ...
· What is the role of community-based organizations in ART programs? · When should ARVs be administered?
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From page 183... ...
: · To coordinate and help develop an appropriate operations research agenda relevant to the needs of ART programs. · To seek data on the impact of scaling up ART on prevention and risk behav ior, on mitigation, and on stigma and discrimination.
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From page 184... ...
has been cited as one example of a program specifically developed to facilitate and coordinate the exchange of clinical research information, in this case between scientists in The Netherlands and Australia and Thai investigators in an effort to address treatment questions of particular relevance to Thailand (The HIV Netherlands Australia Thailand Research Collaboration, 2004)
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From page 185... ...
APPLIED CLINICAL RESEARCH The WHO guidelines provide an excellent, evidence-based set of criteria for determining when to initiate therapy, how to monitor therapy, when to change drugs or regimens, how to incorporate care and treatment for opportunistic infections into ART, and so on. Nonetheless, the recommendations are intended to serve only as a starting point for the development of national guidelines.
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From page 186... ...
Operations research can also help develop optimal programs for ARV resistance screening in individuals and surveillance in larger community populations. Several different methodological approaches could be used in applied clinical research.
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From page 187... ...
Development and field evaluation of simple, rapid, inexpensive laboratory tests for diagnosing HIV infections and for monitoring therapeutic responses should be a high priority. The shortage of laboratories and laboratory technicians in resource-poor countries, together with the millions in need of HIV testing and treat ment monitoring, underlines the priority of developing tests with these characteristics.
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From page 188... ...
Another priority for applied clinical research arises from the vital role of prophylaxis for opportunistic infections, including TB, in reducing AIDSrelated mortality, at least in the short and medium terms. This point is illustrated by the experience of both Brazil and South Africa.
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From page 189... ...
BEHAVIORAL RESEARCH Implementing ART in resource-poor settings poses difficult, complex medical, technical, and logistical questions, many of which have yet to be addressed through operations research programs. Yet many would argue that the social and behavioral dimensions of scaling up ART programs raise equally, if not more, challenging questions.
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From page 190... ...
and encouraging more people to seek counseling and ART, it cannot be assumed that this will inevitably happen. Since prevention and treatment programs must be intertwined for optimal synergy, behavioral research is needed to better understand how not only to foster adherence to ARV regimens, but also to improve primary prevention.
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From page 191... ...
Strategies in this area encompass creating settings that support testing and counseling and encouraging practices that prevent transmission between HIV positive and negative persons, such as delaying the onset of sexual activity in young people and encouraging proper use of condoms when serostatus is unknown. Using the family to foster norms supportive of safer sexual practices and therapeutic adherence, providing HIV/AIDS education within the context of the family, and enhancing communication skills between parents and their children can be effective strategies for reducing detrimental behaviors.
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From page 192... ...
. Accordingly, a priority research objective is to better understand how to design effective HIV prevention and treatment interventions for women and girls, including how to improve adherence.
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From page 193... ...
Improving Methodological Tools To address the above behavioral research needs rapidly and in a meaningful manner, the qualitative and quantitative methodological tools used in behavioral research, including those for evaluating HIV prevention interventions, need to be strengthened and expanded. New and rigorous methodological and statistical techniques should be encouraged.
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From page 194... ...
Research is needed as well to better understand the underlying factors that contribute to the co-occurrence of HIV/AIDS and the progression of AIDS with other infectious diseases, substance abuse, alcohol abuse, and mental illness. Such research should encompass how to design efficacious and cost-effective strategies for addressing such comorbid conditions.
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From page 195... ...
Considering the familial, political, economic, and institutional destabilization that could well occur without these infusions of assistance, as well as the costly international military responses that could be required to restore and maintain peace (and ensure access to important natural resources) as a result of such breakdowns, ongoing support for ART programs may well be more economically prudent than the alternative.
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From page 196... ...
Cape Town, South Africa: South African Medical Research Council. The HIV Netherlands Australia Thailand Research Collaboration.
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From page 197... ...
Clinical Infectious Diseases 37(Suppl 1)
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