Behavioral Practices Research Priorities
Thomas J. Coates, PhD Michael and Sue Steinberg Professor of Global AIDS Research Director, UCLA Program in Global Health David Geffen School of Medicine University of California Los Angeles
Behavioral Practices Research Priorities
What do we need to know? About whom? For what purposes? Who gets the data and how soon? Must always be cognizant of disparities (between and within countries) Time to Change the Framework HIV prevention is more difficult than anyone ever imagined it would be HIV prevention is even more difficult now HIV is no longer a highly lethal disease when treatment is accessible as well as continuous and monitoring is adequate Combination prevention is the order of the day Prevention cannot be subtle or short-term; needs to be multi- level, sustained, and constantly changed in response to community needs The best solutions are not imposed from outside Testing and treatment are integral to prevention And prevention needs to be a central part of treatment HIV prevention is not always the priority of leadership in established or emerging advocacy movements HIV prevention is not always the priority of people at risk of acquiring or spreading HIV Holistic Approach to Prevention Holistic Approach to Prevention Holistic Approach to Prevention San Francisco Young Men’s Health Study
AJPH, 1994; 84: 1933 -37 Holistic Approach to Prevention
Scheer et al, STI, in press Holistic Approach to Prevention
Scheer et al, STI, in press Combination Prevention
Treatment/ Behavioral ARV/STI/ LeadCommunity Change Antiviral
Highly Active HIV Prevention
Biomedical Social Justice
Leadership& scalingup of Strategies and Human treatment/preventionefforts Rights
Coates, Richter & Caceres, The Lancet, 2008 Provided by Courtesy of Robert Bank, GMHC Provided by Courtesy of Robert Bank, GMHC Provided by Courtesy of Robert Bank, GMHC Typical Studies Usually with Different Samples
Behavioral epidemiology Correlates of risk Evaluations of preventive interventions Randomized controlled trials Program evaluations Treatment Access, facilitators and barriers, adherence HIV testing Rates, barriers, facilitators, outcomes It’s a Different World Now
Antiretroviral Therapy Cohort Collaboration Crude mortality rates decreased from 16.3 deaths/1000 person years in 1996-99 To 10 deaths/1000 person years in 2003-05 7.5 deaths/1000 person years for those under age 45 Life expectancy at age 20 increased from 36.1 to 49.4 years
Lancet, 2008; 372: 293 -299
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Photo Courtesy of Bernie Branson - CDC Difficulties Difficulties Difficulties
AmFAR : MSM, HIV and the Road to Universal Access Implications of the New Framework Range of Behaviors Are of Interest
Behavioral epidemiology Prevalence and incidence of male-to-male sexual and health-seeking practices Characteristics of individuals and groups engaging in M-T-M sex and how they access health care Descriptions of venues and circumstances of M-T-M sex and perceptions and practices related to health care Implications of the New Framework Range of Behaviors Are of Interest
Actions to avoid acquiring HIV Decrease in number of partners Serosorting Seropositioning Avoiding certain behaviors Using protective devices Using antivirals (orally or anally) Male circumcision Implications of the New Framework Are we sex police or prevention specialists Implications of the New Framework Range of Behaviors Is of Interest
Testing and retesting Care-seeking And barriers to care Adherence to medications Actions to avoid spreading HIV Disclosure Implications of the New World Other Experiences Are Important Too
Behavioral responses to Legal and social discrimination
Empirical legal research Violence and climates that condone such violence Discriminatory or stigmatizing health care systems Disparities in access to new technologies, devices, and medications Implications of the New World Re-examine Frameworks for Assessing Determinants/Correlates Deficit models Skills, intentions Drugs, mental health, past experiences Stigma, discrimination, oppression Paternalistic models Strength or choice models People make choices to have certain kinds of sexual encounters under certain conditions Determinants/Correlates
Proximal Substances Behavioral options Mental Health Somewhat distal Very distal SEC Abuse Implications of the New World Program Efficacy
Across the spectrum of uninfection to diagnosis to infection to treatment Meanings and circumstances of sexual activities and practices as well as easy and non-discriminatory access to health care Top down or bottom up? Implications of the New World Advocacy and Community Development
What leads to community development? What leads to formation of advocacy groups? What leads to effective policy change? Implications of the New World Let’s Go Where We Have Limited Information
Focus on those parts of the world with the least data Or those populations in developed countries with the least data Incorporate data on male-to-male sex within the DHS (Demographic Health Surveys) Include transgenders
Caceres, Aggleton, & Gales, AIDS , 2008 Where Are Data and Where Data Are Not
31 middle income countries vs. 7 low income countries 15 from the Americas 7 from Asia 12 from Europe 4 from Africa
Baral, Sifakis, Cleghorn, & Beyrer PLOS Medicine 2007 Time to Change the Framework
Behavioral practice studies need to be linked to epidemiology but not constrained by that science Also needs to be linked to social and clinical science as well as legal and human rights studies People may have higher priorities than avoiding HIV HIV prevention and care behavioral research needs to acknowledge and accommodate this reality Comprehensive perspective on behaviors/practices based on combination prevention/treatment framework Needs to include the full spectrum of behaviors/practices that protect against HIV at the individual and community level New models and more powerful or explanatory studies of determinants/correlates Improved evaluation models Here Are the Challenges
We know quite a bit so the goal is not just to conduct more research Goal would be to change the research framework Behavioral/practice research needs are highly contextual Let’s not come up with a laundry list How do we collect data that are usable and get it into the right hands in a timely way? How can we prioritize?