Lyn@ Community Implementers Forum at the Birchwood Hotel, Boksburg on 24/11/2010

The FPD and the Compass Project launched the Community Implementers’ Guide to TB and HIV Research at a series of events.  This guide was developed with funding from the Kingdom of the Netherlands and the AIDS Foundation of South Africa.CABSA is one of the group of partner organisations of COMPASS, which also includes Soul City, The AIDS Consortium, LifeLine and NACOSA. Download resource below.

As usual, my brief notes from the event is limited by my typing speed, and I apologise to the very interesting and competent presenters if I do not give accurate reflection of their thoughts.  I repeat some of the points I heard. The presentations are available here. and a news report on the meeting here.

The day was introduced by Janine Mitchell from Compass. I later asked Janine why this was an important process for their organisation: (This was my first attempt at a mini video interview!  Thanks Janine for being my "guinea pig" Next time I will eliminate some of the mistakes!)


The aim of the community implementers’ knowledge management process is to ensure that the knowledge from conferences and academic events reaches the community level and makes an impact. 

Janine highlighted the relevant dates for the SA AIDS Conference in 2011 and encouraged the involvement of the NGO community.

The first speaker of the day was Prof Geoff Setswe, Head of the School of Health Sciences, Monash University, South Africa.  As always, he managed to convey the complexities of some of the international research in a clear and concise way.

What is Research? Social and Behavioural Interventions to Prevent HIV/AIDS,

Prof Setswe started with a explanation of What is seen as research evidence?

-          Evidence refers to Facts or Testimony in support of a conclusion statement or belief
-          Proof that something works
-          Law uses witness and other evidence
-          Epidemiology uses randomised controlled trials

Strategies for obtaining research evidence:

-          Systematic review or meta-analysis
o   uses a collection of randomised controlled trials
-          Experimental designs
o   Randomised controlled trials (gold standard)
o   Cohort studies
o   Case control studies
-          Quasi-experimental designs
o   Pre and post test intervention designs
-          Survey designs
o   Cross sectional surveys
o   Case studies
-          Qualitative research
o   Key informant interviews and focus group discussions
o   Participant observation

Prof Setswe emphasised that not all research is viewed equally. In order to show that Certain approaches are classified more highly, he provided the following “pyramid” indicating which types of research is regarded as more credible

H e also proposed the following levels to evaluate the value of research evidence:

Proposed levels of research evidence:

  • 80+% - Best evidence
  • 60-79% - Good
  • 30-59% Promising evidence
  • Less than 30% - Poor or No evidence

Biomedical HIV prevention

Best evidence
– male condom - 80-95%
- female condoms - 94-97%
- PMTCT - 92-98%
Good evidence           
- HAART - 60-80%
- Male Circumcision - 65%
Promising Evidence
-HPTN 035 (PRO 2000) - 30%
- STI Treatment – 40% (in one study)
- RV 144 Thai Vaccine trail -31%
Poor or No Evidence
- HIV vaccine trial network
- early generation microbicides
Randomised Control trials which so far has shown no efficacy
- Behaviour change
- Diaphragm

Behavioural HIV Prevention Interventions

  1. Condom use-
    1. Male Condoms -UNAIDS,  90% effective if consistently and correctly                                                             
      1. Safe and relatively effective for family planning
      2.   Condom use self report in SA increasing significantly in all age groups, with young people 15-24 particularly encouraging (85% M, 73% F) report condom use at last sexual intercourse.
      3. However, in younger adults, MCP also increased.
  1. Abstinence only and ABC interventions
    1. Abstinence only programmes
                                                              i.      Cochrane Meta review of 13 RCT of abstinence only programmes show no reductions or exacerbation of HIV in American youth
    1. No randomised studies of ABC programmes.  Anecdotal reports or reports of isolated small programmes show some success
                                                              i.      “ABC infantilizes prevention, oversimplifying what should be an ongoing strategic approach to reducing incidence” Collins et al AIDS 2008
    1. Behavioural interventions that were successful in increasing knowledge did note necessary change behaviour for young people:
                                                              i.      In school education programmes
                                                            ii.      Mass media
                                                          iii.      Community
                                                          iv.      Workplace
                                                            v.      Health Facility
  1. Voluntary counselling and testing
    1. Changes behaviour for those who are positive, but not for those who test negative
  2. MCP
    1. SADEC think-tank: MCP with low consistent condom use in the context of low male circum
    2. As yet not agreement that there is Cross sectional studies, no RCT or observational studies conclusive evidence that MCP are key drivers of the HIV epidemic in Southern Africa
  3. Structural social HIV prevention intervention
    1. Stepping Stones
                                                              i.       failed to lower HIV-1
                                                            ii.      had variable effect on changing risk behaviour
                                                          iii.      less intimate partner violence
                                                          iv.      problem drinking
                                                            v.      men reported less transactional sex
                                                          vi.      Women reported MORE transactional sex!!
    1. IMAGE Study – Microfinance for AIDS and Gender Equity
                                                              i.      Intimate partner violence decreased by 55%
                                                            ii.      No reduction in unprotected sex or HIV

Summary

Good evidence

-          Condoms
-          HCT for HIV Pos individuals

Promising evidence

-          Stepping Stones and IMAGE on drivers of HIV

Poor evidence

-          Abstinence only
-          HCT on negative
-          Stepping Stones and IMAGE on HIV
-          Concurrency

However, this does not mean that we should stop these interventions:“Behavioural HIV Prevention works!” Dr Helene Gayle

There should not be a fight between behavioural and biomedical prevention interventions – behavioural interventions need to be targeted!

Lyn’s Comment: I think as community implementers we should seriously consider the way we operate and the implication this has on the amount of research available.  Many of what is anecdotally described as good or successful programmes are not documented accurately and the necessary pre and post implementation evaluation is not done.

Dr Kerrigan McCarthy, TB Technical Advisor, Reproductive Health and HIV Research Unit (RHRU), spoke about Integration of TB and HIV,

TB is the top killer of young people in South Africa!

If we understand the way in which the HIV and TB epidemics are intertwined and the drivers of the epidemics, we can create appropriate interventions.

The dilemma with TB is that it can for significant periods be latent and asymptomatic. When we have weakening immune systems, such as with HIV, it can lead to activation of the latent disease, and to the disease becoming infectious.

There are high levels of undiagnosed TB in communities with high HIV prevalence. In a study by Robin Wood et al individuals with TB were typically undiagnosed and infected for a period of more than a year.

More than 80% of South Africans in the study had latent asymptomatic TB infection!

Risk of activation of latent TB:
-          HIV+ 5-10% per year
-          HIV- persons – 10% per lifetime
The drivers of the TB epidemic in the community are Smear positive cases + HIV infection. If we want to address this, we need to:
-          Find, diagnose and treat HIV
-          Find, diagnose and treat TB!
By looking only at smear test, we miss more than half of all TB cases!
By not treating HIV in patient with TB and HIV, we fail!
We need integrated services – the right service, at the right time, to all clients, every time – to ensure we break the HIV/TB cycle
The Roadmap of TB/HIV Care is a useful tool to ensure this happens
-          Treatment should include INH prophylaxis if appropriate
It is critical that TB infection control is practiced in all clinical settings by managing suspended bacilli  in the air. These Bacilli (or TB germs) are extremely small and light and stay suspended for long periods (they float in the air).  Preventing infection
o   Administrative control
§  Manage cough (teach people to cough safely/cough hygiene)
§  Treat patients who are coughing quickly
§  Investigate symptomatic patients for TB
o   Environmental Control
§  Fresh air
§  Ventilation
§  Outside waiting areas
§  Air circulation
§  UV lights
§  PPE and Risk reduction – reduce risk of health workers inhaling
§  Filter
§  Know HIV status
o   Create enabling environment

Don’t wait! We need Integrated HIV/TB services now!

To end a very interesting morning, Dr Janet Frohlich of CAPRISA highlighted a few key points on “Combination HIV Prevention –Need for a paradigm shift in Community Involvement.”

Key issues:

-          Know you epidemic
-          Focussed intervention on specific target population
-          Scale up prevention
-          We need synergy between science and activism
-          Treatment scale up is critical
-          We need a more balanced portfolio of prevention interventions
Change paradigm of HIV prevention science
-          Move from individual to structural interventions
-          We need to move from advisory committees to true ethics of partnership

There is a shift to greater and truer participatory methods and acknowledgement of community significance

Key to research success is that it should be shaped and informed by critical community input.

Social mobilisation through community partnerships is critical to their support

-          Household level mobilisation
-          Address fear of stigma and discrimination

The ethics of community consultation should be considered in the planning, implementation and dissemination of research.

-          Enhanced protection
-          Enhanced benefits
-          Legitimacy
-          Shared responsibility

Acknowledge communities as change agents and advocates in combined prevention strategies!

Gerard Payne from the AIDS Consortium facilitated the Dialogue session. Some of the points raised included:

-          Test and treat as prevention? Affordability, Health system constraints
-          HIV competent communities
-          Is the role of migrant communities accurately reflected
-          Are statistics reliable?
-          We need to ensure that we understand each community’s needs
-          Address household level of understanding through comprehensive programmes starting with social needs and education
-          Can we use street councils to address community needs?
-          How do we use community care workers?
-          Address stigma!! Expand testing

Much to soon the interesting morning was over.  Well done, Compass!

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