Searching for effective HIV-prevention and care in sub-Saharan Africa: focusing on local contexts

Research area(s):
Bio-medical/clinical - HAART
Bio-medical/clinical - PMTCT
Community approaches - General social/cultural
Community approaches - Orphans
Community approaches -Prevention
Epidemiological approaches - Behavioural

Project start:
30.08.2004

Project end:
31.12.2010

Co-ordinators:
Fylkesnes, Knut

Institutions:
Centre for International Health, University of Bergen
Faculty of Health and Social Sciences, Bergen University College
Research Centre for Health Promotion (HEMIL), University of Bergen

Funding source(s):
The Research Council of Norway,

Project description:
Searching for effective HIV-prevention and care in sub-Saharan Africa: focusing on local contexts

1. Background
In Sub Saharan Africa, the severe HIV epidemic is a major factor undermining development. A mounting body of evidence has been generated regarding the devastating impact on child and adult mortality, life expectancy, the social/health sector and economic growth . As HIV seriously impairs productivity, it is both a major cause and consequence of poverty . Poverty, as the driving force of HIV epidemics, was given great emphasis in the declaration of commitment adopted by the Special Session of the UN General Assembly on HIV/AIDS in 2001 . For the first time ever, time-bound targets were established implying much stronger focus on prevention and on the need to readdress global poverty as a necessary part of prevention strategies. Strong international support and co-operation is an obvious prerequisite for the affected countries to be able to reduce incidence and mitigate the impacts of the epidemic.

However, after nearly 20 years of experience with HIV prevention programmes, the number of people infected with HIV continues to rise, and there are still few examples of declining epidemics (4). The low effectiveness of HIV preventive efforts so far, has led to an important debate on priorities in prevention. It has been suggested that many countries are failing because they are not paying enough attention to the local context, e.g. to knowledge on local transmission patterns and risk exposure (5-6). There is an obvious need to tackle structural factors that fuel the spread of HIV. In the short-term perspective, however, plans for effective prevention will have to rely on a proper understanding of the local dynamics and trends of the epidemics. Furthermore, the strong focus on antiretroviral treatment through the "3 by 5" and other initiatives may endanger preventive efforts. Although it has been suggested that treatment may contribute to prevention, the focus on treatment may divert attention from prevention (7). The project will address these possible important effects and interactions between treatment and prevention.

These research and development challenges call for stronger multidisciplinary efforts.
This proposal from the Centre for International Health (CIH), the HEMIL Centre, other departments at the University of Bergen, Bergen University College and the Norwegian Institute for Urban and Regional Research (NIBR) represents a continuation and a further extension/development of the project funded by the RCN/Global health (for 2 years, 01.10.2004-31.10.2006, project number 164049/S30) "Searching for effective HIV-prevention and care in sub-Saharan Africa: focusing on local contexts". The ongoing project is progressing well and will benefit from the extensions outlined in this proposal. The common focus is on the generation of appropriate knowledge on local contexts to guide preventive and care efforts. With NIBR as the new partner we are in the position to extend the focus to critical issues that relate to institutional and financial structures at national and local levels and related capacity aspects of the collaboration between the public sector, civil society and NGOs.

2. Objectives
Based on the above description of the knowledge-gap regarding effective HIV interventions and the recognised need for stronger multidisciplinary efforts, we propose a project which will enable different disciplines/research groups already involved in research and development relevant to HIV prevention and care, to strengthen joint efforts. The programme is a continuation and extension of the RCN/Global health funded research project 164049/S30 (2 years, 01.10.2004-31.10.2006).
Overall objective
Strengthen HIV prevention through i) studies on factors determining differential transmission and the use of research-based frameworks in the development of new and evaluation of ongoing community interventions, ii) appropriate communication processes.
Specific objectives
• To study patterns and trends of HIV transmission, risk exposures and their determinants.
• To study inter-personal communication on sexuality and risk related to HIV among adolescents.
• To study ongoing HIV interventions in terms of social and cultural aspects of prevention and adherence to care/treatment.
• To study community and caregiver responses and strategies to meet the needs of orphans.
• To generate knowledge on the i) institutional and financial structures for local level implementation of national HIV programmes, ii) collaboration between public sector and civil society) to achieve joint capacity for local level HIV prevention and care, and iii) equity issues.

3. Activities and research approaches

This project is linking ongoing research projects established in co-operation with partner institutions in sub-Saharan Africa (with severe HIV epidemics) and partner institutions in Europe. A common feature of these projects is that better understanding of local contexts is considered a key. This joint proposal is a response to the urgent need to document what works in concrete community-based HIV intervention and care programmes. It accommodates overlapping research components involving multidisciplinary research groups. Component 1, the application of epidemiological approaches to studying transmission and risk (see below), is of general relevance to all the other proposal components. The study on communication on sexuality and HIV-related risk among adolescents (Component 2) is part of a school-based intervention research project to develop cost-effective and culturally sensitive interventions. Components 3 are studies that will employ different qualitative methods in the search for a better understanding of how different groups respond to ongoing preventive interventions and in relation to the complex issues of adherence in particular. The 4th component is part of an action oriented research project focusing on how communities and caregivers respond to the needs of children orphaned by AIDS, including risk factors among these children. Finally, in the 5th component, the research focus will be on critical issues that relate to institutional and financial structures at national and local levels and related capacity aspects of the collaboration between the public sector, civil society and NGOs.

4. Deliverables and expected results
The ongoing project made it possible to recruit one researcher, one-postdoctoral fellow and 3 PhD fellows, with the postdoctoral fellow and 1 PhD funded by the UoB as part of "own funding" to projects supported by the RCN/Global Health (see detailed description below). UoB will continue to fund these two positions if continued RCN support is achieved for 1 more year (postdoc and PhD). UoB will in addition for this application round offer own funding in terms of 1 PhD fellowship over 4 years. The input in terms of positions to be involved are:

Funded by RCN:
- 2006-2008: 1 new PhD (related to component 5)
- 2007: 2 PhDs given a third year of funding as a continuation of the ongoing project
- 2008-2010: 1 post doctoral fellowship linked to component 1
- 2009-2010: 1 post-doctoral fellowship linked to component 4
- 2006-2010: 2 25% position researchers linked to component 5.
Funded by UoB:
- 2006-2009: 1 PhD (open)
- 2007: Continue funding of 1 PhD (related to component 1)
- 2007-2008: continued funding of 1 post-doc. (related to component 3)

Generated outputs in terms of publications: approximately 25 publications in international journals and one edited book. All new candidates will take part in the organized PhD training at the respective partner institutions. The research group will arrange regular workshops for the senior scientists, the research fellows and a selection of the most relevant partners in the different components. The research group will during the project period arrange international conferences in collaboration with the HIV Research Net funded by RCN (2004-2007). This will be done through a joint effort with the research groups in partner institutions in the South as specified in the NUFU- and EU-funded projects related to this proposal.

Dissemination of results will be made to the scientific community as well as to policy makers and administrators in the collaborating countries and will take place in relation to the scientific workshops and meetings of the NUFU- and EU-funded projects groups that form the basis for this collaboration. Furthermore, to secure implementation of relevant research findings, the project will provide input to the development of plans and strategies in the relevant communities and countries for improved HIV prevention and better care for orphaned and vulnerable children. Development of appropriate communication strategies and materials will be a part of these activities.


5. Components and principal investigators and links to partners

Component 1: Studying dynamics and trends of HIV transmission, risk behaviours, socio-demographic impact and the link to preventive interventions.
Principal investigator: Professor Knut Fylkesnes, Centre for International Health.
This study is linked to an ongoing NUFU-funded project in Zambia and a EU-funded project, REACT, in Zambia, Kenya and Tanzania where CIH is responsible for the HIV-related work package.

Component 2: Interpersonal communication on sexuality and risk related to HIV/AIDS - a study among adolescents in Tanzania and South Africa
Principal investigator: Professor Leif Edvard Aarø, Research Centre for Health Promotion, UoB. This component is linked to the EU-funded SATZ project that was fully described in the initial application for 3 year funding.

Component 3: Social and cultural aspects of HIV prevention and adherence to care/treatment.
Astrid Blystad is Karen Maie moland are the principle Investigators.

Both studies have components in Tanzania (at Haydom Lutheran Hospital – HLH- and at Kilimanjaro Christian Medical Centre (KCMC) respectively) and in Ethiopia (at Yirga Alem Hospital and in Dilla).

Component 4: Community and caregivers’ responses and strategies to meet the psychosocial and developmental needs of children orphaned by AIDS in selected areas of Tanzania
Principal investigator: Professor Gro Th. Lie, Centre for Health Promotion, University of Bergen.

Component 5: Strengthening local level institutions and decentralised implementation of national HIV programmes: analysing institutional collaboration patterns, local level capacity and equity of programme funds in Malawi, Tanzania and Eritrea
Principal investigators: Berit Aasen, Senior Researcher at Norwegian Institute for Urban and Regional Research (NIBR) and Associate Professor Dr. Arild Schou, Buskerud University College HIBU.

Countries: