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JAIDS Journal of Acquired Immune Deficiency Syndromes:
doi: 10.1097/QAI.0b013e3181605e5d
Conclusion

Future Directions for HIV Prevention Research: Charting a Prevention Science Research Agenda

DiClemente, Ralph J PhD*†; Wingood, Gina M ScD, MPH*†; Blank, Michael B PhD‡§; Metzger, David S PhD‡§

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From the *Rollins School of Public Health, Emory University, Atlanta, GA; †Social and Behavioral Sciences Core, Center for AIDS Research, Emory University, Atlanta, GA; ‡Department of Psychiatry, School of Medicine, University of Pennsylvania, PA; and §Social and Behavioral Sciences Core, Center for AIDS Research, University of Pennsylvania, PA.

Correspondence to: Ralph J. DiClemente, PhD, Rollins School of Public Health, 1518 Clifton Road, NE, Suite 554, Atlanta, GA 30322 (e-mail: rdiclem@sph.emory.edu).

Globally, the HIV epidemic continues to exact a substantial toll on the health and well-being of many, causing considerable morbidity and mortality as well as significant disruption to the social and economic infrastructure of severely impacted countries. The HIV epidemic exploits and amplifies existing social and economic disparities in many parts of the globe, particularly in sub-Saharan Africa.1 Productivity has been adversely affected, and national revenues have and may continue to decline. HIV is undermining human capacity and, through early death and prolonged illness of key segments of the workforce, is incapacitating systems, making attempts at improving governance increasingly challenging. The net effect is institutional fragility and a downward spiral of reduced state capacity, creating an environment that, unfortunately, further exacerbates the HIV epidemic.

The scope of the HIV epidemic is daunting. Since the first cases of AIDS were reported in 1981, infection with HIV has grown to pandemic proportions, resulting in an estimated 65 million infections and 25 million deaths.1 During 2005 alone, an estimated 2.8 million persons died from AIDS, 4.1 million were newly infected with HIV, and 38.6 million were living with HIV. HIV continues to disproportionately affect certain geographic regions (eg, sub-Saharan Africa, the Caribbean) and subpopulations (eg, women in sub-Saharan Africa, men who have sex with men [MSM], injection drug users [IDUs], sex workers). Although effective prevention and treatment of HIV infection with highly active antiretroviral therapy (HAART) are now available, even in countries with limited resources, there remains an urgent need to develop comprehensive programs and expand access to reach all persons who require treatment and prevention services.

At the core of the HIV epidemic is “behavior.” Although HIV is the etiologic agent associated with AIDS, it is people's behavior, or rather the lack of appropriate HIV-preventive behavior, that propels the epidemic. However, HIV-associated risk behavior is not random, uncontrollable, or inevitable. Indeed, HIV-associated risk behavior is modifiable. Whether the behavior in question is condom use, reducing the number of sexual partners, cleaning IDU equipment, or adherence to HAART, it is behavior that is the root cause of the epidemic and it is that behavior that must be modified to stem the epidemic.

Currently, correct and consistent condom use is one of most efficacious methods for the prevention of sexually transmitted HIV. New biomedical interventions for HIV prevention, such as prophylactic microbicides, pre-exposure prophylaxis (PrEP), suppression of genital herpes (herpes simplex virus-2 [HSV-2]), and cervical barriers, are in various stages of development and evaluation. Underlying all these prevention approaches is behavior, with behavioral and biomedical approaches requiring the adoption and maintenance of HIV prevention strategies over protracted periods of time. As new biomedical prevention technologies are developed, however, social/behavioral science needs to be integrated with biomedical science to understand acceptance, adoption, and adherence to these technologies better and to address such concerns as condom migration, behavioral disinhibition, partial efficacy of the technologies, and access to these technologies should they be efficacious in reducing HIV infection. Indeed, even the advent of an effective prophylactic microbicide for men or women would not be optimally efficacious without adherence. Thus, social/behavioral scientists and biomedical scientists need to collaborate to enhance HIV-preventive behaviors, whether that behavior is condom use, adherence to HAART, adherence to microbicide use, or acceptance of an HIV vaccine.

As the HIV epidemic continues to evolve, so too must we as social and behavioral scientists evolve our thinking, our research, our interventions, and our methodologies to confront this epidemic. In this issue, we report a series of publications that emerged from the First Social and Behavioral Sciences Research Network (SBSRN) Conference held in Philadelphia in October 2006. The SBSRN conference was designed to create an infrastructure for social/behavioral scientists and biomedical scientists to interact in a collegial environment with the endpoint being the exchange of topical and relevant information and the formation of research ideas and interdisciplinary research teams. By marshaling new data, we hope to address new research questions, create new opportunities for interdisciplinary collaboration, and utilize more efficiently limited existing resources.

The articles presented in this issue reflect the collaborative exchange of ideas in task groups. They address emergent issues that are critical for confronting the HIV epidemic. They do not, however, represent an exhaustive portfolio of topic areas for HIV prevention. That would be beyond the scope of this supplement. Moreover, rather than attempt to recapitulate these articles, our goal is to highlight key recommendations for future HIV prevention research.

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RECOMMENDATIONS

1. Enhance support for developing and evaluating mentoring models, whereby social/behavioral and biomedical scientists collaborate in providing interdisciplinary training and support to nurture the next generation of HIV prevention scientists.

2. Enhance support for developing much needed tools in the area of HIV prevention, including user-friendly automated computer software packages to enhance the standardization and collection of cost data and mathematic modeling to examine the effects of a diverse array of determinants on HIV transmission dynamics.

3. Enhance support for developing models that guide the adaptation of evidence-based HIV interventions and promote the development of phase 4 HIV prevention effectiveness trials to facilitate quantization of an intervention's “true” public health benefit.

4. Enhance support for understanding HIV risk among understudied populations, such as African-American men, and for examining barriers to providing integrated services for populations, such as doubly and triply diagnosed patients with HIV/substance abuse/mental illness.

5. Enhance support for collaborative research designed to examine and reduce health disparities that fuel the HIV epidemic.

6. Enhance support to foster collaboration between social/behavioral and biomedical scientists in the development, implementation, and evaluation of biomedical HIV prevention approaches.

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CONCLUSIONS

The challenge of preventing HIV is formidable. Our experience over the past 2 decades has shown that the HIV epidemic continues to evolve, is relentless, and is devastating from an individual and societal perspective. The SBSRN conference and the articles spawned from that conference represent an attempt to capitalize on the interdisciplinary collaboration of prevention scientists to accelerate innovation in the field of HIV prevention. Although the research agenda charted through our recommendations are not exhaustive, they do reflect critical gaps in the field. Addressing these gaps through the development of targeted research programs requires mobilizing support for the allocation of resources to countenance these critical issues adequately. Without adequate resources to conceptualize, stimulate, and support the HIV prevention agenda further, we miss an opportunity to advance the science of HIV prevention significantly and, more importantly, to have an impact on the HIV epidemic.

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REFERENCE

1. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2006 Report on the Global AIDS Epidemic. Geneva, Switzerland: UNAIDS; 2006. Available at: http://www.unaids.org/en/hiv_data/2006globalreport/default.asp. Accessed September 14, 2007.

© 2008 Lippincott Williams & Wilkins, Inc.

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