There is growing recognition in international development that research is never purely an academic exercise. We often hear that research should provide evidence that can be used to strengthen policy and programming for vulnerable populations. In other words, we are aiming for policy relevant research because this will improve the lives of citizens. Policymaking is not a straightforward process and can be a messy exercise, with domestic political agendas, norms, values, regional commitments and global movements all influencing the way policy is formulated and implemented. Evidence is often regarded as a neutral player in the game and promoted for its ability to present scientific facts and logic without favouring a specific policy outcome.
There is a silent global epidemic of sexually transmitted infections (STIs) that is threatening to undermine health gains as well as prospects for reaching the Sustainable Development Goals. It seems that insufficient attention is being paid to these diseases that undermine the health of adults and cause congenital abnormalities and death in infants.
Global data from WHO in 2016 shows that there were 357 million cases annually of four curable STIs (chlamydia, gonorrhoea, syphilis, trichomonas), and around 300,000 foetal and neonatal deaths from syphilis in pregnancy. This latter is more than double the number of AIDS-related deaths in children under the age of 14 years globally, which UNICEF estimates at 120,000 in 2017.
We apply various forms of evidence to navigate controversy. Evidence is sometimes regarded as a neutral player in the game, presenting scientific facts and logic without favouring a specific policy outcome. But as we know, for HIV prevention for key and vulnerable populations, the picture is a lot more complicated.
AIDS Impact 2017
Without youth-friendly services, the battle for adolescent sexual and reproductive health will be lost. Early findings from three of EHPSA’s adolescent research studies, presented at the AIDS Impact Conference in Cape Town (November 13-15, 2017), reflected on this conundrum in different ways.
The Girl Power study in Malawi presented findings from focus group discussions, where young people compared the clinics in the experimental arm of the study to standard care. Four major differences emerged...
While it is generally agreed that the HIV response has failed adolescents, there has been relatively little attention paid to the some two million HIV-positive adolescents in sub-Saharan Africa who have been truly “left behind”.
The Mzantsi Wakho study, which is partly funded by EHPSA, has spent the past three years trying to understand the lives and needs of positive adolescents in South Africa’s Eastern Cape province. Researchers interviewed 1,060 HIV-positive adolescents receiving care in 53 health facilities - visiting them in 150 schools and homes. This is the largest cohort of positive adolescents to be studied worldwide, and findings presented on Tuesday at the AIDS Impact Conference in Cape Town should go some way towards filling a serious evidence gap.
The opening session of the 13th International AIDS Impact Conference in Cape Town (13-15 November 2017) laid bare the challenges ahead for the global HIV community. On the one hand, the campaign to scale up HIV treatment has been successful and, according to UNAIDS South African country director Mbulawa Mugabe, 18 million people are accessing the drugs. We are well on our way to meeting the agreed 90-90-90 treatment targets.
On the other hand, new HIV infections are unacceptably high, particularly among adolescents in eastern and southern Africa. There are two thousand new HIV infections a week among South African girls and young women: two thousand reasons to do things better.
Did you know you can create really professional-looking icons, figures and infographics in PowerPoint? I discovered this for the first time during the EHPSA Communications workshop that we hosted for RRIF researchers in Johannesburg in early November 2017.
Now that EHPSA researchers are in the final stages of their studies they require a range of skills to disseminate and communicate their findings to appropriate audiences. The workshop was also attended by colleagues from the UNAIDS Regional Support Team for Eastern and Southern Africa who had the opportunity to network with researchers and learn new skills.
Global Evidence Summit, 2017
The last day of the 2017 Global Evidence Summit was packed with a fascinating convergence of concepts and experiences, largely devoted to the role of evidence in a “post-truth” world. It was also the day for EHPSA’s presentation on its approach to Evidence into Action.
Last year, “post-truth” was named word of the year by Oxford Dictionaries, mainly driven by the popularity the word gained within the context of the US elections and the Brexit movement.
Day 3 of the 2017 Global Evidence Summit focussed on how international collaboration and innovative technology can be used to solve emergent global crises and what is needed to prepare for future epidemics. The early morning plenary session explored different tools, methodologies and platforms for rapid production and appraisal of evidence in the face of an epidemic.
Global Evidence Summit, 2017
Day 2 of the Global Evidence Summit 2017 focused on evidence ecosystems, with different sessions exploring the links between actors and strategies for closing the gaps between evidence and improved care.
Various papers were presented showing different evidence ecosystems, but all shared a common set of players: producers, synthesisers, disseminators, implementers and evaluators/improvers. Not only does this ecosystem have to be balanced for evidence to be used effectively, but the ecosystem itself must be able to exist alongside and within other broader societal systems. Simply put, having evidence is one thing, making the evidence work within complex socio-cultural ecosystems is another thing.
Global Evidence Summit, Day One
The most important message from day one of the Global Evidence Summit surfaced in the context of the role evidence can play in transformation and the struggle for universal equity. Harasha Doyal of the South African Government Department of Planning Monitoring and Evaluation (DPME) told the meeting “...Rigour must not trump relevance”. She said that consensus needs to be reached on what evidence is needed, when, why, and in what form - to ensure that it contributes to transformation unpinned by the principle of equity.
EHPSA is represented at the 2017 Global Evidence Summit in Cape Town, South Africa, which ha the overall theme Using Evidence, Improving Lives.The summit, which is being held for the first time on the African continent, brings together over 1400 delegates from 77 countries to share experiences and deliberate on how evidence can be used to improve the quality of people’s lives.
On Saturday EHPSA will be presenting learning from the programme – so watch this space!
There is growing recognition in international development that research is never purely an academic exercise.
We often hear that research should provide evidence that can be used to strengthen policy and programming for vulnerable populations. In other words, we are aiming for policies and programmes that are informed by evidence because this will improve the lives of citizens. From our experience in EHPSA I would like to debunk five popular myths about Evidence into Action (EiA).
Myth number 1: Evidence is neutral
Zambia and the 90s
An EHPSA-funded study, P-ART-Y*, is providing insights into the challenges and progress towards achieving the ‘three 90s’ targets for adolescents in Zambia.
A session at IAS 2017 in Paris was devoted to interim findings from the large PopART study (HPTN 071) in which P-ART-Y is nested. After two years of this multi-pronged intervention it was estimated that 87% of Zambians now know their HIV status –the country is well on its way to achieving the first 90.
At a Tuesday session at IAS 2017, Jpiego’s Daniel Were presented Kenya’s approach to a national scaled-up programme that is based on the latest epidemiological data. The evidence shows that young people count for 46% of Kenya’s new infections and key populations experience a disproportionate burden of HIV, with 29.3% of sex workers and 18% of MSM 18% being infected.
IAS 2017, July 23-26
At the opening session of the 9th IAS Conference on HIV Science in Paris, IAS Chair Prof Linda-Gail Bekker compared the global environment with that of the previous conference, commenting that since 2015 it seems that “the world has turned upside down”. Not least of which, the period has seen a decline in global funding for HIV, and important donors are proposing substantive cuts to research and treatment. This threatens to erode former gains. But, says Bekker, these setbacks can lead to new partnerships and “creativity can grow out of chaos”.
South Africa’s National Strategic Plan (NSP) for HIV, TB and STI’s 2017 – 2022, not surprisingly, dominated the June 15 closing plenary session of SA AIDS 2017. Dr Connie Kganaka, acting CEO of the SA National AIDS Council (SANAC), provided an overview of the eight goals of the NSP. She emphasised Goal 6, which focuses on promoting leadership and shared accountability for a sustainable response. This is a new inclusion in the NSP and attempts to foster a collective responsibility or “mutual accountability” across sectors and SANAC structures.
A spanner in the works?
“PrEP is here and in our toolbox today,” said an upbeat Prof Linda Gail Bekker, IAS Chair and Deputy Director of the Desmond Tutu HIV Centre. Wednesday’s plenary session at the 8th SA AIDS Conference was devoted to the “nuts and bolts of HIV prevention”. Leading scientists discussed advances in biomedical research including pre-exposure prophylaxis (PrEP), vaccine development, steps towards a functional cure and the latest thinking on HIV transmission dynamics, drug resistance and barriers to elimination.
The opening session of the 8th SA AIDS Conference, “The Long Walk to Prevention”, set the scene by inviting youth voices to frame the major challenges ahead for HIV in the region. The conference began in darkness with the voice of 22-year-old Saidy Brown reading a personal poem to HIV. “Because of you,” she said, “there goes all my happy days”.
In a carefully scripted drama, a group of young people took us through all the parameters of youth HIV risk: poverty, gender-based violence, stigma against young key populations, the generation divide... They made a convincing plea to be involved as active partners in big decision-making, complaining that HIV organisations are filled with old people whose top-down programmes have failed to work, “Stop starting new campaigns, “they said. “This year ‘She Conquers’, next year ‘He Conquers’, the following year ‘They Conquer!”
It has long been recognised that new models of HIV care are essential if we are to reach the 90-90-90 treatment targets. In a preconference session to the 8th SA AIDS Conference, FHI360 presented their experience of differentiated models of care in Nigeria and six countries in eastern and southern Africa. Innovations include a range of strategies across the 90-90-90 cascade, such as multi-month scripting, spaced clinic visits, decentralised care, ART clubs and ART refills in community, targeted services for adolescents and key populations, task shifting and many others.
“The lifeblood of parliaments is information... you can have people disagreeing on politics but not about facts... this is why reliable evidence is so important for policy.” Dr Rasheed Draman, Executive Director of the African Centre for Parliamentary Affairs (ACEPA).
On Monday 24th April I attended an event held in Westminster that shed light on navigating parliamentary systems and offered advice and lessons to better understand the complexities surrounding evidence uptake and usage in parliaments. The event provided useful tips for researchers and policymakers.
Around 50 leading researchers, policy makers and programme implementers from eastern and southern Africa gathered in Johannesburg at the end of March to discuss strategies for strengthening HIV prevention services for men who have sex with men.
In January I had the pleasure of attending the first two days of the annual meeting of the STD/AIDS Collaborative Research Group, Nairobi, Kenya on behalf of EHPSA.
The first thing that struck me was the rich legacy that this collaboration has left - both in terms of the sheer number of Kenyan researchers, and the local ownership of research. The Kenyan National AIDS Council (NACC) participated actively in the meeting and invited researchers to continue to work with the NACC and align their work with the needs identified in national plans.
“What is evidence good for? – Absolutely nothing”. This was one of the most tweeted quotes from the opening plenary of the What Works Global Summit in London in September. The meaning – evidence itself is worthless without strategies to get it into policy and practice.
In September members of the EHPSA team attended two different conferences looking at evidence-based policy making, or evidence-into-action (EiA). The African Evidence Network regional conference was held in Pretoria, (21-23 September) and structured around the three themes of Engage. Understand. Impact. The What Works Global Summit (London 26-28 September) was the inaugural conference of an international network of academics, policy makers and practitioners from a wide range of sectors.
When we were invited to attend the Study Advisory Group (SAG) meeting for the P-ART-Y study in Lusaka in July, I didn’t expect to start the meeting surrounded by traditional dancers. What a great way to invigorate the crowd... it definitely helped to get the P-ART-Y started!
Highlights and insights
Just as Durban 2000 marked the beginning of the era of mass treatment, IAS’s President, Chris Beyrer, set the scene for Durban 2016 at a pre-conference, marking this moment as the new era for innovative HIV prevention strategies such as pre-exposure prophylaxis (PrEP).
Highlights and insights...
The largest generation in Africa are now entering the age when they are most at risk of HIV. This was the stark warning Bill Gates delivered to a packed session room at AIDS 2016 on Wednesday afternoon. Even though there have been great successes, especially in the field of treatment, the demographics are against us.
At last!! A session that presented new and exciting scientific data, coming from a collaboration between CAPRISA, the Univ. Manitoba (just a coincidence that I’m excited?) and the Univ. Washington. Some elegant research finally demonstrating by phylogenetic analysis of the virus in HIV-positive individuals that young women (less than 25 years of age) were being infected by men aged 25-40, but these men were being infected by women aged 25-40 (who had presumably been infected themselves earlier by older men). A cycle of infection that could be broken by VMMC and ART for the men, test and treat for the older women and PrEP for the younger women. A harder task would be changing community norms about older men – younger women relationships.
Highlights and insights
What do girls want? This was the question posed by a panel-led discussion at AIDS2016 on Tuesday. The reality is that girls around the world face a host of cultural, political and economic barriers to good health and many suffer gender based violence (GBV) from both long term partners (and husbands) and in more casual relationships. In fact, women are 1.5 times more likely to acquire HIV if they experience gender based violence. Whilst there was of course talk of female empowerment, the panel encouragingly steered away from discussion what girls can do to combat the dual epidemic of HIV and GB - to what role the community and, specifically, men, play: “Don’t tell us to raise our voices; some of us have been raising our voices for a very long time” exclaimed one female delegate....
Sessions on clinical care for MSM and LGBTI provided living proof that it is possible to train healthcare workers to deliver sensitive and competent health services, even in countries where homosexuality is criminalised. GALZ’s Caroline Maposhere described how she runs sessions in Zimbabwe – starting with a discussion on stereotyping. She encourages participants to speak about stereotyping of twins and left-handers before moving onto the more thorny issues of gender identity. To demonstrate the pain of stigmatising behaviour she does the “paper crushing” exercise. Once crushed into a tiny ball the sheet of paper is opened out and no matter how hard she tries, she can’t erase the crease lines. “You can say sorry,” she says, “but the damage is permanent.”
Here in South Africa, where gender diversity is protected by law, Anova's Health4Men programme has trained staff of over 250 of the state sector's primary care clinics in MSM sensitivity and competence. SANAC has also presented the draft SA National LGBTI Framework which proposes to make PrEP available to MSM and other key populations. The plan will be finalised and launched within the next few weeks.
The EHPSA Team Leader and colleagues visited London recently to share the purpose and progress of the programme more widely, both within DFID and with other UK-based organisations. In DFID, EHPSA met with the Evidence into Action (EiA) unit and the SRHR and Inclusive Societies/’Leave no-one behind’ Policy Teams.
On June 8 UN member states adopted the Political Declaration on HIV and AIDS:On the Fast-Track to Accelerate the fight against HIV and to end the AIDS epidemic by 2030. The declaration called for urgent action to ensure that no one is left behind in the AIDS response.
It’s now halfway through the EHPSA programme and a good time to review progress and discuss strategies to make our work more effective. In mid-May the team met for three days to see how we could "up our game". We also discussed the recommendations of the recent Annual Review of the programme and how to operationalise our response.
The 2nd African Conference on Key Populations (KP) in the HIV Epidemic, held in Dar es Salaam from the 16th to 18th December 2015, focussed on “key insights, key advances, key partnerships”. The conference was well attended with approximately 100 different papers being presented in parallel sessions over a 3-day period. Amongst presenters and participants were people from KP and organisations representing the interests of KP.
Those of you here at ICASA will have noticed the opening statement of many speakers starting as follows: “I stand in solidarity with African key populations, men who have sex with men, women who have sex with women, trans-gender people in all their diversity, adolescents and young people and people living with HIV, in order to end AIDS. “ The growing unity and solidarity among key populations is visible and clearly linked to the difficult situation key populations find themselves in, even here at the ICASA conference in Zimbabwe, where the MSM space was broken down early into the conference.
Delegates of ICASA had an opportunity today to seek an answer to the big question: when will the clever scientists discover a cure for AIDS and an HIV vaccine? I found myself brave enough today to engage with the “real scientists”. Unfortunately, I quickly discovered that I am part of the so-called lay public. But with me, in the same boat, were most of the policy makers in the room, trying their best to keep up with incomprehensible jargon, graphs and randomised control trials.
Unlike many other research programmes, EHPSA does not wait for final research results to be out before considering what impact they may have on the policy and practice of HIV prevention. Thus it was that in October EHPSA research grantees gathered in Johannesburg to discuss and agree on the “policy influence” objectives of their research.
The Regional Research Fund is going from strength to strength. First quarterly reports from the nine research teams show that the majority are making steady progress. Some have already received ethical approval for their studies and have begun the implementation phase of their research.
These are exciting times as EHPSA launches its very first Fellowship Scheme in Swaziland, linking their national AIDS commission, NERCHA, to Prof. Alan Whiteside from the Balsillie School of International Affairs & Wilfrid Laurier University.
Much of 2015 has been taken up with selecting the research proposals for funding and we are now very close to finalising the contracts with the successful research institutions. We have also been working hard to develop the exchange programmes that will link researchers to policy makers across the region. The EHPSA programme is now ready to move into a new and exciting phase.
Since the end of the inception period there has been a lot going on behind the scenes to prepare for full implementation of the EHPSA programme in 2015. Prevention experts have been reviewing the research EOIs in order to develop a short list of candidates that will be invited to apply for funding from the Regional Research Fund.
The inception period of the EHPSA programme has been a busy one. An important development in this period has been the decision of the Swedish International Development Cooperation Agency (Sida) to contribute funding to the Regional Research and Innovations Fund.
The EHPSA programme got off to an official start in May when we began working out what this programme was really about, hiring staff and consultants, setting up administrative systems, refining the programme log frame and all the other prerequisites of a four-year programme.