Assessing Individual and Disseminated Effects in Network-Randomized Studies

Implementation trials often involve clustering via risk networks, where only some participants directly received the intervention. The individual effect is that among directly treated persons beyond being in an intervention network; the disseminated effect is that among persons engaged with those directly treated. We employ a causal inference framework and discuss assumptions and estimators for individual and disseminated effects and apply them to HIV Prevention Trials Network 037. HIV Prevention Trials Network 037 was a Phase III, network-level, randomized controlled HIV prevention trial conducted in the US and Thailand from 2002 to 2006 that recruited persons who injected drugs, who received either intervention or control, and their risk network members, who received no direct intervention. Combining individual and disseminated, a 35% composite rate reduction was observed in the adjusted model (95% confidence interval = 0.47, 0.90). Methodology is now available to estimate the full set of these effects enhancing knowledge gained from network-randomized trials. Although the overall effect gains validity from network randomization, we show that it will, in general, be less than the composite effect. Additionally, if only index participants benefit from the intervention, as the network size increases, the overall effect tends to the null, an unfortunate and misleading conclusion

HIV-prevention science at a crossroads: advances in reducing sexual risk.

Purpose of review—We review the current state of evidence-based prevention strategies for reducing sexual transmission of HIV. The combined programmatic and scientific efforts through 2008 to reduce sexual transmission of HIV have failed to reduce substantially the global pandemic. Recent findings—Prevention interventions to reduce HIV infection target behavioral, biomedical, and structural risk factors. Some of these prevention strategies have been evaluated in randomized clinical trials (RCTs) with HIV seroincidence endpoints. When RCTs are not feasible, a variety of observational and quasiexperimental research approaches can provide insight as to program effectiveness of specific strategies. Only five RCTs have demonstrated a notable decrease in sexually acquired HIV incidence. These include the Mwanza study of syndromic management of sexually transmitted diseases and three male circumcision trials in East Africa; a microbicide trial reported in 2009 shows substantial promise for the efficacy of PRO 2000 (0.5% gel). Summary—The combined programmatic and scientific efforts to reduce sexual transmission of HIV have made incremental progress. New prevention tools are needed to stem the continued spread of HIV, though microbicides and vaccines will take many more years to develop, test, and deploy. Combination strategies of existing modalities should be tested to evaluate the potential for more proximate prevention benefits

Overall, Direct, Spillover, and Composite Effects of Components of a Peer-Driven Intervention Package on Injection Risk Behavior Among People Who Inject Drugs in the HPTN 037 Study

We sought to disentangle effects of the components of a peer-education intervention on self-reported injection risk behaviors among people who inject drugs (n = 560) in Philadelphia, US. We examined 226 egocentric groups/networks randomized to receive (or not) the intervention. Peer-education training consisted of two components delivered to the intervention network index individual only: (1) an initial training and (2) “booster” training sessions during 6- and 12-month follow up visits. In this secondary data analysis, using inverse-probability-weighted log-binomial mixed effects models, we estimated the effects of the components of the network-level peer-education intervention upon subsequent risk behaviors. This included contrasting outcome rates if a participant is a network member [non-index] under the network exposure versus under the network control condition (i.e., spillover effects). We found that compared to control networks, among intervention networks, the overall rates of injection risk behaviors were lower in both those recently exposed (i.e., at the prior visit) to a booster (rate ratio [95% confidence interval]: 0.61 [0.46–0.82]) and those not recently exposed to it (0.81 [0.67–0.98]). Only the boosters had statistically significant spillover effects (e.g., 0.59 [0.41–0.86] for recent exposure). Thus, both intervention components reduced injection risk behaviors with evidence of spillover effects for the boosters. Spillover should be assessed for an intervention that has an observable behavioral measure. Efforts to fully understand the impact of peer education should include routine evaluation of spillover effects. To maximize impact, boosters can be provided along with strategies to recruit especially committed peer educators and to increase attendance at trainings

Advancing Cervical Cancer Prevention Initiatives in Resource-Constrained Settings: Insights from the Cervical Cancer Prevention Program in Zambia

Groesbeck Parham and colleagues describe their Cervical Cancer Prevention Program in Zambia, which has provided services to over 58,000 women over the past five years, and share lessons learned from the program's implementation and integration with existing HIV/AIDS programs

Incidence of WHO stage 3 and 4 conditions following initiation of Anti-Retroviral Therapy in resource limited settings

To determine the incidence of WHO clinical stage 3 and 4 conditions during early anti-retroviral therapy (ART) in resource limited settings (RLS)

Closing the Mental Health Gap in Low-income Settings by Building Research Capacity: Perspectives from Mozambique

Background: Neuropsychiatric disorders are the leading cause of disability worldwide, accounting for 22.7% of all years lived with disability. Despite this global burden, fewer than 25% of affected individuals ever access mental health treatment; in low-income settings, access is much lower, although nonallopathic interventions through traditional healers are common in many venues. Three main barriers to reducing the gap between individuals who need mental health treatment and those who have access to it include stigma and lack of awareness, limited material and human resources, and insufficient research capacity. We argue that investment in dissemination and implementation research is critical to face these barriers. Dissemination and implementation research can improve mental health care in low-income settings by facilitating the adaptation of effective treatment interventions to new settings, particularly when adapting specialist-led interventions developed in high-resource countries to settings with few, if any, mental health professionals. Emerging evidence from other low-income settings suggests that lay providers can be trained to detect mental disorders and deliver basic psychotherapeutic and psychopharmacological interventions when supervised by an expert. Objectives: We describe a new North-South and South-South research partnership between Universidade Eduardo Mondlane (Mozambique), Columbia University (United States), Vanderbilt University (United States), and Universidade Federal de São Paulo (Brazil), to build research capacity in Mozambique and other Portuguese-speaking African countries. Conclusions: Mozambique has both the political commitment and available resources for mental health, but inadequate research capacity and workforce limits the country’s ability to assess local needs, adapt and test interventions, and identify implementation strategies that can be used to effectively bring evidence-based mental health interventions to scale within the public sector. Global training and research partnerships are critical to building capacity, promoting bilateral learning between and among low- and high-income settings, ultimately reducing the mental health treatment gap worldwide

Curtailing the communicability of psychiatric disorders

Although psychiatric disorders are classified as non-communicable diseases, we believe this classification is too rigid and limiting. We present evidence of the communicability of psychiatric disorders through three major pathways: infectious and ecological, familial, and sociocultural communicability. Successful strategies developed to control the spread of communicable infectious diseases are relevant to curtailing the communicability of psychiatric disorders, thereby reducing their burden. Current interventions and policies that conceptualise psychiatric illnesses as non-communicable mostly focus on the individual. By applying strategies from infectious disease and chronic illness prevention models within a socioecological framework, we posit a broad communicable chronic disease psychiatric illness control plan for effectively treating the patient with the psychiatric disorder (host) as early as possible, providing benefits to their family and the community, and preventing transmission to others

A randomized trial of the intrauterine contraceptive device vs hormonal contraception in women who are infected with the human immunodeficiency virus

The purpose of this study was to determine whether the intrauterine contraceptive device (IUD) is effective and safe among women who are infected with the human immunodeficiency virus (HIV)

Global health education: a pilot in trans-disciplinary, digital instruction

Background: The development of new global health academic programs provides unique opportunities to create innovative educational approaches within and across universities. Recent evidence suggests that digital media technologies may provide feasible and cost-effective alternatives to traditional classroom instruction; yet, many emerging global health academic programs lag behind in the utilization of modern technologies. Objective: We created an inter-departmental University of Southern California (USC) collaboration to develop and implement a course focused on digital media and global health. Design: Course curriculum was based on core tenants of modern education: multi-disciplinary, technologically advanced, learner-centered, and professional application of knowledge. Student and university evaluations were reviewed to qualitatively assess course satisfaction and educational outcomes. Results: ‘New Media for Global Health’ ran for 18 weeks in the Spring 2012 semester with N=41 students (56.1% global health and 43.9% digital studies students). The course resulted in a number of high quality global health-related digital media products available at http://iml420.wordpress.com/. Challenges confronted at USC included administrative challenges related to co-teaching and frustration from students conditioned to a rigid system of teacher-led learning within a specific discipline. Quantitative and qualitative course evaluations reflected positive feedback for the course instructors and mixed reviews for the organization of the course. Conclusion: The development of innovative educational programs in global health requires on-going experimentation and information sharing across departments and universities. Digital media technologies may have implications for future efforts to improve global health education