Public health triangulation: approach and application to synthesizing data to understand national and local HIV epidemics

<p>Abstract</p> <p>Background</p> <p>Public health triangulation is a process for reviewing, synthesising and interpreting secondary data from multiple sources that bear on the same question to make public health decisions. It can be used to understand the dynamics of HIV transmission and to measure the impact of public health programs. While traditional intervention research and metaanalysis would be ideal sources of information for public health decision making, they are infrequently available, and often decisions can be based only on surveillance and survey data.</p> <p>Methods</p> <p>The process involves examination of a wide variety of data sources and both biological, behavioral and program data and seeks input from stakeholders to formulate meaningful public health questions. Finally and most importantly, it uses the results to inform public health decision-making. There are 12 discrete steps in the triangulation process, which included identification and assessment of key questions, identification of data sources, refining questions, gathering data and reports, assessing the quality of those data and reports, formulating hypotheses to explain trends in the data, corroborating or refining working hypotheses, drawing conclusions, communicating results and recommendations and taking public health action.</p> <p>Results</p> <p>Triangulation can be limited by the quality of the original data, the potentials for ecological fallacy and "data dredging" and reproducibility of results.</p> <p>Conclusions</p> <p>Nonetheless, we believe that public health triangulation allows for the interpretation of data sets that cannot be analyzed using meta-analysis and can be a helpful adjunct to surveillance, to formal public health intervention research and to monitoring and evaluation, which in turn lead to improved national strategic planning and resource allocation.</p

Using health surveillance systems data to assess the impact of AIDS and antiretroviral treatment on adult morbidity and mortality in Botswana

Introduction: Botswana's AIDS response included free antiretroviral treatment (ART) since 2002, achieving 80% coverage of persons with CD450% and >30% through 2011, while continuing to increase in older women. Conclusions: Adult mortality in Botswana fell markedly as ART coverage increased. HIV prevalence declines may reflect ART-associated reductions in sexual transmission. Triangulation of surveillance system data offers a reasonable approach to evaluate impact of HIV/AIDS interventions, complementing cohort approaches that monitor individual-level health outcomes

HIV decline in Zimbabwe due to reductions in risky sex? Evidence from a comprehensive epidemiological review.

Published versio

How Uganda Reversed Its HIV Epidemic

Uganda is one of only two countries in the world that has successfully reversed the course of its HIV epidemic. There remains much controversy about how Uganda's HIV prevalence declined in the 1990s. This article describes the prevention programs and activities that were implemented in Uganda during critical years in its HIV epidemic, 1987 to 1994. Multiple resources were aggregated to fuel HV prevention campaigns at multiple levels to a far greater degree than in neighboring countries. We conclude that the reversed direction of the HIV epidemic in Uganda was the direct result of these interventions and that other countries in the developing world could similarly prevent or reverse the escalation of HIV epidemics with greater availability of HIV prevention resources, and well designed programs that take efforts to a critical breadth and depth of effort

Mortality among patients with tuberculosis requiring intensive care: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>To describe the characteristics of patients with tuberculosis (TB) requiring intensive care and to identify the factors that predicts in-hospital mortality in a city of a developing country with intermediate-to-high TB endemicity.</p> <p>Methods</p> <p>We conducted a retrospective, cohort study, between November 2005 and November 2007. The patients with TB requiring intensive care were included. Predictors of mortality were assessed. The primary outcome was the in-hospital mortality.</p> <p>Results</p> <p>During the study period, 67 patients with TB required intensive care. Of them, 62 (92.5%) had acute respiratory failure and required mechanical ventilation. Forty-four (65.7%) patients died. Coinfection with human immunodeficiency virus was present in 46 (68.7%) patients. Early intensive care unit admission and ventilator-associated pneumonia were independently associated with the in-hospital mortality.</p> <p>Conclusions</p> <p>In this study we found a high mortality rate in TB patients requiring intensive care, especially in those with an early ICU admission.</p

Uganda’s HIV Prevention Success: The Role of Sexual Behavior Change and the National Response. Commentary on Green et al. (2006)

The paper by Green et al. (vol. 10, this issue

Experience of sexual coercion and risky sexual behavior among Ugandan university students

<p>Abstract</p> <p>Background</p> <p>Growing worldwide evidence shows that the experience of sexual coercion is fairly prevalent among young people and is associated with risky sexual behavior thereafter. The causal mechanisms behind this are unclear but may be dependent on specific contextual determinants. Little is known about factors that could buffer the negative effects of coercion. The aim of this study was to assess the association between the experience of sexual coercion and risky sexual behavior among university students of both sexes in Uganda.</p> <p>Methods</p> <p>In 2005, 980 (80%) out of a total of 1,220 students enrolled in Mbarara University of Science and Technology in Uganda participated in a self-administered questionnaire covering socio-demographic and religious factors, social capital, mental health, alcohol use, and sexual behavior. A validated scale of six items was used to assess the experience of sexual coercion. Logistic regression analyses were applied to control for confounders. Potential buffering factors were analyzed by testing for effect modification.</p> <p>Results</p> <p>Fifty-nine percent of those who responded had previously had sexual intercourse. Among the male students 29.0%, and among the female students 33.1% reported having had some experience of sexual coercion. After controlling for age, gender, and educational level of household of origin, role of religion and trust in others sexual coercion was found to be statistically significantly associated with previously had sex (OR 1.6, 95% CI; 1.1-2.3), early sexual debut (OR 2.4, 95% CI; 1.5-3.7), as well as with having had a great number of sexual partners (OR 1.9, 95% CI; 1.2-3.0), but not with inconsistent condom use.</p> <p>Scoring low on an assessment of mental health problems, reporting high trust in others, or stating that religion played a major role in one's family of origin seemed to buffer the negative effect that the experience of sexual coercion had on the likelihood of having many sexual partners.</p> <p>Conclusion</p> <p>The findings of this study suggest that the experience of sexual coercion is common among youth/young adults in Uganda and is subsequently associated with risky sexual behavior in both sexes. The existence of individual and contextual factors that buffer the effects mentioned was also demonstrated. In the Ugandan context, this has implications for policy formulation and the implementation of preventive strategies for combating HIV/AIDS.</p

Uganda's HIV Prevention Success: The Role of Sexual Behavior Change and the National Response

There has been considerable interest in understanding what may have led to Uganda's dramatic decline in HIV prevalence, one of the world's earliest and most compelling AIDS prevention successes. Survey and other data suggest that a decline in multi-partner sexual behavior is the behavioral change most likely associated with HIV decline. It appears that behavior change programs, particularly involving extensive promotion of “zero grazing” (faithfulness and partner reduction), largely developed by the Ugandan government and local NGOs including faith-based, women’s, people-living-with-AIDS and other community-based groups, contributed to the early declines in casual/multiple sexual partnerships and HIV incidence and, along with other factors including condom use, to the subsequent sharp decline in HIV prevalence. Yet the debate over “what happened in Uganda” continues, often involving divisive abstinence-versus-condoms rhetoric, which appears more related to the culture wars in the USA than to African social reality

Assessment of BED HIV-1 Incidence Assay in Seroconverter Cohorts: Effect of Individuals with Long-Term Infection and Importance of Stable Incidence

BACKGROUND: Performance of the BED assay in estimating HIV-1 incidence has previously been evaluated by using longitudinal specimens from persons with incident HIV infections, but questions remain about its accuracy. We sought to assess its performance in three longitudinal cohorts from Thailand where HIV-1 CRF01_AE and subtype B' dominate the epidemic. DESIGN: BED testing was conducted in two longitudinal cohorts with only incident infections (a military conscript cohort and an injection drug user cohort) and in one longitudinal cohort (an HIV-1 vaccine efficacy trial cohort) that also included long-term infections. METHODS: Incidence estimates were generated conventionally (based on the number of annual serocoversions) and by using BED test results in the three cohorts. Adjusted incidence was calculated where appropriate. RESULTS: For each longitudinal cohort the BED incidence estimates and the conventional incidence estimates were similar when only newly infected persons were tested, whether infected with CRF01_AE or subtype B'. When the analysis included persons with long-term infections (to mimic a true cross-sectional cohort), BED incidence estimates were higher, although not significantly, than the conventional incidence estimates. After adjustment, the BED incidence estimates were closer to the conventional incidence estimates. When the conventional incidence varied over time, as in the early phase of the injection drug user cohort, the difference between the two estimates increased, but not significantly. CONCLUSIONS: Evaluation of the performance of incidence assays requires the inclusion of a substantial number of cohort-derived specimens from individuals with long-term HIV infection and, ideally, the use of cohorts in which incidence remained stable. Appropriate adjustments of the BED incidence estimates generate estimates similar to those generated conventionally