Achieving the potential of HIV prevention interventions: critical global need for collaborative dissemination efforts

Since the beginning of the epidemic, more than 25 million people have died from AIDS [1], and an estimated 33 million individuals are living with HIV/AIDS worldwide [1]. Every day, over 5700 individuals die from AIDS [1], and approximately 6800 people become newly infected with HIV [1]. In the absence of an effective HIV prevention vaccine, and in light of substantial vaccine-development setbacks [2], the current best means for combating the epidemic is widespread implementation of effective HIV prevention interventions [3], including those that are medically focused (e.g., circumcision and antiretrovirals for prevention of vertical transmission) and those that are behaviorally focused (e.g., interventions to increase condom use, HIV testing, and safer injection drug use practices). To date, medical, behavioral, and social scientists have dedicated a tremendous amount of time and resources to develop evidence-based HIV prevention interventions for a range of populations and prevention settings, using an array of intervention approaches and intervention delivery methods [4]. Despite such advances, widespread application of effective HIV prevention interventions has been minimal. A considerable number of HIV infections and AIDS deaths worldwide are a result of inadequate access to HIV prevention services rather than the lack of important breakthroughs in the prevention field [5]. Mathematical modeling techniques have identified cost-effective and even cost-saving evidence-based medical and behavioral interventions with the ability to avert millions of new HIV infections [5]. However, we will fail to prevent a significant number of deaths if we do not take immediate action toward disseminating these effective HIV prevention interventions widely. Reassessing current dissemination practices Significant barriers contribute to the lack of systematic dissemination of evidence-based HIV prevention interventions. First, funding agencies have historically emphasized the conduct of basic HIV prevention research (i.e., ‘discovery science’) rather than research on the application and dissemination of proven effective HIV prevention techniques (i.e., ‘delivery science’) [6]. Second, researchers may be more focused on conducting strong basic science research trials (e.g., testing new theoretical models) than dissemination science research trials (e.g., exploring how to increase the adoption of evidence-based interventions). Third, the rigorous scientific development of HIV prevention interventions tends to emphasize internal validity and overlook issues pertaining to external validity [7,8]. As a result, interventions may be time-consuming, complex, and costly, which limits their reach beyond the research phase. Fourth, limited information is made available about these evidence-based interventions to the stakeholder public charged with delivering prevention services to their constituents (including community-based organizations, healthcare provider settings, etc.) [9]. The few researchers who actually do make their intervention materials available tend to do so on an unintegrated, ad hoc basis rather than in a systematized, organized fashion. Moreover, information needed to adopt interventions is rarely – if ever – presented in sufficient detail to allow any public entity to effectively implement them [9], and publications in professional outlets are often only available to other researchers rather than those in a position to provide such services. In the circumstances when sufficient detail is provided, it is often replete with technical jargon unknown to frontline workers. Researchers, organizations, oversight groups, and funding agencies have started to take notice of the disparity between research and practice [10], providing an important counterweight to historical bias in favor of intervention trials and corresponding neglect of dissemination of effective interventions. However, preliminary efforts to actually disseminate evidence-based interventions have been fraught with challenges, frustration, and lack of demonstrated effectiveness [11]. These disappointments should come as no surprise, given that we have inadequate empirical and conceptual knowledge of what thwarts and facilitates the effective dissemination of HIV prevention interventions [10]. Unfortunately, it will likely take years to establish a scientifically based foundation of knowledge on dissemination of evidence-based interventions. In the interim, we need to make every effort to ensure that extant medically and behaviorally focused HIV prevention efforts have the greatest impact possible and are being applied well beyond research trials. To this end, we advocate the following actions. The role of individual researchers and practitioners There are numerous practical ways in which researchers and practitioners can facilitate dissemination efforts. First, investigators need to acknowledge that HIV prevention interventions should be designed from the onset with dissemination in mind [12]. Intervention efficacy trials typically operate in resource-rich settings, supported by multimillion-dollar grants, multiple staff members, technological support, and extensive training. With the availability of fiscal and personnel support in funded efficacy trials, researchers are often tempted to develop complex, time-consuming interventions (i.e., 40-h, 5-day training program for the staff to implement 15-session school-based curriculum [13]) that, although effective, are impractical in real-world settings in which sufficient resources simply do not exist. Because some researchers do not develop interventions with dissemination in mind, local organizations (e.g., schools, community-based organizations, and healthcare settings) charged with providing prevention services must make considerable adaptations to fit their limited resources [11], often resulting in alterations that make the interventions less effective, if not ineffective. To avoid these pitfalls, researchers must work with representatives from the target population and organizations charged with implementing HIV prevention services during the creation of interventions. Rather than a one-way transfer of knowledge, which tends to characterize interactions between researchers and these stakeholder groups, collaborations need to be developed whereby each party has an essential contribution to intervention development. Second, it is imperative that researchers and practitioners package interventions so as to promote and facilitate dissemination. At minimum, packages need to include intervention materials, training protocols, cost estimates, implementation plans, and evaluation tools [14]. Manuals and protocols need to be written in common, everyday language that is comprehensible to both scientific and layperson audiences. Cost estimates need to include equipment, materials, and other necessary resources to implement the intervention, as opposed to research operations per se. Implementation plans should include descriptions of necessary staff, schedules for intervention protocol training, and possibilities of ongoing technical support. Suggestions for possible ways to cut intervention costs, adapt intervention components, and make other potential modifications – in ways that are unlikely to sacrifice outcomes – should be provided as well. The role of professional organizations Professional organizations (including those that are scientific, medical, behavioral, and research focused) need to create and uphold standards to promote dissemination of evidence-based HIV prevention interventions. For example, journal editors should mandate that publication of HIV prevention intervention outcome studies is contingent upon authors providing full access online to the types of intervention materials described above. Professional organizations have made significant efforts to improve the quality and reporting of research trials by stressing the importance of internal validity in randomized controlled trials. However, although essential for high-quality research, a preoccupation with internal validity has often overshadowed the need for a focus on external validity of research trials, which most certainly limits the ability of evidence-based research to be disseminated and thus have a substantial impact on HIV prevention efforts. In addition to providing intervention materials, professional organizations should mandate that researchers address external validity issues when publishing intervention outcome studies. For example, the Consolidated Standards of Reporting Trials statement (http://www.consort-statement.org/) should require researchers to describe in detail the issues pertaining to external validity (e.g., generalizability, attrition, adaptation, and adoption [7,8]) in addition to internal validity criteria, in order to improve the quality of reporting of randomized controlled trials and the potential of such interventions to be effectively transitioned into practical settings. The role of foundations, institutes, and centers Private and public foundations, institutes, and centers (e.g., WHO, UNAIDS, National Institutes of Health, and Bill and Melinda Gates Foundation) need to commit more of their financial resources to promote the dissemination of evidence-based HIV prevention interventions. Such entities should be charged – as a critical part of their mission – with increasing accessibility of interventions beyond efficacy trials. In addition, these organizations should create, support, and keep updated an extensive, international database of evidence-based HIV prevention interventions. One might envision a database in which evidence-based interventions are categorized by several different variables, including target population (e.g., men who have sex with men, commercial sex workers, and adolescent women), specific risk behavior (e.g., unprotected intercourse and injection drug use), implementation setting (e.g., healthcare settings, community-based organizations, and schools), cost, and conceptual framework, as well as a catalogue of supportive outcome evidence presented in nontechnical language. In addition to a search engine database, this site would serve as a repository for prepackaged intervention materials (i.e., training protocols, cost estimates, etc.), with free access and download for all rather than the lengthy process of having to contact the original investigators, request a copy or pay a fee, and wait. Existing databases in other health domains (e.g., http://cancercontrolplanet.cancer.gov/ and http://www.nrepp.samhsa.gov/) may serve as appropriate templates for the development of an international HIV prevention intervention database and repository. Conclusion As we enter the third decade of the HIV epidemic, we must reflect on the fact that we have been unsuccessful in disseminating effective HIV prevention interventions. Despite our attempts, there remains a substantial disconnect between HIV prevention research ‘breakthrough’ and HIV prevention dissemination ‘follow through’ [15]. We need to embrace new, creative ways for disseminating evidence-based HIV prevention interventions, without which the value of our research is merely academic. Acknowledgements All authors contributed to the ideas presented in this paper and edited the manuscript. W.E.N. drafted the manuscript. The authors are grateful to K. Rivet Amico for comments on an earlier draft of the manuscript. This work was supported in part by a Ruth L. Kirschstein National Research Service Award predoctoral fellowship, F31MH079768, to W.E.N. from the National Institute of Mental Health, Bethesda, Maryland, USA, and grant R01 MH077524 to J.D.F., principal investigator, and W.A.F., coinvestigator, from the National Institute of Mental Health, Bethesda, Maryland, USA. There are no conflicts of interest.

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