Investigating Combination HIV Prevention: Isolated Interventions or Complex System
INTRODUCTION:
Treatment
as prevention has mobilized new opportunities in preventing HIV transmission
and has led to bold new UNAIDS targets in testing, treatment coverage and
transmission reduction. These will require not only an increase in investment
but also a deeper understanding of the dynamics of combining behavioural,
biomedical and structural HIV prevention interventions. High-income countries
are making substantial investments in combination HIV prevention, but is this
investment leading to a deeper understanding of how to combine interventions?
The combining of interventions involves complexity, with many strategies
interacting with non-linear and multiplying rather than additive effects.
DISCUSSION:
Drawing
on a recent scoping study of the published research evidence in HIV prevention
in high-income countries, this paper argues that there is a gap between the
evidence currently available and the evidence needed to guide the achieving of
these bold targets. The emphasis of HIV prevention intervention research
continues to look at one intervention at a time in isolation from its
interactions with other interventions, the community and the socio-political
context of their implementation. To understand and evaluate the role of a
combination of interventions, we need to understand not only what works, but in
what circumstances, what role the parts need to play in their relationship with
each other, when the combination needs to adapt and identify emergent effects
of any resulting synergies. There is little development of evidence-based
indicators on how interventions in combination should achieve that strategic
advantage and synergy. This commentary discusses the implications of this
ongoing situation for future research and the required investment in
partnership. We suggest that systems science approaches, which are being
increasingly applied in other areas of public health, could provide an expanded
vocabulary and analytic tools for understanding these complex interactions,
relationships and emergent effects.
CONCLUSIONS:
Relying
on the current linear but disconnected approaches to intervention research and
evidence we will miss the potential to achieve and understand system-level
synergies. Given the challenges in sustaining public health and HIV prevention
investment, meeting the bold UNAIDS targets that have been set is likely to be
dependent on achieving systems level synergies.
- 1Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia.
- 2Centre for Social Research in Health, University of New South Wales, Sydney, Australia; Graham.brown@latrobe.edu.au.
- 3Centre for Social Research in Health, University of New South Wales, Sydney, Australia.
- 4Kirby Institute, University of New South Wales, Sydney, Australia.
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