Program Science: Maximizing Impact, Efficiency and Return on Investment of STD/HIV Prevention Sevgi Aral, PhD, MA, MS Curitiba, Brazil May 2011 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of STD Prevention "The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention."
So many efficacious STI/HIV interventions – so little impact maximize impact
So many resources invested in STI/HIV prevention – So much waste ( insufficient impact) maximize efficiency; return on investment of STI/HIV prevention dollars
Outline Program Science in Context The Program – Science Gap The Opportunity to Adopt a Scientific Approach to maximizing Impact and ROI
NIH Conferences on Dissemination and Implementation 2008 2009 2010 300 attendees 9,000 attendees
Health Systems Strengthening An important component of global health
Implementation/ Delivery Science Basic Science Clinical Science • Evaluation • Science Adapted from James Yon Kim 2009 Keynote address to the NIH Dissemination and Implementation Science Conference.
Health Care Delivery and Implementation Science Global Health Delivery Project
Implementation Dissemination Scale-up
Evidence Based Practice (EBP) Clinical Practice Improvement (CPI) Practice Based Evidence (PBE) Best practices
“Does X intervention work for Y clinical problem?” “What is the best approach for Y clinical problem?” Joseph Matthew ̶ Indian Pediatrics March 17, 2010
“The dissemination and implementation science initiative not helpful ̶ interventions offered not feasible within the budgetary and health system capacity constraints.” Tom Farley New York City Commissioner of Health
The Gap Between Science and Program and the Need for a “Program Science” Focus CS210010
High impact successful programs Scientific findings The Science — Program Gap (The ignored 13)
Science focuses on individual pathogens (HIV, HSV-2, Gc, . . . ) – STD programs need to control and prevent the spread of all pathogens
Science focuses on either the prevention of spread or the prevention of sequelae (HPV vs cancer; chlamydiavs PID) – STD programs need to prevent both spread and sequelae.
Science (most) focuses on treatment and prevention at the individual level — STD programs need to control and prevent spread and sequelae at the population level
Science focuses on individual interventions — STD programs need to implement a multiplicity of interventions (the intervention mix)
Science evaluates interventions at a specific point in time in the evolution of epidemics — STD programs need effective interventions during all phases of epidemics. Evolution of the HIV/AIDS epidemic Source: UNAIDS, 2006 Report on the global AIDS epidemic
Science evaluates interventions among a narrowly defined group of eligibles and only among those who agree to participate in the study — STD programs need interventions that work well in all groups — often particularly among those who are ineligible or those who refuse to participate in research.
Science evaluates interventions under ideal conditions — STD programs need to implement interventions under “everyday” often far-from-ideal conditions.
Science evaluates interventions with sufficient financial resources — STD programs need to implement interventions with inadequate financial resources.
Science employs “the best” human resources in evaluating interventions — STD programs at best employ “typical” human resources.
Science evaluates interventions to assess if they work when first implemented — STD programs need information on how long to implement an intervention; when to start, when to stop.
Science focuses on internal validity and often ignores external validity or generalizability — STD programs need to know an intervention will work in their context.
What’s love got to do with it? STD Program: What’s science got to do with it?
Important programmatic questions unanswered The Science — Program Gap
The important programmatic questions often not answered by intervention research The Science — Program Gap
STD Prevention requires that attention be paid to a multiplicity of factors on many fronts: Multiple pathogens Multiple target populations Multiple interventions Multiple categories of disease burden Multiple sources of morbidity-cost Multiple sources of intervention cost
Under the most ideal circumstances STD Prevention Programs Put together the many pieces of a gigantic jigsaw puzzle Define and implement a package of interventions that will improve the health of the population by limiting the spread of STI in the population
Often Science Individual interventions • Expensive • High intensity • Labor intensive • Individual level • Multi-session • Difficult to implement • Non-culture-sensitive • Non-generalizable
Global realities suggest seriously declining resources; particularly financial resources available for STD Prevention in the future.
Thus Cost of morbidity Cost of interventions Cost-benefit of interventions Cost-efficacy of interventions Cost-effectiveness of interventions Antagonisms and synergies across interventions Incremental (marginal) benefits and costs All become increasingly important to consider.
Not One, but Three GiganticJigsaw Puzzles The intervention package puzzle (structural interventions; social marketing; interventions targeting HCPs; interventions targeting core groups; interventions targeting general population) The STD epidemiology puzzle (risk groups; differential morbidities; differential vulnerabilities and risk behaviors) The Resource Allocation puzzle $$ per pathogen; $$ per target group; $$ per intervention; $$ per unit benefit (QALY; DALY); comparative $$ considerations
A new scientific paradigm is needed to address needs of STD prevention programs “Program Science”
Program Science – The scientific study of the three jigsaw puzzles: STD epidemiology; intervention packages; resource allocation The goal of program science – Identify science-based solutions to prevention program questions, dilemmas – Answer questions of Who(to target);When(to implement);How(to implement) – Synthesize existing evidence based on program questions not available intervention studies
Population-based Produces knowledge about policy and program interventions that have the potential to impact health at the population level Includes interventions that operate within and outside the health sector Program Science
Includes interventions that modify social determinants of morbidity Includes research into “required and achievable coverage” or reach of interventions Includes research into “incremental” or “marginal” benefits of additional interventions Program Science
Includes research into “incremental” and “marginal” costs of interventions Includes research into synergies and antagonisms across interventions Includes research into differential uptake of interventions Program Science
Includes research on issues of adherence to interventions by the population Includes operational research on implementation of interventions Includes scientific study of sustainability of interventions and their routinization Program Science
Focuses on packages of interventions Considers issues of resource expansion, advocacy, and mobilization Includes evaluation and evaluation research Program Science
The journal published by BioMed Central starting in 2005. Implementation Science
Most of this work focuses on Scientific finding Implementation However . . .
There is important and good work being conducted on: How best to synthesize research findings How best to disseminate individual interventions and research syntheses How best to prepare organizations to implement scientific findings
Articles published in “Implementation Science” are mostly focused on how to change provider recommendations for individual conditions in individual patients.
Opportunities for Adopting A Scientific Approach to Maximizing Impact and Return on Investment.
Goal: To prevent individual acquisition To prevent individual transmission To reduce population incidence
Prevention of individual acquisition and transmission Reduction of population incidence