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'Implementation Science' Used to Test Rollout of Anti-HIV Strategies in Developing Countries

As PEPFAR program enters next phase, new framework will help show 'what worked and why'

An "implementation science" approach will play a critical role in the next phase of The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), according to an editorial in JAIDS: Journal of Acquired Immune Deficiency Syndromes. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

"Implementation science, including monitoring and evaluation, operations research, and impact evaluation, provides a broader framework for a full assessment of both the effectiveness and efficiency of programs, and will serve as the basis for PEPFAR's knowledge-generation activities moving forward," according to the new article. The lead author is Nancy S. Padian, PhD, of the Office of the U.S. Global AIDS Coordinator.

Are HIV/AIDS Programs Truly Working? Implementation Science Will Help Provide Answers
PEPFAR has played a major role in accelerating the introduction of HIV treatment and prevention services in developing countries around the world. In the first phase of PEPFAR, the focus was on making existing treatments and interventions more widely available on an emergency basis. The goal was to reduce deaths and suffering from HIV "as quickly and effectively as possible."

As the second phase of PEPFAR gets underway, the emphasis shifts to sustainable programs that can demonstrate value and impact in resource-poor countries. It's especially important to show evidence that programs are achieving the desired effects. That information can be used to make "mid-course corrections" in implementing, or re-evaluating interventions.

To collect this type of evidence, PEPFAR has adopted a new implementation science framework. "Implementation science is the study of methods to improve the uptake, implementation, and translation of research findings into routine and common practices (the 'know-do' or 'evidence to program' gap)," Dr. Padian and coauthors explain. It provides "a valuable tool…not only to improve program effectiveness but also to explain what worked, why, and under what circumstances."

The PEPFAR implementation science framework begins with ongoing monitoring and evaluation, permitting continuous assessment of inputs, outputs, outcomes, and impacts. Although extensive "M&E" activities have been a part of PEPFAR from the start, establishing a universal implementation science framework will enable more comprehensive assessment of program activities.

In addition, patients in the prehabilitation group also had less pain when performing the functional tests. For patients receiving standard care, performance on some functional tests actually decreased in the weeks before surgery-possibly reflecting increased pain scores.

The framework also includes operations research, focusing on methods of making program delivery more efficient and effective-an urgent priority in developing programs that will be sustainable over the long term. Using techniques borrowed from pharmaceutical supply chain management, operations research will help in "determining the optimal combination of interventions in various parts of the world."

This raised concerns that other causes of bacterial meningitis might become more common, or that meningitis caused by GBS might shift from early-onset to late-onset cases. "Nevertheless, at the dawn of the 21st century, GBS remains the dominant cause of neonatal bacterial meningitis in developed countries such as France," Dr. Gaschignard and co-authors write.

The third component is impact evaluation, which seeks to show that programs are leading to changes in specific outcomes. These methods can be used on an ongoing basis to determine whether a program is on track, by assessing intermediate outcomes that can be causally linked to the outcome of interest. PEPFAR has developed a "toolkit" of approaches to provide strong evidence of cause-and-effect relationships-without the high investments of costs, time, and manpower needed to conduct formal randomized trials.

Implementation science framework will help to ensure that programs are achieving the intended results through "strategic use of real time data collection that permits ongoing program corrections," Dr. Padian and colleagues write. "Applying an IS framework to PEPFAR programs will sharpen our ability to support partner countries in choosing strategic programs that provide the most benefit using the most efficient methods."

Indeed, gathering and sharing of knowledge about HIV/AIDS program implementation with the global community will be an important part of the next phase of PEPFAR. "Acceleration of this work will permit PEPFAR to support strategic interventions and focus them where they will have the most impact, while simultaneously improving implementation efficiency and sustainability," the authors conclude.

Journal of Acquired Immune Deficiency Syndromes (JAIDS) is the trusted, interdisciplinary resource for HIV- and AIDS-related information with a strong focus on basic science, clinical science, and epidemiology. Co-edited by the foremost leaders in clinical virology, molecular biology, and epidemiology, JAIDS publishes vital information on the advances in diagnosis and treatment of HIV infections, as well as the latest research in the development of therapeutics and vaccine approaches. This ground-breaking journal brings together rigorously peer-reviewed articles, reviews of current research, results of clinical trials, and epidemiologic reports from around the world.

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