7
Building Capacity for AIDS-Related Research

INTRODUCTION

In this report, the panel identifies research and data priorities intended to improve our understanding of the social and behavioral factors influencing the spread of HIV/AIDS in sub-Saharan Africa. In turn, this understanding can be used to inform the development of prevention and mitigation strategies designed to arrest the spread of HIV/AIDS. The panel realizes, however, that if effective research is to be undertaken and research results are to be applied appropriately and effectively, the necessary infrastructure must be in place, a prerequisite that is often lacking in sub-Saharan Africa. As a result, virtually all research undertaken on AIDS in sub-Saharan Africa to date has been made possible only with technical cooperation and foreign assistance from the international community.

Thus, beyond the immediate challenge of the panel's mandate—identifying the critical research questions—there remain enormous practical challenges of actually obtaining the answers: Who is going to do the research, where, and with what resources? The objective of this chapter is to identify the constraints on conducting research in sub-Saharan Africa and to offer a series of recommendations for addressing these constraints in the short term. It is worth nothing that although the focus of this chapter is on capacity building for HIV/AIDS-related research, many of the obstacles identified here are also hindrances to optimal management and implementation of AIDS prevention and mitigation efforts.1

1  

 For further discussion of the obstacles to implementing successful AIDS-prevention programs, see N'Galy et al. (1990).



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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences 7 Building Capacity for AIDS-Related Research INTRODUCTION In this report, the panel identifies research and data priorities intended to improve our understanding of the social and behavioral factors influencing the spread of HIV/AIDS in sub-Saharan Africa. In turn, this understanding can be used to inform the development of prevention and mitigation strategies designed to arrest the spread of HIV/AIDS. The panel realizes, however, that if effective research is to be undertaken and research results are to be applied appropriately and effectively, the necessary infrastructure must be in place, a prerequisite that is often lacking in sub-Saharan Africa. As a result, virtually all research undertaken on AIDS in sub-Saharan Africa to date has been made possible only with technical cooperation and foreign assistance from the international community. Thus, beyond the immediate challenge of the panel's mandate—identifying the critical research questions—there remain enormous practical challenges of actually obtaining the answers: Who is going to do the research, where, and with what resources? The objective of this chapter is to identify the constraints on conducting research in sub-Saharan Africa and to offer a series of recommendations for addressing these constraints in the short term. It is worth nothing that although the focus of this chapter is on capacity building for HIV/AIDS-related research, many of the obstacles identified here are also hindrances to optimal management and implementation of AIDS prevention and mitigation efforts.1 1    For further discussion of the obstacles to implementing successful AIDS-prevention programs, see N'Galy et al. (1990).

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Problem Statement As noted above, undertaking effective research requires that a basic infrastructure be in place. Key aspects of this infrastructure include access to adequate funding, skilled labor, and appropriate technology, as well as sufficient managerial and administrative capacity to plan, execute, monitor, and evaluate a study. Even in developed countries, amassing the resources required to undertake complex research endeavors is difficult, but these difficulties are multiplied many-fold in sub-Saharan Africa. Many sub-Saharan African universities have been badly neglected in recent years. The poor preparedness of matriculating students, entirely inadequate salaries for all levels of professional and support staff, neglect of buildings and libraries, and a lack of core funds necessary to move institutions into the technological age have contributed to the universities' slow demise and the widespread flight of their faculties into the private sector. When research has been conducted in sub-Saharan Africa, it has usually lacked a coordinated plan. Furthermore, many of the findings that have emerged from the research have not been adequately disseminated, so that results are not widely known across the continent. As a consequence, the contributions of social and behavioral scientists have not been fully utilized. As noted above, the objective of this chapter is to consider constraints on designing, implementing, and disseminating AIDS-related research in sub-Saharan Africa. The basic constraints to be addressed are as follows: Insufficient/poorly allocated funds, Inadequate manpower, Unintended negative consequences of donor policies, Inadequate coordination of research efforts, and A harsh environment for conducting research. There are no easy solutions to these problems, but after discussing each in turn, we make several recommendations that may marginally improve the situation in the short run and should be considered in developing any long-term strategies for conducting and applying research in sub-Saharan Africa. Data Sources This chapter draws on two types of information: (1) existing documents, including evaluations of national AIDS control programs conducted in the late 1980s and early 1990s; and (2) interviews conducted by members of the panel during site visits to Zambia, Tanzania, and Cameroon during January and February 1995 (see Appendix A for detail on these visits). These countries differ greatly with regard to HIV/AIDS infection rates, the extent and nature of their response to the epidemic, and the importance of social and behavioral research in

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences prevention and mitigation strategies. In Zambia, where HIV/AIDS is widespread, the Ministry of Health has developed a strong and coordinated response to the epidemic. This coordination contrasts sharply with the situation in Tanzania, where the response is fragmented and implemented largely through the uncoordinated activities of nongovernmental organizations. In Cameroon, the epidemic is less advanced and has generated a lower level of government and nongovernmental organization response. Within each country, the panel interviewed individual researchers and representatives of various research units, nongovernmental organizations, donor agencies, and government offices. The panel acknowledges that this fieldwork does not provide an exhaustive assessment of the state of AIDS research and prevention and control programs throughout sub-Saharan Africa, but it does provide some indications of the pertinent problems. CONSTRAINTS ON RESEARCH IN SUB-SAHARAN AFRICA This section reviews each of the five constraints listed above. Insufficient/Poorly Allocated Funds The single largest barrier to conducting research in sub-Saharan Africa is grossly inadequate funding. As with most activities in developing countries, resources for research are in short supply; this is especially true for AIDS-related social and behavioral research in sub-Saharan Africa. Funding for salaries, facilities, equipment, and even basic office supplies is inadequate. In African universities, the limited budgets available are spent on wages, leaving very few resources for maintaining buildings or equipment, purchasing general office supplies, providing staff training and development, and initiating and sustaining a research program. At the same time, a lack of managerial and administrative capacity leads to inefficiencies in the way money is allocated and spent and results in a less-than-optimal utilization of existing resources. Data on the total amount of money spent in sub-Saharan Africa each year on AIDS-related research from all sources are not readily available. However, a large share of behavioral and social science research in sub-Saharan Africa is being funded by international donors,2 and some information is available about expenditures on AIDS research by the 10 major industrialized countries and the European Community. In 1991, these countries spent US $1.55 billion on HIV/AIDS-related research, more than in any year previously, although the pace of growth slowed after 1989, and spending has begun to show signs of reaching a 2    A review of 559 AIDS-related research projects identified in Africa in 1989 found that 47 percent were funded from national resources alone, while 53 percent were collaborative projects with various external donors (Heymann et al., 1990).

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences plateau (Mann et al., 1992). Yet there is little correspondence between the severity of the epidemic and the allocation of research funding. For example, recent WHO estimates conclude that of the 18 million adult HIV infections that occurred from the start of the epidemic until the end of 1994, 11 million were in sub-Saharan Africa. Yet of the US $1.55 billion spent on HIV/AIDS-related research by developed countries in 1991, for example, only US $179 million (3 percent) was allocated to research on developing countries (Mann et al., 1992). An analysis of 10 years' worth of AIDS-related studies cataloged in MEDLINE, an electronic database of primarily medical journals, found that only 3 percent addressed AIDS in Africa (Elford et al., 1991). Furthermore, social and behavioral research has received a relatively small share of the available resources, despite the fact that experts both within and outside the behavioral sciences agree that traditional health education messages are insufficient to induce widespread behavior changes (Mann et al., 1992). A recent review of all HIV/AIDS-related research cataloged on MEDLINE over the period 1983-1989 identified more than 20,000 papers on HIV/AIDS-related research, of which only 2,299 (11 percent) pertained to the social and behavioral sciences. Of these, 1,262 (55 percent) addressed studies of homosexuality and AIDS or substance abuse and AIDS, both of which have limited relevance as modes of transmission in Africa (Mann et al., 1992). Researchers throughout sub-Saharan Africa often face a lack of basic resources. For example, Uganda is one of the countries in the epicenter of the AIDS epidemic. It was among the first countries in sub-Saharan Africa to report the presence of HIV and as of July 1993 had the second-highest cumulative total number of AIDS cases anywhere in Africa (World Health Organization, 1994). In a recent report, the National AIDS Commission in Uganda identified many research-related items for which funding is either unavailable or inadequate, including the following: Salary support, Rehabilitation of research infrastructure (e.g., laboratories, computer rooms, protected storage for data and various specimens), Capacity for data storage and retrieval, Maintenance capacity for new specialized equipment imported for AIDS-related research, including tools, spare parts, and skills (both in operation and in maintenance), and Low-cost HIV testing kits. In all likelihood, the experience of Uganda is not unique. The dominance of international donors in AIDS research in Africa is the consequence of a lack of domestic funding for such research in the region. Tragically, AIDS has hit sub-Saharan Africa at a time of severe economic crisis. Yet African governments appear complacent about the current and expected magnitude

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences of the epidemic and to date have contributed little to HIV/AIDS research. In 1991, a WHO/GPA study that examined the mix of external support and domestic contributions to national AIDS programs in developing countries concluded that their ''governments were not at all or very insignificantly sharing the resource burden for AIDS control" (World Health Organization, 1991:531, cited in Mann et al., 1992). Not surprisingly, therefore, a recent expenditure survey of national AIDS control programs in 24 sub-Saharan African countries reported that in 9 countries, no funding is allocated for research; in 6 countries, less than 3 percent of the national AIDS control program budget is allocated to research; and in 8 other countries, between 3 and 5 percent of the budget is allocated to research. Cameroon has designated 10 percent of its national AIDS control program budget for research, more than twice the amount spent by the next-highest country (Mann and Tarantola, forthcoming). Current spending levels on research within national AIDS control program budgets, both in absolute and in relative terms, appear not to be a function of the severity of the epidemic, the country's total national AIDS control program expenditure, or the overall size of the economy. In reality, of course, sufficient funds will never be available to answer all the questions and address all the issues identified in this report, so they must be prioritized in some way. Moreover, even if sufficient funding were available, it would be impossible to implement all the research recommendations made in this report without technical assistance from outside Africa because of a shortage of well-trained African social and behavioral scientists (as discussed in the next section). Yet the dependence on international donors for AIDS research in sub-Saharan Africa raises a number of issues. Support from international donors for AIDS-related research in sub-Saharan Africa has not been able to meet demand, for a variety of reasons. First, the global political climate is characterized by a growing complacency; this in turn has resulted in shrinking donor budgets, particularly at WHO/GPA, which historically has been a significant funder of AIDS-related research (see also Chapter 1). Second, AIDS research priorities in sub-Saharan Africa must now compete with similar demands for funding created by emerging AIDS epidemics in other parts of the world, particularly Latin America and Asia. Third, the priorities of foreign donors may be inconsistent with those of a country's national AIDS control program, so that research priorities established in a country are either underfunded or not funded at all. This last issue—the misalignment of donor funds and benefactor needs—is illustrated by information compiled on competing research priorities of three parties active in AIDS prevention in Tanzania (Susan Hunter, personal communication, 1995). The second column of Table 7-1 shows the research priorities of the Tanzanian national AIDS control program (which presumably reflect Tanzanians' perceptions of their own needs) alongside the research priorities identified by two sets of outside experts from agencies based in Washington (third column) and Tanzania (fourth column). All three groups of experts rated 12 potential areas for future AIDS-related research as being a high priority, a low priority, or

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences TABLE 7-1 Research and Data Collection Priorities in Tanzania   Level of Priority Area National AIDS Control Program Washington (AIDSCAP) Tanzania AIDS Project Research Innovative behavior change and communication interventions N H H Links between prevention and care N H H Workplace structure and interventions N H H Women in stable relationships: approaches to sexual safety N H L Male responsibility in sexuality and family N N H Social and economic factors in HIV risk H H L Behavioral consequences of policy (e.g., medical barriers to STD care) N H H Female condom N H L Counseling and testing H H L STD screening in family planning clinics H N H STD interventions for high-risk groups H N H Family structure and adaptation to HIV/AIDS H N H Data Collection AIDS knowledge, attitudes, beliefs, and practices H H H Condom use availability H H H STD incidence H H H STD points of first encounter H H H National nongovernmental organization inventory and database H N H NOTES: H = high priority; L = low priority; N = not a priority. SOURCE: Susan Hunter (personal communication, 1995).

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences not a priority for funding. No single area received a high rating from all three groups, although there was more consensus on priorities for data collection activities. In July 1991, the Tanzanians held a 4-day workshop to prioritize research areas in the country "so as to optimize research efforts in support of the objectives of the second Medium Term Plan … [by identifying research that] most closely relate[s] to the problems of, and may help answer questions relevant to, the National AIDS Prevention and Control Programme" (United Republic of Tanzania, 1991:1). However, research projects that had been funded were established outside Tanzania rather than in collaboration with Tanzanians, and their objectives were not always consistent with the priorities established by the national AIDS control program in 1991. In Uganda, the Uganda AIDS Commission recently complained that funding of donor-driven priorities has led to an overemphasis on large-scale studies and an excessive concentration of resources in a small area of the country, leaving many other districts, cultures, and target groups understudied (Uganda AIDS Commission, 1992). Furthermore, some Ugandan researchers have complained that "several western-financed studies have not included a service commitment to the local population, and there is a tendency [for western researchers] to address problems more relevant to western populations rather than those felt most appropriate by local workers" (Serwadda and Katongole-Mbidde, 1990:843). In Cameroon, because several major donors each focus their efforts in one particular province, considerable research is done in some geographical areas, while in others there is none. In Zambia, the Director of the National AIDS/STD/TB & Leprosy Programme concluded that donors' assistance during the period 1986-1990, including funding for research, had not been as effective as expected because "most of the major donors, in particular the bilateral donors, insisted that the Government of Zambia follow the package of interventions that they [the donors] have defined" (Msiska, 1994:16). Inadequate Manpower A second fundamental constraint on implementing AIDS-related research in sub-Saharan Africa is the shortage of competent indigenous researchers. The few highly trained or exceptional African social or behavioral researchers currently working in the AIDS arena are in constant demand and are already involved in multiple projects. At the same time, AIDS itself has probably disproportionately affected the more-educated population (see Chapter 6), which may have affected the pool of professionals and researchers in African cities even further. Research capacity within Africa cannot be improved without an increase in the number of well-trained African researchers. Many sub-Saharan African institutions suffer from having few competent professionals, and those institutions that are well staffed have enormous difficulty retaining their best staff. Many of the best

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences African scholars are attracted abroad by higher salaries, greater job satisfaction, and better opportunities for their children and families. A recent research needs assessment conducted by the Uganda AIDS Commission identifies behavioral researchers and interdisciplinary specialists as categories of professionals that are in short supply, particularly ethnomedical researchers, social scientists with qualitative research skills (e.g., anthropologists), and meta-analysts (Uganda AIDS Commission, 1992). The report also identifies the need for more basic research scientists and clinical and laboratory researchers. The lack of manpower results, in part, from the lack of emphasis placed on training AIDS researchers by national AIDS control programs and other funders, low wages, and a decline in the quality and availability of higher education in the decades preceding the epidemic (as discussed further below). AIDS has yet to be firmly established as a field of academic study in many African universities. In the early 1980s, when AIDS first struck the African continent, national AIDS prevention programs drew upon existing expertise within a small pool of researchers who had been trained in tropical disease control. Although this strategy may have been appropriate as a short-term response to the initial outbreak of the epidemic, it is impossible to rely on resources borrowed from other fields over the long term. Now that the nature and magnitude of the epidemic are better understood, there is an urgent need for universities to develop appropriate curricula to train researchers as AIDS specialists. Furthermore, the epidemic led to an immediate need for professionals who were trained in disciplines that were not popular when the epidemic first erupted, such as social anthropology and communication. As a result of these limitations of indigenous manpower, and given the tremendous pressure on the donor community to respond quickly to the emerging epidemic, donor agencies have preferred to rely on experienced researchers from the United States and Europe. The unintended negative consequences of this and other donor policies that affect capacity building are discussed next. Unintended Negative Consequences of Donor Policies Although many donor agencies emphasize the importance of capacity building, the net result of their investments in this area to date has been quite modest (World Bank, 1991; Cohen, 1993; Berg, 1993; Jaycox, 1993). Consequently, the entire modus operandi of donor agencies has come under increasing attack. A recent World Bank report suggests that donors' lack of an overall, consistent, and coherent strategy may have inadvertently contributed to Africa's current shortfall in capacity, of which research capacity would be one element (World Bank, 1991). For example, donor agencies typically design projects on a short (2-year) time-frame that, while appropriate for accomplishing certain program objectives, is insufficient to build a sustainable in-country research capacity. In some instances,

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences donor agencies also "cream off" talented individuals by offering them better pay than they would receive in academia. Perhaps the most controversial issue in the current literature on capacity building is whether donors employ the right mix of local and foreign workers. In response to weak indigenous research capacity, many donor agencies have favored a model of assistance built around resident foreign consultants as project directors, who are meant to transfer skills to their African counterparts over the life of a project. Many agencies prefer to use expatriate labor, even when local manpower is available. Some African government officials view such donor policies as "biased towards the use of costly external technical assistance with little or no consideration of local capacity building to ensure sustainability of programs" (Msiska, 1994:16). Moreover, persistent reliance on expatriate technical assistance personnel is extremely expensive compared with the cost of hiring local nationals; thus it drives up the cost of conducting research in Africa and leaves fewer resources for other purposes. Furthermore, expatriates often are not skilled in using an apprentice model and often focus too intently on getting the study done at the expense of substantive collaboration or local capacity building (Family Health International, 1992). Indeed, it is not unusual for the life of a project to take the following course. First, the project identifies a capable African who is designated as the resident consultant's counterpart and local collaborator. Second, as part of the project's activities and with the specific objective of developing local capacity, the counterpart is sent abroad for further graduate studies. Consequently, the counterpart is not on site for half the length of the 2-year project. Third, immediately after the trained counterpart returns, he or she is promoted and reassigned to duties elsewhere. Such scenarios create cynicism and distrust on the part of Africans. Compounding the above problems is the fact that donor agencies have tended to measure the success of a project in terms of the significance (and quantity) of the scientific publications that result, rather than the number of national staff who have been trained or the extent to which local institutions have been strengthened. Many donor agencies also try to sidestep official bureaucracies, administering programs themselves, as opposed to working with the relevant department in the Ministry of Health or elsewhere. Thus, projects sometimes operate as small, semiautonomous units designed and administered by foreign expatriates. Local personnel for these projects are diverted from other activities, creating a void elsewhere. Sub-Saharan African governments often view such arrangements as the price of financial assistance, rather than as a response to local needs (World Bank, 1991; Ali, 1994). Moreover, once funding for the project has expired, personnel and equipment are dispersed, thus vitiating any lasting impact of the project. For these and other reasons, it is becoming increasingly evident that the standard model of 2-year development projects with resident foreign advisers has not worked in the area of capacity building. Skills and technologies are not being

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences transferred adequately, local capacity is not being developed, and many projects are being discontinued shortly after expatriate assistance has been withdrawn (World Bank, 1991; Cohen, 1993; Berg, 1993; Jaycox, 1993). A further problem is that the few African researchers who are currently available are in such high demand that they are often recruited onto projects without any expectation that they will contribute significantly to the projects' goals. Many funding agencies, national research boards, and sub-Saharan African governments require a local element in every international research project, so that most projects are required to list local collaborators as part of the project personnel. An unintended negative consequence of this policy, however, is that it places very heavy demands on a few African researchers. As a result, in far too many instances, Africans are invited to participate in projects without any intention of actually having them integrally involved in the research. The African is paid some (often paltry) consulting wage, and there is no expectation of any work being done. When reinforced over time and over many projects, such a policy creates the expectation among both parties that African collaborators do not function as equal partners in collaborative research projects, which in turn quickly becomes a self-fulfilling prophesy. Thus, there is an urgent need to change work practices and standards on international collaboration research projects and to reestablish a social contract that links pay to productivity. With the knowledge that AIDS will continue to plague sub-Saharan Africa for many years into the future, it becomes clear that donor agencies would maximize the return on their investment in AIDS research in sub-Saharan Africa by placing greater emphasis on developing an indigenous research capacity relative to utilizing foreign expertise. An important step has been the establishment of the AIDS International Training Research Program in 1989. This program supports the training of foreign scientists in the United States and their home countries, as well as collaborative research between U.S. and foreign scientists. It is the largest global research training program for HIV/AIDS. Between 1989 and 1993, the program provided instruction in the United States for over 200 African health professionals from 18 sub-Saharan African countries. It also supported 65 in-country training courses in 7 sub-Saharan African countries, although only a small number of those trained were in the behavioral and social sciences. Nevertheless, the program has been quite successful, so that a significant proportion of the papers authored or coauthored by African researchers at international AIDS conferences are likely to have been written by former trainees in this program (United States Department of Health and Human Services, 1994). Inadequate Coordination Undoubtedly, the major constraints to conducting social and behavioral research in Africa are insufficient money and a lack of capable personnel. However, more could be accomplished with existing funding by eliminating overlap

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences between projects and establishing a system for prioritizing prospective projects. Specific problems include a lack of information on previous and ongoing research efforts, a lack of research-needs assessment and the difficulty of coordinating funding from multiple sources, and a lack of cooperation among donor agencies. Lack of Information on Previous and Ongoing Research Efforts Researchers and policy makers in sub-Saharan Africa are often poorly informed about previous research findings. Part of the problem is that the findings of some studies are simply not written up and widely disseminated (e.g., through publication in a major international journal), perhaps because the researchers lacked the necessary time or skill or because an intervention was unsuccessful. This latter reason is particularly disturbing because valuable lessons can often be learned from failed efforts. The other aspect of this problem is that even if the research is written up, it is often difficult to obtain copies of the reports. Often, it is easier to obtain copies of papers from outside the country of the study than from within. Furthermore, English and French are both spoken widely in sub-Saharan Africa, but it is difficult to obtain information about activities in Francophone Africa in English and even more difficult to obtain information about activities in Anglophone Africa in French. In most sub-Saharan African countries, there is no central repository for research or reports on AIDS-related activities, nor is there a bibliography or database of research efforts. Between August 1988 and February 1989, a team from WHO/GPA conducted a systematic country-by-country inventory of AIDS-related research projects in sub-Saharan Africa. The survey was designed to ascertain what research was being undertaken at the time; to identify the gaps, if any, in the research agenda; and to identify any major duplication of effort (Heymann et al., 1990).3 Over 50 percent of the 559 studies identified were unknown to the relevant national AIDS control committee. In a small number of countries, such as Uganda and Zimbabwe, there have been recent efforts to develop annotated bibliographies, specifically on published social and behavioral research results (Olowo-Freers and Barton, 1992; Bylmakers, 1992). In Tanzania, 3    A total of 559 AIDS-related research projects were identified in 35 sub-Saharan African countries. Of these, 62 percent were concerned with HIV-1 or HIV-2 seroprevalence among general populations or populations thought to be at risk of infection; 11 percent with knowledge, attitudes, and behavior in response to the AIDS epidemic; 11 percent with perinatal transmission; 9 percent with the association between HIV and other sexually transmitted diseases; 8 percent with the natural history of the infection; 8 percent with the association between HIV and tuberculosis; and 4 percent with rapid field diagnosis of HIV infection (Heymann et al., 1990). The database was updated once in 1991, but insufficient funds forced the cancellation of the project shortly thereafter.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences the national AIDS control program recently devoted resources to development of a national database of AIDS research. Ignorance about other efforts can lead to duplication of research. Moreover, in cases where some duplication or validation of research in a second location would be desirable, the lack of ready access to reports on previous research means that researchers often do not follow the same study design or benefit from the experiences of other researchers. Consequently, "reinvention of the wheel" is a widespread phenomenon. There is an urgent need for more information sharing among AIDS professionals both within and among sub-Saharan African countries. In the absence of an up-to-date inventory of existing research, it is impossible to identify gaps in research relative to any established set of priorities. Another problem is that because few local outlets exist for publishing research results, researchers rely on international journals for widespread dissemination of their work. Results are withheld until they have been accepted and published, a time-consuming process that can take 2 years or longer. Thus, there is a considerable delay in making study findings available to policy makers and other researchers. Mechanisms are needed to facilitate more rapid dissemination of research results through local conferences and regional journals in which researchers can present and publish interim findings. Information sharing could also be facilitated by donors' sponsoring innovative information exchange activities and mechanisms for communication within and among countries. Such mechanisms might include newsletters; electronic bulletin boards; national or regional clearinghouses for materials, articles, and relevant questionnaires; local, national, or regional HIV-prevention conferences and training workshops; traveling "road shows" that would showcase model programs and experienced program managers; and sending of experienced managers and researchers as consultants to HIV-prevention programs in other countries. One example of an effort to promote information exchange is ongoing in Zambia, where Morehouse University (Atlanta, Georgia) is planning a workshop to review and disseminate research findings for researchers working there (see Appendix A). This first step is encouraging because to date, there have been no efforts in Zambia to synthesize research findings, and there is no readily accessible bibliography of AIDS-related social and behavioral research. Lack of Research-Needs Assessment and Difficulty of Coordinating Funding from Multiple Sources Few African countries have undertaken a needs assessment for social and behavioral research or established research review boards to prioritize and coordinate research proposals. Consequently, the potential for inefficient use of resources and overlap of activities is considerable. Even if the national AIDS control program or another agency were to achieve a broad consensus on research priorities, the coordination of funding for all

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences priority areas would be difficult. Funds for AIDS-related social and behavioral research come from a variety of sources, many of which have themselves established priorities. Among these sources are (1) national AIDS control programs, which allocate small percentages of their annual budgets to AIDS research (Mann et al., 1992), primarily sentinel surveillance; (2) sub-Saharan African governments that support research through in-kind contributions of manpower and office space; and (3) nongovernmental organizations and international development agencies that fund their own research agendas, as well as support African research institutions through donations of technical equipment and support. In addition, many African researchers collaborate on an ad hoc basis with colleagues from developed countries who have access to research funds. Lack of Cooperation Among Donor Agencies AIDS research in sub-Saharan Africa is characterized by an overall lack of cooperation among donor agencies. "Virtually without exception [donors] are reluctant to cooperate and coordinate with each other … [resulting in] duplication of activities, while, paradoxically, other critical intervention areas are almost entirely ignored" (Msiska, 1994:16). The cumulative effect of this lack of cooperation is depressing and contributes to several of the problems discussed earlier in this section: (1) virtually all research projects proposed by outside donors are approved if funding is forthcoming, and local collaborators can be identified; (2) sub-Saharan African governments have been slow to establish their own priorities, and local researchers have no independent means of identifying and mobilizing funds for their projects; and (3) no mechanisms exist for identifying potential duplication of effort in past and current research activities. Harsh Environment for Social and Behavioral Research The many constraints inherent in working in developing countries are well known. Overcoming these constraints on a broad scale would require substantial political, economic, social, and technological developments, well beyond the scope of this report. It is important to acknowledge, however, that on a day-to-day basis, researchers working in developing countries must overcome many obstacles that researchers in more developed countries do not have to face. Unfavorable Political Climate The overall political climate of a country can be neutral, positive, or negative with regard to AIDS research. Typically, single-party regimes, which historically have been common in sub-Saharan Africa, fall into the last group, tending to favor censorship over open dialogue on the state of the economy and other

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences matters of national interest, including AIDS. Overall, this environment is not conducive to rational decision making on the basis of sound research and policy analysis and results in less-informed debate about policy alternatives (World Bank, 1991). Such political environments also are not supportive of centers that might develop institutional capacity through research and training (World Bank, 1991). Early in the epidemic, AIDS researchers faced considerable hostility. When AIDS was first discovered, there was a widespread perception that the European and North American press wanted to blame Africa for infecting the world with the disease; this perception caused many African politicians to deny the epidemic's existence (N'Galy et al., 1990). In February 1987, the President of Kenya, perhaps fearing that the presence of the disease would adversely affect international tourism and despite the fact that the Ministry of Health had just launched an anti-AIDS campaign, minimized the extent to which the epidemic had spread through the Kenyan population (Harden, 1987). Furthermore, given the many problems facing sub-Saharan African governments, the problem of AIDS may not appear as immediate as other social issues, a perception that may, in part, explain their attitude toward the disease. In Zaire, the government did not establish a national AIDS control program until 1987 or report AIDS cases to WHO/GPA until 1988, even though a well-known research team in Kinshasa had been presenting papers at international AIDS conferences as early as 1985 that showed hundreds of confirmed cases of AIDS in the country (Mann et al., 1992). Denial and complacency about the epidemic on the part of the general public were equally serious obstacles. Second, many sub-Saharan African governments have become excessively bureaucratic, in part as a result of social welfare programs that have established governments as the employers of last resort. Researchers petitioning the government, whether for permission to undertake a project, for access to data, or for some other reason, must endure a long and laborious process of obtaining approval. Third, the existence of corruption is poorly documented but extremely pervasive throughout the region (Kpundeh, 1994). Consequently, sub-Saharan African institutions have experienced serious problems in managing finances and disbursing supplies and equipment. Once widespread corruption and poor work habits had been established at senior levels, they rapidly filtered down through the administrative structure, becoming next-to-impossible to eradicate. Decline of Higher-Education Systems in Sub-Saharan Africa Institutes of higher learning in sub-Saharan Africa have not been shielded from the negative consequences of the current economic crisis. In some cases, universities have been viewed as the centers of organized protest against government policies, and as a result some have been closed or starved for resources.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Rapid population growth, coupled with persistently low and, in some cases, negative rates of economic growth, has constrained public expenditures for education. As a result, funds for higher education have declined, enrollment rates have stagnated, and the quality of education has deteriorated substantially. Since independence, the priority of sub-Saharan African governments has been to expand the number and size of universities without sufficient regard to their quality. Consequently, the growth in the number of university graduates has been spectacular, but the quality of education offered has fallen dramatically (World Bank, 1988). Currently, higher education in sub-Saharan Africa is characterized by (1) a general overproduction of poorly qualified graduates; (2) an overproduction of the wrong types of graduates, that is, an inappropriate mix of outputs; and (3) a high price tag (World Bank, 1989). The decline in quality at all levels of education, but particularly at the tertiary level, has had severe repercussions for the region's short-term analytical and research capacity. The flight of many top faculty and the rapid deterioration of sub-Saharan African universities have resulted in the loss of high-quality research centers able to supply policy makers with research results and policy analysis for planning purposes. But in the long term, the decline in higher education will result in a much more serious loss: a decline in the quality of these institutions' future graduates. Inadequate Infrastructure On a day-to-day operational level, inadequate transportation and communications systems make project implementation infinitely more challenging in sub-Saharan Africa than in developed countries. Inadequate roads make it more difficult for researchers to work in comparatively remote areas; consequently, they are forced to work in more developed areas of the country. Lack of phone systems and electronic communications equipment hinders collaboration and slows the execution of a project. Unstable electrical systems make computer equipment vulnerable to damage and interrupt the project's work plan. Economic Weakness AIDS struck the African continent just at a time when it was undergoing its worst financial crisis since independence. The weakness of many African economies contributes to their difficulties in developing an indigenous capacity to conduct research. In an attempt to stimulate growth and reverse economic declines, many sub-Saharan African governments have been forced to institute structural adjustment programs. A key element of these programs is to bring government budget deficits under control. Despite abundant evidence of overstaffing, most sub-Saharan African governments have found it politically infeasible to reduce the

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences number of government employees and have sought to ease their fiscal burden by allowing inflation to outpace salary increases. In many cases, salaries have fallen below acceptable living standards. A recent survey of eight sub-Saharan African countries found real starting salaries had declined between the early to mid-1970s and 1983 for virtually all grades within the civil service, in some cases by 30 percent or more (Lindauer et al., 1988). In Somalia, salaries in 1985 were only one-twentieth of their real value in 1975 (Robinson, 1990). The decline in real wages has had disastrous consequences for morale and work efforts throughout the public sector. A report on pay and working conditions in Sudan concluded that: … the dramatic reduction in real pay has had an equally dramatic effect on performance, motivation and the general level of civil service activities. Attendance at work is unreliable, and performance when at work is low and unsatisfactory for many parts of the civil service … it is a matter of some urgency that morale and performance be raised (International Labour Office, 1987:127, 130). In Uganda, the deterioration of pay and working conditions in the public sector has led to an increase in fraudulent practices such as improper use of allowances, kickbacks on government purchases, illicit payments for not enforcing laws and regulations, diversion of public goods into private hands, and bribes for licenses and permits (Republic of Uganda, 1988, cited in Chew, 1990). The most visible adaptation by civil servants to a reduction in their real wages has been a massive reduction in the number of hours worked. To recover lost wages, many government employees work less than half a normal working day and spend the remainder of the day engaged in small-scale farming or moonlighting in the private sector (Chew, 1990). Because the majority of sub-Saharan African researchers are employed by public universities, they have experienced declines in real wages comparable to those of other public-sector employees. Not surprisingly, these pay cuts have negatively affected their morale and work performance and made opportunities outside academia more attractive. Many faculty have left. Those who have remained spend much less time than before concentrating on research or other activities necessary to reestablish the university as a center for excellence. Rather, they are forced to spend their time looking for ways to supplement their meager government salaries through consultancies or participation in other business ventures. Weak Policy Support for the Health Sector The health sector has not been spared cutbacks as hard times have forced sub-Saharan African governments to implement fiscal austerity measures (Cornia et al., 1987). These measures have seriously impaired the ability of sub-Saharan African health ministries and national AIDS control programs to function efficiently

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences and achieve their objectives. Between 1975 and 1989, the percentage of government expenditures for health fell in 13 of the 22 countries for which time series data are available (World Bank, 1994). In 1985, the average per capita expenditure for health care by sub-Saharan African governments equalled US $5.32, as compared with per capita expenditures of US $1,340 in developed countries and US $323 for the world as a whole (World Bank, 1994). Low Value Placed on Social and Behavioral Research An appreciation of the multifaceted cultural, social, and behavioral contexts throughout sub-Saharan Africa and how they are changing in the face of the AIDS epidemic is essential for understanding the spread of the epidemic and for evaluating the potential effect of intervention programs (see Chapter 2). Yet social and behavioral research has been underappreciated and largely neglected. To date, the vast majority of funds for HIV/AIDS research has gone toward clinical research in an attempt to understand the nature of the virus, as a logical starting point for identifying a vaccine or a cure. However, a growing consensus is emerging that while a preventive vaccine and an effective cure remain long-term goals, they will not be achieved soon, and that research on the social and behavioral aspects of the disease—which strongly shape the speed and extent of transmission—has been neglected. Given the social, economic, and cultural diversity in the region, there is an urgent need for more local behavioral and social science knowledge. A lack of appreciation for the potential contributions of behavioral and social science is not unique to sub-Saharan Africa. In the United States, expert advisory groups similar to this panel have repeatedly demanded more and better behavioral and social science research to increase our understanding of HIV/AIDS and inform policy makers and health planners concerned with slowing the spread of the epidemic (Institute of Medicine [United States], 1986, 1988; Miller et al., 1990; National Commission on AIDS [United States], 1991, 1993; Turner et al., 1989). Researchers themselves are partly responsible for the lack of appreciation for the role of social and behavioral research in controlling the spread of AIDS. In large part, they have not been successful in working with policy makers to translate their findings into better prevention programs. RECOMMENDATIONS In the long run, it is essential to help sub-Saharan African countries develop their own research capacity by strengthening their universities and augmenting the technical skills of their researchers. There is considerable debate and controversy, however, about how best to achieve this goal. Regardless of what the best mechanisms may be, no significant progress is likely to be made until the region's

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences governments understand that they must put AIDS more squarely on their own research and policy agendas. Clearly, a major constraint on the amount of HIV/AIDS research that is undertaken is inadequate funding. Potential sources of funding include communities, private-sector firms, the public sector, and international donors. Because it is unlikely that donors are going to increase significantly their levels of funding in the near future, the governments will have to find additional resources. Given the weak economic position of most sub-Saharan African countries, however, it will be difficult to persuade their governments to pursue more vigorous research agendas in the near future. There are no easy solutions to the problems discussed in this chapter, but below are several recommendations that could improve the situation marginally in the short run and should be considered in developing any long-term strategies for conducting and using research in Africa. KEY RECOMMENDATION 5. Linkages between sub-Saharan African institutions and international research centers must be established on a wide range of activities, including teaching, research, and faculty and student exchanges. International donors should seriously consider establishing a sub-Saharan African AIDS research institution with a strong behavioral and social science element. There is a critical need to strengthen African research institutions in sub-Saharan Africa. Linkages with international organizations, especially if built on an evolving and well-defined research agenda, can help local institutions develop and assist local researchers by providing relatively secure long-term funding, offering support for the preparation of data and manuscripts for publication and dissemination, and providing in-country technical assistance and research training. Experience in a number of settings has demonstrated that such long-term collaboration, in addition to contributing significantly to understanding of the HIV/AIDS epidemic, is mutually beneficial to all institutions involved; it could be very successful in providing highly skilled African researchers with support and the possibility of remaining in their country of origin. Recommendation 7-1. The number of African scientists well trained to conduct research on HIV and AIDS must be increased. Research capacity in sub-Saharan Africa cannot be improved without an increase in the number of well-trained local researchers. Many African institutions suffer from a serious shortage of competent professionals, and those that are well staffed have enormous difficulty retaining their best people. The lure of

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences high salaries in the private sector or from international donors is often strong enough to pull many Africans out of local research institutions, including universities. Many others migrate abroad. Furthermore, the rapid emergence of AIDS meant that the only short-run solution to the dearth of AIDS researchers was to borrow from related disciplines. Now that the nature and magnitude of the epidemic are better understood, there is an urgent need for universities to develop appropriate curricula to train researchers as AIDS specialists. Four possible ways to introduce and keep more researchers in the field are to (1) integrate more graduate students and young professionals into all new AIDS-related research initiatives; (2) establish small grants programs to fund the projects of young researchers; (3) adjust pay scales to attract and retain talented professionals; and (4) provide other incentives for researchers to remain in their home institutions, including small-scale research grants, fewer teaching or administrative responsibilities, and more opportunities for international travel. Providing technical assistance to local researchers is an important priority. Local researchers could benefit from workshops that would help them design research projects, prepare research proposals, identify potential sources of funding, write reports describing interim results, and prepare final manuscripts for submission to peer-reviewed journals. Recommendation 7-2. Each national AIDS control program should establish a local AIDS-information center that would develop and maintain a database of all AIDS-related research conducted in the country. These centers should be linked via available technology, such as the Internet. They should also have AIDS databases available on CD-ROM. (CD-ROM equipped computers are available in most national AIDS control program offices.) In addition, national and regional conferences should be held to provide forums at which researchers can discuss their research plans and present their results to a larger group of local researchers than those that attend international conferences. Recommendation 7-3. There is an urgent need for sub-Saharan African countries to establish and periodically update research priorities at the regional and national levels, providing a basis for discussions with donors on AIDS-related research. It is important to reduce the proportion of donor-driven research taking place in the region. Recommendation 7-4. International organizations and donors should utilize existing local resources to the fullest extent possible.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences It is paradoxical that donors underutilize existing talent in the region. Utilizing local expertise can strengthen local institutions, generate employment, and create opportunities for talented researchers in sub-Saharan Africa. Recommendation 7-5. Greater dialogue between researchers and policy makers is necessary. Not only is there an urgent need to increase indigenous capacity to conduct research, but there is also a need to better synthesize and translate research findings into effective prevention and control programs and policies. Otherwise, prevention programs will be only marginally based on local needs or tailored to local conditions, and research will be even more undervalued and underfunded. Researchers need to do a better job of drawing out the policy implications of their work, and planners and policy makers need to articulate more clearly to researchers what information they need for effective planning and programs (Uganda AIDS Commission, 1992). Recommendation 7-6. If more effective strategies for AIDS prevention and mitigation are to be developed in the future, better coordination among donors is needed, particularly sharing of information about which prevention and control efforts work and which do not. The role of the new cosponsored United Nations Programme on AIDS (UNAIDS) will be critical to future work.4 Success will also require greater political will and commitment on the part of the governments of sub-Saharan Africa and other countries. 4   Announcing Dr. Peter Piot's appointment as the head of the newly formed United Nations Programme on AIDS, Dr. Boutros Boutros-Ghali declared that ''faced with a truly global emergency and its multisectoral needs, it is imperative that the UN response is comprehensive and effective. HIV/AIDS will not be controlled unless all of us, acting as a global community, unite our efforts, coordinate our actions, and reduce duplication" (World Health Organization, 1995:1).