5
Translating Research into Action

A variety of interventions are available for preventing HIV infections (see Appendix B). Many of these interventions emphasize changing risk behaviors related to sexual practices or drug use, under the assumption that the adoption of “safer” behaviors will reduce individuals’ risk of exposure to (and infection with) HIV. Other interventions rely on technological approaches to preventing HIV transmission. Although research and clinical trials can evaluate the efficacy of these interventions, the true test of whether or not they are useful for HIV prevention is how well they actually function in community or “field” settings. In order for the interventions to make the transition from the research setting to the field setting, they must be “transferred”—that is, disseminated and adopted—to community-based organizations (CBOs), AIDS service organizations (ASOs), and other groups that can implement them on a local level.

In this chapter, the Committee examines the efforts that have been made in transferring prevention technologies, and we present testimony by community members about the usefulness and effectiveness of these efforts. The Committee also provides recommendations for how technology transfer can be improved.

CURRENT EFFORTS IN PREVENTION TECHNOLOGY TRANSFER

Over the years, the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and other federal agencies have



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No Time to Lose: Getting More from HIV Prevention 5 Translating Research into Action A variety of interventions are available for preventing HIV infections (see Appendix B). Many of these interventions emphasize changing risk behaviors related to sexual practices or drug use, under the assumption that the adoption of “safer” behaviors will reduce individuals’ risk of exposure to (and infection with) HIV. Other interventions rely on technological approaches to preventing HIV transmission. Although research and clinical trials can evaluate the efficacy of these interventions, the true test of whether or not they are useful for HIV prevention is how well they actually function in community or “field” settings. In order for the interventions to make the transition from the research setting to the field setting, they must be “transferred”—that is, disseminated and adopted—to community-based organizations (CBOs), AIDS service organizations (ASOs), and other groups that can implement them on a local level. In this chapter, the Committee examines the efforts that have been made in transferring prevention technologies, and we present testimony by community members about the usefulness and effectiveness of these efforts. The Committee also provides recommendations for how technology transfer can be improved. CURRENT EFFORTS IN PREVENTION TECHNOLOGY TRANSFER Over the years, the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and other federal agencies have

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No Time to Lose: Getting More from HIV Prevention funded social and behavioral research that has yielded interventions that significantly reduce HIV-related risk behavior, thereby reducing HIV infection risk. Although such research projects are valuable for the development of better social and behavioral prevention tools, their findings typically have been disseminated in a very select manner (e.g., peer-reviewed articles) via very select mechanisms (e.g., clinical or academic journals and conferences) to a very select audience (e.g., other researchers). This strategy is effective in reaching mainly academic audiences, but it is ineffective in disseminating the methodologies and findings to those who need them the most: state- and local-level workers who are planning, developing, adapting, and implementing prevention activities in their communities. In recognition of the need for greater dissemination of prevention technologies, the Presidential Advisory Council on HIV/AIDS (PACHA) recommended in 1996 that the President “should instruct the Secretary of Health and Human Services to ensure that federally funded research on HIV prevention interventions include specific mechanisms for rapid dissemination of findings, including resources to allow replication of programs with demonstrated effectiveness” (PACHA, 1996). To address this, the CDC responded that its Prevention Research Synthesis (PRS) project—which, at that time, was already in development—would meet the recommended objective. The PRS project created an ongoing database of HIV prevention interventions that were selected for their methodological rigor and that had substantial evidence of effectiveness. Additionally, the PRS project was charged with developing mechanisms for the dissemination and adoption of these interventions. For example, the project led to the development of the Compendium of HIV Prevention Interventions with Evidence of Effectiveness (CDC, 1999a), the Characteristics of Reputationally Strong Programs Project (CDC, 2000b), and the CDC Behavioral and Social Science Volunteer Project (CDC, 2000a). The CDC and various partners also have provided technical assistance to support the implementation of science-based prevention. These and other vehicles for improving access to research also have been developed by federal and private agencies and are available to the general public. Examples of these methods are presented in Table 5.1.1 Each of the resources listed in Table 5.1 provides brief descriptions of specific prevention interventions, including information about their meth- 1   The Committee did not conduct a systematic review of the technical assistance activities offered by the CDC and other organizations. This table illustrates the kinds of technical assistance currently offered.

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No Time to Lose: Getting More from HIV Prevention TABLE 5.1 Examples of HIV Prevention Research Dissemination Authors Title Description of Interventions Dissemination Tool CDC/NCHSTP (CDC, 2000d) REP+: Replicating Effective Programs Plus http://www.cdc.gov/hiv/projects/rep/default.htm Science-based, tested behavioral interventions with demonstrated evidence of effectiveness in reducing HIV risk behaviors Intervention packages/kits CDC/NCHSTP (CDC, 1999a) Compendium of HIV Prevention Interventions with Evidence of Effectiveness http://www.cdc.gov/hiv/projects/rep/compend.htm Prevention interventions that have been tested in research settings, have shown no negative findings, and have yielded statistically significant changes in HIV risk behavior Document CDC/NCHSTP (CDC, 2000b) C-RSP Project: Characteristics of Reputationally Strong Programs http://www.cdc.gov/hiv/projects/rep/crspproj.htm Prevention programs that are “well-respected” and “reputationally strong,” but that have not been evaluated by research trials and are seldom published Document

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No Time to Lose: Getting More from HIV Prevention CDC/NCCDPHP-DASH (CDC, 2000c) Programs that Work http://www.cdc.gov/nccdphp/dash/rtc/hiv-carric/htm HIV prevention programs specifically designed for use in adolescent and school-based populations Curricula and fact sheets NASTAD, AED, CDC (NASTAD et al., 2000) Bright Ideas: Innovative or promising practices in HIV prevention and HIV prevention community planning http://www.cdc.gov/hiv/pubs/brightideas.pdf A compilation of innovative state-level prevention (and community planning) activities that “jurisdictions’ peers felt were notable” Document Sociometrics Program Archives Program Archive on Sexuality, Health, and Adolescence (PASHA) http://www.socio.com/pasha/poview.htm “A collection of promising teen pregnancy and STD/HIV/AIDS prevention programs for teens” Intervention packages/kits for sale Sociometrics Program Archives HIV/AIDS Prevention Program Archive (HAPPA) http://www.socio.com/pasha/happa.htm “A collection of promising adult HIV/AIDS prevention programs” Intervention packages/kits for sale   SOURCE: CDC: Centers for Disease Control and Prevention; NCSTP: National Center for HIV, STDs, and TB Prevention; NCCPDHP-DASH: National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health; NASTAD: National Alliance of State AIDS Directors; AED: Academy of Educational Development

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No Time to Lose: Getting More from HIV Prevention odologies, target audiences, and program effects (e.g., significant changes in risk behavior). Further, each resource lists whom to contact to obtain more information about the interventions, and each of them is available via the Internet. In some cases (e.g., the Sociometrics Program Archives), ready-made intervention “kits” are available for purchase for those wishing to adopt interventions in school, group, or community settings. In many cases, these kits have been adapted so that the materials and curricula are user-friendly and written in language appropriate for local-level use. In addition to the resources listed in Table 5.1, the CDC Behavioral and Social Science Volunteer Project links technical prevention science volunteers with local prevention providers for the purpose of helping to build intervention research and implementation skills. State and local level health departments can also offer technical assistance to community organizations (NASTAD, 2000a). Indeed, health departments are in a good position to provide coordinated assistance and capacity development to community prevention service providers because they have access to infected and at-risk communities, as well as access to relevant federal agencies. Additionally, because they are federally mandated to provide such assistance, health departments are more likely to have the necessary infrastructure in place to effectively provide support to community-level colleagues (NASTAD, 2000a). BARRIERS TO EFFECTIVE TECHNOLOGY TRANSFER AT THE COMMUNITY LEVEL Despite the above-mentioned efforts, community representatives (ranging from state health department officials to outreach workers) reported to the Committee that the actual level of technology transfer and technical assistance being offered by both federal, state, and local agencies is not enough to help them address “real world” prevention needs (see Appendix E for summary of public comments). Although the representatives acknowledged and appreciated the efforts that have been made by the CDC and other federal agencies that fund prevention activities, they generally felt that the technical assistance being delivered is insufficient in terms of quantity and occasionally variable in quality. Several representatives expressed a need for technical assistance to improve the organizational capacity of CBOs and ASOs so that they could successfully support prevention services for their constituents. According to these representatives, the lack of organizational capacity is, in some cases, due to insufficient personnel resources at the organization and the need for more staff to help manage the increases in workload that come with the adoption of new prevention programs. In other cases, the general lack of information from technical assistance providers regarding the type of infra-

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No Time to Lose: Getting More from HIV Prevention structure needed for implementation of new prevention programs precluded the organization from being able to assess where their own organizational capacity was lacking. Some representatives also expressed a need for technical advisers who would spend significantly more time at their site (e.g., one to two weeks) to get better acquainted with the service-providing organization and the prevention needs of the targeted risk groups, as well as to help the organization muster support from the community. The representatives felt that, with a deeper understanding of the local context, technical specialists could provide more useful advice regarding the organizational and implementation-related problems that occur on a day-to-day basis. With regard to current efforts, some representatives believed that the intervention dissemination process is too slow to keep up with the social and behavioral risk trends that continue to occur in the highest risk communities. Some representatives also said that social and behavioral interventions that are too heavily focused on theory are not practical or culturally relevant when applied at the field level, and that disseminating “interventions in a box” does not work without resources to aid adaptation and implementation. And some representatives stressed the need for building local-level capacity so that CBOs and ASOs could design their own interventions that would be both scientifically sound and better suited to the prevention needs and realities of their constituencies. It was felt that such capacity building could be done on a “peer-to-peer” basis using local community experts or through improved, egalitarian collaborations with research groups and state health departments. It also was clear from the testimony of the community representatives that other important information, skills, and methodologies are not being effectively disseminated to the field. For example, many representatives cited difficulty in obtaining current data regarding the effectiveness of programs, including cost-effectiveness, for prevention interventions. Some representatives pointed out the need for valid, reliable evaluation methodologies, as well as for training on their use, to evaluate both the effectiveness and cost-effectiveness of prevention programs that could be used at the local level by health departments, CBOs, and others to better estimate the true impact of the interventions on the HIV infection rates in their communities. It also was felt that such information could provide better guidance for choosing the right interventions to suit both constituents’ needs and local operating budgets. Because the continuation of funding for state and local prevention services often depends on some indication of the program’s effectiveness, the absence of such data or the methodology with which to collect these data has potentially serious consequences for the continuity of HIV prevention services in a given community.

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No Time to Lose: Getting More from HIV Prevention Lastly, many community representatives cited issues related to funding as obstacles to optimal implementation and maintenance of prevention services. For example, several representatives specifically mentioned that the prevention and care needs of individuals diagnosed with multiple disorders could be better served if organizations were better provided with technical assistance on obtaining and sustaining funding for prevention services. Such assistance could take the form of training in grant writing, or guidance regarding how to use merged funding streams to provide complementary HIV prevention services (e.g., substance abuse treatment and HIV prevention outreach) that are supported through different federal agencies. Such technical assistance could be provided at the state and local levels by liaisons from federal agencies and through closer collaborations with research organizations and health departments. The views expressed by the community representatives are not new. Such views have been documented in the research literature (Stevenson and White, 1994) and in community public forums (Goldstein and Lew, 1998). Also, the Presidential Advisory Council, in its 1997 response to the Clinton Administration’s actions regarding its technology transfer recommendation, stated that although it was pleased with the CDC’s development of a program concerning technology transfer, “The Council lacks sufficient information to evaluate the effectiveness of this program” (PACHA, 1997). The Council added that, in general, the federal effort in this area “falls well short of what is needed to ensure that local prevention service providers have access to the latest prevention research findings.” The 1999 Work Group Report on HIV Prevention Activities at the CDC, submitted to the CDC Advisory Committee for HIV and STD Prevention (ACHSP), echoed the call for more effective mechanisms for disseminating prevention technologies, recommending that the CDC “develop a technical assistance process that drives a real technology transfer agenda” (CDC, 1999b). The report further noted that “technical assistance is NOT technology transfer.” OPPORTUNITIES FOR IMPROVING PREVENTION TECHNOLOGY TRANSFER There are several key mechanisms by which the transfer and adaptation of prevention research can occur in a more timely fashion. At the state and local levels, one way in which prevention technologies can be more effectively transferred to and implemented by communities is through the establishment of additional collaborative partnerships between prevention researchers (who are often based in universities) and local prevention service providers (Shriver et al., 1998; Sanstad et al., 1999; Schensul, 1999). These collaborations can facilitate the development

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No Time to Lose: Getting More from HIV Prevention of program evaluations and new interventions that are more realistic and culturally appropriate to the communities to which the interventions are targeted (Grinstead et al., 1999; Klein et al., 1999). Such partnerships may initially be difficult to forge because of perceived power differentials, differences in social class, and trust issues. To be successful these partnerships must be egalitarian, mutually respectful, and bi-directional in their level of information exchange (Schensul, 1999). An example of such a partnership is the Center for AIDS Prevention Studies (CAPS) model of community-based collaborative research at the University of California, San Francisco (Sanstad et al., 1999; Schensul, 1999). Created and initiated in 1991 in response to National Institute of Mental Health’s (NIMH) mandate for community involvement as a condition for receiving funding, the underlying goal of the CAPS model is to bring the skills of science to the service of HIV prevention and the knowledge of the service providers into the domain of research. This model has been applied in two different programs, one that is limited to the Bay Area2 and one that is statewide.3 Process and outcome evaluations of these programs indicate that they have improved interorganizational communication and increased the value of research for service providers, and that, in some cases, their research findings have influenced policy at the agency level in terms of service delivery (Schensul, 1999). Compared to national organizations, state and local research centers that are funded by NIH agencies (such as the National Institute for Drug Abuse and the NIMH) are ideally suited to help implement technology transfer. They are not only able to provide research expertise, but also are able to provide continuing consultation and on-site technical assistance to the CBOs implementing prevention interventions. Given that such federally funded centers exist throughout the country, they have the opportunity to form regional networks of technology transfer centers that can work with communities to address the HIV epidemic as it manifests itself in those locations. This sort of active collaboration has been shown to result in more successful adoption of science-based prevention programs 2   The program in the San Francisco Bay Area is the HIV Prevention Evaluation initiative. Managed by CAPS, the initiative brings together CBOs, CAPS researchers, CAPS program administrators, and area philanthropists to implement HIV prevention intervention research (Sanstad et al., 1999). For more information about this program, see: http://www.caps.ucsf.edu/capsweb/ncgindex.html. 3   The Statewide Community HIV Evaluation Project consists of researcher-CBO teams located throughout California, who implemented formative and outcome research (Sanstad et al., 1999). For more information about this program, see: http://www.caps.ucsf.edu/capsweb/projects/schepindex.html.

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No Time to Lose: Getting More from HIV Prevention at the community level (Kelly et al., 2000), and such collaboration also has been shown to be a contributing factor to successful community-based research overall (Goldstein et al., 2000). Although the CAPS model has been replicated by universities, funding agencies, and CBOs nationally (Goldstein et al., 2000), the testimony submitted by community representatives to the Committee regarding the need for ongoing, more comprehensive technical assistance and research collaborations suggests that this mechanism for technology transfer is still underutilized. At the federal level, there are several opportunities for improving prevention research technology transfer. For example, the CDC has extensive interaction with prevention service providers at the state and local levels and it already provides a substantial amount of technical assistance to community-based organizations. Given this established role on the “front lines” of prevention, the CDC should evaluate the quality and quantity of technical assistance that it has provided in order to determine how the process can be improved. For example, a 1996 report on the CDC’s HIV Prevention Community Planning Process found that there was limited incorporation of behavioral research into community planning (Collins and Franks, 1996). Some of the barriers included the lack of group training on the use of behavior research; questions about the applicability of the research to specific at-risk populations or geographic areas; gaps in the behavioral research literature; and widely divergent levels of planning group members’ expertise, education, and familiarity with research information (Collins and Franks, 1996). While the CDC is the lead prevention agency, other agencies in the Department of Health and Human Services also have a substantial role in the national HIV prevention effort, and their roles can be expanded. For example, while the 18 NIH-funded Centers for AIDS Research (CFARs) currently have a mandate of “facilitating technology transfer and development through promotion of scientific interactions between CFARs and industry,” (NIH, 1995), this mission could be expanded to include more active collaborations between CFARs specializing in prevention research and non-industry organizations, such as state and local health departments and community-based HIV prevention service providers. Similarly, the NIMH’s Center for Mental Health Research on AIDS, which supports basic and applied behavioral research on HIV prevention (NIH, 1999), could expand its mission to include greater support of research pertaining to the dissemination and adaptation of effective prevention interventions into community settings. Such actions were called for in the 1996 Report of the NIH AIDS Research Program Evaluation Working Group of the Office of AIDS Research Advisory Council, which urged NIH “to continue to support HIV community involvement in AIDS research programs” (Office of AIDS Research Advisory Council, 1996). The report

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No Time to Lose: Getting More from HIV Prevention further stated that “translating basic laboratory and behavioral sciences research into public health and clinical practice is an essential aspect of a (AIDS Research) Center’s program that can in turn, provide further basic research opportunities” (Office of AIDS Research Advisory Council, 1996). Because NIH supports a significant amount of research activities related to HIV prevention, it might be the agency best suited to investigate ways to better disseminate and adapt prevention technologies to the community level. Such efforts should be undertaken in collaboration with partner agencies which have a large role in local-level prevention efforts, such as the CDC, the Substance Abuse and Mental Health Services Administration, and the Health Resources and Services Administration. Based on this evidence, the Committee acknowledges that, without greatly improved HIV prevention dissemination and adoption mechanisms and associated technical assistance, the organizations that operate HIV prevention programs at the state and local levels will continue to struggle against the obstacles that limit their effectiveness. Therefore, the Committee recommends: Key Department of Health and Human Services agencies that fund HIV prevention research and interventions should invest in strengthening local-level capacity to develop, evaluate, implement, and support effective programs in the community. The Committee further recommends that these agencies invest in research on how best to adapt effective programs for use in community-level interventions and research on what constitutes effective technical assistance for optimal research-to-community transfer of prevention programs; these agencies should also be responsible for the widespread dissemination of the results of this research. Such efforts will require the participation and collaboration of the funding agencies, researchers, service providers, and communities. REFERENCES Centers for Disease Control and Prevention (CDC), Prevention Research Synthesis Project. 1999a. Compendium of HIV prevention interventions with evidence of effectiveness. Atlanta, CDC. Centers for Disease Control and Prevention (CDC). (Work Group on HIV Prevention at the CDC). 1999b. Final report to the Advisory Committee on HIV and STD Prevention. Atlanta, CDC. Centers for Disease Control and Prevention (CDC). 2000a. Behavioral and Social Science Volunteer Program [Web Page]. Located at: www.cdc.gov/hiv/projects/rep/bssv.htm.

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No Time to Lose: Getting More from HIV Prevention Centers for Disease Control and Prevention (CDC). 2000b. The C-RSP Project: Characteristics of Reputationally Strong Programs [Web Page]. Located at: www.cdc.gov/hiv/projects/rep/crspproj.html. Centers for Disease Control and Prevention (CDC). 2000c. Programs that Work: HIV Prevention Curriculum and Fact Sheets [Web Page]. Located at: www.cdc.gov/nccdphp/dash/rtc/hiv-curric.htm. Centers for Disease Control and Prevention (CDC). 2000d. Replicating Effective Programs Plus [Web Page]. Located at: www.cdc.gov/hiv/projects/rep/default.htm. Collins C and Franks P. 1996. Improving the use of behavioral research in the CDC’s HIV prevention community planning process: Centers for AIDS Prevention Studies, University of California, San Francisco. Monograph Series, Occasional Paper #1. Goldstein E, Freedman B, Richards A, Grinstead O. 2000. The legacy project: Lessons learned about conducting community-based research [Web Page]. Located at: www.caps.uscf.edu/bibindex.html#S2C. Goldstein E and Lew S. 1998. New Directions in Prevention. Presentation. Mayor’s Summit on AIDS and HIV, San Francisco, CA [Web Page]. Located at: hivinsite.uscf.edu/social/misc._documents/2098.3723.html. Grinstead OA, Zack B, Faigeles B. 1999. Collaborative research to prevent HIV among male prison inmates and their female partners. Health Education and Behavior 26(2):225–238. Kelly JA, Somlai AM, DiFranceisco WJ, Otto-Salaj LL, McAuliffe TL, Hackl KL, Heckman TG, Holtgrave DR, Rompa D. 2000. Bridging the gap between the science and service of HIV prevention: Transferring effective research-based HIV prevention interventions to community AIDS service providers. American Journal of Public Health 90(7): 1082–1088. Klein D, Williams D, Witbrodt J. 1999. The collaboration process in HIV prevention and evaluation in an urban American Indian clinic for women. Health Education and Behavior 26(2):239–249. National Alliance of State and Territorial AIDS Directors. 2000a. Technical assistance and capacity building provided to community based organizations by health departments. NASTAD Issue Briefs. National Alliance of State and Territorial AIDS Directors, Academy of Educational Development, Centers for Disease Control and Prevention. 2000b. Bright Ideas: Innovative or Promising Practices in HIV Prevention and HIV Prevention Community Planning [Web Page]. Located at: www.cdc.gov/hiv/pubs/brightideas.pdf. National Institutes of Health. 1995. Centers for AIDS Research (CFAR) Mission Statement (developed by the CFAR Directors at the 1995 Annual Directors Meeting) [Web Page]. Located at: www.niaid.nih.gov/research/cfar/Mission2.htm. National Institutes of Health. 1999. Overview of the Mission of the Center for Mental Health Research on AIDS [Web Page]. Located at: www.nimh.nih.gov/oa. Office of AIDS Research Advisory Council.1996. Report of the NIH AIDS Research Program Evaluation Working Group of the Office of AIDS Research Advisory Council [Web Page]. Located at: www.nih.gov/od/oar/public/public.htm. Presidential Advisory Council on HIV/AIDS. 1996. PACHA recommendations—unresolved only. Council Recommendation III.P.4. Washington DC: PACHA. Presidential Advisory Council on HIV/AIDS. 1997. PACHA recommendations—unresolved only. Council Assessment of Response III.P.4. Washington DC: PACHA. Sanstad KH, Stall R, Goldstein E, Everett W, Brousseau R. 1999. Collaborative community research consortium: A model for HIV prevention. Health Education and Behavior 26(2): 171–184. Schensul JJ. 1999. Organizing community research partnerships in the struggle against AIDS. Health Education and Behavior 26(2):266–283.

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No Time to Lose: Getting More from HIV Prevention Shriver M, de Burger R, Brown C, Simpson HL, Meyerson B. 1998. Bridging the gap between science and practice: insight to researchers from practitioners. Public Health Reports 113 (Suppl 1):189–193. Sociometrics. HIV/AIDS Prevention Program Archive (HAPPA) [Web Page]. Located at: www.socio.com/pasha/happa/htm. Sociometrics. Program Archive on Sexuality, Health, and Adolescence (PASHA) [Web Page]. Located at: www.socio.com/pasha/poview.htm. Stevenson HC, White JJ. 1994. AIDS prevention struggles in ethnocultural neighborhoods: Why research partnerships with community based organizations can’t wait. AIDS Education and Prevention 6(2):126–139.