The document discusses strategies for translating HIV/AIDS research into policy and practice, highlighting the importance of ensuring research evidence is used to inform management, policy, and clinical decision making. It also outlines challenges in HIV prevention for most-at-risk populations and proposes combination prevention approaches that integrate biomedical, behavioral, and structural interventions to effectively address the epidemic. Barriers like stigma, discrimination, access to services, and enabling environments must be overcome to improve HIV prevention efforts.

1. Translating Research into
Policy and Practice
The Way Forward
Adeeba Kamarulzaman
University of Malaya

2. • Strategies that try to ensure that knowledge
gained from the best evidence is actually
used in practice.
• Enhance the utility of research that involves
making research evidence more usable and
improving the capacity of management,
policy, and clinical decision makers to use it.

3. Initial Reports
• June 5, 1981: 5 cases of
PCP in gay men from
UCLA (MMWR)
• July 3, 1981: 26
additional cases
• Dec 10, 1981: 3 NEJM
3papers describe cases
Gottlieb MS NEJM 2001;344:1788-91

4. Adults and children estimated to be living with HIV | 2009
Western & Eastern Europe
Central Europe & Central Asia
820 000 1.4 million
North America [720 000 – 910 000][1.3 million – 1.6 million]
1.5 million East Asia
[1.2 million – 2.0 million] 770 000
Middle East & North Africa [560 000 – 1.0 million]
Caribbean 460 000
240 000 [400 000 – 530 000]
South & South-East Asia
[220 000 – 270 000] 4.1 million
Sub-Saharan Africa [3.7 million – 4.6 million]
Central & 22.5 million
South America [20.9 million – 24.2 million] Oceania
1.4 million 57 000
[1.2 million – 1.6 million] [50 000 – 64 000]
Total: 33.3 million [31.4 million – 35.3 million]

5. HAART became available

6. HPTN 052
• Participants – 1763 sero-discordant couples
• HIV infected partners: 890 males, 873 females
• HIV transmissions
– 39 infections, 28 linked
– 1 transmission in immediate ART group
– 27 transmissions in deferred ART group
– 96% protection in immediate ART group
NIH Press release May 2011

7. E-MTCT Targets
Towards the Elimination of New Paediatric
HIV Infection among Children by 2015 and
Keeping Their Mothers Alive, Global Plan
2011-2015
Launched June 2011
2015 Targets in the Global Plan:
• 90% reduction in new child HIV infections
• 50% reduction in HIV-related maternal
deaths
• <5% MTCT (final transmission)
• Other targets for all 4 prongs of PMTCT

10. THE 4 KNOWS
• Know Your Epidemic
– Analysis of data on prevalence and incidence to prioritize
populations and geographic areas that are most at risk for
HIV.
• Know Your Context
– Data to contextualize the epidemic. Ensure cultural
relevance.
• Know Your Response
– Tracking the epidemiological alignment, scope, coverage
and effectiveness of prevention efforts.
• Know Your Costs
– Knowing what is spent, and what the output for investment
is; prioritizing interventions based on cost-effectiveness.

11. Malaysian HIV Epidemic
1986-2010
Cumulative no of reported cases 91362
Cumulative no of deaths 12943
Cumulative no of females with HIV 8759
Children < 12 with HIV 909
New HIV infections reported in 2010 3652
HIV/AIDS related deaths 2010 904
No of PLHIV receiving ARV 12000
Estimated adult HIV prevalence 0.5%

12. Integrated Biobehavioural Surveillance:
Kuala Lumpur 2009
Period of data collection: 2009
Respondent Driven Sampling, VDTS
FSW TS IDU MSM
N 552 541 630 517
HIV 59 50 139 20
Prevalence (10.5%) (9.2%) (22.1%) (3.9%)

13. BIOMEDICAL
• ART treatment for eligible patients and PreP
• Safe Male Circumcision
• PMTCT
• HIV Testing (routine/opt-out) linked to ART and
behavioral change programs TLC
• STI-screening and treatment of MARPs & PLHIV
• Harm reduction programs

14. BEHAVIORAL
• Condom Use Promotion Programs
• Peer education HIV prevention programs addressing
condom use, transactional sex targeting high risk
groups
• Couple counseling
• Disclosure promotion programs
• Delay sexual onset
• Adherence to ART support programs
• Positives Counseling Programs
• Positive Health Dignity and Prevention (PHDP)
• Abstinence and Faithfulness programs
14

15. SOCIAL/STRUCTURAL
• Women Empowerment Programs
• PLHIV programs addressing stigma
• Human Rights and Empowerment Interventions for
Sex Workers, IDU’s
• Easing access to care for Sex Workers, IDU’s
• Creating enabling environments through law and
policy changes

16. WHY NEW HIV INFECTIONS REMAIN HIGH....
Current HIV Low coverage of programs for sex workers and their clients
Prevention
not always
aligned to Low coverage of harm reduction programs
epidemic
drivers:
Socio-cultural and gender norms often neglected
Coverage of HIV testing not linked to access to care and services
key HIV
prevention
services still Over 50% of IDUs have no access to ART
sub-optimal
to make Over half of risky sex not protected with condoms
public health
impact Quality of HIV prevention services not optimal

18. SOCIAL/STRUCTURAL DRIVERS OF HIV
• Socio-cultural drivers
• Gender Norms
• Socio-Economic
– Poverty/wealth, Dependency , mobility
• Human rights violations
• Inequities in access to health services
• Stigma and Discrimination

19. IMPLEMENTATION STRATEGY
• Combination HIV Prevention
– Referral linkages, Integration of services, Health Systems
Strengthening
• Realignment of funding priorities
– Increased domestic and external resources
• Improved Coordination
– Multisectoral response, Health sector
• Monitoring and Evaluation
– Results-based, Strengthening of M&E systems, Alignment of
M&E systems, Improved reporting and surveillance systems
– Impact evaluation, Resource tracking, Improved information
management and sharing

20. Challenges for Providing HIV
Prevention to MARPS
• Enabling environment
– Legal barriers
– Policy barriers
– Stigma and discrimination
– Community support
– Hard to reach
• Access to medical services
– Stigma and discrimination
– Lack of professional training
– Lack of MARP friendly services
– Drug and alcohol abuse treatment
• Access to targeted prevention services
– Understanding the community
– Providing appropriate prevention services
• Data
– Identification of country specific MARPs
– HIV prevalence
– Behavioral risk data
– Size estimation

21. Combination HIV Prevention
Structural
Biomedical Behavioral
Cross-cutting
Ref: The Lancet, Vol 372, August 9, 2008

22. MARP: Structural Prevention Approaches
• Laws
– Decriminalization of behaviors
– Inheritance laws
• Policy
– 100% condom use
– Care settings
– HIV testing protocols
– Allocation of resources
– Task shifting
• Community
– Addressing stigma and discrimination
– Empowering MARP groups
• Economic
– Income generation activities

23. MARP: Behavioral Prevention Approaches
• Behavior change communication
• Community outreach
• Peer-based outreach programs
• Increased condom availability
• Increased condom use
• HIV counseling and testing
• Prevention for positives

24. MARP: Biomedical Prevention Approaches
• ART
• STI diagnosis and care
• Medical male circumcision
• HIV counseling and testing
• Referrals to substance abuse counseling
and treatment
• Emerging technologies

25. MARP: Cross-cutting Prevention
Approaches
• Collection and use of epidemiologic data
– Behavioral risk
– Size estimation
• Program Monitoring and Evaluation
• Laboratory
– Mobile services
– Rapid tests
• Care and treatment
– Facility, community, and mobile services
– Health care worker training to reduce stigma and
sensitize to special needs

26. People Who Use Drugs
• Community-based outreach
• Needle Syringe Programs
• Opioid substitution therapy (OST) and other drug
dependence treatment;
• HIV counseling and testing
• ART for IDUs living with HIV;
• Prevention and treatment of STIs
• Condom programs for IDUs and their sexual partners;
• Targeted information, education and communication (IEC)
for IDUs and their sexual partners;
• Vaccination, diagnosis and treatment of viral hepatitis
• Prevention, diagnosis and treatment of tuberculosis.

27. Commercial Sex Workers
• Target group participate in the development,
implementation and monitoring of prevention programs
• Promote consistent and proper use of condoms with
clients and regular non-paying partners
• Ensure consistent availability of male and female
condoms and lubricant
• Ensure availability of comprehensive health care services
• Referral to other non HIV/AIDS services as appropriate.
• Integrate violence reduction (both social and structural) in
prostitution settings
• Link with relevant social welfare services for the target
group and their families
• Provide vocational training

28. Men who have Sex with Men
• Ensure participation of MSM in the
development, implementation and monitoring of
prevention programs
• Promote consistent and proper use of condoms
with both regular and non-regular partners
• Ensure consistent availability of quality male
and female condoms and lubricant
• Ensure availability of comprehensive health
care services with linkages to HIV treatment
and care services

29. Clients of Persons Engaged in Sex Work
• Ensure participation of target group in the
development, implementation and monitoring of
prevention programs
• Promote consistent and proper use of condoms with
both clients and regular non-paying partners
• Ensure consistent availability of quality male and
female condoms and lubricant
• Ensure availability of comprehensive health care
services; provision of or linkages to HIV treatment and
care services; and referral to other non HIV/AIDS
services as appropriate.
• Integrate interventions addressing gender norms and
violence

30. Scaling Up
• Estimate population(s) size
• Tailor prevention package for defined
populations
• Plan services
• Monitor progress and refine activities

31. Wish List
• Political Will
– Funding
– Legal and policy reviews
• Multisectoral
• Community Engagement
• Capacity Building
• Integration of Health Systems
• Task Shifting
• Addressing Stigma & Discrimination