Investigating combination HIV prevention

This article discusses the need for systems thinking to support HIV prevention policy and research to be more aligned to the complexity and messiness of the real word.

Brown, G., Reeders, D. Dowsett, G.W., Ellard, J., Carman, M., Hendry, N., and Wallace, J. (2015). Investigating combination HIV prevention: isolated interventions or complex system. Journal of the International AIDS Society, 18:20499. (Open Access)

Introduction: Treatment as prevention has mobilized new opportunities in preventing HIV transmission and has led to bold new UNAIDS targets in testing, treatment coverage and transmission reduction. These will require not only an increase in investment but also a deeper understanding of the dynamics of combining behavioural, biomedical and structural HIV prevention interventions. High-income countries are making substantial investments in combination HIV prevention, but is this investment leading to a deeper understanding of how to combine interventions? The combining of interventions involves complexity, with many strategies interacting with non-linear and multiplying rather than additive effects.

Discussion: Drawing on a recent scoping study of the published research evidence in HIV prevention in high-income countries, this paper argues that there is a gap between the evidence currently available and the evidence needed to guide the achieving of these bold targets. The emphasis of HIV prevention intervention research continues to look at one intervention at a time in isolation from its interactions with other interventions, the community and the socio-political context of their implementation.

To understand and evaluate the role of a combination of interventions, we need to understand not only what works, but in what circumstances, what role the parts need to play in their relationship with each other, when the combination needs to adapt and identify emergent effects of any resulting synergies. There is little development of evidence-based indicators on how interventions in combination should achieve that strategic advantage and synergy. This commentary discusses the implications of this ongoing situation for future research and the required investment in partnership. We suggest that systems science approaches, which are being increasingly applied in other areas of public health, could provide an expanded vocabulary and analytic tools for understanding these complex interactions, relationships and emergent effects.

Conclusions: Relying on the current linear but disconnected approaches to intervention research and evidence we will miss the potential to achieve and understand system-level synergies. Given the challenges in sustaining public health and HIV prevention investment, meeting the bold UNAIDS targets that have been set is likely to be dependent on achieving systems level synergies.


Publication: lessons from the Australian health-promotion response to HIV

Brown, G., O’Donnell, D., Crooks, L., & Lake, R. (2014).Mobilisation, politics, investment and constant adaptation: lessons from the Australian health-promotion response to HIV. Health Promotion Journal of Australia, 25(1), 35-41.
Pre-publication version here.

Issue addressed: The Australian response to HIV oversaw one of the most rapid and sustained changes in community behaviour in Australia’s health-promotion history. The combined action of communities of gay men, sex workers, people who inject drugs, people living with HIV and clinicians working in partnership with government, public health and research has been recognised for many years as highly successful in minimising the HIV epidemic.

Methods: This article will show how the Australian HIV partnership response moved from a crisis response to a constant and continuously adapting response, with challenges in sustaining the partnership. Drawing on key themes, lessons for broader health promotion are identified.

Results: The Australian HIV response has shown that a partnership that is engaged, politically active, adaptive and resourced to work across multiple social, structural, behavioural and health-service levels can reduce the transmission and impact of HIV.

Conclusions: The experience of the response to HIV, including its successes and failures, has lessons applicable across health promotion. This includes the need to harness community mobilisation and action; sustain participation, investment and leadership across the partnership; commit to social, political and structural approaches; and build and use evidence from multiple sources to continuously adapt and evolve.

So what?: The Australian HIV response was one of the first health issues to have the Ottawa Charter embedded from the beginning, and has many lessons to offer broader health promotion and common challenges. As a profession and a movement, health promotion needs to engage with the interactions and synergies across the promotion of health, learn from our evidence, and resist the siloing of our responses.

SiREN Symposium: Building on the foundations for ‘innovation’

The Sexual Health and Blood-Borne Virus Applied Research and Evaluation Network (SiREN) is proud to host a symposium bringing together practitioners, researchers and policy makers with an interest in evidence-based practice in preventing and reducing the impacts of sexually transmissible infections (STIs) and blood-borne viruses (BBVs). The Symposium will take place in Perth on 7 April. Information on the symposium, including registration, is available here.

The W3 Project team will be presenting in one of the sessions.

The links and excerpts below outline different ways of explaining systems thinking, and have helped others to gain and understanding of key concepts related to this approach.

AFAO Conference

AFAO conference

The W3 Project team will be attending the AFAO National Gay Men’s HIV Health Promotion Conference, Sydney, Tuesday 8 April to Wednesday 9 April.

In addition to the main conference, the team will present on the Skills Building Day, Thursday 10 April. This one day workshop will:

  • Discuss current developments in evaluation, quality improvement and systems thinking approaches for peer and community based programs in HIV and HCV;
  • Apply systems thinking approaches in the evaluation of peer based programs to demonstrate their role and contribution within a broader health promotion ‘system’ of organisations, policies and social contexts; and
  • Trial and critique some of the draft tools and approaches being developed within the W3 project. 

For more information on the conference please contact: Sean Slavin at AFAO on 02 8568 1118


Thinking Systemically

Learning how to think systemically is a matter of capacity development. There is knowledge to be acquired, skills to be gained and opportunities to be sought to apply the knowledge and skills. Where do you start? Generally speaking the best choice is to start where you are right now. For instance, do the notions of focusing on inter-relationships, perspectives and boundaries help you improve your own understanding of capacity development? If they do, then start there. If that is insufficient, then dive a little deeper, pick a systems method or approach that seems promising for a particular issue you are engaged in. A gateway for capacity development has a number of articles about thinking systematically. This article outlines the history of three systems concepts: inter-relationships, perspectives and boundaries; and how understanding these support capacity development.

QI Tools

Under construction.