The Evidence Base for the Planning, Implementation and Evaluation of STI/HIV Prevention Programs
Background and Rationale
Three decades into the emergence of the Human Immune Deficiency Virus (HIV) epidemic; centuries into the appearance of other sexually transmitted infections (STI's); and despite the development of many efficacious individual, group and structural level interventions, it is clear that advances made in the prevention of HIV and other STI's have not been sufficient to get ahead of these epidemics. The emerging consensus points to the focus on singular prevention strategies and the formidable gap between innovations and health program delivery, particularly to communities in the developing world, as potential causes of this failure. Even in countries with more public health resources there are important strategic questions about how best to design and deliver programs to achieve impact efficiently. Combination prevention, which combines biomedical, behavioral and structural interventions; and implementation science, which provides a scientific framework to guide the delivery and scale-up of preventive interventions have been identified as current needs. The addition of a third component, "program science", may further enhance the power of this current approach to affect population level health outcomes and achieve impact.
Program science can perhaps best be defined as the systematic application of theoretical and empirical scientific knowledge to improve the design, implementation and evaluation of public health programs. While implementation science is primarily concerned with the proper implementation of evidence-based interventions, program science is concerned with three additional aspects of prevention programs:
As such, the focus of program science extends beyond the optimal implementation and coverage (scale-up) of combination intervention packages and focuses on the development of the prevention program in its totality including issues of resource allocation, definition and prioritization of target populations, development and prioritization of intervention packages, identification of stopping rules to prevent indefinite implementation of specific interventions beyond the cessation of their usefulness, advocacy and community mobilization.
Program science encompasses and integrates different spheres of knowledge, including epidemiology, transmission dynamics, policy analysis, intervention efficacy and effectiveness research, surveillance, operations research and monitoring and evaluation. These knowledge spheres are brought together with the different domains of health program practice including strategic planning and policy development, program implementation and program management, in order to choose the best strategy for the right populations at the appropriate time; do the right things the right way and ensure appropriate scale and efficiency [Figure 1]. The end point for program science is population level impact on incidence of infections; and the goal is to bring an appropriate body of scientific evidence to shed light on prevention program issues and assist program managers. It is time to move the planning, development, management and evaluation of prevention programs from an art form to a scientific discipline.
Moving the "Program Science" Agenda Forward
Ten years ago Gibbons proposed the development of a new social contract between science and society whereby "science must leave the ivory tower and enter the agora"1. This would have important implications for how "knowledge translation" occurs, shifting from a paradigm whereby science produces "reliable knowledge" that it then communicates to society to a model whereby scientific knowledge is "social robust", and that its production is both transparent and participative.
Over the past few years many academic institutions have established new "global health" centers with the expectation that these institutions will more effectively engage in the production and translation of knowledge that will contribute to the improvement of health in populations around the world. However, the establishment of new structures within academic institutions per se will not allow them to fully realize their potential contribution. They also need to establish effective new processes whereby they can actively engage in the co-production and translation of knowledge with policy makers, program managers and implementers to maximize the impacts of public health programs. Similarly, there is a growing recogntion of the need to implement a more robust knowledge translation process in North America and Europe to optimize resource allocation and improve impact. A "program science" initiative offers a way forward to achieve these goals. Specifically, such an initiative would seek to:
To achieve these objectives a "Program Science" strategic planning meeting was held (Rome, May 2010) to bring together leaders from academic institutions, government health programs and global health policy and funding institutions, government health programs and global health policy and funding institutions. The meeting expected to result in the refinement of the scope and elements of a program science agenda and to make substantial progress towards developing practical program science projects in on or more countries and/or world regions that would serve as vanguards in developing the program science approach and provide global leadership in this field.
1 Gibbons M. Science's new social contract with society. Nature 1999;402(suppl):C81-4