Public health triangulation: approach and application to synthesizing data to understand national and local HIV epidemics.

BACKGROUND: Public health triangulation is a process for reviewing, synthesising and interpreting secondary data from multiple sources that bear on the same question to make public health decisions. It can be used to understand the dynamics of HIV transmission and to measure the impact of public health programs. While traditional intervention research and meta-analysis would be ideal sources of information for public health decision making, they are infrequently available, and often decisions can be based only on surveillance and survey data. METHODS: The process involves examination of a wide variety of data sources and both biological, behavioral and program data and seeks input from stakeholders to formulate meaningful public health questions. Finally and most importantly, it uses the results to inform public health decision-making. There are 12 discrete steps in the triangulation process, which included identification and assessment of key questions, identification of data sources, refining questions, gathering data and reports, assessing the quality of those data and reports, formulating hypotheses to explain trends in the data, corroborating or refining working hypotheses, drawing conclusions, communicating results and recommendations and taking public health action. RESULTS: Triangulation can be limited by the quality of the original data, the potentials for ecological fallacy and "data dredging" and reproducibility of results. CONCLUSIONS: Nonetheless, we believe that public health triangulation allows for the interpretation of data sets that cannot be analyzed using meta-analysis and can be a helpful adjunct to surveillance, to formal public health intervention research and to monitoring and evaluation, which in turn lead to improved national strategic planning and resource allocation.

Population-level HIV declines and behavioral risk avoidance in Uganda.

Uganda provides the clearest example that human immunodeficiency virus (HIV) is preventable if populations are mobilized to avoid risk. Despite limited resources, Uganda has shown a 70% decline in HIV prevalence since the early 1990s, linked to a 60% reduction in casual sex. The response in Uganda appears to be distinctively associated with communication about acquired immunodeficiency syndrome (AIDS) through social networks. Despite substantial condom use and promotion of biomedical approaches, other African countries have shown neither similar behavioral responses nor HIV prevalence declines of the same scale. The Ugandan success is equivalent to a vaccine of 80% effectiveness. Its replication will require changes in global HIV/AIDS intervention policies and their evaluation.

AIDS communications through social networks: catalyst for behaviour changes in Uganda.

OBJECTIVE: To investigate distinctive communications through social networks which may be associated with population behaviour changes and HIV prevalence declines in Uganda compared to other countries. METHODS: We undertook a comparative analysis of demographic and HIV behavioural data collected in Demographic and Health Surveys (DHS III) in Uganda, Kenya, Tanzania, Malawi, Zambia and Zimbabwe as well as Knowledge, Attitudes and Behaviours (KABP) surveys in Uganda in 1989 and 1995. AIDS behaviours, social communications and channels for communication about AIDS and people with AIDS were analysed by age, sex and country. Modelling was developed to investigate at what stage of the epidemic a majority of people will know someone with AIDS, given differing communication patterns through social networks. Finally AIDS reporting and Voluntary Counselling and Testing (VCT) trends were analysed to assess if the impact of social communications worked through clinical services and interventions or more directly at the population level in community contexts. RESULTS: Uganda showed unique patterns of communications through social networks including a shift from mass and institutional to personal channels for communicating about AIDS, 1989-1995. This was associated with higher levels of knowing someone with AIDS through social networks and, in turn, positive risk ratios for behaviour change including reducing casual sex and condom use. Youth had distinctively high levels of knowing someone with AIDS in Uganda, suggesting widespread community communication across age groups. Patterns of disclosure, AIDS diagnosis and reporting were influential on social communications about AIDS. Over 90%, 45% or under 20% of people know someone with AIDS at peak HIV incidence and high AIDS mortality, depending on whether communications through social networks are extensive or restricted. CONCLUSION: There are distinctive patterns for communicating through social networks about AIDS and people with AIDS in Uganda. They appear to work directly at population level rather than in response to clinical interventions and testing and may be important in the uptake of the latter services. This communication response provides an important basis for HIV prevention if it is to be scaled to the population level. Vertical prevention (and even treatment) interventions need to engage more closely with local, horizontal communication and behavioural responses to AIDS. Communication programmes have to take root at the level of social networks working though local networks of meetings, chiefs, churches and health personnel as well as the media. Mobilising basic social communications may be a necessary resource (as much as services and finance) to scale HIV prevention and treatment to the population level.

Behaviour and communication change in reducing HIV: is Uganda unique?

The clearest example of declines in HIV prevalence and changes in sexual behaviour comes from Uganda. Are there lessons to learn for other countries or is Uganda unique? In this paper, we assess the epidemiological and behavioural data on Uganda comparatively to other African countries and then analyse data from other populations where HIV has declined. In Uganda, HIV prevalence declined from 21% to 9.8% from 1991-1998, there was a reduction in non-regular sexual partners by 65% and greater levels of communication about AIDS and people with AIDS through social networks, unlike the comparison countries. There is evidence of a basic population level response initiated at community level, to avoid risk, reduce risk behaviours and care for people with AIDS. The basic elements-a continuum of communication, behaviour change and care-were integrated at community level. They were also strongly supported by distinctive Ugandan policies from the 1980s. We identify a similar, early behaviour and communication response in other situations where HIV has declined: Thailand, Zambia and the US Gay community. In Thailand, visits to sex workers decreased by 55% and non-regular partners declined from 28% to 15% (1990-1993): as important as the '100% condom use policy'. Similarly, in Zambia and Ethiopia risk behaviour has decreased and analysis of Sexually Transmitted Disease (STD) rates among Gay populations in the USA shows a decline from as early as 1985 in White Gay populations, with later declines in Hispanic and Black Gay populations. These responses preceded and exceeded HIV prevention. However, where they were built on by distinctive HIV policies, HIV prevention has been scaled and led to national level declines in HIV. It is not easy to transfer the lessons of these successes. They require real social and political capital in addition to financial capital. Nevertheless, similar characteristics are present in community responses in Africa, Asia and USA, and even in fragmented signs of HIV declines in other African cities. Only in a few situations has this behaviour and communication process been recognised, mobilised and built on by HIV prevention policy. Where this has occurred, HIV prevention success has been greater than biomedical approaches or methods introduced from outside. It represents a social vaccine for HIV from Africa, and is available now.