- Open Access
The HIV/AIDS epidemic in sub-Saharan Africa: thinking ahead on programmatic tasks and related operational research
© Zachariah et al; licensee BioMed Central Ltd. 2011
- Published: 6 July 2011
Until now, we have all been desperately trying to run behind the HIV/AIDS epidemic and catch up with it, but despite all our efforts, the epidemic remains well ahead of us. In 2010, the antiretroviral treatment (ART) gap was about 60%, AIDS-related deaths were almost two million a year, and on top of these figures, for every one person started on ART, there were two new HIV infections. What is needed to change this situation is to think ahead of the epidemic in terms of the programmatic tasks we will be faced with and try to act boldly in trying to implement those tasks. From a programmatic perspective, we: a) highlight what needs to fundamentally change in our thinking and overall approach to the epidemic; and b) outline a number of key task areas for implementation and related operational research.
- Operational Research
- Male Circumcision
- Isoniazid Preventive Therapy
- Viral Load Test
- United Nations Millennium Development Goal
Until now, we have all been desperately trying to run behind the HIV/AIDS epidemic and catch up with it, but despite all our efforts, the epidemic remains well ahead of us. The annual estimates of people living with HIV/AIDS, new HIV infections and AIDS-related deaths since the dawn of the epidemic three decades ago provide undeniable justification to this statement. Although we are beginning to see some encouraging trends  we remain far from any epidemiological ideal of control.
In 2009, there were 5.25 million people receiving anti-retroviral treatment (ART) in low- and middle-income countries, which is a 40% coverage of those estimated to be in need of treatment . However, with 2.6 million new HIV infections in 2009, for every person started on ART, there were two new infections, a sobering statistic that belies any claims that we are on top of this epidemic. AIDS continues to take its toll, with an estimated 1.8 million AIDS-related deaths in 2009 .
In summary, the backlog is high and the pipeline of new HIV/AIDS cases remains wide open. Given the enormity of the problem, it is not surprising that all the set implementation targets, such as the “3 by 5” Initiative  and “Universal ART access by 2010”  were not achieved. In the current state of affairs, the likelihood of achieving, by 2015, the United Nations Millennium Development Goal (MDG)  targets and the “Getting to Zero” target  (the three zeros: zero new HIV infections, zero discrimination and zero AIDS-related deaths) of the Joint United Nations Programme on HIV/AIDS (UNAIDS) seem highly unlikely.
What is needed is to look forward, think of appropriate strategies and follow these with bold action. Such action needs to be guided by embedding operational research into programmes. From a programme perspective, operational research has been defined as the search for knowledge on strategies, interventions or tools that can enhance the performance of health programmes in which the research is being conducted . The authors of this paper have been involved with HIV/AIDS and related operational research at the programme level in sub-Saharan Africa for many years.
From a programme perspective, we: a) highlight what needs to fundamentally change in our thinking and overall approach to the epidemic; and b) outline a number of key task areas for implementation and related operational research.
First, we need to imagine what the epidemic will look like in five to 10 years from now, as well as and the related programmatic challenges . In this light, UNAIDS’s new innovative Treatment 2.0  is one example of the kind of approach that is needed. This approach describes how ART and HIV/AIDS care delivery systems should evolve to become simpler and more accessible on a wider level so as to have a significant impact in closing the current treatment gap, as well as in preventing HIV infection. This approach could save up to 10 million lives and prevent millions of new infections .
Second, in light of the massive current gaps in both treatment and prevention, we must look beyond maintaining the status quo, which is not making an adequate “dent” in the epidemic.
Third, we need to overcome the current gaps of the traditional approach in documenting efficacy of new tools and strategies, such as randomized controlled trials, and the science of how to translate these into large-scale field implementation. Social science, in particular, is critical here and assists in contextual understanding of various issues. For example, randomized controlled trials have shown that circumcised adult men may have some protection against HIV infection [9, 10], and it is now recommended that this surgical intervention be scaled up .
What is missing is a careful assessment of the potential consequences of large-scale, male circumcision initiatives that are currently taking place in six African countries . It is quite possible that there are group or societal effects, including behavioural changes that may reduce, or enhance, the effect of male circumcision as a preventive strategy. The randomized controlled trial design avoids such contextual considerations, but in real life, these trials play an important role, especially when considering implementation on a large scale [13, 14]. In particular, social science research on context-specific and gendered understanding and community messaging is likely to be vital in large-scale roll out.
Another example is the history of prevention of mother to child transmission of HIV (PMTCT), for which evidence and international recommendations exist . However, contextual and feasibility challenges in sub-Saharan Africa have greatly affected uptake, with only about half of all HIV-infected pregnant mothers receiving antiretroviral drugs for PMTCT [1, 12]. It is clear that gendered power relations within and beyond the household are likely to have a key role in whether or not mothers decide to engage with PMTCT programmes .
Finally, there is a need for new tools and new innovative strategies – even daring and bold action, things that most people might simply dismiss as being unfeasible – in different contexts.
Turning the tide of the devastating HIV/AIDS epidemic will require us to think ahead about the challenges with regards to policy, care and prevention that we will be facing in the years to come. It is beholden upon us both as implementers and researchers to act now through bold action and operational research so that will be able to face up to current and impending tasks related to the epidemic.
We are grateful to our many donors, who encourage and support operational research and the related training and capacity-building efforts in low-income countries.
This article has been published as part of Journal of the International AIDS Society Volume 14 Supplement 1, 2011: HIV/AIDS epidemic in sub-Saharan Africa: Facing up to programmatic and operational challenges. The full contents of the supplement are available online at http://www.jiasociety.org/supplements/14/S1. This supplement was financially supported by the Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France in collaboration with the Operational Research Unit, Médecins sans Frontières, Brussels Operational Centre, Luxembourg.
- UNAIDS: UNAIDS report on the global AIDS epidemic 2010. UNAIDS/10.11E/ JC1958E. 2010, [http://www.unaids.org/documents/20101123_GlobalReport_em.pdf]Google Scholar
- WHO: Towards Universal Access;: scaling up priority HIV/AIDS interventions in the health sector. 2010, [http://www.who.int/hiv/pub/2009progressreport/en/index.html]Google Scholar
- WHO: The 3 by 5 Initiative. Treat three million people with HIV/AIDS by 2005. 2002, [http://www.who.int/3by5/en/]Google Scholar
- United Nations: Millennium Development Goals. Traget 6. 2000, [http://www.un.org/millenniumgoals/aids.shtml]Google Scholar
- UNAIDS: Getting to Zero. 2011-2015 strategy. 2011, [http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/JC2034_UNAIDS_Strategy_en.pdf]Google Scholar
- Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, Massaquoi M, Van Herp M, Reid T: Operational research in low-income countries: what, why, and how?. Lancet Infect Dis. 2009, 9 (11): 711-717. 10.1016/S1473-3099(09)70229-4.View ArticlePubMedGoogle Scholar
- UNAIDS: Taking long term-view. 2010, [http://www.ftpress.com/store/product.aspx?isbn=0132614146]Google Scholar
- UNAIDS: Treatment 2.0. Is this the future of treatment?. 2009, [http://data.unaids.org/pub/Outlook/2010/20100713_outlook_treatment2_0_en.pdf]Google Scholar
- Mills E, Cooper C, Anema A, Guyatt G: Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis of randomized trials involving 11,050 men. HIV Med. 2008, 9 (6): 332-335. 10.1111/j.1468-1293.2008.00596.x.View ArticlePubMedGoogle Scholar
- Mattson CL, Campbell RT, Bailey RC, Agot K, Ndinya-Achola JO, Moses S: Risk compensation is not associated with male circumcision in Kisumu, Kenya: a multi-faceted assessment of men enrolled in a randomized controlled trial. PLoS One. 2008, 3 (6): e2443.Google Scholar
- WHO: Male circumcision for HIV prevention. 2007, [http://www.who.int/hiv/topics/malecircumcision/en/index.html]Google Scholar
- WHO, UNAIDS, UNICEF: Towards Universal Access. Scaling up priority HIV/AIDS interventions in the health sector. Progress report. 2010, [http://www.who.int/hiv/pub/2010progressreport/summary_en.pdf]Google Scholar
- Weiss HA, Dickson KE, Agot K, Hankins CA: Male circumcision for HIV prevention: current research and programmatic issues. AIDS. 2010, 24 (Suppl 4): S61-69. 10.1097/01.aids.0000390708.66136.f4.PubMed CentralView ArticlePubMedGoogle Scholar
- Fox M, Thomson M: HIV/AIDS and circumcision: lost in translation. J Med Ethics. 2010, 36 (12): 798-801. 10.1136/jme.2010.038695.View ArticlePubMedGoogle Scholar
- WHO: Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. 2009, [http://www.who.int/hiv/pub/mtct/antiretroviral2010/en/index.html]Google Scholar
- WHiPT: (Womens HIV Prevention Tracking Project). Making Medical Male Circumcision Work for Women. 2010, [http://www.avac.org/ht/a/GetDocumentAction/i/28715]Google Scholar
- MSF: HIV/AIDS Progress Under Siege Double Blow of Reduced Funding and High Drug Prices Blocks Impact of Latest Science and Treatment Recommendations for People Living With HIV/AIDS. 2010, [http://www.doctorswithoutborders.com/oublications/article.cfm?id=489O&cat=special-report]Google Scholar
- Levine R, Oomman N: Global HIV/AIDS funding and health systems: Searching for the win-win. J Acquir Immune Defic Syndr. 2009, 52 (Suppl 1): S3-5.View ArticlePubMedGoogle Scholar
- El-Sadr WM, De Cock KM: Health systems exist for real people. J Acquir Immune Defic Syndr. 2009, 52 (Suppl 1): S1-2.View ArticlePubMedGoogle Scholar
- Sherr K, Pfeiffer J, Mussa A, Vio F, Gimbel S, Micek M, Gloyd S: The role of nonphysician clinicians in the rapid expansion of HIV care in Mozambique. J Acquit Immune Defic Syndr. 2009, 52 (Suppl 1): S20-23.View ArticleGoogle Scholar
- Makombe SD, Jahn A, Tweya H, Chuka S, Yu JK, Hochgesang M, Aberle-Grasse J, Pasulani O, Schouten EJ, Kamoto K, Harries AD: A national survey of the impact of rapid scale-up of antiretroviral therapy on health-care workers in Malawi: effects on human resources and survival. Bull World Health Organ. 2007, 85: 851-857.PubMed CentralPubMedGoogle Scholar
- Mwagomba B, Zachariah R, Massaguoi M, Misindi D, Manzi M, Mandere BC, Bemelmans M, Philips M, Kamoto K, Schouten EJ, Harries AD: Mortality reduction associated with HIV/AIDS care and antiretroviral treatment in rural Malawi: evidence from registers, coffin sales and funerals. PLoS One. 2010, 5 (5): e10452-10.1371/journal.pone.0010452.PubMed CentralView ArticlePubMedGoogle Scholar
- Badri M, Wilson D, Wood R: Effect of highly active antiretroviral therapy on incidence of tuberculosis in South Africa: a cohort study. Lancet. 2002, 359: 2059-2064. 10.1016/S0140-6736(02)08904-3.View ArticlePubMedGoogle Scholar
- Lawn SD, Wood R: Antiretroviral therapy for control of the HIV-associated MDR and XDR tuberculosis epidemic in South Africa. Am J Respir Crit Care Med. 2010, 182: 1567-author reply 8-9View ArticlePubMedGoogle Scholar
- Lawn SD, Badri M, Wood R: Tuberculosis among HIV-infected patients receiving HAART: long term incidence and risk factors in a South African cohort. AIDS. 2005, 19: 2109-2116. 10.1097/01.aids.0000194808.20035.c1.View ArticlePubMedGoogle Scholar
- Nakanjako D, Kiragga AN, Castelnuovo B, Kyabayinze DJ, Kamya MR: Low prevalence of Plasmodium falciparum antigenaemia among asymptomatic HAART-treated adults in an urban cohort in Uganda. Malar J. 2011, 10: 66-10.1186/1475-2875-10-66.PubMed CentralView ArticlePubMedGoogle Scholar
- Mermin J, Ekwaru JP, Liechty CA, Were W, Downing R, Ransom R, Weidle P, Lule J, Coutinho A, Solberg P: Effect of co-trimoxazole prophylaxis, antiretroviral therapy, and insecticide-treated bednets on the frequency of malaria in HIV-1-infected adults in Uganda: a prospective cohort study. Lancet. 2006, 367: 1256-1261. 10.1016/S0140-6736(06)68541-3.View ArticlePubMedGoogle Scholar
- Myer L, Akugizibwe P: Impact of HIV treatment scale-up on women's reproductive health care and reproductive rights in Southern Africa. J Acquir Immune Defic Syndr. 2009, 52 (Suppl 1): S52-53.View ArticlePubMedGoogle Scholar
- Harries AD, Zachariah R, Lawn SD, Rosen S: Strategies to improve patient retention on antiretroviral therapy in sub-Saharan Africa. Trop Med Int Health. 2010, 52 (Suppl 1): 70-75.View ArticleGoogle Scholar
- Jaffar S, Lazarus JV, Onyebujoh P, Chakaya J, Garrib A, Mwaba P, Mboup S, Bellis K, Egwaga S, Corrah T, Coutinho A: Health services strengthening in Africa-research is a key component. Trop Med Int Health. 2010, 15: 1270-1273. 10.1111/j.1365-3156.2010.02626.x.View ArticlePubMedGoogle Scholar
- Anyangwe SC, Mtonga C: Inequities in the global health workforce: the greatest impediment to health in sub-Saharan Africa. Int J Environ Res Public Health. 2007, 4 (2): 93-100. 10.3390/ijerph2007040002.PubMed CentralView ArticlePubMedGoogle Scholar
- Van Damme W, Kober K, Kegels G: Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: how will health systems adapt?. Soc Sci Med. 2008, 66 (10): 2108-2121. 10.1016/j.socscimed.2008.01.043.View ArticlePubMedGoogle Scholar
- Van Damme W, Kheang ST, Janssens B, Kober K: How labour intensive is a doctor-based delivery model for antiretroviral treatment (ART)? Evidence from an observational study in Siem Reap, Cambodia. Hum Resour Health. 2007, 5: 12-10.1186/1478-4491-5-12.PubMed CentralView ArticlePubMedGoogle Scholar
- Hardon AP, Akurut D, Comoro C, Ekezie C, Irunde HF, Gerrits T, Kglatwane J, Kinsman J, Kwasa R, Maridadi J, Moroka TM, Moyo S, Nakiyemba A, Nsimba S, Ogenyi R, Oyabba T, Temu F, Laing R: Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa. AIDS Care. 2007, 19: 658-665. 10.1080/09540120701244943.View ArticlePubMedGoogle Scholar
- Wools-Kaloustian KK, Sidle JE, Selke HM, Vedanthan R, Kemboi EK, Boit LJ, Jebet VT, Carroll AE, Tierney WM, Kimaiyo S: A model for extending antiretroviral care beyond the rural health centre. J Int AIDS Soc. 2009, 12 (1): 22-10.1186/1758-2652-12-22.PubMed CentralView ArticlePubMedGoogle Scholar
- Jaffar S, Amuron B, Fosters S, Birungi J, Levin J, Namara G, Nabiryo C, Ndembi M, Kyomuhangi R, Opio A, Bunnell R, Tappero JW, Mermin J, Coutinho A, Grosskurth H: Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda: a cluster-randomised equivalence trial. Lancet. 2009, 374 (9707): 2080-2089. 10.1016/S0140-6736(09)61674-3.PubMed CentralView ArticlePubMedGoogle Scholar
- Decroo T, Telfer B, Biot M, Maikere J, Dezembro S, Cumba LI, Dores CD, Chu K, Ford N: Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. J Acquir Immune Defic Syndr. 2010,Google Scholar
- Zachariah R, Reid SD, Chaillet P, Massaguoi M, Schouten EJ, Harries AD: Why do we need a point-of-care CD4 test for low-income countries?. Trop Med Int Health. 2011, 16: 37-41. 10.1111/j.1365-3156.2010.02669.x.View ArticlePubMedGoogle Scholar
- Zachariah R, Ford N, Philips M, Lynch S, Massaguoi M, Janssens V, Harries AD: Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2009, 103 (6): 549-558. 10.1016/j.trstmh.2008.09.019.View ArticlePubMedGoogle Scholar
- Harrington M: Community involvement in HIV and tuberculosis research. J Acquir Immune Defic Syndr. 2009, 52 (Suppl 1): S63-66.View ArticlePubMedGoogle Scholar
- WHO: Antiretroviral therapy for HIV infection in adults and adolescents: Recommendations for a public health approach. 2010, [http://www.who.int/hiv/pub/arv/adult2010/en/index.htm]Google Scholar
- Severe P, Juste MA, Ambroise A, Eliacin L, Marchand C, Apollon S, Edwards A, Bang H, Nicotera J, Godfrey C, Gulick RM, Johnson WD, Pape JW, Fitzgeralc DW: Early versus standard antiretroviral therapy for HIV-infected adults in Haiti. N Eng J Med. 2010, 363 (3): 257-265. 10.1056/NEJMoa0910370.View ArticleGoogle Scholar
- Ford N, Kranzer K, Hilderbrand K, Jouquet G, Goemaere E, Vlahakis N, Trivino L, Makakole L, Bygrave H: Early initiation of antiretroviral therapy and associated reduction in mortality, morbidity and defaulting in a nurse-managed, community cohort in Lesotho. AIDS. 2010, 24 (17): 2645-2650. 10.1097/QAD.0b013e32833ec5b2.View ArticlePubMedGoogle Scholar
- Tayler-Smith K, Zachariah R, Massaquoi M, Manzi M, Pasulani O, van den Akker T, Bemelmans M, Bauernfeind A, Mwagomba B, Harries AD: Unacceptable attrition among WHO stages 1 and 2 patients in a hospital-based setting in rural Malawi: can we retain such patients within the general health system?. Trans R Soc Trop Med Hyg. 2010, 104 (5): 313-319. 10.1016/j.trstmh.2010.01.007.View ArticlePubMedGoogle Scholar
- Braitstein P, Einterz RM, Sidle JE, Kimaiyo S, Tierney W: "Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings. J Acquir Immune Defic Syndr. 2009, 52 (Suppl 1): S54-57.View ArticlePubMedGoogle Scholar
- Nash D, Elul B, Rabkin M, Tun M, Saito S, Becker M, Nuwagaba-Biribonwoha H: Strategies for more effective monitoring and evaluation systems in HIV programmatic scale-up in resource-limited settings: Implications for health systems strengthening. J Acquir Immune Defic Syndr. 2009, 52 (Supp 1): S58-62.View ArticlePubMedGoogle Scholar
- Douglas GP, Gadabu OJ, Joukes S, Mumba S, McKay MV, Ben-Smith A, Jahn A, Schouten EJ, Landis Lewis Z, van Oosterhout JJ, AIlain TJ, Zachariah R, Berger SD, Harries AD, Chimbwandira F: Using touchscreen electronic medical record systems to support and monitor national scale-up of antiretroviral therapy in Malawi. PLoS Med. 2010, 7 (8):Google Scholar
- Siika AM, Rotich JK, Simiyu CJ, Kigotho EM, Smith FE, Sidle JE, Wools-Kaloustian K, Kimaiyo SN, Nyandiko WM, Hannan TJ, Tierney WM: An electronic medical record system for ambulatory care of HIV-infected patients in Kenya. Int J Med Inform. 2005, 74 (5): 345-355. 10.1016/j.ijmedinf.2005.03.002.View ArticlePubMedGoogle Scholar
- Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball TB, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA: Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenyal): a randomised trial. Lancet. 2010, 376 (9755): 1838-1845. 10.1016/S0140-6736(10)61997-6.View ArticlePubMedGoogle Scholar
- WHO: Accelerating the implementation of the Three I's for HIV/TB and earlier initiation of ART in Southern African countries Johannesburg, South Africa, Workshop Report. 2011, [http://www.stoptb.org/wg/tb_hiv/assets/documents/Workshop%20report.pdf]Google Scholar
- WHO: Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource-constrained settings. 2011, [http://whqlibdoc.who.int/publications/2011/9789241500708_eng.pdf]Google Scholar
- Harries AD, Zachariah R, Corbett EL, Lawn SD, Santos-Filho ET, Chimzizi R, Harrington M, Maher D, Williams BG, De Cock KM: The HIV-associated tuberculosis epidemic--when will we act?. Lancet. 2010, 375 (9729): 1906-1919. 10.1016/S0140-6736(10)60409-6.View ArticlePubMedGoogle Scholar
- Harries AD, Zachariah R, Tayler-Smith K, Schouten EJ, Chimbwandira F, Van Damme W, EI-Sadr WM: Keeping health facilities safe: one way of strengthening the interaction between disease-specific programmes and health systems. Trop Med Int Health. 2010, 15 (12): 1407-1412. 10.1111/j.1365-3156.2010.02662.x.View ArticlePubMedGoogle Scholar
- Van Damme W, Kober K, Kegels G, Laga M: Scaling'3 by 5' to Universal Access requires enhanced prevention. Real Health News. 2006, 5: 29-32.Google Scholar
- Montaner JS, Hogg R, Wood E, Kerr T, Tyndall M, Levy AR, Harrigan PR: The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet. 2006, 368 (9534): 531-536. 10.1016/S0140-6736(06)69162-9.View ArticlePubMedGoogle Scholar
- Donnell D, Baeten JM, Kiarie J, Thomas KK, Stevens W, Cohen CR, McIntyre J, Lingappa JR, Celum C: Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010, 375 (9731): 2092-2098. 10.1016/S0140-6736(10)60705-2.PubMed CentralView ArticlePubMedGoogle Scholar
- Fox W: Realistic Chemotherapeutic Policies for Tuberculosis in the Developing Countries. Br Med J. 1964, 1 (5376): 135-142. 10.1136/bmj.1.5376.135.PubMed CentralView ArticlePubMedGoogle Scholar
- Zachariah R, Harries AD, Philips M, Arnould L, Sabapathy K, O’Brien DP, Ferreyra C, Balkan S: Antiretroviral therapy for HIV prevention: many concerns and challenges, but are there ways forward in sub-Saharan Africa?. Trans R Soc Trop Med Hyg. 2010, 104 (6): 387-391. 10.1016/j.trstmh.2010.01.004.View ArticlePubMedGoogle Scholar
- Fendall NR: Auxiliaries and primary medical care. Bull N Y Acad Med. 1972, 48 (10): 1291-1300.PubMed CentralPubMedGoogle Scholar
- Grant RM: Antiretroviral agents used by HIV-uninfected persons for prevention: pre- and postexposure prophylaxis. Clin Infect Dis. 2010, 50 (Suppl 3): S96-101.PubMed CentralView ArticlePubMedGoogle Scholar
- Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, Goicochea P, Casapia M, Guanira-Carranza JV, Ramirez-Cardich ME, Montoya-Herrera O, Fernandez T, Veloso VG, Buchbinder SP, Chariyalertsak S, Schechter M, Bekker LG, Mayer KH, Kallas EG, Amico KR, Mulligan K, Bushman LR, Hance RJ, Ganoza C, Defechereux P: Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010, 363 (27): 2587-2599. 10.1056/NEJMoa1011205.PubMed CentralView ArticlePubMedGoogle Scholar
- Abdool Karim Q, Abdool Karim SS, Frohlich JA, Grobler AC, Baxter C, Mansoor LE, Kharsany AB, Sibeko S, Mlisana KP, Omar Z, Gengiah TN, Maarschalk S, Arulappan N, Mlotshwa M, Morris L, Taylor D: Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 2010, 329 (5996): 1168-1174. 10.1126/science.1193748.PubMed CentralView ArticlePubMedGoogle Scholar
- Mgone C, Volmink J, Coles D, Makanga M, Jaffar S, Sewankambo N: Linking research and development to strengthen health systems in Africa. Trop Med Int Health. 2010, 15 (12): 1404-1406. 10.1111/j.1365-3156.2010.02661.x.View ArticlePubMedGoogle Scholar
- Zachariah R, Tayler-Smith K, Ngamvithayapong-Yana J, Ota M, Murakami K, Ohkado A, Yamada N, Van Den Boogard W, Draguez B, Ishikawa N, Harries AD: The published research paper: is it an important indicator of successful operational research at programme level?. Trop Med Int Health. 2010, 15 (11): 1274-1277. 10.1111/j.1365-3156.2010.02630.x.View ArticlePubMedGoogle Scholar
- CDC: Field Epidemiology Training Program. 2010, [http://www.cdc.gov.tw/ct.asp?xItem=7726&CtNode=2488&mp=5]Google Scholar
- Harries AD, Rusen ID, Reid T, Detjen AK, Berger SD, Bissell K, Hinderaker SG, Edington M, Fussell M, Fujiwara PI, Zachariah R: The Union and Médecins Sans Frontières approach to operational research. Int J Tuberc Lung Dis. 2011, 15 (2): 144-154.PubMedGoogle Scholar
- Thacker SB, Dannenberg AL, Hamilton DH: Epidemic intelligence service of the Centers for Disease Control and Prevention: 50 years of training and service in applied epidemiology. Am J Epidemiol. 2001, 154 (11): 985-992. 10.1093/aje/154.11.985.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.