the intervention mix sevgi o. aral rome, italy may 2010
TRANSCRIPT
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The Intervention Mix
Sevgi O. Aral
Rome, Italy
May 2010
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Ipsum lorem . . . !@#$%***??
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Single causes for disease states challenged by
→ factors at multiple levels (biological, behavioral, group)
health and disease
→ interrelation among factors includes dynamic feedback + change
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Solution: paragidm shift
Public health ≡ complex system
→ complex systems dynamic analytic approaches
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Alassio, West Ligurian Riviera, Italy
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Condom Use Number of Partners
Sex Work
Casual PartnersMultiple Partners
Early Age at Sexual Debut
Concurrent PartnersShort Gaps
Same Sex Partners
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Condom Use
Transactional Sex
Drug Use
Casual PartnersMultiple Partners
Age at Sexual Debut
Concurrent Partners
Forced Sex
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Condom Use
Transactional Sex
Drug Use
Casual PartnersMultiple Partners
Age at Sexual Debut
Concurrent Partners
Forced Sex
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Clustered risk
behaviorsSyndemics
System of
behaviors
Net effect of
behavior
system
Infection
risk
X
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Sexual behaviors
Prevention behaviors
Risk compensationDisinhibition
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Relationship among behaviors
Conditional: condoms only with SWS
Contextual: serosorting following accurate and honest disclosure
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Relationship among behaviors
Causal:
Circumcision →↑ # of partners
Concurrent partnerships →↑ condom use
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Behavioral effects on incidence
Synergistic
Antagonistic
Additive
Duplicative
conditional
eg: risk of UAI with infected
partner >risk of
AI + risk of
sex with
infected
partner
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Complex system of behaviors
Complex adaptive system of behaviors
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Complex adaptive system?
Complex system?
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Complex System
• Interconnected parts
• Non-linear interactions
• Emergent properties
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Complex adaptive systems
• Diverse
• Multiple interconnected elements
• Capacity to change
• Capacity to learn from experience
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Examples
• Stock market
• Cell & developing embryo
• The brain
• The immune system
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Behaviors of an individual =
complex adaptive system
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Living organisms – complex adaptive systems
• Multiple participating agents• Hierarchical organization• Extensive organization• Extensive interactions among genetic and
environmental effects• Non-linear responses to perturbation• Temporal dynamics of structure and function• Distributed control• Redundancy• Compensatory mechanisms• Emergent properties
Rea et al., 2006
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“ . . . moving beyond the individual into the realm of social and policy processes must surely increase complexity of the causal process exponentially.”
Galea, et al., 2010
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ComplexityComplex adaptive systems
Complexity science
HealthMedicine
Health care
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XX
Newtonian science
Positivism
Scientism
Reductionism
Complexity science
Complexity theory
Complexity thinking
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Health
Medicine
Health care delivery
Individual’s health[d (complex, interrelated, multi-
level factors)]
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STD/HIV epidemiology and prevention best described as complex adaptive systems
Complex adaptive system of STD/HIV prevention interventions (CASSPI)
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“ . . . the emphasis in prevention research is shifting to evaluation of combination prevention packages in which synergies among interventions with modest levels of effect might lead to substantial efficacy overall.”
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Counseling and testing
Condom use
PMCT
↓ Concurrency
Mass media interventions
↓ # partners
Abstinence
Microbidcides
PREP
Male circumcision
Test and treat
→ duplicative, conditional, additive← antagonistic or synergistic
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Counseling and testing
Condom use
PMCT
↓ Concurrency
Mass media interventions
↓ # partners
Abstinence
Microbidcides
PREP
Male circumcision
Test and treat
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“Multiple interventions from multiple professionals are provided concurrently. Interaction of interventions may significantly influence outcomes. The relatively small, nonsignificant effects of a simple intervention may be magnified when used in combination with other interventions. Interventions that seem effective in isolation may be antagonistic when provided together. In addition, effectiveness of combination of interventions is likely to be different for different patients. It is impossible for a randomized clinical trial to test all possible interactions among interventions encountered in routine practice.”
Horn, et al., 2007
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Adherenceduring RCTs > Adherence
during program rollout
> Everyday adherence
Adherence to single intervention > Adherence to
multiple interventions
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Timing of interventions
→ Within developmental life course (individual)
→ Within the epidemic trajectory (population)
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Population level
Ds in one subpopulation
Compensatory Ds in other subpopulations
Ds in sexual and drug use networks
Unintended, unanticipated net effects
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↑ # FSW → ↓ # new HIV infections
↑ # internet based FSW → gonorrhea rates
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Scott Cunningham – Baylor University
Internet technology → ↓ relative cost of advertisements
↓ relative cost of security
↑ indoor sex work market
↓ relative share of street work
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Epidemiological context (sexual partner network-mixing-concurrency-heterogeneity)
Intervention impact
Epidemiological context
Interactions among interventions
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Context: economic, political, social environment
+
budget, organizational capacity, culture
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Condom promotion: acceptable, effective
↓ # partners – MSM: politically unacceptable, ineffective
Dr. Thomas Farley,New York City Health
Commissioner
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Intervention cost
Available resources
Resource allocation
Cost effectiveness
Comparative effectiveness
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Coverage
&
Frequency
↓
Impact of interventions
Dodd, et al., 2010
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Required levels of coverage and frequency may be different for systems of interventions
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Required coverage vs achievable coverage
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POP I Trial
• Effects of single chlamydia test over 12 months overestimated
• Most cases of PID over 12 months not prevented by a single chlamydia screen
• Most cases of PID occurred in women who were negative for chlamydia at baseline
Oakeshott, et al., BMJ, 2010
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“Policy makers might consider focusing on more frequent testing of those at higher risk, such as women with a new sexual partner or a recent history of chlamydial infection.”
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Targeting
“Who should receive prevention interventions?”
For chlamydia control
Annual screening
<25 — USA
<24 — UK
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Universal interventions
For
Highly network-dependent infections
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“The impact of many interventions can be amplified by targeting those that are most at risk of acquiring and transmitting infections.”
Garnett & Anderson 1995
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→ Impact of targeted vaccination and behavioral interventions
║
Impact of population-wide interventions
→ Follow-up interventions targeting higher risk individuals enhance impact of widespread screening programs
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Phase of the epidemic
The extent to which targeting enhances intervention impact
→ During earlier epidemic phases targeting high risk groups is particularly effective
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Should all interventions target the same subpopulations?
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Targeting
Intervention frequency
coverage
Resources
Costs
Cost effectiveness
Resource allocation
Health system capacity
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Duration
Intensity
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Sequencing of component interventions
Layering of multi-level interventions
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Copyright ©2010 American Public Health Association
Frieden, T. R. Am J Public Health 2010;100:590-595
The health impact pyramid
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Frieden’s Health Impact Pyramid focuses on:
Health system infrastructure
Societal composition
Societal organization
Societal operation
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Copyright ©2010 American Public Health Association
Frieden, T. R. Am J Public Health 2010;100:590-595
The health impact pyramid
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Test and treat
Screening and partner notification
A B C (abstinence, be faithful, condom use)
Counseling and testing
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Prevention program perspective
Test & treat
Counseling & testing
Screening & partner notification
Target individual perspective
A B C
Serosorting and condom use
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A systematic approach
for
“Context appropriate complex adaptive intervention systems”
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Thank you!