Central Asia HIV Research Center – Draft Proposal

Susan S. Witte, Ph.D.
Assistant Professor
School of Social Work
Columbia University

Introduction

The sharp rise in HIV and other co-occurring epidemics in Central Asia demand rigorous behavioral and social science research to address gaps in prevention efforts, treatment interventions, and social and economic policies. To meet this need, the Social Intervention Group (SIG) at the Columbia University School of Social Work (CUSSW), in collaboration with the Institute of Social and Economic Research and Policy (ISERP) at Columbia University and the Columbia Center for New Media Technology and Learning (CCNTML) will establish The Central Asia HIV Center (CAHC), a regional interdisciplinary center in Almaty, Kazakhstan for research on HIV/AIDS and other co-occurring epidemics of tuberculosis (TB), Hepatitis C (HCV), sexually transmitted infections (STIs) and substance abuse in Central Asian Region (See Appendix A for map of countries).

The Central Asia HIV Center aims to develop the research infrastructure and strengthen the capacity of local institutions and investigators to conduct research related to prevention, treatment and care of HIV/AIDS and other co-occurring epidemics. The CAHC approach is unique in that it provides a multidisciplinary, cross cutting approach to establish linkages among regional investigators, public health officials, community institutions, health care providers. The Center will actively involve a broad range of professionals at the local and international level from different disciplines and sectors (i.e. academia, research institutes, government agencies, donor agencies, and NGOs) who have wide-ranging expertise in addressing HIV/AIDS and other co-occurring epidemics. This crosscutting network of experts will better prioritize needs for HIV related research, identify best practices through rigorous research, and develop practical solutions to disseminate effective interventions on a wide scale.

This proposal offers an overview of the CAHC, providing background in the pressing global health needs in the region, proposed mission and activities of the CAHC as well as short-term and long-term goals for establishing and expanding the Center’s operations.

How does the Center address the global health initiatives and mission of CU and CUSSW?

The Central Asia HIV Center will place Columbia University in a leading role in the area of HIV/AIDS research in Central Asia. This Center dovetails with Columbia University’s global health initiatives to promote international interdisciplinary research on infectious diseases such as HIV/AIDS and other co-occurring epidemics. The Center will also continue to build CUSSW’s academic partnerships in the region in order to strengthen the capacity of social work as an emerging field that is addressing the prevention, treatment and care of HIV and other co-occurring epidemics. By promoting academic exchanges of faculty, post docs and students between CUSSW and universities in the region, the Center will also enrich the international social welfare field of practice at CUSSW.

Center Mission

The mission of this center is to develop the research infrastructure and strengthen the capacity of institutions and investigators in Central Asia to conduct rigorous behavioral and social science research that will inform effective prevention, treatment and care of HIV/AIDS and other co-occurring epidemics. More specifically, the aims of this center are to:

1) To develop and sustain a regional research infrastructure to enhance behavioral and social science HIV/AIDS related research by promoting new research directions, fostering on-going research partnerships, and facilitating interactions across disciplines. Infrastructure development and capacity strengthening would include: research administration, ethical review and oversight, data management and storage, instrument design and data collection, data analysis, information exchange and translation of research into practice.

2) To increase number of research scientists, faculty, pre-doc and post doc in the region and at Columbia University who conduct behavioral and social science research on HIV/AIDS and other co-occurring epidemics in Central Asisa. These local researchers will emerge as recognized leaders in fields of behavioral and social science research on HIV/AIDS.

3) To establish cross-cutting linkages among investigators, public health officials, community institutions, health care providers to identify research needs and generate practical solutions to translate research into practice.

4) To employ state-of-the-art media technology and communication systems to enhance the effectiveness, scale and sustainability of the core activities of the Center.

5) To promote the development of Social Work as a profession in Central Asia and to advance the field of international social work at CUSSW by serve as a field placement and training site for students from regional universities and CU. The field placement will offer social work interns an opportunity to learn about research and practice on HIV/AIDS and co-occurring epidemics, as well as to study social and economic polices related to these issues.

Why establish the Center?

1. Social, economic, and public health rationale

The incidence of HIV/AIDS in Central Asia has shown exponential growth over the past ten years. UNAIDS reported the amount of newly reported infections in the region in 1995 at only 88, while experts currently estimate that the number of people living with HIV/AIDS in the region is now over 90,000 (World Bank, 2005). The dramatic increase in HIV/AIDS infection in the region can be attributed to the post-Soviet period of socioeconomic transition that entailed vast social, demographic, and cultural changes. The increase in unemployment and poverty spurred the growth of informal economies that included illicit drug trade and sex work as well as increased population migration and mixing. This combination of factors has created a multitude of “risk environments” which have fueled the explosive spread of HIV/AIDS and co-occurring epidemics of TB, HCV, and other sexually transmitted infections.

The greatest risk factor for the spread of HIV/AIDS remains injection drug use. According to UNAIDS and other studies, between 60 and 70 percent of all the newly registered HIV/AIDS cases in Central Asia are linked to transmission by injecting drug users (Radio Free Liberty, 2006). This places a very large group of individuals at risk for HIV/AIDS transmission as experts estimate that the number people using drugs in Central Asia has risen to approximately 500,000 (World Bank, 2005). This number is only likely to increase since Central Asia sits along the corridor between Afghanistan and Europe through which much of the world’s drug trade passes.

While drug use remains the main threat, sexually transmitted HIV is on the rise as well. Many female drug users are also engaged in sex work and in general there is very little awareness of or adherence to safe sex practices among the general population, especially among youth. A warning sign for the potential growth of HIV/AIDS are the emerging epidemics of syphilis, gonorrhea, and other sexually transmitted infections (STI), which fuel the transmission of HIV. STI infections in Central Asia have increased a hundred fold between 1991 and 2001 (USAID, 2006).

Finally, multidrug-resistant tuberculosis (MDR-TB) has emerged as a major threat in the region, reaching a prevalence rate of 10-14 percent, and is particularly dangerous in combination with the spread of HIV/AIDS. TB-HIV co-infection reduces the effectiveness of treatment and care and is one of the leading causes of death in HIV patients (USAID, 2006). HIV also widens the TB epidemic, especially in regions where the prevalence of both diseases is high.

The emerging crisis of HIV/AIDS and other epidemics in the region has been accompanied with a downward shift in social and economic conditions during the Post Soviet Union era. This shift has led to a weakening of the public health and social service infrastructure and its capacity to respond to the rapidly emerging epidemics of HIV/AID and other infectious diseases. Health clinics and hospitals are chronically under funded and lack resources to treat those infected with infectious diseases let alone conduct public health outreach or other preventative health care. In addition, social science research institutes which previously would have been at the forefront of addressing the HIV/AIDS epidemic have largely fallen apart as a result of severe financial constraints and the brain drain of research scientists to Russia and the West. Although scientists in Central Asia have very strong academic and research backgrounds, lack of funding has resulted in outdated research methods, limited access to information on recent research findings, and antiquated technological resources.

2. Unique Role of the Center in Addressing the HIV/AIDS Crisis

Recognizing the magnitude of the public health problem in Central Asia, donors and multilateral organizations are rushing to fill the gap in public health awareness efforts, provision of medication, improving social service interventions, and capacity building for NGOs working to serve at risk populations. Prominent leaders in the fight against HIV/AIDS include the Soros Foundation, USAID, UNAIDS, the World Bank, WHO, and CDC. These programs largely follow a harm reduction approach and are seeking to target regions with high HIV/AIDS infection rates, at-risk populations such drug users, youth, sex workers and migrant workers. Funders also promote a multi-disciplinary, problem solving approach by bringing together stakeholders from the government, private, and NGO sector to share resources, information, and coordinate interventions.

While these efforts represent a positive step forward in addressing HIV/AIDS and other infectious diseases, there is a real need to develop sustainable infrastructure in the region that can offer rigorous, scientific research on the nuances of the epidemic, determine effective intervention strategies, and scale up proven methods and approaches. There are currently no centers in the region which are designed to build a research infrastructure and strengthen capacity to conduct research related to the prevention, treatment and care of HIV/AIDS and other co-occurring epidemics. The Center complements the mandate of NGOs and government programs which are currently addressing HIV/AIDS in the region and strengthens these efforts by promoting rigorous research to identify best practices and effective interventions and by training service providers and scaling up effective interventions and best practices. This unique approach will equip countries in the region with sustainable knowledge, resources and research tools they need to advance the prevention, treatment and care of HIV/AIDS and other co-occurring epidemics.

4. The Columbia University Partnership of SIG, ISERP and CCNTML

The Center will draw on a complementary, synergistic partnership among three different Centers at Columbia University, SIG, ISERP and CCNTML.

For the past 17 years, Dr. Nabila El-Bassel, Louisa Gilbert and their colleagues at SIG have conducted nine randomized controlled trials to test the efficacy culturally congruent HIV prevention interventions with a wide range of vulnerable populations funded by the National Institute of Health (NIH). Several of their HIV prevention interventions which have shown to be efficacious have been funded for dissemination trials. The proposed study will build upon extensive experience gained through the following RCTs and other program evaluation research related to the prevention, treatment and care of HIV/AIDS and other co-occurring epidemics. Over the past 5 years, SIG has conducted epidemiological and prevention intervention research on HIV/AIDS and the co-occurring problems of STIs, HCV and substance abuse (see appendix B) in Central Asia. Through this growing portfolio of HIV/AIDS related research in the region, SIG has built partnerships with local universities, public health officials, and local and international NGOs and researchers (See Appendix B for a more in depth portfolio of SIG’s research in Central Asia). The Center will continue to build upon and strengthen these partnerships.

ISERP was founded in 1944 to serve as the research arm of the social sciences at Columbia University. ISERP has produced cutting edge research and shaped public policy by integrating knowledge and methods across social scientific disciplines. ISERP has a long track record of providing ongoing education and training to international scholars as well as CU faculty, postdoctoral fellows, master students, and community leaders in the area of public policy. More recently, ISERP has been funded by Robert Wood Johnson to establish the Health & Society Scholars Program which is designed to address more effectively the broad range of factors affecting health. Dr. Peter Bearman, the Director of ISERP, the Cole Professor of Sociology, and Co-Director of the Health & Society Scholars Program at Columbia University, is a specialist in network analysis. Dr. Bearman co-designed the National Longitudinal Study of Adolescent Health and has used the data extensively for research on topics including adolescent sexual networks and networks of transmission of HIV and other STIs. SIG and ISERP are currently collaborating together on an epidemiological study of HIV risk and STIs among a migrant population of market vendors in Almaty, Kazakhstan.

Begun in March 1999, CCNMTL works closely with professors and other experts to develop teaching and research tools that are not merely bells and whistles but that significantly enhance teaching, learning and research capabilities. In partnership with the faculty, the Center is committed to advancing the purposeful use of new media and digital technologies in research and the educational programs of Columbia University. Over the past two years SIG has collaborated with Dr. Frank Moretti, the executive director of CCNMTL and his staff to develop Multimedia Connect, an online, multimedia representation of a couples-based HIV prevention intervention, which has recently been funded for a dissemination trial by CDC. CCNMTL will ensure that the Center and its partners are dynamically connected to the emerging world of new media technology and communications to enhance the efficacy and broaden the scale of the Center activities. More specifically, CCNMTL may work with Center partners to use multimedia technology in packaging and disseminating effective interventions and in developing on-line multimedia training programs for service providers to deliver effective interventions in low resource community based settings. CCNTML may also partner with the CU Library to create an electronic library and digital teaching materials related to the Center activities. In addition, CCNMTL may collaborate with Center partners on: (1) building an on-line curriculum to prepare students and faculty fellows for academic exchanges, (2) using the latest Audio Computer Assisted Self-Interview ACASI programming to conduct surveys; and (3) using video conferencing and other advanced systems of communication to increase systematic interaction and collaboration among the Center partners.

Center Activities

The Center will comprise four cores—Research, Training, Community Consultation, and Translation of Research to Practice—that will work together to carry out the key strategic priorities of the Center. Below are more detailed descriptions of each core.

Research Core—The primary aim of this core is to create a research infrastructure for and train a cadre of regional experts in epidemiological, policy, and intervention research along the key strategic priorities of the Center. This core will apply for research grants to conduct innovative and applied behavioral and social science research that may inform effective prevention, treatment and care of HIV/AIDS and other co-occurring problems. At the same time, this core will enhance the capacity of research scientists by providing training and state-of-the-art technology on all aspects of conducting behavioral and social sciences research, including: research design and methods, assessment, data collection, bio-specimen collection and testing, recruitment and retention of participants, ethical issues and human subjects certification, data management and statistical analysis. This Center will establish an independent Institutional Review Board, which will review and approve the human subject protocols, consent forms and data safety monitoring plans of research studies. This IRB will adhere to international IRB standards but will also work with regional experts to be contextually specific in considering human subject risks and protection strategies.

Training -- This core will aim to provide training to faculty and pre- and post-doc fellows in multidisciplinary, substantive areas that are related to HIV/AIDS, such as innovative intervention methodologies, practice methods, and theoretical models. To advance international academic dialogue, the training core aims to promote exchange of faculty, post doctoral and pre-doctoral fellows between CU and regional universities in areas related to the key strategic priorities of the Center. This core will also serve as a field placement for social work students from CU and other regional universities who seek to gain training and experience working in HIV/AIDS and related co-occurring problems. The Center will also provide opportunities for research and educational exchange for faculty, students, and alumni from CU and this region. This Center will draw on professional, research and academic ties that have been established by the CUSSW over the course of more than five years of a broad range of research programming in the region as well as student and faculty exchanges. Since 1999 over 50 students from Central Asia and the Caucasus, many with significant professional experience, have received fellowships from the Soros Foundation to complete Master’s degrees in Social Work at CUSSW. CUSSW has recently started a visiting faculty exchange program in which scholars in the fields of sociology, social work, public health, and public policy collaborate on research and curriculum development with their CUSSW peers over three semesters, of which two are at CUSSW and one is at their home institution. A total of five scholars have participated in the faculty exchange program since its inception last year.

Community Consultation – This Core will provide scientific consultation and relevant resources for local and international donor agencies, NGOs, and government agencies seeking assistance in conducting all aspects of needs assessment and evaluation of programs and policies related to HIV/AIDS. This Core will conduct needs assessment and scientific evaluation of existing prevention efforts and treatments in a broad range of settings. This Core will aim to identify the best culturally congruent practices related to prevention, treatment and care of HIV/AIDS and other co-occurring epidemics. Funding for this core will be supported by client user fees as well as grants.

Translation of Research to Practice --- This central aim of this Core is to broaden the scale of effective interventions and disseminate empirically validated best practices in different community based settings in the region. This Core will translate findings both from the Center’s research studies and other regional research efforts into practice implications for service providers and consumers. This Core will write grants and collaborate with partners to disseminate tested and proven efficacious interventions in community settings. The core will take a comprehensive approach to work with community based organizations to ensure that new interventions take hold and are administered properly. This Core will use state-of-the-art multimedia technology to package effective interventions, develop standardized interactive training on interventions for service providers in low resource settings and provide on-going support and evaluation of the adoption of effective interventions in the field. Core staff will provide follow-up visits and supervision to address problems that arise as the interventions are rolled out into community based settings. This Core will identify a range of mediums (i.e., internet, publications, conferences) to identify and engage practitioner and consumer audiences for these translational and “scaling up” initiatives.

Infrastructure of the Center

The Center will be located in Almaty, Kazakhstan and will be structured tooperate as a subsidiary or a branch office of CU and as a local NGO. The Center will be directed by Dr. Nabila El-Bassel and Louisa Gilbert from the Social Intervention Group at CU, Dr. Peter Bearman from Institute for Social and Economic Research and Policy (ISERP) at CU and Dr. Frank Moretti of Columbia Center for New Media and Technology (CCNMTL). Dr. Assel Terlikbayeva will be the local Director who will manage the day-to-day operations of the Center in Almaty. The Center will have an Executive Board, which will be responsible for with overall Center direction and implementation and fiscal operations will be under the auspices of CU and managed by the local Director. The Center will also have two advisory boards: a Community Advisory Board and a Research Advisory Committee Board. The administrative structure of the Center is described in detail below.

Executive Board

Comprising CU staff in NYC and local Center staff in Almaty, participating via conference call, the Executive Board will meet once a week (or more frequently as required) to coordinate and fulfill the following responsibilities: The team from Almaty will participate on a conference call.

• Administering the Center, including general oversight of the program and grant management, planning, and executing decisions regarding Center activities;

• Overseeing budgets and expenditures, including equipment/supplies, pilot studies, travel, etc.;

• Implementing recommendations from the Scientific Advisory and Community Advisory Boards on how to effectively manage the Center

• Creating an infrastructure that will facilitate the development and implementation of high quality design, data collection, analysis, and publications in an efficient and effective manner;

• Ensuring human subjects protection and expeditious compliance with IRB among all Center funded activities;

• Promoting of the program and the trainees (e.g., website, newsletters); and

• Evaluating the development of trainees, assessing the impact of the Center activities, and examining factors associated with achieving or not achieving the Center’s outcomes.

The Executive Board will ensure that the Center remains responsive to emerging research issues, needs of investigators, institutional requirements, and communities’ needs. Members will review pilot proposals; review progress toward attainment of the program objectives; and further interdisciplinary collaboration both in Central Asia and in the US.

Community Advisory Board

This Board will review and guide the Center’s research focus, implementation and dissemination and review grants to ensure their relevance to the community. The Community Advisory Board will have the following responsibilities:

· Consulting on all aspects of studies (e.g., design, human subjects, implementation, dissemination);

· Developing ideas for new studies;

· Generating guidelines and review practices to ensure that the relationships between SIG and collaborative partners are mutually beneficial;

· Translating key study findings for service providers and consumers

· Identifying and pursuing opportunities for enhancing the capacity of community partners to conduct evaluation and write grants

The Community Advisory Board will consist of influential governmental policy makers, social and community service providers from the fields of HIV/AIDS and other related infectious diseases. Members of the Boards are currently being recruited. Thus far, x individuals have been recruited and have committed to the mission of the Center. Each country will have at least two representatives who will serve on the Community Advisory Board. The Board will consist of a total 10-12 members and will meet quarterly.

The Research Advisory Board

The Research Advisory Board will include regionally recognized leaders and international experts in the field of HIV/STI research, biostatistics, and methodology. The Research Advisory Board will consist of 10-12 members and meet quarterly and will be convened and chaired by the Executive Board. This Board will be responsible for the following:

· Advising the Director and Co-Directors of the Program on the research agenda and training needs;

· Assisting t the Executive Board in building an enduring infrastructure that will offer regional researchers and faculty valuable research development experiences;

· Ensuring that regional researchers receive adequate training and advising on the structure and content of seminars and workshops;

· Ensuring the Executive Board and all the other Program units have adequate counsel regarding the administration of the Program;

· Systematically reviewing the progress of the overall Center, not only in relation to scientific and training activities, but also in relation to advancing knowledge that is accessible to communities, public policy makers and governmental officials. Making recommendations to improve performance of the Center based on systematic review;

· Reviewing the strategic plan of the Center, and making recommendations to the Executive Board to ensure that the Center remains responsive to emerging research issues, institutional requirements, and communities’ needs.

· Conducting a mock peer review process of research proposals and articles of regional researchers

· Advancing interdisciplinary linkages by suggesting consultants for proposed projects.

Dissemination Plan

Information about the Center, including evaluation of measurable outcomes and assessment of the success, will be disseminated regularly via a variety of methods as well as a range of venues. A website dedicated to the Center will provide a current and detailed description of the activities and accomplishments, including hyperlinks for downloading deliverables (e.g., articles). The newsletter, which will highlight updates on Center activities will be distributed in hardcopy and electronic form to colleagues, research institutes, universities, graduate programs at institutions. Postal and electronic mailing lists will be created and shared. The Center will actively seek to disseminate information about the Center and outcomes by presenting at scientific conferences, meetings.

Potential Central Asia Collaborators

Universities

Al-Farabi Kazakh National University (AKNU)

Kazakh National Medical University (KNMU)

Kazakh School of Public Health (KSPH)

Almaty School of Postgraduate Medical Education (ASPME)

Eurasian University named after L. Gumilev (Astana)

Karaganda State University

US

US Embassy

USAID

KZ Government

Almaty Department of Health

Republican AIDS Center

NGOs

Kazakh National Association of Social Workers

National Association of AIDS Service Organizations

BRIEF Agency

Short term plan

1.) Provide funding for two years, $x per year (obtain through seed money)

2.) Hire a local Director (Dr. Assel Terlikbayeva) and program coordinator in Almaty, Kazakhstan

3.) CU will develop an Agreement or Memorandum

4.) Develop a set of regulations for Center’s operations

5.) Rent a location for the Center

Short-Term Outcomes

1.) Build research and operational infrastructure

2.) Recruit research scientists from the US, Central Asia,

3.) Build relationships with universities in the region

4.) Establish a marketing strategy and materials to publicize the center and establish relationships with potential donors, government agencies, and universities in the region

Long-Term Outcomes

1.) Obtain funding to sustain the center beyond the two years

2.) Establish training opportunities for pre doc, post doc, and visiting faculty from CU

3.) Establish faculty exchange program from the region and CU in social work and related fields

4.) Obtain research and training funding

References

USAID. Health Profile: Central Asia HIV/AIDS. Retrieved October 4, 2006 from the World Wide Web: http://www.usaid.gov/our_work/global_health/aids/Countries/eande/careregion_04.pdf

UNAIDS. 2006 Report on the global AIDS epidemic. Retrieved October 4, 2006 from the World Wide Web: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp.

World Bank. (February, 2005). “Central Asia issue brief: HIV/AIDS in Central Asia. Retrieved October 4, 2006 from the World Wide Web: http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/EXTECAREGTOPHEANUT/EXTECAREGTOPHIVAIDS/0,,contentMDK:20319451~menuPK:616563~pagePK:34004173~piPK:34003707~theSitePK:571172,00.html

Radio Free Liberty. “Central Asia: Drug Trafficking Has Devastating Social, Economic Impact (Part 2).” Retrieved October 4, 2006 from the World Wide Web:

http://www.rferl.org/featuresarticle/2004/06/0761f337-a1de-4b7c-a5d0-bbdaeb20d5f1.html

Appendix A

Map of Central Asia