D. Practical research designs for investigating modes of HIV
transmission. Invited presentation at the 11th annual
meeting of the Safe Injection Global Network, World
Health Organization, Dubai, United Arab Emirates,
November, 2010. Presentation available at SSRN: http://dx.doi.org/10.2139/ssrn.2542630.
Despite 30 years of epidemiologic research on HIV
transmission, no published investigations in sub-Saharan
Africa or Asia have involved study designs that allow HIV
transmission modes to be determined with confidence.
Consequently, there is much uncertainty about what is driving
HIV transmission in these regions, which hampers prevention.
There are four design elements in a rigorous investigation:
inclusion of persons with incident HIV infection (cases) and
uninfected controls, comprehensive assessment of blood and
sexual exposures, tracing of contacts to such exposures for
both cases and controls, and sequencing of infected persons'
HIV DNA to identify persons with genetically related
infections. Although all four elements are necessary to
determine transmission modes with greatest confidence,
investigations with the first two or three elements provide
stronger evidence than exists currently and offer useful
guidance on prevention strategies until more definitive
investigations can be conducted. Investigations with these
design elements can piggyback on existing clinical and other
health services, and thus require little or no funding to
implement. Scientific help is available for conducting these
investigations. The most important requirement for starting
this kind of project is the desire to know what is driving HIV
transmission in one’s community.
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