Hundreds of HIV/AIDS studies have been implemented throughout the world. The range of potential topics for HIV/AIDS operations research is vast. Most of these topics fall under two primary categories—prevention of HIV transmission or mitigation of the effects of HIV/AIDS. These two areas are not mutually exclusive. A few topics fall under both of these categories, such as stigma reduction, discrimination, and other human rights violations that hamper efforts to prevent HIV transmission and to provide care, support, and treatment to those affected by HIV/AIDS. Prevention of HIV transmission remains a key strategy for reducing the effects of the epidemic on future generations. Most prevention strategies focus on changing sexual behaviors and require a clear understanding of the social context within which the behaviors take place. Mitigation strategies usually consist of care, support, and treatment activities that address the needs of people living with HIV, orphans, and other vulnerable groups. For the purpose of illustration only, we list below some topic areas that are associated with prevention or mitigation and that are often the focus of operations research studies.

Selected Topic Areas for OR on HIV Prevention

Condom promotion
Promotion of both male and female condoms continues to receive major attention in most countries. But consistent condom use remains an elusive goal. Many OR studies examine different approaches to obtaining higher and more consistent levels of condom use among groups most vulnerable to sexually transmitted infections (STIs). Programs often use behavior change communications to encourage safe sex practices.

Prevention and management of STIs
The presence of STIs greatly facilitates the transmission of HIV. Strategies to prevent and control STIs through condom promotion, the use of peer educators, and periodic presumptive treatment with antibiotics have been the focus of several OR studies.

Voluntary counseling and testing (VCT)
VCT programs are often the link between prevention and mitigation activities. For those who test negative for HIV, VCT can be a powerful incentive to change high-risk sexual or injecting drug use behavior in order to remain negative. For those who test positive, VCT can serve as a link to care, support, and treatment options. In many countries, OR has tested new approaches to encourage people to seek VCT.

Reaching young people
Youth, particularly young girls, are highly vulnerable to HIV infection. OR studies that address youth issues sometimes focus on school-based youth or out-of-school youth. Most programs seek to increase access to information and services for youth, sometimes by using peer educators. A particularly important role for OR is testing new programmatic approaches that address gender and power issues within sexual relations and that seek to increase the self-esteem of girls.

Prevention of mother-to-child transmission  
Numerous prevention of mother-to-child transmission issues can be addressed through OR. Examples include exploring different ways to involve men more actively in the counseling and care of pregnant women, testing strategies for mobilizing communities to support prevention of mother-to-child transmission programs, and testing counselor training strategies.

Maintaining preventive behaviors
Preventing HIV transmission requires sustained safe sex behaviors for a lifetime. A major challenge for programs is how to find effective ways to sustain these behaviors for extended periods.

Integrating family planning and HIV/AIDS services
Family planning programs present an opportunity to introduce HIV/AIDS education and services, and HIV/AIDS programs provide a similar opportunity to introduce family planning services. OR studies have been directed at promoting condoms for dual protection, which means protection against both pregnancy and STIs, including HIV. A major challenge for OR is to develop and test cost-effective strategies for integrating these services.

Selected Topic Areas for OR on AIDS Mitigation

Assisting orphans
Large increases in adult mortality due to AIDS have been followed by large increases in AIDS orphans. The death of one or both parents affects orphans in many ways, causing setbacks in education, health, nutrition, and psychosocial wellbeing, as well as increased vulnerability to HIV and STI infection. OR studies are urgently needed to identify cost-effective models for assisting AIDS orphans.

Administering antiretroviral therapy
With the decrease in the cost of antiretroviral (ARV) drugs, many countries and organizations within countries are initiating treatment programs for people living with HIV. These programs face numerous operational issues that urgently need to be addressed. For example, what is the best way to ensure that a logistics system provides an uninterrupted supply of drugs? How can high levels of adherence to ARVs be maintained among patients? What is the role of community-based organizations in ARV programs? When should ARVs be administered? Can nonphysicians administer ARVs safely and with high standards of quality of care? These and many other issues concerning ARVs can be addressed through operations research.

Building the capacity of people living with HIV organizations
In most countries of the world, people living with HIV support groups have been formed. OR is needed to find ways of strengthening and sustaining the capacity of these groups by, for example, providing ongoing psychosocial support to people living with HIV as they deal with fear, guilt, stigma, anger, depression, discrimination, and isolation from society.

Impact on family caregivers
HIV/AIDS has had a huge impact on family caregivers. Caregivers often suffer from grief, exhaustion, isolation, and a lack of resources to help family members suffering from AIDS. OR studies need to test ways of reaching family caregivers to alleviate these problems.

Expanded Example of OR Topics Related to Access to Treatment

The complexity of HIV/AIDS and the numerous topics that could be addressed through operations research is best illustrated by presenting an expanded example of the topics concerning just one area: access to treatment with ARVs and to treatment of opportunistic infections. Little is known about the many operational issues that face countries trying to initiate large-scale drug treatment programs using ARVs and other drugs. A research question of significant importance is how to ensure the safe and effective administration of drugs on a continuous and uninterrupted basis to the largest number of infected people at the lowest possible cost. Some of the many questions about expanding access to treatment that could be addressed through OR studies are listed below.

Service delivery
Policymakers and program managers dealing with treatment issues face many unknowns. For example, most health care workers in the world, including physicians and nurses, have received very little if any training in the delivery of ARVs. What kind of training do these health care workers need to develop the competence to deliver ARVs, and how long should that training last? The delivery of ARVs also requires substantial attention to a host of health services, administration, and infrastructure issues, including supplies, equipment, record keeping, and expanded VCT services. The health care systems of most developing countries are already severely constrained and have difficulty delivering even the most basic curative drugs. Can these systems be rapidly upgraded to deliver far more complex ARVs? OR studies that address this question need to be implemented.

Behavior
OR also needs to examine better ways to improve patient adherence to complex drug regimens. ARVs must often be taken at fixed times of the day and in particular combinations for a lifetime. Frequently, patients experience side effects that can discourage continued use of the drugs. What is the best way to ensure patient adherence? One suggestion is to adapt a directly observed treatment short course (DOTS) approach similar to that used to treat tuberculosis. The tuberculosis DOTS program, however, is not always successful, and with HIV/ AIDS there is the added complication that every day patients must identify themselves as infected and thus risk stigma, discrimination, and possibly violence. How can high levels of adherence to drug regimens be maintained to get the maximum benefit from the drugs and avoid the development of resistant HIV strains that can occur when adherence is low?

Equity
ARV treatments are not likely to be available in sufficient quantities for everyone who needs them, a situation that raises human rights, ethical, and gender issues about who gets treatment. Which policies and procedures can best ensure equitable and nondiscriminatory access to ARVs and other drugs? What role does gender play in obtaining access to drugs?

Community mobilization
While it is clear that the public health care system in many countries will not be able to meet all treatment needs, it is not yet clear which other institutions and organizations could become involved. OR can help NGOs and community-based organizations effectively mobilize to play a supportive role in treatment.

Private sector
The private sector is likely to be a major actor in the delivery of ARVs. Increasingly, many companies and other private sector groups in some countries have indicated that they will begin to provide ARVs to their workforce. However, the best ways to provide these drugs while maintaining the confidentiality of workers is not known.

Cost
Cost issues will be crucial in the delivery of ARVs. Which program approaches can be used to keep costs low? Besides the costs of drugs, what are other program costs involved in increasing access to drugs, and how can these costs be reduced to a minimum? These are just a few of the many research questions about access to treatment. Other HIV/AIDS topics such as mother-to-child transmission, voluntary counseling and testing, stigma, and discrimination are equally complex and raise numerous questions that can be answered through operations research.