Christopher Colvin (UCT) and Alison Swartz (UCT)
Since the beginning of the global HIV epidemic, issues of gender and sexuality have been front and centre in efforts to understand how the epidemic has unfolded around the world, and how we might best slow down and manage its effects. Despite real progress in recent years in some HIV prevention efforts, and in the widespread accessibility of antiretroviral therapy (ART), significant challenges remain. Maintaining a ‘gender lens’ on the epidemic remains crucial if we are to maintain these gains and address persisting challenges in the HIV response.
The Division of Social and Behavioural Sciences (DSBS) in the School of Public Health and Family Medicine at the University of Cape Town (UCT) has recently received significant funding to research gender and HIV (D43 TW011308) from the Fogarty International Center (FIC) and the National Institute of Mental Health (NIMH) at the US National Institutes of Health (NIH). This grant will allow us to establish a 5-year social science training programme in two critical areas of contemporary gender and HIV research:
1. reducing HIV incidence in adolescent girls and young women (AGYW), and
2. improving the performance of men in HIV prevention, treatment and care services.
Along with other recent funding from the NIH, the South African Medical Research Council (SA-MRC) and the South African National Research Foundation (NRF), this new Fogarty/NIMH funding will allow the Division to significantly expand its ability to conduct research and train new South African researchers in these vital areas of research.
South Africa has both the world’s largest HIV epidemic – nearly 20% of all infections globally – and the largest ART programme. Yet only half of the 7 million people in the country who need treatment are on ART (1), which means that South Africa is in need of significant progress to realise the World Health Organisation’s (WHO) 90-90-90 goal (2). The journey toward ‘treatment for all’ has started with WHO setting the following ambitious targets: by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained ART, and 90% of all people receiving ART will be virally suppressed. In South Africa, only 45% of people living with HIV know their HIV status, only 48% of those diagnosed are on ART, and only 76% of those on ART are virally suppressed (3). In the coming years, treatment and prevention will continue to preoccupy our HIV response.
Successful long-term ART, however, is not straightforward. There are challenges at every stage along the ‘cascade’ of HIV care, from prevention and testing through to treatment and long-term adherence. We face particular challenges with respect to men. Although women continue to experience greater HIV incidence and prevalence than men and shoulder far more of the burden of care of others (4), women start treatment and remain engaged in care at significantly higher rates than men. In sub-Saharan Africa (SSA), men are less likely than women to test for HIV, link to and remain engaged in care, and achieve viral suppression, and are more likely to be living infected but undiagnosed, and to die from the disease (5, 6). Getting men successfully and sustainably onto ART is not only a human rights and public health priority – it will also significantly improve the health of their partners, families and communities.
At the same time, we also need to stem the flow of new infections, particularly among adolescent girls, who are now the majority of new HIV cases (3). HIV is the leading cause of death among adolescents in sub-Saharan Africa, the only group for whom HIV-related mortality has still been rising (7). Adolescents and young people (15-24 years old) account for 40% of all new HIV infections each year, with the majority residing in sub-Saharan Africa (8, 9). In South Africa, HIV infection rates are eight times higher among teenage girls than among teenage boys (10), a pattern that has remained relatively unchanged for over a decade (11). Preventing new infections in adolescent girls and young women is an urgent public health priority. Both challenges have been identified by South Africa and UNAIDS as critical areas for research and intervention.
To address these emerging HIV priorities, we are using the new Fogarty/NIMH funding to establish the Building Research in Interdisciplinary Gender and HIV through the Social Sciences (BRIDGES) Programme. BRIDGES will support interdisciplinary social science training and will contribute to the evidence base by conducting research toward 1) reducing HIV incidence in adolescent girls and young women, and 2) improving the performance of men in the HIV cascade.
In the last few years, important biomedical innovations have reduced HIV incidence in women and worked to better support the prevention and treatment needs of men. The promise of these innovations, however, has been limited by an insufficient understanding of gendered sociocultural factors, as well as institutional and local contextual factors, which shape the implementation and uptake of these interventions. The VOICE, ASPIRE and RING studies, for example, tested promising woman-controlled forms of prevention (various types of ‘pre-exposure prophylaxis’ or PrEP) but had disappointing results partly because of lower than expected adherence by women (12). Similarly, while there is good evidence that voluntary male medical circumcision (VMMC) can reduce HIV risk for men, getting men to take up VMMC in large numbers has been a challenge (13).
In order for biomedical innovations to reach their transformative potential, they must be accompanied by high-quality, contextually-specific social science research that demonstrates how local contexts shape the direction and impact of public health interventions. Indeed, since the beginning of the global HIV epidemic, social science has been crucial for understanding and enhancing the impact of local contexts on the delivery and impact of medical interventions (14-16).
Simply conducting rigorous social science research is not enough to turn this tide. There is often little meaningful collaboration across disciplines and between social scientists and researchers engaged in clinical, epidemiological and public health HIV research. Working effectively across disciplines is difficult. ‘Bridging the gap’ between the social sciences and other public health disciplines requires understanding and then tackling multiple well-known but stubborn and complex obstacles, including disciplinary differences, professional hierarchies, institutional barriers, and the current nature of the research funding environment. There is considerable potential, however, for truly interdisciplinary research to deepen the impact of biomedical public health interventions. The BRIDGES Programme will contribute to bridging the gap between the critical social sciences and applied disciplines of public health by enabling students and staff to work effectively in multidisciplinary teams with clinical researchers, epidemiologists and other public health specialists.
Our Division, along with our many partners and collaborators, offers a strong foundation for the BRIDGES programme. Nonetheless, significant challenges remain in building and sustaining this kind of social science research. These include:
Developing Professional Social Scientists Beyond the Masters Level: We have had great success in our Division training Masters-level public health students, who learn foundational skills in health social science research. In the long-run, however, developing the next generation of professional social scientists will require a solid pipeline of more advanced postgraduate (PhD) and early-career researchers (postdoctoral and beyond) who are committed to and well-capacitated for establishing their careers in social science research in public health. The BRIDGES Programme will offer focused, integrated and advanced training to BRIDGES Fellows in this critical and under-served section of the pipeline.
Building a Curriculum for Advanced Postgraduate Students and Junior Scholars: To develop this next generation of research leaders, we need to ensure that they receive rigorous, well-rounded training. PhD and postdoctoral candidates in South Africa generally do not take courses or receive other structured forms of training, and instead receive support directly from their supervisors, who are generally focused primarily on supporting the production of a doctoral thesis. Many advanced postgraduates do not even have a cohort of fellow PhD students from whom they can draw support and peer mentoring. This lack of formal instruction and support during advanced graduate training is widely recognized as a deficit in the South Africa model (17). In order to address this deficit, we will provide structured and concentrated training in areas including proposal development, the responsible conduct of research, and advanced methodological training. We believe this will better equip BRIDGES Fellows for an independent research career in South Africa.
Broadening Access to Networks and Opportunities: In order to develop their capacity for conducting rigorous social science research, raising research funding, writing and presenting effectively, and ensuring the widest possible impact on policy and practice, early-career researchers need access to opportunities for mentoring, professional development and expanding their networks. For five years our Division has been running the SASH Programme (a capacity-building programme focused on supporting Masters students), which provides access to a range of teaching, mentoring, writing, and research activities to support the individual development of the next generation of scholars working on HIV social sciences. In the SASH Programme, one of the most effective ways of addressing this networking need has been institutionalising the Annual SASH Forum, a yearly event that brings SASH Fellows working on their Master’s degrees together with a wide array of faculty from UCT, Brown University, the SA-MRC, and many of our other partners. For BRIDGES, we will institutionalise the BRIDGES Symposium, a similar annual event that will allow BRIDGES Fellows to present their research, build their skills through our targeted workshops, and grow their networks by being connected with our partners and collaborators.
Developing Research Careers for Black and Female Students: The challenges confronting black and female South African graduate students have been well-documented (18, 19). A research workforce that excludes these perspectives and contributions would be both unjust, as well as significantly intellectually impoverished. Our experience in the Division and the SASH Programme has confirmed this belief, and has given us insight into the many daily ways in which black and female students face social, economic and institutional barriers to developing and sustaining careers in research. The BRIDGES Programme will incorporate lessons we have learned about how to address barriers to individual capacity-building from our successful previous training and mentoring programmes.
Strengthening Institutional Links within the University: Finally, while we have been fortunate to work with numerous like-minded health social scientists at UCT, the fact remains that institutional support for this kind of interdisciplinary health social science work is weak within UCT (as it is within most universities). Many researchers end up feeling like they are working unsupported and in silos. Working closely with other gender and HIV researchers at UCT is a critical part of our strategy in the BRIDGES Programme. To that end, we will be working closely with staff and students from the AIDS and Society Research Unit (ASRU), the Desmond Tutu HIV Foundation, the UKRI GCRF Accelerating Achievement for Africa’s Adolescents (Accelerate) Hub, and the Centre for Infectious Disease Research and Epidemiology (CIDER).
The overall aim of this Programme is to strengthen UCT’s place as a leader in gender and HIV social science research by: a) helping to develop the next generation of researchers capable of conducting rigorous, interdisciplinary social science research on gender and HIV, and b) strengthening the institutional training platform for innovative gender and HIV social science research in South/sub-Saharan Africa.
In particular, we will:
Expand the pool of early-career social science researchers working on gender and HIV in South Africa by recruiting and intensively training and mentoring 2 Postdoctoral Fellows and 4 PhD Fellows in the Division’s graduate program in HIV health social sciences.
Grow the capacity of the DSBS training platform for PhD and Postdoctoral Fellows in gender and HIV by developing and delivering i) new courses for PhD students and ii) new short courses for health social scientists at UCT and beyond.
Increase opportunities for training, networking and professional development in gender and HIV social science at UCT by hosting an Annual BRIDGES Symposium that will give Fellows the opportunity to present their work, engage with senior local and international gender and HIV researchers, and participate in intensive workshops in research methods, academic publishing, grant-raising, and knowledge translation.
BRIDGES Programme activities will be tightly integrated with ongoing work in our NIH/SA-MRC/NRF-funded iALARM project (Using Information to Align Services and Link and Retain Men in the HIV Cascade). For more information on BRIDGES, iALARM, SASH and any of our other research programmes and training initiatives, please see our Division website or review some of the other articles on our Fieldnotes platform.
Finally, we have recently announced a call for applications for short courses and new MPH, PhD and Postdoctoral Fellowships in the Division. You can download the call here.
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Christopher Colvin is an associate Professor and head of DSBS. He has a PhD in socio-cultural anthropology from the University of Virginia and a Masters in Public Health from UCT in epidemiology. His research interests include HIV and masculinity; health activism and community health governance; trauma, subjectivity and narrative; and the interface between communities and health systems in the context of HIV/AIDS, TB and maternal and child health.
Alison Swartz is a lecturer in DSBS. She has an honours in Social Anthropology and a Masters in Public Health (MPH) and a PhD in Public Health from UCT. Her PhD explored the ways that young people used their gender identities and sexual partnerships in attempt to access a more adult form of identity. Alison currently convenes three course on the UCT MPH Programme: Public Health and Society, Qualitative Research Methods and Qualitative Data Analysis. She also convenes the Social and Behavioural Sciences Track on the MPH programme.
Division of Social and Behavioural Sciences
School of Public Health and Family Medicine
Level 3 Falmouth Building
University of Cape Town