AIDS at 25

One catchphrase that permeated the conference this past week was "scaling up." I just want to wrap up my posting here with a brief discussion of what that is, and what that means as far as HIV/AIDS prevention and treatment.

Readers who are scientists or who have some kind of science background will probably be famililar with the concept of a "pilot study." This is a study, generally small in scale, where new ideas are tested, and preliminary data are gathered. For example, a pilot study looking at how the ABCs of prevention work may take 100 individuals and split them into two groups: 50 who are taught about Abstinence, Be faithful, and Condoms, while the other group may be given no additional information, or be taught only about abstinence, for example. These two populations then can be followed and, depending on the study, outcomes measured. (Did they acquire HIV at a similar rate over, say, the next 2 years? Did faithfulness within a relationship increase in the group who were taught the ABCs? Did the abstinence-only group actually practice abstinence outside of the context of a marriage?) When the final data were examined, then, the researchers will decide whether the pilot study has achieved the outcomes specified in the beginning. If it had, these interventions could then be applied to a much larger group; it can be "scaled up" in terms of money and population.

"Scaling up" doesn't always mean going from a pilot study to a larger, more inclusive study, however. Imagine now that the researchers had now carried out that second-phase study, and wanted to implement these prevention measures nation-wide. This is another scale-up; moving from scientific research to public policy. There are obstacles at each scale-up, of course. Researchers need to prove their case in order to secure funding for large studies, which can be difficult. Even more difficult, generally, is scaling up from a scientific study to a matter of policy, because this involves, in some cases, major infrastructure building.

For example, using the ABC scenario I outlined above. If this becomes policy, who will fund the employment of educators to reach out to the population, especially those at high risk of acquiring HIV? How, exactly, will these educators even identify people to teach? Will this be done through existing clinics, schools, community organizations? Or will new physical structures be built to cater to this need?

Similar concerns exist for any kind of massive scale-up. For treatments, who pays for them? How are the drugs delivered? How are testing and anti-retroviral treatment coordinated? Can one create a comprehensive program for prevention, education, testing, and treatment, or are separate entities in charge of the various components?

"Scaling up" is the goal of many programs centering on HIV/AIDS, whether it's scaling up efforts aimed at prevention, treatment, or other facets that come into play. But going from demonstrated success in research studies to successful programs at the level of a nation (or even a city) is a difficult and massive undertaking, fraught with red tape and other trappings of politics.