New Frontiers or status quo: Moving beyond RCTs in HIV prevention sciences?

Clearly, structural determinants in the spread of HIV require structural interventions. What these need to look like in the realm of new frontiers in HIV prevention sciences is less clear. As we heard from the panel of five distinguished speakers this afternoon, combining the science of the RCT in an effort to scale up HIV prevention interventions with the needs of community raises a complex array of social, political and economic dilemmas.  In her presentation on  “Addressing structural determinants of HIV and measuring change”, Julia Kim offered an excellent overview of a microfinance initiative in South Africa which allowed for the ‘piggy backing’ of HIV prevention. This synergy allowed for not only a cross-sectional intervention but also for community involvement in all aspects of the prevention intervention. In Jeff O’Malleys’ presentation we were again reminded of the need for community involvement in addressing issues of capacity, indentifying prevention priorities, and adding needed interventions along the way. The need for strong theoretical frameworks, including those derived from social capital theory, political science, health economics and planning theory were identified as critical elements of combination prevention interventions.  Although other panelists argued for the need for ongoing RCTs, there was also consideration of the economic realities of finite resources and the need for better alignment of HIV prevention science and prevention needs, particularly in resource limited settings where HIV may need be regarded as a key priority.  The issues of sound evaluation methodologies beyond process evaluations and the lack of systematic approaches and tools for use in the scaling up of HIV prevention efforts were also regarded as key challenges in this session.