The contributions and future direction of Program Science in HIV/STI prevention

The contributions and future direction of Program Science in HIV/STI prevention Background: Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health. Discussion: To achieve this, Program Science involves the systematic application of theoretical and empirical knowl- edge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States. Conclusion: In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science. Keywords: Program Science, HIV prevention, STI prevention, Public health programs The beginning of Program Science bidirectional approach. At the core of Program Science The field of Program Science was introduced to the sci - is the principle of getting research out of programs and entific community and applied as a novel framework for into practice [7], whereas the other frameworks focus on understanding how best to implement an intervention. generating new knowledge for—and from—HIV and sex- Program Science was conceptualized in response to ually transmitted infection (STI) prevention programs [1, challenges encountered at the interface of research and 2]. Program Science is defined as the systematic applica - programs in HIV/STI prevention, where there remained tion of theoretical and empirical knowledge to optimize a disconnect in the perspectives and priorities of scien the scale, quality and impact of public health programs - [1]. The Program Science initiative draws on and encom - tists, program implementers and policy makers [1, 8, 9]. passes many key elements of other research frameworks, Program Science was conceived as an iterative, multi- including Implementation Science [3, 4], Operations phase research and program framework, within which Research [5] and Translational Research [6] to answer scientists, program implementers, and policy makers critical programmatic questions (as illustrated in Fig.  1). work together [1, 2] so that practice informs research While there is overlap with all of these frameworks, one and research informs practice and policy [7]. This strat - of the distinguishing features with Program Science is its’ egy fosters an adaptive response which enables programs to continuously and systematically examine its’ program processes, outputs and outcomes and then use this new *Correspondence: marissa.becker@umanitoba.ca knowledge as described below. Marissa Becker and Sharmistha Mishra contributed equally Centre for Global Public Health, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 2 of 7 knowledge generated from scientific enquiry, systemati - cally addresses all three spheres. The strategic planning sphere of a program cycle cent - ers on making informed decisions about program priori- ties and resource allocation. For example, heterogeneity in risk—through place or geographic location and social determinants—underpin HIV and STI epidemics [10– 13]. Thus, epidemic control requires a program aligned with local epidemic context in order to address this het- erogeneity [14–16]. The implementation phase of a pro - gram cycle centers on making informed decisions about ‘where’, ‘what’, ‘how’, and ‘for whom’ to deliver interven- tions. Critical decisions for program implementation include the locations for implementation and the popula- tions that will be focused on by the program, the specific combination of interventions to be implemented, as well as how best to deliver these services. Finally, program Fig. 1 Program Science and its relationship with other research evaluation requires the generation of robust evidence frameworks as part of program management. It is an ongoing and iterative process that allows for the re-development and re-design of programs to respond to program indicators Three spheres of Program Science and outcomes and to evolving epidemics, structures and The three spheres of a program cycle include: (1) strate - drivers of an epidemic. For example, as a public health gic planning; (2) program implementation; and (3) pro- program progresses, the knowledge on heterogeneity gram management and evaluation (see Fig.  2) and these is then used to fine-tune decisions on the ‘where’, ‘what’, form the basis for the application of Program Science. ‘how’, and ‘for whom’ and program monitoring focuses on By encompassing these three spheres of a program cycle, whether gaps, or inequities, in a program are improving. Program Science, as both a program and research frame- Program Science supports the generation of knowledge work, is able to ensure that scientific enquiry is driven across these spheres in order to inform HIV/STI pro- by these spheres, and the subsequent application of the grams with some examples discussed below. Fig. 2 The three key spheres of a Program Science cycle and illustrations of critical steps within each sphere Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 3 of 7 Director, recently wrote that “programmatic mapping are Program Science in practice the foundation for high quality HIV programs” [32]. Programs at the national and sub-national level [1, 2, 17, While programmatic mapping provides data on micro- 18], HIV prevention researchers [19, 20], policy makers level geographic concentration of risk, there has also [21, 22], and community-based organizations [23, 24] been work to understand the macro-level spatial dis- have implemented a Program Science approach to tackle tribution of the epidemic at the province/state/district issues of public health importance [19, 20, 25] and this level as highlighted in work led by Tanser et al. and Abu- approach has generated important scientific contribu - Raddad et  al. [13, 16]. Tanser demonstrates that in tions, as shown in Table 1 and discussed here. regions where the HIV epidemic was traditionally felt to be a generalized epidemic, that in fact, there were impor- Strategic planning tant zones of high HIV transmission signifying the pres- For HIV/STI program design, the necessary evidence ence of concentrated sub-epidemics. Prioritizing finite involves an incisive appraisal of the social and epidemi- resources by place (e.g. province or state) may be more ological drivers and mediators of local epidemics. This efficient than universal distribution of resources across a includes understanding the places and drivers that might country [33] to reduce HIV infections. Similarly, re-allo- disproportionately place key populations (KPs) at higher cation of resources to better align service delivery with risk of HIV/STI acquisition as well as characterizing pop- disease burden and disparities requires detailed mapping ulation-level chains of transmission. of health-states and services, including how individuals Innovations in Programmatic Mapping involves a sys- navigate health systems [34, 35]. tematic approach to generating key information about Additional innovations have included approaches for the size and distribution of KPs within a defined geo - characterizing HIV epidemics by understanding the graphic area [26]. Other methods, including multiplier causal pathway of HIV transmission at a population-level methods or capture-recapture techniques, provide over- rather than focusing on HIV acquisition at an individual all size estimates but do not provide the granular infor- level. For example, condomless sex acts in the context of mation required for detailed program planning and sex work may lead to a small number of HIV infections implementation. For example, geographic mapping pro- in the short-term, but contribute to a large number of vide city-wide KP size estimates and also provide data HIV infections over time through onward transmission on micro-level hotspot (places where KPs congregate to [36–38]. Disentangling the causal pathways may require solicit sex/drug using partners) level KP size estimates, a more in depth understanding of the local context of sex as well as generate information on the physical locations partnerships, which in turn, leads to a better understand- where KPs congregate and the characteristics of these ing  of the sources of heterogeneity in risk of HIV trans- locations, such as the typologies of sex work. The detailed mission, and of acquisition. For example, the importance population size data allow programs to set coverage goals of transactional sex (sex in exchange for money/goods/ and the location data enable programs to plan for out- resources wherein exchange was not explicitly negotiated reach and concentrate resources in areas of greatest need. prior to sex) leading to high proportion of HIV acquisi- Programmatic mapping has been used by many countries tion  was recognized when a revised Modes of Trans- in Asia and Africa [27–30] and there is growing global mission Model was parameterized to the local Nigerian recognition of the importance of mapping data [31]. context [36]. David Wilson, the World Bank’s Global AIDS Program Table 1 Key scientific contributions of Program Science and future directions Program Science spheres Scientific contributions Future directions Strategic planning 1. Geographical mapping 1. Rapid ethnographic assessments and enhanced geo- 2. Hotspots-spatial distribution of epidemics graphical mapping 3. Transmission dynamics 2. Micro-level (within city) appraisals of risk clusters 3. Program design by epidemic phase Program implementation 1. Intervention mix 1. Delivery platforms for agentic, individual and structural 2. Community engagement and mobilization interventions 2. Context specific adaptation Program management and evaluation 1. Tools for field level monitoring 1. Complex systems evaluation 2. Real time evaluation for responsive adaptation 3. Optimized indicators aligned to program stage Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 4 of 7 The uptake of some of these innovations into policy for utilization [47]. The use of a Program Science frame - resource allocation can be seen with an example from work allowed for a dynamic response; as the needs of the the Centers for Disease Control and Prevention (CDC). community changed, the program also evolved, using In 2013, the National STD Prevention Program in the evidence to reshape and redesign the program and its’ United States was revised to incorporate a strategic plan- implementation. ning component to its state funding allocation and pro- An important dimension of Avahan’s effectiveness is vides a useful example of the application of Program the integration of community knowledge in informing its Science in a northern hemisphere country context. The intervention mix. Ashodaya Samithi [44, 48, 49], the first Division of STD Prevention at the Centers for Disease intervention site supported by Avahan, has developed Control and Prevention in Atlanta is responsible for all of community-centric processes and responses that allow STI prevention in the United States. The funding require - communities to prioritize their issues, set the agenda for ments use a Program Science framework for resource the way forward, and ensure community ownership of the allocation [22], using STI disease burden by subgroup, intervention. This is achieved at multiple levels, initially and subgroup population size, and thereby requiring pro- through community engagement and involvement, and grams/states to generate local knowledge about STI epi- later through ownership of the intervention and capac- demiology through methods like programmatic mapping. ity building that ensures sustainability of the intervention [23]. These levels of community involvement have been Program implementation found to result in communities re-interpreting and trans- The Avahan India AIDS Initiative of the Bill and Melinda lating intervention messaging at the local level to develop Gates Foundation was a large scale focused HIV and STI contextualized responses to public health challenges [24]. Prevention Program in South India for KPs. Avahan used programmatic mapping for strategic planning and spe- Program management and evaluation cifically to determine where, when, and for whom inter- Improving program efficiency requires an approach to ventions should be prioritized. Avahan is also a very nice identify and define existing opportunity gaps. The Program example of using Program Science to determine what Science Initiative in Kenya, through a Technical Support intervention mix is required and how to deliver these Unit (TSU) to the National AIDS and STI Control Pro- interventions in their programs [23, 39, 40]. gramme (NASCOP), developed innovative field level tools Avahan clearly demonstrated the need to combine to capture data on HIV/STI prevention program indica- behavioural, biomedical and structural interventions to tors. HIV prevention programs in Kenya follow a combi- achieve the maximum impact in reducing HIV and STI nation prevention approach with a focus on biomedical, rates. Biological and behavioural surveys conducted behavioural and structural interventions. The tools devel - among female sex workers (FSWs) revealed a decline in oped and used by these programs were developed to col- HIV, syphilis, chlamydia and gonorrhea prevalence in lect data on all aspects of the program covering all three most sex work sub-groups and most locations as a result of these intervention focus areas. Kenya, as many other of combination prevention interventions which included countries do, has several funders of KP programs. As such, STI prevention and treatment [41–44]. As the program implementers were using many different reporting formats matured, the “what” and the “how” also evolved. The used by the many different funders. The TSU, with support program began to incorporate structural interventions from NASCOP, worked with all funders and implementing aimed at reducing violence and improving community partners through the National Key Population Technical mobilization [23]. The inclusion of these interventions Working Group to develop standard data collection tools. was driven by needs voiced by community members A basic 15 indicator reporting tool was developed and all (members of KPs) as well as a program aim to further implementing partners were mandated to report to NAS- reduce HIV and STI rates. The process of designing COP on a quarterly basis on all 15 indicators [50, 51]. This and implementing these structural interventions cen- standard tool was useful to both simplify and harmonize tered on comprehensively engaging with policy makers, data collection and reporting. The reports are compiled at police, lawyers, media and sex work communities. With the national level by TSU and NASCOP and county wise the incorporation of these interventions into the exist- analysis is shared with the implementing partners, county ing multi-pronged prevention programs, reductions in governments and funders on a quarterly basis to: (1) exam- reported violence and improved individual and collective ine data quality; (2) evaluate trends such as changes in HIV mobilization and empowerment were also seen [45, 46]. testing uptake over time and (3) assess program achieve- These changes also resulted in increases in the number ments as compared to national targets. Figure  3 illustrates of FSWs accessing government social programs and in the layers of data collected and highlights the differences in some areas, improvements in condom use and service coverage across the counties in Kenya. Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 5 of 7 where and how much early HIV risk exists will help refine the design and delivery of programs for FSWs and other vulnerable young women. Additional future directions for strategic planning involve an adaptive design by the phase of the epidemic (growing, stable, declining) and in the context of baseline and co-existing interventions [55, 56]. Next steps for implementation include resolving tensions between agentic, individual and structural interventions with a focus on optimizing synergies across delivery plat- forms [57]. Considerable scope remains to advance Pro- Fig. 3 Program monitoring data for HIV/STI Prevention among FSWs gram management drawing upon evaluation frameworks in Kenya (April-June 2013) and focusing on complex adaptive systems. By treating public health programs as complex systems, opportuni- ties exist for identifying emergent properties and learning Future directions for Program Science through the life course of a program in real time. Important next steps within Strategic Planning include enhanced geographic mapping along with micro level Future directions: expanding the tools appraisals. For example, a particular challenge noted by The scientific arms of Program Science comprise a range program staff in several countries was the provision of of methods and disciplines—and most importantly—a services to young and new FSWs with high rates of HIV multidisciplinary scientific approach. Empiric evidence acquisition prior to program engagement [52, 53]. Targeted covers multiple ‘layers’, from the molecular to environ- preventive interventions generally reach women only after mental (Fig. 4), while conceptual frameworks that under- they self-identified as sex workers [52]. To understand the pin the science are grounded in socio-behavioural [58, distribution and population size of young FSW, enhanced 59], complexity, and mathematical theory [60, 61]. geographic mapping which involved micro level (within Future expansions of the Program Science toolbox city) appraisals in Kenya and Ukraine to map locations include the development of new mathematical mod- where young women seek sexual partners, including paid, els with novel applications; effective data visualiza - transactional and casual sex partners [54]. Knowing who, tion tools for program monitoring to reflect complex Fig. 4 Layers of evidence used within Program Science. Empirical evidence is generated in many forms, including program data. Hypotheses are tested using several methods. A key component of Program Science involves syntheses of knowledge across multiple levels and scope, including realist reviews, and the integration of these data and syntheses with mathematical models to project public health impacts on health and costs. For infectious diseases such as HIV and STIs, public health impacts are estimated using transmission dynamics models Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 6 of 7 Competing interests interactions; analytic frameworks to integrate multiple The authors declare that they have no competing interests. layers of biological (host and pathogen) and behavioural data to disentangle causal pathways to population-level Consent for publication Not applicable. transmission; resource allocation tools that incorporate explicit trade-offs within programs, health-systems, and Availability of data and materials communities. Not applicable. Finally, expansion of Program Science includes the Ethics approval and consent to participate development of a Community-Based Program Science Not applicable. framework which draws on scaling up the principles of Funding participatory engagement. No specific funding was received for the writing of this manuscript. Conclusion Publisher’s Note Program Science is an emerging field in public and popu - Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. lation health. Through the country examples, this paper highlights some of the important scientific contributions Received: 8 September 2017 Accepted: 18 May 2018 that have developed over the past 5  years. Program Sci- ence as a framework is unique among other research strategies because it systematically combines the pro- gram cycle with the research strategy by embedding References 1. Blanchard JF, Aral SO. 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Lancet. 2011;378(9790):515–25. transmitted infections following HIV preventive interventions among female sex workers in five districts in Karnataka state, south India. Sex Transm Infect. 2010;86(Suppl 1):i17–24. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Emerging Themes in Epidemiology Springer Journals
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Abstract

Background: Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health. Discussion: To achieve this, Program Science involves the systematic application of theoretical and empirical knowl- edge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States. Conclusion: In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science. Keywords: Program Science, HIV prevention, STI prevention, Public health programs The beginning of Program Science bidirectional approach. At the core of Program Science The field of Program Science was introduced to the sci - is the principle of getting research out of programs and entific community and applied as a novel framework for into practice [7], whereas the other frameworks focus on understanding how best to implement an intervention. generating new knowledge for—and from—HIV and sex- Program Science was conceptualized in response to ually transmitted infection (STI) prevention programs [1, challenges encountered at the interface of research and 2]. Program Science is defined as the systematic applica - programs in HIV/STI prevention, where there remained tion of theoretical and empirical knowledge to optimize a disconnect in the perspectives and priorities of scien the scale, quality and impact of public health programs - [1]. The Program Science initiative draws on and encom - tists, program implementers and policy makers [1, 8, 9]. passes many key elements of other research frameworks, Program Science was conceived as an iterative, multi- including Implementation Science [3, 4], Operations phase research and program framework, within which Research [5] and Translational Research [6] to answer scientists, program implementers, and policy makers critical programmatic questions (as illustrated in Fig.  1). work together [1, 2] so that practice informs research While there is overlap with all of these frameworks, one and research informs practice and policy [7]. This strat - of the distinguishing features with Program Science is its’ egy fosters an adaptive response which enables programs to continuously and systematically examine its’ program processes, outputs and outcomes and then use this new *Correspondence: marissa.becker@umanitoba.ca knowledge as described below. Marissa Becker and Sharmistha Mishra contributed equally Centre for Global Public Health, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 2 of 7 knowledge generated from scientific enquiry, systemati - cally addresses all three spheres. The strategic planning sphere of a program cycle cent - ers on making informed decisions about program priori- ties and resource allocation. For example, heterogeneity in risk—through place or geographic location and social determinants—underpin HIV and STI epidemics [10– 13]. Thus, epidemic control requires a program aligned with local epidemic context in order to address this het- erogeneity [14–16]. The implementation phase of a pro - gram cycle centers on making informed decisions about ‘where’, ‘what’, ‘how’, and ‘for whom’ to deliver interven- tions. Critical decisions for program implementation include the locations for implementation and the popula- tions that will be focused on by the program, the specific combination of interventions to be implemented, as well as how best to deliver these services. Finally, program Fig. 1 Program Science and its relationship with other research evaluation requires the generation of robust evidence frameworks as part of program management. It is an ongoing and iterative process that allows for the re-development and re-design of programs to respond to program indicators Three spheres of Program Science and outcomes and to evolving epidemics, structures and The three spheres of a program cycle include: (1) strate - drivers of an epidemic. For example, as a public health gic planning; (2) program implementation; and (3) pro- program progresses, the knowledge on heterogeneity gram management and evaluation (see Fig.  2) and these is then used to fine-tune decisions on the ‘where’, ‘what’, form the basis for the application of Program Science. ‘how’, and ‘for whom’ and program monitoring focuses on By encompassing these three spheres of a program cycle, whether gaps, or inequities, in a program are improving. Program Science, as both a program and research frame- Program Science supports the generation of knowledge work, is able to ensure that scientific enquiry is driven across these spheres in order to inform HIV/STI pro- by these spheres, and the subsequent application of the grams with some examples discussed below. Fig. 2 The three key spheres of a Program Science cycle and illustrations of critical steps within each sphere Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 3 of 7 Director, recently wrote that “programmatic mapping are Program Science in practice the foundation for high quality HIV programs” [32]. Programs at the national and sub-national level [1, 2, 17, While programmatic mapping provides data on micro- 18], HIV prevention researchers [19, 20], policy makers level geographic concentration of risk, there has also [21, 22], and community-based organizations [23, 24] been work to understand the macro-level spatial dis- have implemented a Program Science approach to tackle tribution of the epidemic at the province/state/district issues of public health importance [19, 20, 25] and this level as highlighted in work led by Tanser et al. and Abu- approach has generated important scientific contribu - Raddad et  al. [13, 16]. Tanser demonstrates that in tions, as shown in Table 1 and discussed here. regions where the HIV epidemic was traditionally felt to be a generalized epidemic, that in fact, there were impor- Strategic planning tant zones of high HIV transmission signifying the pres- For HIV/STI program design, the necessary evidence ence of concentrated sub-epidemics. Prioritizing finite involves an incisive appraisal of the social and epidemi- resources by place (e.g. province or state) may be more ological drivers and mediators of local epidemics. This efficient than universal distribution of resources across a includes understanding the places and drivers that might country [33] to reduce HIV infections. Similarly, re-allo- disproportionately place key populations (KPs) at higher cation of resources to better align service delivery with risk of HIV/STI acquisition as well as characterizing pop- disease burden and disparities requires detailed mapping ulation-level chains of transmission. of health-states and services, including how individuals Innovations in Programmatic Mapping involves a sys- navigate health systems [34, 35]. tematic approach to generating key information about Additional innovations have included approaches for the size and distribution of KPs within a defined geo - characterizing HIV epidemics by understanding the graphic area [26]. Other methods, including multiplier causal pathway of HIV transmission at a population-level methods or capture-recapture techniques, provide over- rather than focusing on HIV acquisition at an individual all size estimates but do not provide the granular infor- level. For example, condomless sex acts in the context of mation required for detailed program planning and sex work may lead to a small number of HIV infections implementation. For example, geographic mapping pro- in the short-term, but contribute to a large number of vide city-wide KP size estimates and also provide data HIV infections over time through onward transmission on micro-level hotspot (places where KPs congregate to [36–38]. Disentangling the causal pathways may require solicit sex/drug using partners) level KP size estimates, a more in depth understanding of the local context of sex as well as generate information on the physical locations partnerships, which in turn, leads to a better understand- where KPs congregate and the characteristics of these ing  of the sources of heterogeneity in risk of HIV trans- locations, such as the typologies of sex work. The detailed mission, and of acquisition. For example, the importance population size data allow programs to set coverage goals of transactional sex (sex in exchange for money/goods/ and the location data enable programs to plan for out- resources wherein exchange was not explicitly negotiated reach and concentrate resources in areas of greatest need. prior to sex) leading to high proportion of HIV acquisi- Programmatic mapping has been used by many countries tion  was recognized when a revised Modes of Trans- in Asia and Africa [27–30] and there is growing global mission Model was parameterized to the local Nigerian recognition of the importance of mapping data [31]. context [36]. David Wilson, the World Bank’s Global AIDS Program Table 1 Key scientific contributions of Program Science and future directions Program Science spheres Scientific contributions Future directions Strategic planning 1. Geographical mapping 1. Rapid ethnographic assessments and enhanced geo- 2. Hotspots-spatial distribution of epidemics graphical mapping 3. Transmission dynamics 2. Micro-level (within city) appraisals of risk clusters 3. Program design by epidemic phase Program implementation 1. Intervention mix 1. Delivery platforms for agentic, individual and structural 2. Community engagement and mobilization interventions 2. Context specific adaptation Program management and evaluation 1. Tools for field level monitoring 1. Complex systems evaluation 2. Real time evaluation for responsive adaptation 3. Optimized indicators aligned to program stage Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 4 of 7 The uptake of some of these innovations into policy for utilization [47]. The use of a Program Science frame - resource allocation can be seen with an example from work allowed for a dynamic response; as the needs of the the Centers for Disease Control and Prevention (CDC). community changed, the program also evolved, using In 2013, the National STD Prevention Program in the evidence to reshape and redesign the program and its’ United States was revised to incorporate a strategic plan- implementation. ning component to its state funding allocation and pro- An important dimension of Avahan’s effectiveness is vides a useful example of the application of Program the integration of community knowledge in informing its Science in a northern hemisphere country context. The intervention mix. Ashodaya Samithi [44, 48, 49], the first Division of STD Prevention at the Centers for Disease intervention site supported by Avahan, has developed Control and Prevention in Atlanta is responsible for all of community-centric processes and responses that allow STI prevention in the United States. The funding require - communities to prioritize their issues, set the agenda for ments use a Program Science framework for resource the way forward, and ensure community ownership of the allocation [22], using STI disease burden by subgroup, intervention. This is achieved at multiple levels, initially and subgroup population size, and thereby requiring pro- through community engagement and involvement, and grams/states to generate local knowledge about STI epi- later through ownership of the intervention and capac- demiology through methods like programmatic mapping. ity building that ensures sustainability of the intervention [23]. These levels of community involvement have been Program implementation found to result in communities re-interpreting and trans- The Avahan India AIDS Initiative of the Bill and Melinda lating intervention messaging at the local level to develop Gates Foundation was a large scale focused HIV and STI contextualized responses to public health challenges [24]. Prevention Program in South India for KPs. Avahan used programmatic mapping for strategic planning and spe- Program management and evaluation cifically to determine where, when, and for whom inter- Improving program efficiency requires an approach to ventions should be prioritized. Avahan is also a very nice identify and define existing opportunity gaps. The Program example of using Program Science to determine what Science Initiative in Kenya, through a Technical Support intervention mix is required and how to deliver these Unit (TSU) to the National AIDS and STI Control Pro- interventions in their programs [23, 39, 40]. gramme (NASCOP), developed innovative field level tools Avahan clearly demonstrated the need to combine to capture data on HIV/STI prevention program indica- behavioural, biomedical and structural interventions to tors. HIV prevention programs in Kenya follow a combi- achieve the maximum impact in reducing HIV and STI nation prevention approach with a focus on biomedical, rates. Biological and behavioural surveys conducted behavioural and structural interventions. The tools devel - among female sex workers (FSWs) revealed a decline in oped and used by these programs were developed to col- HIV, syphilis, chlamydia and gonorrhea prevalence in lect data on all aspects of the program covering all three most sex work sub-groups and most locations as a result of these intervention focus areas. Kenya, as many other of combination prevention interventions which included countries do, has several funders of KP programs. As such, STI prevention and treatment [41–44]. As the program implementers were using many different reporting formats matured, the “what” and the “how” also evolved. The used by the many different funders. The TSU, with support program began to incorporate structural interventions from NASCOP, worked with all funders and implementing aimed at reducing violence and improving community partners through the National Key Population Technical mobilization [23]. The inclusion of these interventions Working Group to develop standard data collection tools. was driven by needs voiced by community members A basic 15 indicator reporting tool was developed and all (members of KPs) as well as a program aim to further implementing partners were mandated to report to NAS- reduce HIV and STI rates. The process of designing COP on a quarterly basis on all 15 indicators [50, 51]. This and implementing these structural interventions cen- standard tool was useful to both simplify and harmonize tered on comprehensively engaging with policy makers, data collection and reporting. The reports are compiled at police, lawyers, media and sex work communities. With the national level by TSU and NASCOP and county wise the incorporation of these interventions into the exist- analysis is shared with the implementing partners, county ing multi-pronged prevention programs, reductions in governments and funders on a quarterly basis to: (1) exam- reported violence and improved individual and collective ine data quality; (2) evaluate trends such as changes in HIV mobilization and empowerment were also seen [45, 46]. testing uptake over time and (3) assess program achieve- These changes also resulted in increases in the number ments as compared to national targets. Figure  3 illustrates of FSWs accessing government social programs and in the layers of data collected and highlights the differences in some areas, improvements in condom use and service coverage across the counties in Kenya. Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 5 of 7 where and how much early HIV risk exists will help refine the design and delivery of programs for FSWs and other vulnerable young women. Additional future directions for strategic planning involve an adaptive design by the phase of the epidemic (growing, stable, declining) and in the context of baseline and co-existing interventions [55, 56]. Next steps for implementation include resolving tensions between agentic, individual and structural interventions with a focus on optimizing synergies across delivery plat- forms [57]. Considerable scope remains to advance Pro- Fig. 3 Program monitoring data for HIV/STI Prevention among FSWs gram management drawing upon evaluation frameworks in Kenya (April-June 2013) and focusing on complex adaptive systems. By treating public health programs as complex systems, opportuni- ties exist for identifying emergent properties and learning Future directions for Program Science through the life course of a program in real time. Important next steps within Strategic Planning include enhanced geographic mapping along with micro level Future directions: expanding the tools appraisals. For example, a particular challenge noted by The scientific arms of Program Science comprise a range program staff in several countries was the provision of of methods and disciplines—and most importantly—a services to young and new FSWs with high rates of HIV multidisciplinary scientific approach. Empiric evidence acquisition prior to program engagement [52, 53]. Targeted covers multiple ‘layers’, from the molecular to environ- preventive interventions generally reach women only after mental (Fig. 4), while conceptual frameworks that under- they self-identified as sex workers [52]. To understand the pin the science are grounded in socio-behavioural [58, distribution and population size of young FSW, enhanced 59], complexity, and mathematical theory [60, 61]. geographic mapping which involved micro level (within Future expansions of the Program Science toolbox city) appraisals in Kenya and Ukraine to map locations include the development of new mathematical mod- where young women seek sexual partners, including paid, els with novel applications; effective data visualiza - transactional and casual sex partners [54]. Knowing who, tion tools for program monitoring to reflect complex Fig. 4 Layers of evidence used within Program Science. Empirical evidence is generated in many forms, including program data. Hypotheses are tested using several methods. A key component of Program Science involves syntheses of knowledge across multiple levels and scope, including realist reviews, and the integration of these data and syntheses with mathematical models to project public health impacts on health and costs. For infectious diseases such as HIV and STIs, public health impacts are estimated using transmission dynamics models Becker et al. Emerg Themes Epidemiol (2018) 15:7 Page 6 of 7 Competing interests interactions; analytic frameworks to integrate multiple The authors declare that they have no competing interests. layers of biological (host and pathogen) and behavioural data to disentangle causal pathways to population-level Consent for publication Not applicable. transmission; resource allocation tools that incorporate explicit trade-offs within programs, health-systems, and Availability of data and materials communities. Not applicable. Finally, expansion of Program Science includes the Ethics approval and consent to participate development of a Community-Based Program Science Not applicable. framework which draws on scaling up the principles of Funding participatory engagement. No specific funding was received for the writing of this manuscript. Conclusion Publisher’s Note Program Science is an emerging field in public and popu - Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. lation health. Through the country examples, this paper highlights some of the important scientific contributions Received: 8 September 2017 Accepted: 18 May 2018 that have developed over the past 5  years. Program Sci- ence as a framework is unique among other research strategies because it systematically combines the pro- gram cycle with the research strategy by embedding References 1. Blanchard JF, Aral SO. 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