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South Africa HIV and TB Implementation Research Priorities


South Africa HIV and TB Implementation Research Priorities
Prepared by the South Africa HIV and TB Implementation Research Advisory Committee

August 2016

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Summary

The South Africa government has adopted UNAIDS 90-90-90 goals for HIV and is committed to strengthening the national TB program.  In order to provide guidance to researchers, program implementers and funders, the South Africa National Department of Health (NDoH) convened a South Africa HIV and TB Implementation Research Advisory Committee consisting of HIV and TB experts from the South Africa government, World Health Organization (WHO), academic institutions, program implementers and health care providers.  Through a threestep process, the committee has developed a list of priority HIV and TB implementation research questions:  (1) the committee assembled a list of priority implementation research questions submitted by multiple South African stakeholders; (2) experts scored the priority questions against uniform criteria; and (3) the committee convened a broad range of experts and stakeholders for a workshop to validate and refine the priority questions.  The resulting priority HIV and TB implementation research questions and their scores are listed in Appendix A.

Purpose

South Africa is home to the largest HIV epidemic in the world, with an estimated 7.0 million people living with HIV and an estimated 370,000 new infections each year.[1]  South Africa has the sixth largest TB burden and the highest number of people co-infected with TB and HIV in the world.[2]  The South Africa government provides anti-retroviral treatment (ART) to more than 3.4 million people living with HIV, and plans to continue aggressive scale up of HIV and TB prevention and treatment.  In order to reach South Africa goals as described in the National Strategic Plan on HIV, STIs and TB (NSP),[3][4] South Africa must optimize program impact, requiring constant innovation and implementation of efficient and effective programs.  

Current priority goals in South Africa include UNAIDS 90-90-90 targets for HIV

(90% of people living with HIV know their HIV status; 90% of those diagnosed with HIV receive ART, and 90% of those on ART are virally suppressed4), implementing a 90-90-90 strategy for TB,[5] identifying gaps and bottlenecks in HIV and TB prevention and treatment cascades, and developing high-impact prevention interventions for at-risk populations.  Expert reviews routinely identify opportunities to improve program implementation, and the South Africa government is quick to adopt evidence-based policies endorsing effective programs.  

Implementation research is a tool to investigate, test and build evidence for effective programs; to identify models for the scale-up of successful programs; to improve uptake of innovation and best practices; and to promote the translation of research findings into policy and practice.[6]  Strategic implementation research can provide valuable inputs to achieving South Africa programmatic goals by providing evidence to support optimized program implementation.  With these goals in mind, the South Africa HIV and TB Implementation Research Advisory Committee identified four initial objectives:

(1)            Develop a South Africa HIV/TB Implementation Research Agenda.   A research agenda appropriate to South Africa, including the identification of priority implementation research questions, will provide guidance for researchers, program implementers, and funders.

 

(2)            Support Capacity Building for the Conduct of HIV/TB Implementation Research.  There is a need for additional capacity building to increase the quality and quantity of implementation research studies in South Africa.  Investigators and program implementers have opportunities to design and rigorously analyze successful programs and publish results about implementation innovations that are effective, generalizable, and can be scaled-up.  

 

(3)            Facilitate the Dissemination of HIV/TB Implementation Research. There are opportunities to better disseminate and make use of implementation research findings, and to develop a common platform for a curated and accessible database of implementation research relevant to South Africa.  

 

(4)            Support for the Conduct of HIV/TB Implementation Research. The committee will identify opportunities to support priority implementation research studies.

 

Identification of Priority HIV and TB Implementation Questions

In January 2015 the NDoH convened the Implementation Research Advisory Committee to provide advice and assistance on HIV and TB implementation research in support of NDoH goals and the NSP.  Members of the Advisory Committee were invited based on their expertise in HIV and TB program implementation and research.  The Committee co-Chairs are Dr. Yogan Pillay, Deputy Director General, South Africa National Department of Health, and Steven Smith, Health Attaché U.S. Embassy, and the members of the Committee are listed on Appendix B.  The Committee led the development of the South Africa HIV and TB Implementation Research Agenda through the following three stage process.[7]  


Stage One: List of High Priority Implementation Research Questions

In Stage One, the Implementation Research Advisory Committee initially assembled a catalog of HIV and TB implementation research questions and topics from programmatic and literature reviews of implementation and operational research activities in South Africa that were funded and published between 2009 and 2014, and from the relevant focus areas outlined in the National Strategic Plan on HIV, STIs and TB (NSP).  This initial list included over 300 questions and formed the first draft of the South Africa HIV and TB Implementation Research Agenda. 

The Advisory Committee circulated the initial list of questions to the Advisory Committee members, stakeholders in the South Africa government, and HIV and TB experts in the South Africa HIV Think Tank and the South Africa TB Think Tank, and requested these experts to rank the questions as “High Priority”, “Priority”, or “Not a Priority”.   The responses were compiled to create a short list of consensus “High Priority” and “Priority” questions. 

Stage Two: Ranking of the Implementation Research Questions

In Stage Two, the Advisory Committee developed a Scorecard with 8 Criteria,  ranked on a 4 point scale.  Details are listed in Table 1.  

TABLE 1

Scoring Criteria for Priority Questions

 

Burden

What is the magnitude of the health problem that this implementation research question addresses?

4- High Burden Across South Africa 3 – Moderate burden or limited affected population

2- Neutral or limited data on burden and affected population

1- Low burden; limited affected

 

 

population in South Africa

Impact

What is the likelihood that results from this question will reduce disease burden or improve patient or community outcome?

4 – High Impact; likely to improve outcomes

3 – Somewhat likely to improve

outcomes

2 – Neutral

1 – Low impact; unlikely to improve outcomes

Cost and CostEffectiveness

What is the comparative cost

effectiveness of the intervention?

4 – High cost effectiveness

3 – Moderate cost effectiveness

2 – Neutral

1 – Low cost effectiveness

Sustainability

Does the addressed intervention have the potential for long term sustainability?

4 – High potential for sustainability

3 - Moderate potential for sustainability

2 – Low potential for sustainability

1 – Not sustainable

Scalability

Can the intervention be scaled-up?

4 – High potential

3 – Moderate potential

2 – Low potential

1 – No potential

Available

Research Findings

Is there adequate current published research on the topic?

4 – No published research

3 – Large gaps in published research 2 – Fair; good published data but substantial research needed

1 – Abundance of high quality research in South Africa

Research Resources

Are resources available to undertake the implementation research: expertise, infrastructure, cohorts, support systems?

4 – Excellent resources available

3 – Good resources available

2 – Fair; significant additional resources needed

1 – Resources not available

Alignment

How does the intervention align with the NSP and South Africa health policy goals?

4 – High alignment to South Africa priorities

3 – Moderate alignment to current

South Africa priorities

2 – Low alignment to South Africa priorities 1 - None


The Advisory Committee disseminated the scorecard to over 100 South Africa HIV and TB experts in two formats: Microsoft Excel and Google Forms.  The average score for each question was calculated as follows: (1) for each question, the sum of scores from each respondent was divided by the number of respondents; (2) the total score per question is the sum of the average score per criteria.  The maximum score possible per question was 32 points.  Scoring results are included in Appendix A.

Stage Three: Research Agenda Setting Validation Workshop

In Stage Three, the Advisory Committee convened an expert stakeholder workshop, with approximately 80 participants, to review and discuss the results of the scoring exercise and to identify priorities that may not have been appropriately reflected in the results from the first two stages.  This workshop allowed experts to provide additional input regarding priorities as identified in the scoring exercise.   Workshop participants were presented with the scoring results and an overview of the how the questions were ranked.  The participants then moved to smaller discussion groups to carefully review the priority questions.

These groups were divided into the major subject areas in the scorecard: HIV Prevention, HIV Care and Treatment, Tuberculosis, and Health Systems Strengthening, and Strategic Information, Laboratory, and Civil Society. 

The smaller group sessions held discussions to clarify, elaborate, support or dispute the rankings of the Implementation Research questions.  These smaller group sessions were led by a facilitator who was on their Advisory Committee as well as an expert in the subject area.  The facilitators and the note takers drafted a summary of the meeting with highlighted major points from each small group session.  These notes where then reported to the larger group for consideration in the afternoon session of the workshop. 

The workshop provided valuable input to improve the final list of priority questions contained in Appendix A.  For the most part, the workshop participants validated the priority questions as developed during the first two stages.  The workshop resulted in minor revisions to some questions, and the experts proposed adding a limited number of additional high priority questions that had not been identified in stages one and two.[8]  


Discussion

One important conclusion from the expert stakeholder workshop is the acknowledgment that all of the questions contained in Appendix A reflect priority implementation research topics related to South Africa HIV and TB programs and the NSP.  While the tabulated scores rank some questions higher than others, all questions received scores at the upper end of the possible scoring range.  The experts at the workshop endorsed the identification of priority questions contained in Appendix A.

Workshop participants agreed that there are many examples of best practice models in South Africa HIV and TB program implementation that can be researched more rigorously, evaluated, and taken to scale.   There are opportunities for further integration of HIV programs with TB programs, and for HIV and TB programs to learn implementation lessons from each other. 

Respondents and workshop participants generally noted that some questions in Appendix A are complex and could be addressed in multiple studies that might investigate a component of a larger topic.  Workshop participants further recommended that implementation research and dissemination of findings focus not only on evidence for successful implementation strategies, but also on findings and lessons learned from underperforming implementation efforts.  Programs that fail can provide lessons just as valuable as programs that succeed.  Workshop participants strongly recommended that while prioritization of general questions and topics is important, there should also be systematic attention to populations with special considerations, such as children, pregnant women, young women and young men, populations at high-risk, health care workers, and populations with co-infections.  In regard to each priority implementation research question, workshop participants suggested that the cost and costeffectiveness of interventions should be evaluated to assess feasibility and sustainability.  There was a strong recommendation that TB implementation questions and research be prioritized in recognition of the high burden of TB in South Africa.  Overall, a knowledge management platform that highlights findings from implementation research studies would make a significant contribution to support program goals.

Conclusion

The list of implementation research questions in Appendix A reflects priorities in the South Africa HIV and TB programs.  Continued efforts to investigate these questions and act on the evidence can improve the effectiveness and efficiency of

South Africa’s HIV and TB programs toward the goals of improved health for South Africans.  This effort to identify priority implementation research questions will complement related initiatives, such as the South Africa Investment Case[9] and the development of a comprehensive list of South Africa TB research priorities.  The South Africa government and HIV and TB Implementation Research Advisory Committee will continue to pursue related objectives of capacity building for implementation research and broader dissemination and use of implementation research findings.   

Appendix A

South Africa HIV and TB Implementation Research Priority Questions

PREVENTION

Score

Combination

Prevention and Multilevel Interventions

What is the best combination of behavioral, biological and structural prevention interventions to achieve the highest impact on HIV or TB transmission and incidence?

25.4

Key Populations

What is the best combination of services (including interventions and engagement with communities and the private sector) to identify and retain key populations in prevention and treatment cascades?

24.6

Key Populations

What interventions for key populations and vulnerable populations will increase use of HIV prevention tools and reduce incidence?

25.1

Key Populations

What linkages to services (e.g. psychosocial, legal and human rights) improve retention and patient outcomes for key populations?

22.3

Adolescent Girls and

Young Women 

What interventions individually or in combination targeting adolescent girls and young women decrease their risk of acquiring and transmitting HIV?

26.9

Adolescent Girls and

Young Women

What is the most effective combination of cash transfers, educational subsidies and combined social and economic empowerment programs for reducing risk of acquiring HIV?

21.9

Adolescent Girls and

Young Women

What are impacts of programs designed to delay sexual debut, reduce non-regular partners, or reduce age gap between partners?

22.3

Young Men

What behavioral and adherence interventions individually or in combination targeting young men decrease their risk of acquiring and transmitting HIV?

Added at Workshop

Voluntary Male

Medical Circumcision 

What high performing business and marketing models of voluntary male medical circumcision (VMMC) promotion and service delivery will maximize VMMC uptake among target populations and age groups?

25.7

Treatment as Prevention  

What universal test and treat strategies to result in optimal patient and community outcomes?

27.6

 

High Burden Areas and

Targeted Prevention

Interventions

What combination of interventions (e.g. expanded testing, care and treatment, rigorous adherence support, VMMC) will most rapidly and sustainably reduce prevalence and incidence in high burden communities?

25.8

HTC

What are the best programs and strategies to increase routine HIV testing for men and highrisk populations?

26.3

HTC

What are the best strategies to increase HIV testing for men, particularly asymptomatic and sexually active men at high risk of transmitting HIV?

26.1

Structural

Interventions

What community-level interventions, including at schools and workplaces, reduce HIV transmission?

25.1

Stigma and

Discrimination

What strategies can reduce the impact of stigma, gender bias, prejudice and homophobia on HIV prevention, care and treatment?

22.3

Stigma and

Discrimination

What interventions can address attitudes and behaviors of healthcare providers (that promote stigma, gender bias, prejudice, and homophobia)

that may result in barriers to HIV and TB services?

22.8

PrEP

What are the essential program elements needed to roll-out oral pre-exposure prophylaxis (PrEP), including identification of high-risk individuals, counseling, testing and adherence support, health worker training, drug distribution, and monitoring and evaluation?

24.2

PrEP

What health system programs and infrastructure changes are needed to effectively initiate and support PrEP for high-risk populations while continuing to scale up treatment for PLHIV?

24.2

PrEP

What counseling and support will optimize adherence to PrEP?

23.6

PrEP

What is needed to create demand for PrEP among target populations?

23.3

 

 

 

 

CARE AND TREATMENT

 

 

Initiation on Treatment

What is the optimal strategy for initiation of lifelong anti-retro-viral therapy (ART); what counseling is required and can ART be initiated immediately upon diagnosis?

27.3

Adherence and Retention

What are the best interventions to improve adherence to ART and minimize loss to followup?

28.2

Adherence and Retention

Compare the impact of adherence and retention interventions such as counseling, adherence clubs, treatment buddies, SMS reminders, innovative drug dispensing (e.g. clubs, home delivery or pharmacy dispensing), and other strategies on newly-initiated patients, stable patients, defaulting patients?

26.5

Adherence and Retention

What are the impacts of adherence clubs on patient outcomes?

26.2

Adherence and Retention

How do different models of organizing and operating adherence clubs impact sustainability and patient outcomes?

Added at Workshop

Adherence and Retention

What models of alternative drug dispensing strategies improve adherence and patient outcomes?

27.3

Linkage to Care

What strategies will best ensure patients testing positive for HIV are linked to and initiate care?

26.2

Integrated Services

What are the best practices for referral and integration of other essential services (such as reproductive health/family planning) with HIV and/or TB services?

27.2

TB SPECIFIC ISSUES

 

Case Detection

What models of contact management: (i) provide the highest yield, (ii) are most costeffective, (iii) are most effective in reaching at risk groups, and (iv) are effective in different contexts (workplace vs. community for example)?

26.2

Case Detection

What innovative models of TB screening will improve TB case finding, including in high risk groups?

25.7

Case Detection

What are optimal TB testing algorithms, including for high risk groups?

26.3

 

Adherence/Retention

What strategies and support structures will improve adherence to TB treatment regimens (e.g. social protection measures, subsidized transport, standardized adherence counseling, mhealth, nutritional support, and provision of mental health support/services), including for atrisk populations?

25.7

Interruption of Transmission

What strategies can reduce transmission in households, communities, schools, and public transportation?

24.7

MDR and XDR TB

What strategies scale up diagnosis and treatment initiation for MDR and XDR TB patients?

26

MDR and XDR TB

What clinical management and adherence support strategies will contribute toward increasing the MDR TB cure rate?

26.4

MDR and XDR TB

What are optimal care and treatment models for de-institutionalization and de-centralization of drug-resistant TB services?

26.8

MDR and XDR TB

What are optimal clinical and contact management models of follow-up for discharged MDR and XDR patients and their contacts?

25

MDR and XDR TB

Which high-risk populations should be screened for MDR and XDR TB, and when should they be screened?

24

IPT

What models of care increase the proportion of at-risk individuals receiving isoniazid preventive therapy (IPT)?

Added at Workshop

Loss to Follow up

What strategies reduce initial loss to follow-up for TB and drug-resistant TB patients?

Added at Workshop

HEALTH SYSTEMS STRENGTHENING

 

 

Optimal Staffing Patterns

What different models of service organization and staffing patterns (including numbers of staff and mix of skills) result in improved patient outcomes?

26.1

Health Program

Management and Leadership

What health facility and program management interventions impact HIV and TB patient outcomes?

27.7

Health Program

Management and

Leadership

What models of health worker supervision, capacity building, and mentoring (e.g. routine supervision, audits with feedback, continuous quality improvement, etc.) are effective to

26.6

 

 

impact health worker performance, retention, and patient outcomes?

 

Health Program

Management and Leadership

What strategies will reduce patient waiting times?

25.6

Differentiated Models of Care

What models of differentiated care can be applied to different types/needs of patients without decreasing the quality of care?

Added at Workshop

Public Private Partnerships

How to expand access to care and treatment for vulnerable and marginalized populations by involving private and alternative care providers?

23.2

Targeted Services in Informal Settlements

What HIV and TB prevention and treatment interventions can reduce incidence and improve patient outcomes among people living in informal settlements?

Added at Workshop

Customer Friendly

Clinic Settings

What modifications to clinic hours (evening hours, weekend hours) will improve access by men, key populations, and high risk populations?

26.6

STRATEGIC

INFORMATION

 

 

Data Systems

How can site-level data systems be optimized for both patient management and for follow-up and reporting?

Added at Workshop

Unique Patient

Identifier

How to standardize use of unique patient identifiers for all patient records, tests, and health care engagement?

27.6

LABORATORY

 

 

Clinic-Laboratory Interface

What is the optimal implementation of diagnostic and laboratory technologies integrated with clinical practice?

Added at Workshop

Expansion of Viral Load Monitoring

What are the optimal elements of a program to scale-up viral load monitoring in order to improve individual patient outcomes and monitoring of community burden of disease?

26.6

Expansion of Viral Load Monitoring

What is the optimal balance between viral load and CD4 testing?

22.5

Optimal

Implementation of GeneXpert

What is the most effective TB testing algorithm utilizing GeneXpert and other rapid molecular diagnostics?

24.4

 

 

 

CIVIL SOCIETY AND

COMMUNITY

ORGANIZATIONS

 

 

Civil Society and

Community

Organizations

What activities by community-based civil society organizations improve testing yield, linkage to care, adherence and retention for HIV, TB and other NCDs?

23.8

 

Appendix B

Members of the South Africa HIV and TB Implementation Research Advisory Committee

 

NAME

Affiliation

David Allen

Bill & Melinda Gates Foundation

Peter Barron 

National Department of Health

Nulda Beyers

Desmond Tutu TB Centre Stellenbosch

Zameer Brey

Bill & Melinda Gates Foundation

Jacqueline Burgess

U.S. Department of Health and Human Services

Gavin Churchyard

Aurum Institute

Ernest Darkoh

BroadReach Healthcare

Mary Glenshaw

Centers for Disease Control and Prevention

Ameena Goga

South Africa Medical Research Council

Glaudina Loots

Department of Science and Technology

Marian Loveday

South Africa Medical Research Council

Cathy Matthews

South Africa Medical Research Council

Erasmus Morah

UNAIDS

Saiqa Mullick

Wits Reproductive Health and HIV Institute

Pren Naidoo

Desmond Tutu TB Centre Stellenbosch

Patrick Nadol

Centers for Disease Control and Prevention

Yogan Pillay

National Department of Health

Babatunde Sanni

WHO

Claire Serrao

BroadReach Healthcare

Olive Shisana

Human Sciences Research Council

Steven Smith

U.S. Department of Health and Human Services

Cristina Stefan

South Africa Medical Research Council

Grant Theron

Stellenbosch Univ.

Taryn Young

Stellenbosch Univ.

Thulile Zondi

National Department of Health

Participants in Implementation Research Priority Setting Workshop

 

Last Name

First Name

Company

Afriye-Matuba

Ranahnah

USAID

Allen

David

Bill and Melinda Gates Foundation

Barber

Sarah

WHO

Barron

Peter

National Department of Health

Black

Andrew

Wits Reproductive Health and HIV Institute

Brey

Zameer

Bill & Melinda Gates Foundation

Burgess

Jacqueline

US Department of Health and Human

Services

Buthelezi

Sandile

ICAP at Columbia University

 

Chihota

Violet

Aurum Institute

Chikanda

Cephas

Pulse Health

Chimatira

Raymond

Centers for Disease Control and Prevention

Chipeta

Zawadi

Centers for Disease Control and Prevention

Chirowodza

Admire

South to South Programme for

Comprehensive Family HIV Care and Treatment, Stelle

Conradie

Francesca

International Union for TB and LUNG disease

Evans

Denise

Health Economics and Epidemiology

Research Office, Department of Internal Medicine

Fairlie

Lee

Wits Reproductive Health and HIV Institute

Feucht

Ute

University of Pretoria

Greene

Greg

Centers for Disease Control and Prevention

Hall

Carolyn

Centers for Disease Control and Prevention

Houghton

Juliet

CHIVA South Africa

Igumbor

Ehimario

Centers for Disease Control and Prevention

Isherwood

Lynsey

National Health Laboratory Service

Jankelowitz

Lauren

SA HIV Clinicians Society

Kindra

Gurpreet

Centers for Disease Control and Prevention

Kiwango

Eva

UNAIDS

Loots

Glaudina

Dept of Science and Technology

Loveday

Marian

South African Medical Research Council

Magula

Nombulelo

University of KwaZulu-Natal

Mansoor

Leila

Centre for the AIDS Programme of Research in South Africa (CAPRISA)

Martinson

N

Perinatal HIV Research Unit (PHRU)

Medina-Marino

Andrew

Foundation for Professional Development

Mokoka

Kgaogelo

FUNDISA

Moorhouse

Michelle

Wits Reproductive Health and HIV Institute

Mophosho

Zanele

U.S. Department of Defense

Mosane

Andrew

Treatment Action Campaign

Moyana

Calvin

US Embassy

Mphaphuli

Edzani

Pulse Health

Mullick

Saiqa

Wits Reproductive Health and HIV Institute

Muthivhi

Tshilidzi

National Department of Health

Nadol

Patrick

Centers for Disease Control and Prevention

Naidoo

Kogieleum

CAPRISA

Page-Shipp

Liesl

The Aurum Institute

Plessis

Deborah

National Institute for Communicable Diseases

Rangana 

Noma

Treatment Action Campaign

Rousseau

Petro

SANAC

Semugoma

Nsubuga

Anova Health Institute

Serrao

Claire

BroadReach

Shamu

Simukai

Foundation for Professional Development

Sifunda

Sibusiso

Human Sciences Research Council

Slabbert

Mariette

South Africa National AIDS Council

Smith

Steve

U.S. Dept. of Health and Human Services

Titi

Nondwe

South African Medical Research Council

Tucker

Tim

SEAD Consulting

Uys

Margot

Foundation for Professional Development

Vahedi

Mahnaz

WHO/TDR

Wallis

Carole

BARC SA

Naidoo

Pren

Desmond Tutu TB Centre, Stellenbosch University

Adams

Siraas

Metropolitan Health

Chetty

Kamy

Independent

Dlamini

Cindy

USAID

Grobbelaar

Nelis

Anova Health Institute

Herman- Roloff

Amy

Centers for Disease Control and Prevention

Ibisomi

Latifat

University of the Witwatersrand

Igumbor

Jude

Wits University

Makombe

Robert

University Research Co

Mhlongo-

Sigwebela

Ntombi

University Research Co

Mokhele

Idah

Right to Care

Mvusi

Lindiwe

National Department of Health

Pelzman

Kerry

USAID

Sakatsie

Margaret

WHO

Venter

Francois

Wits Reproductive Health and HIV Institute

Vilakazi

Kgomostso

National Department of Health

Worku

Selamawit

Centers for Disease Control and Prevention

Beyers 

Nulda

Desmond Tutu TB Centre, Stellenbosch University

Firnhaber

Cindy

Right to Care

Grimwood

Ashraf

Kheth'Impilo

Knight

Nancy

Centers for Disease Control and Prevention

Lopez Gonzalez

Laura

Health-e News

Magwaza

Sphindile

Centers for Disease Control and Prevention

Mathe

Moeketsi

SA HIV Clinicians Society

Motsieloa

Lifutso

South Africa National AIDS Council

Mudau

Maanda

Foundation for Professional Development

Sanne

Ian

Clinical HIV Research Unit

Serote  

Portia

Treatment Action Campaign

 

 

 



[1] UNAIDS South Africa HIV and AIDS Estimates. http://www.unaids.org/en/regionscountries/countries/southafrica; http://www.unaids.org/en/dataanalysis/datatools/spectrumepp  

[3] National Strategic Plan for HIV and AIDS, TB and STIs 2012-2016.  http://sanac.org.za/2013/07/01/the-national-strategic-plannsp-2012-2016-in-a-nutshell/

[4] –90–90 - An ambitious treatment target to help end the AIDS epidemic. 

http://www.unaids.org/en/resources/documents/2014/90-90-90

[5] Communiqué of the IV Meeting of BRICS Health Ministers. http://brics.itamaraty.gov.br/category-english/21-documents/242ivhealth  

[6] For descriptions of implementation research, see Framework for Operations and Implementation Research in Health and

Disease Control Programs http://www.who.int/hiv/pub/operational/or_framework.pdf; Fogarty International Center Implementation Science Information and Resources 

http://www.fic.nih.gov/researchtopics/pages/implementationscience.aspx; National Library of Medicine Dissemination and Implementation Science http://www.nlm.nih.gov/hsrinfo/implementation_science.html; PEPFAR http://www.state.gov/r/pa/prs/ps/2012/08/195936.htm, http://www.pepfar.gov/documents/organization/157942.pdf; World Bank, So what exactly is the “science of delivery”? http://blogs.worldbank.org/developmenttalk/so-what-exactly-is-the-scienceof-delivery;  An Introduction to Effectiveness, Dissemination and Implementation Research https://accelerate.ucsf.edu/files/CE/edi_introguide.pdf.

[7] The South Africa HIV and TB Implementation Research Advisory Committee would like to thank the experts who have participated in submitting questions, scoring questions, the stakeholder workshop, and providing other valuable inputs into this effort.  PEPFAR provided support for the expert stakeholder workshop.  PEPFAR support for the workshop does not impart a funding commitment by PEPFAR for prioritized research.

[8] Priority questions proposed at the workshop and not scored in advance do not have a corresponding score in Appendix A.

[9] Optimising South Africa’s HIV Response: Results of the HIV and TB Investment Case 

http://www.croiconference.org/sessions/optimising-south-africa%C2%92s-hiv-response-results-hiv-and-tb-investment-case