Development and the HIV Epidemic

Development and the HIV Epidemic: A forward-looking evaluation of the approach of the UNDP HIV and Development Programme

CASE STUDY 1: ENHANCING NATIONAL CAPACITY THROUGH HIV ACTION RESEARCH

Although the economic determinants of vulnerability to HIV at both the individual and societal levels are increasingly being recognised and studied, most attention so far in the social sciences has been focused on the impact of HIV, primarily in the industrialised world. The socio-economic impact of HIV on developing societies has been less well studied and understood. The HIV epidemic threatens social and economic development because, in contrast to other life-threatening infections which attack primarily the young, the aged and the infirm, HIV affects people responsible for the support and care of children, the elderly and extended family members, and it affects adults in their economically and socially most active years. HIV-related illness and death have the potential to deplete the labour force, undermine public sector capacity to govern, and lead to social and civil unrest.

At the macro-economic level, selective erosion of slices of the economy occurs as people with critical capacities such as bank managers, teachers, engineers or nurses become ill. Reduction in productivity and workforce depletions in key formal sector industries such as mining, tourism or agriculture can affect gross domestic product, export earnings and public revenue generation. Countries may then experience investment reductions in education and training which, combined with the loss of skilled labour, can lead to decreased output, skills, experiences, and aspirations with resultant further decreased investment. These macro-economic effects compound those of structural adjustment programmes in many countries (Lurie et al., 1995).

At the household level, reductions in earning capacity, increases in health related expenditures, the opportunity cost of time spent caring for the sick, and extra burdens placed on women threaten to substantially reduce household resources. Coping mechanisms may include changes in household composition and the modification of roles and activities within the family. Children may be withdrawn from school to assist with household duties or to enter the job market (Ainsworth and Koda, 1993, 50), cash crops may be abandoned in favour of subsistence crops that require less attention (Barnett and Blaikie, 1992, 89), traditional knowledge systems may be irrevocably lost and customary mechanisms for the care and support of orphans may be overwhelmed. Conventionally determined direct and indirect costs will clearly underestimate the real psychosocial, interpersonal, emotional, and economic consequences and costs of the HIV epidemic at the individual, household, community and national levels.

This case study describes and discusses the generalisability of a programme, currently underway in four African countries, which is aimed at enhancing the capacity of nation states to understand the threat that the HIV epidemic poses to their economic, social and political development and to respond effectively.

Extractive Research Approaches in Developing Countries

Research can provide information critical to formulating effective programming and policy initiatives that can increase the capacity of countries to meet the challenge of the HIV epidemic. To date, however, a good proportion of HIV-related research has not achieved these ends, which is not surprising given the long and notorious history of North-South research relationships. The approach used is the antithesis of local capacity building. Researchers from industrialised countries define a line of inquiry and then seek out local collaborators, both to ensure that the relevant approvals can be obtained and to provide on-the-ground assistance with the challenging logistics of data collection.

Following the operational phase, some data entry, verification and cleaning may be conducted locally but, more often than not, the information leaves the country with the industrialised country researchers never to be seen again. If and when the results are published, it is in the form of a scientific article, in a highly-rated journal priced beyond the resources of institutions such as the local university, let alone local collaborators. Local members of the research team are lucky to be included as co-authors, the standard gesture often being a simple acknowledgement of their help. Increasingly this approach is being rejected but it remains common.

Local Research Processes and the Link to Programming and Policy

The charges levelled at foreign investigators can also apply to the way local researchers behave. Indigenous scientists trained in industrialised countries, or in similarly-styled regional learning institutions, now form the elite cadre in developing countries. Following traditional approaches, topics and methodology may often reflect the individual curiosity of the researcher. In other, perhaps more common cases, research priorities and methodologies may be determined by donors with little interest in what is needed for more effective responses to the epidemic. Indeed, even in those unfortunately rare circumstances where local priorities are taken into account there is very little evidence that research is effectively used in the formulation of policy and programmes. For example, among 73 studies profiled in a directory of social and behavioural research on HIV and AIDS compiled in Zimbabwe in 1994, fully 71 per cent gave no indication that the results were being used in the formulation of programmes and policies (Misihairabwi et al., 1994, 23). Many studies conducted in developing countries are never published in local journals or even in the form of a final report and only exceptionally are results disseminated to the communities which were researched or to service providers and decision makers. It is unsurprising that in the conditions which prevail in many countries, where the norm has research being largely externally funded and determined, that This case study describes and discusses the generalisability of a programme, currently underway in four African countries, which is aimed at enhancing the capacity of nation states to understand the threat that the HIV epidemic poses to their economic, social and political development and to respond effectively.

Extractive Research Approaches in Developing Countries

Local Research Processes and the Link to Programming and Policy

The charges levelled at foreign investigators can also apply to the way local researchers behave. Indigenous scientists trained in industrialised countries, or in similarly-styled regional learning institutions, now form the elite cadre in developing countries. Following traditional approaches, topics and methodology may often reflect the individual curiosity of the researcher. In other, perhaps more common cases, research priorities and methodologies may be determined by donors with little interest in what is needed for more effective responses to the epidemic. Indeed, even in those unfortunately rare circumstances where local priorities are taken into account there is very little evidence that research is effectively used in the formulation of policy and programmes. For example, among 73 studies profiled in a directory of social and behavioural research on HIV and AIDS compiled in Zimbabwe in 1994, fully 71 per cent gave no indication that the results were being used in the formulation of programmes and policies (Misihairabwi et al., 1994, 23). Many studies conducted in developing countries are never published in local journals or even in the form of a final report and only exceptionally are results disseminated to the communities which were researched or to service providers and decision makers. It is unsurprising that in the conditions which prevail in many countries, where the norm has research being largely externally funded and determined, that local policy and programme needs are low on the agenda and that results are rarely translated into effective programmes or policy changes.

In addition to an evident opportunity cost to the status quo, ethical concerns are raised by issues of ownership of the data. At issue is whether research, particularly research addressing the cultural context and meaning of sexuality, will provide baseline data for programme development and evaluation or whether it will simply produce voyeuristic impressions and serve to increase the stigmatisation of the community and its members.

Methodological concerns have been raised about the extractive research model and the tendency for quantitative questionnaire surveys to reflect the pervasive and tenacious assumptions of biomedicine about culture and behaviour (Schoepf, 1991). Ultimately, choice of methodologies, whether quantitative or qualitative, will depend on the nature of the research question being posed and should be based on whether the research findings generated by the chosen methodology will be informative and valid, and have the potential to significantly advance understanding and stimulate social change. Mobilising society will be essential for an effective response to the HIV epidemic and research which is capacity building is thus an important instrument in the process of strengthening social capital.

Capacity Building Through Research

Responses to the complexity of the HIV epidemic must be timely and must act to slow down the spread of the virus and provide support and care to those affected within communities. Research will play a critical role if results contribute to the development of effective HIV programming and policy and if the research process itself is empowering for research participants and their communities.

If research is to support the development of effective HIV programming, it should fit within a locally articulated plan of research needs and priorities, be timely and be affordable. Moreover, given the urgency of the problems to be addressed through policies and programmes there has to be a reasonable likelihood that research will in fact yield results which can be embodied in effective responses to the epidemic. Small-scale, multifaceted, multidisciplinary projects may be more cost-effective than expensive large-scale ones and may furnish results more rapidly. The best way to ensure that such findings are used by those responsible for HIV programme development is to involve decision makers, programme developers, community activists and representatives from National AIDS Programmes (NAPs) from the outset of research design and continuously throughout the research process. The latter are critical partners since NAP staff know what research is being undertaken, planned or has been completed, and are the point of contact at the national level for bilateral and multilateral donors.

Individuals affected by HIV are central to a complex understanding of the nature of the epidemic and to the utilisation of eventual findings, and should be fully integrated into research processes from the start. Effective action-oriented research will involve people living with HIV and affected by HIV in the setting of research priorities, in the choice of researchquestions, in evaluations of the relevance of proposed investigations, in the research design phase, and in study conduct, analysis and dissemination of results.

Development is now understood as sustainable if it empowers people to take charge of their own well-being, if it builds on the strengths of local knowledge and values, and if an enabling environment is created at national and international levels which fosters and supports local initiatives (Banuri et al., 1994). In development practice the role of experts or donor agencies is increasingly understood as involving facilitation of processes for creating norms, values and practices that enable people and their organisations to gain greater control over their lives. In this paradigm, development is constituted by local sources of experimentation, of innovation, and of diversity fostered within a supportive macro-level institutional, policy and legislative environment.

At the heart of this new form of development practice is the recognition that sources of learning must be local in part so as to enable people to engage with "the global" on their own and better terms (Appadurai, 1990). For ideas and programmes to take root within communities, they must spring from within, they must be based on the realities of lived experiences, and they must be disseminated and defended from there. At the centre of this new development practice are concepts of consensus building, promotion of partnerships between the organisations of civil society and public institutions, human and social capacity building, ethical practice, and facilitation.

Participatory research initiatives can support and strengthen local processes of social learning and national capacities which transform social learning into policy and programmes. Community level responses empower participants, particularly infected individuals and communities, to identify their own needs and to ensure that chosen strategies can be implemented and maintained. It follows that researchers who are close to or part of affected communities are better placed than external teams to identify research themes and methodologies which are relevant and to ensure that their findings are of ultimate benefit to affected people, activists and organisations responding to the epidemic.

Programme Development: The UNDP Research Capacity Building Initiative

Based on a development approach of social learning and capacity building, the UNDP partnership programme was created to assist selected communities, academic institutions and countries to create capacity to undertake action-oriented research into the extent and nature of the psychological, social and economic causes and consequences of the epidemic; to analyse the data and findings in ways that would be directly relevant to programme and policy development; and to assist community organisations, programme managers, activists and leaders to assess and redesign their policies and interventions in light of the research findings. This work is being undertaken in Senegal, Central African Republic, Zambia and Kenya (Hankins, 1994, 1995a, 1996) as well as Myanmar (Porter, 1995) and Nicaragua. This case study focuses on progress to date in the African component, and includes discussion of the difficulties encountered and lessons learnt to date.

Programme Implementation Phase I of this pilot programme began in April 1993 with the formation of Country Groups in four African countries. Research topics were chosen, infrastructural support was provided, an inter-country training seminar was held in Senegal, research protocols were elaborated, technical support missions conducted, and presentations made to donors. Phase II, which focuses on the translation of data into programming and policy, was launched in August 1995 with skills building workshops for Country Group representatives, NAP managers, technical support partners, donors and African academics.

Phase I: From Research Needs to Raw Data

The four African countries evaluated for eventual participation in the Partnership Programme were chosen to represent both East and West Africa, francophone and anglophone cultures, and to provide a spectrum of HIV prevalence ranging from Senegal with the lowest rates at one per cent (Mbaye et al., 1993), Central African Republic at approximately ten per cent (Global Programme on AIDS, 1991), through to Zambia and Kenya in the ten to twenty per cent range for overall country HIV prevalence among adults (Hira et al., 1989; Kitabu et al., 1992; Mungai et al., 1992). Between April and June 1993, exploratory missions were conducted in each country, with NAP personnel, other pertinent government ministries, and key donors being consulted as to the relevance of such a programme. Their willingness to participate actively in the programme was assessed since neither the HIV and Development Programme in New York nor the HIV and Development Regional Project in Dakar would be directly funding any of the research projects developed within the initiative. Potential candidates for the multidisciplinary Country Groups were interviewed and asked to provide a written statement of why they wanted to participate. They were informed that the exchange being contemplated was one in which their time contribution would be balanced by new knowledge, skills and contacts. The Country Groups included a mix of senior and junior researchers, concerned community members, affected persons, institutional leaders and other users of research findings.

Country Group meetings were held to define priority areas for research and to draft initial proposals equivalent to letters of intention. A seminar attended by all Country Groups during September 1993 discussed principles, methodologies and ethical issues involved in psychosocial and economic research. It aimed to strengthen participants' awareness of the nature, determinants and consequences of the HIV epidemic and, in particular, to create a common conceptual framework for viewing HIV and development. The seminar paved the way for a collaborative effort among researchers from within and outside the region, and quantified the financial resources required to undertake designed studies and follow-up activities. Infrastructural support of $US5,000 was then provided to each team for research training, language courses and pre-pilot work.

In 1994, a technical assistance consortium of experienced researchers from within Africa, from other regions of the developing world and from elsewhere was established with the resultant diverse blend of researchers having both scientific expertise and experience working in partnerships of equals with others. Following this, technical support missions to Senegal, Central African Republic and Zambia focused on quantitative and qualitative research methodologies, economic theory and analysis, ethical issues, and presentation strategies. These assisted Country Groups to finalise their research objectives, determine appropriate research methodologies and study sample sizes, refine analysis plans, justify budgets, and prepare workplans. Fourteen proposals were prepared initially by the four teams. By early 1996, data collection had been completed in two projects and was underway in three others. Strong donor interest had been expressed in a further four projects and funding negotiations were proceeding. Research projects underway include evaluations of the management of HIV infection within the family, the socio-economic determinants of the HIV epidemic, the role of church groups in HIV/AIDS prevention and care, the socio-cultural factors associated with HIV prevalence, and the impact of AIDS in the business sector.

Phase I: Lessons Learnt

The lessons learnt during this pilot project are as relevant to Asia, and other parts of the world, where the socio-economic impact of the HIV epidemic is also being felt (Panyarachun, 1995), as they are to Africa. How well each step of the programme was implemented had predictable consequences for subsequent steps. Countries and their National AIDS Programmes had varying levels of commitment to the programme, some research teams were not well-balanced with respect to experience and motivation, stakeholders did not participate fully in the defining of research priorities, infrastrucutural funds were not disbursed in a timely manner, some members of the technical assistance consortium lacked process facilitation skills, and several local donors were reticent to fund projects. Some suggestions for avoiding these and other problems are presented in the discussion which follows.

Countries chosen should be those most likely to implement the programme successfully, to attract funding for research activities, and where the NAP and local UNDP offices have expressed interest. Although the partnership process is UNDP's responsibility, particular attention should be paid to ensuring that key individuals in the NAP comprehend what is being attempted and are prepared to integrate research projects into the NAP.

Country Groups have a tripartite composition of researchers (intergenerational and interdisciplinary), data users (government, civil society, professional associations), and members of concerned communities and affected individuals. The mix of disciplines and perspectives within Country Groups can be maximised by ensuring that those interviewing and selecting members have a clear understanding of the implications of the capacity building objectives for the choice of participants. Medical doctors, epidemiologists, survey sociologists, economists and other quantitative researchers should be fully complemented by anthropologists, ethnographers and others with qualitative research and strong conceptual backgrounds. In each Country Group, it is essential to have at least two representatives from infected and affected communities and their support organisations so as to reduce the possibility that illness will interrupt community representation or that token representation will lead to reduced participation due to intimidation based on hierarchy and position.

To minimise the tendency for Country Groups to define areas of inquiry on their own without outside consultation, a workshop should be held within each country to create a common understanding of the HIV epidemic and of the objectives of the programme. This should occur after the creation of the Country Groups and prior to any definition of relevant research tasks. Such a workshop could initiate a process of consultation with key stakeholders, such as representatives of both governmental and non-governmental organisations, community-based groups, donors, individuals and communities affected by HIV and others. Incorporating brainstorming sessions concerning the range of possible research topics, the workshop would help create top-level commitment to the process, and engender in the researchers a moral engagement for ongoing consultation and follow-through with key stakeholders and in particular with users of the research including the NAP and the Ministry of Planning. Although responsiveness to the needs of civil society is critical if social capital and social change are to be created it is important to be inclusive because the focus of each country's response to the epidemic is its strategy for HIV in which the National AIDS Programme plays a pivotal role.

Team building activities should incorporate a team-driven self-assessment of individual capacities and complementarities as well as of overall team composition, allowing for the possibility of adjustments. Team cohesiveness depends on several factors including leadership, team composition, personality factors, previous relationships, individual commitment and strategic replacement of members who leave the team because of lack of interest, conflicts of interest or new job responsibilities. Criteria for selection and procedures for choosing replacement members should be defined by participants at the first country workshop. Since both the personality and vision of the leader were found to be critical to team functioning and progress, selection criteria could be suggested at the time of Country Group formation. This may reduce the possibility that pre-existing local power relationships play the predominant role in the designation of team leaders. The underpinning philosophy is one of minimisation of direction to the teams with emphasis on a process of technical cooperation which is based on principles of process consultation. This means providing guidance, challenging old ways of looking at things by raising new questions, offering expert information, analysis, and judgement while facilitating collective ownership in the design and implementation of new capacity building approaches to research, policy, and programme development (Joy & Bennett, 1994).

To avoid misunderstandings, it is important that the conditions of research participation be made clear from the outset. Team members are asked to make a personal commitment to exchange their time on a quid pro quo basis for capacity building without the possibility of either assured project funding or personal monetary recompense. Once a research project has been financed, direct payment of Country Group members or reimbursement to the employers of salaried individuals to cover time devoted to actual research work, such as the conducting of

key informant interviews or participation as assistant moderators in focus groups, is justifiable.

The timing and objectives of a regional inter-country seminar should be carefully defined. The 1993 seminar succeeded in encouraging South-South collaboration and inter-country cooperation within the region and across language barriers but failed to meet some objectives, in part because often the definition of research needs had been carried out in isolation and, in part, because protocol development was well underway. Ideally, the initial inter-country seminar should follow country seminars and local processes of consultation for research question definition. Representatives of the Country Groups and of technical consortium members who have been involved in facilitating country workshops can usefully participate in the planning and programming of the inter-country one.

The establishment and maintenance of an appropriately skilled technical consortium were crucial to the success of the partnership initiative. In addition to specific technical back-up, more general support was provided for enhancing comprehension of the concepts of HIV and development and of the principles of research into the psychosocial and economic dimensions of HIV. Capacity to use research in programme design was strengthened by discussions identifying the linkages between research and policy and programme development. These in turn laid the groundwork for collaborative efforts among researchers, decision makers, affected communities, activists, and organisations responding to the epidemic. Down to earth advice on identifying and quantifying the financial resources required to undertake designed studies led naturally to the development of strategies for follow through at country level with donors and UNDP field offices.

Finding members for the technical assistance consortium with a broad understanding of both the HIV field and participatory development strategies, with appropriate scientific skills, and with personalities suited to a mutual learning process was challenging. Constituting a technical support team composed of individuals who would complement each other in specifically addressing the needs of each country required consultation with numerous sources, evaluation of consultant capacity, performance appraisal of participants, and an element of luck concerning availability for specific missions. Facility in the language of the Country Group was obviously essential. The calibre of each technical support team had direct effects on the quality of the interactions between mission members and their country counterparts as well as on the overall benefits derived from technical visits, benefits which varied by country. Drawing on the specific expertise of members of the technical consortium, technical support missions provided assistance for three projects in Senegal, two in the Central African Republic, five in Zambia, and four in Kenya. Lack of time prevented assistance being given to most projects in the development of research instruments, codification manuals or interview guides as had been originally intended. Practically, Country Groups could choose two projects for external technical consultation which would provide the template for refinement by the research teams of any additional protocols.

The provision of supportive and facilitative technical assistance can tread a fine line between critique and criticism. Personality factors play a major role as does the experience of country counterparts and mission members in honest but affirming project review procedures. When most technical mission members come from industrialised countries and not all have training in process consultation principles and techniques, positive interactions may be hindered and traditional North-South one-way information transfer reinforced. Members of the technical assistance consortium must fully understand the implications of the programme's capacity building objectives for modes of interaction. The provision of specific training sessions designed to enhance the preparedness of consultants to participate effectively in the programme, combined with on-the-job training and performance appraisal, should be built into the programme. An emphasis on skill development with respect to process consultation (Joy and Bennett, 1994) and strategic questioning (Peavey, 1994) would help avoid inappropriate consultant behaviour during technical support missions.

To strengthen intraregional ties, two of the three technical support missions included at least one member from a country within the region. As the programme matures two or more regional resource people should be used. As part of national capacity building, Country Groups should first assess whether technical assistance is available within the group and then if necessary seek assistance from other resources within the country. External technical support should be called upon only as a last resort although the provision of local assistance will also need to be facilitated to ensure that the programme's capacity building objectives are understood and respected. Technical support missions can reinforce the importance of qualitative research methodologies C such as focus groups, key informant interviews, and rapid appraisal techniques C in a synergistic blend with quantitative methodologies in the overall response to the epidemic. Technical support needs in the realm of qualitative research should be identified early so that technical mission composition reflects these needs.

As with all work undertaken by UNDP's HIV and Development Programme, the research capacity initiative is intended to be taken up and supported by UNDP country offices and other partners. Funding of specific protocols by UNDP was not an expected outcome of the programme since it would not have built local capacity to secure research funds. However, the local donor community often identified the research protocols as "UNDP projects" rather than acknowledging UNDP's role in a process of capacity building that led, inter alia, to the production of research protocols. Once such hurdles are overcome, donors who potentially may fund the actual research work should be involved early in the process to increase the likelihood that funds will be made available in a timely way. Expeditious financing of an initial project or of a pilot research activity, such as key informant interviews or questionnaire testing, significantly strengthens team cohesiveness and allows people to learn by doing.

The process of obtaining research funding commitments was facilitated by two factors. First, Country Group members who developed convincing formal presentations engendering donor confidence in the research teams' capacity found these to be effective in generating commitments from funders. Thus, an emphasis on refining funding presentation skills should form part of the technical support mission terms of reference. Second, Country Groups that created strong ties to the National AIDS Programme (NAP) and ensured that their work was perceived to be C and actually was C integral to the development of programmes and policies were more likely to obtain funding. The interrelationships between NAPs and the Country Groups, and the priorities and interests of both parties should be the focus of formal and informal ongoing discussions throughout the programme.

Phase II: From Data to Policy and Programming

The first Phase II workshops, held in August 1995, focused on skills for the transformation of collected raw data into findings useful for policy and programme development. Participants included members of the Country Groups, NAP managers, technical support partners, invited African academics, and multilateral and bilateral donors. Workshop formats were derived from notions of partnership and shared responsibility for programming. Specific sessions considered a spectrum of issues, including processes to ensure continuing ownership of research by the communities involved, appropriate dissemination of research findings, research as empowerment, and strengthening capacity to use research in programming and policy. Skills building focused on facilitation, process consultation, strategic questioning, and development of performance appraisal criteria. Communication was enhanced and links forged between NAP managers and respective partnership programme Country Groups. Short and medium-term plans for in-country activities were developed through collective problem solving. The workshops highlighted the implications that capacity building approaches to research C aimed at stimulating social learning, building local research capacity and meeting the needs of programme managers, activists, and decision makers C have for technical cooperation, bilateral donor procedures, current practices of peer review and academic publication, and development practice.

Social Learning and Implications for the Provision of Technical Assistance

The UNDP partnership programme is based on the recognition that participatory research initiatives have the potential to support and create local processes of social learning which, when complemented by strengthened national capacities for thinking, reflection and analysis, lead to the transformation of social learning into policies and programmes (Banuri et al., 1994, 27). In addition to building local capacities for social learning, as this case study has shown, this UNDP initiative aims to create new approaches to the provision of supportive technical assistance. National teams and local communities take direct responsibility for establishment of research priorities and methodologies and for the development of ethical principles to govern the research. They set the conditions under which technical assistance is provided and determine the areas where their own research competence needs supplementation or strengthening. Technical assistance is then provided in a way that is both more complicated and yet more relevant and sustainable, with outside expertise fitted into local processes of social learning. The programme facilitates the drawing down of assistance from the best available external academic and development sources, national, regional and international. Currently this includes individuals from academic as well as national institutions in countries as diverse as Canada, France, the US, the UK, South Africa, Zimbabwe, Senegal, Ivory Coast, Spain and Australia. The processes of learning and skills building occur within, facilitated from without.

The HIV epidemic provides the impetus for rethinking the role of outsiders, be they governments or others, in the creation of social change and in development practice. It poses a set of dilemmas for classical approaches to research and, since the issues it raises are the basic ones of development, research findings and processes will necessarily contribute to both development theory and practice. For research to play a critical role in the response to the HIV epidemic, communities, non-governmental organisations and community-based groups, as well as policy makers and programme planners, will have to come to view research as a useful tool for programming and forge mutually beneficial partnerships with researchers and donors. For the researcher, as for everyone, a new paradigm is required, one which Chambers (1994) describes as being people centred, participatory, empowering and sustainable. Much of the challenge is to give up power, to enjoy handing over the initiative to others so they can do more and in their own way, and to learn to value and enjoy these satisfactions.

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This Case Study was prepared by Catherine Hankins, MD, MSc, FRCPC, a founding member, Group for Research to Action, McGill AIDS Centre, Montreal; Elizabeth Reid, Director, HIV and Development Programme, United Nations Development Programme, New York; and Des Cohen, Chief Economist, HIV and Development Programme, United Nations Development Programme, New York.

Acknowledgements

Catherine Hankins, Elizabeth Reid and Des Cohen wish to thank Sylvie Gauthier, Fiona Percy, and Mina Mauerstein-Bail. Coordinated by the Centre for AIDS Studies of the Public Health Unit of the Montreal General Hospital, now known as the Group for Research to Action of the McGill AIDS Centre of McGill University.