Brewer, D. D. Practical research designs for investigating modes of HIV transmission. Invited presentation at the 11^th annual meeting of the Safe Injection Global Network, World Health Organization, Dubai, United Arab Emirates, November, 2010. Presentation available at SSRN: http://dx.doi.org/10.2139/ssrn.2542630.

Despite 30 years of epidemiologic research on HIV transmission, no published investigations in sub-Saharan Africa or Asia have involved study designs that allow HIV transmission modes to be determined with confidence. Consequently, there is much uncertainty about what is driving HIV transmission in these regions, which hampers prevention. There are four design elements in a rigorous investigation: inclusion of persons with incident HIV infection (cases) and uninfected controls, comprehensive assessment of blood and sexual exposures, tracing of contacts to such exposures for both cases and controls, and sequencing of infected persons' HIV DNA to identify persons with genetically related infections. Although all four elements are necessary to determine transmission modes with greatest confidence, investigations with the first two or three elements provide stronger evidence than exists currently and offer useful guidance on prevention strategies until more definitive investigations can be conducted. Investigations with these design elements can piggyback on existing clinical and other health services, and thus require little or no funding to implement. Scientific help is available for conducting these investigations. The most important requirement for starting this kind of project is the desire to know what is driving HIV transmission in one’s community.

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