Christopher J. Burman

Reducing the overall HIV-burden in South Africa: is reviving ABC an appropriate fit for a complex adaptive epidemiological HIV landscape?

This article questions the recommendations to ‘revive ABC (abstain, be faithful, condomise)’ as a mechanism to ‘educate’ people in South Africa about HIV prevention as the South African National HIV Prevalence, Incidence and Behaviour Survey, 2012, suggests. We argue that ABC was designed as a response to a particular context which has now radically changed. In South Africa the contemporary context reflects the mass roll-out of antiretroviral treatment; significant bio-medical knowledge gains; a generalised population affected by HIV that has made sense of and embodied those diverse experiences; and a government committed to confronting the epidemic. We suggest that the situation can now be plausibly conceptualised as a complex, adaptive epidemiological landscape that could benefit from an expansion of the existing, ‘descriptive’ prevention paradigm towards strategies that focus on the dynamics of transmission. We argue for this shift by proposing a theoretical framework based on complexity theory and pattern management. We interrogate one educational prevention heuristic that emphasises the importance of risk-reduction through the lens of transmission, called A-3B-4C-T. We argue that this type of approach provides expansive opportunities for people to engage with the epidemic in contextualised, innovative ways that supersede the opportunities afforded by ABC. We then suggest that framing the prevention imperative through the lens of ‘dynamic prevention’ at scale opens more immediate opportunities, as well as developing a future-oriented mind-set, than the ‘descriptive prevention’ parameters can facilitate. The parameters of the ‘descriptive prevention’ paradigm, that maintain — and partially reinforce — the presence of ABC, do not have the flexibility required to develop the armamentarium of tools required to contribute to the management of a complex epidemiological landscape. Uncritically adhering to both the ‘descriptive paradigm’, and ABC, represents an historically dislocated form of prevention — with restrictive options for reducing the overall burden of HIV-related challenges in South Africa.

Methodological approach and tools for systems thinking in health systems research: technical assistants’ support of health administration reform in the Democratic Republic of Congo as an application:

In the field of development cooperation, interest in systems thinking and complex systems theories as a methodological approach is increasingly recognised. And so it is in health systems research, which informs health development aid interventions. However, practical applications remain scarce to date. The objective of this article is to contribute to the body of knowledge by presenting the tools inspired by systems thinking and complexity theories and methodological lessons learned from their application. These tools were used in a case study. Detailed results of this study are in process for publication in additional articles. Applying a complexity ‘lens’, the subject of the case study is the role of long-term international technical assistance in supporting health administration reform at the provincial level in the Democratic Republic of Congo. The Methods section presents the guiding principles of systems thinking and complex systems, their relevance and implication for the subject under study, and the existing tools associated with those theories which inspired us in the design of the data collection and analysis process. The tools and their application processes are presented in the results section, and followed in the discussion section by the critical analysis of their innovative potential and emergent challenges. The overall methodology provides a coherent whole, each tool bringing a different and complementary perspective on the system.

Re-imagining decision making: addressing a discrete social driver of HIV/ AIDS through the lens of complexity science

This article argues that decision making is a discrete social driver that can be associated with the HIV/AIDS epidemic in the Limpopo province in South Africa. The authors argue that complexity science can inform future research and interventions by presenting two decision making frameworks arising out of complexity science that have the potential to enable young people to better negotiate decision-making contexts whilst simultaneously opening spaces of dialogue that can mitigate the impact of HIV-risk in specific, punctuated contexts. The methodological design was prompted by findings from youth-oriented community engagement projects that include Communication Conversations and Sex & Relationships Education. The proposed methods have the potential to exploit the phenomenon of leadership emergence as a product of decision making at critical moments. This has the potential to promote the growth of home-grown leadership skill sets that make sense to young people and to enable them better manage their own health, thus reducing risk and vulnerability to HIV infection and sexual violence.

Weak signal detection: A discrete window of opportunity for achieving ‘Vision 90:90:90’?

Abstract Introduction: UNAIDS’ Vision 90:90:90 is a call to ‘end AIDS’. Developing predictive foresight of the unpredictable changes that this journey will entail could contribute to the ambition of ‘ending AIDS’. There are few opportunities for managing unpredictable changes. We introduce ‘weak signal detection’ as a potential opportunity to fill this void. Method: Combining futures and complexity theory, we reflect on two pilot case studies that involved the Archetype Extraction technique and the SenseMaker® Collector™ tool. Results: Both the piloted techniques have the potentials to surface weak signals – but there is room for improvement. Discussion: A management response to a complex weak signal requires pattern management, rather than an exclusive focus on behaviour management. Conclusion: Weak signal detection is a window of opportunity to improve resilience to unpredictable changes in the HIV/AIDS landscape that can both reduce the risk that emerges from the changes and increase the visibility of opportunities to exploit the unpredictable changes that could contribute to ‘ending AIDS’.

Leadership emergence: the application of the Cynefin framework during a bio-social HIV/AIDS risk-reduction pilot.

This article focuses on the utility of a knowledge management heuristic called the Cynefin framework, which was applied during an ongoing pilot intervention in the Limpopo province, South Africa. The intervention aimed to identify and then consolidate low-cost, innovative bio-social responses to reinforce the biomedical opportunities that now have the potential to “end AIDS by 2030″. The Cynefin framework is designed to enable leaders to identify specific decision-making domain typologies as a mechanism to maximise the effectiveness of leadership responses to both opportunities and challenges that emerge during interventions. In this instance the Cynefin framework was used to: (1) provide an indication to the project managers whether the early stages of the intervention had been effective; (2) provide the participants an opportunity to identify emergent knowledge action spaces (opportunities and challenges); and (3) categorise them into appropriate decision-making domains in preparation for the next phases of the intervention. A qualitative methodology was applied to collect and analyse the findings. The findings indicate that applying the Cynefin framework enabled the participants to situate knowledge action spaces into appropriate decision-making domains. From this participatory evaluation a targeted management strategy was developed for the next phases of the initiative. The article concludes by arguing that the Cynefin framework was an effective mechanism for situating emergent knowledge action spaces into appropriate decision-making domains, which enabled them to prepare for the next phases of the intervention. This process of responsive decision making could have utility in other development related interventions.

An evaluation of the innovative potentials of a HIV pilot exploring medical pluralism in rural South Africa

ABSTRACT This article reflects on an internal evaluation undertaken to estimate the potentials of a community-university pilot project to be developed into a bonafide innovation that can be applied at scale. The focus of the community-university partnership has been to reduce the unintended consequences of medical pluralism on the HIV and AIDS epidemic in Waterberg district, Limpopo Province, South Africa. Despite promising outputs from the partnership – including an increase in adherence to antiretroviral therapy and a reduction in stigma among traditionalists living with HIV – the partnership wished to establish whether further funding should be applied for to take the pilot from its current prototype status to a more established innovation. In order to evaluate the innovative potentials of the pilot, the opportunity vacuum model of innovation was adapted and applied. The findings indicate that (1) the application of the opportunity vacuum model of innovation to evaluate the potentials of the pilot to be developed into a bonafide innovation was fit for purpose and (2) the pilot contains the key ingredients that are associated with innovations in the making. The discussion reflects on the social potentials of the pilot to contribute to 90-90-90 from a global, national and local perspective. The reflection concludes by suggesting that the opportunity vacuum model of innovation is a versatile heuristic that could be applied in other contexts and the community-university pilot represents a nascent innovation which has sufficient potential to justify further development.