Engaging scientists from low- and middle-income countries (LAMICs) as lead investigators on research projects can be both rewarding and challenging. These researchers make invaluable contributions by offering a better understanding of their local issues and conditions. An intimate understanding of one’s own culture positively affects the quality of the data collected, and the interpretation of that data also may be uniquely valid and meaningful. Yet some LAMIC investigators may lack sufficiently rigorous training or experience in designing and conducting research.

It is vital for scientists to answer locally generated research questions to gather the evidence upon which local prevention and clinical care decisions are based and to publish their findings in the international literature. It is unfortunate, however, that scientists from LAMICs often lack the time to devote to the lengthy process of manuscript preparation or that some may lack familiarity with the orthodoxy of assembling a publishable article. Publications of local studies are needed to inform international guidelines, which are often handed down to LAMICs from international and multilateral health agencies, such as the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Given that prevention and care guidelines around the world are increasingly evidenced-based, it is essential that LAMIC investigators publish the findings of their local research, which then can be included in literature reviews and made more widely available. Also, research discoveries in one setting may generate new ideas for research in others.

Historically, researchers from high-income countries have been better positioned to compete for funding from their national institutes of health or from multilateral granting agencies, even if the target of that research is LAMICs. The choice by these researchers whether to include scientists from LAMICs as lead or co-investigators on their research teams may be driven by a perceived or real lack of trained researchers with whom to partner. Concomitantly, local research is conducted by many LAMIC scientists on a shoestring budget and independent of foreign funding sources that might support training and career development. It may, therefore, seem expeditious for scientists from resource-rich settings to take the lead in writing papers based on data generated by local scientists, rather than to face the challenges, and the expense in time and resources necessary, to help them first-author their own work or to build deeper and supportive collaborations.

It has been our goal at the International Program at the University of California, San Francisco, Center for AIDS Prevention Studies (UCSF-CAPS) to create a network of skilled and experienced researchers from LAMICs who can design and conduct their own research and who can collaborate with foreign researchers on projects ranging from pilot studies to large, international, multisite trials. Since 1989 at UCSF-CAPS, we have offered 6- to 10-week intensive short courses in research methods, data management and analysis, and scientific writing. The main product of our research methods course is a protocol for a pilot study in which the research question has been initiated by the scientist and which will be fielded in his/her home country. The main product of the scientific writing workshop is a manuscript to be submitted for publication in an international, peer-reviewed journal. We also offer condensed versions of our training modules in several countries outside the United States, including regular course offerings in Brazil, Uganda, and Croatia; UCSF-CAPS faculty co-teach these in-country courses with alumni of our training programs. We provide technical assistance to our program alumni in fielding their research studies, monitoring human subjects, analyzing data and preparing publications. The career guidance and mentorship that we provide after the completion of coursework has, in many instances, lasted for decades. We now are working with the next generation of researchers, some of whom are students of scientists who trained with us in the early 1990s. To date, we have assisted hundreds of scientists in designing, fielding, and writing the results of research on questions they have initiated. In so doing, we believe we are successful in aiding scientists from LAMICs to make meaningful contributions to the evidence base that informs their local HIV/AIDS prevention and care decisions.

We have identified a range of common challenges in assisting LAMIC scientists to publish the results of their research. Academics generally are given paltry salaries in LAMICs, and many are constrained by a lack of time due to competing professional and clinical responsibilities; few have been able to afford the luxury of acquiring skills in the design and conduct of rigorous research or in scientific writing. Many lack access to published articles or extensive exposure to the scientific literature and must rely instead on syntheses, news articles, and bulletins. Thus, although they may have a keen sense of the research questions that need to be answered about their local HIV/AIDS situations, they may not have had the opportunity to clarify the methodology required to answer these questions. As a result, there may be limitations in their ability to clearly present detailed or nuanced findings from their data when the time comes to prepare publications. The UCSF-CAPS scientific writing workshops offer scientists from LAMICs protected time away from their normal work environments, as well as substantial resources and training, to allow them to focus their attention on manuscript preparation.

Another common challenge faced by scientists from LAMICs who wish to publish their research findings is the language barrier. For the majority of the first authors in this supplement, English is not their first language. As a result, we found it difficult to assess the merit of some of the manuscripts we received in answer to our call for papers. We felt compelled to help these authors because if local investigators are to contribute to the international literature and the guidelines generated by international organizations, they must publish their work in English or another language in which scientific publications are widely available. Given this reality, our task included analyzing some articles line-by-line, making sure that we understood the intent of the author, and helping shape the language to the orthodoxies of Western scientific journals, both in content and tone. Also assisting were UCSF scientists—full-time academics and native English speakers—as well as bilingual researchers fluent in an array of languages from Farsi to Vietnamese.

Even authors who have the experience to compose an English-language manuscript, but who are from LAMICs, may face reviewers and editors who underestimate the value of their research. In a few cases, reviewers suggested that we reject an article, not because it lacked scientific merit, but because it was deemed to be only of local importance, and thus would not contribute to the international literature. Clearly, we differ with this line of thinking and argued the merits of including an article if we believed it was relevant to the problem of HIV/AIDS, either locally or globally. A secondary goal of the training at UCSF-CAPS is to develop the careers of these scientists and improve their chances of being awarded regional or international research grants; publication in international peer-reviewed journals is one important way to garner recognition as a researcher and increase the ability to compete for these grants.

The articles in this supplement of AIDS and Behavior went through the same peer-review process as other articles submitted to the journal. We did, however, request that reviewers be chosen who had international experience; we believed that this knowledge would inform their ability to recognize the suitability and acceptability of submissions. Following initial review, we were able, as guest editors, to discuss reviewers’ recommendations with the editor-in-chief of AIDS and Behavior, assess the relevance of the critiques, and make editorial decisions about whether to ask an author to revise and resubmit his/her manuscript, or to reject it. If we believed that a manuscript was potentially worthy of publication, we chose to send it back to authors a second (or even a third) time for revisions; more often the problems turned out to be ones of language rather than substance.

In a number of cases, we invited revisions on papers in which we recognized methodological problems (e.g. sampling design or questionnaire construction) which could not be rectified, as data collection was already complete. Rather than dwell on the methodological shortcomings, we chose instead to focus on what the scientists accomplished and how they shed light on their local situation, remembering the time and resource constraints that shaped the design and field implementation of the study. We worked closely with these authors to be certain that they had fully recognized and clearly stated the limitations of their studies, but did not let this be a roadblock to final publication.

Some of us remember the days when we could rely on a copyeditor to pore over an accepted manuscript, to correct grammar, check the accuracy of tables and their correspondence to text, and ensure that the article conformed to all journal specifications. Due to globalization and economic pressures in the publishing world, that dependable person in a publishing house in London or New York is now likely to be in a country where the native language is different from that of the journal. The journal’s instructions to the copyeditor may be to issue proofs quickly rather than to take time to perfect a manuscript. Given that the majority of our first authors are not native English speakers, nor were some familiar with the rigors of publishing in an international journal, we decided to provide our own in-house copyediting services. We recognize that this kind of additional assistance will not be available to authors from LAMICs in most cases, but full-time academics in partnering institutions in resource-rich settings can do much to help in finalizing manuscripts for publications.

In recent years, we have experienced an increasingly high demand for our scientific writing workshops at UCSF-CAPS. We are unable to admit many qualified applicants with promising data sets because of lack of space and funding. This issue of AIDS and Behavior, the fourth in a series (AIDS and Behavior; 2000 March; 4(1), 2002 September; 6(3), 2006 July; 10(4), Supplement), features the work of scientists from LAMICs who are alumni of our UCSF-CAPS and in-country training programs, many of whom have attended one of our scientific writing courses. The supplement also includes articles first authored or co-authored by postgraduate fellows and faculty from UCSF and elsewhere who have collaborated with our program alumni or international colleagues.

The first article in this supplement is from Iran, a nation in a region where, as of 2008, there is scant empirical evidence on HIV/AIDS. To bring this article to press, we paired Vahid Mojtahedzadeh, an Iranian psychiatrist who works in Tehran’s public health sector, with a postgraduate fellow at UCSF-CAPS, Nooshin Razani, who is Iranian-American and speaks Farsi. They analyzed programmatic data from a project that integrated substance abuse treatment and HIV prevention into Iran’s primary health care system. The authors present a convincing case for the likelihood of a concentrated HIV epidemic developing among injection drug users along major opium trafficking routes that traverse rural Iran. They describe a unique opportunity to intervene using prevention measures that can be readily implemented given Iran’s well-developed primary health care system.

In a second article addressing HIV prevention among injection drug users, Fu et al. examined sentinel surveillance data trends over a 10-year period in Guangdong, a province of approximately 86 million people in southern China. The authors found increasing HIV prevalence among injection drug users in the relatively under-developed western region of the province, with stabilization in the center and east. These findings help more effectively to direct the scale-up of prevention programs, particularly methadone maintenance and needle exchange. Dr. Fu collaborated on her analysis and writing with the San Francisco Department of Public Health, whose leadership has shown a commitment to addressing HIV/AIDS as a global epidemic and not merely to attending local prevention and care needs.

There is an urgent need to build an evidence base about youth at high-risk for HIV infection. Youth culture is different in every country. It is informed and shaped by what happens in the local communities, not only by an increasingly global media presence. Fialho et al. address incarcerated youth, an especially vulnerable group, and the behaviors that increase their risk for HIV and other infectious diseases. This is the first of five papers in this supplement resulting from collaborations between UCSF-CAPS and Brazilian scientists that have been ongoing since 1989. The research team in northeastern Brazil undertook a study of the prevalence of HIV, hepatitis B and C, human T cell lymphotropic virus, and syphilis, as well as risk behaviors among incarcerated adolescents in Salvador, Brazil. The authors argue for the need to address the shortcomings in the health care offered to incarcerated youth.

Miranda et al. address the effect of Brazil’s HIV and STI syndemic on young women. They conducted a population-based study among young women in Vitória, Brazil, measuring HIV prevalence, hepatitis B and C exposure, syphilis exposure, and related risk behaviors among young women aged 18–29 years. A vast majority of the women was sexually active and many had at least one of these infections. The study findings will be used by the local public health department, which collaborated on the study, to develop prevention and care programs for these preventable STIs among young women in Vitória.

The role of truck drivers in acquiring and transmitting HIV has been well documented in Africa and Asia (Mbugua et al. 1995; Bryan et al. 2001), yet less is known about this population in Brazil. Moreover, the high mobility of this profession makes representative sampling challenging in a given locale. Ferreira et al. implemented time-location sampling (TLS) to measure HIV risk behaviors among truck drivers at a major crossroads in northeast Brazil. The researchers found a generally low level of unsafe sex with partners met on the road; however, stimulant use and its association with unprotected sex appear to be particular occupational hazards that also could be a point of intervention to reduce sexual risk behaviors. Although these findings are not surprising considering what we know about the spread of HIV along commercial truck routes, there remains a need to intervene locally. This intervention requires supplying local government and non-government organizations with an understanding of the conditions that exist along provincial highways. In turn, the involvement of local authorities will help to generate policies that are relevant to these settings.

A unique and under-researched population in Brazil is volunteer blood donors. Ensuring the safety of the blood supply relies in part on understanding the motivations of these donors. Goncalez et al. conducted a survey of 1,600 blood donors at a blood bank in São Paulo and found that altruism was the main motivation for blood donation. Of particular significance, however, is the authors’ finding that some donors were utilizing the blood banks to find out their HIV status. As HIV testing is commonly known to be conducted as part of the screening process at blood banks, individuals who wished to know their HIV status could avoid the stigma or longer wait for results associated with going to HIV testing sites by donating blood. Dr. Goncalez, as well as our other Brazilian authors, were able to benefit from UCSF-CAPS’ largely bilingual core faculty, facilitating the process of fielding and writing up the results of these studies.

We present three articles about secondary HIV prevention in the context of care and treatment. The first article is from Croatia, a small eastern European country that currently is experiencing a low-level HIV epidemic. The University Hospital for Infectious Diseases in Zagreb, the largest city in the country, is affiliated with the Andrija Stampar School of Public Health and serves as a hub of HIV/AIDS research and training activities for the region, including northern Africa and the Middle East. Begovac et al. examined whether interventions funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria were successful at attracting HIV-infected persons to present earlier for medical care. This is a paper that was singled out by one reviewer as having questionable relevance internationally because of Croatia’s low-level epidemic. Instead, we saw the local importance of this work as a strength, in part because the research team in Croatia is well poised to provide consultation to regions where HIV/AIDS is under-researched and where epidemics are just now beginning to escalate.

Dr. Sampaio-Sa and her team at the Universidade Federale do Bahia in Salvador, Brazil, conducted a intervention to increase adherence to antiretroviral therapy (ART) among HIV-positive ART-naive patients. They compared a motivation and behavioral skills workshop with a video-session control and found no difference in self-reported adherence over a 1-year follow-up period. Although no effect was found, this remains an interesting negative finding given that Brazil is a country that has long championed the availability of ART free-of-charge to all patients with HIV/AIDS where treatment is indicated. The authors speculate that participants in the study were already highly adherent to ART protocols. They suggest that further studies should be conducted in groups that may be perceived to be non-adherent. As the Brazilian policies of providing early and free universal access to ART have become a general success, targeted behavioral interventions to increase adherence in these groups may result in even more expanded ART access.

While large international clinical trials networks struggle to answer vital clinical questions about HIV that are applicable to us all, what may be given short shrift are studies about the effect of HIV at a community level. Such studies are needed to document the local experiences of people living with HIV/AIDS. Stigma and discrimination can affect quality of life, access to and uptake of health services, and, ultimately, health outcomes. These challenges and their causes and sequelae are naturally affected by the cultural context. Thi et al. conducted a qualitative study of stigma and discrimination experienced by people living with HIV/AIDS in Ho Chi Minh City, Vietnam, where public attitudes have been shaped in part by propaganda associating HIV with the so-called “social evils” of sex work and drug use. For some of our Vietnamese colleagues, the level of English-language proficiency, as well as a lack of formal research training, continues to present barriers to deeper collaboration. We first engaged Ms. Thi when she was a health educator at one of Ho Chi Minh City’s condom cafés; she became a counselor at Vietnam’s first anonymous HIV test site, which was established in collaboration with UCSF-CAPS, and went on to earn an MPH at Tulane University.

In LAMICs, prevention research efforts targeting men who have sex with men (MSM) finally are beginning to get the attention and funding that they deserve. In the United States, stigma and discrimination imposed by cultural proscriptions can lead to increased sexual risk behaviors (Stall 2007). Choi et al. examined the mediating role of sex partner concurrency in explaining associations between homophobia, financial hardship, and HIV risk behavior among MSM in Shanghai, China. The researchers suggest interventions that consider contextual and cultural factors to address the challenges of stigma and discrimination and thereby reduce HIV risk behaviors. This research would not have been possible without a close collaboration with the Shanghai Municipal Center for Disease Control, and Dr. Zhao Ning, an alumnus of the UCSF-CAPS International Program.

The topic of MSM in sub-Saharan Africa also has been garnering attention recently, in part due to the courage of local researchers and activists, some of whom have risked their careers to shed light on this highly stigmatized population (Kajubi et al. 2008). Lane et al. conducted a behavioral survey in peri-urban South African townships that involved the Soweto HIV/AIDS Counselors Association and OUT, a Pretoria-based LGBT organization. Many gay-identified men from Soweto had sought HIV testing and support services at the University of Witwatersrand Perinatal HIV Research Unit, and researchers there chose to initiate research that would focus on the HIV prevention and treatment needs of local MSM. In spite of South Africa’s enlightened legal approach to homosexuality, a majority of sexually active men in Lane’s study reported unprotected anal intercourse, underlining the urgent need for prevention interventions that target MSM.

In Croatia, MSM currently represent the largest HIV-infected population, albeit the infected population remains relatively small. In this second paper from the research team at the University Hospital for Infectious Diseases in Zagreb, Zekan et al. captured a majority of the known HIV-infected population in the country to conduct a study of risk behavior among both MSM and heterosexual patients. Countries with low-level epidemics represent a special challenge for HIV/AIDS prevention. It is vital to tease out factors that may be culturally protective as an explanation for a low prevalence of HIV infection, but it also is essential to avoid complacency that can result in inadequate epidemiological and behavioral surveillance.

Our last four articles address methodological issues involved in recruiting hard-to-reach populations. Stigma and discrimination can lead not only to high-risk behaviors and poor health outcomes, but also to difficulty in reaching these individuals to gather evidence about their behaviors and assess their prevention and care needs. Long-chain referral recruitment of MSM, a method used in respondent-driven sampling (RDS) whereby participants refer other eligible participants to the study, is a promising methodology for these reasons. He et al. conducted a comparative study of long-chain referral recruitment and convenience sampling in reaching MSM in Guangzhou, China. Dr. He was selected to come to UCSF-CAPS as a result of an ongoing collaboration between the Chinese Center for Disease Control and Prevention and the San Francisco Department of Public Health.

In a study comparing three different methods for sampling MSM in Fortaleza, in northern Brazil, Kendall et al. found that RDS produced a better representation of men with lower socio-economic status (SES) than either snowball sampling or TLS. Capturing lower SES men is particularly important in this local setting as the largest number of reported AIDS cases among MSM is among those of low SES. This research team included Dr. Ligia Kerr, an alumna of our UCSF-CAPS training program, as well as several other local investigators.

In using relatively new methodologies such as RDS, it is critical to know their strengths and limitations and to elucidate critical factors for their success. Malekinejad et al. conducted a review of 128 HIV surveillance studies conducted outside the United States that used RDS to describe common operational and analytical factors that affect recruitment. The research team argues that a list of key data should be reported for all RDS studies, as has been done for randomized controlled trials (Moher et al. 2001) and other study designs. This article will be useful as a guide for researchers considering using RDS in their future research projects. Dr. Malekinejad is a native of Iran and is completing his doctoral studies at the University of California, Berkeley. He also has been a lead investigator on the UCSF-CAPS Iran AIDS research team.

In a companion piece, Johnston et al. use the same body of RDS studies to examine the predictors of poor study outcomes, such as the ratio of recruited versus calculated sample sizes. The results indicate that problems in defining eligibility criteria, structuring social network size questions, selecting design effects, and conducting statistical analysis all resulted in poor outcomes. Results from this review will allow researchers planning to use this methodology in accessing hard-to-reach populations to learn from past challenges and maximize this method’s utility.

In summary, publishing the research findings of scientists from LAMICs requires a multi-faceted approach to peer-reviewing and copyediting. To bring some of these articles to press, we needed to address the limitations of their facility with the English language, the effect of resource constraints that sometimes result in less-than-optimal research designs, and some reviewers’ lack of familiarity with the realities of conducting research in these international settings. Concomitantly, we concentrated on the relevance and potential of submissions to address local issues. Some articles were returned for multiple revisions, but always with the understanding that the underlying scientific contribution was valuable. Some articles required a heavier than usual hand in copyediting to help translate unclear ideas—ideas that were usually crystal clear in the investigators’ own languages—into writing that would pass muster in international peer-reviewed journals such as AIDS and Behavior. In the end, it has been our privilege to help bring the voices of local researchers to an international audience.