Background
With the failure of the latest vaccine trial, HVTN-505, HIV prevention efforts remain critical [
1]. While interdisciplinary, international research collaborations often are indicated as best practice in developing new knowledge in global health [
2] and an important component of the leadership in health systems, this does not mean they are free of challenges. Rather than offering solutions we aim to contribute to the debate about the object and purpose of global health research [
3,
4] in the context of developing international research partnerships. Despite global efforts to prevent, treat, and ultimately cure HIV, the epidemic today affects 34 million people worldwide, including 1.9 million people living in Latin America and the Caribbean [
5]. Social and structural factors contributing to HIV and STI transmission are in a large part comprised of stigma associated with sexual violence, persons living with HIV (PLHIV) and sexual and gender minorities (SGM). Undeniably there is ongoing marginalization of, and stigma directed toward, SGM worldwide that preclude human rights and full access to health services [
6,
7]. This situation is a public health and human rights problem in low and middle income (LMI) countries such as Peru—our case study [
8‐
11]. It is also a persistent concern in high income countries (HIC) such as the US and Canada [
12‐
15], demonstrating the transnational nature of these issues [
16]. UNAIDS [
17] reported that in 2011, of 74,000 PLHIV in Peru, 50,000 were men. The same report defined priority populations as including people involved in sex work, transgender persons, and men who have sex with men (MSM). It was estimated that most of the 5,800 new cases in 2011 belonged to these populations [
17]. However, as in other global regions [
18], statistics on gender-specific HIV incidence and prevalence are incomplete. Research has indeed indicated a ‘heterosexual bridging’ of HIV and syphilis transmission involving Peruvian MSM [
19]. ‘Bridging’ in this case characterized the behaviors of men (bridgers) who reported sex with both men and women in the past year [
19].
Although youth as a whole represent a global population at risk for HIV and STI infections, there is a great deal of variability within this developmental period and within high-risk subgroups [
20]. In Peru, disaggregated statistics reveal increased risk for key populations of youth; male youth, sex workers, and other SGM populations are overrepresented in new HIV and STI cases in Peru [
21]. The median age of persons living with AIDS in Peru in 2013 was 31 years old, which means that at least 50% were exposed to HIV before reaching 21 years of age [
21]. These statistics point clearly to the importance of focusing on youth in HIV and STI prevention in Peru. Youth in Peru (15–29 years old) represent approximately 28% of the population of 8 million [
22]. The United Nations Population Fund (UNPFA) released a report in 2012 that details the characteristics of the ‘demographic bonus’ of Peru. This concept refers to contexts where a majority of a population falls into the range of 15–59 years old and therefore is employable, the current context of Peru [
22]. While the immediate consequence is an extremely competitive job market, the future is more concerning, as the current youth get older and the younger group occupies a much smaller proportion in the population pyramid. Youth in Peru are, however, a heterogeneous group: 48% are migrants living in large urban zones; only 1/3 are studying, while 83% work full or part-time; 37% of teenage girls that have only elementary education are also teen mothers; and 81% of youth in poverty are sexually active before 19 years of age [
22]. While HIV and overall sexual health prevention programs targeting youth in Peru have been implemented [
7], a review of local literature and discussions with local researchers and community groups indicated that the role of HIV stigma, sexual violence, cultural diversity and health literacy in the effectiveness of those programs warrants further attention. Of special concern is the dearth of policies that protect the sexual and reproductive health and rights of youth, in particular SGM youth [
23]. Human rights are premised on the notion of human dignity; human dignity requires that individuals do not suffer from discriminatory legislation [
24]. In Peru, the exclusion of youth in sexual health rights legal frameworks indicates that youth also lack overall civil and political rights, the core of human rights.
We are three social sciences and clinical researchers living and working in Canada; two of us are from South America (ES from Peru and JFA from Venezuela) and one from Canada (CL). While one of us has a program of research based in Peru (ES), the others are based in diverse global regions (e.g. Jamaica, South Africa, Haiti) and Canada. We represent different disciplines and universities, and travelled to Peru together to meet local agencies and researchers in May 2013. Our paper is based on reflections and dialogue that emerged during our research trip.
We plan to examine HIV and STI prevention priorities among youth in two culturally and geographically diverse cities in Peru: Lima, the capital city, and Ayacucho, in the Andean region. Peruvian researchers have reported on the intercultural diversity regarding how social and health indicators such as sexual violence, homophobia [
25], religion, sexuality, sexual health and politics [
26] are expressed and embraced in different provinces of Peru. The most significant differences were found between the coastal region (Lima) and the Andean region (Ayacucho), which is why we choose these two regions as the focus of our interest. This paper reflects our initial discussions on how best to prepare ourselves for international and interdisciplinary research in global health. After a preliminary trip exploring local priorities and local partnerships it was clear to us that in order to develop a viable cultural, age and gender appropriate HIV/STI prevention research agenda with key populations of youth in Peru, it is essential to work in partnership with community agencies, health researchers and knowledge users. Mindful of reported difficulties in facilitating youth participation—in particular vulnerable youth—in the creation of global health knowledge, which should be the foundation of international HIV policy [
20,
27], we intend to use interdisciplinary tools to facilitate this participation. Our discussion on how disciplinary understandings influence our practice as international health researchers is organized around the three thematic tensions on global health knowledge suggested by Rowson et al. [
4]: What is the
object of knowledge? What is the
purpose of knowledge? What are the
types of knowledge? The article is structured around our professional conversations and outlines the challenges we have experienced as health researchers in bridging the mentioned divides in global health in the context of our current project. Rather than offering solutions or recommendations it is a representation of our interpretations and deliberations; hence our exchanges are open for debate.
Summary
In contrast with the popular trend of focusing on the technical tools of “how to do” global health research this debate focuses instead on thoughts about the “why” and “what” of global health knowledge which are essential deliberations for HIV research and prevention. Balancing the various priorities and strengths of social and biomedical sciences, including the multiple levels of focus (individual, social structural) and multiple actors involved (youth, parents, health care providers, community-based organizations) are all significant factors to be considered when situating global health discussions. By discussing the tensions surrounding what the object and purpose of global health knowledge is, we highlight the connection of global health with an international human rights framework and with interdisciplinary and cross-sectoral debates. By emphasizing a context-specific, participatory, and interdisciplinary approach in global health we are also considering that global health problems have distinctive significance and solutions in different international settings. We contend that where knowledge is co-created by knowledge users and researchers a multidirectional flow of global health knowledge can be achieved. With globalization we have witnessed an increased global flow and exchange of services and practices generally from North to South; we hope to encourage a more humbling approach in global health research, that is, a reciprocal, multidirectional flow of knowledge from the South to the North.
Competing interests
Authors declare no competing interests.
Authors’ contributions
ES and CL formulated the original idea for this debate article. ES wrote the first draft and CL and JFA contributed with additional sections. ES prepared the final draft and all authors read and approved the final manuscript.