The NHBS formative research activities described in this article yield practical information for surveillance operations as well as contextual information for understanding HIV risk in these populations and geographic areas. Formative research data allow each project site to design a surveillance system that is culturally appropriate and locally relevant while remaining consistent with the core elements of the national NHBS protocol.
One of the strengths of this model is that it involves the use of an array of qualitative data collection methods. In addition to providing project sites with different methods to cross-check and verify the information they collect, having several methods to choose from gives project sites the flexibility of selecting the method that may be best suited to a given situation, such as exploring sensitive topics or conducting interviews at particular locations. Moreover, because the methods used to collect qualitative data are inherently interactive, they can serve as important mechanisms by which local NHBS staff get out into the community and gain visibility for the NHBS project. Achieving visibility for the project can be critical in determining people's willingness to participate once the behavioral survey gets underway.
As with any new data collection system, a number of valuable lessons for improving the formative research component of this behavioral survey were learned along the way. During the NHBS-MSM cycle, qualitative data collection activities were primarily focused on identifying venues in the community where MSM could be recruited. However, beginning with the NHBS-IDU cycle, formative research guidance emphasized the importance of collecting preliminary information about HIV risk behaviors among members of the study population of interest and about the cultural, social, and economic contexts in which those behaviors occurred. For the NHBS-HET cycle, a separate activity to help project sites identify and elicit the support of community stakeholders was added to the list of formative research activities, as was the recommendation that project sites hire an ethnographer to guide all aspects of qualitative data collection, including analyzing the information collected and writing the ethnography report.
Valuable lessons for improving CDC's guidance to project sites were also learned. During the first round of NHBS, CDC did not provide training in qualitative data collection methods. It was assumed that such training, if needed, would be conducted at the local level by the project site's ethnographer. Instead, while the majority of project sites worked with an ethnographer, most ethnographers were hired on a part-time basis for very limited data collection tasks; very few were directly involved in training local staff. CDC is currently working with NHBS project sites to address these challenges and improve the quality of formative research data collected in future NHBS cycles.