PI: Robert de la Grecca - 2015 Peru
Title: Stigma, coping, mental health, and adherence to care among newly diagnosed HIV patients: a longitudinal test
A major strategy for reducing HIV transmission is ensuring immediate treatment, initiation, and retention in comprehensive care for newly diagnosed individuals. Correlates of treatment, adherence, and retention among people living with HIV/AIDS have been well-studied, including stigma, coping, and mental health. Since the majority of these studies have been cross-sectional, casual relationships have been difficult to assess. This study conducts a secondary data analysis of data collected through ¿SABES?, a longitudinal study in Lima, Peru that tracks men who have sex with men from an HIV- status through HIV acquisition and HIV care.
PI: Jennifer Slyker - 2015 Kenya
Title: Financial Incentives to Increase Pediatric HIV testing
Most of the world’s 3.2 million HIV-infected children are diagnosed only when hospitalized or severely ill, after which they have extremely high mortality. Although early initiation of HIV treatment in children decreases mortality substantially, children lag adults in HIV treatment. ART-eligible children are a third less likely to be on treatment compared to adults. Although infants are systematically tested in prevention to mother-to-child HIV transmission (PMTCT) programs, there are no effective systems to systematically test older children until they are ill.
The Counseling and Testing of Children at Home (CATCH) study recently found that systematically asking HIV-infected patients to test their children increased testing 4-fold; however, 71% of parents still did not accept testing. New approaches are needed to motivate parents to test their HIV-exposed children. Financial incentives have been used to motivate desirably health behavior changes, including immunization, school attendance, medication adherence, smoking cessation in pregnancy, and tuberculosis screening. Dr. Slyker and her colleagues are aware of no studies to date that have examined financial incentives for pediatric HIV testing.
PI: Renee Heffron- 2015
Title: Global-to-Local: Safer Conception among Seattle Area HIV-1 Serodiscordant Couples
PI: Sylvia LaCourse - 2014 Kenya
Title: Latent Tuberculosis in Pregnancy Study (“LTiPs)
This pilot study leveraged an ongoing study of TB in pregnancy, or “TiPS”. The current study is cross-sectional and involves clinical and TST evaluation of 300 pregnant women at a single time-point. For the remaining 150 women enrolled after funds for this proposal became available, Dr. LaCourse and her colleagues added IGRA testing at baseline as well as longitudinal follow-up for repeat IGRA testing in women who are IGRA negative at baseline (estimated 105 women). This study was conducted in the Nyanza Province of Western Kenya at antenatal clinics located at the Ahero Sub-district Hospital and Bondo District Hospital. The specific aims of this study were to:
- Determine prevalence and correlates of LTBI as detected by IGRA and concordance of IGRA with TST LTBI detection in HIV-1-infected pregnant women.
- Determine incidence of IGRA and TST conversion (indicating potential new LTBI) in HIV-infected pregnant women accessing PMTCT.
These studies provided data on IGRA/TST detection of LTBI in pregnancy including concordance of LTBI detection methods, prevalence, and correlates of LTBI. With this information, the researchers are able to estimate incidence of post-partum IGRA conversion and identify women at risk for IGRA conversion. Data from this pilot study helped to develop cost-effective models for LTBI detection as well IPT candidate identification.
PI: Noelle Benzekri - 2015 Senegal
Title: HIV, malnutrition, and food insecurity in Senegal: a pilot study
The purpose of this cross-sectional pilot study was to obtain baseline data on malnutrition and food insecurity among HIV positive persons seeking care in two regions of Senegal and to pilot study tools for use in future studies. The specific aims of this study were to:
- Determine prevalence of malnutrition and food insecurity among HIV positive individuals in Dakar and Ziguinchor, Senegal.
- Determine the association between HIV outcomes (CD4 count, ART adherence, WHO clinical stage) and malnutrition and food insecurity.
- Pilot different methodologies for assessing food insecurity, dietary diversity, and malnutrition among HIV positive individuals in Senegal.
This pilot study was conducted among HIV positive adults receiving care in both inpatient and outpatient settings in Dakar and Ziguinchor, Senegal. The study took place at the Centre Hospitalier National Universitaire de Fann located in the urban setting of Dakar, the country’s capital, and l’Hôpital Regional de Ziguinchor located in Casamance, in a more rural setting in the southernmost region of the country. The study enrolled 100 consecutive patients (outpatients only) from each site.
Results: This study found that severe food insecurity and malnutrition are highly prevalent among HIV-infected adults in both Dakar and Ziguinchor, and are associated with poor HIV outcomes. Severe food insecurity was associated with missing clinic appointments (p=0.01) and not taking antiretroviral therapy due to hunger (p=0.02). Malnutrition was associated with lower CD4 cell counts (p=0.01). Urgent interventions are needed to address the unacceptably high rates of malnutrition and food insecurity in this population. These results have contributed to two successful grant applications, including a Career Development Award, which will fund studies to evaluate potential interventions.
PI: Jaqueline Naulikha - 2013 Kenya
Title: Evaluating the epidemiology and clinical implications of early-onset neonatal sepsis in Western Kenya
Globally, over 3 million infants died in the first month of life in 2010. In sub-Saharan Africa, the neonatal mortality rate (NMR - the number of deaths in the first 28 days of life per 1000 live births) is estimated as 44 per 1000 live births, four times the rate in Europe (11 per 1000 births) and the Americas (12 per 1000 births). In Kenya, the NMR is estimated at 31 deaths per 1000 live births and this early mortality accounts for 60% of all deaths occurring in the first year of life. Further, in the Nyanza Province of western Kenya, the NMR rate is the third highest in the country at 39 per 1000 live births.
Neonatal sepsis (NS) is the third most common contributor to neonatal deaths worldwide, with early-onset sepsis (EOS) associated with a 2-fold higher mortality rate than late-onset sepsis (onset occurring >72 hours of age). In sub-Saharan Africa where the burden of HIV is high, maternal HIV infection and associated immunosuppression may either increase neonatal exposure to pathogens that cause sepsis in the delivery process and/or the reduced transfer of antibodies may inhibit and infants’ ability contain and recover from invasive infections. Despite an established increased risk of sepsis in HIV-infected compared to uninfected neonatal children, more data is needed on the impact that maternal HIV-infection plays on the risk and etiologies of EOS.
Among HIV-infected or exposed infants, there may be other pathogens including mycobacteria that are not typically cultured but that may cause EOS in neonates, particularly those who are exposed to HIV and HIV-associated pathogens. Diagnostic biomarkers and syndromic predictors of culture-proven early onset neonatal sepsis, caused by both bacteria and mycobacteria bloodstream infections, are urgently needed to guide management of neonates suspected to have this condition. C-reactive protein (CRP) levels are one of the only biomarkers available at most Kenyan regional hospitals that have shown some potential as predictors of bacteremia in this group, but it needs to be explored further and validated.
PI: Alison Roxby - 2013 Kenya
Title: Hormonal contraception and innate immunity in the female genital tract: a prospective study
This study used samples collected during a prospective cohort study of HIV-1 acquisition among women in Mombasa, Kenya, to determine whether HIV-1-seronegative women who initiate DMPA have changes in specific markers of vaginal innate immunity. This study demonstrated that use of DMPA led to significant changes in vaginal microbiota; the quantity of G. vaginalis declined after initiation of DMPA, and this decline was sustained during long-term DMPA use. Total vaginal bacterial load also declined with DMPA use. There were marked decreases in pro-inflammatory mediators IL-6, IL-8 and regulatory protein IL-1ra following DMPA initiation, suggesting that either DMPA exposure or the observed microbiota shifts precipitated change in the immune environment of the vagina. This award allowed Dr. Roxby to obtain the pilot data necessary for a K award. In addition, there has been intense interest in the results of this study including invitations to travel to domestic and international conferences for presentations.
PI: Joseph Babigumaira - 2012 Uganda
Title: Operational Feasibility of Increased HIV Testing Through a Shopkeeper-Initiated Voucher-Based System in Kalangala District in Uganda
In low income countries, and rural areas in particular, access to health services through government health facilities or private health facilities is limited because of the high cost and large amount of resources required. For non-invasive, non-specialized health services, such as initiation of HIV testing, provision of mosquito bed nets, and treatment for febrile illnesses, it may be possible to leverage the efficiencies of the private sector to increase access. This study assessed the operational feasibility of a private sector-based system of incentivizing HIV testing in an underserved rural island district in Uganda with high HIV prevalence. The study determined the distribution of private shops, private and public health centers, and homesteads in the district to understand the relative physical accessibility of health facilities to homesteads, assessed whether existing health facilities were sufficient to sustain increased HIV testing, and established the minimum amount of money required to elicit a testing response in the population. Data from the study has been important in planning, implementing, and evaluating interventions that leverage the private sector in the provision of health services and contributing to the knowledge base on the potential utility and impact of private sector participation in improving health service delivery to underserved rural areas in poor countries. The specific aims were to:
- Determine if private shops in the Kalangala district were more physically accessible to people compared to private health facilities and to government health facilities.
- Determine if the health facilities, both private and public, were of sufficient quantity to sustain increased HIV testing.
- Determine the amount of money required to elicit an HIV test seeking response in the population in Kalangala district in Uganda.
Results: The key finding in this pilot study was that individuals with HIV traveled significantly larger distances to receive healthcare implying that there is a tangible stigma in this setting. This study also established that the private sector can be leveraged to increase HIV testing.
PI: Mary Campbell - 2012 Senegal
Title: HIV and the Oral Microbiome in ART-Naïve Adults in Dakar, Senegal
The human microbiome comprises the bacterial, fungal, and viral communities living in and on the human body, with their associated genomes, gene products, and metabolites. It is hypothesized that the microbiome is critical to health, particularly with respect to human metabolism and immunity. Research is beginning to reveal the resident organisms of the skin, oral cavity, and respiratory, gastrointestinal, and urogenital tracts of healthy individuals and of individuals affected with various disorders. However, few publications have addressed the microbiome in persons living with HIV/AIDS and these publications have focused mainly on the genital and gastrointestinal tract. In addition, almost all research on the human microbiome has been in developed world settings, so the microbiome in African populations remains largely unexplored. Dr. Campbell and her colleagues proposed a pilot study on the oral microbiome in participants recruited in the pre-antiretroviral therapy (ART) era in Dakar, Senegal, using a repository of oral fluid specimens collected from HIV-1 infected (HIV+) and uninfected volunteers. The specific aims were to:
- Compare the microbial metagenome of HIV-1+ participants and matched HIV- controls in stored oral samples from an observational cohort in Dakar, Senegal.
2. Evaluate the relationship between the oral microbiome, oral and plasma HIV-1 viral loads, and oral health conditions.
Results: The oral metagenome in HIV infected individuals did not exhibit a shift toward a higher relative abundance of periodontal pathogens such as the ‘red complex’ bacteria Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia, but analysis was incomplete, due to the large amount of sequencing data, and Dr. Campbell was unable to determine whether higher proportions of periodontal pathogens are correlated with the magnitude of oral HIV shedding, plasma viral load, and clinically apparent oral disease. The data generated through CFAR funding allowed for submission of an R01 application on the oral microbiome; although the R01 application was not funded, preparing the application was a useful scientific and career development activity for Dr. Campbell. In addition, the data generated through the award is now available to Dr. Campbell’s mentor Dr. Geoff Gottlieb and his research group for use in future projects and grant applications.
PI: Alison Drake - 2012 Kemya
Title: Determinants of Contraceptive Desire and Method among Postpartum Adolescents at High Risk of HIV and Repeat Pregnancy
Recent data suggests that hormonal contraception may be associated with HIV acquisition, with younger women demonstrating a higher risk than older women. Adolescent girls are also increasingly the face of the global HIV-1 epidemic, with over 50% of all infections occurring in women and a substantially higher risk of infection among women <24 years. Together, this data suggests that there is a growing need to examine influences on use of non-hormonal methods of contraception in adolescent populations at risk for pregnancy and HIV. The role of perceived HIV risk on selection of contraceptives in areas with a high prevalence of HIV has also not been described. Furthermore, clinicians providing family planning services may also lack training in IUD placement and have misconceptions about eligibility for IUD use.
This study investigated the determinants of contraceptive desire, type of method selected, and IUD knowledge, among postpartum Kenyan women. Dr. Drake and her colleagues recruited 32 women to participate in a survey on contraceptive knowledge and individual in-depth semi-structured interviews (IDI). After the knowledge survey was completed, women received a brief educational overview of contraceptive methods. The specific aims of this project were to
- Measure and compare determinants of contraceptive desire and type of contraceptive method between younger (age 14 – 18 years) and older (age 19 – 21 years) adolescent Kenyan women at high risk for HIV acquisition and repeat pregnancy.
- Determine whether perceived HIV risk modifies contraceptive desire and type of contraceptive method among HIV-1 uninfected adolescent postpartum Kenyan women.
- Ascertain IUD knowledge, attitudes, and practices of clinicians providing family planning services to Kenyan women
Results: Originally, Dr. Drake and her colleagues had planned to develop and pilot test a contraceptive knowledge survey among adolescents receiving infant immunization visits at the local maternal child health (MCH) clinic and implement the survey among adolescents attending 6 week postpartum study visits for a large prospective cohort of HIV acquisition conducted at these sites; however, due to delays in obtaining ethical approval in Kenya and lower than anticipated enrollment in the prospective cohort (enrollment was stopped at 1300 women, rather than the original 2000 anticipated) – Dr. Drake was unable to implement a comprehensive version of this survey in the cohort since most women had already exited the study at 9 months postpartum. Therefore, Aim 1 results were restricted to the initial contraceptive knowledge survey, but with plans to nest the more comprehensive survey within a new cohort of postpartum adolescents subject to funding availability.
PI: Susan Cassels - 2010 Ghana
Title: HIV testing and migration in an African slum: Using a network perspective
The objectives of this cross-sectional, descriptive study were to estimate HIV prevalence in Agbogbloshie (an urban slum in central Accra, Ghana), and to investigate whether migrants and the partners of migrants have differential rates of HIV than non-migrants and their partners. Households were screened for inhabitants who meet the study definition of recent migrant or traveler, defined as living outside their city/village of birth, and having moved within the last 2 years. A traveler is someone who has traveled and slept away from home at least 10 times in the last year. In households selected, all women and men age 18-49 were eligible for independent and confidential interview and HIV testing.
Results: The study team surveyed nearly 650 housing structures, from which 484 index respondents were recruited. From those respondents, the study team recruited 106 linked cohabiting sexual partners. Overall, 91% of survey respondents agreed to HIV test. Using weighting schemes based on our sample, 5.5% of the population was HIV-infected, with 2.8% of men and 7.2% of women testing positive for HIV-1 (no HIV-2 infections were diagnosed). Two-thirds of men and three-quarters of women were born outside Greater Accra, 76% of men and 77% of women had traveled at least once in the past year, and 12% of both men and women engaged in travel of at least one month. Dr. Cassels received an NIH grant to extend this work on migration, sexual networks, and HIV in Accra, Ghana, and has published 14 papers relating to this work.
PI: Brandon Guthrie - 2010 Kenya
Title: Accelerating ART Initiation Through VCT-based Interventions
The goal of this project was to assess the feasibility of providing on-site CD4 testing combined with home-based follow-up strategies, and to evaluate the effectiveness of the CD4 testing and follow-up counseling in promoting linkage to care. There has been a critical need to develop interventions to ensure that patients testing positive for HIV-1 at voluntary testing and that counseling (VCT) centers are linked with pre-ART care to maximize treatment coverage. The existing system provides minimal direct linkage between VCTs and comprehensive care centers (CCC), offering an opportunity for improvement. This study was a randomized controlled trial of four HIV/AIDS care promotion strategies: VCT counseling only, VCT counseling + CD4 testing, VCT counseling + home-based follow-up, and VCT counseling + CD4 testing + home-based follow-up. The specific aims of this project were:
- To assess the feasibility of onsite CD4 count testing at the VCT center and home-based follow-up as strategies to improve linkage to care following a positive HIV-1 test.
- To evaluate the impact of onsite CD4 count testing at the VCT center following a positive HIV-1 test on linkage to care at a CCC.
- To determine if peer counseling and follow-up after a positive HIV-1 test improves linkage with care following a positive HIV-1 test at a VCT center.
Results: Dr. Guthrie and his colleagues found that the intervention strategies they evaluated were well integrated into the standard procedures within the VCT and were acceptable to both patients and clinicians and counselors in the VCT. While not statistically significant, they found some indication that CD4 testing at the time of HIV diagnosis, peer counseling, or a combination of the two may improve linkage to care by ~20% within a facility with high baseline linkage to care. They also found preliminary evidence that such interventions may have an immediate benefit by preventing deaths that occur soon after VCT diagnosis. Future studies with greater power are needed to confirm these effects and to determine if these interventions have great effect in settings with lower baseline linkage to care. The findings from this study and the resulting infrastructure have led directly to two currently funded studies, a K01 and a UW CFAR New Investigator Award. These awards enabled Dr. Guthrie to secure a faculty position in the UW Department of Global Health.
PI: Maria Lemos - 2010 Peru
Title: Implementation of polarized HIV infections with foreskin tissue explants
The objective of this project was to test the feasibility of carrying out polarized explant infections with HIV, using fresh and frozen foreskin samples from Peruvian men. Over the past two years, this research team has developed the infrastructure and technical laboratory capacity to collect foreskin tissue and prepare samples for immune assays. This study aimed to extend this work to test their ability to carry out ex vivo HIV infections in fresh and frozen explants using polarized epithelium viral exposure and sensitively detect viral penetration. This pilot provided data and evidence to identify the best methods to collect, transport and preserve foreskin tissue collected at international locations for infectivity assays.
The four circumcisions in the project were completed with no procedure-related and all participants recovered successfully from the surgery. The samples were received in Seattle and used for the assays proposed: testing three cryopreservation methods, developing an ex vivo assay that uses human foreskin explants to replicate the polarized viral entry, and comparing foreskin tissue from 4 donors, demonstrating that the inner and outer foreskin were both equally able to support cell-free HIV infection in polarized assays: they hope that this approach could be used efficiently as a model to evaluate the efficacy of prevention strategies. This work allowed Dr. Lemos to receive a New Investigator award scholarship at the AIDS Vaccine Meeting in 2012, and to present her work at the meeting.
PI: Thuy Le - 2010 Vietnam
Title: Exposure Risk Factors for Penicillium marneffei Infection in Patients with AIDS in Ho Chi Minh City, Viet Nam: A Case-Control Study
This project was awarded conditional funding by the University of Washington and the University of Hawaii, pending approval of a resubmission at the end of a supported mentoring process. The objectives of the study were to investigate the exposure risk factors for penicilliosis in individuals with AIDS in Vietnam and to understand in spatial terms the relationship between disease, environment, and location. The review committee felt that the PI of this study is a very strong investigator and that the research question is important, however the study design needed improvement. The UW and the University of Hawaii committed joint support for this project to improve the design of this study. Dr. Le was matched to a research mentor specializing in case control study design (Dr. Noel Weiss, UW) and funding was provided for Dr. Le to attend the UW Principles of HIV/STD Research Course in Seattle, WA in July 2011. Following the supported mentoring, Dr. Le resubmitted her application and funding was awarded after its approval. The specific aims of this award were:
- To investigate the exposure risk factors and risk behaviors for penicilliosis in equally susceptible individuals with AIDS in Viet Nam using a case-control study design.
- To apply new epidemiology tools: Global Positioning System (GPS) mapping and Geographical Information System (GIS) to study geo-spatial distribution of penicilliosis cases and controls and to understand in spatial term the relationship between disease, environment and location. Creation of a penicilliosis spatial epidemiology dataset is critical for our next step of investigation to pursue environmental samplings for P. marneffei and to elucidate its ecology.
Pilot CFAR funds allowed for increased sample size to 200 cases and 400 controls in order to improve the power to detect differences in exposure/behavior risk factors of P. marneffei infection as well as expand the study to another site in Hanoi, Vietnam to capture region specific risks and to improve the generalizability of findings. This study strengthened Dr Le’s PhD application to the University of Oxford to study the epidemiology of P. marneffei and constituted a chapter of her PhD thesis.
PI: Wi-Ti Chen - 2008 China
Title: Testing a culturally sensitive questionnaire in PLWHA in China
Dr. Wei-Ti Chen’s proposed project involved a cross-sectional survey to test the Simoni model of antiretroviral adherence and use the ACASI survey approach to better understand adherence to antiretroviral therapy (ART) among Chinese people living with HIV/AIDS (PLWHA). The specific aims were to:
- Transfer a paper-format survey to a computer-format survey, and to test the ACASI feasibility in an HIV-positive population in Shanghai, China.
- Test an adherence study model by having 50 HIV-positive patients complete a culturally sensitive questionnaire. The paper version of the survey has been transferred to a computer based platform, and the study questionnaire has been tested in Shanghai.
Mental support, stigma and sleep disturbance were among the most commonly reported issues in this population. The data from this pilot award has led to the publication of 28 related manuscripts and one K23 grant.
PI: Heather Jaspan - 2008 South Africa
Title: Infant Feeding practices, immune activation, and susceptibility to HIV
This pilot study explored whether mixed infant feeding (MF) increases the level of immune activation in the infant, and whether this increased immune activation is due to an alteration in the microbial makeup of the infant gut, which may lead to increased rate of HIV transmission. The specific aims of this project were:
- To ascertain whether different methods of infant feeding impact the level of systemic immune activation measured in the peripheral blood. This proposal assessed infants in South Africa at 6 weeks of age that were fed exclusively breast fed (EBF), formula exclusively, or a combination of breast milk and formula (MF, mixed fed).
- To determine if the different methods of infant feeding, breast, formula, or mixed, alters the levels of lipopolysaccharide (LPS) in peripheral blood of the infants at 6 weeks of age.
- To characterize the differences in the gastrointestinal microflora of infants fed breast milk exclusively, formula exclusively, or mixed fed at 6 weeks of age.
- Cellular activation levels: all infants have tested HIV DNA PCR negative. The preliminary data did not identify a statistical difference between EBF and MF infants in peripheral blood mononuclear cells.
- Quantitative real time RT-PCR assays for detection of inflammatory cytokines: in the preliminary analysis, when testing for significance of individual cytokines, a higher level of TNF-a was detected in MF compared to EBF infants’ blood (p=0.02)(Fig 1). Thus far, the levels of IFN-a or -g, IL-2, -4, -10, -12, IP-10, OAS, Rantes, or TGF-b were not determined to be significantly different between the EBF and MF infant groups.
- Quantification of microbial translocation from the gut: in collaboration with Dr. Douek at the NIH, they quantified plasma levels of microbial byproducts and their ligands in these infants. Activation was measured as a percentage of CD4+ T cells that exhibited either one or two phenotypic markers. The study team observed that the activation of circulating lymphocytes was significantly correlated with sCD14, which may be due to bacterial translocation. Future studies using the 16srDNA assay or more advanced assays developed by Dr. Douek’s laboratory will likely be useful in identifying the translocation of microbial products in the in the plasma of the South African infants.
- They quantified the levels of pro and anti-inflammatory cytokines in the saliva of predominantly BF vs. MF infants and found higher in IL7 and IFNa in the PBF infants (fig 2), although these differences were not statistically significant after adjusting for multiple comparisons.
- Stool microbial makeup. There was a clustering of microbial patterns according to feeding practices.
Ongoing partnerships from this work include US and international collaborations between US, Canadian, South African, and Nigerian collaborators. The preliminary data from this award has led to two larger grants, a 2010 UW CFAR NIA and a K08 award from the Eunice Kennedy Shriver Institutes of Child Health and Human Development (K08 HD069201), and a longitudinal study to further explore feeding practices, immune activation, microbial translocation, and susceptibility to HIV.
PI: Tuofo Zhu - 2007 China
Title: Extraordinarily Low Levels of HIV-1 Infection in China
The primary goal of this pilot study was to initiate a screening for ELLHI from 100 high risk individuals in China by taking advantage of newly developed ultrasensitive high throughput PCR. This new PCR detection method is sensitive to detect one HIV-1 copy from genomic ACH2 DNA and has been applied to testing primary infected patient samples in Chinese high risk seronegative individuals. Dr. Zhu used the new PCR methods while screening for HIV-1 DNA from 5 million PBMC of 100 high risk seronegative individuals including partners of HIV-1 infected individuals and injecting drug users collected at Chinese collaborative sites. The team performed sequence analyses to verify the PCR positives. The specific aims of this project were:
- To screen for ELLHI in seronegative persons with high-risk exposures in China.
- To confirm ELLHI and characterize HIV-1 sequences in ELLHI.
Results: The team found that two of the 100 high risk seronegative individuals were HIV-1 DNA positive. The team performed sequence analyses to verify the PCR positives. They also performed further confirmation studies including second PCR test on HIV-1 DNA positive samples identified from first screening, and performed sequencing and sequence analyses for positive PCR products. One of the two high risk seronegative individuals who were initially HIV-1 DNA positive at one time point sample were confirmed with HIV-1 C2-V3 sequences and confirmed as ELLHI.
Building on research from this award, Dr. Zhu’s research group has obtained funding for two major international collaborative studies resulting in 7 publications
PI: Pedro Goicochea - 2007 Peru, Brazil, Ecuador
Title: Formative Research to Assess MSM Acceptability and Willingness to Participate in a Circumcision Trial
The aim of this project, led by Dr. Pedro Goicochea was to assess the feasibility of implementing a male circumcision intervention in four cities in South America. Interviews and focus groups took place in Lima and Iquitos, Peru (INMENSA and ACSA); Rio de Janeiro, Brazil (FioCruz), and Guayaquil, Ecuador (Equidad) and between late 2008 and early 2009. Thirty six interviews and 18 focus groups were conducted, and all interviews were transcribed, coded and entered into a qualitative database. The specific aims of this study were:
- To assess willingness and acceptability to participate in a male circumcision trial for HIV prevention
- To identify concerns and cultural and ideological differences and barriers for participating in a male circumcision trial for HIV prevention
- To identify information needs, potential recruitment strategies and recruitment messages for a male circumcision trial among HIV-negative MSM in South America
- To assess the feasibility of male circumcision intervention as a public health policy
Results: Circumcision for HIV prevention was acknowledged as a positive new strategy, but when informants were asked if they would undergo the surgical procedure, none said that they would, for various reasons. Concerns, cultural and ideological barriers to participating in a male circumcision trial for HIV prevention are related to shame and the potential lack of sex appeal and other reasons had to do with possible changes in sexual role. There was very little knowledge about male circumcision among informants in this study; some informants considered that the ability to pull back the prepuce retracted was being circumcised. Overall, male circumcision for HIV prevention in MSM would be a good public health policy if it proves to be effective, but there are challenges such as stigma and prejudice towards this population in public health services.
This award enabled Dr. Goicochea, his institution, and colleagues, to conduct investigator-initiated research in a topic of interest for HIV prevention in the South American region and enhanced South-South collaboration in HIV prevention research.
PI: Ann Kurth - 2006 Kenya
Title: Supporting Antiretroviral Adherence and HIV-1 Transmission Risk Reduction: Using Personal Digital Assistants to Standardize Counseling and Assess Patient Behavior
This study hypothesized that ART adherence and HIV transmission risk reduction can be improved by training delivered to front-line HIV clinical providers on, and evaluated among HIV-positive patients, by PDAs. Investigators developed and pilot an intervention using PDAs, the ‘Pambazuko-PALM’ version, to: 1) deliver a clinical protocol to enhance the counseling skills of nurses in supporting HIV-1 positive patient ART adherence and sexual risk reduction; and 2) survey patients regarding their ART and sexual risk behaviors and to assess counseling communication with their health providers.
The ‘Pambazuko-PALM’ version in Kiswahili and English assesses HIV patient risks in these areas, and includes a module for HIV nurses regarding evidence-based positive prevention/ART adherence support. Findings suggest that audio-enhanced computer tools may be culturally appropriate way to support health worker training as well as ART adherence and safer sex for persons with HIV, and that use of these tools in resource-constrained settings such as in Kenya is acceptable. Extensions of the pilot grant include a funded R24 sub-study that will use PDAs to train providers in an evidence-based approach to prevention with positives and medication adherence counseling, and a R01 grant with co-PI James Kiarie to utilize PDAs for spatial sampling and enrollment of heterosexual couples in a community cohort in western Kenya. The couples will complete audio-narrated PDA surveys like that piloted in this CFAR international pilot award study, and using the training techniques developed.
PI: Nelly Mugo - 2006 Kenya
Title: Promotion of Couples HIV Counseling and Addressing Barriers to HIV Disclosure and Willingness of Men to be Tested for HIV in East Africa
Objectives of this study were to: 1) facilitate uptake of couples HIV counseling and testing (CHCT) by compiling testimonials of HIV discordant couples educating communities and individuals about the significance of HIV discordancy; 2) support HIV disclosure by providing talking points and materials derived from HIV positive persons from post-test clubs, VCT and HIV care clinics; and 3) address common barriers to men’s willingness to be tested, conducting focus groups and pilot community mobilization efforts targeting promotion of couples testing. Ultimately, the project sought to develop written brochures and a booklet regarding disclosure, HIV discordancy and reasons men should be tested with their partner for VCTs, PLWHA and clinics caring for HIV positive persons.
This study explored barriers, challenges and experiences that confront couples in HIV counseling and testing as well as barriers to disclosure. In depth interviews were completed in November, 2008 and preliminary findings were presented at the at the 2010 University of Nairobi STD/AIDS Collaborative Review Meeting in Kenya. During interviews, disclosure to children was reported to be a great challenge. Out of seven HIV positive women, only two had disclosed to their children; while none of the eight HIV positive men had disclosed to their children. There was no consensus on the right age to disclose HIV status to children, with most participants reporting that the children were “too young” to understand. Preliminary data analysis on barriers to disclosure to partners has identified the following themes: fear of blame, fear of rejection, fear of abandonment, and fear of discrimination.
Most of the participants expected discrimination, separation or divorce, physical abuse, and accusations of being unfaithful from their partners; however, most of the participants received unexpected support from their HIV negative spouses. Dr. Mugo was able to secure additional funding based on preliminary results of this pilot to continue this work and Dr. Mugo has many publications that can be attributed to the greater support provided as a result of this Pilot Award.
PI: Kawango Agot - 2005 Kenya
Title: Widow inheritance and HIV: Where does the inheritor fit in the risk puzzle
The International Core awarded its first pilot grant to Dr. Kawango Agot, a former UW AIRTP scholar, to examine ‘Widow inheritance and HIV: Where does the inheritor fit in the risk puzzle?’ This study was conducted in conjunction with her Fogarty GRIP award, which was the first of its kind to study the association between the cultural practice of widow inheritance and HIV incidence in the Luo community. Dr. Agot plans to use the HIV prevalence data from the widows and inheritors, the prevalence in the general Luo population, and the detailed sexual networks of inheritors and widows, to model the role of widow inheritance in the spread of HIV among the Luo, with support from the CFAR Socio-behavioral Prevention Research Core and the CFAR Scientific Program in Mathematical Modeling. Additionally, Dr. Agot planned to work with the Clinical Retrovirology Core to explore the possibility of analyzing the viral sequences of concordant HIV-positive widows and inheritors to determine transmission patterns.