Author: Elizabeth Knippler

Dr. Preeti Manavalan has been a member of the Option B+ study team since 2017, when she joined the team during the research year of her Infectious Diseases fellowship at Duke to help with data collection, analysis, and dissemination of findings. As a Fogarty Global Health Fellow, Dr. Manavalan is completing a year of research at Kilimanjaro Christian Medical Center in Moshi. During this time, she has had the opportunity to pursue her own research interests related to development of high-quality care models for people living with HIV and non-communicable diseases.

For her research, Dr. Manavalan aims to develop a task-shifting intervention to address hypertension among HIV-infected adults in Moshi. Hypertension is a leading risk factor for cardiovascular mortality and is an emerging threat among people living with HIV, but efforts at control have been largely neglected in resource-limited settings. Dr. Manavalan is collecting qualitative data to better understand the standard of care for hypertension management and to identify barriers and facilitators for improved care. She has screened patients for hypertension to determine the prevalence among HIV-infected adults engaged in care, and is assessing their risk factors, knowledge, attitudes, and practices of hypertension. Using this qualitative and quantitative data she will develop an integrative task-shifting intervention to improve blood pressure control among adults engaged in HIV care, and will evaluate its feasibility, fidelity and acceptability with a pilot feasibility study.

Dr. Manavalan hopes that results from her study will be used as formative data to inform future research for the development, integration and scale-up of task-shifting strategies to improve cardiovascular outcomes among people living with HIV.

From December 3-5, researchers, policy makers, government officials, and stakeholders involved in HIV work met in Arusha, Tanzania to share and discuss strategies, guidelines, innovations, and research findings on HIV and AIDS. The goal of the meeting was to disseminate the health sector HIV and AIDS guidelines and strategies, to share innovations and research findings to inform the HIV and AIDS response, and to prepare regional action plans to address identified challenges. Over the course of the meeting, the Option B+ team had three presentations and participated in discussions to inform the National AIDS Control Program (NACP)s action plan for the Northern Zone of Tanzania.

On the first day of the meeting, Linda Minja and James Ngocho presented data on retention in HIV care under Option B+ across 39 clinics in the Kilimanjaro region. The analysis used medical record data obtained from the Tanzania National AIDS Control Database. Findings highlighted the high loss to follow-up during initiation of PMTCT care and during the postpartum period, with higher loss of newly diagnosed clients. Results pointed to the need for targeted interventions that recognize the vulnerability of newly diagnosed patients, and address both early and postpartum retention.

On the third day of the meeting, Dr. Melissa Watt, who was visiting from the U.S., presented results from the Option B+ cohort to continue the conversation about care retention among pregnant and postpartum women. After sharing findings about facility-level implementation of Option B+ guidelines, care engagement at six months, depression, HIV disclosure, and barriers to care, the presentation concluded with a discussion of next steps, leading into an introduction of the stigma-based counseling intervention. Dr. Jane Rogathi then presented an overview of the new R21 activities and goals. The presentations stimulated great conversation, ideas, and support from attendees.

We are thrilled to celebrate the graduation of our study coordinator, Dr. Jane Rogathi, who received her PhD in Epidemiology (Public Health) from Kilimanjaro Christian Medical University College on November 17. Jane completed her thesis research on intimate partner violence and depression affecting women during pregnancy and after childbirth. The study was based in antenatal clinics at two sites in Moshi municipality. Jane’s expertise and experience in the clinic is a great asset to our team, and we are so grateful to have her helping to lead the implementation of our study.

Hongera sana, Dr. Rogathi!

In 2015, Dr. Melissa Watt received a small grant from the Duke Center for AIDS Research to explore HIV care engagement for women initiating ART during pregnancy in Cape Town, South Africa. This research, conducted in collaboration with researchers at the University of Cape Town, helped lay the foundation for the team’s current work in Tanzania and Dr. Watt’s broader research program on the prevention of mother-to-child transmission (PMTCT).

In Cape Town, researchers conducted repeat interviews with twenty women during pregnancy and again within three months after giving birth, to explore and understand the challenges women faced and the support they received navigating their HIV care as a new mother. Disclosure of women’s HIV status emerged as an important theme, with findings detailed in a manuscript recently published in AIDS and Behavior. The Duke Global Health Institute (DGHI) featured the article on its website and in its newsletter.

You can read the research brief and find a link to the article here.

On August 9, 2018, the team hosted a scientific symposium and stakeholder meeting at KCMC to discuss addressing HIV stigma in PMTCT in the Kilimanjaro Region. The aim of the meeting was to bring together scientists and health practitioners working on PMTCT-related activities in order to share our preliminary research findings on PMTCT in the Kilimanjaro Region, and  solicit input on an intervention to address HIV stigma in the context of PMTCT. The meeting was attended by representatives from the Tanzanian Ministry of Health, the Elizabeth Glaser Pediatric AIDS Foundation, the KCMC Community Advisory Board (CAB), and representatives from local healthcare facilities.

The day’s presentations and group activities generated great discussion about the study findings and implications for PMTCT care in the region, as well as ideas for the proposed stigma intervention.

It is our hope that this symposium provides a platform from which we can identify areas of synergy and collaboration to strengthen PMTCT research and implementation within Kilimanjaro Region.

After a year of hard work coordinating the Option B+ study at KCMC, Godfrey Kisigo will have the chance to further his training in global health research at the Duke Global Health Institute. Godfrey will bring his multitude of experiences, dedicated work ethic, and bright smile to Durham as he joins 29 other classmates as part of the new Master of Science in Global Health cohort at DGHI.

While the KCMC team was sad to see Godfrey leave Moshi, we are grateful that Godfrey will continue to work with the Option B+ team as he completes his studies at DGHI!

Read more about Godfrey and his fellow classmates at DGHI here.

 

 

As the Option B+ team prepares for the launch of the new stigma study, we are excited to welcome Jane Rogathi as our Study Coordinator at KCMC. Jane is a nurse with graduate-level experience in epidemiology and applied biostatistics. As part of her research for her PhD, she conducted studies to examine intimate partner violence affecting women during pregnancy and after childbirth. Her research interests in reproductive and mental health, as well as her work ethic, thoughtfulness, and leadership, will be a great asset to the team. We look forward to future study successes under Jane’s direction. Karibu sana!

 

The Option B+ Team continues to make great progress as we wrap up our 12-month follow-up of cohort participants and continue data analysis. Preliminary findings have helped us to better understand the challenges pregnant and postpartum women face, and demonstrate the need to address stigma among pregnant women navigating prevention of mother-to-child transmission (PMTCT) services.

Dr. Watt and Dr. Mmbaga responded to a funding opportunity to develop stigma reduction interventions leading to better outcomes for the prevention and treatment of HIV/AIDS and improved quality of life of people living with HIV in low- and middle-income countries. The team saw a unique opportunity to address HIV stigma at entry into antenatal care (ANC), reaching all pregnant women who receive routine HIV testing and counseling services. Addressing HIV stigma at the first ANC visit can help women who test positive to overcome stigma-related barriers to the initiation and maintenance of HIV care, and can help women who know their status to deal with HIV-related stigma during pregnancy and transition to PMTCT services.

With funding from the Fogarty International Center (R21 TW011053), the team will develop and pilot test a brief, scalable intervention called Maisha (Swahili for ‘life’), a counseling intervention that addresses HIV at entry into ANC. We are excited to build upon our existing PMTCT research infrastructure and collaborations with local clinics.

Our study coordinator, Godfrey, visited Duke at the end of February to attend the Global Reproductive Health Leadership Symposium. The goal of the symposium was to bring researchers from DGHI priority partner locations in East and South Africa together with their mentors and other Duke faculty, students, and trainees “to strengthen research capacity, develop leadership and mentorship skills, and identify gaps in reproductive health research in sub-Saharan Africa.”

Over three days, Godfrey attended presentations, engaged in discussions, and participated in research skills sessions focused on developing leaders in global reproductive health. Godfrey had great things to say about his experience:

‘Attending the Global Reproductive Health Leadership symposium presented a unique experience to interact with notable researchers from East Africa and Duke University. I enjoyed the mentorship session the most, as it was featured with the presence of my mentor. I believe we have created potential collaborations in reproductive health research across East Africa and Duke University at large. I should not forget to mention that food was amazing, and the organizing committee was rocking.’

Godfrey was also present at Duke to celebrate the launch of the Center for Global Reproductive Health, led by Dr. Megan Huchko. At the event, which coincided with International Women’s Day, Godfrey was one of three speakers who shared a short story about how he became invested in improving the health of women around the world. We share Godfrey’s optimism about the future successes of the Center!

‘I am indeed grateful to be part of this inauguration. I have so much hope that the center will strive to address inequalities in reproductive health. The center is made up of an enthusiastic team, and their commitment to reproductive health research will improve quality of life to many, especially our women from low- and middle-income countries.’

As we follow our cohort of HIV-infected women in Tanzania, it is important for us to place our research within the broader context of Option B+ implementation across Africa. Our team conducted the first systematic review synthesizing the growing body of literature describing the PMTCT care cascade in the Option B+ era in Africa. The review was guided by 2 study aims: (1) to summarize the proportion of HIV-infected pregnant women initiating and retained in HIV care and Option B+ programs at various time points after starting lifelong ART, and (2) to identify the factors associated with retention in HIV care and loss to follow-up under Option B+.

The analysis, led by Brandon Knettel and Cody Cichowitz, includes 35 articles representing more than 60,000 African women initiating ART under Option B+. Pooled estimates of retention were 72.9% at 6 months for studies reporting < 12 months of follow-up and 76.4% at 12 months for studies reporting ≥12 months of follow-up. These retention rates, which are lower than those of the general adult population, underscore the need for interventions that target the unique and complex circumstances of women initiating care under Option B+. Risk factors for poor retention included younger age, initiating antiretroviral therapy on the same day as diagnosis, initiating during pregnancy versus breastfeeding, and initiating late in the pregnancy. Retention was compromised by stigma, fear of disclosure, and lack of social support. Furthermore, the review notes the inconsistency of methods used across the studies, and in response includes recommendation for future studies measuring retention to help standardize procedures for tracking and reporting retention.

Full citation:

Knettel, B. A., Cichowitz, C., Ngocho, J. S., Knippler, E. T., Chumba, L. N., Mmbaga, B. T., & Watt, M. H. (2018). Retention in HIV care during pregnancy and the postpartum period in the Option B+ era: A systematic review and meta-analysis of studies in Africa. Journal of Acquired Immune Deficiency Syndromes (JAIDS) 15;77(5):427-438. doi: 10.1097/QAI.0000000000001616

Abstract and full article available at:

https://www.ncbi.nlm.nih.gov/pubmed/29287029