A collaboration between the Duke Global Health Institute and the Kilimanjaro Clinical Research Institute. Funded by the Fogarty International Center and the National Institute of Allergy and Infectious Diseases.
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.
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
Option B+ team members Melissa Watt and Cody Cichowitz traveled to Cape Town, South Africa to present at the AIDS Impact Conference, an international behavioral and psychosocial science conference addressing issues related to HIV/AIDS prevention, treatment, and care. Cody gave two oral presentations reflecting work from the B+ cohort and analysis of Kilimanjaro region medical record data. His presentations on retention in care across the PMTCT continuum under Option B+, and HIV-related shame, HIV acceptance, and attitudes about long-term ART fit well into their respective symposia, “Preventing mother-to-child transmission: new insights” and “Stigma: the invisible killer.” In addition to sharing early results from the team’s work, the conference provided valuable opportunities to meet fellow researchers, share ideas, and foster a renewed commitment to addressing the AIDS epidemic.
As part of the Masters of Science in Global Health program at the Duke Global Health Institute (DGHI), students complete a faculty-mentored, field-based research experience between the first and second years of their program. The Option B+ team was lucky to have a wonderful MSc student, Dr. Lilian Chumba, join the team during her time at DGHI. Over the summer of 2017, Lilian, a trained medical doctor from Kenya, completed qualitative data collection focusing on Aim #1 of the study, examining facility- and provider-level factors affecting Option B+ implementation. Lilian completed observation protocols at three of the Option B+ healthcare facilities, noting the clinic set up, provider-patient interactions, provider-provider interactions, clinic record keeping, and relationships among the clinic departments. She complemented these observations with 30 key informant interviews with health service providers involved in HIV care for pregnant women, including doctors, nurses, and home-based care providers.
Lilian presented preliminary findings from her project at the DGHI Student Showcase on November 1st, 2017 and will continue to analyze the data as part of her Master’s thesis. The data are crucial to understanding how the Option B+ protocol is implemented in Tanzanian healthcare facilities, and addressing the facility-level factors that support or impede successful implementation. Lilian’s work will be used to make recommendations to local clinics on how they may improve in their implementation of the Option B+ protocol, and will also inform new interventions aimed at addressing lapses in HIV care.
According to conference organizers, the one-day meeting was inspired “by the large and growing number of women in global and public health, and frustration about the lack of diversity and representation of women in global health leadership positions.”
“Women comprise as much as 75% of the health workforce in many countries and the majority of students in academic global health tracks. Yet they hold only 8 of 34 World Health Organization executive board positions and fewer than 1 in 4 global health leadership positions at the top 50 U.S. medical schools.’
Drs. Watt and Mmbaga met with other emerging and established women leaders in the field, discussed strategies to engage and support women in the workforce, and learned how to build their own leadership skills.
We are grateful to have these two accomplished women leading our team and providing wonderful mentorship and support!
The Option B+ team achieved an important milestone today, reaching our goal of enrolling 200 clients in our cohort! This completes our study enrollment, but there is no shortage of work ahead. The team will continue to follow all 200 women, with a brief check-in after they have given birth, and completing follow-up surveys at 3, 6, and 12 months postpartum. The team will also continue to focus on the qualitative portion of the study, which involves completing interviews with a subset of 24 cohort participants at enrollment and again at 3 months postpartum. Will will also be reviewing medical record data to help us gain a comprehensive understanding of the implementation of Option B+ in the Kilimanjaro region. We are so appreciative of our hardworking team who have helped to make this happen, especially the study nurses in charge of enrolling participants and completing the study interviews. We would also like to extend a heartfelt thanks to our participants, who are dedicating their time and energy to helping us understand and improve care engagement among pregnant and postpartum women.
It was a bittersweet goodbye as the Tanzania team said farewell to Cody Cichowitz, who spent the last year in Moshi working on the project as a Doris Duke International Clinical Research Fellow. The fellowship program, sponsored by the Doris Duke Charitable Foundation, supports the training and professional development of the next generation of clinical investigators working in global health by offering a year-long mentored research opportunity in global health.
“The program not only provided a unique opportunity to engage in global health research and build practical experience, but it also created a space to learn from and work alongside Tanzanian researchers. Working in Tanzania for a year helped me develop foundational research skills, but I’m most grateful for the relationships I built and the ways in which I was able to learn about the health care system and challenges facing patients and providers.”
Cody is an invaluable member of the Option B+ team, and while the Tanzania team will miss his presence at KCMC, we look forward his continued involvement in the study. We wish him the best of luck as he returns to Johns Hopkins University to complete his MPH and MD degrees.
On May 26, 2017, the Duke Global Health Institute (DGHI) co-hosted a symposium at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania, where research teams shared their ongoing projects related to the prevention of mother-to-child transmission of HIV (PMTCT) in Tanzania. The symposium brought together a range of stakeholders to discuss findings and consider how research might best inform the implementation of national PMTCT guidelines.
Panels included updates on PMTCT policy guidelines, considerations of the barriers to care among HIV-infected pregnant women, strategies for capacity building in research and statistics, implementation science research on PMTCT care delivery, and presentations of ongoing research by KCMC students and trainees. The symposium welcomed representatives from the Tanzanian Ministry of Health, Elizabeth Glaser Pediatric AIDS Foundation, and several local health facilities.
The symposium was organized by the Option B+ study PIs Blandina Mmbaga, director of the Kilimanjaro Clinical Research Institute, and Melissa Watt, assistant research professor of global health at DGHI and Associate Director of the Duke Center for AIDS Research Social and Behavioral Sciences Core. The intended purpose of the meeting was to connect researchers, policy makers, and care providers working on PMTCT services. The symposium also provided an opportunity for Drs. Mmbaga and Watt to present on study progress, insights, and next steps, and for Dr. James Ngocho to share his findings on antenatal depression and anxiety among women in the B+ cohort.
“The meeting was an important step in closing the research-implementation gap in PMTCT care,” Watt noted. “The reason we do research is to improve care delivery and patient outcomes, and this symposium offered an opportunity to reflect on how we can make sure our research is serving that goal.”
Read more about the symposium and ongoing PMTCT research in Tanzania here.