Past GHES Fellows

Fellowship Site: Makerere University, UgandaUs Institution: Yale UniversityProject Title: Oral swab testing using GeneXpert Ultra for TB screening among PLHIV Background: Tuberculosis (TB) is the leading cause of death among people living with HIV (PLHIV) worldwide (WHO report, 2019). PLHIV are at an increased risk of TB, and in some African countries, on average 60% of persons with TB have HIV (Dye, 2019). However, identifying active TB in PLHIV poses a diagnostic challenge with the traditional approaches (Candice, 2011). We aim to evaluate the performance of oral swabs to rule-out active TB disease and to facilitate early initiation of TB preventive therapy (TPT).Rationale: Early confirmation and treatment of active TB is lifesaving for PLHIV while exclusion of active TB is a critical first step in prescribing preventive therapy. This reduces mortality in PLHIV, but has low rates of uptake in most of Sub-Saharan Africa (WHO report, 2020).Study objectives:1. To compare the yield of Xpert Ultra testing of material collected from repeated (up to 10 based on prior studies) Copan FLOQswabs among PLHIV with confirmed TB (i.e., positive sputum Xpert Ultra result)2. To evaluate the sensitivity and specificity of oral swab-based Xpert Ultra testing using the optimal number of Copan FLOQswabs among PLHIV initiating (antiretroviral therapy) ART.Methods: Leveraging infrastructure from my mentors ongoing NHLBI-funded studies of TB diagnostics in Uganda, we will collect up to 10 oral Copan FLOQswabs from PLHIV initiating ART. We will compare the yield (Aim 1) and accuracy (Aim 2) of Xpert Ultra testing of material from one vs. two Copan FLOQswabs.Importance of the study: The proposed study will establish a novel method that utilizes the widely available GeneXpert platform and an alternative, simple to collect sample for TB screening to overcome challenges with the current approach to systematic screening for TB among PLHIV. The data will either support larger evaluations of the optimal protocol for oral swab analysis using Xpert Ultra or inform efforts to further refine oral swab analysis using alternative molecular assays. A rapid and sensitive screening tool of this type could result in earlier diagnosis and treatment of TB, facilitate early initiation of TPT, and pave a way for rapid MDR-TB detection in this vulnerable patient population

Fellowship Site: Ukrainian Institute On Public Health PolicyUS Institution: Yale UniversityProject Title: Adapting and testing an informed decision-making aid for opioid agonist therapy in Ukrainian prisonsEastern Europe and Central Asia (EECA) has the most rapidly growing HIV epidemic world-wide, compounded by high rates of incarceration and drug injection. Opioid agonist therapies (OAT) like methadone and buprenorphine are highly effective HIV prevention strategies for PWID, yet they are under-scaled in prisons globally, especially in EECA.OAT was newly introduced in Ukrainian prisons in 2020, with only 38 patients on treatment. While the available evidence suggests that patients would choose to initiate OAT in prisons, given their heightened vulnerabilities, they often don’t do so due to misinformation, prison-specific social pressures, and overconfidence in their ability to prevent relapse post-release. As such, an implementation science theory-informed strategy to increase OAT uptake is urgently needed to address these barriers for PWID in prisons, specifically in the EECA context.Informed decision-making (IDM) aids are evidence-based tools that may facilitate OAT implementation and scale-up in prisons as they assist PWID in deciding whether to adopt OAT or not and, if so, decide which treatment. IDM aids incorporate evidence and preferences to help prisoners with opioid use disorder (OUD) with two key decisions: 1) whether to initiate OAT in prison; and 2) which type of OAT to select. Such preferences, however, must be empirically assessed in order to understand their impact on adoption. While IDM aids are highly effective tools in health, none are available in the Ukrainian context or for prisoners. The specific aims for my GHES research are to:1)  To understand the OAT preferences of prisoners with OUD in Ukraine;2)   To systematically adapt an IDM aid for OUD to the Ukrainian prison context;3)  To assess the effectiveness of this IDM implementation tool to scale-up OAT in prisons and its hypothetical impact on HIV and HCV transmission over a 10-year horizon among PWID in Ukraine, using a Markov-based dynamic state-transition model. These findings can be used to guide adoption of this implementation strategy throughout EECA prisons, which have similar structures due to vestiges of the prison system of the former Soviet Union.

In Samoa, Courtney Choy serves as a Fulbright Research Fellow at the Ministry of Health where she is leading a project to explore mothers’ views regarding factors that influence early childhood feeding practices and physical activity levels, and to understand the role of the Samoan home environment in the development of healthy behaviors. This research project is an extension of her Yale MPH summer research under the mentorship of Dr. Nicola Hawley. She also supports various nutrition activities and community outreach programs in both the Samoan islands of Upolu and Savaii, enjoying the unique Pacific Island culture. Courtney looks forward to meeting new people during her fellowship in Samoa in hope of further promoting cultural understanding and working together to promote and sustain good health and wellbeing of communities in the Pacific.

Fellowship Site: University Of Cheikh Anta Diop, SenegalUS Institution: Yale UniversityThe ultimate goal of this proposal is to conduct an in-depth study of the virulent rifin gene expression on erythrocyte remodeling and rosetting, and assess the role of genetic diversity of the rifin genes in this process. The first hypothesis to be tested is whether rosette formation correlates with a specific rifin gene expression profile. Ex vivo RNA and short-term parasite cultures will be initiated and RNA will be harvested in the first generation at the late trophozoite to mid-schizont stage. The rosetting assay will be performed, and assessed by fluorescent microscopy. cDNA will be synthesized from extracted RNA, and rifin expression measured using a set of 15 primers previously described. The study will be conducted in Senegal, during the transmission season in Thies region, and comparisons will be made during the dry season as well. The results will have implications on our understanding of immunity and vaccines development strategies in malaria elimination strategies.

Fellowship Site: University Of Jos, NigeriaUS Institution: University Of ArizonaProject Title: Barriers and Facilitators to Cervical Cancer Screening Among Women in Jos Nigeria: A Mixed Methods Study ProposalCervical cancer is the second leading cause of cancer related deaths among Nigerian women. There is a consensus in the literature that the primary reasons for such high mortality include limited access to the human papillomavirus (HPV) vaccine, lack or access to and/or limited knowledge about cervical cancer screening, and the prevalence of HIV infection in the general population. In Nigeria, like in many low- and middle-income countries, the gold standard for cervical cancer screening is visual inspection via acetic acid, and this has proven to be cost effective in detecting cancer. However, while there are health systems in place meant to detect and treat cervical cancer, the literature suggests that there are several barriers to accessing health systems in Nigeria.The purpose of this study is to identify and describe barriers and facilitators to accessing cervical cancer screening in Central Nigeria from patient and provider perspectives and to determine ways to leverage Jos University Teaching Hospital (JUTH) process to develop and sustain increased uptake of screening services in order to downstage cervical cancer incidence among at risk women. Using a mixed-methods design, we aim to describe the barriers and facilitators to screening among women living in Jos and surrounding communities and determine the effect of HIV status on the use of screening services. We also aim to provide recommendations to JUTH in order to optimize screening services for these women.

Fellowship Site: Iccrd,B, BangladeshUS Institution: UC BerkeleyProject Title: Contribution of gut microbiome and nutritional status in clinical outcome of intravenous immunoglobulin (IVIg)-treated patients with Guillain-Barré syndrome in BangladeshGuillain-Barré syndrome (GBS) is a post-infectious, immune-mediated neurological disease. Currently, intravenous immunoglobulin (IVIg) is one of the standard treatments for GBS patients; but, one-third of GBS patients did not response with IVIg treatment. Therefore, it is utmost importance to find a biomarker of treatment response that, preferably, can be determined within the first 2 weeks after the disease onset to enable a personalized medicine approach. The gut microbial diversity and gut microbiome specially the V4 region of the 16S rRNA gene may give us a new insight in searching “hidden” dysbiosis in IVIg-responder or non-responder GBS patients with respect to healthy controls. In addition, poverty and poor nutritional status may also have influence on gut microbiome community and subsequent treatment with IVIg in patients with GBS. We will investigate the relationship between IVIg responsiveness in association with variation in gut microbiome and host nutrition in GBS that would possibly provide new information regarding effectiveness of IVIg and could lead to develop new preventative methods employing bacteria as therapeutic probiotics. Blood and fecal samples along with the clinical, demographic, anthropometric data will be collected from 25 patients with IVIg-treated GBS patients and 25 age/sex matched healthy controls from Bangladesh for microbiome study and nutritional status analysis. DNA will be extracted from all fecal samples and V4 region will be amplified by polymerase chain reactions using universal primers. The V4 region of 16S rRNA gene will be sequenced using Illumina MiSeq and sequences will be analyzed using QIIME2-DADA2 pipeline. Data comparisons, alignment, assembling, phylogenetic trees, diversity check will be done using web resources through bioinformatics tools. Data will be analyzed through unpaired t-test, one way ANOVA test and logistic regression analysis. Written informed consent from all participants and approval of the study will be obtained from Institutional Review Board (IRB) of icddr,b. Bangladesh. Data obtained from this prospective case-control study will be helpful to determine the possible roles of gut microbiome and nutritional factors in IVIg-responsiveness and to select future personalized strategies of healthcare for poor patient who will unable to bear the high expense treatment of IVIg

Fellowship Site: Addis Ababa University, EthiopiaUS Institution: University Of ArizonaProject Title: Cervical cancer screening uptake and preferences of Ethiopian women by HIV status: Comparing community- vs. facility-based practicesIn Ethiopia, a National Cancer Control Plan was first established in 2015, outlining ambitious activities to reduce cancer burden including rolling out a nationwide cervical cancer screening program using visual inspection with acetic acid (VIA) (Ethiopian Federal Ministry of Health, 2015). In recent years, providers have been trained to provide facility-based VIA cervical screening for all women, including those living with and without HIV, and were equipped with materials such as cryotherapy machines to increase coverage of single-visit “screen-and-treat” cancer prevention services. Still, Ethiopia experiences low uptake of screening, ranging from 0 to 24.8% in various communities (Tilahun, 2019; Aynalem, 2020; Tekle, 2020; Ruddies, 2020; Belete 2015). Provider-reported challenges to screening implementation include low community awareness, environmental barriers, inaccessibility of health services, and the perception that traditional cervical exams are embarrassing or culturally taboo (Gizaw, 2019; Tilahun, 2019; Getachew, 2019; Bayu, 2015). Therefore, there is an increased interest in community-based approaches to screening that increase accessibility of services, allow women to self-sample in the comfort and privacy of their own home, and reduce the burden of screening on patients (Gizaw, 2019). Some concerns exist for women living with HIV who may have client privacy jeopardized during home visits by health workers and who may prefer to access cancer screening services at a health facility, supplemental to regular antiretroviral therapy visits. This mixed method research project will explore women’s perspectives and preferences for screening in community and facility settings, critically assessing appropriateness of various approaches with regard to HIV status, and will culminate in a pilot study of an intervention to improve cervical cancer screening uptake through community-based HPV self-sampling. GHES Fellow, Breanne Lott, will apply her training in health promotion sciences, global health, and cultural anthropology to assess cervical cancer screening from a health behavior lens. She looks forward to returning to Ethiopia where she has previously lived and worked as a Peace Corps Volunteer and Cervical Cancer Epidemiology Education in Special Populations Fellow. Breanne will collaborate with mentors Professor Damen Hailemariam and Dr. Dawit Worku of Addis Ababa University and Dr. Purnima Madhivanan of University of Arizona.

Fellowship Site: Ukrainian Institute On Public Policy, UkraineUS Institution: Yale UniversityProject Title: The Syndemic Approach to Addressing HIV, Opioid Use Disorder, and Depression within a Primary Healthcare Setting in UkraineHIV in Ukraine is concentrated among people who inject drugs (PWID).2,4,5 Previous studies have shown that HIV and opioid use are syndemic with and compounded by underlying depression and anxiety.6-8 The prevalence of psychiatric disorders among PWID in Ukraine exceeds 50%,9,10 and is higher among PWID with HIV.11 These mental health states increase HIV risk and also impede HIV treatment, as my previous work in Ukraine suggests.11 Moreover, international guidelines suggest that all people with HIV (PWH) should be screened for depression, but screening and treatment is suboptimal in most settings, including Ukraine. In order to prepare for a future trial of integrating screening and treatment for depression in clinical care settings, specifically for PWH, we will explore the effects of depression on a number of HIV outcomes in PWH at both primary care and addiction treatment settings. Therefore, the aims of this research are:1.    To examine the prevalence and variation of depression among PWID with HIV on MOUD  and assess whether and how depression and depression severity contribute to HIV treatment outcomes, using the subset of PWH in the MEDIUM and IMPACT studies.2.    Because of the concentration of PWH in PCC and addiction treatment programs is high (45-50%), we will explore the barriers and facilitators of integrating depression screening and subsequent treatment for for depression for PWH in these settings. We will assess barriers and facilitators using nominal group technique (NGT). Because these barriers may differ based on whether a PCC has already integrated other services (e.g., IMPACT sites), I will match PCC at 6 IMPACT sites with providers in the same city for six non-IMPACT sites. During NGT, I will explore: a) what gets in the way of integrating screening and care for depression for PWH into your clinic; and b) what would need to change before integrating care for depression for PWH into your setting. Findings from aims 1 and 2 will help guide a future pilot study of integrating care for depression for PWH into primary care settings to improve HIV incidence and treatment outcomes.

Fellowship Site: University Of Gondar, EthiopiaUS Institution: Yale UniversityProject Title: Improving clinical cardiac care at the University of Gondar Comprehensive Specialized Referral Hospital by assessing the influence of organizational cultureGlobally, cardiovascular diseases are a leading cause of death (WHO, 2017), and have overtaken the disease burden due to HIV/AIDS, TB and respiratory infections, malaria and diaharria (WHO, 2018). There has been a transition from communicable to non-communicable disease, and cardiovascular disease is the leading communicable disease that causes mortality in Ethiopia. Improving organizational culture helps to improve clinical outcomes in different healthcare settings (Curry et al., 2018). Despite increased global awareness on the influence of organizational culture in hindering and supporting the success of healthcare centers, there is a scarcity of studies in a low-income countries including Ethiopia. The purpose of this study is to improve clinical cardiac care by assessing the influence of organizational culture at the University of Gondar Comprehensive Specialized Referral Hospital. The study aims to (1) characterize the organizational culture of the University of Gondar Specialized Referral Hospital (2) explore healthcare organizational culture change needs and identify barriers to culture change at the University of Gondar Comprehensive Specialized Referral Hospital and (3) improve clinical cardiac care services by assessing the influence of healthcare organizational at the Cardiac Unit of the University of Gondar Comprehensive Specialized Referral Hospital. The study is designed to follow a mixed research method to collect both qualitative and quantitative data from hospital employees. It is planned to use the organizational culture for the cardiovascular care scale to measure the organizational culture of the University of Gondar Comprehensive Specialized Referral Hospital. The instrument consists of 31 items to measure the five domains of hospital organizational culture including the learning environment, psychological safety, and commitment to the organization, senior management support, and time for improvement efforts.  Interview and focus group discussion with selected cardiac unit heads, workers and patients are preferred data collection tools to explore healthcare organizational culture change needs and identify barriers to culture change. The findings of this research will be used to improve clinical cardiac care at the University of Gondar Comprehensive Specialized Referral Hospital.

Fellowship Site: University Of ZimbabweProject Title: Implementing and evaluating an electronic herbal medicine reconciliation tool towards safe integration among HIV infected people (CHeMU_i.e.)The goal of my research is safe integration of conventional and herbal medicine. While people living with HIV appreciate the effectiveness of antiretroviral therapy, they still choose to use herbal medicines for various reasons. However, their clinicians are often unable to guide them because of the limited clinical evidence base. This exposes patients to adverse events such as hypersensitivity reactions, toxicity and herb-drug interactions which may lead to poor adherence, treatment failure and drug resistance. Medication reconciliation lists that do not incorporate herbal medicines may also inadvertently overlook related adverse events, particularly in HIV clinics were herbal medicine use is high. Previous work showed that medication reconciliation tools and processes employed at HIV clinics in Zimbabwe are not targeted enough to document herbal medicine use in a useful way. However, clinicians considered herbal medicine reconciliation important and were willing to probe and document use provided a concise tool was made available. This proposal will therefore implement electronic herbal medication reconciliation into HIV clinical practice and evaluate its utility and acceptability among HIV clinicians. An electronic herbal medicine use data capturing tool will encourage communication and standardised documentation of herbal medicine use by HIV care providers. To achieve this, a paper-based herbal medicine data capture tool developed with input from clinicians and current literature recommendations, will be used to augment electronic medication history taking tools currently in use at selected HIV clinics. Clinicians at the sites will be trained on how to use the tool and asked to incorporate it into daily practice. Consenting clinicians involved with medicine history-taking will be invited to participate in focus group discussions to evaluate their experiences. The database will also be reviewed to determine any change in the rate of herbal medicine use capture after implementation of the tool. The vision is to establish an electronic herbal medicine use database that will serve as a source of information. This database will help to rapidly identify herbal medicines that should be prioritised for further clinical assessments such as potential herb-antiretroviral drug interactions, effect on liver and kidney function, as well as impact on HIV treatment outcomes.

Fellowship Site: Manipal Academy Of Higher Education, IndiaProject Title: Lived experience of the double burden of COVID-19 and cardiac diseases among women in a coastal town of South India: An exploratory studyCOVID-19 patients with underlying cardiac diseases have an extremely poor prognosis, with higher mortality compared to those without a cardiac history. In the Indian subcontinent, with patriarchal societies, the double burden of COVID-19 infection and a cardiac complication can increase the health care expenditure of the families. Social security schemes and Direct Benefit Transfer policies might sometimes fall short to meet the demands and might not be timely due to bureaucracy issues. The present study is aimed to focus on the lived experience of these women during the unexpected pandemic. Aim 1: Using qualitative methods, to explore the experiences of women with cardiac diseases during COVID-19 pandemic from their own perspectives. Aim 2: Using qualitative methods, to understand the constraints faced by women with cardiac dieases with respect to health seeking behaviour and treatment in the context of COVID-19 pandemic. For Aim 1, we intend to explore the familial and in-patient experiences of women with cardiac manifestations adopting a descriptive, qualitative design with a phenomenological approach. Purposive sampling and in-depth interviews will be conducted to uncover the stressors, challenges and barriers faced by women to access and avail diagnosis and treatment services in the region. These interviews would provide insights and reveal the interpersonal and sociocultural context affecting their experience during the pandemic situation For Aim 2, the interviews will explore how the participants faced the changes in health care services due to COVID-19 situation. This will help comprehend contextual changes like loss of jobs, home bound spouse domestic violence, home-bound children with online mode of schooling with increased demands on their personal time and space. The changing family and social dynamics will be explored to understand their influence on the treatment seeking behaviour and if any coping strategies were adopted to circumvent the transition in familial and community environment. The outcome of this research can enable the frontline health workers and skilled health care providers to put in place guidelines for co-existent emergencies in future.

Fellowship Site: Kenya Medical Research InstituteUS Institution: Stanford UniversityDengue virus (DENV) is the most widespread arboviral disease worldwide, causing 390 million infections annually. Incidence of this potentially life-threatening infection has increased 30-fold in the last 50 years (WHO, 2012) due to urbanization, climate change, water insecurity, and inadequate vector control. Chikungunya virus (CHIKV), which causes post-infectious arthritis or neurologic sequelae in up to half of infected individuals, has also emerged recently. These arboviruses are spread by Aedes aegypti, an efficient vector that thrives in urban settings, particularly slum-like conditions with poor water infrastructure. Transmission is affected by human behaviors and environmental conditions. Mosquito density and vector competence for viral transmission are particularly influenced by rainfall and temperature. Recent laboratory models suggest the optimal temperature for DENV and CHIKV in Aedes aegypti is 29 °C, much higher than the 25 °C optimum modeled for malaria. A shift towards higher global temperatures could contribute to a shift from malaria to more arboviral infections across the African continent. LaBeaud recently validated the model of optimum temperature for malaria in Kenya. Under LaBeaud’s mentorship, I aim to evaluate the impact of temperature on DENV and CHIKV transmission at the GHES field sites in Kenya, comparing these empirical findings to Mordecai’s ecological model and potentially validating the important impact temperature has on vector-borne disease transmission in Kenya. Potential impact: Identifying optimal temperature ranges for DENV and CHIKV can help predict where these viruses may emerge in coming years with climate change. This would allow for increased surveillance, vector control planning, and medical provider training.

Fellowship Site: Universidad Peruana Cayetano HerediaUS Institution: Yale UniversityProject Title: Prevention of Osteoporosis-Related Fractures Among HIV Positive Women in Peru: Assessment of Risk Scores, Knowledge and Health BeliefsAround the world, osteoporosis-related fractures cause significant morbidity and mortality. Patients with HIV are at increased risk for osteoporosis and fractures due to a combination of traditional risk factors, the nature of chronic infection, and antiretroviral therapy. Dual-energy x-ray absorptiometry (DXA) is the gold-standard technique to assess bone mineral density (BMD), the measure by which osteoporosis is diagnosed. Because it is often not economically or logistically practical to obtain DXA scans for all individuals of a certain age or gender, osteoporosis risk scores have been developed to assist clinical judgement and identify patients at highest risk so they can be referred for DXA screening. In countries like Peru, where DXA machines are not widely available, this targeted approach is particularly important.In the general population, several osteoporosis risk scores have been validated, however, none of these tools have been studied in HIV positive women in Latin America, and no literature exists on how they can be incorporated into osteoporosis prevention strategies for this population. To optimize the uptake of prevention strategies among women with HIV, understanding patient-oriented factors such as knowledge and health beliefs regarding osteoporosis is critically important. Approximately 1250 women receive care at the HIV clinic at Loayza Hospital in Lima, Peru. Our proposal will work with a cohort of HIV-positive women over the age of 50 years with previously collected BMD results to measure the performance characteristics (sensitivity, specificity, area under the receiver operating characteristic curve) of four validated osteoporosis risk scores (Osteorisk, SCORE, ORAI, OST). Patients returning for routine follow up to the HIV clinic will complete the osteoporosis knowledge test and osteoporosis health beliefs score. These surveys are theory-driven, validated tools for assessment of osteoporosis-related knowledge and health beliefs that have been used successfully among community-dwelling Peruvian women. The ultimate goal of our project is to provide valuable insight into how screening and prevention of osteoporosis may be optimized, within the resource practicalities of countries like Peru, for an HIV positive population.