Dr. Ralph Baric Finds Dengue Fever Antibodies Can Fight Zika

Business Student Heads to Zambia

Jane Chaffee ’17 MBA/MSPH spent nearly three weeks in Zambia this May with Global Business Projects.

Jane Chaffee ’17 MBA/MSPH spent nearly three weeks in Zambia this May with Global Business Projects.

By Jamie Gnazzo, Features Writer, UNC Global

It wasn’t until her first job out of school that Jane Chaffee ’17 MBA/MSPH realized her passion for public health. After graduating from the University of North Carolina at Chapel Hill with a bachelor’s degree in political science in 2011, Chaffee accepted a position at a small healthcare law firm in Washington, D.C. The work sparked her interest in the world of healthcare, and combined with the global perspective gained from her political science studies, Chaffee decided to return to Chapel Hill to pursue her master’s degree in health policy and management at the Gillings School of Global Public Health.

Within the first year of her master’s program, Chaffee also enrolled in the MBA program at Kenan-Flagler Business School. It was almost serendipitous, then, that one of the Global Business Projects offered through the school focused on the expansion of the women’s department at the University Teaching Hospital (UTH) in Zambia.

“As soon as I saw the email about that project back in February, I knew I had to apply,” Chaffee says. “It was the perfect combination of my interests.”

The maternity ward at the University Teaching Hospital in Zambia. Photo courtesy of Rachel Kreis.

The maternity ward at the University Teaching Hospital in Zambia. Photo courtesy of Rachel Kreis.

With Global Business Projects – a program that gives students the opportunity to consult on projects for real companies around the world – Chaffee served as the project leader for a team of seven students tasked with developing a business plan to expand the UTH women’s department, which is affiliated with the UNC Department of Obstetrics and Gynecology’s Global Women’s Health division.

For two and a half weeks in May, Chaffee and her team worked on the ground in Zambia’s capital city, Lusaka, interviewing clinicians and nurses, observing hospital practices, and meeting with government officials and construction companies. The team collected a slew of data during their time in Zambia in order to determine the cost of building an entirely new women’s hospital, and what such a facility would require.

“This project gave us a chance to synthesize what we’ve learned in the classroom and apply it to the real world,” Chaffee says. “I appreciated the gravity of the situation, because the work we were doing actually had a life-or-death aspect to it. There are a lot of women in Zambia who die because of a lack of resources, and we were trying to change that.”

A midwife swaddling a baby at the University Teaching Hospital in Zambia. Photo courtesy of Rachel Kreis.

A midwife swaddling a baby at the University Teaching Hospital in Zambia. Photo courtesy of Rachel Kreis.

Returning stateside, Chaffee’s team finalized a presentation that included their findings from data collection and recommendations for the new hospital that will be used as a pitch deck for potential investors. Chaffee notes that her team’s work marked only the starting point for the women’s hospital project, which will likely extend for another three to five years.

“From a very personal point of view, this project solidified my passion for the area of healthcare and showed me that business can facilitate public health initiatives,” Chaffee says. “It’s the most important thing I’ve done in my entire school career.”

With a year left before she completes her graduate programs, Chaffee will spend the summer in Boston interning for the center for external innovation at a Japanese pharmaceutical company. “It’s an interesting shift to go from the work we did in Zambia to thinking about in-licensing and deals with biotech firms because it’s a completely different side of healthcare,” she says.

Though still undecided about the path her career will follow come graduation next May, Chaffee found a love for the type of consulting work the Global Business Project offered.

“That kind of work requires a more creative thought process and has a great potential for impact,” Chaffee says. “Especially in Zambia, the culture is much more intimate and the way people interacted with each other was inspiring. That really humanized the business process, and it’s that human side we tend to forget in the U.S.”

Dr. David Wohl Discusses PrEP Knowledge Gap with Asheville Citizen-Times

Rotary Peace Fellows’ Projects Merge Global and Local Health

Osborn Kwena, MPH, credits his education at the Duke-UNC Rotary Peace Center and Gillings School of Global Public Health with preparing him for a career in water, sanitation and hygiene.

Osborn Kwena, MPH, credits his education at the Duke-UNC Rotary Peace Center and Gillings School of Global Public Health with preparing him for a career in water, sanitation and hygiene.

Growing up in Busia, Kenya, Osborn Kwena, MPH, never saw himself coming to the United States let alone graduating from one of the top American graduate schools for public health. Yet, his first job at Innovations for Poverty Action, a non-profit research organization that provided water, sanitation and hygiene (WaSH) interventions in rural areas, opened his eyes to the disproportionate access to clean water in his country.

“I was privileged to grow up in an environment where we had running tap water and proper sewerage facilities,” Kwena says. “I had heard that was not the case every where in Kenya. But hearing this and seeing this are very different. Working at Innovations for Poverty Action, which required travelling and traversing the rural areas of Kenya, was an eye-opening experience. It allowed me to see firsthand the poverty and the gaps – lack of access to safe and clean drinking water, inadequate sanitation and open defecation practices in these communities.”

After working for four years with Innovations for Poverty Action, Kwena’s desire to pursue a career in public health solidified. Two students from UNC also worked with him and they told him about the Duke-UNC Rotary Peace Center. Funded by the Rotary Foundation, the Duke-UNC Rotary Peace Center is one of six centers worldwide. It is the only one in North America and the only one jointly supported by two universities. Through the Rotary Peace Fellowship Program, Rotarians and the Center select up to 10 fellows each year who desire to improve world peace and promote conflict resolution in their future careers. In addition to classes and a core curriculum in peace and conflict resolution for all fellows at both universities, the fellows also earn a master’s degree at either Duke or UNC. Kwena applied to the fellowship and the UNC Gillings School of Global Public Health’s Department of Environmental Science and Engineering. He was accepted and headed to Chapel Hill.

Click here to listen to interviews with the Class of 2016 Peace Fellows as told to Gabriel Maisonnave, a Duke-UNC Rotary Peace Fellow and a master’s student at the UNC School of Media and Journalism.

“The Rotary Peace Fellowship Program, through the Duke-UNC Rotary Peace Center, brings superb students to the Gillings School of Global Public Health,” says Peggy Bentley, PhD, UNC Faculty Director of the Duke-UNC Rotary Peace Center, Associate Dean for Global Health in the UNC Gillings School of Global Public Health, and Associate Director for Education at the UNC Institute for Global Health & Infectious Diseases. “Students apply to the degree program that best fits their experience and career trajectory. Since its inception 13 years ago, we’ve had Rotary Peace Fellows completing their MPH degrees in Environmental Sciences and Engineering, Health Behavior, Public Health Leadership, and Maternal and Child Health. Although each department provides the knowledge, theory, skills, and methods that are appropriate to their discipline, all of the students benefit from the integration of ‘global and local’ public health in the curriculum, which is one of the cornerstones of our educational philosophy.”

In addition to his classes, Kwena was part of the Water Institute at UNC where he worked closely with Jonny Crocker, PhD, and his advisor and Water Institute Director Jamie Bartram, PhD, on community-led total sanitation project evaluation being carried out in Kenya. He graduated in May and hopes to return to Kenya in two years to advise local organizations and government officials developing WaSH policies.

“This experience has been a game changer for me. The Duke-UNC Rotary Peace Center is an amazing program because it provides the opportunity to experience a new level of consciousness in terms of peace and conflict management. I now feel like I have the platform of skills, attitude and connections to help change the world,” Kwena says. “You need to be able to see good to do good. Kenya doesn’t have leaders that have seen good WaSH systems. I hope to be their eyes.”

Natsuko Sawaya spent time working with children in Dakar, Senegal, before applying to the Rotary Peace Fellowship Program.

Natsuko Sawaya spent time working with children in Dakar, Senegal, before applying to the Rotary Peace Fellowship Program.

The Magic of Rotary
The words “international relations” usually bring to mind images of improving the world for adults. But Natsuko Sawaya always envisioned children when she heard these terms. Growing up with a single mother in Japan, she was not able to afford to attend a college where she could major in OB/GYN or international relations. She earned her bachelor’s degree in French studies and began working at an international pre-school in Tokyo. This experience sparked her interest in early childhood development and maternal and child health. Thanks to a Rotary Ambassadorial Scholarship and the Rotary Peace Fellowship, Sawaya has studied in Italy, Senegal, the Democratic Republic of the Congo, Zimbabwe, the United States, and this summer, Malawi.

“The word ‘Rotary’ is like magic to me,” Sawaya says.

The Ambassadorial Scholarship from the Rotary Foundation funded Sawaya’s bachelor’s degree in education from the Universita di Bologna in Italy. While earning that degree she spent one month each in Senegal, the Democratic Republic of the Congo and Zimbabwe studying the early childhood development of children growing up in institutions, including orphans. A center for infants in Dakar, Senegal, struck a cord with her. When the Rotarians in Bologna offered to send her to any place that would benefit her career, she chose to return to Senegal. Sawaya remained there for two years.

“The first time I went to Senegal, I worked at an infant center with about 90 babies in Dakar,” Sawaya says. “When I went back, I chose to work at a larger center in Mbour with more than 200 infants. I worked with a local psychology professor and volunteers to create a series of seminars to train the caregivers.”

After working for three years in the Japanese embassy in Mauritania and about one year working for the International Organization for Migration, Sawaya applied for a Rotary Peace Fellowship and was assigned to the Duke-UNC Rotary Peace Center with plans to study in Gillings’ Department of Maternal and Child Health. She was accepted and has completed the first year of the program. This summer, she will travel to Malawi to work with a local NGO to implement Kangaroo Mother Care, an evidence-based method of infant care where the baby is held skin-to-skin on the mother or caregiver’s chest.

“There is high mortality of pre-mature infants in Malawi,” Sawaya says. “The World Health Organization recommends the Kangaroo Mother Care method, especially for premature babies. The method is effective for thermal control, higher initiation of breastfeeding and bonding in all newborn infants. It is also an important tool for addressing neonatal mortality in developing countries or conflict zones where adequate health services are limited.”

Beccah Bartlett, MPH, RNM, finished her training with at the Duke-UNC Peace Center and Gillings. She is now working on a mobile health app for refugees in Europe.

Beccah Bartlett, MPH, RNM, finished her training with at the Duke-UNC Peace Center and Gillings. She is now working on a mobile health app for refugees in Europe.

Refugees Are People First
“I graduated from Gilling’s Department of Maternal and Child Health on a Saturday and was on a flight the following Monday to determine the feasibility of a mobile app for improving the health of refugees in Europe,” says Beccah Bartlett, MPH, RNM, a Duke-UNC Rotary Peace Fellow. “I was working for years to put my knowledge and skills together to work with refugees and Rotary saw the potential in me. It’s an absolute gift.”

The skills Bartlett merged include an education and background in World War II history, anthropology, nursing, midwifery, and maternal and child health. Born and raised in Australia, Bartlett said she saw parallels between the obstetric care she was providing indigenous women and that of refugees in Europe.

“I was treating an indigenous woman in Australia after she had given birth and I realized she was hemorrhaging,” Bartlett says. “She almost died. This was eye-opening to me because I thought getting to a hospital for care would be the biggest challenge. But hospitals in low-resource areas treat sicker patients with minimal staff. People simply didn’t understand the complexities of this case.”

“It’s a similar situation with refugees because they too have a lack of resources,” she continues. “How do you help rebuild a community after war? This is what we are currently facing in Europe. This is one of the largest increases of refugees since World War II, which is the time period in history I majored in at university in Australia … Now I can look at this situation from the viewpoint of a lay historian and anthropologist and as a registered nurse and midwife. I can add the skills in peace and conflict resolution I learned through Rotary with my degree in maternal and child health from Gillings to create a more meaningful health intervention.”

After graduating from UNC this May, Bartlett headed to Europe to meet with refugees and stakeholders about developing a mobile health app.

“Many people mistakenly think refugees sit in camps waiting for handouts,” Bartlett says. “But in reality, many refugees in Europe are very well-educated. They want to learn the language of their new country. They want their children to attend school. And they have mobile phones. This led me to think about developing a mobile health app.”

During her initial trip to Europe, Bartlett was met with support from stakeholders like the department of health and the technology community as well as members of the refugee communities themselves. She will soon return to Europe for the next phase of her project – network analysis. Working with stakeholders and refugees, they will make decisions on what questions to include, what languages to use and how to code the app.

“There is a coding academy for refugees and we are hoping to develop this app with them,” Bartlett says. “It makes sense because it not only builds their skillset, but also to gives them control of their own destiny. They are people first and refugees second. I have a set of tools, but I want them to decide how to build this house. By asking them to lead this process, it will hopefully give them a sense of ownership and it promotes a more peaceful integration into their new society. I wouldn’t be doing this work without the Duke-UNC Rotary Peace Center. I am proof that their investment in people like me has a broad, meaningful reach.”

Eron Honored for AIDS Service

Bruce Curran, right, serves on the board of the NC Community AIDS Fund. He presented Joe Eron, MD, with the group's Outstanding Achievement Award.

Bruce Curran, right, serves on the board of the NC Community AIDS Fund. He presented Joe Eron, MD, with the group’s Outstanding Achievement Award.

The desire to treat people living with HIV grew from Joe Eron’s first inpatient rotation as a medical student in the early 1980’s.

“There was this young man who was so sick and we did not know what was wrong with him,” Eron recalls. “I was struck by two things. First, it was such a complicated case. We would get one thing under control and something else would flare up. And second, this man’s partner was so devoted to him, remaining by his side constantly. This man died of what we now know is AIDS. He and his partner left such an impression on me. I desperately wished we had known more about HIV at that time so we could have saved his partner’s life.”

Thirty years later and Eron has helped save countless lives as an HIV clinician-researcher. He is a Professor of Medicine in the Division of Infectious Diseases at UNC and the Director of the UNC Center for AIDS Research (CFAR) Clinical Core. The North Carolina Community AIDS Fund bestowed its outstanding achievement award to him this spring in recognition of “outstanding individual effort and personal sacrifice” for serving “in a variety of roles helping individuals in NC who are HIV positive and living with AIDS.”

“The North Carolina Community AIDS Fund Red Ribbon Award was given to Dr. Eron in celebration of the 20th anniversary of his New England Journal of Medicine paper that was published on the first combination therapy study with AZT/3TC in treatment naive patients,” says Bruce Curran, member of the NCCAF Advisory Board. “That publication was one of the major turning points in the fight against HIV/AIDS.”

From Consultant to Primary Care Provider
Eron knew early in his medical training he wanted to combine his passions for science, problem solving and caring for people. He decided to specialize in infectious diseases at after completing his residency at the Massachusetts General Hospital and two years in the Indian Health Service in Zuni, New Mexico. His interest in infectious diseases was tempered by the fact that the role of the ID clinician was that of a consultant with patients often returning to their referring doctor for care. HIV changed all of that.

“The discovery of HIV shifted the role of infectious diseases clinicians to that of primary care providers for people diagnosed with the virus,” Eron says. “After diagnosis, we would manage their care, which was ideal as we were keeping on top of the latest drug discoveries to treat the virus and its opportunistic infections, including a deadly fungal form of pneumonia.”

During his fellowship in infectious diseases at Massachusetts General Hospital, Eron met Martin Hirsch, MD, who was one of the first people to study HIV in the lab. At this time, AZT, the first antiretroviral therapy or ART, was being given to patients. As side effects for AZT became apparent and patients stopped responding to the medication, Eron focused on studying the drug’s resistance.

“I really enjoyed the work in the lab, but I missed being with patients,” he remembers. “Once I completed fellowship, I looked for a job where I could make a difference from the bench to the bedside. I wanted to continue treating patients, but also conduct research that would inform clinical care and save lives.”

The 20th anniversary of his study proving the health benefits of combination antiretroviral therapy and the impact it has had on the field is what prompted the North Carolina Community AIDS Fund to honor Joe Eron, MD.

The 20th anniversary of his study proving the health benefits of combination antiretroviral therapy and the impact it has had on the field is what prompted the North Carolina Community AIDS Fund to honor Joe Eron, MD.

The Road to UNC
Eron interviewed with Martin Blaser, MD, then Chief of Infectious Diseases at Vanderbilt University. Blaser asked him where else he was interviewing and Eron mentioned he had an upcoming interview at UNC.

“I told Marty, ‘I will take this job at Vanderbilt and cancel with UNC,’” Eron recalls. “But he told me to go and interview with UNC first and then make a decision.”

Eron traveled to Chapel Hill and met Myron Cohen, MD, Chief of the Division of Infectious Diseases. Cohen offered to drive Eron back to the airport. It was during this drive that Cohen made the case for choosing UNC.

“I parked for two hours in the no parking zone at the airport to make my case because I thought UNC was a better fit for Joe’s career,” Cohen says. “We had more faculty committed to HIV research and we had a global reach with the establishment of UNC Project-Malawi. I wasn’t trying to steal him from Vanderbilt. I knew that door was open, but I felt UNC was the most appropriate choice for his career.”

Eron accepted a position directing UNC’s Infectious Diseases Clinic in 1992 and has built an accomplished clinical care, research and teaching career at Carolina ever since. His first clinical trial led to a groundbreaking conclusion – combinations of antiretroviral therapy worked better than single-drug treatment. Patients stopped dying. The results were published in the prestigious New England Journal of Medicine.

“Combination therapy is when things really started to change for ID clinicians,” Joe says. “We went from being end-of-life-care advocates – helping patients tell their loved ones they were dying, or sometimes staying with them as they died alone – to giving them a new outlook on life.”

The 20th anniversary of this discovery and the impact it has had on the field is what prompted the North Carolina Community AIDS Fund to honor Eron.

“Joe has been a huge force worldwide in terms of intellect, compassion and leadership skills,” Cohen says.

Now that therapy with minimal side effects exists, Eron is seeking answers to the next big question – how do you return people living with HIV back to complete health? Although people living with HIV live longer lifespans than those diagnosed before effective antiretroviral therapy, their lives are still cut short when compared to people who do not have the virus.

“We have so many theories about this – are the meds not good enough? Should we start antiretroviral therapy sooner? Is the immune system too damaged by the virus to be repaired?” Eron asks. “We need to understand how to fully restore the immune system. There’s no textbook on how to do this. But at UNC, we’ve assembled a team that understands the biology of viral latency, study design and clinical care. It will take a village, but it can be done.”

Division of ID: Awards & Honors

From L-R: Pearlie Chong, Joe Eron, Michelle Floris-Moore, J. Victor Garcia, Lisa Hightow-Weidman, the HPTN award, Jon Juliano, and Angela Wahl.

From L-R: Pearlie Chong, Joe Eron, Michelle Floris-Moore, J. Victor Garcia, Lisa Hightow-Weidman, the HPTN award, Jon Juliano, and Angela Wahl.

From being honored with distinguished teaching awards to acceptance into national honor societies, UNC Division of Infectious Diseases faculty and staff have had an impressive academic year. Check out a full list of awards and honors.

Pearlie Chong, MD, was selected as a 2015-2016 UNC School of Medicine Teaching Scholar.

Joe Eron, MD, was presented with the Outstanding Achievement award from the NC Community AIDS Fund in honor of the 20th anniversary of a New England Journal of Medicine article proving that combination antiretroviral therapy prevented death from HIV/AIDS.

Michelle Floris-Moore, MD, was selected as the Associate Director of UNC’s Simmons Scholar Career Development Program. The program provides three to five years of salary support, structured mentorship, and career and leadership development opportunities. It is available to all UNC School of Medicine faculty from a population underrepresented in the medical field.

J. Victor Garcia, PhD, was elected as a 2016 Fellow of the American Academy of Microbiology.

Lisa Hightow-Weidman, MD, MPH, was presented with the John Bartlett Innovation in Research Award from the NC Community AIDS Fund. She also recently received a U.S. National Institute of Child Health and Human Development (NICHD) Cooperative Research Program Project (U19) Award to study and develop technology-based interventions about the HIV care continuum for youth in the United States. Look for a profile about Dr. Hightow-Weidman in August.

Our UNC Chapel Hill and Hanoi, Vietnam, HIV Prevention Trials Network (HPTN) sites won several awards during the HPTN’s annual meeting in June. The Chapel Hill Clinical Research Site (CRS) was honored for Outstanding Retention based on the 93 percent combined retention on HPTN studies 069 and 073. The Hanoi CRS was recognized for Data Quality and Laboratory Excellence as well as an honorable mention for study enrollment.

Jon Juliano, MD, received UNC’s Distinguished Teaching Award for Post-Baccalaureate Instruction. He was the only recipient from the UNC School of Medicine this year.

Angela Wahl, PhD, received a multimillion-dollar R01 award from the NIH to investigate the role of gut microbiota in rectal HIV acquisition. The coveted R01 grant establishes a scientist’s independence, as it provides significant research dollars and allows the principal investigator to hire junior scientists as research staff. It is very unusual for a researcher just completing a postdoctoral program to receive the R01.

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Our Dr. Cindy Gay Talks about HIV Cure Research, Treating Patients & Traveling with UNC Dept of Medicine

Aging, ART & Prevention Focus of HIV Update

Myron Cohen, MD, spoke about how men and women metabolize PrEP differently.

Myron Cohen, MD, spoke about how men and women metabolize PrEP differently.

Medical case manager Casey Norton from Triad Health Project in Greensboro was eager to learn more about how the field of antiretroviral therapy is moving from oral medications to injections and even the development of implants.

“My clients are all living with HIV,” Norton said. “To have one day have a treatment that is implanted would be great.”

Norton was one of more than 430 HIV providers from around North Carolina who attended UNC’s HIV Clinical Care update at the Friday Center on May 2. For more than 20 years, Carolina has partnered with the Greensboro Area Health Education Center (AHEC) to provide health care professionals who treat people living with HIV with the latest clinical and research news.

“UNC has taken a leadership role in caring for people living with HIV in North Carolina,” said conference organizer Heidi Swygard, MD, MPH, Clinical Associate Professor of Medicine at UNC. “We teach today and tomorrow’s providers about HIV. We know not everyone can afford to travel to the big conferences, so we ask the experts to present here each year.”

Presenters included many faculty from UNC’s Division of Infectious Diseases. Myron Cohen, MD, Chief of UNC’s Division of Infectious Diseases and Director of the Institute for Global Health & Infectious Diseases, spoke about HIV prevention efforts. He said researchers at the UNC Eshelman School of Pharmacy found that Truvada, a pill to prevent HIV, works differently in men and women. Women need to take this form of pre-exposure prophylaxis, or PrEP, once daily. Men seemed to remain protected with only two doses a week.

Joe Eron, MD, presented a history of antiretroviral therapy.

Joe Eron, MD, presented a history of antiretroviral therapy.

“I didn’t realize PrEP works differently in men and women,” said Renee Rosser, a medical case manager at Triad Health Project. “I would not have known that if I hadn’t come to this conference.”

Cohen also shared that researchers had tested vaginal gels and rings for HIV prevention, but had found adherence played a role in the interventions’ effectiveness. In an effort to take adherence out of the equation, studies investigating long-acting injections and broadly neutralizing antibodies or BnABs to prevent HIV are being led by the HIV Prevention Trials Network.

Joe Eron, an HIV clinician at UNC’s Infectious Diseases Clinic and a Professor of Medicine at UNC, presented a timeline about antiretroviral therapy or ART.

“There are about 35 million people in the world living with HIV,” Eron said. “The goal of ART is to restore and maintain the health of people living with HIV through the suppression of HIV replication.”

Modern day antiretroviral therapy consists of a three-drug combination, although studies are being done to test the efficacy of two-drug combinations, Eron said. He called this the era of integrase inhibitors, a class of anti-HIV medications that are potent, yet well tolerated. Developing new forms of ART, including long-acting injections, is also being explored to help those who develop a resistance to current treatment, to make taking ART and getting pregnant safer, and to prevent any drug-drug interactions for people taking other medications as they age.

David Wohl, MD, went over six ways to age successfully with HIV.

David Wohl, MD, went over six ways to age successfully with HIV.

Speaking of HIV and aging, more than half of the population of people living with HIV in the US are over the age of 50. UNC Professor of Medicine David Wohl, MD, dedicated his talk to this topic.

“Many people think living with HIV accelerates the aging process,” Wohl said. “Aging is very complex and influenced by many factors, including genetics, lifestyle, environment and disease. People living with HIV are at a greater risk for conditions associated with aging, like heart disease and cancer, but I don’t think we can say definitively that having HIV is causing this.”

People living with HIV are twice as likely to smoke, which is a factor that influences heart disease, Wohl said. He shared with the group ways to improve aging with HIV, including starting ART immediately upon being diagnosed with HIV, quitting smoking, knowing heart disease risk factors and getting regular cancer screenings. Wohl said kidney and bone health are also extremely important for people living with HIV as some ART can negatively impact the kidneys and cause bone loss.

Giving a Voice to the Voiceless

Catherine Grodensky, MPH; David Rosen, PhD, MD; and Steve Bradley-Bull, MEd, LCC, lead UNC's Criminal Justice and Health Working Group.

Catherine Grodensky, MPH; David Rosen, PhD, MD; and Steve Bradley-Bull, MEd, LCC, lead UNC’s Criminal Justice and Health Working Group.

Ensuring North Carolina’s inmate population is represented in research that leads to better clinical care is at the forefront of David Rosen, Catherine Grodensky, and Steve Bradley-Bull’s minds.

“The incarcerated population is invisible,” says Grodensky, MPH, Project Manager, the Prison Medicaid study. “When you review health care guidelines or attend a medical conference, you never hear about incarcerated folks. They are just not considered, and that is incredibly unjust.”

Rosen, Grodensky and Bradley-Bull co-lead UNC’s Criminal Justice and Health Working Group within the Division of Infectious Diseases. The trio recently replaced long-time leaders David Wohl, MD, Professor of Medicine in the Division of Infectious Diseases, and Cathie Fogel, PhD, RNC, Professor of Nursing. The group is an extension of the Center for AIDS Research or CFAR’s Social and Behavioral Research Core. Since 1999, UNC has contracted with the state’s prison system to provide infectious diseases care to inmates. Rosen says research studies would never have been possible without the many UNC Division of Infectious Diseases clinicians who have provided care in the prison system over the years, gaining the trust of inmates and prison staff alike.

“We think about common narratives about inmates’ behavior and health and then wonder, ‘are these accurate,’” says Rosen, PhD, MD, Research Assistant Professor of Medicine in the Division of Infectious Diseases. “About 23,000 people come into the prison system each year. The stock population of the prison system is around 36,000. Incarceration not only affects inmates. It impacts their families and the communities they return to.”

Each year since its inception, the Criminal Justice and Health Working Group has added to the body of research about prison inmates in North Carolina. Using blood samples from mandatory syphilis testing, Carol Golin, MD, Associate Professor in the Department of Health Behavior, and Wohl, were able to show the prevalence of HIV among incoming inmates in NC prisons was 1.5 percent, and more than 90 percent had been diagnosed prior to entering prison.

“Although the yield of undiagnosed cases coming into prison was lower than expected, there are about 800 people living with HIV in North Carolina’s prison system each year,” Rosen says. “Now we are focusing on research to maximize their health and wellbeing while they are incarcerated and in anticipation of their release.”

Building off of these completed studies, Rosen, Grodensky, and Bradley-Bull are now seeking answers to questions about inmates’ experiences receiving HIV care in prison and enrollment in Medicaid during incarceration and in the community.

“Since we are attempting to help society by gaining new knowledge with this research, I believe it is vitally important to sit down with these inmates to not only hear about their experiences, but to also hear about what ideas they have about improving their health and wellbeing,” says Bradley-Bull, MEd, LCC, Project Manager.

The Prison Cascade Study
Rosen is leading a study called Prison Cascade to capture the experiences of inmates living with HIV in prison.

“When you are incarcerated, you have access to free medications and transportation to your HIV clinic appointments,” Rosen says. “So if you are still not accessing HIV care in prison, what are those barriers?”

There are 56 prisons in North Carolina, but each prison does not have its own infectious diseases clinic. Thus, the majority of inmates have to travel for care, which could be one of the barriers to seeking treatment for HIV while incarcerated, Rosen says.

“We’ve learned that inmates are often told the night before or the morning of their clinic visit that they will be leaving at 4 a.m. They are shackled while traveling and are sometimes away from their base prison for a week, even though a clinic visit may be less than an hour,” Rosen says. “But on the other hand, we have heard from inmates that they like the care they are receiving at the infectious diseases clinics. As we conduct more interviews, we will get a clearer picture.”

In addition to speaking with inmates, Bradley-Bull will conduct qualitative interviews with health care providers in the clinic and outreach nurses as part of the Cascade study. Outreach nurses, who travel throughout the prison system providing limited HIV care, could be another reason inmates choose not to receive care in one of the clinics.

The Prison Medicaid Study
If inmates are enrolled in Medicaid when they are sent to prison, they lose their coverage. However, if they become ill while incarcerated and need to be sent for treatment at a community hospital, the prison system’s social workers will re-enroll them in Medicaid.

“Billing Medicaid for these community hospital stays saves the prison system $10 million a year,” Rosen says.

Rosen is leading the Prison Medicaid study, which seeks to understand inmates’ experiences with Medicaid prior to coming to prison and whether their enrollment in prison leads to continued benefits after release. Since the prison does not track inmates’ health or use of Medicaid upon their release, the researchers are hoping the Medicaid study will allow them to discover what role Medicaid plays in an inmate’s life after release.

“If Medicaid is activated while an inmate is in prison so he or she can access care at a community hospital, it remains active for one year,” Grodensky says. “If they are released from prison within that year, they still have to travel to their county’s social services office to keep it active. If they are incarcerated longer than a year after Medicaid was activated, then they would have to start the enrollment process from scratch upon release. But being enrolled in Medicaid during incarceration could increase the chances that their Medicaid application will be successful in the community.”

Qualitative interviews have been conducted with the prison system’s social workers who enroll inmates into Medicaid. Now interviews with prisoners who have recently returned from stays at community hospitals using Medicaid coverage will be done. She says the questions will focus on inmates’ experiences with Medicaid, their understanding of Medicaid, their medical history and lifestyle choices. Answers from these qualitative interviews will be used to create a survey to be given to 300 inmates.

“The Central Prison in Raleigh has a hospital that many prisoners returning from stays at community hospitals must go through before returning to their assigned prison,” Grodensky says. “We are conducting our interviews at Central Prison and we’re trying to discern if prison is a logical place to educate people about Medicaid.”

Rewarding Work
Grodensky, Rosen, and Bradley-Bull say they cannot imagine working with a different population as they feel they are giving a voice to the voiceless.

“When we conduct our qualitative interviews and hear their stories, we become that link between inmates and the community,” Grodensky says. “Their voices are not heard otherwise.”

Rosen says UNC’s Criminal Justice and Health Working Group is also hoping to secure funding to investigate other factors the can negatively impact inmates’ health in addition to HIV, including hepatitis C virus, mental health and substance abuse. They are also seeking to initiate health projects in NC’s county jails.

“The US has the highest rate of incarceration in the world. And some diseases are much more prevalent in incarcerated populations versus the general population. For example, 10-20 percent of inmates have hepatitis C virus while only 1 percent of the general population has HCV,” Rosen says. “How can we improve inmates’ health and address their healthcare needs as they re-enter the community? Conducting research in the prison system can be challenging, but with nearly all inmates returning to their communities, we see these studies as not only addressing prison health, but also public health.”