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Our Dr. Cindy Gay Talks about HIV Cure Research, Treating Patients & Traveling with UNC Dept of Medicine
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.
“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.
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.
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.”
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.”
The Explorations in Global Health faculty research grants are designed to foster the development of research partnerships and projects in global health. Grants are made to UNC faculty for international travel or to bring international colleagues to campus to establish or maintain research relationships (with the aim of applying for external funding) or to undertake small-scale, discrete research projects with international collaborators.
This year, the IGHID is supporting six, diverse projects in Nicaragua, Liberia, Zambia, Burkina Faso, Chile and Brazil.
Zika in Nicaragua
“Diagnostics to define epidemiology and clinical aspects of Zika Virus infection”
Natalie Bowman, MD, MPH, Assistant Professor, Division of Infectious Diseases, UNC School of Medicine and Aravinda de Silva, PhD, Professor of Microbiology and Immunology, UNC School of Medicine
In recent months, Zika virus has been prominent in the scientific news as well as the popular press. This was largely catalyzed by reports from Brazil that Zika infection might be linked to a massive increase in cases of microcephaly. There is now both an urgent need to better understand the epidemiology and potential for pathogenesis of ZIKV via sustained and systematic research programs that focus on this emerging pathogen. This research proposal seeks to understand the epidemiology of emerging Zika virus in León, Nicaragua and to define exposure to Zika virus in a flavivirus immune population.
Ebola in Liberia
“Understanding the impact of stigma on sexual behaviour and relationships of female survivors of Ebola”
Kavita Singh, PhD, Research Associate Professor, Department of Maternal and Child Health, UNC Gillings School of Global Public Health, and Christine Godwin, MSPH, Doctoral Student
The unprecedented scale of the recent West African Ebola outbreak, together with
improvements in patient care and treatment, has resulted in over 17,000 individuals who
became infected with Ebola and survived, an estimated 5,800 of whom live in Liberia. Thus, the current outbreak has created a unique need and opportunity to understand the farreaching social, psychosocial, and sexual implications of Ebola infection on survivors, especially for women. Given the limited nature of previous Ebola outbreaks, prior to 2014, only a handful of studies had investigated the stigma and social rejection that many survivors face upon exiting the Ebola Treatment Unit. To date, no studies have explored the complex impact that Ebola survivorship can have on the sexual relationships of female survivors. The proposed study would seek to quantify and understand the mechanisms through which Ebola can affect social and sexual relationships for women. The findings from this study will be used to develop recommendations for counseling and support services to women who survive Ebola.
HPV in Zambia
“Human Papillomavirus (HPV) and Preterm Birth (PTB) in Lusaka, Zambia”
Lisa Rahangdale, MD, MPH, Associate Professor, Department of OB/GYN, UNC School of Medicine, and Nurain Fuseini, MD, MHS, Master’s of Science in Clinical Research Fellow, UNC Gillings School of Global Public Health
There are over 13 million annual preterm births (PTBs) worldwide, which are responsible for approximately one-third of global neonatal deaths. Children who survive a preterm birth are at significant risk for developmental delay and increased risk of life long non-communicable diseases. PTB in Zambia is estimated at 12.9 percent. Placental human papillomavirus (HPV) infection has been associated with PTB and in a recent systemic review and meta-analysis, HPV has been associated with an odds ratio of PTB of 2.12 (95 percent CI 1.51-2.98). This project aims to add to the growing literature and assess whether HPV is associated with PTB in sub-Sahara Africa where such research has not been conducted before. Sub-Sahara Africa has a higher prevalence of (3.2 percent to 47.9 percent) and sequelae from HPV than any other continent in part due to insufficient vaccination,screening, and treatment. If an association between PTB and HPV is validated, the role of the HPV vaccine and screening for and treating HPV infection can be expanded to support the prevention of PTB.
Food Insecurity in Burkina Faso
“Exploring the Geography of Food Insecurity: Assessing sub-National Patterns in West Africa”
Colin West, PhD, Assistant Professor, UNC Department of Anthropology
Africa is too often portrayed as a continent wracked by hunger, famine and extreme food insecurity. Africans and researchers who work with them, however, recognize that food security is highly variable over space and time. According to the latest Food and Agriculture Organization (FAO) estimate, 805
million people are chronically undernourished and this figure indicates a global decline of 23.4
to 13.5 percent in developing countries. On the one hand, these figures are staggering and show how food insecurity is an enormous problem. On the other, however, they also show we are making substantial progress toward reducing global hunger. These FAO statistics represent decades of careful monitoring of key health indicators through multiple surveys by FAO, the World Health Organization (WHO), USAID, and other international agencies. In recent years, access to this “big data” has drastically improved and researchers are becoming increasingly able to use these datasets for their own particular studies. This project will integrate quantitative USAID Demographic Health Survey (DHS), qualitative USAID Famine Early Warning System (FEWS) food insecurity report, and remotely sensed satellite imagery to identify areas of food insecurity within Burkina Faso. This project will develop a methodology for investigating geographic patterns and temporal trends in food insecurity for the Sahelian country of Burkina Faso.
Unhealthy Food Consumption in Chile
“Beyond Sugar sweetened beverages and food /beverage taxes: Impacts of restrictive labelling and marketing regulations on unhealthy food consumption in Chile”
Francesca R. Dillman Carpentier, PhD, Associate Professor, UNC School of Media and Journalism
In Chile, nutrition- and obesity-related non-communicable diseases (NCDs) account for 83 percent of all deaths. Chile’s continued economic growth has been accompanied by increased expenditures on ultra-processed food and other food high in refined sugar, unhealthy saturated fats, added salt, and low amounts of fiber; these types of foods are linked to increased obesity across gender and age groups. Chile also leads the globe in consumption of sugar-sweetened beverages (SSBs). Unlike other Latin American countries, Chile is taking very different regulatory measures beyond introducing SSB or other food/beverage taxes to reduce unhealthy food consumption. In April 2012, the Chilean Senate passed the country-wide National Law of Food Labeling and Advertising, which has 2 major components: (i) mandatory front-of-package labels that identify foods high in added sugar, saturated fats, sodium, and energy, and (ii) restrictions on marketing, advertising, and sales of unhealthy foods to children under age 14y over an array of media including television, internet, and school environments. The situation in Chile provides a unique opportunity to provide the first evaluation of an SSB tax in addition to an increasingly restrictive labeling and marketing regulation on key nutrients.
Lead Exposure in Brazil
“Using Participatory Action Research to Engage Multiple Stakeholders”
Courtney Woods, PhD, Lecturer, Department of Environmental Sciences and Engineering, UNC Gillings School of Global Public Health
Globally, there are close to 700,000 deaths attributed to lead exposure, many of which are from cardiovascular diseases. There is a large body of epidemiological evidence of chronic disease from lead exposure in adults, including anemia, cardiovascular changes, kidney damage, hypertension, cerebrovascular disease, and neurobehavioral disorders. There is even greater concern for exposure in infants and children, which can lead to low birth weight and behavioral and cognitive impairments. The most widespread and ongoing instance of environmental lead exposure in Brazil is in Santo Amaro, Bahia. The city was home to a lead smelter COBRAC/PLUMBUM from 1960 – 1990s, which eventually closed and relocated due to controversy over high levels of occupational exposure to lead. One of the complaints of the population refers to the number of surveys and research conducted over 40 years, with no implementation of health intervention. This fact has led to disinterest on the part of the population to participate in research and disappointment in local and state government responses to improve the health of the affected population. An important aspect of this project is the use of participatory action research (PAR) methods that will engage a range of stakeholders, particularly community residents. While PAR methods are quite common in the social sciences in Brazil, they are not commonly used in public health, even for program implementation or evaluation research, though they have shown effectiveness in other countries for improving health outcomes among participants.
The U.S. Department of Health and Human Services mentioned the North Carolina AIDS Training and Education Center‘s searchable, online PrEP locator in a recent blog post. PrEP, or pre-exposure prophylaxis, is a once daily pill to prevent HIV.
“We were t he first group to try to put together a map of PrEP providers at a statewide level,” says Christopher Hurt, MD, Clinical Assistant Professor of Medicine, Division of Infectious Diseases in the UNC School of Medicine. “Many other states have created directories at city and state levels and posted them for people to find online, but maps like ours are a rarity.”
In addition to North Carolinians seeking PrEP, the NCATEC website also provides clinicians with information about how PrEP is beneficial for their at-risk patients. Dr. Hurt also designed wallet-sized brochures in the shape of the blue PrEP pill with a QR code linking people to the NCATEC website for more information about PrEP.
Kathy “KJ” James, Administrative Support Specialist within the Division of Infectious Diseases, is the recipient of the UNC Employee Forum’s Peer Recognition Award. KJ won in the Call of Duty category, which honors UNC staff who go above and beyond their job description.
“KJ makes everyone else’s job easier and does so in a way that just makes you smile,” says David van Duin, MD, PhD, Associate Professor of Medicine within the Division of Infectious Diseases.
Van Duin and Irving Hoffman, PA, MPH, Research Professor within the Division of Infectious Diseases and the U.S. Director of UNC Project-Malawi, nominated James for the award. In his nomination letter, Hoffman provided an example of how James took the initiative to ensure a visiting, international nurse, who missed the driver that was sent to meet her at the airport, made it to her accommodations safely.
“The nurse panicked and was in tears. The only number she could find on that Sunday night was Kathy’s,” Hoffman wrote. “And in a snowstorm late at night, Kathy drove nearly an hour one way from her rural home to pick up the nurse, console her and get her settled. That is Kathy James. She exemplifies what UNC is all about.”
James will be honored and receive a certificate during the Employee Forum’s Peer Recognition Awards Ceremony on Wednesday, June 8.