The following Poster Abstracts were presented at the Implementation Science and Global Health satellite meeting on March 17, 2010 at Bethesda, Maryland.
Poster 1: Assessment of psychosocial needs and development of pilot psychotherapy intervention among HIV-positive people in China
Shi Chuan, MD
Peking University Institute of Mental Health
- Yu Xin, MD, Peking University Institute for Mental Health
- Wu Zunyou, MD, PhD, National Center for AIDS/STD Control and Prevention, China CDC
- Jin Hua, MD, HIV Neurobehavioral Research Center, University of California, San Diego
- Robert K. Heaton, PhD, HIV Neurobehavioral Research Center, University of California, San Diego
This paper will describe a program of implementation research aimed at assessing mental health problems of HIV positive persons in China, the development and initial evaluation of a pilot group-support intervention, and initiation of a program to train HIV professionals to run these groups. The project is being carried out by a team of clinicians and researchers from the Peking University Institute for Mental Health.
Needs assessment: The team conducted two studies to evaluate the current mental health status of HIV positive people and their desire for services. First, the team evaluated 203 HIV positive subjects with BDI and CIDI to identify their current and lifetime depression, as well as suicide-related problems. We found a lifetime rate of Major Depression Disorder of 13.8% (using CIDI), and a current depression rate of 40.4% (using BDI). Among this sample, 10.8% reported suicidal thoughts, and 8.4% reported having a plan to commit suicide. Some studies in China have found even higher rates, with studies finding as many as 92% of HIV positive persons suffering depression and 64% having suicidal ideation. Our study also found that depression was negatively correlated with quality of life. Our second study was a small survey aimed at determining acceptability of mental health interventions for this population. We surveyed 28 HIV positive subjects, finding that 93% of this cohort would be willing to accept psychotherapy and 50% reported acceptability of antidepressant medications.
Intervention: Based on the data above, we have initiated a pilot intervention among HIV positive people, and a program of training among staff who work with HIV positive people. First, we provided group therapy to 8 HIV positive persons. Sessions included exercises like ‘blind walk’ to strengthen their trust and ‘open the knot’ (of people’s arms woven together) to deal with sorrow. Initial evaluation found the intervention feasible: participants enjoyed the groups and expressed a desire to continue. A preliminary evaluation found that participants tended to become more open and change some dysfunctional cognitions. Training: Based on these findings, the team has begun a program of training professionals who can become leaders of such groups. The training includes two elements: lectures, and taking part in group therapy. We organized a set of 4 lectures concerning psychotherapy skills in 2009. The attendance was always more than 90%, and participants responded positively and reported that the training is very helpful to their clinical work. Almost every staff who took part in the group therapy reported positively on their new experiences, and found that they got close to HIV positive persons and learned more about them. To date, this has been a pilot program for HIV positive people and HIV professionals. Initial evaluation suggests the program is feasible and helpful. The next steps being planned include developing a manual for support groups and for training leaders, and more formal process and outcome evaluation of the next round of interventions. We recommend that the CDC should invest more funds to implement such a program of psychosocial interventions.
Poster 2: Clinical training in stroke research and patient care in Da Nang, Vietnam
Annette L. Fitzpatrick, PhD, MA
Research Associate Professor, Department of Epidemiology
Adjunct, Department of Global Health
University of Washington
The impact of chronic diseases in developing nations is accelerating. This current health transition, a shift from acute to chronic disease, is the result of many interrelated factors including a reduction in infectious diseases, increasing longevity, and adoption of certain aspects of the western lifestyle. Cerebrovascular disease is the leading cause of disability-adjusted life years (DALYs) in the world; stroke kills about 10% of the world’s population and leaves millions of others disabled. Of the four stages of the epidemiological transition pertaining to cardiovascular disease, Vietnam has been classified as being at stage II, disease related to hypertension such as stroke and hypertensive heart disease, similarly to other Asian countries such as China. In Vietnam, while there is great need for epidemiological research to better understand disease prevalence, incidence and risk factors, great interest in providing care for stroke patients is also growing. In our efforts to build capacity for doing research on cerebrovascular disease in Da Nang, Vietnam, we have provided training and begun development of a stroke registry at Da Nang Hospital, the largest and most widely used health care provider in the province. Efforts to provide training and use of the stroke registry include
- provision of a training course on clinical stroke for physicians involved in stroke care;
- incorporation of stroke severity scales into practice;
- design methods to re-organize medical records from admission level to patient level files;
- develop a system for follow-up of stroke patients;
- implement a stroke surveillance system based on medical records abstraction to minimize physician burden; and
- use of the stroke registry to track trends and develop further applications for stroke management and prevention.
The week-long training course was provided in cooperation with the Da Nang Ministry of Health. It was attended by 75 clinical staff including 25 physicians who provide stroke care in the emergency room, intensive-care of cardiac care units. Other attendees were nurses or other related therapists. Course content included stroke presentation, recognition and management of acute stroke, subtype classification, stroke scales, and development of a stroke unit. A data collection instrument for the stroke registry has been pretested and methods for collecting informed consent are underway. Imaging consultation, computer training, a course in epidemiological methods, and a household survey targeting risk factors for stroke are planned in the coming year. In addition to generating much needed data on cerebrovascular disease in Vietnam, the efforts in this project strengthen relationships and help set the stage for modifying policy to improve stroke care in Da Nang.
Poster 3: Implementing and evaluating a model of mental health services for persons with depression in the workplace in China
Yantao Ma, MD
Peking University Institute of Mental Health
Research Fellow, Department of Social Medicine and Global Health, Harvard Medical School
This paper describes an on-going project designed to implement and evaluate an innovative model of mental health services that may ultimately be extended to a large population of industrial workers in China as part of the government’s commitment to provide occupational and mental health through the primary care system. The research is being conducted by a team from the Peking Institute for Mental Health, working in collaboration with the Ministry of Health of Guangdong Province.
Background: Rapid economic and political development in China over the over the past 30 years has led to remarkable increases in job-related stress and a concomitant rise in mental health problems among governmental employees and industrial workers. A 2007 survey of workers in Beijing found a rate of 30% of self-reported job-related stress. Researchers predicted that without timely intervention, half of those suffering from job-related stress were at risk of developing major depression (MDD) (Lyness JM 2006). Subsyndromal symptomatic depression (SSD) has been found to be common in workplace settings manifesting as work-related stress. Research suggests that SSD may be a precursor to MDD and that treatment interventions for SSD may decrease the risk of patients developing MDD.
Method: The purpose of this study is: 1) to determine the rates of SSD and MDD among industrial workers in large factories in Shenzhen; 2) to develop a model for prevention and treatment of SSD and MDD; and 3) to evaluate the feasibility and outcome of such a model.
A survey of 5000 industrial workers, using standardized instruments for depression and occupational stress, is currently underway (December 2009-March 2010). Initial design of an intervention is based on predicted baseline rates of SSD as 30% and MDD as 5% among industrial workers in the sample. The intervention plan for SSD includes: 1) health education for administrators, doctors, nurses, and workers; 2) interventions in administrative practices, including establishment of reasonable shift management, new skills education, peer group support, employee assistance programs; 3) development of counseling services for workers; and 4) providing workers with information about self-help and medical resources. For MDD, a referral pathway plan will include routine treatment of mild or moderate depression and emergency services for severe depression with high risk of suicide. Outcomes to evaluate the intervention will include: worker absentee rates and health care utilization rates for persons with SSD before and after intervention; health care utilization rates for persons with MDD under the referral system; and the overall cost and economic benefits of the program for the factories.
Conclusion: This program is designed explicitly to evaluate a model for reducing occupational stress and depression among industrial workers. It is intended to increase awareness among government policy makers of the effectiveness of interventions for mild depression in reducing risk for serious depression and suicide and in reducing worker absenteeism, as part of a new basic health care services agenda.
Acknowledgements: The project is supported by WHO funds for Health Care Activities in the Western Pacific Region.
Poster 4: Intestinal dysfunction at the time of initiation of HAART as a potential risk factor for drug malabsorption and treatment failure
Rita Isaac, MD, MPH
Professor and Head, The Rural Unit for Health and Social Affairs (RUHSA)
Christian Medical College and Hospital (CMC), India
Introduction: The antiretroviral (ART) roll-out program in India has made it possible for HIV infected individuals to have access to first line NNRTI based ART. As the second line therapy is not available in India through the public funded ART program due to cost, the need for the initial regimen to be durable is critical. The reports from developed countries show that there is an emergence of ARV-resistant virus and failure of first line ART. Antiretroviral drug resistance can occur under selection pressure as a result of viral replication in the presence of inadequate drug exposure. The central hypothesis of this ongoing cohort study is that more than 50% of those with CD4 less than 250 cells/mm3 and become eligible for HAART in India will have marked intestinal dysfunction that will potentially lead to drug malabsorption, sub-therapeutic concentrations of antiretrovirals in plasma, emergence of viral resistance and failure of therapy. This presentation will discuss the magnitude of intestinal dysfunction at the time of initiation of ART and its impact on plasma levels of nevirapine.
Methods: The proposed longitudinal cohort study will recruit a sample of 208 HIV infected men and women over 5 years, at the time of initiation HAART which includes 2 nucleoside reverse transcriptase inhibitors plus nevirapine, having a CD4 count between 150 and 250cells/mm3. Intestinal function using lactulose/mannitol intestinal permeability test, plasma concentrations of nevirapine at pre-dose (Ctrough) and at 2 hours after the morning dose, CD4 cell count and BMI are measured at baseline, 6 and 12 months and viral load and viral resistance mutation at baseline and 12 months during the 1 year follow-up of the participants. We present baseline data from 30 participants.
Results: The longitudinal study enrolled 30 participants, 17 (56.7%) men, 12 women (40%), 1 transgender (3.3%) with a median age of 35 years (range 21-59years), a median CD4 count of 201 cell/mm3 (range 156 -318 cells/mm3) and median viral load of 64973 copies/mL (range 617- 3235171 copies/mL). Thirteen participants (43.3%) had a body mass index less than 18.5. Thirty percent of participants had increased intestinal permeability as indicated by high lactulose/mannitol ratio (>.08). At pre-dose (trough) sampling, 5 participants (16.7%) and at 2 hours after drug intake, 3 (10%) had sub-therapeutic concentrations of nevirapine (less than 4mg/ml).
Conclusions: There is a high prevalence of intestinal dysfunction among the HIV infected patients with CD4 less than 250cells/mm3 in India. Furthermore, there is a trend towards increased occurrence of sub-therapeutic concentrations of nevirapine. The findings suggest a potential danger in treatment failure and emergence of viral resistance to first line regimen in India. The importance of achieving viral suppression with the first line regimen is paramount, in order to minimize the risk of development of resistance and to preserve future treatment options.
Application: The preliminary report reveals that up to 30% of HIV patients have intestinal dysfunction at the time of initiation of HAART in India that can potentially lead to drug malabsorption and treatment failure. Hence this study has policy implication in India with regards to when to initiate the antiretroviral therapy. Acknowledgements: This research is supported by the Fogarty International Center of the National Institute of Health (1 R01 TW008145-01).
Poster 5: Public health strategies to control congenital syphilis in Cali, Colombia
Juan C. Salazar, MD, MPH
Associate Professor, Pediatrics, University of Connecticut Health Center
Director, Division of Pediatric Infectious Diseases, Connecticut Children’s Medical Center
Background: Despite efforts by public health authorities in Cali, Colombia, to improve early identification of gestational and congenital syphilis (GS & CS), and provide antibiotic treatment for such patients, the prevalence remains high.
Objectives: 1) To better understand the disease burden of GS/CS; 2) to determine the seroprevalence of syphilis in young people who live in areas found to have high rates of GS/CS and; 3) to ascertain what young people understand about the risk of acquiring syphilis, and how it can lead to GS/CS.
Methods: 1) Detection of GS/CS was done through an active surveillance program implemented in 183 city wide health centers; 2) Seroprevalence data was obtained by performing RPR tests in individuals living in communities with a high prevalence rates of GS and CS; 3) Knowledge, attitudes and understanding of risk factors associated with acquiring and transmitting syphilis, were ascertained from a cross sectional cohort of people (age 15-24 years) living in these areas, by using a standardized survey.Conclusions: Socio-economically deprived urban regions in Cali have the highest rates of GS and CS, and high seroprevalence of syphilis. Self reported high risk sexual behavior and the lack of knowledge about the disease, contribute to the high rates of GS/CS. Intense educational campaigns are underway to address this grave problem.
Results: Between 2006-2008, 765 women and 270 children were diagnosed with GS and CS. Most cases were from 3 distinct socio-economically deprived urban regions. Between 6.3-6.8% (depending on the region) out of 25,190 individuals tested, had reactive RPRs, and were treated on site with penicillin. Higher seropositivity rates were observed in female sex workers (29%), men who had sex with men (14%) and transsexuals (39%). Survey data from 1109 participants indicated that young people in these communities frequently engage in high risk sexual activities, have little understanding about syphilis, and do not know were and how to get treated.
Poster 6: Utility of a diagnostic tool for HIV-associated cognitive impairment and peripheral neuropathy in western Kenya: Pilot testing
Ana-Claire Mayer, MD, MSHS
Assistant Professor, Department of Neurology, University of California, San Francisco, San Francisco General Hospital
Family AIDS Care and Education Services, Kenya Medical Research Institute (KEMRI)
- Dr. Judith Kwasa, Center for Microbiology Research, Kenya Medical Research Institute
- Dr. Deanna Cettomai Center for Microbiology Research, Kenya Medical Research Institute, University of California, San Francisco
- Dr. Edwin Lwanya, Center for Microbiology Research, Kenya Medical Research Institute
- Dr. Dennis Osiemo, Center for Microbiology Research, Kenya Medical Research Institute
- Dr. Patrick Oyaro, Center for Microbiology Research, Kenya Medical Research Institute
- Dr. Caroline Kendi, Center for Microbiology Research, Kenya Medical Research Institute
- Dr. Elizabeth Bukusi, Center for Microbiology Research, Kenya Medical Research Institute
- Dr. Richard Price, University of California, San Francisco
- Dr. Craig Cohen, University of California, San Francisco
- Dr. Gretchen Birbeck, Michigan State University
Background: Cognitive impairment and peripheral neuropathy are common treatable neurologic complications of HIV infection which are difficult to diagnose in resource-constrained settings. We hypothesize that simple diagnostic tools for use by non-physician health workers can accurately identify HIV-infected persons with these disorders.
Methods: We enrolled a convenience sample of 23 HIV-infected outpatients from an HIV-care clinic in Kenya. A non-physician health worker administered two diagnostic tools: (1) dementia tool [brief clinical assessment, neuropsychological (NP) tests based on the International HIV Dementia Scale (IHDS), assessment of functional status]; and (2) neuropathy tool [Single Question Neuropathy Screen (SQNS), Subjective Peripheral Neuropathy Screen (SPNS), and Brief Peripheral Neuropathy Screen (BPNS)]. Both tools were validated against a neurologist’s clinical assessment, NP test battery, and chart review. Cognitive impairment was classified using Memorial Sloan Kettering (MSK) criteria and was dichotomized into no impairment (MSK 0-0.5) or impaired (MSK 1-4). Peripheral neuropathy was dichotomized to none/mild or moderate/severe. Sensitivities and specificities were generated for each tool.
Results: Participants had a mean age of 40.4 years, 65% were male and 48% had less than a secondary school education. Mean CD4 count was 348 cells/μL and 27% had WHO Stage IV disease. Per the neurologist’s assessment, 78% (18/23) had no cognitive impairment and 22% (5/23) had mild cognitive impairment. Mean score on the dementia tool was not significantly different between individuals with and without cognitive impairment (mean 21.8 vs. 21.7; p=.93). Using a cutoff of >24, the tool was 40% sensitive and 67% specific. Per the neurologist’s clinical assessment, 22% (5/23) had moderate/severe peripheral neuropathy. In detecting individuals with moderate/severe peripheral neuropathy: SQNS was 80% sensitive and 72% specific, SPNS was 80% sensitive and 83% specific, and BPNS was 0% sensitive and 89% specific.
Conclusion: Pilot testing suggests the dementia tool needs further development and testing to improve its utility in identifying individuals with mild cognitive impairment. SQNS and SPNS accurately identify patients with moderate to severe peripheral neuropathy. These tools have the potential to help non-physician health care workers identify individuals in low-resource settings with these disorders and ultimately improve health outcomes.
Poster 7: Workforce needs and development in cancer prevention and control: Morocco as a case study
Hala Azzam, PhD, MPH
Adjunct Assistant Professor College of Public Health and Health Professions (PHHP)
Director of International Program, Emerging Pathogen Institute (EPI), University of Florida
More than 50% of the global burden of disease is due to non-communicable diseases and disproportionately affects low and middle income countries. Today, cancer is the second leading cause of deaths globally with 70% of all cancer deaths occurring in developing countries. 20-25% of all cancers can be attributed to chronic infections and according to the World Cancer Report, as much as one third of all cancers worldwide can be prevented by tackling diet, smoking and infections, and another one third can be cured if detected early. While the critical shortage for physicians and nurses in developing nations is well advertised much less is known regarding shortage of public health professionals. Very few schools of public health exist in low and middle income countries to address the health needs of a nation. The needs are greater in the Eastern Mediterranean Region (EMRO) as pointed out by the 2006 World Health Report where only 8 schools of public health (relative to 137 medical schools, 225 nursing schools, 35 dental schools and 48 pharmacy schools) exist for the whole region. With a population of 32 million and life expectancy at 75.5 years, Morocco is a lower middle-income country in EMRO that exemplifies the needs in public health training. Today communicable diseases represent 33% of DALYS and non-communicable diseases 56% of DALYS and the cancer burden ranges between 30,000-54,000 cases a year. This poster describes the preliminary findings of our planning grant and ongoing efforts to strengthen the lack of formal programs in public health and cancer research training in Morocco.
Updated August 2010