October 2011

Wafaa El-Sadr Awarded the 2011 Society Citation from the Infectious Diseases Society of America

ICAP Director Wafaa El-Sadr was selected by the Infectious Diseases Society of America to receive the 2011 Society Citation Award for her outstanding contributions to the field of infectious disease. The Society Citation is a prestigious award that recognizes exemplary contribution to IDSA and outstanding achievements in the field of infectious diseases in research, clinical investigation, or clinical practice. Dr. El-Sadr received the award at the 49th Annual Meeting of the Infectious Diseases Society of America on October 20, 2011 in Boston.

November 4 Event: Infectious Disease-Epidemiology Cluster Seminar The next Infectious Disease-Epidemiology Cluster Seminar Series hosted by ICAP and the Department of Epidemiology at Columbia University’s Mailman School of Public Health is on November 4, 2011 from 3:00pm - 4:30pm in the Allen Rosenfield Building, Room 1101 at the Mailman School of Public Health. This month’s seminar will feature highlights of faculty research work in infectious disease and epidemiology.

November 17 ICAP Grand Rounds Webinar: "Success and Challenges of Syringe Access, Methadone and Overdose Prevention in SSA” with Dr. Sharon Stancliff, November 17, 2011, 9:00 am ET Join webinar.

Webinar Recap: Bill Reidy, PhD presented on "“Basic epidemiologic measures of disease occurrence”during the ICAP Methodology Webinar on October 27. View webinar

Webinar Recap: Robert Remien, Phd presented on "“Improving effectiveness of counseling in HIV treatment settings” during the last ICAP Grand Rounds Webinar on October 19. View webinar

ICAP was founded in 2004 at Columbia University’s Mailman School of Public Health. Now a global leader in HIV/AIDS services, ICAP has supported work at more than 1,200 sites across 21 countries. More than one million people have received HIV services through ICAP-supported programs.

For more information about ICAP, visit here. For more information about ICAP leadership, visit here.

Supported by Doris Duke Charitable Foundation, Bill and Melinda Gates Foundation, William and Flora Hewlett Foundation, Robert Wood Johnson Foundation, Henry J. Kaiser Family Foundation, Stephen Lewis Foundation, John D. and Catherine T. MacArthur Foundation, National Institutes of Health, David and Lucille Packard Foundation, Rockefeller Foundation, and Starr Foundation.

© 2011 ICAP

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ICAP in Rwanda Brings Integrated HIV and Mental Health Services to a Recovering Population

“Mental illness is common around the world, but until recently such conditions were not widely recognized in low-resource countries and there was little to offer those who suffered from them,” said Francine Cournos, senior project officer for adherence, psychosocial support, and mental health at ICAP. One of the major challenges of the work has been diagnosing when a mental disorder is present. Cournos explained, “In resource-limited countries, there is less awareness of common mental illnesses like major depression and anxiety disorders. Psychotic illnesses, which manifest with obviously disturbed behavior, are easier to recognize.”

To respond to the challenge of HIV and mental illness, ICAP is supporting efforts to raise awareness of these conditions and enable effective response to dually affected individuals.

Information from Ndera Neuropsychiatric Hospital, the key referral hospital in Rwanda for mental health, suggests that severe mental disorders in Rwanda include many of the same disorders that challenge patients and providers in resource-rich settings.  According to a 2010 annual report from Ndera, 51 percent of the patients are diagnosed with schizophrenia and other psychotic disorders, 24 percent with bipolar disorders, 10 percent with severe depression, and 5 percent with substance use.

In many countries in sub-Saharan Africa, mental health has received less priority, largely due to other, often more life-threatening health issues such as communicable diseases, perinatal conditions, and nutritional deficits. Recently, the threat of non-communicable diseases in low and middle-income countries has also been acknowledged, however, mental illness—which is associated with significant morbidity—has received limited attention globally.

In the context of HIV, various challenges arise when considering how to integrate HIV and psychiatric services. For example, healthcare workers require knowledge and skills in the co-management of the two conditions; mental health clinicians need to appreciate the interactions between psychiatric medications and antiretrovirals; and HIV clinicians need to learn how to screen for mental disorders. An integrated approach is ideal to meet the needs of the patients.
Another complication is that HIV-infected patients can manifest disturbed behavior due to HIV-related complications. In these situations, healthcare workers may mistake such behavior for a psychotic disorder when in fact there is another cause. Cournos explained, “Kidney failure, metabolic disturbances, high fever or dehydration can do this. Training in distinguishing these conditions from psychiatric illnesses is very important.”

Post-traumatic stress disorder (PTSD) is also a concern. After the 1994 genocide, substantial numbers of individuals in Rwanda experienced some form of PTSD and depression. Recent research by Naasson Munyandamutsa in 2009 found that 29 percent of Rwandans have symptoms of chronic PTSD and the majority of them experience depressive symptoms.

Isaie Nzeyimana, who worked as a clinical advisor with ICAP in Rwanda during the formative stages of its mental health initiative, explained, “From April to July, Rwandese mark the anniversary of the genocide—this is a difficult time for the nation. People are reliving what happened from April to June 1994.” Alfred Ngirababyeyi, a clinician at Ndera, added, “During the genocide commemoration periods, we see an increase in manifestations of stress and trauma consistent with acute PTSD.”

ICAP’s efforts to integrate mental health and HIV services began in 2008, with its support of HIV care and treatment services at Ndera Neuropsychiatric Hospital. Ndera is one of 57 sites that have been supported by ICAP.

At the time, reports from Ndera substantiated the need to link HIV and mental health services—an increasing number of patients were living with HIV (from 46 in 2006 to 84 in 2008), and mental health professionals were not trained to provide HIV care to people in need. In 2008, ICAP’s work sought to bring together these two areas of care to bridge the divide between HIV and mental health services.

In addition to supporting HIV care and treatment activities, ICAP also began support for HIV screening of people who were already in care at Ndera. Those who accept HIV counseling and testing and are found to have HIV are provided with access to the same comprehensive HIV-related services, including antiretroviral therapy, that they would find at any other HIV care and treatment clinic. “The program has brought HIV counseling and testing to the hospital,” said Peter Twyman, regional program director for ICAP. “Psychiatric patients are now routinely counseled and tested for HIV. If they test positive, they are immediately referred to care and treatment services within the facility itself, ensuring continuity of care.” From March 2009 to date, a total of 2,597 patients have been screened for HIV and, as of September 2011, 166 patients were enrolled in HIV care and treatment.

A major challenge comes upon release of patients from Ndera. Ruben Sahabo, ICAP’s country director in Rwanda, noted, “A main issue is linkage of these patients upon release as well as retention of HIV-infected patients with mental illness in general. Those dealing with mental illness as well as HIV are frequently lost to care. To address this, we needed to ask how we could better screen people for both mental health and HIV and how we can increase adherence to treatment, so those who need vital services aren’t lost in the system.” To address this challenge, ICAP helped launch two new support groups at Ndera in 2010. Forty-five patients are currently members of these groups and, in 2011, an association of patients was created to improve their quality of life beyond access to care and treatment.
ICAP, in partnership with the Rwanda Biomedical Center, is now using the experience at Ndera to inform a larger initiative that aims to integrate mental health services into HIV care and treatment programs at nine district hospitals.  ICAP helped develop tools to screen for mental illness among people living with HIV who are enrolled in care. Because depression is the most common problem seen in HIV patients and is associated with poor adherence to care and ART, it is hoped that mental health screening interventions can improve patient outcomes.  

Additionally, ICAP is considering how to regularly screen mental health of patients suspected of treatment failure and how to expand mental health services to include infants and adolescents. Since March 2011, 2,375 clients have received mental health screening at the 9 district hospitals in Rwanda and 386 clients have been referred to mental health services.

With these efforts, Rwanda is tackling an important challenge and informing other programs of how to optimize the outcomes for this vulnerable population.

New Course For Health Professionals Focuses on Health Systems Strengthening

Ministries of Health and US Government staff from around the world joined the Columbia University Mailman School of Public Health (MSPH) this week for the online phase of a new course on health systems strengthening hosted by ICAP in partnership with the MSPH Departments of Population and Family Health, Sociomedical Sciences, and Health Policy and Management.

Thirty-five professionals from health ministries in Barbados, Jamaica, Kenya, Namibia, South Africa, Tobago, Uganda, and Vietnam and their country counterparts from the US Centers for Disease Control and Prevention (CDC) and the US Agency for International Development (USAID) convened for this novel initiative, which aims to enhance health professionals’ ability to design, implement, and evaluate health systems strengthening activities.

“This course goes beyond a simple review of health system building blocks,” said Helen de Pinho, assistant professor of population and family health and associate director of the Averting Maternal Death and Disability Program at the Mailman School. “Cross cutting themes include the need for systems thinking and the interactions between different components of the health system.” Other course topics include human resources management, health financing, governance and accountability, and the integration of targeted health programs into broader health systems.

Using a blended onsite and online curricular design, the first phase of the course brought participants together for a five-day intensive workshop in Cape Town, South Africa in July 2011 led by Health Systems 20/20 with ICAP, CDC, and USAID. The second phase, launched this October, employs distance learning and face-to-face instruction for six months, using collaborative tools, including a course website, wiki, discussion board, as well as pre-recorded lectures and real-time online lectures and discussions. Building on its experience with distance education, ICAP is leading this phase in partnership with Health Systems 20/20, CDC, and USAID

“We are very pleased to see the high level of engagement and enthusiasm from participants,” said Tegan Culler, ICAP health systems training officer, who has worked with each country team to facilitate access to the web-based tools. “Participants are already applying their health system strengthening knowledge in their day-to-day work.” 

The health systems strengthening course is supported by CDC and USAID, and is part of a larger portfolio of health systems research and training led by Wafaa El-Sadr, director of ICAP, and Miriam Rabkin, director for health systems strategies at ICAP. Marita Murrman, associate clinical professor of sociomedical sciences, and Margaret Kruk, assistant professor of health policy and management, have also been instrumental in the design and implementation of the course.

Strengthening Data Collection of Key Populations at Risk in Mali

In the Republic of Mali—one of the world’s poorest countries—approximately 66,000 of the nation’s 14.5 million people are living with HIV; more than half of the infected are women age 15–59. While women are disproportionately affected, several key populations are at risk and have yet to be included in routine HIV surveillance in Mali. These at-risk populations may include men who have sex with men, miners, incarcerated populations, and drug users.

This October, ICAP partnered with the International Center for Excellence in Research (ICER-Mali) at the University of Bamako to begin work on HIV strategic information strengthening in Mali. ICAP and ICER-Mali will concentrate on supporting the Mali Ministry of Health to enhance HIV surveillance in the country and develop monitoring and evaluation capacities that will help to characterize and quantify the level of risk and burden of HIV infection among most at-risk populations, including men who have sex with men and informal and formal miners. Through this work, ICAP and ICER-Mali aim to support the national understanding of the HIV epidemic in Mali with respect to the key populations at risk. The partnership also intends to build capacity to design a more effective response to the epidemic, as well as assess the progress and effectiveness of HIV, STI, and integrated health programs.

Model that Predicts Expanded HIV Treatment for Discordant Couples Could Significantly Reduce Global HIV Epidemic

A new study uses a mathematical model to predict the potential impact of expanding treatment to discordant couples on controlling the global HIV epidemic—in these couples, one partner has HIV infection and the other does not. The research conducted by ICAP in collaboration with the Semel Institute of Neuroscience and Human Behavior at University of California in Los Angeles (UCLA) is the first to assess the anticipated effect of the expansion of such treatment in couples on the HIV epidemic in certain African countries.  

In “Modeling the Impact on the HIV Epidemic of Treating Discordant Couples with Antiretrovirals to Prevent Transmission,” authors Wafaa El-Sadr, ICAP director, and Brian Coburn and Sally Blower at UCLA’s Center for Biomedical Modeling, designed a mathematical model that determined the number of infections prevented as a result of treating discordant couples. They used their model to make predictions for Ghana, Lesotho, Malawi and Rwanda. The study’s full findings were e-published on October 11, 2011 in the Journal, AIDS.

The authors use data for their modeling from the recent clinical study, HPTN 052, which showed that treatment of couples where one partner was HIV-infected and the other was not infected was successful in reducing transmission by 96 percent. “The findings from the modeling study provide insights into what countries can expect from expanding such a prevention strategy,” noted Dr. El-Sadr.

“The most important aspect of our study is that by using a model to scale up the results of a clinical trial, we were able to predict the effectiveness of the intervention in controlling HIV epidemics,” said Dr. Coburn. “It was very exciting to find that this couples-based intervention could be extremely effective.”

The authors also demonstrate a practical approach for identifying countries where the expansion of HIV treatment in discordant couples is likely to have a strong effect in terms of preventing further spread of HIV. Such information is of great value as policy makers and public health leaders tackle tough decisions in terms of determining their HIV control programs.   

Multidisciplinary Team Training Projects Kicks Off in Rwanda

ICAP in collaboration with the Kigali Health Institute (KHI) recently launched the Multidisciplinary Team Training (MDT) Project in Rwanda.  The MDT Project, funded by Pfizer Inc., is a training initiative that emphasizes intensive mentorship and teamwork to build public health skills among young African professionals. During three months of immersive training, the MDT Project reinforces interdisciplinary collaboration in an environment where health issues are complex and require a diversity of knowledge, skills, and expertise to address. 

Six young professionals from Rwanda and Tanzania, with varying backgrounds in nursing, medicine, education, public health and biomedical laboratory sciences, became the first cohort of the MDT Project. Under close mentorship from ICAP and KHI staff, the cohort will work on projects in line with ICAP’s global health initiatives. Several trainees, for example, are working on strengthening ICAPs Sexual and Gender Based Violence (SGBV) project, which identifies victims of sexual and gender-based violence in Rwanda, and supports the victims with comprehensive medical and psychosocial care and legal aide. Other trainees are working on a project that increases access to appropriate HIV prevention, treatment, and care services for men who have sex with men.

Initial participant feedback shows that both trainees and mentors are gaining valuable professional lessons from the MDT Project. Trainees noted that their visits with healthcare providers at various facilities have helped them understand the complex nature of the Rwandan health system and have supported their learning of critical skills such as program implementation and evaluation. Mentors are also discovering the professional benefits. Benoite Umubyeyi, a KHI mentor notes, “Mentoring trainees from various backgrounds has been a very rich experience. My work as a mentor in the MDT Project has shown me that local capacity building programs play a crucial role in developing and enhancing health systems.”