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Susan Allen
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  Susan Allen's research, which follows the longest-standing and largest heterosexual HIV-discordant couples cohort in the world, means many things to many people. For scientists and AIDS researchers with the Rwanda Zambia HIV Research Group (RZHRG), it means a wealth of new insights about transmission methods and prevention strategies. For the African nations, in which spousal heterosexual transmissions account for 60% to 70% of all new HIV infections, it means hope. And for students at the Rollins School of Public Health (RSPH), it means an unequalled opportunity to work alongside Allen, professor in the Hubert Department of Global Health and a leading AIDS researcher on studies of global importance. As one of Allen's students says, working in the field is "where the magic happens."  
  'No one has died yet'  
  Kathy Hageman knew she wanted to focus her career on AIDS research and treatment after her second trip to Botswana. Hageman, who is currently a second-year doctoral student in Behavioral Sciences and Health Education at the RSPH, made her first visit in the mid-1990s, when she spent three years teaching English to junior high students in a remote village in the Okavango Delta. At that time, the prevalence of HIV in the general Botswana population was 33%, and it was over 50% in women who had children. So Hageman and other Peace Corp volunteers spent much of their time educating the students about the virus.
     When Hageman returned to Botswana in 2002 to assist a former Peace Corps colleague with data collection for a research project, the prevalence of the disease had risen to 38%. She was able to meet with some of her former students, now grown with children of their own. "I distinctly remember how the first former student I saw proudly announced that he knew of no classmates who had died yet," recalls Hageman. "The honesty they shared about their desires to stay disease-free, yet their frank acknowledgement of their reality truly touched me. I knew I needed to get back into HIV work."
     So Hageman enrolled in the master's program at the RSPH the following year. For the next two years, she analyzed data collected from the field in the project's Atlanta office at Emory, an experience that convinced her to continue on to earn a PhD.
Kate Hageman
       "I remember when I started at Rollins being asked if I would be interested in pursing a PhD, and my response was, ‘No! Never! I want to work in the field,'" recalls Hageman, among the school's first six doctoral students in behavioral science. "But the more I learned about behavioral research and its hands-on aspect, the more I became fascinated with it and energized by its possibilities."
     After completing her first year in the doctoral program, Hageman finally got a chance to try some of that "hands-on" work in the field. In June, she joined Allen and ZEHRP, the Zambian arm of RZHRG, in Lusaka.
     "When I arrived, I was overwhelmed at the complexity and the breadth of the project," she says. "Even though I had been working in the home office for two years and felt like I understood the infrastructure, it literally took the first two weeks of rotation through the various departments to really understand the complexity of identifying discordant couples and retaining them in a long-term study."
     From the community workers, who follow up with clients who have missed a study visit, to the counselors who inform previously discordant couples that they are now both HIV positive, the ZEHRP staff inspired awe in Hageman.
     She knows her experiences in Lusaka will inform her work going forward. "In general, when you are doing research, there is a great focus on study design, sample size, data analysis strategies, and maintaining scientific integrity," says Hageman. "With such a focus, it is easy to forget that every study participant is a real person. It takes seeing the couples walking through ZEHRP's gates every day to make the experience very real and very worthwhile."
Emily Mendenhall
  Central America bound  
  For Emily Mendenhall, the best thing about working with Allen on her ZEHRP project was the freedom and responsibility she was given. "Dr. Allen really allows students to get their hands dirty," says Mendenhall, who received her MPH in global health in May. "She allows students to work with her data, gather their own, analyze it, write scientific papers—she really lets students become a part of it."
     Mendenhall spent her time poring over wills written by HIV-affected couples. She was looking for provisions to guard against "property grabbing," which is a big problem in Lusaka, says Mendenhall. "When the husband dies, the paternal clan often come and take the house and all the property, leaving the wife and children in absolute poverty."
     She discovered that even when a will specifically stated that the extended family was not allowed to tamper with the possessions in the event of death, property grabbing still occurred. These findings, along with her recommendation of an education initiative to inform women of their rights to retain property, were published in the summer issue of AIDS Care.
     As exciting as it was to publish a paper (as first author, yet), even that thrill paled when compared with the opportunity to spend the summer with the project in Zambia. "I worked in conjunction with Dr. Allen's project for two years in Atlanta, and it was great to see how a structured, successful HIV research project is run," says Mendenhall. "But when you are in the field, that's where the magic happens. In Zambia, the staff is amazing and supportive and really focused on the people they are serving. It's kind of like a family unit there."
     Mendenhall was so impressed by the couples approach to HIV voluntary testing and counseling that she is taking it to Central America. "I've helped develop a pilot project with two Humphrey fellows from the Hubert Department of Global Health based on many of the things Dr. Allen has published and proven effective," says Mendenhall, who has moved to Guatemala for the project. "We are still waiting to hear if the pilot study will be funded, but we have an organization interested in piloting the HIV prevention approach in Central America. This project is really exciting because, although RZHRG has successfully translated the project from Rwanda to Zambia, some of the strategies developed there could be really effective transnationally in a low HIV-prevalence area where HIV risk is high."
  Two halves of a whole  
  If she wasn't sold on Allen's couples approach to voluntary AIDS counseling and testing before, Rebecca Cramer became a believer in Zambia. She was sitting in on one of her first interview sessions for a man who was HIV positive.
     "The interviewer asked him if he received any support," recalls Cramer, who received her MPH in May. "The man smiled and said, ‘Oh yes. I have plenty of support.' So the interviewer asked who provided the support, and he said, ‘My wife.'
     "That really opened my eyes to how critical it is to counsel couples together," continues Cramer. "That way they can be much more educated and supportive of each other."
     And, like Mendenhall, Cramer valued the opportunity to conduct her own research. "Dr. Allen just lets people go," says Cramer. "You go in to the field, and you are the one responsible for making your project happen. That's a great opportunity for students."
     Cramer seized that opportunity and conducted a study—from proposal to data analysis—to look at the barriers to tuberculosis (TB) treatment adherence among people who were HIV-positive.
     "Tuberculosis is the most common opportunistic infection among people with HIV," says Cramer. "I was interested specifically in adherence to treatment regimes because Zambia is now starting a massive scaling up of ARV (antiretroviral) treatment. Many of the same factors that influence adherence to TB treatment will likely impact ARV treatment because the two treatment regimens are similar in complexity and side effects. If we can minimize barriers to adherence for TB treatment, this will likely have positive impacts for ARV treatment as well."
Rebecca Cramer
       Through one-on-one interviews conducted through a translator with patients at the ZEHRP TB clinic, Cramer found that cost is the most significant barrier to TB treatment adherence. "This has implications for decentralized health care systems like you find in Zambia," says Cramer. "Decentralization in theory decreases cost and increases convenience. However, if decentralization is not accompanied by improved transportation and treatment infrastructure, patients will still have lots of problems getting care."
     After her 10-week stint in Zambia, Cramer returned to Atlanta to work with Allen's project for another year. She researched a paper on the demographic makeup of the clinics in Rwanda and Zambia. She found several differences.
     "Each clinic had different types of people affected and different modes of transmission," says Cramer. "People tend to look at sub-Saharan Africa as one big AIDS problem, but there are differences in every country. For an AIDS prevention and treatment program to be successful, it has to be tailored to that specific country."
     Her time spent with the ZEHRP project opened Cramer's eyes to a new career path. "I really see now how clinical medicine and research can be merged," she says.
     Cramer is now enrolled in the University of Wisconsin–Madison School of Medicine and Public Health. "I know I want to continue working abroad with underserved populations, and I want to stay in preventive care," she says. "I think public health and medicine are two halves of a whole, and I would like to be a part of that."

Martha Nolan McKenzie is an Atlanta freelance writer.


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