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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." |
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'No
one has died yet' |
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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. |
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"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." |
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Central
America bound |
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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." |
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Two
halves of a whole |
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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."
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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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