HIV/Aids

Every single one of my experiences abroad took me further into the world of global health – Global Health Alumni Interview with Julia Harris (2007, WCAS)
May 16, 2012 by Guest Bloggers
Name: Julia Harris (2007, WCAS)
Major: Anthropology (Human Biology)
Minor: Global Health

What did you do after graduation and where are you now?

Julia during her 3rd year clerkship at Soroka University Medical Center in Beer Sheva, Israel

I graduated in 2007 with a degree in Anthropology (Human Biology) and a minor in Global Health. I was pre-med, but I was not sure exactly what I wanted to do. I took the MCAT after my junior year and managed to get out a few med school applications right before I graduated. I knew that if I didn’t do the apps while in an academic environment I would never apply. What was more important to me at the time was to attempt to really work in some capacity in the global health world. So, I went to Brazil. I was born there and have a Brazilian passport, so I was able to get an internship at the National School of Public Health. I had an amazing experience. I split my time between research and shadowing a doctor who was doing a residency in public health. Public health is not a residency option in many countries; in American terms it’s a bit like family medicine mixed with an MPH. The public health residents ran a clinic located in the School of Public Health which serviced the low income communities who live in favelas surrounding the campus. In working at this clinic I had the opportunity to see the implementation of a primary care focused public health care system from multiple angles. I saw the process from policy making, to home visits and even clinical medicine. It was a phenomenal experience that really tied together the knowledge base I gained in undergrad and made me realize I really wanted to be a physician. I felt my inadequacies. I wanted a distinct skill set that could allow me to better serve the population and I decided I could do this best through the pursuit of an MD. It’s a great day when you suddenly know what you want to do, even if you know it’s going to take a lifetime to get there.

I was accepted to the Medical School for International Health while I was living in Brazil. This school is a 4-year American style medical school located in the deserts of southern Israel and was established in association with Columbia University. I graduate on May 23^rd, 2012 and will be working as resident physician in Obstetrics and Gynecology in Philadelphia at Drexel University’s Hahnemann Hospital.

Just a quick plug, cause I love my med school and it really is the perfect place to go if you want to go into medicine and global health all at once. My med school integrates a global health perspective into its curriculum and allowed me the opportunity to go to other countries such as India and Ethiopia to work in hospitals in a variety of interesting settings. Additionally, the day to day life here in Beer Sheva, Israel is quite diverse. The population served by our tertiary care center (where we study) is 50% Arabic speaking, predominately Bedouin. The other 50% is made up of immigrants from Russia and Ethiopia, refugees from Sudan and of course the Jewish population.

Which IPD program did you choose for your studies abroad and how has it influenced you?

While at Northwestern I studied abroad a few times, all along the lines of global health. I went on the Northwestern global health program to Mexico City the summer after freshman year. This really opened the doors for me. I was exposed to public health research, I shadowed doctors in a clinical setting, and I lived on my own in a foreign country for the first time. I had such an awesome time and realized that I could really pursue global health as an undergrad. This experience inspired me to continue to go abroad. In the summer after sophomore year I went to Buenos Aires to study Spanish and do a research internship at a public hospital. Then I went to South Africa on a global health SIT trip for the fall semester. During this trip I got involved in HIV/AIDS education and decided to return to South Africa to do my senior thesis. I was lucky enough to get an Undergraduate Research Grant (URG) which made the whole trip possible. Northwestern has so many opportunities for students who are interested in global health, as long as you are personally motivated people will get behind you and help you run after whatever dream you have (within reason).

Every single one of my experiences abroad took me further into the world of global health. There are so many lessons to learn from cultural sensitivity (trust me I have committed every faux pas) to one’s own limitations in language, in academics, and personal boundaries. Every time I put myself out of my comfort zone I learned so much about myself. I became totally addicted to the thrill of landing somewhere completely new and having to figure it out. I also loved learning about a country through its health care system. Working in the health care field allows you a certain intimacy with people that perhaps we do not deserve. For instance as a physician I have been able to enter peoples’ lives, peoples’ homes and through them I have been exposed to such amazing cultures, languages and life lessons. However, I must say as a disclaimer two very important things. Firstly, I have learned that one does not need to leave the US to accomplish what I just described. It is completely possible to experience a diversity of cultures in the US. There are people lacking access to health care and good health care policies everywhere in the world. The second disclaimer I have to offer is that despite my training I am not sure I am the person to bring health to the world. No matter how culturally sensitive you attempt to be, walking into a clinic somewhere in a developing country you will never have all of the skills to truly understand the culture of those you are treating. That being said I do think that global health leads to an amazing and fulfilling life and career no matter how you approach it, I just think that one has to be realistic. It’s great to want to change the world and help people but know your limitations and be humble. I will relate a small story to express what exactly I mean to say.

What’s one life lesson that you have learned since you started working?

Julia taking blood pressure of a woman in a rural town in central India called Bhidi, where she was running a clinic during her 4th year elective

I had the opportunity to do an elective in rural India during my last year of medical school. I was shocked by what I saw. I felt that the Hippocratic Oath was being ignored left and right because the best medicine, which I had learned to administer was not being practiced. The innumerate barriers that existed to giving what I believed to be appropriate eventually revealed themselves. One day a man was brought in bleeding from a motor vehicle accident. My med school colleague and I were the only ones trained in CPR and we did our best while surrounded by a crowd of screaming villagers to save this patient. We then jumped in a van “ambulance” and continued our CPR while standing and travelling over 120 kilometers per hour towards the nearest tertiary care center. We were not successful. I was so angry about the lack of CPR training and the prevalence of such situations that necessitated it. Then I realized that the cost of training a nation in a technique that is overwhelmingly not successful and often results in a patient with great medical needs may not be financially beneficial. If I were the minister of health in India I may decide that investing in CPR is not my biggest priority or an efficient investment of the limited funds available.

Do you have any advice or suggestions for current global health students on how to get involved or how to choose their career path in global health?

I have loved the great majority of my international life for the past 9 years but there are ethical debates every day that I have with myself. I attempt to abide by the Hippocratic Oath and do no harm to those I have the privilege of treating or working with. However, despite my plethora of global health training I will on occasion do wrong. I will give patients treatments that do not mesh with their cultural or religious beliefs or I will accidently say things that offend and alienate my patients or colleagues. If you choose to work in global health I think it is best to remember that you are a guest in someone else’s world and it is your duty to learn from your hosts in addition to lending a hand.

If you want a career in global health you have to make it happen. Spend time finding a place, a project or a community that really inspires you and go. There are always people who need or want volunteers but if you want to really make a career in global health it involves a long term commitment, stepping out of your comfort zone and finding the right people who can open doors for you. It is always best to find an expat or an English-speaking person who has made his/her life as a foreigner successfully integrated into wherever it is you are trying to go. The right contact can be everything. OK that’s all I got, the rest is just a little bit of luck and a lot of perseverance.
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Category: Brazil, India, Israel | Tags: Beer Sheva, Brazil, clinical medicine, Drexel University’s Hahnemann Hospital, Hippocratic Oath, HIV/Aids, home visits, Israel, Medical School for International Health, National School of Public Health, policy making, Public Health in Mexico, Undergraduate Research Grant, URG | Comments (0)
Global health: A political evolution
March 30, 2012 by Rian Ervin
Global health is a common buzzword among grassroots organizations, independent foundations and news outlets, but what exactly led to the popularity and creation of this term?

Guest lecturer Richard G. Parker spoke about his most recent work, a study of the political history of HIV, AIDS and sexual matters and the invention of global health in a keynote address Thursday.

Parker, a professor of sociomedical sciences at Columbia University, kicked off a two-day event, Libidinal Investments, organized by the Sexualities Project at Northwestern.

Global health is a “boom” industry; there is nothing hotter on U.S. college campuses, Parker said. In order to unravel the meaning behind this popular label, Parker looked back on 50 years of history.

He identified three key sets of processes leading to the invention of global health:

Professor Richard G. Parker discussed his latest work, the invention of global health against a background of political history, at Northwestern University Thursday. Source: Rian Ervin

- Population control, demographic thinking and the politics of international development

- The politics of HIV, sexual difference and the imagination of the global

- The struggle for reproductive rights

Each of these three processes emerged during a specific period of political change. Increased health research, the invention of international health organizations and social advocacy formed and shaped politics.

At the end of World War II, the concept of “developed” and “underdeveloped” countries emerged, resulting in the notion that international health problems existed, Parker said.

International organizations such as the World Health Organization and UNICEF were created to solve these problems, and the field of international health was born.

At the same time, an increased fear of population explosion placed new emphasis on the desire to develop third world countries, Parker said.

Population dynamics and research became central units of investment. Three large surveys analyzing fertility, contraceptive use and demographic health circulated the world for the first time.

The emergence of HIV in the 1980s resulted in a second wave of change.

HIV took on an essential role in the shift from the programmatic to the global vision of health, said Parker. Instead of creating organizations to solve health problems, cultural activism emerged, he said.

Population research shifted to sexuality research, bringing new focus to discussions of gender, sexuality and power. The HIV outbreak gave a voice to minorities, women and the LGBT community, Parker said.

The creation of international HIV and AIDS organizations, along with a global network of those living with the disease truly connected people across the world.

While Parker attributes HIV as the main historical element responsible for the invention of a global health community, he said there is still a long way to go in perfecting social and political mobilization.

The struggle for reproductive rights is the latest issue, according to Parker, and has been evolving over the past 15 years.

The ongoing abortion debate and 9/11 have caused huge shifts in how people think about health security and health rights, Parker explained.

While he isn’t sure how this issue will evolve, Parker said women’s empowerment is at the center of debate in the international arena.

Moving the ideas of feminism and LGBT sexual diversity across ethnic and cultural boundaries “is not simple,” said Parker. However, these fields are being discussed globally. “There is an expanding notion of inclusion,” he said.
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Category: Global Initiatives, Healthcare Industry, HIV/Aids | Tags: 9/11, abortion debate, demographic thinking, feminism, health rights, health security, HIV/Aids, international development, Invention of Global Health, LGBT, population control, population dynamics, reproductive rights, Richard G. Parker, UNICEF, WHO, women's empowerment | Comments (0)
Dr. Evan Lyon on current projects at Partners in Health
March 9, 2012 by Laura Ruch
“Whatever it takes. Just as we would do if a member of our own family—or we ourselves—were ill.” This mindset lies at the heart of the mission of Partner’s in Health (PIH), a Boston, MA based non-profit health care organization founded in 1987 by Dr. Paul Farmer, Ophelia Dahl, Thomas J. White, Todd McCormack, and Dr. Jim Young Kim. On Thursday, March 1, 2012, Dr. Evan Lyon of PIH spoke to a class of undergraduate and graduate students enrolled in Prof. Michael Diamond’s “Managing Global Health Challenges” course.

Dr. Evan Lyon - photo courtesy of the Media Co-Op (http://www.mediacoop.ca/)

Dr. Lyon has been a part of the Boston/Haiti team of PIH for 10 years. He learned HIV medicine in Haiti, where he spent half of his residency. When the January 2012 earthquake struck, Dr. Lyon was working in rural Alabama, although he says that he was immediately pulled back into Haiti after the disaster. While the situation in the Caribbean nation was already very difficult before the earthquake, today the magnitude of the problems – from infrastructure damage to malnutrition, displacement of families to an outbreak of cholera – is much greater. The effects of deforestation include food insecurity, crop destruction, and flooding year after year. In addition, the complete failure of a public health intervention is evident through the prevalence of totally preventable diseases such as tuberculosis, malaria, tetanus, and measles.

About 9 million people live in Haiti, and while the country lies very close to the US proximally, it is quite unique intellectually, politically, and culturally. To understand Haiti today, one must understand Haiti’s unique history. For about a century, from 1697 until 1804, Haiti was a colony of France, and many of the people living on the island were African slaves imported by French colonists. After the revolution, France began demanding “reparations” under threat of invasion, and Haiti was forced to borrow cash (from France) to repay this debt because no one else was willing to trade with a “combatant” country. This is the first example in history of foreign indebtedness, and it meant that Haiti had less control over its own development. The Haitian economy was created with financial policies geared toward the export industry instead of trying to protect the health and well being of the country’s own citizens. Considering years of other setbacks, including US occupations, a US backed Duvalier dictatorship, coups in 1991 and 2004, as well as repeated embargos and manipulation, one can understand why Haiti is in its current position.

Dr. Lyon, unlike the majority of physicians in the US, strongly believes in the idea that “illness and most suffering that goes along with illness comes from the social conditions that push someone to be vulnerable and unhealthy.” Social and economic conditions are closely tied with health, and “social medicine” seeks to understand this relationship. “From a health point of view,” Dr. Lyon said, “medicine is a relatively weak tool…there is much we can learn from the social sciences.” In addition, when the outcome of social and economic structures is greater suffering and early, unnecessary death, “it is right to call this violence,” said Dr. Lyon. “If the forces are unavoidable, as in they can’t move away from it—then it’s a structural thing.”

Partners in Health started in Cange and more recently has expanded in the Artibonite river valley. At the heart of its model is a commitment to serving the poor through the public sector, granting access to basic primary health care, and removing barriers to health care and education for the poor. The organization will see about 2 million patient visits this year, and it employs 5,000 people, half of whom are community health workers. As the largest health care provider in Haiti, PIH also provides jobs for Haitians. 99% of PIH employees in Haiti are from the country. While PIH is Boston-based, it’s partner organization, Zanmi Lastante, is run entirely by local Haitian leadership. For the last decade, everything that the organizations have been doing has been in collaboration with the Haitian government and the Ministry of Health. Haitian leadership decides where the priorities lie for the organization.

PIH has put heavy investment in community health work and a delivery mechanism that provides for people within the context that they are living. Rather than focusing on creating new technologies, PIH believes in the idea that there are many great technologies out there that aren’t reaching the poor because of delivery problems – not because those technologies are too high-tech. The idea of “accompaniment”, or sticking with a patient while they are sick or until they can stand on their own feet, is a central philosophy of PIH. Rather than having patients trek to the clinic when they are sick or need medicine, PIH employs local Haitians who know the patients and their community, who can get to their house every day, deliver medicine, make sure they take it, and check in with the patient. In this way a physical and emotional connection is created as PIH works side-by-side with they people they serve. This system also provides great adherence for following a drug regimen, and it provides a safety net so that sicknesses can be caught in their early stages before they become a major problem.

Currently, the organization is creating a new teaching hospital in Mirebalais. After the earthquake destroyed many of the existing hospitals, the government asked PIH to make the existing project bigger. The hospital will include an ER, trauma center, and cancer care, among other types of care. It will provide high quality education for the future generation of health care providers in Haiti. The hospital’s electricity will be provided through 400kW photovoltaic roof-mounted solar collectors. “Really, this is all happening because of the leadership of the Haitian government and the generosity of donors,” said Dr. Lyon.

Another current project is a cholera vaccination program aimed at easing the burden for the current outbreak. Nearly half a million cases have been reported in Haiti in 2011, and 6,600 Haitians have died since the onset of the outbreak. In addition to long-term solutions, such as providing chlorinated water, introducing hygiene measures, and improving the sanitation system, PIH decided to start an oral vaccine program in January of 2012. While there has been some apprehension about the program from other public health organizations – particularly because the vaccine has a limited supply and is not 100% effective— Dr. Lyon addressed this by pointing out that “If there was a cholera outbreak in Evanston, IL, there would be no question. You would get the vaccine. It’s one more tool that we have that will save lives.” Indeed, PIH sees the their friends in Haiti as deserving of the same standard of medical care as people receive in the states.
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Category: Community Health, Global Initiatives, Haiti, HIV/Aids, Natural Disaster | Tags: Earthquake, health education, HIV/Aids, Ministry of Health, Partners in Health, social medicine, Zanmi Lastante | Comments (0)
Sexual network models to fight HIV
August 25, 2011 by Sarah Moore
Let’s call him Naskar. Naskar grew up in a small village outside Calcutta, and moved to the city when he was 22. He is homosexual, and quickly developed a likeminded group of friends. He doesn’t do drugs, though he sometimes drinks. He sees his family infrequently, and spends most of his time inside the city at his minimum-wage job. Naskar has a boyfriend and a few lovers on the side; he assumes his boyfriend has lovers too, and doesn’t mind. In a few years he will marry, but he will continue to have sex with multiple men, as a giver and as a receiver. He contracted HIV a while ago, but does not yet realize it. By the time he does, he will have given it to his wife, and will have no idea who gave it to him.

These are not the only facts of Naskar’s life – far from it. But to those who study networks as a means of combating HIV, they are the most important. When plugged into a network of similarly profiled individuals – who will have different answers to the same questions – he becomes a data point. A probability. A pattern. A likelihood. An average.

As an individual, he is just Naskar. As a data point, he could save lives.

* * *

Circumcision, methadone treatment and marriage counseling might seem like oblique ways to combat HIV, but they are all part of the rapidly growing arsenal of responses to the worldwide epidemic, which infected 2.2 million new adults in 2009, according to international HIV & AIDS charity AVERT. Even here in the United States, where treatment is more available than almost anywhere in the world, 1 in 5 HIV-positive people don’t know they are infected. A full range of treatment options can cost up to $12,000 a year, making prevention more crucial than ever. And despite steps like President Obama has taken – asking people to get tested no matter what, even doing so himself – the sneaky and mutative disease still defies science’s attempts to see the big picture. At last, though, they may have found one.

Sexual network modeling is when medical engineers and healthcare workers use data gathered from individuals about their romantic interactions with others to build maps of connections within a certain society or subset of that society. Doing so can provide guidelines for where to treat HIV and how.

“A network model is useful because it captures homogeneity and behavior and susceptibility differences among person in the population,” says Elisa Long, assistant professor of operations management at Yale University. “Diseases spread in the same way that rumors spread or a new product is diffused in the market.” The way a particular disease, like HIV, moves through a group of people will dictate how treatment and prevention efforts should progress. And whether it’s vaccines, vaginal gels and more traditional remedies (like drug treatment regimes) or circumcision and counseling, healthcare workers must offer preventatives and remedies that mesh well with the societies in which they’re offered and the problems they are meant to address.

For instance, circumcision can prevent men from getting HIV during intercourse by removing tissue both easily torn (providing an entry to virus) and hospitable to virus growth. It is not, however, a viable preventative in countries religiously opposed to the practice. Similarly, methadone treatment can reduce the number of intravenous drug users in the population, but is useless without a means to target them, says Benjamin Armbruster, assistant professor of industrial engineering and management sciences at Northwestern University’s McCormick School of Engineering.

One of the biggest challenges to HIV’s eradication is that, so far, completely reliable methods of treatment and prevention continue to elude scientists and medical practitioners. When a person is first infected, the amount of virus in their bloodstream is extremely high. This period, which is known as acute infection and follows a 2-4 week incubation stage, is the most infectious and lasts roughly two months. By the time a person finds out they are infected, chances are excellent they have already transmitted the disease to someone else, often several.

And the problem of identification always remains. “Not enough people know their status and that’s part of the story of how it’s getting transmitted: people just don’t know they have it,” says Armbruster. Even in high-risk populations, people often lack the resources or ability to get tested, or simply choose not to. In fact, even groups classified “at increased risk” often don’t perceive themselves as such, according to Shannon Galvin, associate director of research at Northwestern’s Center for Global Health. “That’s just basic psychology,” she says. “Despite everyting we know, there are still approximately 50-60,000 new cases in the US each year,” says Robert Murphy, director for Northwestern University’s Center for Global Health. “That’s more people that get killed in automobile accidents per year.”

* * *

Providing testing, prevention and treatment options tailored to specific groups of people, combining interventions and convincing people to get treated are all ways network modeling can help, Armbruster says.

Modeling can offer glimpses into a society at several different stages of the HIV epidemic. How HIV enters a population, for example, depends on how it is constructed. When a large population of sex workers exists, for example, the disease is likely to appear there first, spreading quickly among them and then to their clients, after which it will trickle into the population from clients to their spouses and other partners. Where polygyny (men keeping multiple wives) is practiced, these partners are likely to be infected quickly. The women, however, are not nearly as likely to infect others as they would be in a society that condoned women having more than one lover. Once these women get it, they are unlikely to spread it further. By constructing these maps, medical workers can begin to tell who to target for treatment and how.

It’s easy to confuse the issue, says Armbruster, who cautions against thinking of models as accurate representations of any given group. It’s not like Facebook, he says, where anyone you might wish to treat is already plugged in to the network with his/her social relationships neatly laid out and on view. Rather, constructing a model of a given area can tell medical practitioners and engineers about the ground rules of that society: How do its members tend to relate sexually? (Are they polygamous? Promiscuous? Do they wait until marriage?) What are the most common sexual interactions? (Homosexual? Heterosexual? Bisexual? Does sex with different partners often occur within a short time period?) Which sexual interactions do not happen? What taboos need to be respected? (In societies with an underground homosexual scene, how can treatment occur without publicizing certain activities? What are the alternatives to circumcision for the religiously opposed?)

Through his work with sub-Saharan African communities, Armbruster has learned that partners of infected people have a drastically higher chance of being infected themselves. Whereas the population-wide prevalence in Malawi hovers around 10 percent, network modeling has shown that the chances an infected individual has an HIV-positive partner are closer to 50 percent. This has major implications for treatment.

“With the screening program, at least to some extent, people get tested because they’re sick,” Armbruster says. “Once they’re sick, it’s pretty late. In the early stages is where treatment helps the most.” HIV has fairly mild, flu-like symptoms, which can be easy to miss – more severe, opportunistic infections don’t generally develop for a number of years, and are almost always characteristic of the development of AIDS. If a person is coming to a testing center for symptoms like these, then they have likely been living for years with undiagnosed HIV. So once they’re sick, in other words, they’ve almost certainly transmitted it, and there is a good chance that at least some of their partners have done so in turn.

Finding the people most likely to have been infected or to get infected in the near future is a major preventative strategy. “Early treatment can reduce HIV transmission by about 96%,” Long says. This makes getting the infected on regimes one of the most reliable methods of intervention available.

The question then becomes: what is the best way to find and treat people early? Armbruster proposes contact tracing, a fancy term for a simple process: asking people who their partners are or were. This isn’t as simple as it sounds. “First of all asking people who their sexual partners are is not easy,” Armbruster says. “Second of all you have to find them. So it’s not obvious that this is a cheap way of going about things.” However, the chance that the partner of an HIV-positive individual is also positive is extremely high, Armbruster adds, which makes finding them a better idea. “It mitigates the increased costs,” he says. “Instead of a one in 10 chance, we have a one in two or so.”

* * *

HIV can be a difficult infection to treat simply by virtue of its sexual nature: the more private a society considers it, the more difficult it becomes to discuss. In India, where homosexual roles have historically been clearly defined but are now changing, the prevention and treatment picture is pretty difficult to define. John Schneider, assistant professor of medicine & epidemiology at University of Chicago, uses network data to figure out how these changing roles affect intervention options. “In India there’s traditionally been these set sexual roles that men take on, where men identify as a certain sort of person that participates in a certain type of behavior,” he says. This is not unique to India – it happens in South America and other places as well, Schneider says. There are “insertive” and “receptive males” – similar to tops and bottoms in the U.S. – whose roles have been prescribed for centuries. But that is now changing to include a versatile role – a “double-decker.”

“What’s happened so far is identity is strongly tied to behavior, but increasingly, there are breaks between identity and behavior,” says Schneider. This makes intervention difficult. If you tell a receptive individual to put on a condom during sex, but his insertive partner does not, you’ve done nothing but waste a condom. Similarly, if you circumcise a receptive individual, that might not help much.

Modeling can help, by indicating which individuals engage in which behavior, how and how often they are likely to be infected, and which treatments are effective. Having really flexible models is important here, Schneider adds. What happens to the population if the numbers of insertive, receptive and versatile change? Transmission methods and rates would alter accordingly, inevitably changing the necessary preventatives and treatments.

* * *

Georges Reniers, assistant professor of sociology and public affairs at Princeton University, studies marriage patterns in societies with a high prevalence of HIV, specifically how people stay in unions or choose new ones based on anticipated risk on infection. His work is closely related to Armbruster’s.

Several factors play in to how a sexual network will end up looking. Age of marriage is an issue, since populations with early marriage ages for females look different than later ones. “In populations that practice polygyny, you don’t have that very long interval between first sex and first marriage, so sex in these populations is much more quickly channeled in the context of a marriage.” Frequency of sex is another issue. “Models predicting the effects of partnership concurrency on the epidemic have always assumed that someone who has two partners will have twice as much intercourse as someone who has only one, so the number of coital acts per partnership remains constant.” As it turns out, this is usually untrue, Reniers says. What actually happens is that women in polygynous unions end up having significantly less sex than women in monogamous unions, which changes the network quite a bit. Yet another issue is concurrency, or having multiple sexual partners at one time.

A debate regarding the role of partnership concurrency currently rages within the scientific community. Some organizations, such as USAID, have already deployed anti-concurrency campaigns in countries such as Zambia, Swaziland and Botswana based on the assumption that multiple partners contribute to higher rates of infection. But the empirical evidence for this is actually fairly limited, says Georges Reniers. “We found this negative correlation between HIV and concurrency and we started looking for reasons. One possible explanation is the network structure. Most people who have advanced this theory of concurrency have assumed that both men and women have multiple concurrent partners, and that creates a very different sexual network than is the case where only men have multiple concurrent partners. This network is not as conducive to the spread of HIV.”

Essentially, a network where both men and women have multiple concurrent partners will create a vast web, similar to, say, the flight chart of a popular airline. A network in which only men have multiple partners, however, will tend to be much more limited: many distinct, star-shaped clusters, with a central male and satellite females. Doubtless there will be some connections outside the marriages as well, but far fewer. Studying sexual networks based on sample data may seem academic, but it actually has a huge impact on how funds are spent and treatment and prevention are approached: should treatment and prevention take place within the context of the marriage or not? Who should be targeted for prevention? What would be more effective, marriage counseling or population-wide vaccination attempts?

“Prevention responses also need to take into account the progress of the epidemic,” says the USAID website. Network modeling can inform that progress. “One hypothesis is that in early epidemics, most discordant couples occur when HIV is introduced into a pre-existing relationship, whereas in more mature epidemics, a greater proportion of discordant couples initiate relationships with a new partner who is already infected.” Thus, even within a single society, treatment might vary depending on the disease’s progress. A map could be really useful at a time like that.

* * *

A network cannot be used to plot individuals, stresses Eva Enns, a PhD student in electrical engineering at Stanford University. “Ultimately it’s not likely, in the case of humans to humans on the individual level, that you would map out a network and use it. You’re not going to say ‘Aha! These are the people I should target!’” Instead,

“What you can do is leverage technology to map interactions more easily and more continuously and make structural changes to how people are interacting with each other.”

Enns cites a recent study in which high schoolers were assigned radio frequency identification tags (RFID tags) before going about their daily business. The tags recorded the face-to-face interactions students had with each other, allowing researchers to create a detailed network of the high school. Once they’d mapped it out, the map became a tool in times of crisis. “From there what you could do is to look at that network and say, ‘Are there things in the structure of the school that we could change if a pandemic were detected? Maybe we should change how we have our lunch hour, change how classes enter and exit.’ You could change characteristics of the network, but you wouldn’t be targeting specific individuals.

Sabina Alistar, a PhD student working on resource allocation for control of infectious diseases at Stanford, approaches modeling similarly. For her, though, flexibility is key. “Instead of having a network that models how people interact, you group people by characteristics and group them in buckets where you assume an average of how people interact,” Alistar says. “This is a pretty realistic way of modeling the epidemic.”

There are also issues of combining treatment, Armbruster points out. “If you have two interventions, they are in some sense competing,” he says. “To combine them lessens the sum of the two. What people are just now starting to do is really get the interactions correctly to get a good idea of how you want to distribute your resources.”

The power of the network is best exemplified here, when thinking about where and how people do things, and the combinations between approaches. Health officials can use those high-frequency wheres and hows to direct their intervention efforts. If we think of a network as a vast map of probabilities and likelihoods, then Naskar’s contribution to the cause becomes clear. Sure, treating him will be one small step toward eradicating HIV entirely. More than that, though, Naskar can provide a map to the future: his story is the story of many.
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Category: Community Health, HIV/Aids, India, Infectious Diseases, Malawi, Public Health, South Africa | Tags: HIV case-finding, HIV/Aids, maps, networks, sex | Comments (0)
HIV in Nigeria
November 22, 2010 by Shannon Mehner
There are 22.4 million people in Nigeria living with HIV, said a Fogarty scholar at a campus lecture Friday on the state of HIV in Nigeria.

And though 750,000 affected people require antiviral therapy, only 198,000 people were treated last year—about 10 percent. “This is an area that really bothers me,” said Ifeyinwa Rita Onwuatuelo, who is a visiting Nigerian scholar on a Fogarty scholarship conducting research with the Center for Global Health.

Onwuatuelo has worked since 2004 in the field of HIV/AIDS and is currently working as the Care & Support Officer at the Program Office of AIDS Prevention Initiative in Nigeria in Abuja.

Unlike the transmission of the HIV virus in the U.S., which is mainly a result of same-gender sex, 80-95 percent of the cases in Nigeria are passed on through heterosexual intercourse. 15-30 percent are passed on to unborn babies through mothers during pregnancy.

One of the key factors driving the rapid transmission rate is an overarching belief that individuals aren’t at risk for infection, which leads to less caution in making sexual decisions. “People think ‘I cannot get it, only other people do,’” Onwuatuelo said, which is erroneous and furthers the current cycle.

Some contributing issues include inter-generational sex, sex with multiple partners, inefficient services to treat sexually transmitted infections and poverty. Another major problem is the stigma and discrimination that comes along with an HIV diagnosis, which can deter people from seeking treatment or telling others about their diagnosis.

“This is one of the biggest issues,” she said. “We need to do more to educate people so the cycle can stop.”

Developing countries such as Nigeria are 19 times more likely to be infected with HIV than the general population. And the virus has a major impact on society and its institutions—“HIV places a major burden on families economically, socially and psychologically,” she said.

It can cause families to reject infected members and cause issues in terms of family unity. It can also affect a family’s economic status because diagnosed individuals might not be able to work, Onwuateleuo added. And 2.23 million children are orphaned because of AIDS in Nigeria, a number that is still growing.

Churches and community organizations may also reject people who have been diagnosed. “Religions may discriminate against the faithful [who have been infected] as sinners,“ she said, which isolates infected people who need a support system more than ever.

Some of the treatment and prevention strategies the government and NGOS are employing are HIV counseling and sexual education testing, promoting the use of condoms and increasing media campaigns and public awareness. These types of services need to be increased, she said, along with access to antiviral treatments drugs.

But with the efforts of the Nigerian government, the U.S. government and organizations such as the Bill Gates Foundation, access to treatment and prevention programs continue to grow. With a continued push for early diagnosis and treatment, education and awareness programs and more preventative strategies, HIV can be managed, Onwuatuelo stressed.

“Attitudes are gradually changing,” she said. “But it’s not just a one day thing. We have to continue fighting.”
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Category: HIV/Aids, Nigeria | Tags: blog, Center for Global Health, Fogarty, HIV/Aids, Nigeria | Comments (0)

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HIV/Aids

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Dr. Evan Lyon on current projects at Partners in Health

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HIV in Nigeria

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