Research and Innovation Series https://www.pih.org/ en Research: Doctor Investigates HIV/AIDS Therapy Patterns at Hospital in Haiti https://www.pih.org/article/research-doctor-investigates-hivaids-therapy-patterns-hospital-haiti <span class="field-wrapper">Research: Doctor Investigates HIV/AIDS Therapy Patterns at Hospital in Haiti </span> <span class="field-wrapper"><span lang="" about="/user/4559" typeof="schema:Person" property="schema:name" datatype="">rzimmerman</span></span> <span class="field-wrapper">Tue, 08/02/2022 - 12:50</span> <div class="field-wrapper field field-node--field-large-intro-text field-name-field-large-intro-text field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p>&nbsp;Younger patients, those struggling to meet basic needs more likely to have trouble with medication regimen&nbsp;</p> </div> </div> </div> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2022-08/1200_Ludo.webp?itok=uONGXBYe 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2022-08/1200_Ludo.webp?itok=qiAuc2zU 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2022-08/1200_Ludo.webp?itok=mmoLARe3 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2022-08/1200_Ludo.webp?itok=8G7z71Eq 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2022-08/1200_Ludo.webp?itok=oheASRy0 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2022-08/1200_Ludo.jpg?itok=uONGXBYe 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2022-08/1200_Ludo.jpg?itok=qiAuc2zU 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2022-08/1200_Ludo.jpg?itok=mmoLARe3 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2022-08/1200_Ludo.jpg?itok=8G7z71Eq 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2022-08/1200_Ludo.jpg?itok=oheASRy0 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2022-08/1200_Ludo.jpg?itok=uONGXBYe" alt="Family medicine doctor reviews patient file in Haiti" typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Dr. Ludentz Dorcelus, a family medicine doctor in Haiti and lead author of a study that looked at some of the barriers to antiretroviral therapy (ART) adherence, reviews a patient&#039;s file.</div> </div> </div> <div class="field-wrapper field field-node--field-photo-credit field-name-field-photo-credit field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Photo courtesy of Ludentz Dorcelus</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p>Ludentz Dorcelus clearly recalls the “complete chaos” that overwhelmed his hometown of Port-au-Prince after a 7.0 magnitude earthquake devastated Haiti in 2010, killing some 300,000 people. Dorcelus, 18 at the time, was one semester short of graduating high school when the quake, which leveled the capital city, hit.</p> <p>In order to finish school, Dorcelus and his parents agreed that he would move to the U.S., to the home of an aunt and uncle, in Nanuet, NY—a small town about 30 miles north of Manhattan. There, he graduated, then returned home and passed the local exams to complete high school in Haiti and apply to college, settling on a career in medicine. Now, Dorcelus is in the final year of his residency: he plans to stay in Haiti and practice family medicine.</p> <p>Education was a focus of his family, Dorcelus said, so it’s not surprising that when it came to structuring a research project as part of his medical school “social service” year, his hypothesis was that education was closely correlated with adherence to medication protocols. “A lot of that was based on my own experience,” he said.</p> <p>However, the results of his <a href="https://aidsrestherapy.biomedcentral.com/articles/10.1186/s12981-021-00405-4">research</a>, which looked specifically at adherence to antiretroviral therapy (ART) at one hospital in Haiti and was published in the journal <em>AIDS Research &amp; Therapy</em> last November, undermined that theory. For Dorcelus, the study’s lead author, that finding came as a “big surprise.”</p> <p><strong>Research Findings</strong></p> <p>The study included 411 patients at St. Therese Hospital in Hinche, a public facility in central Haiti, which is also supported by Zanmi Lasante, Partners In Health’s sister organization. Zanmi Lasante, founded in the early 1980s, now comprises a network of 15 clinics and hospitals in some of the country’s most impoverished regions and serves more than 1.3 million people.</p> <p>Researchers, relying on self-reported patient data, found that age and the ability to meet basic needs were the only two factors that significantly correlated with adherence. “The odds of having poor adherence was significantly higher in patients under 40 years compared to those 40 years of age and older,” the study concluded. Additionally, it found: “Patients who could not meet their basic needs were more likely to have poor adherence.”</p> <p>Earlier research has also found that younger patients can have more trouble following medical protocols in similar settings, Dorcelus said. That body of work suggested that older patients were more accustomed to the routine of medical regimens: “The survival instinct was also mentioned in these studies: the elderly patient, in decline, recognized that their life expectancy would be prolonged through good adherence.” At the younger end of the spectrum, “adolescents and young adults were at increased risk of treatment failure due to multiple social, psychological and adherence barriers,” the recent study had found.</p> <figure role="group"> <img alt="bottle of antiretroviral medication and daily journal" data-entity-type="file" data-entity-uuid="76cdcf03-3441-4092-9dd6-d165b06da2df" src="/sites/default/files/inline-images/1200_261166_Lesotho_0218_MLer-HolyCrossHC-ART_CAvila_218.jpg" width="800" height="533" loading="lazy" /> <figcaption>A patient living with HIV holds a bottle of antiretroviral therapy in Mohale's Hoek, Lesotho. Photo by Cecille Joan Avila / PIH </figcaption> </figure> <p><strong>Better Outcome and Survival</strong></p> <p>Adherence matters when it comes to all medications, but in particular, it’s associated with better outcomes and survival among people living with HIV, the study noted.</p> <p>To be sure, most patients in the study —a full 82%— reported their adherence to ART was “excellent.”</p> <p>Among those who reported poor adherence, the reasons varied, but many of them stemmed from general poverty: “Only 9% said they could always meet their basic needs compared with 27.9% who could never meet their needs. Not being able to meet their basic needs was associated with almost three times greater odds of poor adherence.”</p> <p>The study noted that ART is free in Haiti. “Were treatment not free, it would likely pose an even greater barrier to treatment adherence,” the study said. “If they [patients] do not have enough resources for food, they are likely to be more focused on solving this immediate need, instead of achieving viral load suppression. It is also a common belief amongst Haitians that medication should not be taken on an empty stomach. Living in poverty, not having access to water/food may prevent them from taking their medication.”</p> <p><strong>More Studies Needed</strong></p> <p>And while other studies have shown a link between education and adherence, this one did not. The literacy rate in Haiti for those 15 and older is 61%, the study noted, and the Central Plateau region has the nation’s highest illiteracy rate. “Surprisingly,” the authors said, “we found no statistically significant difference between adherence among those that had been schooled compared with those who had received no schooling.” However, they theorized that given the high illiteracy rate and limited ability to meet basic needs, “it is likely that access to education could potentially improve adherence to ART in this area.”</p> <p>Overall, Dorcelus said, more studies— at more hospitals— are needed to figure out all of the complex elements that drive adherence. “We need a nationwide study or a larger study to figure out the other barriers,” he said.</p> <p><strong>The Importance of Social Support </strong></p> <p>Dorcelus’ driving curiosity in the research struck Mary Clisbee, provost for academic affairs and research at the University of Global Health Equity in Haiti. "What I find most amazing is that he recognized the problem, searched the literature, and developed the study on his own, and during his service year!" Clisbee said. "That is unheard of! His level of motivation and autonomy is remarkable."</p> <p>Dr. Ornella Sainterant, director of medical education at HUM adds: "This study proves once again Dr Paul Farmer's teaching on social medicine [and] medical humanism: Our treatment won't work without social support."</p> <p><span style="font-size: inherit;">For now, Dorcelus said he is working on another project looking at the factors linked to poor glycemic control in diabetic patients, while also finishing up his studies. Though his future career path is not clear at this point, one thing is certain.</span></p> <p>“Even though the situation is bad, people are fleeing the country, and we are living in constant fear,” he said, “I grew up in Haiti. I want to stay here and serve my population.”</p> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/hiv-aids" hreflang="en">HIV/AIDS</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> </div> </div> <div class="field-wrapper field field-node--field-do-not-show-in-pih-news field-name-field-do-not-show-in-pih-news field-type-boolean field-label-above"> <div class="field-label">Do not show in PIH News</div> <div class="field-items"> <div class="field-item">Off</div> </div> </div> Tue, 02 Aug 2022 16:50:08 +0000 rzimmerman 8307 at https://www.pih.org Research: Investment in Nurses and Midwives Improves Health Care Outcomes in Rural Liberia https://www.pih.org/article/research-investment-nurses-and-midwives-improves-health-care-outcomes-rural-liberia <span class="field-wrapper">Research: Investment in Nurses and Midwives Improves Health Care Outcomes in Rural Liberia</span> <span class="field-wrapper"><span lang="" about="/user/4512" typeof="schema:Person" property="schema:name" datatype="">jdelzo</span></span> <span class="field-wrapper">Wed, 06/08/2022 - 09:00</span> <div class="field-wrapper field field-node--field-large-intro-text field-name-field-large-intro-text field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p>Published paper highlights importance of advanced training for nurses and midwives<b> </b></p> </div> </div> </div> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.webp?itok=PBvYd_t_ 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.webp?itok=yh66ZWaL 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.webp?itok=JjS2jzTf 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.webp?itok=Wol2ZkVA 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.webp?itok=W5477G5P 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.jpg?itok=PBvYd_t_ 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.jpg?itok=yh66ZWaL 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.jpg?itok=JjS2jzTf 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.jpg?itok=Wol2ZkVA 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.jpg?itok=W5477G5P 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2022-06/289551_liberia_0821_daniel_maweu_jamoo_001.jpg?itok=PBvYd_t_" alt="Daniel Maweu trains nurses " typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Daniel Maweu, nurse-midwife and reproductive health care educator, trains nurses how to use a cardiac monitor. Photo by Jason Amoo / PIH</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p>Nurses and midwives are vital to health care systems. This is especially true in regions with health workforce shortages, such as southeast Liberia. On a daily basis, nurses and midwives help meet patients’ everyday needs and fill in during emergency situations. Simultaneously, they train nursing students.</p> <p>To improve patient care and nurse training, strategic interventions must be carried out. In a new paper—<a href="https://annalsofglobalhealth.org/articles/10.5334/aogh.3251/">published in </a><i><a href="https://annalsofglobalhealth.org/articles/10.5334/aogh.3251/">Annals of Global Health</a> </i>in October 2021—Partners In Health (PIH) leaders and Tubman University partners call for sustained investment in education and training.</p> <p>“Nurses and midwives are the first and sometimes the only health care workers patients meet in Liberia,” says Daniel Maweu, nurse-midwife for PIH Liberia and lead author of the paper. “Due to a shortage in the number of doctors in Liberia, nurses and midwives are expected to perform lifesaving tasks which ordinarily would be the preserve of doctors.”</p> <p>Since 2015, PIH has worked with Tubman University faculty to prepare nurses and midwives in Liberia for the workforce<b> </b>through effective teaching methods, capacity building, and the promotion of nursing.</p> <p>There is a deep gap in Liberia’s health delivery system and rural regions of the country bear the brunt of the problems, according to Maweu and Lydia Johnson, health science instructor at Tubman University and co-author of the paper. Maweu noted that the gap impacts educational interventions, which are key to equipping nursing students to deliver high-quality care.</p> <p>In the paper and through various research projects, Maweu and Johnson investigated hard-hit areas of the health system in rural Liberia to identify optimal interventions, such as training nurses.</p> <p>There’s not a single teaching method that is effective on its own, they say, but rather a combination of theoretical sessions, practical sessions, and group work. More specifically, reviewing case studies, practicing procedures through simulation training, and clinical training with real patients equips nurses with essential skills.</p> <blockquote> <p>“When the capacity of nurses is built in rural Liberia, the positive impact of global health will be felt throughout the country,” says Johnson.</p> </blockquote> <p>Nurse training is constantly evolving due to diseases like Ebola and COVID-19 and advances in technology and research. That makes continuous professional development and curriculum review all the more important. Another strategy for nurse education adopted by the Liberian Board of Nurses and Midwives is the Online Continuous Professional Development Program, which provides hundreds of free short courses for nurses and midwives.</p> <p>“Investing in nurses and midwives has an undisputed potential to contribute to the sustainability of the health workforce, develop resilience of the health system and provide quality universal health access for all,” says Maweu, who hopes to expand the <a href="https://www.pih.org/article/qa-addressing-nursing-shortage-through-education-research-liberia">Nursing Center of Excellence</a> in rural Liberia.</p> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/nursing" hreflang="en">Nursing</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/nursing" hreflang="en">Nursing</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> <div class="field-item"><a href="/tag/article-0" hreflang="en">Research/Innovation</a></div> </div> </div> <div class="field-wrapper field field-node--field-do-not-show-in-pih-news field-name-field-do-not-show-in-pih-news field-type-boolean field-label-above"> <div class="field-label">Do not show in PIH News</div> <div class="field-items"> <div class="field-item">Off</div> </div> </div> Wed, 08 Jun 2022 13:00:00 +0000 jdelzo 8276 at https://www.pih.org Research: Improving Breast Cancer Outcomes for Patients in Haiti https://www.pih.org/article/research-improving-breast-cancer-outcomes-patients-haiti <span class="field-wrapper">Research: Improving Breast Cancer Outcomes for Patients in Haiti</span> <span class="field-wrapper"><span lang="" about="/user/4512" typeof="schema:Person" property="schema:name" datatype="">jdelzo</span></span> <span class="field-wrapper">Thu, 10/28/2021 - 09:50</span> <div class="field-wrapper field field-node--field-large-intro-text field-name-field-large-intro-text field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p><meta charset="UTF-8" />Earlier detection, diagnosis, and treatment can save lives&nbsp;</p> </div> </div> </div> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.webp?itok=bW5jPq7X 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.webp?itok=DdlXq1eD 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.webp?itok=n3mE0-Xm 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.webp?itok=Y2m4un7r 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.webp?itok=B4VXnCDJ 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.JPG?itok=bW5jPq7X 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.JPG?itok=DdlXq1eD 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.JPG?itok=n3mE0-Xm 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.JPG?itok=Y2m4un7r 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.JPG?itok=B4VXnCDJ 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2021-10/Haiti_0118_Oncology-OE_CAvila_002-2.JPG?itok=bW5jPq7X" alt="two clinicians meet with a patient with breast cancer" typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Dr. Joarly Lormil, an internal medicine and oncology physician, and Dr. Erwine Dina Jeune, an OBGYN medical resident, meet with a 35-year-old patient with breast cancer in 2018. Photo by Cecille Joan Avila / PIH</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p>In Haiti, breast cancer is the most common form of the disease among women, as it is worldwide. But there’s a key difference: a higher percentage of women will die from breast cancer in the Caribbean nation than most other countries.</p> <p>While many factors may contribute to this, including that Haitian patients are often diagnosed at later stages, there is limited research detailing how these factors play a role in Haiti. To gain a better understanding of the situation and to assess care delivered at Hôpital Universitaire de Mirebalais (HUM), researchers from Zanmi Lasante—Partners In Health’s sister organization in Haiti—alongside co-collaborators from several institutions in the United States, conducted a comprehensive assessment.</p> <p>Their findings, which were <a href="https://theoncologist.onlinelibrary.wiley.com/doi/10.1634/theoncologist.2019-0951">published</a> last year in <i>The Oncologist</i>, include many important takeaways, with the most encouraging being that basic breast cancer treatment can lead to better outcomes in Haiti, especially when patients are diagnosed and treated early.</p> <blockquote> <p>“We wanted to highlight the fact that we can treat cancer in Haiti. It’s feasible but you need the right resources,” says Dr. Ruth Damuse, clinical care coordinator in HUM’s oncology department and co-author of the study.</p> </blockquote> <p>Their research is the first published assessment of cancer care at HUM since the program (which began in Cange in 2011) moved to the hospital in 2013, the same year the 350-bed, world-class teaching facility opened its doors. HUM has the country’s only public oncology center capable of diagnosing and caring for patients and offering both therapeutic and surgical treatments.</p> <p>As the oncology department at HUM becomes more widely known, patients—80% of whom have breast cancer—have come from all around the country for care.</p> <h4><b>A Closer Look</b></h4> <p>The study included data from 341 female patients with nonmetastatic breast cancer who started treatment at HUM from 2012-2016. Damuse and her colleagues measured “event-free survival” in patients, meaning how much time elapsed before the patient had either a recurrence of cancer, a new tumor, disease progression, or death from any cause. They also reviewed the type of care provided by HUM, taking into consideration what treatments were administered, the time it took for patients to receive that treatment, and the treatment’s duration.</p> <p>Of those patients, 81.5% received curative surgery, or removal of the breast where a tumor was found. (Breast-conserving surgery is not performed in Haiti at this time since it requires patients to receive radiation therapy, which is not available in the country.) Pre- and post-surgical therapies such as chemotherapy were provided to shrink the tumor, and some patients also received further chemotherapy and hormonal therapy after surgery. During the follow-up period, 28 patients died, 77 had disease recurrence, and 10 experienced progression of the disease.</p> <p>Of the patients that had up to 3 years of follow up, over 60% were alive and free of disease.</p> <p>Most patients tended to have more advanced disease at the time of diagnosis—a rate that was even higher than previous studies conducted across Haiti had indicated. The authors believe one reason was the lack of nationwide breast cancer early detection programs. And many of the patients appeared to get breast cancer at an earlier age than patients in the U.S., which previous studies have also found.</p> <p>Lead author Dr. Temidayo Fadelu, PIH’s oncology advisor, says an explanation is illusive and needs further research. “You have an overall younger population, and then you have the possibility that the biology of cancer might be different in a population of African descent. Overlaying that is likely referral bias.”</p> <p>In other words, he wonders: “Is it possible that older patients are having cancer but not making their way to our facility?”</p> <p>The study helped researchers pinpoint several important obstacles to care that will be useful in identifying areas of improvement. For example, researchers found that many patients experience delays when they go to other facilities. When patients wait until their disease has advanced, it becomes more difficult to treat their cancer and more likely that they will have a negative outcome.</p> <p>Damuse said that patients are oftentimes resistant to seeking care for several reasons: stigma related to breast cancer, fear that a mastectomy will make them less feminine, or because they believe breast cancer is a death sentence. In some cases, patients are skeptical of modern treatments. And in rural areas, she says, people tend to be unfamiliar with hair loss associated with chemotherapy or have never heard of a breast being removed to save a patient’s life.</p> <p>Diagnosis is also challenging. For most of the study period, there was very limited access to pathology services and patient samples had to be sent to the U.S. for a diagnosis. In Haiti, clinicians evaluate the extent of the cancer using a chest x-ray and ultrasounds, but other tests common in higher-income  countries such as CT scans, nuclear studies, MRI, and PET scan machines are not readily available.</p> <figure role="group"> <img alt="Marana Toussiant standing outside" data-entity-type="file" data-entity-uuid="314c4a7f-1340-49fc-bb25-85a8209bffac" src="/sites/default/files/inline-images/Haiti_0118_Oncology-MT_CAvila_038.JPG" width="800" height="533" loading="lazy" /> <figcaption>Marana Toussiant was treated for breast cancer by Dr. Ruth Damuse at HUM where she underwent a mastectomy and eight months of chemotherapy. She often talks about her experience. "People think that if you get cancer, you will die," Toussiant said in 2018. Yet she points to her own case and simply tells them "that’s not true." Photo by Cecille Joan Avila / PIH</figcaption> </figure> <h4><b>Implementing Changes at HUM </b></h4> <p>Since conducting the study, the team has worked hard to improve the scheduling system and follow up with patients, with the goal of making sure patients continue treatment.</p> <p>Dr. Joarly Lormil, oncology care coordinator at HUM, has seen thousands of patients in his practice. He estimates that, at the moment, about 150 patients are actively receiving chemotherapy at HUM. Lormil treats patients with all kinds of cancers, but the majority are patients with breast cancer. He has seen firsthand how harmful it can be when patients delay treatment.</p> <p>Lormil recalls seeing a patient in her early 30s who was diagnosed with breast cancer and was a candidate for surgery. However, she was newly married and reluctant to have her breast removed. Nearly a year later, “we finally convinced her to receive the care,” he says. But then the earthquake struck, further delaying her surgery. Two more months passed. Finally she had the surgery and is doing well now, but is at higher risk for further complications and recurrence of her disease.</p> <p>As the oncology team continues to increase its capacity to care for and treat patients in Haiti, increasing its staff and eventually bringing in new technology and treatments will improve patient outcomes, but all this comes at a significant cost.</p> <p>Nonetheless, Lormil is optimistic: “Most men and women with breast cancer can get cancer care, including palliative care.”</p> <p>Take the recent example of a nurse working in HUM’s maternal health unit, who discovered she had breast cancer. When she first got treatment, she felt ill from chemotherapy, but is doing better now. She is free from cancer, says Lormil, adding that the nurse has been sharing her experience with her co-workers and patients.</p> <blockquote> <p>“She is the embodiment that, if you receive care early,” he says, “you can be free of cancer.”</p> </blockquote> <h4><b>Moving Forward</b></h4> <p>The research team identified gaps and areas for improvement, such as increasing the percentage of patients who receive surgery, the proportion of patients who get estrogen receptor testing, and the use of chemotherapies before and after surgery. The team also hopes to reduce the number of patients who fail to follow up and decrease system delays for patients.</p> <p>As a result of the study, HUM staff are now working with local partners on initiatives to teach women how to perform self-breast exams. Clinicians are also providing information and support to patients with the goal of overcoming stigma around cancer care. Further studies are recommended to better understand why there are high rates of breast cancer in Haiti, and why Haitian women seem to get breast cancer at a younger age.</p> <p>The study’s findings have already helped raise the standard of care for breast cancer patients at HUM. For example, the hospital now has a full-time surgeon integrated in the oncology team and dedicated to providing expedited access to surgery.</p> <p>Damuse says the study has given the team confidence and proven the success of HUM’s oncological care model, which can serve as a blueprint for cancer care across Haiti and other developing countries.</p> <p>“The study,” she says, “shows that we can improve cancer care in Haiti going forward.”</p> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/cancer-chronic-diseases" hreflang="en">Cancer &amp; Chronic Diseases</a></div> <div class="field-item"><a href="/programs/research" hreflang="en">Research</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/tag/cancer" hreflang="en">Cancer</a></div> <div class="field-item"><a href="/taxonomy/term/768" hreflang="en">Haiti</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> <div class="field-item"><a href="/tag/article-0" hreflang="en">Research/Innovation</a></div> </div> </div> <div class="field-wrapper field field-node--field-do-not-show-in-pih-news field-name-field-do-not-show-in-pih-news field-type-boolean field-label-above"> <div class="field-label">Do not show in PIH News</div> <div class="field-items"> <div class="field-item">Off</div> </div> </div> Thu, 28 Oct 2021 13:50:25 +0000 jdelzo 8067 at https://www.pih.org Research: In Rural Mexico, Building Trust Is Key To COVID-19 Response https://www.pih.org/article/research-rural-mexico-building-trust-key-covid-19-response <span class="field-wrapper">Research: In Rural Mexico, Building Trust Is Key To COVID-19 Response </span> <span class="field-wrapper"><span lang="" about="/user/3201" typeof="schema:Person" property="schema:name" datatype="">apollard</span></span> <span class="field-wrapper">Thu, 04/29/2021 - 15:42</span> <div class="field-wrapper field field-node--field-large-intro-text field-name-field-large-intro-text field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p>In <em>The Lancet Global Health</em>: Community health workers key to contact tracing</p> </div> </div> </div> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2021-04/mexico_0620_covidresponseces_prodriguez.webp?itok=Ekn7GNyg 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2021-04/mexico_0620_covidresponseces_prodriguez.webp?itok=Fi51GmKI 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2021-04/mexico_0620_covidresponseces_prodriguez.webp?itok=APWspwZ4 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2021-04/mexico_0620_covidresponseces_prodriguez.webp?itok=mytJyP1C 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2021-04/mexico_0620_covidresponseces_prodriguez.webp?itok=91uK-8bm 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2021-04/mexico_0620_covidresponseces_prodriguez.JPG?itok=Ekn7GNyg 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2021-04/mexico_0620_covidresponseces_prodriguez.JPG?itok=Fi51GmKI 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2021-04/mexico_0620_covidresponseces_prodriguez.JPG?itok=APWspwZ4 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2021-04/mexico_0620_covidresponseces_prodriguez.JPG?itok=mytJyP1C 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2021-04/mexico_0620_covidresponseces_prodriguez.JPG?itok=91uK-8bm 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2021-04/mexico_0620_covidresponseces_prodriguez.JPG?itok=Ekn7GNyg" alt="A doctor teaches a nurse how to wear a face mask as part of a larger training on how to manage triage areas in Chiapas, Mexico." typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Dr. Doris Altuzar teaches a nurse how to properly wear a face mask as part of a larger training on how to manage triage areas in the community clinic of Honduras, one of the communities in Chiapas, Mexico where PIH works. </div> </div> </div> <div class="field-wrapper field field-node--field-photo-credit field-name-field-photo-credit field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Photo by Paola Rodriguez / Partners In Health.</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p>In much of the world, contact tracers pick up the phone. But in places like Chiapas, Mexico, they knock on doors.</p> <p>That’s because phone and internet service are hard to come by in Mexico’s southernmost state, where more than 75% of the population lives in poverty. That makes contact tracing a complex and challenging process—but not impossible.</p> <p>In fact, new research <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00112-1/fulltext">published</a> in The Lancet Global Health and presented in the Consortium of Universities for Global Health's 12th Annual Global Health Conference as a poster in March shows how Partners In Health supported hundreds of people in Chiapas with contact tracing, medical care, and essential resources over the past year, mounting an effective COVID-19 response despite structural barriers.</p> <p>The research demonstrates the value of PIH’s approach worldwide: building long-term relationships with local communities and strengthening health systems, before disaster strikes, so that patients receive the care they need, when they need it most.</p> <p>“We, through the community members, have built a contact tracing force,” says Zeus Aranda, a research coordinator at Compañeros En Salud, as PIH is known locally, and co-author of the Lancet Global Health abstract. “At the end of the day, the people who know the community best…are the community members.”</p> <h4>Responding In Rural Chiapas</h4> <p>When the pandemic struck Chiapas in March of last year, the case count was low at first, hovering in the single digits. But then the surge came. Between March 2020 and January 2021, the state of 5.2 million recorded 8,745 positive cases and 1,259 deaths from the virus.</p> <p>Even as case counts soared, critical resources—such as COVID-19 tests and oxygen concentrators—were in short supply. And in Chiapas’ rural communities in the Sierra Madre region, where Compañeros En Salud works, disinformation spread, along with the disease.</p> <p>Despite these challenges, Compañeros En Salud was able to <a href="https://www.pih.org/article/rural-mexico-clinicians-deliver-lifesaving-care-amid-fast-moving-pandemic">mount an effective response</a> in the communities where it works, detecting and supporting 287 suspected cases and 1,111 of their contacts through its contact tracing program and providing groceries and hygiene products for 650 households.</p> <p>But that success didn’t happen overnight.</p> <p>In the Lancet Global Health research, authors Dr. Ariwame Jiménez, Dr. Bruno Vargas, and Zeus Aranda describe Compañeros En Salud’s COVID-19 response in rural Chiapas—and how its impact could reach far beyond the Sierra Madre.</p> <p>“It’s such great news that this abstract is being shared in a journal that has such a large impact,” says Laura Martinez, who supported the research as Compañeros En Salud’s contact tracing coordinator. “What was undertaken here in Chiapas is something that a lot of communities with similar characteristics can reproduce and adapt to their contexts.”</p> <h4>‘Contact Tracing Is Possible’</h4> <p>Compañeros En Salud has been working in Chiapas since 2011, and its decade of work building relationships and operating programs there <a href="https://www.pih.org/article/fighting-growing-covid-19-pandemic-mexico">made it a trusted partner</a> in the Ministry of Health’s COVID-19 response. But it had never run a contact tracing program before.</p> <p>To accomplish that, it enlisted members of one of its longest-running programs.</p> <p>“Community health workers have been the bridge between the clinic and the community for years,” says Jiménez, who coordinates Compañeros En Salud’s community health program and served as a first-year doctor in the community clinic in Soledad.</p> <figure role="group"> <img alt="Dr. Ariwame Jiménez meets with a patient at a clinic in Soledad in 2017." data-entity-type="file" data-entity-uuid="662d7374-9c50-4df0-a04b-e0fc44c1f9b7" src="/sites/default/files/inline-images/mexico_1117_soledad_cavila_013.JPG" width="938" height="624" loading="lazy" /> <figcaption>Compañeros En Salud has been working in Chiapas' rural Sierra Madre communities for nearly a decade. Dr. Ariwame Jiménez meets with a patient at a clinic in Soledad in 2017. Photo by Cecile Joan Avila / Partners In Health.</figcaption> </figure> <p>A cornerstone of public health programs worldwide, community health workers are local residents who are recruited, trained, and then dispatched throughout their communities to provide a range of basic health information and services, medications, and social support.</p> <p>Compañeros En Salud’s community health workers have been knocking on doors in Chiapas’ Sierra Madre communities for nearly a decade, checking in on patients and becoming familiar faces in areas where paved roads and nearby clinics are few and far between.</p> <p>That track record of building trust with the community made them a natural fit for the contact tracing program. Each community that accepted support was assigned one or two community health workers for contact tracing efforts. These community health workers followed a careful set of protocols. First, a check in with the local clinic for a list of suspected cases in their area. Then, door-knocking to follow up with the cases and their contacts. Finally, collecting and entering the data in a centralized database.</p> <p>As COVID-19 intensified in the region, these trusted residents <a href="https://www.pih.org/article/rural-mexico-pih-community-health-workers-accompany-covid-19-patients">became a lifeline</a> and, for the researchers, proof of an important concept.</p> <p>“Contact tracing is possible, no matter how hard the context is or the conditions in that specific area,” says Jiménez.</p> <p>It wasn’t always seamless.</p> <p>In the early days of the pandemic, Compañeros En Salud’s workforce of community health workers halved, plummeting from 84 to 43 people. Two communities declined to participate in the contact tracing program due to skepticism and misinformation about the pandemic. And many community health workers have only basic literacy skills, complicating data collection.</p> <p>But the program moved forward, undaunted.</p> <p>As the pandemic became less novel and more detailed health guidance was released, the vast majority of community health workers returned to work, eventually bringing the staff to 80. Jiménez and her team, along with the infection control and prevention team, met with the communities that declined contact tracing to discuss other ways to provide support. And community health workers without literacy skills found other ways to record their data, often with the help of their supervisors or facility staff.</p> <p>The pandemic is far from over, and Compañeros En Salud continues to battle the virus in Chiapas. But for the researchers, the Lancet Global Health abstract shows that an effective pandemic response is possible, even in the most rural and under-resourced settings. And it taps into another resource that has, at times, felt scarce: hope.</p> <p>“What was done is possible in similar contexts around the world. So many communities are very similar to where we work,” says Martinez. “It’s really motivating and inspiring.</p> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/community-health-workers" hreflang="en">Community Health Workers</a></div> <div class="field-item"><a href="/programs/research" hreflang="en">Research</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/tag/covid" hreflang="en">Covid-19</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> <div class="field-item"><a href="/tag/article-0" hreflang="en">Research/Innovation</a></div> </div> </div> Thu, 29 Apr 2021 19:42:01 +0000 apollard 7897 at https://www.pih.org Research: Integrated Care Improving Outcomes for Patients in Rural Malawi https://www.pih.org/article/research-integrated-care-improving-outcomes-patients-rural-malawi <span class="field-wrapper">Research: Integrated Care Improving Outcomes for Patients in Rural Malawi </span> <span class="field-wrapper"><span lang="" about="/user/366" typeof="schema:Person" property="schema:name" datatype="">mlawrence</span></span> <span class="field-wrapper">Wed, 12/23/2020 - 09:11</span> <div class="field-wrapper field field-node--field-large-intro-text field-name-field-large-intro-text field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p>Integrating care for HIV and non-communicable diseases such as hypertension, diabetes, and mental illness&nbsp;is making treatment more accessible and effective in Neno District&nbsp;</p> </div> </div> </div> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.webp?itok=ciYVEmMW 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.webp?itok=PF8YaUfB 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.webp?itok=bAfnUAbC 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.webp?itok=ET3wRORa 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.webp?itok=xX5g2RCl 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.jpg?itok=ciYVEmMW 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.jpg?itok=PF8YaUfB 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.jpg?itok=bAfnUAbC 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.jpg?itok=ET3wRORa 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.jpg?itok=xX5g2RCl 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2020-12/Malawi-1220-IC3-waitingarea-FunnyKamanga-1200-crop.jpg?itok=ciYVEmMW" alt="People chat in the waiting area of the new integrated care building in Neno, Malawi" typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">A new building that&#039;s dedicated to integrated care opened earlier this year next to Neno District Hospital and has significantly improved space and services for patients with HIV and non-communicable diseases. A new study shows PIH&#039;s integrated care model is making treatment more accessible and effective for patients. </div> </div> </div> <div class="field-wrapper field field-node--field-photo-credit field-name-field-photo-credit field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Photos by Funny Kamanga / PIH</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span>Bringing patients for hypertension, diabetes and other non-communicable diseases under one roof for treatment that’s intertwined with HIV care is significantly improving outcomes in rural Malawi, a new study shows.  </span></span></p> <p><span><span>Partners In Health and Malawi’s Ministry of Health launched their Integrated Chronic Care Clinic, or IC3, in 2015 in Neno District. The IC3 model integrates <strong><a href="https://www.pih.org/programs/hiv-aids">HIV </a></strong>care with treatment for non-communicable diseases, or <strong><a href="https://www.pih.org/programs/cancer-chronic-diseases">NCDs</a></strong>, which can also include asthma, epilepsy, mental illness, and more. </span></span></p> <p><span><span>PIH has worked in <strong><a href="https://www.pih.org/country/malawi">Malawi </a></strong>since 2007, is known locally as Abwenzi Pa Za Umoyo, and supports 12 health centers and two hospitals across Neno District. Dr. George Talama, the team’s primary health care clinical manager, said building integrated care on the foundation of a successful HIV program was a natural progression.   </span></span></p> <p><span><span>“We thought, if we could leverage from our HIV platform, we could expand access to care for NCDs,” he said. “Since NCD care was being delivered only at (PIH-supported) Neno District Hospital and Lisungwi Community Hospital, while HIV care was being provided at all 14 health facilities and with better outcomes, we hypothesized that introducing NCD care to this already existing HIV care platform would increase access to NCD care and improve outcomes.” </span></span></p> <p><span><span>And providing care to clients diagnosed with both HIV and an NCD—on the same day, at the same clinic—would ease burdens on NCD care and make it easier to access, Talama added. </span></span></p> <figure role="group"> <img alt="Clinician Bright Mailosi talks with a patient in Neno, Malawi " data-entity-type="file" data-entity-uuid="f8c9a65d-d880-4db0-ae6e-89638bd864a0" src="/sites/default/files/inline-images/Malawi-1220-IC3-PatientCare-FunnyKamanga%20800.jpg" width="800" height="533" loading="lazy" /> <figcaption>Bright Mailosi, clinical officer for Abwenzi Pa Za Umoyo, talks with a patient in Neno District. Mailosi said providing  integrated care for patients is creating new opportunities to share information about non-communicable diseases.</figcaption> </figure> <p><span><span><strong><a href="https://bmjopen.bmj.com/content/10/10/e036836">The study </a></strong>was published in October in the journal <em>BMJ Open </em>and features several PIH co-authors. It shows that PIH’s integrated clinics are improving the accessibility of NCD care by allowing patients to have all of their chronic conditions treated on the same day at their nearest health facility. The model also makes better, more efficient use of staff time and clinical space. </span></span></p> <h2><span><span>Impacts of Integrated Care</span></span></h2> <p><span><span>Over the study’s three-year period, from 2015-17, integrated clinics at 14 primary care facilities enrolled a total of 6,233 new patients, nearly half of whom presented with one or more chronic NCD. After just a year, retention in treatment stood at 85% of patients with HIV, and 72% of patients with an NCD. Those numbers compare to retention rates as low as 25% found in other studies from similar settings.  </span></span></p> <p><span><span>IC3 patients in Neno not only were staying in regular treatment; they also were getting better. </span></span></p> <p><span><span>Most clinical measurements—such as blood pressure, asthma severity, blood sugar, or number of seizures per month, for patients with epilepsy—showed statistically significant improvement over the course the study. One year after enrolling in IC3 care, more than half of hypertension patients had controlled blood pressure, and patients with epilepsy were reporting fewer seizures overall—with more than 40% regularly reporting no seizures since their previous visit. </span></span></p> <p><span><span>Meanwhile, HIV patients continued to show excellent outcomes with continued high-quality care, despite the addition of NCD clients to the clinic. </span></span></p> <p><span><span>Hypertension, asthma and epilepsy were the most common diagnoses for patients in the study. </span></span></p> <p><span><span>While the concept of integrating HIV and NCD care is not new, the IC3 model is having an outsized impact in Neno. Earlier this year, PIH opened a brand-new, expanded IC3 building adjacent to Neno District Hospital, to better serve growing numbers of patients. </span></span></p> <p><span><span>The need is stark. NCDs are a leading cause of death and disability globally, and especially in underserved areas like Neno, where accessing care can be difficult and materials needed to diagnose and treat hypertension, diabetes, and more, can be scarce. </span></span></p> <p><span><span>“Before IC3, I was the only one providing NCD care at Neno District Hospital,” said Bright Mailosi, a clinical officer with Abwenzi Pa Za Umoyo. There were many challenges at that time, he added, citing staff shortages, an unreliable supply chain and a high rate of default, or patients leaving treatment. </span></span></p> <figure role="group"> <img alt="The new integrated care building next to Neno District Hospital is providing much more space for patients and services " data-entity-type="file" data-entity-uuid="ae0d8d59-7c39-49ce-b8b0-3000171aa10f" src="/sites/default/files/inline-images/Malawi-1220-IC3-BuildingMug-FunnyKamanga%20800-crop.jpg" width="800" height="424" loading="lazy" /> <figcaption>The new integrated care building next to Neno District Hospital opened earlier this year and is providing vastly improved space for patients and services.</figcaption> </figure> <p><span><span>With the launch of IC3, Mailosi was trained to administer antiretroviral therapy and provide HIV care. At the same time, the HIV team learned about NCDs, including how to diagnose different conditions and counsel patients.      </span></span></p> <p><span><span>Mailosi said patients aren’t always as informed about NCDs as they are about HIV.</span></span></p> <blockquote> <p><span><span>“People hear HIV, and they know what that means,” Mailosi said. “For so long, it was a death sentence. But with NCDs, they may not take it so seriously. So you have to take more time to explain the diagnosis, and the medication, and why it’s important that they take it every day.”   </span></span></p> </blockquote> <p><span><span>As IC3 continues to scale up in Neno and across Malawi, maintaining supplies of medications will be a critical consideration, as will the increased workload for health center staff. </span></span></p> <p><span><span>“There are districts that are already overloaded with clients in need of care for HIV,” Talama said. “For those providers to take on NCD clients as well—that could be quite a lot.” </span></span></p> <p><span><span>Nonetheless, Talama said the IC3 has been a huge success so far, and the study indicates the model can serve as a blueprint for integrated HIV and NCD care across Malawi and beyond. </span></span></p> <p><span><span>Before IC3, Talama noted, there was only one facility in Neno providing care for NCDs. </span></span></p> <p><span><span>“Now all 14 (PIH-supported) health facilities are able to provide NCD care,” he said. “Everyone can see the benefits.”</span></span></p> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/hiv-aids" hreflang="en">HIV/AIDS</a></div> <div class="field-item"><a href="/programs/cancer-chronic-diseases" hreflang="en">Cancer &amp; Chronic Diseases</a></div> <div class="field-item"><a href="/programs/mental-health" hreflang="en">Mental Health</a></div> <div class="field-item"><a href="/programs/research" hreflang="en">Research</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/build-systems" hreflang="en">Build Systems</a></div> <div class="field-item"><a href="/hiv-aids" hreflang="en">HIV/AIDS</a></div> <div class="field-item"><a href="/infrastructure-improvements" hreflang="en">Infrastructure Improvements</a></div> <div class="field-item"><a href="/malawi" hreflang="en">Malawi</a></div> <div class="field-item"><a href="/ncd" hreflang="en">NCD</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> <div class="field-item"><a href="/tag/article-0" hreflang="en">Research/Innovation</a></div> </div> </div> Wed, 23 Dec 2020 14:11:44 +0000 mlawrence 7732 at https://www.pih.org New Clinical Trial in MDR-TB Care to Support Hardest to Treat Patients Globally https://www.pih.org/article/new-clinical-trial-mdr-tb-care-support-hardest-treat-patients-globally <span class="field-wrapper">New Clinical Trial in MDR-TB Care to Support Hardest to Treat Patients Globally</span> <span class="field-wrapper"><span lang="" about="/user/290" typeof="schema:Person" property="schema:name" datatype="">lfriday</span></span> <span class="field-wrapper">Tue, 12/22/2020 - 10:41</span> <div class="field-wrapper field field-node--field-large-intro-text field-name-field-large-intro-text field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span>Q&amp;A with Dr. Carole Mitnick, PIH’s co-principal investigator of endTB project</span></span></p> </div> </div> </div> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.webp?itok=aBrQYh7_ 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.webp?itok=HALsRFyG 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.webp?itok=_ElrdocU 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.webp?itok=PVz-kRYE 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.webp?itok=9y071Zwl 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.JPG?itok=aBrQYh7_ 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.JPG?itok=HALsRFyG 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.JPG?itok=_ElrdocU 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.JPG?itok=PVz-kRYE 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.JPG?itok=9y071Zwl 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2020-12/Peru_1217_SESTB_WRodriguez%20_14.JPG?itok=aBrQYh7_" alt="doctor listens to breath of tuberculosis patient in Lima, Peru" typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">An extensively drug-resistant tuberculosis patient is examined as part of the endTB project at Sergio E. Bernales Hospital in Carabayllo, a northern district of Lima, Peru.</div> </div> </div> <div class="field-wrapper field field-node--field-photo-credit field-name-field-photo-credit field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Photo by William Castro Rodriguez for Partners In Health</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span><span><span>Tuberculosis is the most deadly infectious disease, killing more than 1.4 million people globally, most of them in resource-poor countries. Some forms of the disease are resistant to treatment and therefore can’t be cured using standard drugs. These multidrug (MDR)- and extensively drug resistant strains are particularly worrisome to patients and clinicians, and they are rapidly spreading across countries with the least resources to tackle them.</span></span></span></span></p> <p><span><span><span><span>To meet this challenge, <a href="http://www.endtb.org/">endTB</a> was formed. The project, an international partnership among Partners In Health, Médecins Sans Frontières (MSF), and Interactive Research and Development (IRD) and funded by <strong><a href="https://unitaid.org/#en">Unitaid</a></strong>, aims to find shorter, less toxic, and more effective treatments to MDR-TB. This will largely be achieved through the introduction of the first new TB drugs in more than 40 years, two clinical trials testing shorter regimens, and advocacy at national and global levels. </span></span></span></span></p> <p><span><span><span><span>Launched earlier this year, the endTB-Q trial aims to establish the efficacy and safety of shortened, all-oral drug regimens in a subgroup of patients with MDR-TB, those with resistance to the most effective drug in second-line TB treatment. All this has moved forward while the endTB team has faced significant challenges due to the spread of COVID-19, another airborne infectious disease.</span></span></span></span></p> <p><img alt="Dr. Carole Mitnick, co-principal investigator for endTB" data-entity-type="file" data-entity-uuid="f52df7a2-cc3c-4069-ac29-f97364202e02" src="/sites/default/files/inline-images/unitedstates-2017-carolemitnick-0001.JPG" width="800" height="450" loading="lazy" /></p> <p><span><span><span><span>Dr. Carole Mitnick, endTB’s co-principal investigator, a professor of Global Health and Social Medicine at Harvard University, and senior TB researcher with PIH, explains why TB disproportionately affects the marginalized, discusses the importance of the endTB-Q trial, and shares how teams have adapted their work during the COVID-19 pandemic. </span></span></span></span></p> <h2><span><span><span><strong><span><span>Why is TB more present in marginalized populations than in the general population? </span></span></strong></span></span></span></h2> <p><span><span><span><span><span>TB transmits in enclosed, crowded spaces. Like COVID-19, TB transmission is airborne, usually after longer, sustained contact. Poor and marginalized people are more likely to live in crowded environments where they face increased risk of infection. </span></span></span></span></span></p> <p><span><span><span><span><span>About 90% of those infected never get active disease, but nutritional deficiencies and other conditions like HIV, diabetes, and substance-use disorders increase vulnerability to developing active disease.  </span></span></span></span></span></p> <h2><span><span><span><strong><span><span>Why does endTB specifically focus on multidrug-resistant tuberculosis, or MDR-TB? </span></span></strong></span></span></span></h2> <p><span><span><span><span><span>Like TB, MDR-TB is a disease that exploits marginalization, and disadvantage. It occurs commonly among people who suffer from poverty and other associated conditions and who live in countries that make tiny investments in health. These diseases do not inspire private industry to develop drugs; shareholders don’t see big opportunities for earnings in drugs developed for people and health systems that can’t pay. Consequently, drug development for MDR-TB treatment has lagged.  </span></span></span></span></span></p> <p><span><span><span><span><span>Even the recent advances in development of two new drugs have not been adequately resourced to optimize their use. So these 3 NGOs—MSF, PIH, IRD—had to take on this responsibility. </span></span></span></span></span></p> <blockquote> <p><span><span><span><span><span>It’s in our DNA to try to increase access to the best possible treatments and improve their use. And, we believe that poor people with MDR-TB are just as deserving of high-quality evidence to inform their care as, say, rich people with cardiovascular disease. </span></span></span></span></span></p> </blockquote> <p><span><span><span><span><span>So, we had to take this on. To make matters worse, many trials exclude patients with comorbidities. But, because they are real issues faced by people with MDR-TB, endTB includes patients with comorbidities.  </span></span></span></span></span></p> <p><span><span><span><span><span>the proportion of cases that are drug-resistant is growing. In some places, like Kazakhstan, the proportion of TB cases that are resistant is higher than 40%. The more resistant the TB, the more expensive to treat, the less likely people are to get adequate treatment. </span></span></span></span></span></p> <p><span><span><span><span><span>PIH and endTB believe that all patients are deserving of treatment. We know that not treating these patients can have a really devastating impact on the population around them because drug-resistant TB is highly transmissible. </span></span></span></span></span></p> <h2><span><span><span><strong><span><span>Can you explain more about endTB and where ​the project has been conducted?</span></span></strong></span></span></span></h2> <p><span><span><span><span><span>The endTB project is a series of studies that focus on treatment for MDR-TB–the form of TB that’s resistant to rifampin, the most potent drug in the first-line regimens. First, we did an observational study to show that newer (bedaquiline and delamanid) and repurposed (linezolid and clofazimine) drugs could be used safely in effective long regimens for MDR-TB. Then, we launched a randomized, controlled clinical trial to optimize the use of these drugs in shorter, all-oral, simplified regimens for forms of MDR-TB that remain susceptible to fluoroquinolones, which has historically been the most potent drug in second-line treatment. </span></span></span></span></span></p> <p><span><span><span><span><span>This trial, known as the endTB trial, is examining five experimental regimens. It’s unusual to test so many regimens at one time, because normally researchers are looking for “a best.” Instead, at endTB, we are trying to identify as many successful regimens as possible. And, the trial uses “adaptive randomization” to assign patients to various treatment arms. We use information learned through the course of the trial to influence the chance of a patient being assigned to each regimen. More patients will be assigned to the regimens that are more effective. This approach allows us to do this in much less time, with a fraction of the patients than if all five regimens were tested in separate trials</span></span></span></span></span></p> <blockquote> <p><span><span><span><span><span>The trial is being run on every continent except Australia and Antarctica, with active sites in Peru, Lesotho, Kazakhstan, South Africa, Pakistan, and India. </span></span></span></span></span></p> </blockquote> <p><span><span><span><span><span>The regimens we are testing have the following benefits: 1) They are shorter than those currently used, nine months instead 18+-months. 2) They are all-oral [pills] instead of requiring months of daily injections; they may cause fewer negative side effects. 3) They use fewer drugs, no more than five (compared to seven or more), which will make them easier for patients to take and for health systems to stock at points of delivery. </span></span></span></span></span></p> <figure role="group"> <img alt="doctor reviews images of lungs from tuberculosis patient in Lesotho" data-entity-type="file" data-entity-uuid="60a04440-e0bb-459c-9620-45f31e26e8bc" src="/sites/default/files/inline-images/lesotho-1019-botsabelohospital-kschermbrucker-136.JPG" width="800" height="533" loading="lazy" /> <figcaption>Dr. Lawrence Oyewusi, an MDR-TB program manager, reviews a scan of a patient's lungs at Botsabelo Hospital in Maseru, Lesotho. Photo by Karin Schermbrucker for Partners In Health</figcaption> </figure> <h2><span><span><span><strong><span><span>Tell us about the new clinical trial launched this year. ​</span></span></strong></span></span></span></h2> <p><span><span><span><span><span>This year, in the middle of the worst public-health pandemic in a century, we launched the second trial in the project, called endTB-Q. This trial focuses on the patients who have a form of TB resistant to both fluoroquinolones and rifampin, which is the most difficult to treat. </span></span></span></span></span></p> <p><span><span><span><span><span>What’s really groundbreaking</span></span><span><span> about the endTB-Q trial is that it is focused on this especially vulnerable population. endTB-Q is the only trial that tests all-oral regimens specifically for this group using the gold standard of clinical research: a randomized, internally concurrently controlled trial. By the end of 2021, we expect to finish enrollment of 324 participants. We expect to have the results by 2023.</span></span></span></span></span></p> <h2><span><span><span><strong><span><span>How essential are our partnerships with MSF and IRD to the success of endTB trials?</span></span></strong></span></span></span></h2> <p><span><span><span><span><span>It is hard to put into words how important these partnerships are and how difficult this work would be to do on our own. Working with these powerhouse groups amplifies our impact. </span></span></span></span></span></p> <p><span><span><span><span><span>Among the consortium partners, we share a common set of beliefs about the right to high-quality care, regardless of where people happened to be born in the world, their religion, color, ethnicity, political beliefs, socioeconomic status or how much their government chooses to spend on health care. In fact, we all deliberately try to reach those who are most likely to be left behind by other efforts. </span></span></span></span></span></p> <h2><span><span><span><strong><span><span>How have you been adapting to the pandemic while lifting up a major trial? </span></span></strong></span></span></span></h2> <p><span><span><span><span><span>COVID-19 has had an enormous impact on our study sites, patients, staff, and the TB programs in which they’re embedded. Services have been shut down in many places and TB patients are not able to get care and diagnosis. This has deeply worrying consequences for these patients, their families, and communities; multiple models have predicted enormous increases in TB incidence and mortality in coming years, with effects being greatest for MDR-TB.</span></span></span></span></span></p> <p><span><span><span><span><span>In all the sites, there have been moments when health facilities were completely closed or no TB patients were coming to health facilities out of fear. We did face setbacks, like <a href="https://www.pih.org/article/pih-kazakhstan-doctors-recover-covid-19-treat-family-members">when our whole Kazakhstan team got sick with COVID-19</a> and had to suspend the study for a few weeks. </span></span></span></span></span></p> <p><span><span><span><span><span>And, this has resulted in delays in trial enrollment.</span></span></span></span></span></p> <blockquote> <p><span><span><span><span><span>Despite the pandemic, we had to maintain the services we had committed to the trial participants whom we had already enrolled, at the same time, finding a way to continue enrolling patients in the endTB-Q trial. </span></span></span></span></span></p> </blockquote> <p><span><span><span><span><span>Our primary concern was to protect staff and participants from COVID-19 and make sure that participants got their treatment and safety monitoring. We also needed to keep enrolling new patients, knowing that endTB was one of the only sources of care for MDR-TB patients in our study settings.</span></span></span></span></span></p> <p><span><span><span><span><span>We had to set up guidance for the local teams on how to manage the virus, their own safety, and participants’ safety, providing information on what kind of treatments are available. Obviously, all of the staff are getting PPE. In addition, we have tried to provide extra food to support people who need to isolate or quarantine.</span></span></span></span></span></p> <figure role="group"> <img alt="doctor gives audiology test to tuberculosis patient from car in Kazakhstan" data-entity-type="file" data-entity-uuid="096face7-022c-4762-9337-fbb3652d0b0c" src="/sites/default/files/inline-images/kazakhstan-0520-merey-otepbergenova-01.jpg" width="1100" height="733" loading="lazy" /> <figcaption>Dr. Merey Otepbergenova conducts a hearing test in the back of her car in Almaty, Kazakhstan, as part of clinicians' efforts to reach severe TB patients safely during the COVID-19 pandemic. Photo courtesy of PIH-Kazakhstan</figcaption> </figure> <p><span><span><span><span><span>We’ve had to make some <a href="https://www.pih.org/article/groundbreaking-kazakhstan-tb-trial-continuing-amid-covid-19-challenges">changes to the study and patient treatment</a>, for example, moving visits out of health care facilities to either patients' homes, fields, or even cars. </span></span></span></span></span></p> <p><span><span><span><span><span>We started providing accommodation for patients in rare cases, private transportation to get participants to study visits, or to get study workers to participants’ homes. In some sites, we have expanded the hours of the appointment times, ensuring there are fewer people present at one time. </span></span></span></span></span></p> <p><span><span><span><span><span>However, one advantage of having a multi-site trial is that the pandemic’s waves are hitting different areas at different times. </span></span></span></span></span></p> <p><span><span><span><span><span>Overall, this experience has prepared us for inevitable future disruptions. During future pandemics or natural disasters, having shorter, less-toxic treatments for MDR-TB will be a huge win. It also highlights the importance of patience and long-term commitments to complex problems affecting poor people, which has always been a hallmark of PIH’s work. Even before the pandemic, we knew that being on the side of patients with MDR-TB—including through activities such as the endTB and endTB-Q trials—was a long-term proposition. COVID-19 has reinforced this lesson as well as our determination to ensure that funding, policy, and implementation partners remain committed and engaged for the long term. </span></span></span></span></span></p> <h2><span><span><span><strong><span><span>In which ways does PIH ​help patients ​beyond the provision of TB medication and care?</span></span></strong></span></span></span></h2> <p><span><span><span><span><span>We really try to imbue our research with the PIH model of care and support. Treatment is supported by a study worker or community member. Treatment supporters check in with participants to see how they are doing and to assess occurrence of adverse events. And, in both study and routine care, we provide nutritional support and transport. The trial adds the best level of clinical monitoring for disease. And, if study participants require hospitalization, they do not pay. </span></span></span></span></span></p> <p><span><span><span><span><span>To counteract the effects of COVID-19, we have expanded all these supports and added more. </span></span></span></span></span></p> <h2><span><span><span><strong><span><span>What kind of results have you achieved so far with endTB?</span></span></strong></span></span></span></h2> <p><span><span><span><span><span>It’s too early to say about the trials. But, in the first study, the observational one, we provided new regimens to more than 2,800 patients in 17 countries. Some of them were very sick patients who had been treated unsuccessfully over and over again. <a href="https://www.pih.org/article/endtbs-strong-study-results-add-push-use-new-drugs">This was a huge success</a> both in scale of roll-out and outcomes. </span></span></span></span></span></p> <blockquote> <p><span><span><span><span><span>We have seen very promising results; 85% have had great early response: at or six months after start of regimens containing the new drugs, their sputum culture results were negative for the bug that causes TB. These results have been observed in patients without serious complications as well as in those with diabetes and the more resistant forms of MDR-TB. </span></span></span></span></span></p> </blockquote> <p><span><span><span><span><span>Regimens containing new and repurposed drugs are really, really promising, and they are promising both from an effectiveness standpoint and from a safety and tolerability standpoint. The new drugs can replace the old injectable ones that caused terrible side effects, like hearing loss and kidney problems, while the cardiotoxicity risk that many were worried about did not occur frequently.  </span></span></span></span></span></p> <p><span><span><span><span><span>Most importantly, we’ve successfully pushed back on the narrative that regimens containing new drugs can’t safely be introduced in settings with limited resources. </span></span></span></span></span></p> <figure role="group"> <img alt="tuberculosis patient is examined by doctors in Kazakhstan" data-entity-type="file" data-entity-uuid="6aff9eb9-8a9e-4be5-9fde-526c41ab45ed" src="/sites/default/files/inline-images/Kazakhstan_0616_EndTB_YAlgozhin_009-toned.JPG" width="800" height="533" loading="lazy" /> <figcaption>An extensively drug-resistant tuberculosis patient talks to Dr. Zhenisgul Daugarina (center, standing) and Dr. Michael Rich (center, seated) during a visit to the city TB dispensary in Astana, Kazakhstan.</figcaption> </figure> <h2><span><span><span><strong><span><span>What kind of impact do you foresee if the endTB trials are successful​? In other words, would you categorize this as a game-changer for global TB care?</span></span></strong></span></span></span></h2> <p><span><span><span><span><span>The combination of cutting the duration of treatment by more than half and potentially reducing the toxicity burden to reduce demands on the health system is huge. With shorter, more user- and health-system friendly treatment, treatment can be made much more widely available.</span></span></span></span></span></p> <p><span><span><span><span><span>The other thing that’s really transformative is that if it’s the right treatment, patients will stop transmitting sooner. We know that within hours or days of starting effective therapy, people stop transmitting and are no longer a risk to their family members and neighbors. If you get them on the right regimen sooner, that has enormous benefits for reducing the number of people infected overall. </span></span></span></span></span></p> <p><span><span><span><span><span>At the moment, TB programs have to keep 13 to 15 drugs in stock to be able to offer treatment for all forms of TB. If the endTB trials establish safety and efficacy of, say, three novel regimens, programs would only need to purchase and manage five to seven drugs. More patients would be treated with the same drugs, which would give national TB programs more negotiating power with pharmaceutical companies. </span></span></span></span></span></p> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/tuberculosis" hreflang="en">Tuberculosis</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/advocacy" hreflang="en">Advocacy</a></div> <div class="field-item"><a href="/tag/covid" hreflang="en">Covid-19</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> </div> </div> Tue, 22 Dec 2020 15:41:40 +0000 lfriday 7721 at https://www.pih.org Innovation: Marking 10 Years of Mental Health Care in Haiti https://www.pih.org/article/innovation-marking-10-years-mental-health-care-haiti <span class="field-wrapper">Innovation: Marking 10 Years of Mental Health Care in Haiti</span> <span class="field-wrapper"><span lang="" about="/user/366" typeof="schema:Person" property="schema:name" datatype="">mlawrence</span></span> <span class="field-wrapper">Fri, 10/09/2020 - 14:38</span> <div class="field-wrapper field field-node--field-large-intro-text field-name-field-large-intro-text field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span><span><span><span>Emergency response to the&nbsp;devastating 2010 earthquake has grown&nbsp;into a system of care that now serves thousands of patients and has become a&nbsp;model for overcoming systemic and structural challenges</span></span></span></span></span></p> </div> </div> </div> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.webp?itok=gZHLdFoD 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.webp?itok=5oL_YDOT 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.webp?itok=dSbpP5oO 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.webp?itok=DSQwVQWL 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.webp?itok=5N1aItqg 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.jpg?itok=gZHLdFoD 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.jpg?itok=5oL_YDOT 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.jpg?itok=dSbpP5oO 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.jpg?itok=DSQwVQWL 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.jpg?itok=5N1aItqg 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2020-10/Haiti_0110_NegMawonToned_DWalton_1200web_0.jpg?itok=gZHLdFoD" alt="The Neg Mawon statue in Port-au-Prince, Haiti, remained standing after the 2010 earthquake that launched PIH&#039;s efforts to support mental health care in Haiti " typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">The Neg Mawon statue, which commemorates the men and women who freed Haiti from colonial rule, remained standing despite the destruction of Haiti’s 2010 earthquake. The natural disaster spurred PIH&#039;s work to build a system for mental health care in Haiti that has grown ever since, and has served more than 6,300 patients at PIH-supported health facilities over the last five years. </div> </div> </div> <div class="field-wrapper field field-node--field-photo-credit field-name-field-photo-credit field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Photo by David Walton / PIH</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p><em>Content advisory: This article talks about sensitive issues including suicide and mental illness.</em></p> <p> </p> <p><span><span><span>Tatiana Therosme gathered herself for a moment before talking about a young woman, born with HIV, who battled severe depression for years because of stigmatization and mistreatment resulting from people’s perceptions of her diagnosis. </span></span></span></p> <p><span><span><span>Therosme first learned of the woman, Fabiola Noel, through a fellow staff member for Zanmi Lasante, as Partners In Health is known in <strong><a href="https://www.pih.org/country/haiti">Haiti. </a></strong></span></span></span></p> <p><span><span><span>“I was the primary clinician provider, and the nurse called me because she had tried to kill herself,” said Therosme, community health worker supervisor for Zanmi Lasante. </span></span></span></p> <p><span><span><span>What followed was a relationship of support and clinical care that has stretched over years, ever since that phone call.</span></span></span></p> <p><span><span><span>Therosme and other members of Zanmi Lasante’s mental health team quickly began seeing Noel regularly. Therosme learned that Noel’s peers had repeatedly treated her badly, as had a teacher at school. </span></span></span></p> <p><span><span><span>“Because of the context of her HIV, because of the context of stigmatization…she really faced many, many difficulties,” Therosme said. </span></span></span></p> <p><span><span><span>Zanmi Lasante’s ability to support Noel and treat her clinically for anxiety and severe depression—caring for her mental health, as well as physical—is a testament to a mental health system that arose after Haiti’s devastating 2010 earthquake, through a partnership with Haiti’s national government. </span></span></span></p> <p><span><span><span>Over the past decade, that system has grown to serve a population of more than 1.3 million across Haiti’s Central Plateau and lower Artibonite regions, providing care for depression, psychosis, epilepsy, and many other mental health conditions and neurologic disorders.</span></span></span></p> <p><span><span><span>Between January 2016 and September 2019, for example, Zanmi Lasante’s mental health system <strong>delivered more than 28,000 patient visits</strong>, and <strong>served more than 6,300 patients at supported health facilities.  </strong></span></span></span></p> <figure role="group"> <img alt="Patients wait to receive care at PIH-supported University Hospital at Mirebalais" data-entity-type="file" data-entity-uuid="dc9072f4-a7a9-4415-9e57-e52f1da80bdf" src="/sites/default/files/inline-images/Haiti_0316_HUM_CAvila_16_web.JPG" width="800" height="533" loading="lazy" /> <figcaption>Patients wait outside Klinik Extern at University Hospital in Mirebalais, Haiti, in 2016. (Cecille Joan Avila/PIH) </figcaption> </figure> <p><span><span><span>A recently published article details those 10 years of growth, and describes the development of a comprehensive, community-based mental health system in the Caribbean nation, where public mental health services previously were not able to match what was needed. Additionally, the article describes challenges to care stemming from Haiti’s ongoing political and social instability, and finds that despite those challenges, high-quality <strong><a href="https://www.pih.org/programs/mental-health">mental health care</a></strong> can be delivered not only in Haiti, but also in other low-resource settings around the world.</span></span></span></p> <p><span><span><span><strong><a href="https://www.cambridge.org/core/journals/global-mental-health/article/development-of-a-comprehensive-sustained-community-mental-health-system-in-postearthquake-haiti-20102019/3F231A447792BDD499EC1C4C3A6C760E">The article</a></strong>, “Development of a comprehensive, sustained community mental health system in post-earthquake Haiti, 2010–2019,” was published in February by <em>Cambridge University Press</em> in the journal Global Mental Health. Co-authors include Pere Eddy Eustache, director of mental health and psychosocial services for Zanmi Lasante; <span>Dr. Giuseppe “Bepi” Raviola, PIH’s director of mental health; Therosme; and several others. </span></span></span></span></p> <p><span><span><span>“The dedication of various staff across Zanmi Lasante and PIH to maintaining the system and improving the model has led to ongoing program growth and longer-term commitment to build a better system, (offering) hope that anyone in Haiti living with a mental disorder can have access to free, quality mental health care,” the study states. “We can expect that the perception of the Zanmi Lasante program’s relevance as an antidote to despair from mental suffering, both in communities and in the health system, will only increase the demand for services with time.”</span></span></span></p> <p><span><span><span>Noel, whose name has been changed to prevent further abuse, is an example of how much people can achieve when the crushing burdens of mental disorders are lifted. </span></span></span></p> <p><span><span><span>Therosme recalled that Noel assumed she would die young because of her HIV, so she never believed she could become a nurse or clinician. </span></span></span></p> <blockquote> <p><span><span><span>“I remember working together to see what her next plan could be,” Therosme said. “She didn’t think she could make it, but she worked and completed her studies.”</span></span></span></p> </blockquote> <h2><span><span><span><strong>Support, not stigma</strong></span></span></span></h2> <p><span><span><span>Eustache said much of delivering mental health care in Haiti is about helping people understand that the trauma they are living with can be alleviated, and that receiving clinical care and local support are positive steps that should be shared, not stigmatized. </span></span></span></p> <blockquote> <p><span><span><span>“The history of Haiti has been a history of violence. Structural violence, political violence, everything. People are exposed to poverty, and what I call social violence. And the new aspect of violence is what I call environmental, ecological violence,” Eustache said. “Sometimes people are living with trauma, and they are unaware of that.”</span></span></span></p> </blockquote> <p><span><span><span>Eustache said ecological trauma from many sources can affect Haitians. “For example, every time there is a heavy rain, in the slums, walls collapse, followed by casualties,” he said. “Deforestation is strongly active in the destruction of the environment. This is what I call ecological violence. </span></span></span></p> <p><span><span><span>“Drought caused by deforestation creates a cycle of hunger, pushing people to cut trees and make charcoal, destroying the environment, which becomes more and more threatening for people who are more and more vulnerable to trauma,” he continued. </span></span></span></p> <p><span><span><span>Eustache said many of the people who receive mental health care from Zanmi Lasante show behaviors that are related to trauma they experienced in the past, and now appears in other forms.</span></span></span></p> <p><span><span><span>“This is something we live on a daily basis,” he said. </span></span></span></p> <p><span><span><span>“People don’t know how to phrase it, how to verbalize it,” Eustache added. “But we need to remain aware that Haiti is a country that has been prone to trauma.”</span></span></span></p> <p><span><span><span><span>The earthquake on Jan. 12, 2010, struck about 15 miles southwest of Port-au-Prince, Haiti’s capital. The disaster killed nearly 300,000 people, injured hundreds of thousands more, and devastated social services and health care infrastructure. </span></span></span></span></p> <p><span><span><span><span>In the weeks that followed, Haiti’s Minister of Health contacted Zanmi Lasante to request support in developing a national mental health system. </span></span></span></span></p> <figure role="group"> <img alt="Zanmi Lasante's mental health care serves communities including Cange, Haiti " data-entity-type="file" data-entity-uuid="d951cb62-1587-4d95-8936-6b5ff7ea4e5f" src="/sites/default/files/inline-images/012308_Cange_1183_web.jpg" width="800" height="533" loading="lazy" /> <figcaption>Zanmi Lasante's mental health system has grown to serve thousands of patients in Haiti's Central Plateau and lower Artibonite regions, including at this PIH-supported facility in Cange, Haiti.  (Photo courtesy of Rose Lincoln / Harvard News Office) </figcaption> </figure> <h2><span><span><strong><span><span>Service, not scarcity </span></span></strong></span></span></h2> <p><span><span><span>The ministry’s request, initially made in February of 2010, was based on Zanmi Lasante’s previous success in addressing HIV and TB from a community-based model of care. That model included mental health services, with community health workers playing a key role in providing access and support.  Government and health leaders in Haiti believed the model also could be effective for addressing the growing burden of mental illness, itself, as an independent issue outside the framework of any other disease. </span></span></span></p> <p><span><span><span>“After the earthquake we were aware that the need for mental health would be huge, and we needed to understand those expectations,” Eustache said. “So, we started thinking about a mental health program.” </span></span></span></p> <p><span><span><span>Eustache and Raviola worked closely together, starting the week of the earthquake, to bring to reality a model for a community-based program that could be tried and tested in the regions where Zanmi Lasante works.</span></span></span></p> <p><span><span><span>Therosme took Eustache’s comment a step further, saying that Zanmi Lasante jumped on the opportunity to build a structured mental health program that could fill gaps in staff recruitment, training, development of mental health specialists, and more.  </span></span></span></p> <p><span><span><span>Those gaps had long been significant in Haiti, where the majority of people addressed mental health care through traditional treatment channels, such as religious leaders and local healers. Language barriers and local customs often enabled religious and community leaders to build trusting relationships with patients, as opposed to doctors in Port-au-Prince or other urban areas, often far from people’s homes. Financial barriers also played a role. </span></span></span></p> <p><span><span><span>Eustache said that at Haiti’s two psychiatric hospitals, Beudet Hospital and the Mars and Kline Psychiatric Center, both in Port-au-Prince, the government pays clinicians’ salaries, but remaining costs are laid on patients and their families.</span></span></span></p> <p><span><span><span>That means people from rural areas often cannot afford to not only travel to the capital, but also support a hospitalized family member during extended care. As a result, many people would avoid traveling to Port-au-Prince and instead seek local care from traditional healers.</span></span></span></p> <p><span><span><span>These were just some of the factors forming the backdrop as an initial assessment, begun in March 2011, examined the setting for mental health programs in Haiti. </span></span></span></p> <h2><span><span><span><strong>Building a system</strong></span></span></span></h2> <p><span><span><span>The project began with an initial assessment of the local context—beliefs, attitudes and perspectives related to mental health care practice, and priorities. It engaged 15 focus groups and included 11 individual interviews with community members, community health workers, facility-based health workers, people living with mental illness and their families, and religious leaders, including houngan or voudou priests, manbo or voudou priestesses, and Catholic and Protestant priests. </span></span></span></p> <p><span><span><span>The assessment found that, for respondents, the stressful conditions related to poverty experienced in many parts of the country, exacerbated by the earthquake, left everyone vulnerable to all manifestations of sadness and dysthymia, depression, suicide and psychosis. </span></span></span></p> <p><span><span><span>It also found that traditional healers desired a formal mental health system, including psychological treatments, with which to collaborate. </span></span></span></p> <p><span><span><span>This informed Zanmi Lasante’s commitment to build a formal mental health system, in large part, as a response to the devastating disaster. The growing team began by developing care pathways and protocols for depression, psychotic disorders and epilepsy, with the support of Grand Challenges Canada.  </span></span></span></p> <p><span><span><span>“We consider that the earthquake has been an opportunity to raise awareness, and raise funding, to help us maintain the program and make sure that more and more people can get access to care that we are providing,” Eustache said. “We lost 300,000 people—that’s huge for a small country like Haiti. We say that these people shouldn’t have died for nothing.”</span></span></span></p> <p><span><span><span>Zanmi Lasante’s immediate mental health response after the earthquake was providing care for people who had been displaced and were staying in temporary camps. That work evolved into community-based care, built on the foundation of community health workers and referrals to clinics or hospitals, where clinicians could assess patients and develop long-term care plans. </span></span></span></p> <p><span><span><span><span>“What was accomplished by Zanmi Lasante in developing this system has been truly remarkable,” Raviola said. “Clinicians worked under the most challenging circumstances to support people living with unaddressed mental disorders that pre-existed the earthquake, trauma from the earthquake, the effects of additional disasters including the cholera crisis and multiple hurricanes, as well as political violence. The Haiti work also laid the groundwork for PIH’s cross-site learning collaborative in mental health care delivery, which to us represents a model of trans-national dialogue and sharing of experiences and lessons.” </span></span></span></span></p> <p><span><span><span>Between 2010 and 2015, the Zanmi Lasante and PIH cross-site teams developed a system based on five key skill sets for delivering mental health care in low-resource settings, and five key implementation rules.  These include:</span></span></span></p> <p><span><span><span><em>Skill sets:  </em></span></span></span></p> <ul> <li><span><span><span>case-finding, engagement, follow-up, and psychoeducation; </span></span></span></li> <li><span><span><span>targeted psychological interventions; </span></span></span></li> <li><span><span><span>medication management; </span></span></span></li> <li><span><span><span>supervision and consultation; and </span></span></span></li> <li><span><span><span>quality oversight</span></span></span></li> </ul> <p><span><span><span><em>Implementation rules: </em></span></span></span></p> <ul> <li><span><span><span>assess context; </span></span></span></li> <li><span><span><span>identify and map priority care pathways; </span></span></span></li> <li><span><span><span>specify decision support tools; </span></span></span></li> <li><span><span><span>use QI practices; and </span></span></span></li> <li><span><span><span>address sustainability, management, and capacity-building</span></span></span></li> </ul> <p><span><span><span>This process of describing the essential, effective elements of a basic system of care informed learning processes at other PIH sites in important ways, as the PIH cross-site team developed dialogue across all of the sites to build similar, and different, models of care based on local priorities. The Haiti case, for example, is now a key teaching tool for a course at Harvard School of Public Health called “Case Studies in Global Mental Health Delivery.” </span></span></span></p> <h2><span><span><span><strong>Stability, amid instability </strong></span></span></span></h2> <p><span><span><span>All of the skill sets and implementation rules tested in Haiti are delivered in a social and economic setting that has been turbulent, not just in the earthquake’s aftermath, but also in very recent years and to the present. </span></span></span></p> <p><span><span><span>Three different presidents have served Haiti since 2015, amid constitutional crises and frequent civil protests, fueled by allegations of electoral fraud and government misuse of billions of dollars. </span></span></span></p> <p><span><span><span>In 2016, Hurricane Matthew ravaged southern Haiti and displaced 175,000 people, many of whom faced a cholera epidemic, and food shortages brought by widespread damage to crops and livestock.</span></span></span></p> <p><span><span><span>By 2017, 38,000 people were still living in displacement camps built after the 2010 earthquake. The following year brought more waves of street protests, both peaceful and violent, during a new period of national lockdown, known as peyi lòk. Schools closed, roads were blocked, and the country was brought to a standstill, slowing the economy and worsening poverty. </span></span></span></p> <p><span><span><span>All of these crises have had significant effects on the well-being of clinical staff and caregivers themselves. </span></span></span></p> <p><span><span><span>“At a human level, significant challenges currently make service delivery extremely difficult due to the contingencies of the daily reality that providers, coordinators, and managers have been facing over the past decade, a situation that has worsened since 2017,” the 10-year paper notes. </span></span></span></p> <h2><span><span><span><strong>‘We still need to fight’</strong></span></span></span></h2> <p><span><span><span>Despite all of those challenges, Zanmi Lasante’s mental health team has continued to show up, every day, to provide vital care and support—to people including the young woman with HIV. </span></span></span></p> <p><span><span><span>Therosme said that woman now is a nurse administrator and social worker in a Zanmi Lasante hospital, accompanying people with HIV and tuberculosis, supporting their care and social assistance. </span></span></span></p> <p><span><span><span>“She’s come far—she never imagined a day when she would be where she is now,” Therosme said. “Now she is talking about having a child.”</span></span></span></p> <p><span><span><span>Eustache was sitting next to Therosme as she spoke, and noted her emotion. </span></span></span></p> <p><span><span><span>“Tatiana is moved to tears telling this story,” he said. </span></span></span></p> <p><span><span><span>Eustache said that Zanmi Lasante’s mental health mission is at its core about <em>connection</em>, in a country that remains essentially divided into rural and urban societies. Rural Haiti, he said, “has been totally excluded in terms of services and access to care,” along with education, public services, and more. </span></span></span></p> <p><span><span><span>“Historically, Haiti has been going as a nation with two different societies—like two trains going in the same direction that cannot meet together,” Eustache said. “In our work as Zanmi Lasante, we say that our main goal is to make these people part of the whole society, with access to care that has been denied to them.” </span></span></span></p> <p><span><span><span>Joining those train tracks will require continued collaboration between Zanmi Lasante, PIH mental health programs around the world, and other partners across Haiti. </span></span></span></p> <p><span><span><span>“All we have accomplished as milestones is a joint effort from the Zanmi Lasante mental health program and the PIH cross-site mental health program,” Eustache said. “This is a joint effort, with a team spirit.</span></span></span></p> <p><span><span><span>“(And) we have not done enough,” he added. “We still need to fight, to work.” </span></span></span></p> <p> </p> </div> </div> </div> <div class="field-wrapper field field-node--field-paragraphs-content field-name-field-paragraphs-content field-type-entity-reference-revisions field-label-hidden"> <div class="field-items"> <div class="field-item"> <div class="paragraph just-text darktext paragraph--id--3328" style="background-color: #e1e4e2;"> <h2 class="center">A Note from PIH&#039;s Mental Health Team </h2> <p class="header__intro header__intro-para"> The Zanmi Lasante and PIH mental health teams are hopeful for the ongoing evolution of their work. They credit the Zanmi Lasante workforce and the communities they serve for enthusiastically accepting the challenge of building this system. It is hoped that the impact of this work can serve as an effective platform for further advocacy for scale, and broader systems change for mental health in Haiti.<br /> <br /> “Nap viv e nap kontinye! – We are alive, and we will continue!”</p> </div> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/mental-health" hreflang="en">Mental Health</a></div> <div class="field-item"><a href="/programs/research" hreflang="en">Research</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/build-systems" hreflang="en">Build Systems</a></div> <div class="field-item"><a href="/tag/human-rights-and-justice" hreflang="en">Human Rights and Justice</a></div> <div class="field-item"><a href="/mental-health-psychosocial-support" hreflang="en">Mental Health &amp; Psychosocial Support</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> <div class="field-item"><a href="/tag/article-0" hreflang="en">Research/Innovation</a></div> <div class="field-item"><a href="/training" hreflang="en">Training</a></div> </div> </div> Fri, 09 Oct 2020 18:38:49 +0000 mlawrence 7670 at https://www.pih.org Innovation: Research Training Program Creating Opportunities for Rwanda Health Leaders https://www.pih.org/article/innovation-research-training-program-creating-opportunities-rwanda-health-leaders <span class="field-wrapper">Innovation: Research Training Program Creating Opportunities for Rwanda Health Leaders</span> <span class="field-wrapper"><span lang="" about="/user/366" typeof="schema:Person" property="schema:name" datatype="">mlawrence</span></span> <span class="field-wrapper">Mon, 09/21/2020 - 15:31</span> <div class="field-wrapper field field-node--field-large-intro-text field-name-field-large-intro-text field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p>PIH and Harvard Medical School have provided research mentoring and resources to&nbsp;more than 50 health workers in Rwanda&nbsp;over the past five years, working to overcome systemic barriers&nbsp;</p> </div> </div> </div> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-09/Rwanda-research-trainees-convo-Sep20.webp?itok=cQ1AKBPG 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2020-09/Rwanda-research-trainees-convo-Sep20.webp?itok=YWA2xZHr 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-09/Rwanda-research-trainees-convo-Sep20.webp?itok=jzDcQIYs 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-09/Rwanda-research-trainees-convo-Sep20.webp?itok=NeIJbGJ0 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-09/Rwanda-research-trainees-convo-Sep20.webp?itok=p7wKVyOx 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-09/Rwanda-research-trainees-convo-Sep20.jpg?itok=cQ1AKBPG 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2020-09/Rwanda-research-trainees-convo-Sep20.jpg?itok=YWA2xZHr 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-09/Rwanda-research-trainees-convo-Sep20.jpg?itok=jzDcQIYs 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-09/Rwanda-research-trainees-convo-Sep20.jpg?itok=NeIJbGJ0 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-09/Rwanda-research-trainees-convo-Sep20.jpg?itok=p7wKVyOx 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2020-09/Rwanda-research-trainees-convo-Sep20.jpg?itok=cQ1AKBPG" alt="Dr. Ann Miller, left, leads a research training session" typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Dr. Ann Miller of Harvard Medical School (HMS), at left and senior mentor in a research training program hosted in Rwanda by HMS and Partners In Health, talks with (left to right) trainee Alain Ahishaliye of PIH; Katie Beck, then senior nutrition program manager for PIH in Rwanda; and trainee Marie Clarie Abimana, a registered nurse midwife and quality improvement advisor for PIH. </div> </div> </div> <div class="field-wrapper field field-node--field-photo-credit field-name-field-photo-credit field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Photo courtesy of Inshuti Mu Buzima </div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span><span><span>Working in 2015 as a program manager for Inshuti Mu Buzima, as Partners In Health is known in <strong><a href="https://www.pih.org/country/rwanda">Rwanda</a></strong>, <span>Theoneste Nkurunziza realized many of the preventable patient deaths he was seeing had a common cause: delays in referring patients from rural health facilities to hospitals outside the country or in Kigali, Rwanda’s capital. </span></span></span></span></span></p> <p><span><span><span><span><span><span>Nkurunziza became interested in researching root causes of those delays, which were barriers to lifesaving care. But he knew, like other health care workers across low-income countries (LICs), that attempting to conduct that research could present difficult trade-offs. </span></span></span></span></span></span></p> <p><span><span><span><span><span>Dr. Megan Murray of Harvard Medical School and Dr. Joel Mubiligi, executive director of Inshuti Mu Buzima, recently <strong><a href="https://annalsofglobalhealth.org/articles/10.5334/aogh.3039/">described those dilemmas</a></strong> in peer-reviewed journal </span><em>Annals of Global Health:</em></span></span></span></span></p> <blockquote> <p><span><span><span><span><span>“Given limited personnel, facilities, and materials, research comes at short-term costs to patient care, and it is often difficult to predict the long-term value,” Murray and Mubiligi said. “Scarcity is not only a factor in prioritizing health care activities; relatively few LIC health care professionals have the opportunity for research training, and access to medical literature is limited by language, technology, and the cost of journal subscriptions. These barriers make it challenging for even the best-trained LIC researcher to effectively compete for funding.”  </span></span></span></span></span></p> </blockquote> <p><span><span><span><span><span><span>The African continent has only 198 researchers per 1 million people, compared to more than 4,000 in high-income countries, a 2019 study found.<sup> </sup>The disparity persists within Africa itself, with 878 researchers per 1 million people in North Africa but only 88 per 1 million in sub-Saharan Africa. </span></span></span></span></span></span></p> <p><span><span><span><span><span><span>The Intermediate Operational Research Training (IORT) program in Rwanda, run by PIH and Harvard Medical School, is an effort to change those disparities and create opportunities for new research. </span></span></span></span></span></span></p> <p><span><span><span><span><span>The program has supported 52 researchers over the past five years. Combined, these researchers have led 28 papers that were developed as part of the training. Twenty-seven of </span>those papers have been published, including seven that are part of a <strong><a href="https://www.annalsofglobalhealth.org/collections/special/building-health-research-capacity-in-rwanda/">special collection</a></strong> published in September by <em>Annals of Global Health.</em></span></span></span></span></p> <p><span><span><span><strong><span>“</span></strong><span>Research knowledge and skills needed to produce data-driven evidence for informing routine health care delivery are largely lacking in most low- and middle-income countries,” said Dr. Fredrick Kateera, chief medical officer for Inshuti Mu Buzima. “Through a one-year, hands-on mentorship program, IORT leverages IMB’s partnerships with Harvard Medical School to train health care workers in basic epidemiology and biostatics concepts and practices, using data collected as they manage patients and run clinical programs.” </span></span></span></span></p> <p><span><span><span><span>Additionally, Kateera said, the program supports health care workers “from scientific idea formation to publishing manuscripts,” enabling them to produce scientific evidence that informs clinical and program improvements in locally relevant ways. </span></span></span></span></p> <p><span><span><span> <span>Nkurunziza was part of the program’s 2015 cohort. </span></span></span></span></p> <p><span><span><span><span><span>“I knew that I had the zeal and the willingness to do research,” Nkurunziza said. “Here was an opportunity that most people never have access to—to learn and work on my research paper with support from dedicated staff.”</span></span></span></span></span></p> <p><span><span><span><span><span>The program enabled Nkurunziza and a research fellow to collect surgical data, including on referral processes, and publish<strong><a href="https://www.sciencedirect.com/science/article/pii/S0039606016304238"> a 2016 paper</a></strong>,</span></span><span><span><span> “</span></span></span><span><span>Referral Patterns and Predictors of Referral Delays for Patients with Traumatic Injuries in Rural Rwanda.”</span></span></span></span></span></p> <p><span><span><span><span><span>They found that remoteness of a health facility, type of diagnosis, and urgency of treatment were predictors of delays, and that limited availabilities of ambulances and surgical specialists in district hospitals were root causes. Nkurunziza used evidence from the study to advocate for better referral systems and practices. </span></span></span></span></span></p> <p><span><span><span><span><span><span>He’s also more than returned the program’s support, by mentoring subsequent trainees and leading an Introduction to Research Training course, all while furthering his own work and education. </span></span></span></span></span></span></p> <p><span><span><span><span><span>Nkurunziza has been part of 15 publications since 2016, has presented his findings in four countries, and now is pursuing a PhD at The Technical University of Munich. </span></span></span></span></span></p> <p><span><span><span><span><span>Most importantly, the skills he developed in the training program have helped Nkurunziza contribute to research that improves lives in Rwanda and beyond—and he’s not alone.</span></span></span></span></span></p> <h2><span><span><span><span>Child development</span></span></span></span></h2> <p><span><span><span><span><span>Dr. Christine Mutaganzwa was a district clinical director for Inshuti Mu Buzima, in Rwanda’s eastern Kayonza District,</span></span><span> when she began the research training program in 2016. She had been looking for an opportunity to conduct research while receiving support and dedicated research time amid the constraints of her demanding position. </span></span></span></span></p> <p><span><span><span><span><span><span>The program enabled Mutaganzwa to study the implementation of PIH’s pediatric development clinic, held at two district hospitals to support parents and toddlers in the region. <a href="https://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-017-0052-2"><strong>Her research</strong> </a>focused on children at risk of developmental delays because of malnutrition, and showed that implementing pediatric clinics was feasible with non-specialized health providers in rural settings, with mentorship and supervisory support.  </span></span></span></span></span></span></p> <p><span><span><span><span><span><span>“I want to make sure that this group of children is cared for,” she said. “I truly appreciated the time (the program) gave me…especially through separated, week-long research training time and the junior mentors who enabled me to concentrate on my research project.” </span></span></span></span></span></span></p> <p><span><span><span><span><span><span>Mutaganzwa went on to lead the pediatric development clinic, which now features a brand-new facility at PIH-supported at Kirehe District Hospital. Additionally, she has since co-authored 10 papers and recently earned a master’s of medical science in global health delivery at Harvard Medical School. Her thesis explored <span>factors related to follow-up care for parents and children enrolled in the clinics. </span></span></span></span></span></span></span></p> <p><span><span><span><span><span>Mutaganzwa said the training program is invaluable for nurturing researchers in low-income countries.  </span></span></span></span></span></p> <p><span><span><span><span><span>“Everyone who has been a part of IORT learns valuable skills and becomes a mentor,” she said. “Many have gone on to excel in their careers.”</span></span></span></span></span></p> <figure role="group"> <img alt="A PIH program has trained more than 50 health researchers in Rwanda" data-entity-type="file" data-entity-uuid="38434455-eaf3-4a2a-9f58-cdfc31b0e1bc" src="/sites/default/files/inline-images/Rwanda-research-trainees-trio-Sep20.jpg" width="800" height="600" loading="lazy" /> <figcaption>PIH research coordinator Loise Ng'ang'a, center, talks with research trainees Evariste Ntaganda of Rwanda Biomedical Center, left, and Emmanuel Rusingiza from the University of Rwanda about their paper on <strong><a href="https://www.annalsofglobalhealth.org/articles/10.5334/aogh.2719/">heart surgery registries</a></strong>.. (Photo courtesy of Inshuti Mu Buzima)</figcaption> </figure> <h2><span><span><span><span>All Babies Count</span></span></span></span></h2> <p><span><span><span><span>A year after Mutaganzwa, Marie Claire Abimana also used the training program to study child health, as part of the program’s 2017 cohort. </span></span></span></span></p> <p><span><span><span><span>Abimana, a registered nurse midwife, had joined Inshuti Mu Buzima earlier that year, as a quality improvement advisor for a program called All Babies Count. She oversaw mentorship of healthcare professionals, supporting postnatal care and early childhood development in two rural districts. </span></span></span></span></p> <p><span><span><span><span>In the training program, Abimana’s project assessed child development outcomes and found high rates of developmental delays among babies born preterm, with a low birth weight, or with stunting. She recommended improving nutrition and promoting early stimulation for optimum growth.  </span></span></span></span></p> <p><span><span><span><span>Abimana said she appreciated the program’s approach to teaching and improving research skills.  </span></span></span></span></p> <p><span><span><span><span>“I loved the fact that all lessons included practical examples and homework,” she said. “The feeling of working hard at my own research project while learning complex research competencies like statistical analysis was incredible.”</span></span></span></span></p> <p><span><span><span><span>Like Nkurunziza, Abimana became a junior mentor for the cohort that followed her own, passing on the mentorship she had received herself. </span></span></span></span></p> <p><span><span><span><span>She also has engaged with the growing network of training program alumni to partner on additional research, demonstrating the value that national research training programs have for growing the pool of Rwandan researchers and strengthening collaborations across institutions. </span></span></span></span></p> <p><span><span><span><span><strong><a href="https://www.annalsofglobalhealth.org/articles/10.5334/aogh.2629/">Abimana's paper</a></strong> is featured in the Annals collection. She's now pursuing a master’s degree in public health, demonstrating how the research training program is providing not only a year of education and support, but also a platform for lifelong development. </span></span></span></span></p> <h2><span><span><span><span>Partnership and accompaniment</span> </span></span></span></h2> <p><span><span><span>The IORT is a core program that invests in the careers of research leaders at IMB and partner organizations in Rwanda. Adapted from the World Health Organization <strong><a href="https://www.who.int/tdr/capacity/strengthening/sort/en/">SORT-IT model</a></strong>, the training is a cornerstone of comprehensive investments to strengthen research skill, experience, and infrastructure, with the goal of intensive Rwandan leadership on future research work. </span></span></span></p> <p><span><span><span>As Murray and Mubiligi noted, the training reflects the long partnership between PIH and Harvard Medical School. The training featured in the Annals collection was mentored by Harvard faculty Bethany Hedt-Gauthier and Dr. Ann Miller, who along with IMB and HMS junior mentors provided more than 1,200 hours of mentorship and research support to trainees. The program aims to accompany emerging researchers through the entire journey of their paper, from idea to publication. </span></span></span></p> <p><span><span><span>The investments pay off not only in published papers that result, but also in nurturing skills and interest in research among trainees, and in strengthening the research partnership between PIH, HMS and other partners.</span></span></span></p> <p><span><span><span><span>“Through IORT, research careers have been unearthed, study findings have been used to influence policy and practice, and evidence produced in Rwanda is influencing health care implementation and improvements in comparable LMIC settings,” Kateera said.</span></span></span></span></p> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/child-health" hreflang="en">Child Health</a></div> <div class="field-item"><a href="/programs/womens-health" hreflang="en">Maternal Health</a></div> <div class="field-item"><a href="/programs/research" hreflang="en">Research</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/build-systems" hreflang="en">Build Systems</a></div> <div class="field-item"><a href="/education" hreflang="en">Education</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> <div class="field-item"><a href="/tag/article-0" hreflang="en">Research/Innovation</a></div> <div class="field-item"><a href="/rwanda" hreflang="en">Rwanda</a></div> <div class="field-item"><a href="/training" hreflang="en">Training</a></div> </div> </div> Mon, 21 Sep 2020 19:31:22 +0000 mlawrence 7661 at https://www.pih.org Seven-Country Study Examining COVID-19 Impacts on Health Services https://www.pih.org/article/seven-country-study-examining-covid-19-impacts-health-services <span class="field-wrapper">Seven-Country Study Examining COVID-19 Impacts on Health Services </span> <span class="field-wrapper"><span lang="" about="/user/366" typeof="schema:Person" property="schema:name" datatype="">mlawrence</span></span> <span class="field-wrapper">Thu, 08/13/2020 - 18:45</span> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-08/Haiti_COVID_staff_crop.webp?itok=g2cxJUcR 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2020-08/Haiti_COVID_staff_crop.webp?itok=M5vB_fjs 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-08/Haiti_COVID_staff_crop.webp?itok=b9ccA-Zg 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-08/Haiti_COVID_staff_crop.webp?itok=GDwlrwqw 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-08/Haiti_COVID_staff_crop.webp?itok=Hd0m9f6Y 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-08/Haiti_COVID_staff_crop.JPG?itok=g2cxJUcR 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2020-08/Haiti_COVID_staff_crop.JPG?itok=M5vB_fjs 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-08/Haiti_COVID_staff_crop.JPG?itok=b9ccA-Zg 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-08/Haiti_COVID_staff_crop.JPG?itok=GDwlrwqw 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-08/Haiti_COVID_staff_crop.JPG?itok=Hd0m9f6Y 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2020-08/Haiti_COVID_staff_crop.JPG?itok=g2cxJUcR" alt="Lab professionals in Lima, Peru" typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Lab professionals working with Socios En Salud, as Partners In Health is known in Peru, complete tests for COVID-19.<br /> </div> </div> </div> <div class="field-wrapper field field-node--field-photo-credit field-name-field-photo-credit field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Courtesy of Socios En Salud</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span>A new study in seven countries supported by Partners In Health is using routine health data to look for abnormal spikes in ailments that could be related to COVID-19, such as respiratory infections or pneumonia, and assess whether people are changing how they use health services amid the global pandemic. </span></span></p> <p><span><span>A lack of reliable data can be an enormous roadblock for understanding the burden of disease and changes in the use of health services during a public health crisis, severely affecting countries’ ability to plan effective responses. </span></span></p> <p><span><span>COVID-19 also threatens to undermine care and outcomes in important health areas such as maternal health, family planning, childhood vaccinations, HIV, TB, and malaria, along with treatment of non-communicable diseases such as cancer. That threat is particularly severe in low- and middle-income countries, where limited resources may be diverted from those areas to battle COVID-19. </span></span></p> <p><span><span>Additionally, fear of contracting the disease can prevent people from seeking care at health facilities, creating further risks of untreated health problems. </span></span></p> <p><span><span>Clinical and research leaders from PIH teams in multiple countries are undertaking the new study to examine and address these gaps, in collaborative with Dr. Michael Law of the University of British Columbia and Dr. Bethany Hedt-Gauthier of Harvard University. </span></span></p> <p><span><span>The Canadian Institutes for Health Research (CIHR) are providing technical support and funding. The institutes also are supporting postdoctoral researcher Dr. Isabel Fulcher, who has been leading the development of data and analytic methods for the project for several months.</span></span></p> <p><span><span>By working with routine health data that is already collected, Drs. Law and Hedt-Gauthier hope to overcome COVID-19 testing restraints and provide a much-needed source of data on COVID-19 in low- and middle-income countries.  </span></span></p> <p><span><span>PIH Canada recently spoke with Dr. Law about the study. </span></span></p> <p><span><span><strong>What are the study’s objectives? </strong></span></span></p> <p><span><span>The study has two key objectives. The first is to perform syndromic surveillance to detect early signs of a COVID-19 outbreak, and the second is to investigate potential declines in health service use to design and target interventions. Each of these objectives will be carried out in the following seven countries: Haiti, Lesotho, Liberia, Malawi, Mexico, Rwanda, and Sierra Leone.</span></span></p> <p><span><span><strong>Why were these seven countries chosen? </strong></span></span></p> <p><span><span>Actually, the seven sites were already working together and had identified these two topics as a priority. The CIHR funding call provided an opportunity for us to rally resources to respond to these identified needs. </span></span></p> <p><span><span>Because each of these countries are PIH sites, the other important aspect here is that it allows the research project to rapidly scale since we already have the existing relationships and infrastructure within the country to do that. Our research team has really benefitted from the leadership of Jean Claude Mugunga, a deputy chief medical officer at Partners In Health, and Harvard Professor Megan Murray, who is also a PIH Research Director, who have been coordinating cross-site research for COVID-19-related work more broadly.</span></span></p> <p><span><span>Excitingly, this is the most countries that have participated in a single PIH research project at the same time to date.</span></span></p> <figure role="group"> <img alt="Leribe Pontmain Health Centre" data-entity-type="file" data-entity-uuid="523c3496-a6d9-45eb-934e-959c9550f1d8" src="/sites/default/files/inline-images/Lesotho_0218_LeribePontmainHC_CAvila_007.JPG" width="938" height="624" loading="lazy" /> <figcaption>Pontmain Health Centre in Leribe District, Lesotho, in 2018. (Photo by Cecille Joan Avila / PIH)</figcaption> </figure> <p><span><span><strong>What exactly is syndromic surveillance? Is it a replacement for testing? </strong></span></span></p> <p><span><span>Syndromic surveillance is essentially a way to use the data that we have. We know these routine data are being collected, we know they are being assembled. And so, the hope is that those will be useful for being a ‘canary in a coal mine’ in helping highlight when testing might be necessary. </span></span></p> <p><span><span>Syndromic surveillance is especially important in low- and middle-income countries, where testing is both limited and expensive. And while not a replacement for testing, it serves as more of a complementary procedure in which you can glean information on where potential hotspots of COVID-19 may be occurring to target your testing, and subsequently focus health care efforts. For example, if you see a spike in a region with people showing up with respiratory issues, then you might think that would be an area you would like to focus on more closely.</span></span></p> <p><span><span><strong>Why look at other non-COVID-19 health outcomes? </strong></span></span></p> <p><span><span>With the rise of COVID-19 cases, it is likely that people will be more reticent to seek out health care services at a facility where they fear COVID-19 may be spreading. This study is particularly focused on comparing the number of individuals receiving care for things like maternal health, family planning services, childhood vaccinations, and malaria treatment to expected numbers pre-pandemic. If it turns out there is a decline in the use of these services, there can be a lot of downstream impacts. After all, these are services that are really important to protecting and producing population health in these settings. </span></span></p> <p><span><span>The benefit of this data-forward approach is that you can go full circle with it. In other words, you can see where problems are coming up and target a policy towards those problems. Then, the real advantage of using routine data is that you can turn around and evaluate the impact of those policies that you have put in place.  </span></span></p> <p><span><span>There is evidence to show that this approach works. We did some work in the past with the Ebola virus outbreak in the Democratic Republic of the Congo and found that when we instituted a free care policy after the virus outbreak, visits to health facilities actually increased. So, there are policy measures you can take to try and ensure that people don’t stop seeking out health care that we would otherwise want them to continue on with. </span></span></p> <p><span><span><strong>What will this study ultimately accomplish? </strong></span></span></p> <p><span><span>The fundamental goal of this research project is to support the national COVID-19 responses in these seven countries. The study will provide ways of using data to identify hotspots and deal with some of the secondary consequences of COVID-19. </span></span></p> <p><span><span>But there is also the hope to take it one step further by using this study to help demonstrate the value of health data as countries continue to invest in data collection and use. What is going to happen in the coming months with regard to COVID-19 in low- and middle-income countries will largely depend on the policy responses, which in turn are heavily reliant on the data. </span></span></p> <p><span><span>As a result, it is critical that we recognize the importance of data and policy working hand-in-hand to tackle the COVID-19 pandemic and bring it under control. </span></span></p> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/child-health" hreflang="en">Child Health</a></div> <div class="field-item"><a href="/programs/hiv-aids" hreflang="en">HIV/AIDS</a></div> <div class="field-item"><a href="/programs/tuberculosis" hreflang="en">Tuberculosis</a></div> <div class="field-item"><a href="/programs/womens-health" hreflang="en">Maternal Health</a></div> <div class="field-item"><a href="/programs/cancer-chronic-diseases" hreflang="en">Cancer &amp; Chronic Diseases</a></div> <div class="field-item"><a href="/programs/research" hreflang="en">Research</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/build-systems" hreflang="en">Build Systems</a></div> <div class="field-item"><a href="/tag/cancer" hreflang="en">Cancer</a></div> <div class="field-item"><a href="/child-health" hreflang="en">Child Health</a></div> <div class="field-item"><a href="/tag/covid" hreflang="en">Covid-19</a></div> <div class="field-item"><a href="/hiv-aids" hreflang="en">HIV/AIDS</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> <div class="field-item"><a href="/tag/article-0" hreflang="en">Research/Innovation</a></div> </div> </div> Thu, 13 Aug 2020 22:45:46 +0000 mlawrence 7618 at https://www.pih.org EndTB's Strong Study Results Add to Push for Use of New Drugs https://www.pih.org/article/endtbs-strong-study-results-add-push-use-new-drugs <span class="field-wrapper">EndTB&#039;s Strong Study Results Add to Push for Use of New Drugs</span> <span class="field-wrapper"><span lang="" about="/user/366" typeof="schema:Person" property="schema:name" datatype="">mlawrence</span></span> <span class="field-wrapper">Mon, 08/10/2020 - 14:16</span> <div class="field-wrapper field field-node--field-photo field-name-field-photo field-type-image field-label-hidden"> <div class="field-items"> <div class="field-item"> <picture> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.webp?itok=Xc3o2FZ- 1x" media="all and (min-width: 1200px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_large/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.webp?itok=ZQIbKOvU 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.webp?itok=eu2shu04 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.webp?itok=Fjdgzrhd 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/webp"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.webp?itok=4VFAdC0g 1x" type="image/webp"/> <source srcset="/sites/default/files/styles/article_xlarge/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.jpg?itok=Xc3o2FZ- 1x" media="all and (min-width: 1200px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_large/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.jpg?itok=ZQIbKOvU 1x" media="all and (min-width: 900px) and (max-width: 1199px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_xmedium/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.jpg?itok=eu2shu04 1x" media="all and (min-width: 640px) and (max-width: 899px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_medium/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.jpg?itok=Fjdgzrhd 1x" media="all and (min-width: 450px) and (max-width: 639px)" type="image/jpeg"/> <source srcset="/sites/default/files/styles/article_mobile/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.jpg?itok=4VFAdC0g 1x" type="image/jpeg"/> <img src="/sites/default/files/styles/article_xlarge/public/2020-08/Peru_EndTB_patient_meds_SES_Spring2020_web.jpg?itok=Xc3o2FZ-" alt="An endTB patient receives meds in Lima, Peru " typeof="foaf:Image" /> </picture> </div> </div> </div> <div class="field-wrapper field field-node--field-caption field-name-field-caption field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">José Valdivia, técnico de enfermería (nursing assistant) for Socios En Salud, as Partners In Health is known in Peru, gives medicine to an endTB patient in Lima, Peru. Newly published results from endTB&#039;s observational study showed strong early success for bedaquiline and delaminid, two recently developed drugs that are providing patients with shorter, less-grueling regimens in the fight against drug-resistant tuberculosis. </div> </div> </div> <div class="field-wrapper field field-node--field-photo-credit field-name-field-photo-credit field-type-string-long field-label-hidden"> <div class="field-items"> <div class="field-item">Photos courtesy of endTB</div> </div> </div> <div class="field-wrapper body field field-node--body field-name-body field-type-text-with-summary field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span><span><span>A newly published study with several Partners In Health co-authors showed strong results for using new drugs and shorter treatment regimens to fight severe <strong><a href="https://www.pih.org/programs/tuberculosis">tuberculosis</a></strong> (TB), adding to the case for faster rollout of the drugs and creating data that already has influenced World Health Organization treatment guidelines, a lead PIH researcher said. </span></span></span></span></p> <p><span><span><span><span>The endTB partnership conducted the research, which includes observational data from a diverse cohort of patients in 17 countries, including patients in PIH programs in <strong><a href="https://www.pih.org/country/lesotho">Lesotho</a></strong>, <strong><a href="https://www.pih.org/country/peru">Peru</a>,</strong> and <strong><a href="https://www.pih.org/country/kazakhstan">Kazakhstan</a></strong>. The results underscore the need for expanded access to the recently developed TB medicines bedaquiline and delamanid. </span></span></span></span></p> <p><span><span><span><span>The study found that new treatment regimens for multi-drug resistant tuberculosis (MDR-TB), a severe strain of TB, showed early effectiveness in 85 percent of </span></span><span><span><span>patients</span></span></span><span><span>. The </span></span><span><span>cohort included many people with serious additional illnesses, or comorbidities,<span> t</span>hat would exclude them from clinical trials.</span></span></span></span></p> <p><span><span><span><span>By contrast, </span></span><span><span>the historical standard of care, still in use in much of the world, has about 60 percent treatment efficacy globally, along with more grueling treatment regimens that can have harsher side effects and a longer duration than regimens with the new drugs. </span></span></span></span></p> <p><span><span><span>The study was <span>published July 24 in the </span><strong><a href="https://www.atsjournals.org/doi/10.1164/rccm.202001-0135OC"><em>American Journal of Respiratory and Critical Care Medicine</em></a></strong><em><span>.</span></em></span></span></span></p> <p><span><span><span>“This is important evidence that these new regimens will work well for the true population suffering from this disease,” said lead study author Molly Franke, a Harvard Medical School epidemiologist and longtime collaborator with Socios En Salud, as PIH is known in Peru. </span></span></span></p> <p><span><span><span>“In global health we see many vicious cycles, where poverty and lack of access to care combine to make diseases worse,” Franke added. “On the other hand, bringing care delivery, training and research together the way we are in the endTB project can be a kind of virtuous cycle, where each turn of the wheel brings better care, improved health and greater well-being.”</span></span></span></p> </div> </div> </div> <div class="field-wrapper field field-node--field-paragraphs-content field-name-field-paragraphs-content field-type-entity-reference-revisions field-label-hidden"> <div class="field-items"> <div class="field-item"> <div class="paragraph just-text darktext paragraph--id--3164" style="background-color: #e1e4e2;"> <h2 class="center">At a Glance </h2> <div class="header__intro body"> <div class="field-wrapper field field-paragraph--field-body field-name-field-body field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span><span><span><span>New drug regimen for </span></span><span><span>multi-drug resistant tuberculosis shows early <span>effectiveness in</span></span></span><span><span><span> 85 percent of patients</span></span></span> <span><span>in a cohort that included many with serious comorbidities<span>.</span></span></span></span></span></span></p> <p><span><span><span><span><span>The results suggest a global need for expanded access to </span></span><span><span><span>two recently developed medicines, bedaquiline and delamanid.</span></span></span></span></span></span></p> <p><span><span><span><span><span>Study cohort included many people who would have been excluded from trials because of comorbidities, severity of disease, or extent of drug resistance.</span></span></span></span></span></p> <p><span><span><span><span><span>Findings highlight the importance of innovative regimens to improve outcomes for patients with </span></span><span><span>multi-drug resistant tuberculosis<span>.</span></span></span></span></span></span></p> </div> </div> </div> </div> </div> </div> <div class="field-item"> <div class="paragraph just-text darktext paragraph--id--3165" style="background-color: ;"> <div class="header__intro body"> <div class="field-wrapper field field-paragraph--field-body field-name-field-body field-type-text-long field-label-hidden"> <div class="field-items"> <div class="field-item"><p><span><span><span><span><strong><a href="https://clinicaltrials.gov/ct2/show/NCT03259269">EndTB</a></strong><span> is an international partnership with leaders from </span><span>PIH</span><span><span>, <strong><a href="https://hms.harvard.edu/">Harvard Medical School</a></strong>, </span></span><strong><a href="https://www.msf.org/"><span>Médecins Sans Frontières</span></a><span><span>, </span></span><a href="http://ird.global/"><span>Interactive Research &amp; Development</span></a><span><span>, </span></span></strong><span><span>the </span></span><strong><a href="https://www.uantwerpen.be/en/about-uantwerp/faculties/faculty-medicine-health-sciences/healthcare-services-patient-care/institute-of-tropical-medicine/"><span>Institute of Tropical Medicine in Antwerp</span></a></strong><span><span><strong>,</strong> and </span></span><strong><a href="https://epicentre.msf.org/en/acceuil"><span>Epicentre</span></a></strong><span><span>, along with financial partner </span></span></span></span><strong><a href="https://unitaid.org/#en">Unitaid</a></strong>.<span><span><span><span>  </span></span></span></span></span></span></p> <p><span><span><span><span><span><span>TB is the world’s deadliest infectious disease, killing an estimated 1.6 million people worldwide per year.</span></span></span></span></span></span></p> <p><span><span><span>While recent announcements of a price reduction for bedaquiline and expected reduction for delamanid are welcome news, researchers on the study said, more must be done to improve treatment guidelines worldwide and scale up treatment with these new regimens. </span></span></span></p> <p><span><span><span>“Our findings underscore the need for urgent expanded access to these drugs,” said Carole Mitnick, <span>a senior</span> researcher at PIH, co-principal investigator for endTB’s clinical trials, and a co-author of the study. </span></span></span></p> <p><span><span><span><span><span><span><span>Dr. KJ Seung, who has been fighting tuberculosis with PIH since 2001, urged the World Health Organization and national governments in April 2019 to quickly implement new treatment plans for severe TB, in an </span></span></span><strong><span><span><span><a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30186-X/fulltext"><span><span><span>op-ed</span></span></span></a></span></span></span></strong><span><span><span> published in <em><span>The Lancet</span></em> <em><span>Global Health</span></em> and co-authored by Dr. Cathy Hewison of </span></span></span><span><span><span><span><span><span><span><span><span><span><span><span><span><span><span><span>Médecins Sans Frontières.</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></p> <p><span><span>“This (new study) absolutely validates (Seung and Hewison’s) call for faster rollout of regimens containing bedaquiline and/or delamanid,” Mitnick said. “These results support the continued evaluation in global and national policy recommendations to support these drugs in regimens.”</span></span></p> <p><span><span>Mitnick said data used in the new study has contributed to a recent update to WHO guidelines for TB, “which certainly strengthened the recommendations for bedaquiline.”</span></span></p> <figure role="group"> <img alt="Clinical teams prepare to travel for patient visits in Lesotho " data-entity-type="file" data-entity-uuid="49296cdd-70e2-4759-9212-e720134424a3" src="/sites/default/files/inline-images/EndTB_Lesotho_Spring2020_web.jpeg" width="938" height="704" loading="lazy" /> <figcaption>Clinical teams in Lesotho prepare to travel to visit TB patients in remote areas of the mountainous southern Africa nation earlier this year. Each of the red-and-black coolers contains treatment for one patient. </figcaption> </figure> <h2>Long History, New Results</h2> <p><span><span><span>The need for better treatments for multi-drug resistant tuberculosis is dire. </span></span></span></p> <p><span><span><span>The WHO estimates that there are nearly 500,000 new cases of MDR-TB per year and that nearly 200,000 people die each year from MDR-TB. In 2018, only one out of three patients were put under an effective treatment, and among those who were, only half were cured. </span></span></span></p> <p><span><span><span>In the early 2010s, regulatory agencies approved the first new TB drugs in 50 years, bedaquiline and delamanid, offering hope for more effective and less toxic MDR-TB treatment.</span></span></span></p> <p><span><span><span>With the historical standard of care and even with some newer regimens, certain subgroups of patients, including those with HIV or Hepatitis C, or diabetes, experience worse treatment outcomes than patients without these conditions. </span></span></span></p> <p><span><span><span>In addition, these conditions can preclude patients from participating in some clinical trials for the new TB drugs. </span></span></span></p> <p><span><span><span>It’s important to examine if these subgroups experience any of the benefit from the new regimens that might be observed in healthier subjects, the researchers said. </span></span></span></p> <blockquote> <p><span><span><span>The endTB study showed that for the new regimens, early treatment response was similar for patients without serious comorbidities or other complicating factors and for those with diabetes, hepatitis C, and severe drug resistance.</span></span></span></p> </blockquote> <p><span><span><span>Patients with severe TB disease when they started treatment had worse treatment outcomes than patients with less severe disease. Sixty-eight percent of people with severe disease had early favorable response to the new regimen, compared to 89 percent without severe disease. Among patients with HIV coinfection, in 73 percent early outcomes on the new regimens were favorable, compared with 84 percent of those without HIV.  </span></span></span></p> <p><span><span><span>The results are based on an analysis of early treatment results from more than 1,000 MDR-TB patients who had been enrolled in the study between April 2015 and March 2018. The study examines outcome from 6 months into a treatment that lasts 15 months or longer. Long-term effectiveness will be measured at end of treatment and during follow-up. </span></span></span></p> <p><span><span><span>“The early results from these studies offer convincing evidence that these new regimens offer a very promising alternative to the historical regimens that achieve approximately 60 percent success at end of treatment, and to other new treatments that are becoming available,” said Mitnick, who is also an associate professor of global health and social medicine at Harvard Medical School.</span></span></span></p> <p><span><span><span>“We’re eager to follow these patients as they progress through treatment in order to verify the effectiveness of these new regimens,” she added. </span></span></span></p> <h2><span><span><span>Low-resource Settings</span></span></span></h2> <p><span><span><span>Observational research makes many important contributions to improving treatment outcomes for complex illnesses in complicated populations that it is critical to continue research efforts past the stage of clinical trials in illnesses like tuberculosis, the researchers said. </span></span></span></p> <p><span><span><span>While tuberculosis has nearly disappeared in wealthier populations, it remains a critical threat to communities with fewer resources. A big part of the challenge of treating MDR-TB is finding regimens that will work in low-resource settings with complex populations that often include great diversity, including many people who might be undernourished and sick with other illnesses. </span></span></span></p> <p><span><span><span>The partnership is also studying the safety of the new regimens. Preliminary results suggest that side effects from the new regimen may be much less severe than the historical treatment, which has been known to cause deafness and psychosis. </span></span></span></p> <blockquote> <p><span><span><span>“TB is well-controlled where control is easy,” Mitnick said. “We need to find better ways to treat it where it’s difficult.” </span></span></span></p> </blockquote> <h2>TB during COVID-19</h2> <p><span><span><span>The global reach of endTB has now provided clinicians with invaluable hands-on experience with bedaquiline and delamanid and helped change country guidelines, getting the new drugs registered for use in more than half of endTB’s 17 countries, the researchers said. </span></span></span></p> <p><span><span><span>The endTB partnership is using the same model for promoting innovation to prepare for what they hope will be the next change on the horizon in care for DR-TB: all-oral, shortened regimens, which are being studied in the current phase of <strong><a href="https://clinicaltrials.gov/ct2/show/NCT02754765">endTB’s clinical trial</a>.</strong> </span></span></span></p> <p><span><span><span>While the implementation program continues to roll out and hopes to reach new patients, the endTB trial has enrolled 465 patients with MDR-TB in new, all-oral regimens that could transform care for drug-resistant TB. </span></span></span></p> <p><span><span><span>The all-oral regimens used in the endTB observational study and the shortened all-oral regimens studied in the trials would be particularly helpful during international health crises like the coronavirus pandemic, the researchers noted. These all-oral regimens are much easier to deliver in routine times and especially so in times of extreme crises that affect health systems (pandemic, war, disasters).</span></span></span></p> <p><span><span><span>“The majority of these regimens were without an injectable, so people didn’t have to go to health facilities daily to get injected as part of their treatment,” Mitnick said. ”That certainly is helpful at a time when there is enormous pressure on health systems and TB services have been pretty much <strong><a href="https://www.nytimes.com/2020/08/03/health/coronavirus-tuberculosis-aids-malaria.html?referringSource=articleShare">decimated by the COVID-19 outbreak</a></strong>.”</span></span></span></p> <p><span><span><em><span>This story was originally published by </span></em><strong><em><a href="https://hms.harvard.edu/news/promising-progress">Harvard Medical School</a>.</em></strong></span></span></p> </div> </div> </div> </div> </div> </div> </div> </div> <div class="field-wrapper field field-node--field-programs field-name-field-programs field-type-entity-reference field-label-above"> <div class="field-label">Programs</div> <div class="field-items"> <div class="field-item"><a href="/programs/hiv-aids" hreflang="en">HIV/AIDS</a></div> <div class="field-item"><a href="/programs/tuberculosis" hreflang="en">Tuberculosis</a></div> <div class="field-item"><a href="/programs/research" hreflang="en">Research</a></div> </div> </div> <div class="field-wrapper field field-node--field-taxonomy-tags field-name-field-taxonomy-tags field-type-entity-reference field-label-above"> <div class="field-label">Related Categories</div> <div class="field-items"> <div class="field-item"><a href="/advocacy" hreflang="en">Advocacy</a></div> <div class="field-item"><a href="/hiv-aids" hreflang="en">HIV/AIDS</a></div> <div class="field-item"><a href="/kazakhstan" hreflang="en">Kazakhstan</a></div> <div class="field-item"><a href="/lesotho" hreflang="en">Lesotho</a></div> <div class="field-item"><a href="/peru" hreflang="en">Peru</a></div> <div class="field-item"><a href="/research" hreflang="en">Research</a></div> <div class="field-item"><a href="/tag/article-0" hreflang="en">Research/Innovation</a></div> <div class="field-item"><a href="/tag/tuberculosis" hreflang="en">Tuberculosis</a></div> </div> </div> Mon, 10 Aug 2020 18:16:25 +0000 mlawrence 7616 at https://www.pih.org