Capacity Building for Adherence Research in Rural Uganda

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Capacity Building for Adherence Research in Rural
Uganda

• David Bangsberg, MD, MPH
• Associate Professor of Medicine
• Epidemiology and Prevention Interventions Center
• Division of Infectious Diseases
• The Positive Health Program
• San Francisco General Hospital
• AIDS Research Institute, UCSF
• Massachusetts General Hospital
• Harvard Medical School
• Harvard School of Public Health
• Harvard Initiative on Global Health
• May, 2008

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Will widespread, unregulated access to
antiretroviral drugs in sub-Saharan Africa, lead
to the rapid emergence of drug resistant viral
strains, spelling doom for the individual,
curtailing future treatment options, and
leading to transmission of resistant virus?
Preventing antiretroviral anarchy in sub-Saharan
Africa Harries et al Lancet 2001 358410-4.
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UARTO Adherence Over 12 Months for Free ARV
Therapy n174Bangsberg et al CROI 2008
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Explaining Adherence Success Norma C. Ware, John
Idoko, Sylvia Kaaya, Irene Andia Biraro, Monique
A. Wyatt, Oche Agbaji, Guerino Chalamilla, and
David R. Bangsberg 3rd International IAPAC
Adherence Conference
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A Social Model of Adherence for sub-Saharan Africa
Resource Scarcity
Resource Scarcity
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A Social Model of Adherence for sub-Saharan Africa
Resource Scarcity
Resource Scarcity
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A Social Model of Adherence for sub-Saharan Africa
Resource Scarcity
Resource Scarcity
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A Social Model of Adherence for sub-Saharan Africa
Resource Scarcity
Resource Scarcity
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A Social Model of Adherence for sub-Saharan Africa
Individual HIV knowledge Med side
effects Cognitive function Mental health Alcohol
Use
Resource Scarcity
Resource Scarcity
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A Social Model of Adherence for sub-Saharan Africa
Individual HIV knowledge Med side
effects Cognitive function Mental health Alcohol
Use
Resource Scarcity
Resource Scarcity
Cultural Religious Beliefs Respect for
Authority Importance of having children
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A Social Model of Adherence for sub-Saharan Africa
Social Structural Patterns of Inequality, e.g.,
gender inequality
Individual HIV knowledge Med side
effects Cognitive function Mental health Alcohol
Use
Resource Scarcity
Resource Scarcity
Cultural Religious Beliefs Respect for
Authority Importance of having children
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A Social Model of Adherence for sub-Saharan Africa
Social Structural Patterns of Inequality, e.g.,
gender inequality
Individual HIV knowledge Med side
effects Cognitive function Mental health Alcohol
Use
Resource Scarcity
Resource Scarcity
Infrastructural Few treatment sites Distance to
care Cost/Availability of Transportation
Cultural Religious Beliefs Respect for
Authority Importance of having children
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D4T/3TC/Nevirapine17 USD per month
Triomune
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Stopping drugs with different half lives
Last Dose
Day 1
Day 2
Drug concentration
IC90
Zone of potential replication
IC50
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0
24
48
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Time (hours)
S. Taylor et al. 11th CROI Abs 131
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Frequency and Duration of Treatment
Interruptions gt48hrs over 24 weeks Oyugi and
Bangsberg AIDS 2007
Correlates Financial difficulty securing ARVs
and pharmacy stockouts 90 of all missed doses
occur during an interruption
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Duration of MEMS Defined Treatment Interruption
and Probability of NNRTI ResistanceParienti and
Bangsberg IAPAC Adherence Conf 2008 n72
Estimated probability of viral control
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Developing In-Country Research Capacity
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Strengthening research capacity in developing
countries is one of the most powerful,
cost-effective, and sustainable means of
advancing health and developmentInternational
Commission on Health Research 1990 Report
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Mbarara, Uganda
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Research Capacity

• Capacity building components
• Physical
• Administrative
• Scientific
• Bridging cultures
• Sustainability through local leadership

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Mbarara University of Science and
TechnologyPhysical Capacity

• Clinical Activity
• 2000 HIV tests/month
• 12,000 active patients
• 4,000 on ARVs
• 2000 square ft lab CD4, VL
• Research
• Funding
• PEPFAR/Global Fund
• NIH (1-RO-3, 4 R-21s, 1 K-24, 2 RO-1s, 1-UO1)
• 2 Doris Duke Charitable Foundation Grants
• Canadian Government Clinical Trials Network
• MSF Epi-Centre
• Private donor support
• 5 published Ugandan investigators
• 100 Ugandan full time staff
• 10000 sq foot research space
• 3 satellite internet connections
• 10 cars

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Research Capacity

• Capacity building components
• Physical
• Administrative
• Scientific
• Bridging cultures
• Sustainability through local leadership

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Administrative CapacityResearch Manager

• Priority setting
• Planning
• Training
• Team building
• Quality assurance
• Budgeting
• Travel agent/social planner/host
• Relations between institutions

Nneka Emenyonu
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Administrative CapacityCreating a Grants and
Contracts Office

• In-country Challenges
• Training on budgeting, accounting and human
  resource management
• Providing technical assistance while maintaining
  independence
• Start up funds chicken and egg
• Operational funds at 8 indirect return rate
• No fiscal reserves to cover administrative delays
• US-based challenges
• Turn-around time
• Administrative staff making connection across
  oceans and cultures
• Getting to Yes with reasonable risk to the
  institution

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Research Capacity

• Capacity building components
• Physical
• Administrative
• Scientific
• Bridging cultures
• Sustainability through local leadership

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Scientific CapacityCharting a Direction

• Establishing Priorities and Focus
• Global priorities, national priorities, local
  priorities
• Skills, expertise, infrastructure, and resources

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Scientific Capacity Descriptive to
Hypothesis/Theory Driven Research

• Relevance vs novelty/rigor
• Investigator training and experience
• Applicability of theoretical models
• Top-down adaptation
• Bottom-up building

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Investigator Development

• Competing clinical demands
• Creating an academic environment
• Literature review
• Peer review
• Developing technical skills
• Brain Drain
• External brain drain
• Internal brain drain

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Anatomy of a Manuscript18 topic sentences

• Title
• Abstract
• Introduction 3 paragraphs
• 1 What we know,
• 2 What we dont know and why
• 3 One to three objectives and study design
• Methods 5 paragraphs
• 1 Participant selection
• 2-4 Variables and procedures for each primary
  and secondary objective
• 5 Analytic methods
• Results 5 paragraphs depending on number of
  objectives
• 1 Patient recruitment and characteristics
• 2 Evidence for first objective
• 3 Evidence for second objective
• 4 Evidence for third objective
• 5 Sensitivity analyses/alternative analyses
• Tables/Figures One descriptive plus one per
  objective
• Discussion 5 paragraphs
• 1 Summarize main finding

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Research Capacity

• Capacity building components
• Physical
• Administrative
• Scientific
• Bridging cultures
• Sustainability through local leadership

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US and Uganda Cultural Workplace Values

• United States
• Show initiative and speak up
• Initiative, action, and ambition are respected
  traits
• Impersonal in business family and friendships do
  not influence business decision
• Be direct and specific put reserve aside
• Promoting ideas is direct, verbal, and immodest
• Unpleasant fact preferred to ambiguity
• Senior managers are still an apprentice always
  learning
• You are on your own people expect you to care
  for yourself
• Time is money

• Uganda
• Questioning superiors is disrespectful
• Deference to position
• Junior colleagues speak when invited
• Junior colleagues never contradict senior
  colleagues
• Senior colleagues never contradict other senior
  colleagues in front of junior colleagues
• Conflict avoidance
• Analogy as argument
• Self-promotion considered immodest
• Family/friendships important in business
  relations
• Time is life

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Communications

• Face-face meeting 2-3 months
• US investigators to developing country 4-5 times
  per year
• Developing country investigator to US at lease
  once per year
• Meals, holidays/festivals, weddings
• Phone conversation every 2 weeks
• Skype www.skype.com
• Email
• Content fast, cheap and convenient
• Relationship building ineffective and
  potentially dangerous

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Planting the Flag Phenomenon North
American-North AmericanCultural Clashes

• Sources
• Funding
• Space
• Infrastructure
• Limited pool of local investigators
• Solutions
• Guests rather than hosts
• Multinational collaborations
• Shelving the flag

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Research Capacity

• Capacity building components
• Physical
• Administrative
• Scientific
• Bridging cultures
• Sustainability through local leadership

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Challenges to Sustainability

• Retaining scientific talent
• Brain drain
• Funding physical infrastructure
• Automobiles
• Equipment
• Renovation
• Cash-only economies
• Sustaining infrastructure
• Repairs/maintenance
• Currency fluctuations
• Bridging grant cycles

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Reversing Brain Drain Linchpin to Global Health

• Donor support has expanded treatment access
• 2.4 million too few health providers
• Developing countries subsidize developed country
  health care workforce at 500 million/yr
• 1 in 4 developing country health care providers
  living abroad

Kuehn JAMA 20072981853-1855 WHO
http//www.who.int/mediacentre/factsheets/fs301/en
/index.html
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Health Care Provider Emigration Driven by Salary
Gap
Salary Gap
Developing Country Salary
Industrialized Country Salary
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Donor Support Required To Replace Salary Gap
Salary Gap
Developing Country Salary
Industrialized Country Salary
Donor Support
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Leadership Umbrella Drives Health Service
Workforce
Leadership Umbrella
Local Academic Leaders Physicians Nurses Ancillary
Staff
Salary Gap
Developing Country Salary
Industrialized Country Salary
Donor Support
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Targeted Donor Support toExpand Leadership
Umbrella
Leadership Umbrella
Local Academic Leaders Physicians Pharmacists Nurs
es Ancillary Staff
Salary Gap
Developing Country Salary
Industrialized Country Salary
Targeted Donor Support
Donor Support
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Targeted Donor Support toExpand Leadership
Umbrella
Leadership Umbrella
Local Academic Leaders Physicians Pharmacists Nurs
es Ancillary Staff
Salary Gap
Developing Country Salary
Industrialized Country Salary
Targeted Donor Support
Donor Support
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Expanding Leadership Umbrella Increases
Healthcare Workforce Quality and Quantity
Leadership Umbrella
Local Academic Leaders Physicians Pharmacists Nurs
es Ancillary Staff
Salary Gap
Developing Country Salary
Industrialized Country Salary
Targeted Donor Support
Donor Support
Net Benefit Improved Health
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Expanding In-Country Professional Opportunities
Narrows Economic Gap and Decreases Donor Support
Leadership Umbrella
Local Academic Leaders Physicians Pharmacists Nurs
es Ancillary Staff
Professional Opportunity
Salary Gap
Developing Country Salary
Industrialized Country Salary
Targeted Donor Support
Donor Support
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Renewable Social/Economic Capital Further
Decreases Donor Support
Leadership Umbrella
Local Academic Leaders Physicians Pharmacists Nurs
es Ancillary Staff
Social Capital
Professional Opportunity
Salary Gap
Developing Country Salary
Industrialized Country Salary
Targeted Donor Support
Donor Support

• Renewable Social Capital
• Community-designed housing
• Primary/secondary education
• Performing and fine arts

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Improved Opportunities and Living Standards
Repatriates Health Care Workforce
Social Capital
Professional Opportunity
Developing Country Salary
Industrialized Country Salary
Salary Gap
Targeted Donor Support
Donor Support
Reversing the Tide Poor Countries Benefit from
Rich Country Training Investment
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Improved Opportunities and Living Standards
Repatriates Health Care Workforce
Social Capital
Professional Opportunity
Developing Country Salary
Industrialized Country Salary
Salary Gap
Targeted Donor Support
Donor Support
Reversing the Tide Poor Countries Benefit from
Rich Country Training Investment
Accelerate Economic Growth
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Sustainability
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