Research/Projects

Joselyn has 19 years of professional experience in development work, with a focus on HIV response in 15 Asia and Pacific countries. She has acquired technical skills in grant and project management, sustainable HIV financing and transition, stakeholder engagement, technical support management and delivery, community capacity development, risk management, monitoring and evaluation, and proposal development. Jocelyn has developed and maintained collaborative partnerships with regional technical development partners including WHO, UNDP, French 5%, UNAIDS, UNICEF and World Bank in various capacities such as developing research methodology and protocols, program design and implementation.

Joselyn’s Project: My area of interest and focus on my MIST project is implementation of a community-based, patient navigation model to engage people who inject drugs (PWID) into HIV prevention and treatment services.

Mona is an experienced International Technical Assistance provider in Key Populations Interventions, Community System Strengthening (CSS), Gender and Human Rights, Health Systems and Institutional Development, Assessments and Evaluations, Proposal Development; and Grant Implementation Management.

Mona’s Project: Using mixed-method approach to evaluate the effectiveness of a national stigma reduction intervention, measured against health outcomes including uptake of HIV testing, ART treatment, and adherence to ART (possibly in Indonesia – proposal development in progress).

Research Project: Understanding the Barriers and Facilitators of Implementing A Tele-training Program in Malaysian Prison System

As prison health is public health, healthcare in prisons and detention centers play a central role in public health disease management. Although the Malaysian government has globally committed towards curtailing risk and reducing rates of HIV, active and latent Tuberculosis (TB), and hepatitis C (HCV)— health care in prisons and places of detention are still not held to the same standard and priority due to punitive policies and societal stigmas violating fundamental human rights. Coupled with severe overcrowding and limited resources, this has led to high incidence and prevalence of infectious diseases amongst correctional staff and inmates, exhausting the prison health system, and Malaysian health system at large—impacting Malaysia’s ability to achieve global health targets (i.e. United Nations Sustainable Development Goal(s): 3.3, 3.4, 3.5 and 3.8)., particularly for TB, HIV, HCV and COVID-19. In response to the COVID-19 pandemic, Malaysia’s digital health infrastructure strengthened using artificial intelligence / machine learning (AI/ML) for contact tracing solutions such as MySejahtera, MyTrace, and others. Additionally, virtual health clinics and e- appointment activities increased access to healthcare in the community. As COVID-19 rates continue to rise in incarcerated settings in Malaysia, with high prevalence of HIV and TB treatment disruptions, these enhancements provide a precedent to introduce online training for prison doctors to compliment in-facility medical care and empower limited medical personnel and strengthen healthcare service and delivery for people in prison – especially people with HIV and COVID-19. Additionally, such services can reduce transport and related security management costs, while increasing health and clinical services for better health outcomes.

From the beginning of the AIDS epidemic in 1981, the prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population. Several factors have a role in the epidemics of HIV, tuberculosis, and related infections in prisons. Unlike most of Asia where AIDS mortality decreased by 37%, it grew by >20% in Malaysia. People Who Inject Drugs (PWIDs) in Malaysia have low antiretroviral therapy (ART) coverage and high HIV, HCV and TB-related morbidity and mortality. Opioids, the most frequently injected drugs, fuel explosive HIV pandemics in SE Asia. Despite opioid agonist therapy (OAT) with methadone (MMT) or buprenorphine (BMT) being effective for primary and secondary HIV prevention among PWIDs , yet in the 6 countries (including Malaysia) with the highest HIV-related mortality among PWIDs, OAT is inadequately scaled with <2% receiving it.

Criminalization of drug use further concentrates PWIDs with HIV, HCV, and TB within prisons. Globally, 10.2 million are imprisoned and 40-70 million people transition through prisons annually. HIV and TB prevalence in prisoners are 5- and 100-fold higher than in the general population, respectively, resulting in explosive TB outbreaks. Prison crowding also contributes to increased TB risk, particularly among HIV+s and PWIDs who already have elevated risk. Prison mortality is high, with 50%-80% of deaths attributed to TB, especially from HIV/TB co-infection. Nearly all prisoners return to communities where HIV and TB transmission are perpetuated, especially with ineffective transitional care. In low/middle-income countries (LMIC), PWIDs, HIV, HCV, and TB are syndemic and concentrated in prisons and require innovative and integrated programs to effectively transition them to the community.

The entry of Covid-19 in criminal justice settings has posed new challenges to the existing burden of infectious diseases among the prison population. Translating standard Covid-19 prevention, control, and management interventions in a closed community may prove insufficient as prison systems are plagued by overcrowding, poor sanitation, poor ventilation, and high admission rates in both developed and developing countries. In order to counteract the intersection of corona virus with existing burden of HIV, TB, HCV and substance use disorder, it is crucial to increase the capacity of prison healthcare service providers.

The population to doctor ratio in Malaysian prisons is 1:454. The small number of doctors cannot provide adequate healthcare for a large number of prisoners, and that could lead to poor quality healthcare.

Therefore, the Prison Department has the responsibility to train prison doctors on health care, medical ethics, and human rights to ensure fair health service delivery. The proposed project aims to explore the acceptability of implementing a tele-training program for prison doctors and healthcare service providers to increase their capacity in handling the multifaceted burden of covid-19, HIV, HCV, TB, and substance use disorder.

Objectives:

• The objective of the study is to explore the anticipated barriers and facilitators of implementing a popular tele-training program, i.e., Project ECHO@ for prison doctors and healthcare service providers to increase their capacity in handling the multifaceted burden of covid-19, HIV, HCV, TB, and substance use disorder.
• Additionally, the study would identify the specific topics that the prison doctors and healthcare service providers would find important to be trained on.
• The study will explore if tele-medicine can be an effective way to assist prison doctors in handling complex cases.

Rafdzah’s project: The general aim of this project is to explore barriers in implementing a stigma reduction program among staff at all level within the hospital or clinic that provide service to PLWH. She is planning to adapt the Health4All healthcare workers training guidelines by applying the EPIS framework.

Osteoporosis is a silent progressive disease characterized by compromised bone strength and microarchitectural deterioration of bone tissue, leading to increased bone fragility and fracture risk¹. The prevalence of low bone mineral density (BMD) was higher in human immunodeficiency virus (HIV)-infected individuals compared to non-infected controls². In addition, antiretroviral therapy (ART), despite being an effective treatment for HIV disease, was also associated with reduced BMD and a higher prevalence of osteoporosis³. With the use of ART, more patients achieved viral suppression and had a longer life expectancy, therefore making osteoporosis a more important issue to address throughout the recent years⁴. BMD screening is recommended for all HIV-infected individuals aged 50 and above by several expert groups^{5, 6}. However, based on in-house data from the University Malaya Medical Centre, the uptake rate of these tools and dual-energy X-ray absorptiometry (DXA) scan to screen and diagnose osteoporosis among women living with HIV is low. Our long-term goal is to establish a guide to improve screening and diagnosis of osteoporosis among HIV-infected individuals in Malaysia. Herein, we propose to evaluate the rate of osteoporosis screening among HIV-infected men, explore the barriers to screening and develop a guide or tool to remind people to screen for osteoporosis.

References

1. Kanis JA. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: Synopsis of a WHO report. Osteoporosis International. 1994;4(6):368-81.

2. Compston J. HIV infection and osteoporosis. BoneKEy reports. 2015;4:636-.

3. Brown TT, Qaqish RB. Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review. Aids. 2006;20(17):2165-74.

4. May MT, Gompels M, Delpech V, Porter K, Orkin C, Kegg S, et al. Impact on life expectancy of HIV-1 positive individuals of CD4+ cell count and viral load response to antiretroviral therapy. AIDS. 2014;28(8):1193-202.

5. McComsey GA. Bone disease in HIV infection: a practical review and recommendations for HIV care providers. Clinical infectious diseases. 2010;51(8):937-46.

6. Birabaharan M, Kaelber DC, Karris MY. Bone Mineral Density Screening Among People With HIV: A Population-Based Analysis in the United States. Open Forum Infectious Diseases. 2021;8(3).

For my PhD research, I’m looking into developing and testing a novel implementation strategy to scale up the uptake of HIV pre-exposure prophylaxis (PrEP) in Malaysia. When I learned about the rising new HIV infections in Malaysia in recent years, I started looking into PrEP, a biomedical intervention for HIV prevention, which has been proven to be highly effective and safe in reducing the risk of acquiring HIV infection. Despite the inclusion of PrEP in the National Strategic Plan in 2015 and efforts to implement PrEP since 2017, the awareness and uptake of PrEP is still inadequate to have a significant impact on reducing new HIV infections in Malaysia. As I delve deeper, I learned that PrEP implementation efforts in Malaysia have not involved pharmacists. Drawing the experience from successful implementation of pharmacist-led PrEP model in US and Kenya, I see a huge untapped potential in leveraging the widely accessible community pharmacies to improve access to PrEP in Malaysia. The recent Covid-19 pandemic has also spurred the use of electronic prescribing system among community pharmacies to facilitate access to medications through electronic prescriptions. Therefore, for my PhD research, I will be developing and testing the implementation of a pharmacy-led PrEP service delivery model using electronic prescribing system in Malaysia, taking into consideration the current implementation gaps and needs. This research project aims to promote PrEP uptake by offering a convenient, accessible, demedicalized PrEP service in community pharmacy setting. I will begin my research project by understanding the barriers and facilitators of pharmacist-led PrEP service delivery model from the perspectives of PrEP users, community pharmacists and telemedicine physicians. Following the formative research, I will conduct pilot testing prior to implementation, during which implementation outcomes will be measured in both pilot testing and implementation phases to evaluate the effectiveness of this implementation strategy. As such model has not been explored in Malaysia, this study will help address the current knowledge gap and inform the potential of pharmacist-led PrEP service as a demedicalized, differentiated service delivery model for scaling up PrEP. I believe providing better access and more options to key populations will lead to an increase in the PrEP uptake which can significantly bring down the number of new HIV infections in Malaysia.

For her MIST research project, Dr. Nur Afiqah will be exploring the delivery of stepped-care in a primary care setting for people who use amphetamine-type stimulant (ATS). This study entitled, “Development of continuum of care by community health workers for people who use amphetamine-type stimulants (ATS) in primary care”, aims to engage people with a diverse set of evidence-based practices, based on the spectrum of ATS use (i.e. non-problematic, problematic ATS use etc), structured by community health workers. Evidence-based practices such as harm reduction services (needle and syringe exchange program, methadone), referral to HIV care and psychiatric services will be offered by community health workers across different trajectories of ATS use, as determined using the ASSIST tool. A stepped-care model holds to potential to promote better allocation of scarce psychiatric resources at a tertiary care for people who use ATS. Dr. Nur Afiqah hopes to answer important implementation research questions: 1) How can evidence-based practices be effectively packaged and delivered by community health workers for people who use ATS?, 2) What is the potential impact of the development of continuum of care by community health workers on health outcomes of people who use ATS? and 3) What are the barriers and facilitators for community health workers to navigate people who use ATS along the continuum of care?