Cape Town, South Africa – Jessica Magidson, Postdoctoral Fellow, Chester M. Pierce, MD Division of Global Psychiatry, MGH

After leaving Harare, the second part of my trip is in Cape Town South Africa. Here I am focusing on clinical research, primarily to build relationships with faculty in the psychiatry department at University of Cape Town (UCT) who are also involved in the capacity building initiatives in Zimbabwe and the clinical research we were working on while in Harare—to train health care workers in empirically supported behavioral interventions for improving antiretroviral therapy (ART) adherence and depression. In addition to discussing with UCT faculty the ongoing progress on the work in Zimbabwe, I am also discussing ideas for future clinical and research collaborations with their team to pursue during my postdoctoral fellowship. While in Cape Town, I am also spending time at Stellenbosch University and Tygerberg Hospital in the departments of psychiatry, infectious disease, and the department of medicine to become familiar with ongoing research projects and initiatives across these departments.  

One of the projects that my team in Behavioral Medicine at MGH has been planning with faculty in psychiatry at UCT is a randomized clinical trial (RCT) to examine the effectiveness of cognitive behavioral therapy (CBT) for improving depression and ART adherence in the South African setting. In this study, CBT will be implemented by nurses working in HIV clinics in the local townships, for instance in Khayelitsha. Khayelitsha is an impoverished settlement just east of Cape Town where an estimated 500,000 people reside. Recent estimates of the HIV prevalence in this area are approximately 20%. Further, rates of depression are also very high in these areas—among individuals with HIV, it has been estimated that rates of depression reach up to about 40%. There is a huge need for treatments for depression that can be integrated into HIV care in this context.

Khayelitsha

 

A manual for improving HIV medication adherence in HIV clinics in Khayelitsha that was developed by UCT faculty and our behavioral medicine director, Dr. Safren, which incorporates modifications for this setting.

There has been some preliminary work conducted by our team and the UCT faculty to adapt existing adherence interventions such as Life-Steps and CBT for depression for this setting. The resulting intervention culturally tailored for this setting, called “Ziphamandla”, translates as ‘to be empowered’ in Xhosa. Xhosa, by the way, is one of the 11 official languages spoken in South Africa, and one of the most common spoken in the local townships such as Khayelitsha. Interestingly Xhosa has the unique feature of “click” consonants – the word Xhosa, pronounced “Kosa” also begins with a click. 

The CBT Ziphamandla intervention has been implemented thus far by two Xhosa-speaking nurses, one of whom was a psychiatric nurse, the other without previous mental health training. 14 individuals have been recruited from two of the busiest clinics in Khayelitsha, the Ubuntu and Michael Mapongwana ART clinics. The Ubuntu ART clinic was the first clinic in South Africa to offer ART and has approximately 7,000 HIV-positive patients registered in their database, the majority of whom are currently on ART. Initial results evaluating Ziphamandla seem very promising for improving depression, ART adherence, and overall functioning. The lead psychologist conducting this work, Dr. Lena Andersen, and I spent a lot of time during the visit discussing plans to disseminating the findings to the scientific community. The future RCT to compare this intervention with a control comparison condition in a larger sample will be an important future direction of this work and was an important priority for discussion throughout meetings with UCT faculty.

While in Cape Town I have also spent time at Stellenbosch University and Tygerberg Hospital to meet with faculty across different departments, including the Children’s Infectious Diseases Clinical Research Unit (KID-CRU), the psychiatry department, and the department of medicine.

During meetings at KID-CRU, although my clinical and research interests to date have largely focused on adults, we had interesting discussions regarding maternal psychosocial factors that may influence adherence and outcomes among infants and children living with HIV, as well as an emerging concern – psychosocial struggles among adolescents who are now living into adolescence and young adulthood following ART initiation from birth. 

KID-CRU, an impressive clinical research unit with its own pharmacy and laboratory, the site of numerous ongoing clinical trials focusing on improving HIV and TB outcomes among infants and children

This theme again came up while visiting the psychiatry department, where we discussed more in depth the types of psychosocial struggles among HIV-infected adolescents who have been taking ART since birth, and more specifically how factors such as substance use and impulsivity may affect adherence. It was also interesting to learn more about the structure of the psychiatry department at Stellenbosch and the different psychiatric clinical settings in the area (although I unfortunately could not visit the actual department...)

Finally, the meetings in the department of medicine were also very productive. We discussed the importance of integrating behavioral HIV research with other chronic conditions, importantly TB in this setting. We also discussed the lack of psychiatric epidemiological research to date on substance abuse among HIV-infected individuals in South Africa and ways in which initial quantitative research could lend itself to future intervention developmental efforts in an area. It is this area—the intersection of substance use, depression, and HIV self-care behaviors in both the South African and Zimbabwean context—that I hope to continue to pursue both clinically and in research.

I am extremely thankful for the opportunity to meet with faculty at UCT, Stellenbosch, and Tygerberg Hospital during this visit, for the hospitality of our gracious hosts in Zimbabwe, the support of Dr. Conall O’Cleirigh throughout the trip, as well as the mentorship in my global psychiatry fellowship from Drs. Steve Safren, Dave Henderson, and Greg Fricchione. I am very appreciative of the support from the COE travel award to enable these opportunities, particularly to be able to visit Zimbabwe for the first time. This was a fantastic experience for both clinical and research training, and I am already looking forward to the next visit to continue developing this line of clinical research and building  relationships with these clinical research teams in both Harare and Cape Town.

Early morning hike in the clouds up Table Mountain! Beautiful view of Cape Town.