The New York Academy Of Medicine

2003 David E. Rogers Fellowship

Summary of Final Reports

Bebell, Lisa Marie and Douglas B. Berger

College of Physicians and Surgeons, Columbia University

An Epidemiological and Community-Based Approach to Maternal-Newborn HIV Infection in La Romana, Dominican Republic

HIV is perceived to be a significant problem in the Dominican Republic province of La Romana, though data on the rate of HIV infection is limited. There are also few resources for care and treatment of those infected, and little centralized planning aimed at reducing the spread of HIV. Ms. Bebell’s and Mr. Berger’s study focused on the subset of pregnant women in La Romana, and was carried out in conjunction with Family AIDS International (FAI), which is establishing in La Romana the first family-based HIV care center in the Dominican Republic. Their work had two aims: to help determine the prevalence of HIV in women of childbearing age, and to help strengthen relationships among the major obstetrical care centers in La Romana. The were engaged in clinical activities at a variety of hospitals and clinics, and helped FAI expand from four to seven the number of sites where FAI is collecting blood samples from mothers at the time of birth, and also helped increase the standardization of sample collection and data recording. “I feel that I absorbed much cultural knowledge that is applicable to the Dominican community in which I live and work: Washington Heights,” Ms. Bebell writes. “These realizations will help me treat patients with HIV and AIDS better, and understand the cultural isolation they may be experiencing as a result of their disease. I also bring back strengthened interest in practicing medicine in international contexts and, regardless of location, in a way that engages whole communities.”

Burkey, Matthew David

Johns Hopkins School of Medicine

Narratives of Recovery Project

Matthew Burkey’s Rogers Fellowship allowed him to study and explore the role of social relationships in recovery by members of a homeless substance abusing population—aimed especially at understanding the social factors affecting the health of homeless individuals. This study of the perceptions of homeless men towards their own recovery is a subject not previously studied in this population. As part of the project, he carried out a number of in-depth interviews with residents at a drug treatment facility in South Baltimore. Employing a qualitative research method, he began with a focus of inquiry, explored this among a sample population, refined the focus and returned to the field to explore the refined focus in greater depth. His findings on the role of family, recovery networks, and outside relationships should provide health practitioners with greater insight in tailoring treatment to an individual’s needs, helping them understand which relationships are generally positive and serve as resources in the recovery, and which are generally negative and serve to deter the patient from treatment goals. In this way, social ties will be better leveraged in the treatment of addiction. Writes Mr. Burkey: “In the residents (of the treatment facility) I found teachers. They shared hard-earned wisdom that is nowhere to be found in the pages of pathology texts or within the walls of biochemistry laboratories. Through these interactions, I was reminded of my original intent to pursue medicine as a career. As I have begun the second year of my medical education, I have experienced a renewed excitement for learning.”

Delgado, Mucio Christopher

College of Physicians and Surgeons, Columbia University

Gaining Trust and Participation in Clinical Research Among Hispanics: Study of Patient and Provider Experiences in AIDS and Gastroenterology Clinical Trials in Puerto Rico

Hispanics in the United States, including Puerto Ricans, are underrepresented in clinical research. Among the strategies proposed to remedy this situation have been to develop more “culturally competent” recruiting and retention strategies and to increase the number of minority investigators in research. Mr. Delgado’s study examined factors that may affect participation in research in Puerto Rico where investigators and research participants share a cultural background. He conducted a cross-sectional survey of 101 Hispanics in San Juan on such subjects as HIV, gastroenterology and general care. He found that the factors that are important to individuals in deciding whether to participate in research included effective written communication between them and researchers, personal contact with study investigator, referral by a specialist, and access to free counseling and medical treatment. Monetary incentives, media advertisements, hired patient recruiters and community partnerships, however, were shown to have little to no effect on willingness to participate. Mr. Delgado believes that a comparative study is now warranted in the United States. “My experience has given me tremendous insight into my career path. . . . I learned more this summer than I did in my first year at Columbia, and contributed to my interests in pursuing health disparities research and advocacy in the future. I have decided (to) pursue an M.P.H. between my third and fourth year to develop extra skills in epidemiology and statistics. Without the funding from the Rogers fellowship, none of this would have been possible.”

Drain, Paul Kevin

School of Medicine, University of Washington

Selenium Supplementation and Genital Tract Shedding of HIV-1 Among Women in Kenya

Vitamin deficiencies have been associated with HIV-1 infection, more rapid disease progression and AIDS-related mortality, while micronutrient supplementation has been associated with delayed progression to AIDS and improved survival. Micronutrient supplementation thus could offer a simple and relatively inexpensive strategy to slow HIV-1 progression, either alone or as a complement to antiretroviral therapy. Several studies have suggested that serum selenium is associated with HIV-1 disease status, but this relationship has not been fully characterized. Mr. Drain’s study sought to determine whether serum selenium was independently associated with CD4 cell count or plasma viral load. The study involved a cross-sectional analysis using baseline data from 400 HIV-1 seropositive women of low socioeconomic status who were enrolled in a randomized trial of micronutrient supplementation at Coast Provincial General Hospital in Mombasa, Kenya. Results demonstrate that serum selenium is independently associated with serum albumin but not with CD4 count or plasma viral load, and suggest that decreases in serum selenium among HIV-infected patients may simply reflect decreases in serum albumin that occur in advanced HIV-1 disease. Although serum selenium may not accurately reflect total body selenium status, measurement of serum selenium should be interpreted in the context of the serum albumin concentration. In the absence of an independent association between serum selenium and CD4 count or plasma viral load, it seems unlikely that selenium supplementation would have a substantial impact on HIV-1 disease progression. “My summer research experience in Kenya has had a very positive effect on shaping my future medical career in public health and international health, “writes Mr. Drain. “It has encouraged me to continue exploring international health opportunities. At this early stage in my medical training, I am interested in pursuing a career in international health that allows me to practice medicine and conduct research of public health importance. My experience in Kenya further strengthened those goals.”

Goldberg, Joshua Benjamin

Albert Einstein College of Medicine

Factors Contributing to Breast Cancer Treatment Adherence: Socio-Economic Status versus Race/Ethnicity

Lack of adherence to cancer treatment regimens has long been recognized by the medical community as a major problem but, surprisingly, there has been little research into the barriers that patients experience. While many cancer treatments have been shown to improve patients’ prognosis and quality of life, patients continually fail to complete their treatment regimen. One of the major demographic variables that has been shown to influence adherence among cancer patients is race and ethnicity. However, the recent literature has indicated that associating adherence with race/ethnicity is an inaccurate conclusion. Rather, it has been proposed that disparities in adherence are largely a function of patients’ socioeconomic status with race/ethnicity playing a secondary role. Mr. Goldberg’s Rogers Fellowship enabled him to participate in a major study focusing on the relative influence of socioeconomic status versus race/ethnicity in contributing to patients’ adherence. He joined the research team in the early stages of the project and had an active role in the design and early implementation of this ongoing study focusing on African-American women and Caucasian women who are recently diagnosed with breast cancer. “In addition to learning about the various psychosocial parameters, constructing questionnaires and interviews, I gained valuable experience in the intricacies of organizing a multi-center research project. . . . Through the numerous meetings and communications with administrators, physicians, nurses, and social workers I was able to gain insight into the particular needs and desires of each group with regard to research and learn how to get all to work as a team. Prior to this Fellowship I was naïve to this aspect of research and assumed that the development of a hypothesis, appropriate measures and subjects were the primary focus of research. This lesson will prove valuable not only in my future research, but in my clinical practice as well.”

Goodrich, Suzanne Porter

Indiana University School of Medicine

SHARE: A Study of HIV/AIDS Related Education

In 2002 the World Health Organization reported that more than 42 million people worldwide were infected with HIV and that 3.1 million people had died of AIDS that year. The needed response to such a health crisis should address the contributing social, political, economic and health factors. The instruction given during the training of physicians related to HIV/AIDS must be comprehensive and effective and fully enable them to treat their own patients and to contribute meaningfully to local and global efforts to control the HIV pandemic. In her Rogers Fellowship, Ms. Goodrich conducted a research project that looked specifically at the HIV/AIDS curricula presented to students in the basic science and clinical years at two medical schools—in Indiana and in Kenya. She found that the role HIV/AIDS plays in the curricula of the two schools is quite different. In Africa, the study of HIV/AIDS takes a predominant role, especially in the clinical years, due to its prevalence. In Indiana, the role of HIV/AIDS instruction is well defined in the basic science years, but due to low disease prevalence it has a proportionately small role in the clinical years. Ms. Goodrich is continuing to work with her Kenyan colleague and counterpart, a fifth year medical student, to complete the review of transcripts from all the interviews and focus groups that were conducted at both universities and to finish identifying the unifying themes, with the intention of submitting her research to a journal after its completion, as a great amount of interest was generated among the faculty and administration at both schools during the interviewing process and many requests to review the results of the research have been received. “The award has generously allowed me to pursue an aspect of one of my greatest areas of interest in healthcare. . . . My project has not only given me insight into two different curricula related to HIV/AIDS, but I have [also] gained a better understanding of how curricula is planned, organized and delivered at the medical school level. I believe as physicians that we must constantly work to improve our work through both novel research and critical assessment of our practices. I am grateful for the opportunity so early in my medical career to contribute to the knowledge we have about best practices in medicine.”

Huang, Angela Chia-Mei

Brody School of Medicine at East Carolina University

An Investigation of Caregiver Stress in Parents of Severely Emotional Disturbed Children Enrolled in a Public Residential Treatment Program Using Participatory Action Research

Family involvement has been regarded as an integral component of the care of children with serious emotional problems. In the course of her Rogers Fellowship, Ms. Huang worked at Eastern Area Residential Treatment Home (EARTH), a five-day residential treatment facility in eastern North Carolina for children ages 5-12 with severe emotional and behavioral problems. She attended individual, group and family therapy sessions to learn about the ways in which family involvement is integrated into care. To integrate the role of family members as evaluators and researchers, she conducted research with caregivers of children at EARTH using Photovoice, a participatory action research method involving photographs and discussion, to specifically evaluate the stressors and strengths facing these families. The stressors she identified were mainly within the individual or intrapersonal level and included family, grandparents’ raising children after having raised their own children, and concerns by the caregivers about their own health. Some strengths identified included: self-defined “comforts,” support from family and friends, and the joy derived from the children themselves. The project succeeded in empowering these families to be active partners in research: the families decided as a result of their participation to revive parent group meetings at EARTH to increase social support and to provide information for new families enrolling children to increase awareness of the importance of stressors and strengths. Writes Ms. Huang: “My summer experience allowed me to see the side of medicine that, as physicians, we may never have time to see . . . it challenged my immediate notions of childhood, families, and the way people live. It taught me not to assume anything. Children with behavioral and emotional disability look like any other children, but they are distinctly different. They act differently, have different needs, and must be treated differently. Families were not composed of a traditional mother and a father unit, but of grandparents, single mothers, aunts and uncles, and family networks. This experience showed me how to focus on a family’s strengths and not to be distracted by weaknesses even in the worst circumstances. In some families, it was difficult to find the strengths, but working with these children and especially these families, inspired me.”

Kalil, Dominique

University of Texas Health Science Center at San Antonio

Food, Culture and Genetics: A Study of Adolescent Obesity in San Antonio, Texas

An estimated 58 million American adults qualify today as either overweight or obese, and diet and sedentary lifestyles contribute to 300,000 preventable deaths each year. Obesity is now also a pediatric illness of epidemic proportions, as an estimated three-quarters of children born to obese parents will be overweight. Pediatric obese patients also appear to have reduced immune function, suggesting that obesity makes the body susceptible to a host of illnesses against which it would usually be able to defend itself, and in the last two decades hospital costs associated with obesity diagnosis among youths aged 6 to 17 have risen from $35 million to $127 million. Obesity is especially prevalent in San Antonio, Texas—recently crowned “America’s fattest city.” While national figures put overweight or obese adults at about 30 percent, 61 percent of Texas adults today are overweight or obese. In her Rogers Fellowship, Ms. Khalil sought to understand why this is so by evaluating the health implications of pediatric obesity and the Texas state government response. Obese children typically come from lower socioeconomic backgrounds, but in San Antonio very little research has been done within the Hispanic community. Numerous studies have shown however that black and white obese teenagers responded differently to the same treatment. Thus, the most inappropriate treatment would account for ethnic and racial differences. School based programs have the potential to be most effective in educating and treating adolescent obesity, and in many cases have lived up to that potential. In 2001 the Texas Medical Association lobbied for legislation that increased physical activity for school aged children, but as an unfunded mandate without enforceable punishment, schools have failed to follow its guidelines. “Fighting obesity is going to take years,” writes Ms. Khalil, “and to most of the physicians I consulted, will be a problem for decades to come. There are neither quick fixes nor sure solutions, but essentially more funding needs to be directed towards pharmacotherapy and higher taxes imposed on fatty, densely caloric food. Those most vulnerable to obesity need to be targeted by public health campaigns and healthy eating needs to become as common place as safe sex.”

Liu, Constance Wei-fang

Case Western Reserve University

Food Environment Described by Measures of Healthy Food Selection

A 1997 USDA literature review concluded that low-income households spend less money in supermarkets as opposed to other types of food markets and are less likely to be located in suburban locations where prices are typically lower. Thus, those low-income households that are severely limited by the type and availability of stores are faced as well with significantly higher food costs. Quality furthermore tends to be lower for lower-income households. Ms. Liu’s research served as a pilot project to examine the food environment in Cleveland, Ohio using a developed measure of healthy food selection. Although several recent studies have examined the interaction between environment and people’s relative health, her research filled a void in the literature regarding the relationship between people and their food environment. The aim of the study was to describe the food environment and its association with Cleveland’s neighborhood characteristics. In addition to describing the prevalence of food stores, she sought to find a measure describing the relative healthiness of the selection of foods available. In designing her study, she determined that the amount of shelf space devoted to fruits and vegetables would serve as an indicator of the relative healthiness of food environment, as prior research shows that food disparities are most evident in the consumption of fresh fruits and vegetables. Ms. Liu found that large, national chain stores had more than three times as much shelf space devoted to fruits and vegetables as independent stores, and her work will serve as a useful exploratory study that will inform a larger study of the food environment of Cleveland, and for future expansion of research inquiry to include examination of how people interact with their environment. “Through this experience, I came to understand Cleveland in pursuing this relatively unexplored area of research. I have learned not only valuable statistical tools and techniques but also the difficulties of managing even a relatively small database. I believe that it is by understanding the relationship of people to their environment that I can best serve the community, and that as a physician I can come to identify the important research questions and, as a future researcher, answer those questions.”

Loiselle, Christopher R.

Johns Hopkins School of Medicine

Psychological Determinants of Tuberculosis Susceptibility

Tuberculosis is a disease that causes 3 million deaths per year worldwide. While it is uncommon in the developed world, it remains a problem in countries of the developing world like Peru, where incidence is similar to levels in Europe and North America in the 19^th century: 200-400 cases per 100,000 people. TB is currently one of the most frequent infectious causes of death worldwide and both TB prevalence and mortality are increasing in most countries. While TB is a disease of great world significance, contributing psychosocial factors are far less well understood than psychological associations to disease in the western world, like that of the evidence linking stress with major diseases like cardiovascular disease and cancer. For his Fellowship, Mr. Loiselle worked with the non-governmental organization Asociación Benéfica Prisma in Lima, Peru to characterize stress, depression, and anxiety in a shantytown population, and to begin to examine whether these psychosocial characteristics are determinants of TB susceptibility. The aim of his study was to identify psychosocial symptoms that may be risk factors for TB infection. Knowing whether factors such as stress, depression, and anxiety play a role in developing symptomatic TB infection may contribute to a novel strategy for identifying individuals at the greatest risk for developing TB, who may then receive screening and preventative interventions. This study documented considerable prevalence of stress, depression, and anxiety among TB patients and their household contacts, with significantly higher rates of depression among women than men. How to help individuals with depression is a key question that needs to be answered before longitudinal studies can continue. Individuals suffering from depression in this community may be receptive to group interpersonal psychotherapy for depression. Psychiatrists collaborating with the study in Peru are visiting with TB patients and their household contacts who have high scores in depression scales in their homes for a formal psychiatric interview, education about depression, and an explanation about realistic treatment options; however, more sustainable, community oriented and long term interactions are necessary to truly improve the situation.

Moon, Byung Joon

New York Medical College

AIDS Prevention Program Proposal: Assessment of Clinical and Cultural Boundaries in AIDS/HIV Treatment and Prevention in South Korea

Mr. Moon’s project investigated aspects of cultural and socio-economic conditions unique to Korea that appear to serve as obstacles in preventing AIDS/HIV infection. The goal of his study was to clarify and describe which of these obstacles seem most to impede HIV prevention there and his theory was that South Korea’s relatively conservative cultural atmosphere serves as a major deterring factor. In carrying out his research, Mr. Moon worked in a hospital with the guidance of his mentor. He designed and conducted patient interviews, made outpatient clinic visits and talked to residents, and observed any biomedical research that was being done on AIDS/HIV. Other sources of information for his research were the Internet, and visits to support centers for HIV/AIDS patients. He also conducted research into South Korea’s national formal education system and its policy on sex education. He discovered that among the general public, most people professed little knowledge about the disease. The vast majority associated it with sexual promiscuity and unorthodox approaches to sex in general. Some expressed the belief that the disease is a punishment based on religious beliefs—chiefly Buddhism, Christianity and Catholicism. Most people felt that western influence infiltrating Korea brought about these diseases, and some held the advancing influence of Japanese culture responsible. Writes Mr. Moon: “This eye-opening experience made me realize how one disease in one unique socio-economic and cultural setting can differ to another. Spending time in Korea doing research on this topic made me realize that its leaders need to address this issue and that more resources should be put into education, awareness and prevention, and establishing more support networks so that AIDS patients may receive the guidance that they need and seek.”

Scott, Randolph D.

Brody School of Medicine at East Carolina University

JEWEL: Juniors Educated With an Empowering Lifestyle

Data published in 2001 by the North Carolina Department of Health and Human Services states that North Carolinian minority males are ten times more likely to die from AIDS than white males, and that minority females are thirty-six times more likely to die from AIDS than white females. The conception and implementation of Mr. Scott’s research project, Juniors Educated With an Empowering Lifestyle (JEWEL), were inspired by the fact that fully 96 percent of adolescent HIV transmissions are due to sexual activity and intravenous drug use; by the prevalence and incidence of HIV in the African American community; and by his desire to become proactive in helping educate at-risk young people in North Carolina about HIV transmission and prevention. He designed JEWEL to be a comprehensive summer program incorporating HIV education, participant volunteer activities and participant presentations. Through “Act SMART,” an American Red Cross curriculum that assists teens in resisting premature sexual activity, he taught his students how to handle peer pressure. A community service activity at the Pitt County AIDS Service Organization enabled his students to apply classroom learning to real life outcomes. Participant presentations were based upon information gathered in books, in journals and on the Internet. Writes Mr. Scott: “I am inspired to be more persistent and diligent in my pursuit of becoming a physician who is involved in the community. Due to the lessons I have learned, I will reach back to help those who are having difficulty helping themselves. . . .I can’t say it enough: thank you for this opportunity.”

Shirk, Arianna McLain

Wake Forest University School of Medicine: Bowman Gray Campus

Attitudes and Training of Healthcare Providers in Relation to Screening to Identify Women Who Have Experienced Intimate Partner Violence

An estimated three million women suffer injury as a result of intimate partner violence each year. Healthcare workers are uniquely positioned to slow the cycle of abuse before it reaches life threatening extremes through consistent screening and educated intervention. Ms. Shirk’s study sought to identify behaviors and attitudes of healthcare workers in North Carolina about screening for intimate partner violence—and was unique in its attempt to acquire information about the attitudes and behaviors of the entire primary care healthcare workforce in a restricted area. A survey questionnaire was developed and utilized and from the results, several observations were made about the attitudes and behaviors of Forsyth County healthcare workers. In regard to universal screening, the study revealed two statistically significant differences in attitudes of healthcare workers, but their practices in the event of a positive screening varied significantly in nine of twelve of the behaviors addressed in the survey. The most important variable was their day-to-day comfort level and confidence in their training. In previous studies, gender had been noted as a significant factor affecting universal screening practices and general attitudes and behaviors in regard to intimate partner violence. However, the current study showed no significance differences in male and female attitudes. Some results were similar to those reported by other studies, but others may indicate changing trends in healthcare workers’ approach to women in their practices. Hopefully, the results of this study and others like it will lead to more geographically specific interventions to more effectively intervene. Writes Ms. Shirk: “Practically, I learned the steps that are necessary to prepare for publishing a coherent, relevant and understandable paper. I learned the basics of medical research and gained skills that I will use repeatedly in the future. On a more personal level . . . I learned that my awareness and understanding of patients could be as impacted by my training as by my personal beliefs. As far as future endeavors, I want to continue research in the field of intimate partner violence and women’s health. . . . Hopefully, my initial endeavor into academic and social medicine will lead to a more in-depth expansion of these social truths I have begun to explore.”

Shue, Peter Lee

New York University School of Medicine

Prevalence of GBV-C Viremia in the HIV-Infected Pediatric Population of New York City and It's Association in Improving Mortality

The GB Virus type C (GBV-C) is a positive single-strand RNA virus that has been classified as a member of the flaviridae family. GBV-C and hepatitis G virus (HGV) are two variant strains of the same virus. Recent studies on GBV-C co-infection in HIV infected adults have suggested a beneficial interaction between the two viruses. These studies have demonstrated that GBV-C viremia is associated with lower HIV viral loads and higher CD4 counts, and slowing progression toward AIDS. This has important implications in the clinical and therapeutic management of HIV as the prevalence of GBV-C viremia is relatively high (17–41 percent) among HIV patients, given that the mode of transmission is similar. Despite the seroprevalence studies in adults and the promising data on GBV-C as a possible therapeutic agent against HIV, there is a lack of data on the prevalence or effect of GBV-C infection in HIV-infected children. Given that GBV-C infection is high among HIV infected mothers and that vertical transmission rate is high, a high prevalence of GBV-C infection can be expected in HIV infected children. In his study, Mr. Shue investigated the prevalence of GBV-C infection in a cohort of 103 HIV-infected children and 88 children who seroreverted to HIV, and the differences in GBV-C viral load among mothers and infants and whether vertical transmission of GBV-C is correlated with maternal viral load at time of delivery. The study demonstrated that 33 percent of children born to GBV-C mothers acquired the infection. Previous epidemiological studies have suggested that mothers having higher GBV-C titers were more likely to transmit to their infants. Mr. Shue’s study did not find this correlation between maternal GBV-C viral load and rate of vertical transmission. This discrepancy may be due to the difference in study population since mothers in his study were co-infected with HIV. There may be an unidentified interaction between the two viruses that can affect vertical transmission of GBV-C. Writes Mr. Shue: “Not only did I learn a great deal about the pathology of HIV [through my fellowship], but I also learned more about its effects on society. I gained a greater understanding to the many hardships that HIV has placed on the pediatric population, especially those in underserved communities. With this understanding, I hope to better serve the community through education and prevention when I begin my practice. I truly thank The New York Academy of Medicine for sponsoring this incredible fellowship and giving students like myself an opportunity to explore medicine.”

Spector, Andrew Robert

University of Michigan

Assisting Alcoholics in their Quest to Quit Smoking

Mr. Spector’s fellowship entailed designing and administering a smoking cessation program focused on members of the homeless population, chosen because of the obvious benefits to them as well as for the fact that the costliness of participation in smoking cessation therapy precludes their taking advantage of it. Mr. Spector’s study design called for research subjects to take part in nine cognitive-behavioral therapy sessions administered by trained medical students between their first and second years of medical school. Writes Mr. Spector: “The experience of designing a study from the bottom up has taught me a great deal about the research process, but I consider the two most important things I will take from this summer to be my training in cognitive-behavioral therapy with the accompanying insight into the psyche of an addict. The training program allowed me to observe each of these programs and integrate myself into the therapy sessions. I received hands-on training in cognitive-behavioral therapy while simultaneously interacting with the patients to learn their perspectives on the treatments. The most salient observation I made is that medical students are severely underprepared to serve (the homeless) population. Aside from what I learned from [my mentor] academically, I also gained career perspective. . . . I realize [now] it was premature to direct my education toward exclusively clinical goals. Through this experience, my eyes have been opened to the plight of addicts, the field of addiction psychiatry and the blending of research and clinical careers. I have also learned more about cognitive-behavioral therapy than I imagine could ever be possible in medical school.”

Turek, Eva Margo

College of Physicians and Surgeons, Columbia University

HIV-Positive Pregnant Women at CEMI and Adherence to HAART

In 1986, in response to the realization that many HIV infected pregnant women were neither screened for the virus during their visits to their physicians nor monitored post-partum, Dr. Carmen Zorrilla founded the Maternal-Infant Studies Center (with the Spanish acronym of CEMI) in Puerto Rico. By providing education, psychological support, and counseling to HIV-positive pregnant women in addition to antiretroviral therapy, CEMI has been extremely successful in preventing mother-to-child transmission of the virus. The perinatal HIV transmission rate for the pregnant women receiving care at CEMI has been zero since September 1996. A more recent article awaiting publication reports on the good adherence rates reported by CEMI’s pregnant women as compared to the non-pregnant cohort receiving HAART (Highly Active Anti-Retroviral Therapy) —92 percent vs. 70 percent. Ms. Turek devoted her Rogers Fellowship to a more in-depth exploration of the factors related to good adherence, and discovered that the adherence rate among non-pregnant HIV positive participants was 90 percent—a significant increase from previously cited figures. In her study, she interviewed a group of women attending CEMI. Of thirty non-pregnant women, twenty-seven demonstrated complete adherence to their medications. In an effort to understand why the participants in this survey take their medications (or what would serve as motivation for improvement in adherence), Ms. Turek asked them to rank their main motivators. Nearly 58 percent claimed internal motivation such as the desire to prolong one’s life, to maintain one’s health and to feel better in comparison to 42 percent who claimed external motivation such as one’s children, one’s partner, one’s family or the desire to reduce HIV transmission to one’s future baby. This Ms. Turek characterizes as the most interesting finding from her small sample—the seeming relationship between motivation and viral suppression. Her data suggests some connection does exist between viral load (the measure of the outcome of adherence) and motivational factors. “A finding such as this generates new questions and opens new doors for future exploration,” writes Ms. Turek. “I feel both personally and professionally satisfied with my experience in Puerto Rico. I gained a better understanding of the values of doing research in a clinical setting. Another important lesson I learned from this experience is the importance of adherence and the many different ways in which it can be measured. . . . I will forever be sensitive to the issues that (affect) the women at CEMI . . . the realities I faced this summer are empowering because I now have an understanding of treatment that I can take with me in my future as a physician.”

###