Fellowship Site: Peru-Lima-UWash

In Peru, the HIV/AIDS epidemic revolves around core groups of men who have sex with men (MSM) and female sex workers (FSW). The HIV-1 seroprevalence in Lima is approximately 20% in MSM and between 1 and 5% in FSW. This contrasts with rates in the general population of 0.5% among pregnant women. The dynamics of the HIV epidemic in Peru highlight the importance of targeting core groups who are often marginalized and not readily accessible using standard public health measures with interventions to promote HIV testing and prevent transmission. Prostitution in Peru, although not legal, is permitted, and requires periodic STD examination at a Public Health Clinic. Both FSW and MSM are eligible to receive health care at these clinics. With the arrival of the Global Fund in Peru, all HIV-infected people are eligible to receive HAART therapy without charge. University of Washington collaborative research efforts in Peru target FSW and MSM populations and design and conduct interventions aimed at preventing and treating HIV and STD infections in core groups as well as in adolescents and in the general population. Current funded projects include epidemiology and neurologic manifestations of retroviral (HIV, HTLV-1 and 2) infections in high-risk populations (FSW, MSM) and indigenous groups, HPV acquisition in FSW, operational research regarding HIV and TB coinfections, tropical infections of the central nervous system, and cerebrovascular disease.

Research Opportunities:

The strength of our training program is patient-oriented clinical research. Although we collaborate with reference laboratories, none of our Scholars or Fellows (hereafter referred to as “trainee”) have conducted bench research as their major research project. We form mentoring teams for each trainee that includes U.S. and Peruvian researchers who complement the trainee’s area of interest. Over the past 20 years, 60 Peruvians have received their MPH or PhD at the UW – and all currently work in Peru in universities, Ministry of Health offices or non-governmental organizations – providing an extensive network of potential collaborators. Although the majority of our collaborators are based in Lima, we also have ongoing projects with collaborators in Iquitos, Tumbes, Trujillo, Pucallpa, Arequipa and Cusco. While the majority of our Peruvian collaborators work in the fields of retroviral or sexually transmitted infections (STI), we are able to tailor mentoring needs to accommodate any healthcare subspecialty interest. Research projects of prior trainees vary from assessing factors associated with HPV acquisition in female sex workers (FSW), indigenous women and men who have sex with men (MSM); to developing a student-run program for teaching middle school children in a pueblo joven to provide peer education about reproductive and sexual health via radio; to determining the prevalence and risk factors for peripheral neuropathy in people coinfected with HIV and HTLV retroviruses; to determining risk factors for MDR-TB and IRIS in children.

All of our projects are collaborative efforts with Peruvian Universities (Universidad Peruana Cayetano Heredia/UPCH and Universidad Nacional Mayor de San Marcos/UNMSM), non-governmental organizations in Lima (INMENSA) and Iquitos (www.selvaamazonica.org) and Ministry of Health National HIV and TB strategy offices. NIH-funded collaborative research programs provide additional opportunities to observe large-scale clinical trials but often provide only limited opportunities for trainees hoping to develop independent research projects.

These programs include:

HIV Vaccine Trials Unit (HVTU): established in 2000 as a site in collaboration with UW HVTN Director, Dr. Julie McElrath. The goal is to develop a safe HIV vaccine and conduct Phase I, II, and III trials.

HIV Prevention Trials Unit (HPTU): This site was established in Lima in collaboration with UW HPTN Director, Dr. Connie Celum. Over 1,500 MSM in Peru participate in HIV prevention trials, including Phase I-II microbicide trials and a randomized trial of acyclovir suppressive therapy of HSV in at risk men.

International Adult AIDS Clinical Trials Group (AACTU): Lima, as well as five cities outside Lima (Iquitos, Arequipa, Sullana, Pucallpa, and Ica) were developed into sites for international clinical trials sites for UW ACTU studies. These trials assess the safety and efficacy of treatment regimens in HIV-infected people living in Peru.

In addition to collaborative studies of HIV, potential NIH-funded clinical research projects at the UW Peru site are available in the areas of meningitis (CNS Infections) HTLV-1, HTLV-2 and HPV (HPV) infections, in adult or pediatric populations and operational research in HIV and TB infections (ICOHRTA-AIDS/TB)

Future trainees may choose to work in clinical research involving HIV, other retroviruses, STD, or infections of the nervous system; U.S. and Peruvian mentors will work with each trainee to develop a research and training plan tailored to her or his research goals. Such a plan will likely entail performing clinical work in Lima and possibly other Peruvian cities, developing a clinical research protocol and human subjects application, and writing manuscripts. A mentoring team comprised of Peruvian and U.S. physicians with established clinical research will mentor each trainee. Each trainee will be expected to participate in an NIH-sponsored course in Lima regarding responsible conduct of research and good clinical practice. Our hope is that each trainee will return to Peru following completion of the FICRS/F year to continue research initiated.

Potential clinical sites in Peru include public health clinics serving FSW, MSM, and people at high risk for STD, as well as hospitals and reference centers specializing in different areas of health care.

The NIH-funded clinical research includes the following projects:

1. HIV Prevention Trials Unit
2. HIV Vaccine Trials Unit
3. AACTG Lima Unit (Adult AIDS Clinical Trials Group)
4. HPV and HTLV in Female Sex Workers
5. Central Nervous System Infections in Peru
6. Neurologic and Immunologic Manifestations of HTLV-I Infection in Peru
7. Peru ICOHRTA Network for AIDS/TB Research Training

Mentoring: The interests of our prior trainees have been quite varied. We believe a mentoring team provides the most effective form of mentoring. Dr. Silvia Montano (based in Lima) and I provide overall guidance to each trainee, assisting with arranging clinical and research opportunities, developing research protocols and IRB applications and serving as resources for any questions or problems that may arise. After determining research interests, we introduce the trainee to potential mentors at UPCH, UNMSM and INMENSA and at clinical sites. To exemplify how the mentoring team works, the following table is a list of physicians and epidemiologists who have assisted trainees in designing and conducting clinical research projects:

Scholar 1

Scholar 2

Scholar 3

Meetings with PI: At the beginning of the year, I schedule virtual meetings with each trainee on a weekly basis via Skype. These meetings serve to discuss transition to life in Lima, choice of clinical sites for research and training, development of research protocols and IRB applications. As the year progresses and trainees develop relationships with Peruvian colleagues, Skype meetings occur less frequently. I travel to Peru four times per year and meet with each trainee individually while in Lima, and in a group for a social event – including dinner. Dr. Silvia Montano also meets with trainess in Lima on a regular basis. During the first weeks in Lima, Silvia introduces the trainees to site mentors at their assigned institution (UNMSM, UPCH, INMNESA/IMPACTA) as well as potential mentors in their areas of interest. Trainees typically receive mentoring from me, Silvia Montano, the site mentor and 1-2 clinical research mentors at the clinic or hospital where research is performed.

Clinical Research: Over the first three months, each Trainee will be expected to develop a research project in coordination with their primary mentor, Drs. Zunt and Montano. Study proposals will be reviewed by the mentor panel and presented at the quarterly conference in November. The mentor panel will provide assistance regarding protocol design and IRB submission. Additional assistance in biostatistics, epidemiology will be available as needed. Each trainee will be expected to submit a protocol and IRB application during the second half of the year. As IRB approvals are often slow, we encourage trainees to plan to return to Peru following the year. A common concern from trainees at all sites has been slow initiation of research. Given the delays associated with obtaining host country and U.S. IRB approvals, research projects often don’t begin until the later part of the year, or may not begin at all – requiring the trainee to return to the international site or entrust the project to colleagues. We recognize this problem and use two methods to ensure timely initiation of projects:

1. Pre-training discussions: following the March selection meeting, I speak with each trainee to define research interests and start developing a mentoring team and research project.

2. Develop “streams of research” across trainee years: some prior trainees have had interests in similar areas and worked at the same clinical sites. we hope that as each trainee departs, an incoming trainee can continue the research project she/he developed. The benefits of this approach are many: the incoming trainee can immediately participate in a clinical research project, the departing trainee can ensure her/his project continues, and participation in an ongoing project with help the incoming trainee design and implement an independent project later in the year.

Quarterly Conferences: We conduct quarterly “works in progress” conferences for UW and Johns Hopkins trainees. These conferences will provide a forum for each trainee to present and discuss their research with peers and mentors and for development of collegial relationships with other trainees.

LOGISTICS
Principles of HIV and STD:

Following the introductory course at the NIH, trainees fly to Seattle to attend the two-week Principles of HIV and STD Research Course (Principles Course) and one-day operational research course. During these course, trainees will meet with the UW and Peruvian Directors of the Peru Program. After completion of this course, trainees will fly to Peru.

Housing/Meals/Transportation: 

Upon arrival in Peru, each U.S. trainee is met at the airport and brought to a hostel in the middle class neighborhood of Miraflores in Lima. In the past, U.S. trainees have found furnished apartments over the first 1-2 weeks by word-of-mouth, CraigslistPeru, the newspaper or expatriate community websites (http://www.livinginperu.com, http://www.expatperu.com). Some trainees have leased apartments vacated by prior trainees, others have chosen to share an apartment with trainees from the UW or Hopkins programs. Unfortunately, two trainees encountered difficulty with unscrupulous landlords. We now contract with a real estate agent to assist with finding and leasing apartments. Apartment rentals in Lima range from $500-800/month. Travel to clinical or research sites in Lima is typically 20-45 minutes; most trainees use the local buses (“combis”), which cost less than US$1; taxis are also available and typically cost $3-5/trip. Purchase of automobiles is discouraged. Travel within Peru is easily arranged via travel agents or the web (http://www.lan.com/index-es-pe.html)

Health Issues:

See the U.S. Centers for Disease Control website and The Yellow Book: Health Information for International Travel.

The NIH/FICRS program mandates that all Fogarty trainees see a physician prior to their assignment abroad.

Safety Issues: 

Upon arrival, all trainees undergo a safety briefing at the U.S. Embassy to receive information regarding travel and security within Peru. Each trainee will also register with the Embassy and provide contact information in case of emergency. The U.S. Embassy is located in Monterrico, a suburb of Lima, at Avenida Encalada, Block Seventeen; telephone 51-1-434-3000 during business hours (8:00 a.m. to 5:00 p.m.), or 51-1-434-3032 for after-hours emergencies; (http://lima.usembassy.gov). The Embassy website also provides details regarding crime in Peru and anticipated strikes or demonstrations (http://lima.usembassy.gov/warden.html). The majority of crimes against U.S. citizens involve robbery via assault or smashing car windows at traffic lights to grab jewelry, purses, backpacks, or other visible items from a car. This type of assault is particularly common along the main roads leading to Lima's Jorge Chavez International Airport. trainees are encouraged to put all belongings, including purses, in the trunk of a car or taxi and use telephone-dispatched radio taxis or car services when traveling to or from the airport. We recommend trainees live in a middle class neighborhood and avoid taking public transportation at night. The State Department recently launched a website specifically for students traveling abroad; this website also provides multiple different sources of online advice for travel and safety (http://studentsabroad.state.gov).

See the U.S. State Department Web site for information.

Language Requirements Other than English: 

Our program requires a working knowledge of Spanish (conversational level). Although all of the on-site research mentors are bilingual, most of the clinical mentors and nearly all patients speak only Spanish. A conversational level of Spanish will allow the trainee to focus on learning clinical research skills rather than language acquisition. Although we expect each selected applicant to have at least a conversational level of Spanish, we also encourage additional tutoring, language classes or conversation partners once in Lima to further refine language skills. Exception may be made for applicants with a strong skill in other languages, such as Portuguese or French.

What is it like to live in Peru? 

Peru is a country of contrasts: strolling through the center of Lima, evidence of the Spanish conquest remains engrained in balconies and entryways of buildings and churches, while in the district of Miraflores, luxurious high rise condominiums stud the cliffs overlooking the Pacific Ocean; walking along the Avenida Larco, the cosmopolitan atmosphere is permeated with a mixture of the lively South American culture and tropical trees and flowers. Juxtaposed against the antiquity of central Lima, and modernity of Miraflores, are the pueblos jovenes sprawling over the surrounding hills; homes of thatch and corrugated metal, many without electricity or running water, contain the workforce of this city of over 8 million people.

The people of Peru are a mixture of indigenous cultures, and descendents of Spanish, Japanese, and African ancestors. Meals usually include seafood, poultry, pork or beef, served with rice, potatoes, or beans. The food is not spicy, but can be adjusted to a tongue-searing heat by the addition of a scoop or two from the bowl of aji available at all restaurants. The weather varies between a comfortable temperature during the winter months (June-October), when a light jacket is usually required, to a humid, scorching heat during the summer months.

Medical care in Lima varies according to ability to pay; free medical care is available to Peruvians who have seguro social, but the majority of people rely upon the medical care provided at government-subsidized public health clinics, which charge nominal fees for services and prescriptions. Modern diagnostic tools, such as magnetic resonance imaging, are available at private medical clinics, and some hospitals, but the cost of such tools often limits access to wealthy clientele or patients able to raise money through community fund-raising events, such as a pollada, where the patient's family roasts and sells dozens or hundreds of chickens at neighborhood gatherings.