At first glance, there may appear to be few similarities between Zambia, a landlocked country in southern Africa, and rural Alabama. Apart from the 8,000 miles of land and sea between them, however, the two regions both grapple with longstanding HIV epidemics, widespread poverty, and significant barriers to accessing medical care and public health services. Another similarity is the prevalence of alcohol use disorders, substance use disorders, and mental health conditions, all of which can contribute to the spread of HIV.

A five-year, more than $5.8 million P01 (program project) grant awarded to the UAB Marnix E. Heersink School of Medicine from the NIH National Institute on Alcohol Abuse and Alcoholism is funding an innovative series of projects to address these concerns in both Zambia and rural Alabama. Critically, it adapts interventions and strategies that have been proved in one setting to the other.

Karen Cropsey is the Conatser Turner Endowed Professor of Psychiatry in UAB’s Department of Psychiatry and Behavioral Neurobiology and co-director of the Center for Addiction and Pain Prevention and Intervention at UAB.

“This is tech transfer—we are exchanging the best of our practices,” says Karen Cropsey, Psy.D., Conatser Turner Endowed Professor of Psychiatry in UAB’s Department of Psychiatry and Behavioral Neurobiology and co-director of the Center for Addiction and Pain Prevention and Intervention at UAB. “We are adapting a proven therapy from Zambia to Alabama called the Common Elements Treatment Approach, or CETA, and taking our success with patient-reported outcomes from Alabama to Zambia.”

Cropsey is one of the principal investigators for the overall Zambia Alabama HIV Alcohol Comorbidities Program, known as ZAMBAMA, along with Michael Vinikoor, M.D., associate professor in the UAB Division of Infectious Diseases.

ZAMBAMA contains two separate but related projects. Both rely on the Common Elements Treatment Approach, or CETA, a proven, peer-led program of cognitive behavioral therapy originally developed at Johns Hopkins University. CETA combines elements common to effective treatments for problems such as depression and trauma into a single treatment model that can be delivered by trained laypeople. CETA has demonstrated effectiveness in countries from Iraq and Thailand to Zambia, Ethiopia and Myanmar.

“Most therapies are single-diagnosis-focused—just substance use, just depression, etc.,” Vinikoor says. “Therefore, having a single treatment model that caters to a range of symptoms and complex cases reduces the costs of training and time and the need to refer patients to specialty care.”

The project also expands a longstanding collaboration between UAB and the Centre for Infectious Disease Research in Zambia, a Zambian non-governmental institution with an operating budget of more than $40 million per year. Three UAB Heersink School of Medicine faculty are embedded full-time with CIDRZ, including Vinikoor, Carolyn Bolton Moore, MBBS, associate professor of Medicine, and Albert Manasyan, M.D., assistant professor of Pediatrics.

“The collaboration puts UAB experts on the ground in Zambia to strengthen research and public health capacity and address major global health challenges,” Vinikoor says. “Such collaborations are what make UAB a leading U.S. university in global health. In addition to ZAMBAMA, the UAB-CIDRZ team is implementing research focused on a range of conditions, including COVID-19, HIV prevention, maternal and newborn health, cervical cancer, and viral hepatitis. The collaboration also creates opportunities for UAB students and trainees interested in international health to travel to Zambia for a rotations, internships, etc.”

For the ZAMBAMA project, CIDRZ researchers, including social scientist Anjali Sharma, Ph.D., biostatistician Samuel Bosomprah, Ph.D., and infectious diseases expert Izukanji Sikazwe, MBChB, will share with UAB their expertise in integration of CETA into the HIV health system, Vinikoor says.

This will not be the first time that public health lessons learned in sub-Saharan Africa will be translated back to Alabama, Vinikoor adds. In the Finding Respect and Ending Stigma around HIV, or FRESH, study, Janet Turan, Ph.D., professor in the Department of Health Behavior, and Scott Batey, Ph.D., associate professor in the Department of Sociology, implemented a program to reduce HIV stigma among health workers in Alabama that was adapted from Turan’s earlier research in Kenya. “UAB’s global health work impacts not only populations in low- and middle-income countries, but also communities back home in Alabama,” Vinikoor says.

Alcohol consumption is rising in sub-Saharan Africa and, especially since the beginning of the COVID pandemic, in rural Alabama, the researchers point out. And unhealthy alcohol use is often complicated by comorbid mental illness and/or other substance use, they say. 
Rural Alabama and Zambia grapple with many of the same health challenges, making effective solutions transferable between the two.

What is the link between alcohol use and HIV? Research has demonstrated that alcohol use disorders (and mental health problems) contribute to risky behaviors that may expose a person to becoming infected with HIV. In those living with HIV, drinking is associated with delays in learning one’s status through HIV testing, lower engagement in care and treatment, and lower adherence to lifesaving antiretroviral medications. As measured by blood tests, people with unhealthy alcohol use also are less likely to have achieved viral suppression, which makes them more likely to transmit the virus to others. Finally, some data suggest that people with HIV may be more sensitive to the effects of alcohol than those without it.

The Zambia-based project, with Vinikoor as MPI together with Jeremy Kane, Ph.D., from Columbia University, will evaluate the effectiveness, including cost-effectiveness, of implementing CETA and another alcohol-reduction intervention known as a brief alcohol intervention.

It also will utilize patient-reported outcomes, or PROs, in Zambian clinics, learning from UAB’s expertise. PROs, implemented as quick surveys of patients during each clinic visit, have been used successfully at UAB’s 1917 HIV/AIDS Clinic for several years to identify patients with unmet mental health or substance-use concerns. “The patients answer questions about depression, alcohol use, medication adherence, and more,” Cropsey says.

The Alabama project will use telemedicine to implement CETA in rural Ryan White HIV clinics across the state. “This is what we call ‘reverse innovation,’ taking a success from low-resource settings in a developing country and figuring out what lessons we can apply here in Alabama,” says Ellen Eaton, M.D., assistant professor in the UAB Division of Infectious Diseases. Eaton is MPI for the Alabama project, as is Cropsey.

There is a nationwide shortage of clinical psychologists, Cropsey points out, so approaches such as CETA have great promise. For the Alabama project, the intervention will be delivered remotely from Birmingham using clinical psychology graduate students from the UAB College of Arts and Sciences. “Using telemedicine makes this more translatable to a wider variety of settings,” Cropsey says. – Matt Windsor