Aging with HIV: Challenges, Research, and Future Directions in Global Health with Theresia Ambrose Ottaru, MD, PhD

• Ottaru is a physician and epidemiologist at Muhimbili University for Health and Allied Sciences in Tanzania and a rising star in global health research. Her passion for medicine was sparked by witnessing repeated illness in her community without proper measures taken for treatment.
• Ottaru studied epidemiology at the University of Antwerp to better understand disease prevention and received training under the mentorship of  Claudia Hawkins, MD, Director of the Center for Global Communicable and Emerging Infectious Diseases at the Robert J. Havey, MD Institute for Global Health and Lisa Hirshhorn, MD, Director of the  Ryan Family Center for Global Primary Care at the Havey Institute. 
• While Tanzania has made significant progress in the HIV epidemic, challenges persist among adolescent girls and young women, with lower adherence to treatment. There are also emerging challenges as people with HIV live longer. She discusses the increasing prevalence of comorbidities such as hypertension, diabetes, and cardiovascular disease among the aging HIV population. 
• Her research focuses on HIV and aging, she says there is a need for interventions to address health risks this population may face that were previously neglected in HIV care
• She shares her experience in the NIH Fogarty Research Capacity Building Grant program, her work with the Global Health Research Catalyzer Award from the Havey Institute, and the creation of an aging cohort in Tanzania to study the intersection of HIV and comorbidities. Through her research, Dr. Ottaru is aiming to improve the healthcare infrastructure in Tanzania to ensure that aging individuals living with HIV receive comprehensive care that addresses both their HIV needs and age-related health concerns.
• Ottaru’s future plans involve running an HIV and aging cohort with 400+ participants and exploring interventions for cardiovascular care in HIV clinics. She hopes her research findings will influence Tanzanian health policy and programs.

[00:00:00] Dr. Robert Murphy: Welcome to the Explore Global Health Podcast. I'm Dr. Rob Murphy, Executive Director of the Havey Institute for Global Health here at Northwestern University Feinberg School of Medicine.

[00:00:20] Dr. Robert Murphy: Today's guest, Dr. Theresia Ambrose Ottaru, is a rising star in global health and epidemiology. She is a physician and epidemiologist at Muhimbili University for Health and Allied Sciences in Dar es Salaam, Tanzania, where she recently earned her Ph. D. She is also a Havey Institute for Global Health trainee, working closely with our center directors, Dr. Lisa Hirshhorn and Claudia Hawkins, on patient centered outcomes research, studying the health and patient well being among those with HIV in Tanzania. Employing implementation science concepts to improve care and delivery and health outcomes. We welcome her to the show today to talk about her career journey in global health and how her training has prepared her to lead independent research in her home country. Welcome, Theresia.

[00:01:08] Dr. Theresia Ambrose Ottaru: Thank you so much for having me.

[00:01:09] Dr. Robert Murphy: Let's get to know you a little bit, Theresia. You earned your M. D. from Muhabbali University for Health and Allied Sciences in 2013. Tell me about your desire to become a physician. Was there something in your childhood or upbringing that made you want to go into medicine?

[00:01:25] Dr. Theresia Ambrose Ottaru: From growing up in a community where you have a number of people getting sick over and over again and you wish you can do something to help, and I think that's what drive my desire to do medicine because I believe that I could be helpful to that community, not only to my family, but to the community.

[00:01:47] Dr. Robert Murphy: Were there any other doctors in your family?

[00:01:50] Dr. Theresia Ambrose Ottaru: My mother was a nurse, She practiced for some time, but I also had aunts who were nurses,So I grew up with a sister. We are three years apart, she went to medicine before me and she's actually practicing as a pediatrician right now.

[00:02:08] Dr. Robert Murphy: You got a master's degree from the University of Antwerp Can you tell us how you ended up there and how that experience was?

[00:02:15] Dr. Theresia Ambrose Ottaru: After I joined the medical program, I realized that same patients are coming back to the clinic over and over again with conditions that could actually be prevented by simply employing preventive measures, so a simple talk with the patient could prevent the next visit. I realized that public health is equally important. And to understand public health and to study public health, you need to understand the research methods and such concepts and epidemiology. And that's what drives me to epidemiology.

[00:02:57] Dr. Robert Murphy: At what point in your career did you know you wanted to be a physician scientist? And work on research as well as patient care?

[00:03:04] Dr. Theresia Ambrose Ottaru: I think it was in my fourth year of medical school and we did a certain program. It's a module within the medical degree called community health. You get to be exposed to the community and yeah, that's where you really get to understand that first, it's a fraction of people who get to the hospital. So there are still a lot of sick people in the community, and maybe they just don't know how to get to the hospital. 

[00:03:33] Dr. Robert Murphy: Can you tell me a little bit about the HIV epidemic in Tanzania? I understand great strides have been made toward controlling the epidemic in recent years, but there is still much work to be done.

[00:03:44] Dr. Theresia Ambrose Ottaru: Yes, Yes, but I can say the HIV program in Tanzania is one of the programs that has been very successful. But we have specific groups which are still struggling with. So, we have about 1.7 million people living with HIV in this region. Among these, about 87 percent are on ART at the moment and they're being followed up. So that's based on the local data, but according to the UNAIDS data, we have reached the 90 90 goal, but yes, the local data says 97. Maybe if we use the international data, we could say that Tanzania has achieved the third 90, that is 90 percent of the people living with HIV are on treatment. However, we are struggling with specific groups. So for example, the adolescent girls and young women. With this group we have a bigger portion that is still not on ART or they're still not doing their routine visits to the clinic. And it's because of several challenges. So first is the age group itself, but some it's about the parents. So we're still struggling with that population.

[00:04:52] Dr. Robert Murphy: Has the program changed at all in Tanzania because of the changes that are occurring or have occurred already in the USAID funding mechanism. I know many countries have lost a lot of support. Is that the same in Tanzania now? Can you tell us?

[00:05:09] Dr. Theresia Ambrose Ottaru: Yes it's the same. There are a lot of non governmental organizations which are supported by and they had to shut down their program completely,But we have another big program, partly supported by USAID. This program is partially still functioning, but it's partially. It's a struggle to the HIV program and if it continues like this, it's yeah, I don't know what will happen, but, yeah, it's

[00:05:37] Dr. Robert Murphy: Yeah, I don't think anybody knows what's going to happen really in the long term, except it doesn't look very good. Let's move to another area here, a little bit closer to what we're doing at the Havey Institute. As HIV treatment and access to care improves, the affected population's life expectancy grows. With these improvements come new challenges, including increasing rates of age related comorbidity like cardiovascular disease and related disorders such as hypertension, stroke, heart and kidney failure. This is something you are studying. What have you found out about the cardiovascular health of this aging population?

[00:06:14] Dr. Theresia Ambrose Ottaru: So what we found from our study is that we need to pay attention to this group. We need to pay attention to people who are aging with HIV infection. But what we lack at the moment is the comparison with the people who are aging without HIV infection. So what we know, the burden of cardiovascular diseases, risk factors, so especially hypertension. 54 percent of people who are 50 years and older living with HIV are hypertensive. The majority do not know that they are hypertensive. We have people who came for the study visits with blood pressures of over 200. And they came to the clinic, they don't have any symptoms. They were able to come to that visit, but it's when you take their blood pressure, that's when you know their blood pressure is high. It's extremely high, they are also not aware of that. Their kidney functioning is declining, so when you look at people who are 50 years and older, they have, from what we found, the prevalence of, for example, renal insufficiency, is seven times higher in that population compared to those who are 50 years and younger. So it's a population that we really need to find strategies to, especially to maintain the success of the HIV program. So they have been able to live up to that age. We have participants who have lived with HIV infection for more than 30 years and unfortunately now they end up dying from complications of hypertension and diabetes and so on. Now that they are living longer, we really need to shift our focus. They are adhering to their treatment, they are doing well with their ARTs, but what about other comorbidities which put them at a very high risk of mortality?

[00:08:04] Dr. Robert Murphy: How do these overlapping health burdens like hypertension, cardiovascular disease, the things you just mentioned, how does it impact HIV treatment adherence and overall quality of life for your patients?

[00:08:16] Dr. Robert Murphy: Oh, yeah. So that's a very good question. So for people, at least for those who are part of our study, they are struggling with maintaining treatment for multiple conditions that they have. So you might find that one has hypertension, diabetes, in addition to HIV. So they find it very difficult to attend to all these clinics, but what we found from our study is that they prioritize HIV care from all other conditions that they have. And this could be one because HIV care is free, so they receive free medications. but it's also because they fear HIV related complications compared to complications related to hypertension. They have seen before complications of HIV. So before this, some were diagnosed late so they were very sick when they were diagnosed. So they know what HIV could do to them. Unfortunately, they don't know what hypertension or diabetes could do to them. Because yeah, hypertension is a silent killer. They have not experienced the complications of hypertension. So until when they start to develop complications related to hypertension and diabetes, And when that now starts affecting their quality of life now, that's when it becomes a problem. Participants that we have who already have complications of hypertension and diabetes, in addition to HIV, their quality of life is really poor. We did qualitative interviews with such groups, and you can see they are very depressed, very concerned about their lives, very concerned about what will happen as they're getting older. If you listen to their stories you realize that they need an intervention that looks at all the comorbidities that they have, because when they start to cause complications, they really affect their quality of life. And when they start causing complications. It's too late. And before they cause complications, they are not aware of their disease. So they don't know if they are hypertensive or not. It's until when they get complications. So we really need to develop interventions that look at these multimorbidities before they start causing complications . After that we are late and they really affect the quality of life. 

[00:10:44] Dr. Robert Murphy: Part of your doctoral training, you worked on an NIH Fogarty Research Capacity Building Grant with Northwestern Doctors Claudia Hawkins and Lisa Hirshhorn. Can you tell me about this experience and what was your research project in that grant?

[00:10:59] Dr. Theresia Ambrose Ottaru: This training opportunity really transformed me in terms of my research capacity, research skills. So over the four years I've been mentored by mentors who really showed me what mentorship means. So in this part of the world, I mean, in Tanzania, the way I was mentored before was different. I experienced a different kind of mentorship that has transformed me significantly. So I would say I'm a very different person from when I joined a program to when I finished the program, I have transformed completely. I have changed the way I look at things, the way I interpret things, the way I discuss findings, the way I look at research, the way I look at the impact of research. Over the four years, a lot has changed in terms of my research skills and my research capacity. So my project was on cardiovascular health among people who are living with HIV. And at that moment, during that training, I was looking at people who are living with HIV who are just 18 years and older. And within this population, we found that we have almost 50 percent of the population who have poor cardiovascular health. And again, older people living with HIV have had a higher risk for poor cardiovascular health. I also looked at cardiovascular disease risk factors. So I looked at hypertension, I looked at diabetes, I looked at renal insufficiency. And in all these risk factors, older people had a higher risk compared to younger people. I also looked at their experiences with care for cardiovascular diseases, risk factors for hypertension and diabetes. I focused on those two. And then again, I found that people who are older have much worse experiences, more challenges when accessing care for multiple comorbidities. So now I have shifted my research focus into HIV and aging, where I focus on people who are 50 years and older.

[00:13:06] Dr. Robert Murphy: You also received a Global Health Research Catalyzer Award from Northwestern's Havey Institute along with Claudia Hawkins. The title of that was examining the prevalence of cardiovascular disease risk factors and the cascade of cardiovascular disease care among Tanzanians living with HIV. How did you and Claudia end up working together on this project, and what was your experience with that whole catalyzer award program?

[00:13:33] Dr. Theresia Ambrose Ottaru: Catalyzer award was like a stepping stone towards my PhD research work. So with that catalyzer, I was able to build a cross sectional cohort of 629 people living with HIV who are 18 years and older and all my PhD work is based on that cohort and was a great opportunity to receive that award. Because I was able to collect a lot of data and then publish a number of papers from that cohort. My other trainees in the program are also able to use the same data to also write the research work. Some of them are under review in the peer review journals. So the Catalyzer really helped me to start my PhD work. Claudia Hawkins is the PI in the D43 training program. And I happened to be the first PhD trainee to join the program. So we were discussing on how I'm going to start my PhD work and what do I want to do and she mentioned that I could apply for a Catalyzer and I could start my initial work using the research project with the Catalyzer funds and yeah, we moved from there.

[00:14:47] Dr. Robert Murphy: What are your plans for the future? You now have your PhD. You're the first author on a number of publications. What's next for Theresia?

[00:14:55] Dr. Theresia Ambrose Ottaru: Yeah, I'm very excited for the future. We have just built up our HIV and aging cohorts. We have 400 participants who are 50 years and older in this population and we have done a number of assessments. So both on medical comorbidities and also on geriatric morbidity is something that is very new in Tanzania. And we really look forward into publishing our results and disseminate our findings. What we really want to do with this cohort is to show the HIV program that you're doing well, but in the very near future, you're going to face a number of challenges because of these other comorbidities that for a while have been neglected at the HIV clinic. I am happy that some of my PhD work was used to inform some of the strategies that are now going on at the HIV clinics here in Tanzania. So they, now pay more attention to hypertension, not on diabetes and other cardiovascular disease risk factors. Some of the clinics pay attention to creatinine and we have good examples from a HIV and aging cohort where participants have very high levels of creatinine. And from our study, they were called back and they where further assessed or sent to a specialized clinic. So yeah, I'm so happy we have that HIV and aging cohort. And I'm hoping that can inform the HIV program on how to now manage these people who are now aging with HIV infection. But on the other side, physicians on this side now ask people living with HIV, yes, they are aging. This is the minority of the population that is aging in general in Tanzania. And challenges with access to care for multiple comorbidities, they are not only affecting people who are living with HIV, it's also about people who are aging without HIV infection because it's a health system problem. So now we want to build the aging cohort for people who are HIV free. Just to compare the burden of these comorbidities, we understand from previous studies, it's clear that people who are living with HIV have higher burden of these comorbidities. But we want to build a case for Tanzania. We have these two populations with and without HIV. Both of these populations are aging. But look at this population is aging poorly compared to this other group, which is HIV free. So we want to build that case. But on top of that, we want to build a case that we have people who are at a higher risk or have a higher burden. And these people come to the HIV clinic. Some still come every month, some still come three months, there are some who come six months. It's an opportunity to do something for them. to make people who are aging in the general population visit the clinic, that might be difficult, but we have people who are already coming to the clinic and this is an opportunity to offer interventions to reduce the burden of these comorbidities related to aging. So that's another case that we want to build from this cohort. And again, after that, we want to also look at simple interventions that we can introduce at the CTC. So now we are looking into R21 that could support assessments of cardiovascular diseases. So a simple ECG or a simple ACO at the CTC because we have 54 percent of people who are aging with HIV infection who are hypertensive and we want to see if this hypertension is already causing changes or is already causing some of the cardiovascular diseases. That's another step that we are looking into. The aging cohort at Northwestern, they're doing a number of assessments and we also want to see maybe in the future if we could also introduce such assessments to this cohort. They are all related to aging, but we want to filter and find those which would really help to improve the health of this population. So things like AI- ECHO, AI- ECG, first because we have health practitioners maybe who do not have the necessary training to do the ECHO. So with AI, we can simply get the results interpreted at least initially. And they would see that if they need to really refer that patient to a cardiologist. So there are a number of things that I am looking forward to. And hopefully we are going to be able to do that. But again, with what is happening at the moment, at NIH, you can't tell what will happen. But yeah, there are a lot of plans. I have also applied for a K 43. And this K43 is on a geriatric screening program where we want to assess whether people who are aging with HIV infection at the HIV clinic, do they want to be assessed for these aging related comorbidities, are the providers willing to provide such services, and whether we can or we cannot introduce such services at the HIV clinic. So there are, first a number of challenges and then there is a lot of research work that needs to be done to inform strategies to reduce these challenges, especially for people who are aging with HIV infection.

[00:20:29] Dr. Robert Murphy: Well, it sounds like you've put together an incredible cohort that is going to answer many, many questions in this very important field as people with HIV get older and older. Now I have one last question for you that I ask everyone that comes on this podcast. What advice do you have for young people who are just now embarking or wanting to embark on a career in global health?

[00:20:51] Dr. Theresia Ambrose Ottaru: So I once listened to a presentation and I would say an early career researcher was asked this question, What would you advise new researchers or young researchers? And what he said is that “Listen to your mentors." As a new or young researcher, you might think that, you know, I want to do this and I want to do that and I want to do, but it's for sure you need some guidance. For young researchers, you need guidance. You need to find proper guidance, you need to find proper mentorship, and if you find one, maintain it, make sure you 100 percent make use of it, and yeah, I think that's what I would say.

[00:21:36] Dr. Robert Murphy: Well, that's a great answer, Dr. Theresia Ambrose Ottaru. Thank you very much for joining us today and good luck. Good luck with your cohort. Good luck with your career. Good luck with getting your Career Development Award, the K43 you mentioned. I wish you the best.

[00:21:51] Dr. Theresia Ambrose Ottaru: Thank you so much, Rob. Thank you for having me.

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