• Dr A Bashir

07 The Kaida Path: Part I

Our latest episode features Dr Angela Kaida, an Associate Professor in the Faculty of Health Sciences and Canada Research Chair in Global Perspectives in HIV and Sexual and Reproductive Health at Simon Fraser University. In a special two-part series, Part I details Dr Kaida's academic and professional journey to present day, where we also discuss her current research interests. Part II, to be released in about four-week's time, will delve into her life outside of work and the cultural nuances of having lived in both Canada and South Africa with her young family.


You'll find the audio version of this episode, titled 'The Kaida Path: Part I', on our website, Apple Podcasts, Soundcloud, and more.


The transcript of our conversation has been prepared for accessibility purposes, with minor edits for clarity and brevity.


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Dr Asma Bashir: Hello world, and welcome to Her Royal Science. Thanks so much for tuning in. Today, we'll be talking to Dr Angela Kaida, an Associate Professor and Canada Research Chair at Simon Fraser University studying the links between HIV and sexual/reproductive health. She completed her PhD in the School of Population and Public Health at the University of British Columbia and subsequently completed a post-doctoral fellowship at the Women's Health Research Institute at UBC. Her work spans multiple continents, and she actively works with community leaders and decision makers to integrate valuable research into sexual and reproductive health policy. In our recent conversation, we spoke about your path to associate professorship and the beautiful way in which you came into academia, but let's start from the very beginning⁠—what's your story?


Dr Angela Kaida: So, what's my story? I mean, I would say I didn't come into academia through a direct pathway. I was always interested in health and I was always interested in science and research, but I didn't know that the discipline of public health research or epidemiology was a field of study. I kind of stumbled my way towards it if I can describe it that way, and really found that in the research process, it was an area that I could contribute to as a scientist, but also as somebody who was very interested in social justice and very interested in equity. I just found that it was an area of research that allowed me, or sort of encouraged us, to be both. I found that to be very motivating, of course.


I guess my story... It's kind of a big question, but I suppose I'd say that I started my undergraduate training in biology at the University of Waterloo in Ontario, and I think, like a lot of people maybe, sort of wound a pathway around whether I wanted to do medicine, physiotherapy, or optometry. Those were the disciplines that I had come in contact with as a girl kind of growing up. Those disciplines that you may not encounter as readily don't become as obvious to you as a career pathway in many ways, and then [I] sort of found that that was not really my strength or my interest in many ways.


I loved biology. I did not love working in a research lab with rats,dissection, and all of that stuff. It just wasn't my... I wasn't very good at it, I would probably say, and I wasn't that interested in it. I guess I was a teenager when a lot of the HIV crisis really started to explode in Eastern and Southern Africa in particular. I know it was happening in North America as well, but in my own family life it was happening, and I was starting to experience these circumstances where people in my own family became affected or infected with HIV, watching how a close, tight-knit, supportive, extended family reacted to that news. [I] was sad and confused about how illness could intersect with so many social issues—whether it's gender, power, class, race, religion—and intersect with that to create conditions where we weren't really thinking about the infectious agent or the pathogen of HIV. We were thinking about all of the other implications of stigma or, you know, being a good person, or et cetera.


AB: Yeah. At that point, the interest then was not to treat people with HIV and AIDS. It was to understand the nuances of having HIV and AIDS. Because you did have a background in biology or an interest in it, why wasn't [treatment] the default?


AK: Yeah, I mean, it's interesting because when treatment first became available here in 1996—the results of the first treatment trials were announced here in Vancouver—it was a very exciting time, but most of my experience with HIV was before that. It was in the early 1990s—before there was treatment in Eastern and Southern Africa—before there was really any hope of treatment. And of course, it was another 8-10 years before treatment really became accessible, because for some who had the means, treatment became available, but really not accessible to most people. So, my interest in treatment was of course present, and I continue to be interested in treatment around who has access, who doesn't have access, who can be supported to maintain successful treatment, but my own training was less in the pharmacology side of things, [it was] about, 'Okay, how are we gonna figure out what is the appropriate treatment?' and more about the social and structural factors that are going to create circumstances for access to treatment. I was very interested in the lives of people who were affected and infected with HIV, and that was probably [because of my] personal journey.


AB: I can imagine. What were some of the things that you realized about those dynamics? What are some of the statistics that we might not know about, about how gender, social class, and economic status affects HIV and AIDS? I mean, there are some obvious ideas. The less money you have, the less access you have.


AK: Yeah.


AB: But what are some of those other nuances?


AK: I mean, I guess particularly for my work, gender and sex cannot be separated from understanding how HIV has affected particular populations, so a lot of people don't think of HIV as an infection affecting women, but actually there are more women living with HIV around the world than men. And in particular contexts, the difference is massive. 60+ % of people living with HIV in Sub-Saharan Africa are women relative to men, and that plays out in a number of settings around the world. Here in Canada, it's about a quarter of all people living with HIV are women, and I think that gets overlooked a great deal as we conceptualize HIV. Part of what that has led to is that if we don't think about women when we think about HIV, then we don't think about the factors that are very relevant to women's lives, for instance, conversations about pregnancy and family building.


Particularly in early days, the guidelines around pregnancy for women living with HIV were highly dissuasive. We've got stories of women undergoing forced sterilization because of the infection and [there was] so much concern about transmission to infants, which of course I understand the concern about perinatal transmission, but I also first and foremost believe in women's reproductive rights. So, I think when we don't think about women and HIV, we don't think about how women should be supported to achieve their reproductive goals while living with HIV. How can we minimize risk, but maximize her reproductive rights at the same time? Of course, these issues extend to HIV prevention mechanisms; we focus so heavily on condom use, and we want to pretend that how people make decisions about their sexual lives and condom use is free of any power, free of any other forms of negotiation.


AB: Yeah, that's not the case.


AK: We know individually and structurally, that's not the case, so very heavy emphasis on condom promotion without accounting for those dynamics and sexual relationships, those dynamics and sexual power inequities is incomplete. There are a lot of biological reasons at play as well. The risk of transmitting HIV from a male partner to a female partner through vaginal sex is two times higher than it is in reverse, and that risk gets exacerbated when we talk about younger women who may have immature genital tracts; the risk can be quite a bit higher in those circumstances. Of course there's infections, bacterial vaginosis, untreated STIs, that subsequently increase risk from male partners to female partners of acquiring HIV. So, we have these conditions where biological factors, genetic factors, social factors, structural factors all create an environment of HIV risk and consequence, that when we don't think about HIV among women, [it] gets really under-addressed.


This is intersectional work and intersectional thinking, so it's not just about male, female, cisgender woman, or transgender women. There are numerous layers of social factors and identities that intersect here, and fundamentally looking at the differences of sex and gender is one of the motivators for me as I started my own academic research career.


AB: Were there any hurdles to that? Because I know that that's a topic [within] neuroscientific research; predominantly research is done in males. Beyond just male exploration in human beings, it's also male mice and a lot of the times—


AK: Oh, interesting!


AB: —male rats. In fact, I believe the stats currently are 5.5:1 in terms of male to female studies, so it's absolutely ridiculous. Now, there's a push—because we do get a lot of public funding—to obviously explore the female aspects as well. Is there any hurdle in the field that you're in right now to do that? Is there a, 'We don't need to study this,' or are people realizing the importance?


AK: I mean, I'm hope... I'm an optimistic person by nature, so I think that the change is coming. It doesn't happen on its own. It happens because of advocacy and because of several scientists and advocates demonstrating through their research, through their work, how critical this gap is and how by failing to consider sex and gender, our science is weaker for it—


AB: Absolutely.


AK: —and the application of our science is weaker for it. CIHR, as a tri-council agency, has made some moves in that direction to ensure that, as we apply for research funding, we are considering sex and gender within our research approaches. It's a slow process, you know? One webinar is not gonna get us there, but I think as a collective research community, eyes open to the damage that can be done and the opportunity lost.


I know that a lot of the women living with HIV that I work with here in BC, one of the ways they really bring this inequity to light is when they talk about side effects of antiretroviral therapies in their lives—and I'm not an expert on pharmacology and these sorts of things—but when they talk about the side effects of ARTs on their lives, they talk very eloquently and really beautifully about how the dosing of ARTs that they receive is really very similar, whether you're a very small woman or you're a big man and you metabolize drugs more quickly, et cetera. They talk about a whole bunch of different side effects, perhaps that are not life threatening, but certainly affect quality of life and probably affect adherence and all of these other aspects of their lives.


AB: Yeah.


AK: And it's difficult when women are not sufficiently enrolled in clinical trials to be able to capture the consequences or the implications of these types of side effects. We see in clinical HIV trials globally that women are certainly not enrolled in those trials in nearly the proportionate numbers [to] which there are women living with HIV globally. And so, again, that science has consequences for patient lives, for our understanding of the science, for our understanding of hormonal interactions, and there's some really exciting science happening out there about those pathways but, you know, we've got some way to go.


AB: Yeah. But we have made a lot of progress, it seems! Are you ever discouraged by the way things go, or do you feel your progress that you're making is steady but profound?


AK: I mean, yeah, for sure. It is discouraging to see. There was recent study about pre-exposure prophylaxis (PrEP), which is a ARV-formulation that a person who is HIV-negative takes to prevent them from acquiring HIV infection upon exposure. PrEP is really an exciting HIV prevention tool that can offer options to people from who condoms have not been desirable or difficult to use, et cetera. The trial sort of concluded, 'Oh, we only included men in this trial, so we're not sure what the consequences, what the results would look like for women.'


You see that type of science and you think, 'Well, who designed the study? Who designs the study and at what point does that become just unacceptable science?' We know quite a bit about PrEP use in men actually, and we don't know very much about PrEP use in women. Again, as I was sort of outlining who is globally affected by HIV, it's slightly more women than men, so issues of class, privilege, and race come into those to dynamics without question. And I think there's some other structural reasons. One observation that I've had conducting research with women living with HIV here in Canada is that there's less cohesion. There's far fewer women organizations that support women living with HIV, or ways for them to come together. So, thinking a bit cynically, if you wanted to recruit women living with HIV, it would be just a little bit harder to know where to go to find them in some ways, whereas I think for many —not all—but many men living with HIV, there are those types of organizations and groups, so it might be a bit easier to connect in with them.


AB: But science isn't supposed to necessarily be easy!


AK: Exactly! If we know that that's the case, then we need to be funded differently to do the groundwork necessary to bring women into these trials. Of course, it's discouraging to see research like that, and it's discouraging to still continue to see women underrepresented in clinical trials globally, at the same time still trying to be involved in the community groundwork that needs to be done to try to change that.


AB: Is this work similar to what you did when you were a graduate student?


AK: When I was a graduate student, I was working with women living with HIV [and] also those not living with HIV. I was less involved in what I would call 'community-engaged research' than I am now. My work during my PhD was based in South Africa, in Soweto, and it was around the time that I was starting to think about my PhD. Access to antiretroviral therapy in South Africa was starting to really increase. And I mean, South Africa has a very sorted history about acknowledging HIV and providing treatment to its citizens. Around the time that I was starting, that work was also starting to happen, and I had really thought that, 'Oh my gosh, this could really be very transformative to women's sexual and reproductive health,' and I had done some work to sort of anticipate the directions through which those effects might happen.


People are—I've kind of learned over time—worried about HIV in so far as it affects the public, as it affects transmission to other people, and in my experience a bit less worried about the life and experiences of the people who are already living with HIV.


AB: Mm. <affirmative>


AK: I think my PhD work brought that to light for me in many ways. People were worried at the time that once there was widespread access to antiretroviral therapy, people were gonna get on therapy and they could live longer, so they could have all kinds of sex and be transmitting HIV and be having all these babies⁠—


AB: <Laugh> Was that really the thought process?


AK: Yeah, and you can hear it even today. You can hear that kind of rhetoric today. It can be easy to buy into it if you're worried, if you think about public health⁠—which I am a public health research, so I do think about public health⁠—and this kind of conceptualization of women living with HIV as either victims, or vectors, or virgins, and there's this sort of social, I don't know, stigmata about how we think about it.


AB: Yeah.


AK: My research in Soweto really opened up to me about [how] women living with HIV are like women everywhere.


AB: Yeah!


AK: I mean, it seems so trite in some ways, but really many women want to have children and build families, and they want those children to be healthy and they want themselves to be healthy so that they can raise these children and be there for them. And so, what were we doing that was not supporting that and what could we do that would go a much longer way towards supporting that?


AB: What role did your supervisor play in that story for you?


AK: That's such a good question. So, my supervisor was not interested in my specific topic, which if handled properly⁠—which I think he really did—can be a blessing in a way, in that he thought that my research topic was interesting and he thought that it was important, but it wasn't his area of research. He really encouraged me, like, 'Okay, well, if that's what you're going to pursue, you better find other senior researchers that are also interested in this topic, and really do some of your own really outreach.' He was wonderful in kind of making the connections for me with pretty high-level researchers at the time. You know, when you're a graduate student, meeting big shots is so intimidating! <Laugh>


AB: It is! <Laugh> Does it ever get better?


AK: I don't know yet! I'll let you know! I'll let you know if I ever reach that platform, <chuckle> but no, it doesn't because you just value their work so much, and in so many ways you're so deeply connected to it. And yet they're a total stranger to you, so it's a bit of an awkward relationship.


AB: I don't know of any other situation that resembles that relationship! <Laugh>


AK: I think you're right! You know, it's like, 'I've read every single thing you've written!' Yeah, it's awkward, but my supervisor really tried to make those connections for me. Of course, you have to sort of take it from there and you make it what you can. He certainly did that for me and, I think, created opportunities for me, if I can describe it that way.


When you don't know much about being an academic⁠—which I did not know⁠—you need somebody who tells you that actually applying for grants early in your graduate training is a really good way to set yourself up for success. I mean, maybe everybody knows that, but for people who come into academia through different pathways, it's not always obvious. [He was] making sure that I knew about opportunities that a graduate student could apply to, or making sure I knew about opportunities that I could apply to with his name, but my ideas, and figuring out ways to get credit for that; that kind of thing, or what it is that publishing can do for you during your graduate training. In that way, I would say he provided excellent mentorship in the ways of academia, and then created opportunities for me to meet with other researchers that were more interested and invested in the types of questions that I was pursuing. There was a bit of a, I guess, separation of roles where I think a lot of supervisors are supposed to provide both of those roles. In my case, they were separated and⁠—


AB: It worked out, it seems!


AK: Yeah, it worked. I really wanted to answer the questions that I was asking, if that makes sense.


AB: It does. Absolutely.


AK: I was very motivated to kind of do what I could do to make that happen. And he certainly did not stand in my way.


AB: At this point, you're kind of making your way up the ladder of academia. Once you got past your PhD, was there ever an option other than academia for you?


AK: For sure! <Laugh>


AB: Yeah? <Laugh>


AK: For sure! It would be good to see some research on this. I don't know if everybody kinda comes to the end of their PhD and they think like, 'I am gonna pursue an academic tenure-track position,' or 'I'm not' or, you know, throw the cards in the air, [and] see where they might may land.


AB: I have no idea what the stats are at all! <Chuckle>


AK: Yeah, and I think if you've come in, like I said, as a person interested in research, but not that clever <chuckle> or strategic I guess, I don't know how it plays out. Certainly, the way my path had worked is I did my undergraduate and did my Master's very soon after; if it wasn't the next year, [it] was pretty soon. Did my Master's, had a great research experience, and had started to do some global [work]. I do love global work, primarily with Eastern and Southern African stakeholders. And then came to the realization that it was pretty⁠... I don't know... maybe a bit negligent of me to be talking about global public health without having some foundation in how this works in Canada. How do we do public health research in Canada? How do we do public health practice programming here? How do we make decisions? How do we prioritize? What's the data that's available to us here? What’s not available? You know, those sorts of questions.


I started to work as a public health practitioner for several years at a very regional [level]; I was living in Edmonton, [working] at a regional health authority at the provincial health level. And that was great experience for me reorienting to like, 'Okay, how do these processes work? How [can I] be invested in the public health issues in my own community?' When I left that work to come back to do a PhD, I felt like I had a good window into what a career pathway might be if I turned to doing public health practice in the Canadian context. That was exciting, and I liked that. I thought that was really exciting and important work. And so, I certainly was thinking about those pathways throughout.


AB: Could you describe a little bit of the work that you actually do on ground in Eastern and Southern Africa?


AK: Yeah, I would love to! I guess my research program has evolved so that I've primarily work in Uganda, in Mbarara.


AB: I know, which is where my dad was born; Hey Baba!


AK: <Laugh> And I got connected with that work through one of these colleagues that my supervisor had put me in touch with. It was a research collaboration based in Boston, at the Harvard/MGH (Massachusetts General Hospital) Center for Global Health. They were building quite a massive research program in collaboration with MUST, the university in Mbarara, and I was fortunate enough to get involved in that work and really pursue questions about sexual and reproductive health. There were numerous investigators interested in lots of stuff⁠—resistance, antiretroviral adherence, cardiovascular disease and other comorbidities, aging, lots of different things.


So, they were building a very⁠—you know, Americans do things big in my experience⁠⁠—big collaboration across many departments and [with researchers ar] the Faculty of Medicine at MUST, and I got funding from the National Institutes of Health pretty early on to really do an add-on study, I would say. They were following people who were initiating antiretroviral therapy and following them over time, and the driving questions was around adherence, because at the time a lot of questions⁠—pretty racist questions, honestly⁠—were floating around about whether people in rural Uganda could take antiretroviral therapy, adhere to it, avoid resistance and all of this kind of stuff. That was one of their primary research questions.


AB: Yeah.


AK: I came in and I added a research question around, 'Okay, what was happening with sexual and reproductive health? What were our patterns of pregnancy incidents? Were people who were starting ARV therapy also getting access to other forms of healthcare?' A criticism of HIV programming has been, you come in and you provide all of these resources for HIV, but there's nothing else. There's no contraception. There's minimal maternal infant care, et cetera. So, what was happening on these other front? And one of the interesting findings that we started to see in that work was that a lot of people living with HIV reported that they did have fertility intentions, and we did start to see that as they had access to treatment, those attentions sort of become renewed. You're healthier. You feel better, you can have sex. There's all of these things that start to change. But the other thing that started to happen alongside of that is because they were receiving care every three months for HIV, they were just in more contact with the healthcare system, so it had other benefits in terms of if somebody was there to talk to them or provide information about family planning, they could start to be a bit more connected to care in ways that were wonderful, important⁠—


AB: and overlooked!


AK: Exactly. So, our work in that space has started to grow into what we call 'Safer Conception', and essentially it's the idea that if one person's living with HIV and the partner is negative, in order to conceive, most people have to have condomless sex. There's other ways, but most people have to have condomless sex, and that would introduce a risk of transmission from the positive partner to the uninfected partner. But if you could support people to be enrolled in care and there were a lot of strategies available to virtually eliminate that risk, they could conceive, carry pregnancy to term, and not risk transmission, but you had to have a conversation about it. A lot of our work was about, 'Okay, let's talk to providers. What are they offering their patients in this way? Let's talk to people living with HIV. What are their concerns about accessing this type of information and their experiences, et cetera?'


Now we have... we still call it a pilot clinic, but it's been running for a couple years now, the Safer Conception Clinic at the HIV Care Center, where if people are in these circumstances and they want information, support counseling, or care about pregnancy, they can come and receive no judgment, no stigma, reproductive rights-grounded type of care. Our research sort of is built on the information that we're collecting from that setting.


And one of the ways⁠—it's a bit surprising for me⁠—that's transformed in this research is that I focus so heavily on women, and our work there has really led us to also focus on men! <Laugh>


AB: But of course! <Laugh>


AK: But of course! But heterosexual men living with HIV are a group that really also doesn't get a lot of attention, particularly in the realm of sexual and reproductive health, and we're starting to see trends⁠—more in South Africa than in Uganda⁠—where as women get more connected to HIV care and treatment, it's having HIV prevention benefits for men. It benefits their male partners. But if men are not enrolling in care and getting on treatment, they're still not offering this HIV prevention benefit to women. I mean, I care about men also, <chuckle> but it's not the only reason. Obviously, these gender dynamics matter in multiple directions, so some of my work there has really started to move into talking about the sexual and reproductive health needs of men living with HIV, so that's been exciting.


AB: I know! It's multidimensional now. It's not just this maybe underprivileged or under-catered group. It perforates and it touches so many aspects of society, right?


AK: Exactly! And at the end of the day, all of this work still exists within micro-level relationships through to macro-level forces. We can't disassociate those. All of those contextual factors matter, so that's really how our research program sort of builds and grows in that.


AB: I do have a slightly tangential question, though it is relevant. How do you build trust with a population of people that have some level of mistrust with the medical care system? In some cases, the savior complex is incorporated into the medical profession, where people come in from other countries and they try to help or try to treat you or your children or your family members [and] sometimes bad things happen, and that makes people very hesitant to go to the doctor.


AK: Yeah.


AB: If they're not feeling well, how do you make sure that they trust you with their bodies, with their feelings, with their stories? That's also very important.


AK: Yeah. I mean, it's such a beautifully phrased question, and it's pervasive in global health research, not just clinical care. As researchers, we have to be really reflexive on that point. I mean, I think there's no easy way for me to answer this question and I would say it's an ongoing practice. It's not like, 'Oh, we've achieved trust!' <Chuckle>


AB: <Laugh>


AK: 'Badge today!' You know, it's an ongoing process and it's active work. A lot of that for me has been partnerships with leaders at MUST and really trying to find a balance between what's an interesting research question and what's needed. Sometimes, as you well know, they're not the same. Really trying to be mindful, reflective, and iterative in our discussions about, 'This is what we're focused on. Is this really what the primary need is or interest is? Are we doing this in the best way? Are there other people that we need to bring in?'


There's a lot being written right now about huge power inequities among researchers on global health research teams, let alone between the researchers and the participants, which is a whole other domain. Those are complicated issues, and bringing sort of neo-colonial approaches to global health research needs to be really scrutinized, and we all need to be thinking about that and work actively working against it. So, as I said, I don't have an easy answer. I just know it's practice, it's daily kind of work, and I hope that our colleagues think that we are working in that way, but I can't guarantee it, that's for sure.


AB: Is it a conversation that does come up within the group before you make your way to Eastern and Southern Africa, before you leave Canada? Is it a conversation that happens on ground here?


AK: With anybody who's newly joining our group, absolutely.


AB: Good.


AK: I've been working with my colleagues in Uganda for, like, 13 years or something like that, so there's a relationship there. We've been building a relationship over time and with a lot of different people. Same with South Africa, probably about the same amount of time. But anybody new, any trainees that come through, that's critical.


I teach a course, a field course in Durban, and it's done in partnership between the Faculty of Health Sciences at SFU and the Africa Health Research Institute in Durban.Half of the students who come to the course are from Eastern and Southern African universities that are connected to this network, and then the other half are primarily from SFU⁠—a couple from UBC, but are primarily from SFU. One of the things that I just think about all the time and try to work on is around how do you prepare students to learn reflective processes about power, inequity, privilege, social identity, and social location? Our MPH program in the Faculty of Health Sciences does really invest a lot in that aspect of our work, so the students do get quite a bit of training. But I mean, like everything, it's probably not enough, and there's work to be done without question.


AB: Yeah, but it's a work in progress. Any work that is being done is a good and commendable thing. Hearing that does make me quite excited. I obviously have a personal attachment to Uganda, and I know a lot of people, of course, go there and want to do good work, but because of its colonial history and⁠—like you said⁠—those power dynamics that exist, perpetuating it would do more harm than good, without question.


AK: Most definitely.


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AB: Funding for this episode was provided by the Centre for Brain Health and the Graduate Program in Neuroscience at the University of British Columbia. Be sure to tune in for next month's episode, where we continue our conversation with Dr Kaida, delving more into her life alongside her scientific work. As always, peace and blessings.