MSH Supports Growing International Acceptance of Option B+, Encourages Country Adoption, Further Research

Drs Scott Kellerman (left) and Erik Schouten at "Prevention of Vertical Transmission and Beyond: How to Identify, Enroll and Retain Children in Treatment Programmes in Resource-Limited Settings?" a satellite session at XIX International AIDS Conference on Sunday, July 22, 2012. (Photo credit: S. Holtz/MSH)

Drs Scott Kellerman (left) and Erik Schouten at “Prevention of Vertical Transmission and Beyond: How to Identify, Enroll and Retain Children in Treatment Programmes in Resource-Limited Settings,” a satellite session at XIX International AIDS Conference on Sunday, July 22, 2012. (Photo credit: S. Holtz/MSH)

Cross-posted on MSH.org

July 31, 2012 – As the international community gathered for the XIX International AIDS Conference last week, HIV & AIDS experts and key organizations voiced their support for a new approach to preventing mother-to-child transmission of HIV: Option B+.

Option B+ calls for antiretroviral therapy (ART) for life for all HIV-positive pregnant women, regardless of CD4 levels.

The government of Malawi, with the support of MSH, adapted the World Health Organization (WHO) guidelines on preventing mother-to-child transmission, to the needs of Malawi. Current WHO guidelines (2010) distinguish between treatment and prevention (known as “prophylaxis”) and rely on accurate CD4 counts to determine ARV regimens.

Unable to quickly and accurately ensure results from CD4 counts on HIV-positive women, and struggling to adjust treatment regimens given the high fertility rates and frequent pregnancies, Malawi elected to combine ART with PMTCT in a new approach they dubbed Option B which offers lifelong treatment to all HIV-positive pregnant women, regardless of their CD4 levels. The Malawi Ministry of Health devised this approach with support of MSH’s Basic Support for Institutionalizing Child Survival (BASICS) program, funded by USAID.

Dr. Erik Schouten of MSH and colleagues described the bold, new approach in a Lancet article in July, 2011. Option B+ puts women and children first, and, as Schouten and colleagues argue, will likely be cost-effective for countries, like Malawi, in the long-term.

In April, 2012, the World Health Organization (WHO) released a programmatic update on “Use of ARVs for Treating Pregnant Women and Preventing HIV Infection in Infants” (PDF). In the executive summary, the WHO said:

Now a new, third option (Option B+) proposes further evolution—not only providing the same triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting but also continuing this therapy for all of these women for life. Important advantages of Option B+ include: further simplification of regimen and service delivery and harmonization with ART programmes, protection against mother-to-child transmission in future pregnancies, a continuing prevention benefit against sexual transmission to serodiscordant partners, and avoiding stopping and starting of ARV drugs. While these benefits need to be evaluated in programme settings, and systems and support requirements need careful consideration, this is an appropriate time for countries to start assessing their situation and experience to make optimal programmatic choices.

Since July, 2011, MSH has helped trained a cadre of 3,366 health workers in Malawi. Within the first year of implementation in Malawi, the number of HIV-positive pregnant women starting ARV treatment has increased six-fold from 1,200 per quarter prior to implementation, to 7,200 in the quarter ending in June 2012. MSH is currently working on a cost-benefit analysis, and is studying the efficacy and challenges of option B+ scale up for preventing vertical transmission in Malawi.

Now others are following Malawi’s lead, particularly in light of Ambassador Eric Goosby’s and UNAIDS’ Michel Sidibe’s call for eliminating pediatric HIV by 2015 (PDF). Earlier this year, Uganda announced its intention to adopt Option B+; UNICEF began a thorough review of the approach; and other countries have expressed a strong interest in moving toward including Option B+ in their strategies for decreasing vertical HIV transmission.

Throughout the XIX International AIDS Conference, researchers and global health leaders touted the benefits of Option B+, and discussed the potential for combining ART and PMTCT in other countries. At a satellite session on Sunday, July 22, leaders from UNICEF, the International AIDS Society (IAS) and MSH discussed Option B+ for preventing vertical transmission. Dr Chewe Luo, Senior Programme Advisor at UNICEF, discussed the topic in depth during her plenary speech on July 25. And in the closing words of the conference, two rapporteurs gave a hat-tip to Option B+, displaying early data from Malawi, provided by Dr Erik Schouten of MSH.

“Option B+ is a game-changer and one of the most exciting developments in decreasing vertical transmission and pediatric HIV in recent years. In short, it calls for treating the mother, preventing vertical transmission to the child, and continuing to treat the mother. It offers the promise of much reduced vertical transmission rates while simultaneously decreasing maternal morbidity and mortality from HIV,” says Dr. Scott Kellerman, MSH’s global technical lead on HIV & AIDS.

MSH is thrilled that the global momentum toward Option B+ is building. Option B+ may not be right for every country or every situation, but in Malawi – and likely in many more countries – Option B+ will prove efficacious and cost-effective in not only protecting babies, but also in treating HIV-positive women. MSH is proud to have been a part of the inception of this idea and looks forward to working with our broad network of HIV & AIDS programs throughout sub-Saharan Africa and the world, using our technical capacity and research ability to investigate the operational issues that need to be addressed and understood for optimal implementation and scale-up of this approach.

Learn more about Option B+:
For additional information or to arrange for a press interview, please contact Barbara Ayotte, Director of Strategic Communications, at 617.852.6011 or bayotte@msh.org.

 

Day 4: Listening, Learning from Marginalized Populations

After 3 days of plenaries — complete w/ scientists & rock stars, challenges & solutions, and a call for focusing on women & girls — Thursday’s plenary focused on some of the most vulnerable & at-risk populations: men who have sex w/ men (MSM), sex workers, injection drug users, and transgenders.

Related Reading: Reaching the Most Vulnerable Populations: A Health and Human Rights Imperative

Reaching the Most Vulnerable Populations: A Health and Human Rights Imperative

Debbie McMillan of Transgender Health Empowerment speaking at the Thursday plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Steve Shapiro - Commercialimage.net

Debbie McMillan of Transgender Health Empowerment speaking at the Thursday plenary. XIX International AIDS Conference (AIDS 2012) Washington DC — as delegates wearing “Statue of Liberty” crowns listen. © IAS/Steve Shapiro – Commercialimage.net

Related Reading: Listening, Learning from Marginalized Populations (via Storify)

After three days of plenaries — complete with scientists and rock stars, challenges and solutions, and a call for focusing on women and girls — the day four plenary focused on some of the most vulnerable, marginalized, and at-risk populations: men who have sex with men (MSM), sex workers, injection drug users, and transgendered people.

Men Who Have Sex with Men

Paul Semugoma of the Global Forum on MSM and HIV opened Thursday’s plenary with the stark facts about men who have sex with men (MSM). Semugoma urged delegates to “move from being friendly to MSM to being competent in getting them care.”

MSM are at particular risk of HIV, sexually-transmitted infections (STI), and high viral load partners. “If you don’t ask about sexual orientation in the examining room, then you don’t know the patient is high risk. Health workers are uniquely placed gate keepers, but when they don’t know about MSM, they are blind.”

Interventions needed to decrease HIV risk in MSM include: behavioral change, pre-exposure prophylaxis, condoms, and antiretroviral therapy (ART). MSM also are affected by criminalization and targeted by stigma.

Semugoma issued an urgent call to action to end invisibility of MSM in the epidemiology, service delivery, and decisionmaking. We must “take our heads out of the sand,” Semugoma implored. “We cannot achieve an AIDS-free generation without MSM. We need to fight stigma, ignorance, and stand in solidarity with colleagues who are beaten or killed for advocating for MSM, such as David Kato in Uganda.”

No drug users? No sex workers? No international AIDS conference

Cheryl Overs at the Thursday plenary, XIX International AIDS Conference (AIDS 2012) Washington, DC. © IAS/Steve Shapiro - Commercialimage.net

Cheryl Overs at the Thursday plenary, XIX International AIDS Conference (AIDS 2012) Washington, DC. © IAS/Steve Shapiro – Commercialimage.net

People distributed green Styrofoam “Statue of Liberty” crowns along with signs stating: “No drug users? No sex workers? No internat’l AIDS conference” as Cheryl Overs of the Global Network of Sex Work Projects, and a researcher from Melbourne, Australia, began speaking.

Drug users and sex workers have been banned from attending the XIX International AIDS conference due to travel restrictions currently in place in the US.

Overs spoke about the social exclusion, rejection, poverty, and lack of information facing sex workers. HIV tests can often lead to criminal prosecution of sex workers and sex workers have less rights and less choice. “The HIV epidemic is being fueled by repression,” said Overs. “The greatest threat to the health and human rights of sex workers is the inability to find a safe place to work.”

She showed a video taken of a “rescue” of sex workers and said these raids ignored the agony and the rights of the sex workers. “We need a law that gets commercial sex out of dangerous places and into safer ones.” She urged sex work to be made legal and called on governments to make the decision to do this — “the decision is free”.

She cited networks of sex workers helping other sex workers. “We need meaningful participation. Sex workers represent ‘real life’ — not epidemiological categories.” She called for a repeal of the PEPFAR Anti-Prostitution Pledge and for a revision to laws so that sex workers could legally enter the US.

Nothing About Us, Without Us

Debbie McMillan, risk counseling specialist at Transgender Health Empowerment, began by showing videotaped remarks from sex workers and injection drug users gathered in Calcutta and Kiev, because they were barred from entering the US to attend the conference. “We are all human beings, we all have rights.” Lifting the travel ban was not an achievement but a mistake that was fixed, she said.

Debbie is a transgender African-American woman who used to be a drug user and sex worker. She is convinced she contracted HIV in prison. She said that she represents people at the “height of the crisis” that should be included in the programs and conferences.

“I went to the street at age 14 and became a commercial sex worker because I thought it was the only place for someone like me. I got high to dull the reality.” She cited clean syringe programs as a key component to fighting HIV.

“My mother was the only person who completely accepted me. She had 1 cup, 1 fork, 1 spoon, 1 plate. At some point she got infected with HIV and died of complications from AIDS. I had to view my mother’s body while in shackles and handcuffs. Two months later, I was diagnosed with HIV at 20 years old.”

There is no bedside manner from health professionals for transgender people, noted McMillan. The Object Bridge LGBT Program for HIV people saved her life.

“I don’t want to be an outsider looking in. I collaborate with my peers in Calcutta and Kiev because they can’t be here. We need to have a conference where all can participate. Nothing about us, without us.”

Going Beyond 15 Million on Treatment by 2015

Gottfried Hirnschall, Director of HIV at the World Health Organization (WHO) in Switzerland, said that getting 15 million on treatment by 2015 was achievable and noted antiretroviral therapy (ART) scale-up successes in Rwanda, Malawi and Cambodia. He also noted that the evidence is now tipping toward earlier initiation of ART and said it has proven cost-effective.

Hirnschall said we need to work now to aaddress gaps for future scale-up, including considering Option B+, “test, treat and retain” method. He also noted the importance of provider initiated testing and counselling.

Reflections on AIDS 2012: Shameza David

Shameza David, AIDS 2012 Poster Presentation. (Photo credit: S. Holtz/MSH)

Shameza David, AIDS 2012 Poster Presentation. (Photo credit: S. Holtz/MSH)

The thrill of having the opportunity to participate in the XIX International AIDS Conference began some months ago. The International AIDS Society accepted an abstract I authored with colleagues for a poster exhibition. This excitement became more real when I learned that I was one of three winners of an MSH internal abstract contest, and would be given the chance to travel to Washington D.C. to attend the conference and present our poster, “Leadership and Management Training increasing male involvement in PMTCT.”

I could barely sleep on Sunday night. I was nervously thinking about presenting the poster at the conference the next day. (I would have been a lot more nervous had it not been for the practice session held by MSH that helped to prepare us for presenting our posters in a clear and concise manner!)

Coming from a small city like Georgetown, Guyana, I could not conceive the magnitude of the conference or the sheer size of the convention center structure.  From the opening day I was blown away by the number of delegates, presenters, exhibitors and speakers from literally all over the world — all involved in some way in the fight against HIV & AIDS — filling the Walter. E. Washington convention center.

I felt privileged to be part of Management Sciences for Health and be surrounded by warm, welcoming supportive colleagues from our global, hardworking family.

The theme of the AIDS 2012 conference, “Turning the Tide,” flowed throughout the week, from the opening plenary to the closing session. I had goose bumps listening to the passion and conviction with which panelists spoke about their personal experiences and struggles they fought and overcame in the pursuit of reducing the incidence and impact of HIV on lives and livelihoods. These plenary sessions were rich in content, and highlighted studies and interventions, and generated new perspectives that could enhance our existing programs at home to create stronger impact. For example, two plenary sessions on preventing HIV among commercial sex workers highlighted a key group that we’ve missed during our intervention: the regular clients of sex workers. The speakers underscored how initiating behavior change interventions with regular partners could make it easier for commercial sex workers to negotiate condom use in their regular relationships.

Being part of the MSH booth was an excellent way to get a picture of the diversity of people attending the conference. Interacting with those who stopped by revealed delegates from an array of organizations and groups: clinical, behavioral, social, academic, faith-based, and community-based, among many others. It was heartening to find that many people knew of our organization and took an interest in one or more of our several programs. Also, visiting the booths of other organizations was useful for knowledge exchange on programs and resources.

This week will resonate with me for a long time, and I will use the journey home to reflect on the wealth of information shared. I am grateful to MSH for affording me this opportunity, and I return home re-energized and invigorated to continue our work as we contribute towards the shared vision of an AIDS- free generation, and someday soon, the end of AIDS.

Shameza David is program officer for the second phase of the MSH-led Guyana HIV/AIDS Reduction and Prevention Program (GHARP II), funded by USAID.

Emerging World Powers: Leadership to Turn the Tide

XIX International AIDS Conference (AIDS 2012) Washington DC. Special Session: China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?  Aradhana Johri. © IAS/Ryan Rayburn - Commercialimage.net

Aradhana Johri speaking at the XIX International AIDS Conference (AIDS 2012) Special Session: “China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?” © IAS/Ryan Rayburn – Commercialimage.net

The similarities facing China, India, South Africa, and Brazil don’t necessarily jump off the page. However, important commonalities exist that the global health community needs to examine — and perhaps model in low income countries.

China, India, South Africa, and Brazil are emerging world powers that have made important advancements in changing the course of the HIV & AIDS epidemic in their countries.

At a special session of the XIX International AIDS Conference on Tuesday, July 24, hosted by Stephen Morrison of the Center for Strategic and International Studies and anchored by renowned economist, Jeffrey Sachs, high level speakers from each of these countries reflected on significant activities that changed their country’s course in HIV & AIDS management. The leaders also discussed how their countries can help lead the way in the fight against the epidemic.

Three themes developed from the conversation of how these countries were able to successfully manage the epidemic in their countries: (1) A country must invest in health not as the end goal, but as a critical instrument of economic development. (2) Reducing the cost of antiretrovirals (ARVs) is critical to get more people on treatment quickly (each country had a different approach). (3) A strong, educated leadership makes the difference. It is the Ministry of Health and global health professionals job to educate government leaders on health.

The South African Health Minister, Dr Pakishe Aaron Motsoaledi, said the focus on HIV & AIDS is what made the difference for his country. The government worked with partners to dramatically reduce the cost of ARVs by 53% which helped get 1.7M people on treatment. “2009 was our turning point,” he said. “There was a real commitment made by the Government at all levels to improve health impact.”

In China, over 80% of the AIDS budget is from the Chinese government directly, explained Dr Wu Zunyou, director of the National Center for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention. The trigger point was the SARS outbreak: leadership made rapid changes to control the outbreak and their mindset changed to focus on respecting health as a human right and protecting marginalized groups.

Dr Dirceu Greco, who has served as a member of the Brazilian Ministry of Health’s National Commission on AIDS, explains that Brazil set standards early, owned 100% of the response, and most importantly has developed the world’s largest public health system with over 100 million people in the system. Brazil invested in health, not just HIV and that was crucial to curbing the disease in Brazil.

India dramatically scaled up their HIV program to manage the HIV epidemic. From the beginning, they stuck to a scientific, evidence-based approach when addressing the concentrated epidemic in India. Aradhana Johri of India’s National AIDS Control Organisation, said that the key was to never lose the focus on prevention efforts.

As middle income countries, India, China, Brazil, and South Africa have had some advantages in managing the epidemic; the world’s poorest countries may be able to adapt some of these approaches to change the tide in their countries. As these four countries move forward, they must lead by example and show other countries how to face the challenges that still remain in ensuring sustainability, fighting stigma, and reducing drug costs and, hopefully one day soon, immunization prices.

Jeffery Sachs closed the discussion, saying: “We are at a vital crossroads; the Global Fund is in financial crisis.” He encouraged the presenters not only to be the voice in public health, but within the leadership of The Global Fund. He asked the countries to invest in The Global Fund, so the world can continue to see significant changes in the fight against AIDS, Tuberculosis, and Malaria.

Watch the special session: “China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?”

Margaret Hartley is MSH’s knowledge exchange associate.

On Day 3, Three Women, Three Calls: Keep Mothers Alive, Make Women Count, Invest in Programs for Girls

XIX International AIDS Conference (AIDS 2012) Washington D.C. Wednesday Plenary Session Linda H.ScruggsAIDS Alliance for Children, Youth and FamiliesUnited StatesUSA and Canada © IAS/Ryan Rayburn - Commercialimage.net

XIX International AIDS Conference (AIDS 2012) Washington DC, Wednesday Plenary Session, Linda H. Scruggs. © IAS/Ryan Rayburn – Commercialimage.net

Day three of the XIX International AIDS Conference opened with an impassioned plenary by three powerful women speakers, calling for more concerted action for women and girls living with HIV, particularly adolescent girls.

Dr Chewe Luo, Senior Advisor HIV/AIDS, UNICEF, spoke about the Global Plan to Eliminate New HIV Infections in Children by 2015 and Keeping Their Mothers Alive. Targets of the plan include: 1) Reducing infections in children by 90%. (In 2011, 333,000 children were infected with HIV, with 29% of new infections in Democratic Republic of the Congo, Nigeria and Malawi.) 2) Reducing HIV-related maternal deaths of women during pregnancy, delivery or post-delivery, by 50% by 2015.  3) Eliminating mother-to-child-transmission.

Luo highlighted the benefits of giving triple therapy or single dose Nevirapene throughout breast feeding; this could reduce mother-to-child-transmission to less than 5%. She described pilot studies in 11 countries and improvements in access to antiretrovirals (ARVs) for women: from 48% in 2010 to 57% in 2011. Despite improvements in Eastern and Southern Africa, the Caribbean, Eastern Europe and Central Asia, “we still need to do better in Western Africa,” she said. The decline in HIV infections in children was roughly 10.8%  from 2010 to 2011 but, “this is not enough,” said Luo. “We should have reached 20% by now.”

She cautioned that treatment should have started earlier for pregnant women and cited several options that countries have, mostly based on cost: Option A and B which are treatment therapies for the mother for a limited time and the newer Option B+ which provides triple ART for pregnant women for life.

“We will not achieve the goal of eliminating PMTCT without some serious innovations. And that’s what this strategy [Option B+] is about,” said Luo.

OPTION B PLUS: BOLD CHOICE TO SAVE MOTHERS WITH HIV IN MALAWI

Malawi is the first country to implement Option B+. “We need to look at PMTCT as a component of ART and access treatment early,” said Luo. “This is the bottom line for me.”

“Option B+ must be scaled up. I applaud Malawi for being so bold.” Benefits of Option B+ include reduced infant HIV infection.

Luo then turned her attention to the “unacceptable” percentage of children not receiving ART. “We are failing to reach children,” she said.

She ended with a call to action. We need to: 1) simplify our prevention approach and integrate PMTCT and ART programs at the community level; 2) introduce innovative approaches to reach adolescent girls and pregnant teens; 3) change treatment regimens for children; and 4) collaborate with community groups.

GENDER EQUITY AND EMPOWERMENT: LINDA’S STORY

Linda Scruggs, a consultant and a woman living with AIDS, delivered an inspirational account of her own struggles and brought her rousing comprehensive agenda to “Make Women Count” and end gender discrimination and stigma to a standing ovation. Scruggs told many stories of both gender inequity and gender empowerment.

“For the last 20 years, women have been asking for an international platform for their rights, to count us in. Today I stand to give us direction and a recipe for change. We want women  to work with women that have the tools for us, by us, with us. … It is not enough to create a task force or write a paper, what we need is to be part of the solution. We are the Mothers of the Earth.”

Linda reflected: “What does a woman with no self- esteem look like?  What does a woman whose uncle molested her look like? What is a woman who can’t read or write, broken and voiceless? That woman was me.”

Linda told stories of women, broken or affected by disease. “We are at the table and a force to be reckoned with. We need a big change and need to create jobs and training for HIV positive women.”

UNFINISHED AGENDA: PROTECTING  ADOLESCENT GIRLS

Dr. Geeta Rao Gupta, Deputy Executive Director of UNICEF, also made the case to turn the tide for adolescent girls and highlighted the need for gender equality. Adolescent girls aged 15 to 24 bear the brunt of the epidemic. Of the 4.8 million young people with AIDS, 3 million of them are girls.

The challenges of adolescent girls are immense: early sexual debut, child marriage, increased risk of HIV and STIs, sexual violence, and risk of early pregnancy and HIV infection. Many are forced early into transactional sex to survive or they depend on older men to survive. Most lack basic information on condoms or sex education.

Geeta offered recommendations to accelerate the pace of protection for adolescent girls:

  1. We need relevant national plans for high impact with emphasis on girls. Few country plans include anything about adolescent girls.
  2. We need to educate girls — empower them to make choices.
  3. We need to start early; make adolescents visible in routine data systems and follow their health status after age 5. (Right now, they don’t appear in the data unless they get pregnant or contract HIV and then they are included with adult data.)
  4. We need to invest in innovations to reach adolescent girls through social media and networks.
  5. We need to engage with adolescents as partners.

As Anthony Lake of UNICEF has so eloquently said: “We invest so much in keeping girls alive in their first decade of life. We must not lose them in the second.”

We need a world that is AIDS-free and fair for all women and girls. That must be our legacy.

Barbara Ayotte is MSH’s director of strategic communications.

Global Post Covers MSH Satellite Session on HIV and Non-Communicable Diseases

MSH’s satellite session on HIV and Non-Communicable Diseases is featured among the Global Post‘s highlights from AIDS 2012.

Learn more about the session:

The session included opening remarks by MSH’s President and CEO, Dr. Jonathan Quick, and Global Post reporter John Donnelly. Donnelly also authored the MSH 40th anniversary book, Go to the People: 40 Years of Improving Health.