Photos by Sara Holtz/MSH.
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:
- We need relevant national plans for high impact with emphasis on girls. Few country plans include anything about adolescent girls.
- We need to educate girls — empower them to make choices.
- 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.)
- We need to invest in innovations to reach adolescent girls through social media and networks.
- 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.
Photos by Sara Holtz/MSH.
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:
- Session overview with webcast
- Write-up of the session by MSH’s Gloria Sangiwa
- NEW VIDEO: Mildred’s Story: Treating HIV & Chronic NCDs
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.
Photos by Sara Holtz/MSH.
On Sunday, July 22, 2012, Management Sciences for Health (MSH) hosted a satellite session, Beyond MDG 6: HIV and Chronic NCDs: Integrating Health Systems Towards Universal Health Coverage at the XIX International AIDS Conference (AIDS 2012). The session panelists were (left to right): Dr Ayoub Magimba, Till Baernighausen, Dr Jemima Kamano, John Donnelly (moderator), Sir George Alleyne, Dr Doyin Oluwole, and Dr Jonathan D. Quick.
This week at the XIX International AIDS Conference — as panelists and pundits debate whether an AIDS-free generation is actually possible — we must not neglect the other chronic diseases that remain an emerging and alarming threat to both aging HIV-positive and sero-negative populations in these settings. Today, chronic non-communicable diseases (C-NCDs), including cancer, lung and heart disease, and diabetes, kill over 28 million people annually in low and middle-income countries, many of whom are HIV-positive.
According to Till Baernighausen of the Harvard School of Public Health, the total number of HIV-positive people aged 50 years and older is likely to triple over the coming decades from 3.1 million in 2011 to maybe 9 or 10 million in 2040. “We would really expect dramatic increases for the need for C-NCD screening and treatment.”
TURNING THE TIDE THROUGH INTEGRATED HEALTH SYSTEMS
Once deemed a death sentence, HIV is now considered a manageable chronic condition through the use of lifelong antiretroviral therapy (ART). HIV-positive individuals are now living longer, particularly in resource-limited settings where HIV care and treatment were not previously available. In fact, through the global scale-up of HIV and AIDS services, health systems in low- and middle-income countries are now better prepared to tackle other C-NCDs — like cancers, diabetes, chronic lung diseases, and cardiovascular diseases — by leveraging the existing investments, infrastructure, and systems put in place in recent decades.
BUILDING ON THE SUCCESS OF HIV & AIDS PROGRAMS
Over a decade ago, many critics said that bringing life-saving HIV treatment to the most hard-to-reach areas would be impossible. Yet today, more than 8 million people have access to antiretroviral treatment in low-and middle-income countries. The same models used for lifelong ART can be adapted and used for managing and monitoring patients with other C-NCDs. MSH firmly believes we can apply the lessons learned from our experiences with HIV to the C-NCD epidemic. For example, service delivery models — e.g. scaling up of ART and prevention of mother-to-child transmission (PMTCT) — innovations in funding, health care financing models, pricing for drugs and laboratory supplies and equipment, and new technologies for care diagnosis, among other innovations, provide a model for chronic diseases in low- and middle-income countries.
While proven solutions to tackle such conditions exist, the global health community is only now starting to realize the importance of designing cost-efficient, integrated health systems. According to Dr. Jemima Kamano of AMPATH, “One of the hardest things for me as a practicing clinician in Africa is to sit at the HIV clinic and treat HIV patients, counsel them and give them drugs and see them improving. But the minute they develop diabetes or hypertension, then I tell them unfortunately I can’t help them.”
By integrating current health systems and leveraging the existing groundwork laid by HIV and AIDS intervention scale-up, we can leverage existing public infrastructure, pharmaceutical supply chains, and human resources management, among other developments, to benefit patients with chronic diseases.
HIV & AIDS, C-NCDS, AND UHC
HIV and other C-NCDs have serious socioeconomic consequences, often creating a financial barrier for individuals in need of proper care and treatment, and forcing them to pay high out-of-pocket fees. Despite advancements in service delivery, only twenty countries worldwide currently have Universal Health Coverage (UHC) plans in which everyone can receive basic health services.
While some advocates in the AIDS community may see UHC as a threat to the provision of HIV & AIDS resources, others see it as a solution. Sir George Alleyne from the Pan American Health Organization (PAHO) reminds us that UHC is “feasible, socially desirable, and economically possible.”
“We have acceptance that UHC is possible. It is a myth that poor countries cannot afford UHC. There is no country that cannot afford UHC,” Sir Alleyne says. “It is a matter of social justice.”
According to Dr. Jonathan D. Quick, President and CEO of Management Sciences for Health, “UHC is becoming the driving vision for prevention, care and treatment of, and assuring access for, HIV positive and HIV affected people. They live long enough to get chronic diseases and to care for children — and they need the services that are provided through universal health coverage programs.”
The long-term nature of chronic diseases, including HIV, poses many challenges for the health system, but it is crucial that the prevention, care, and treatment of chronic disease be integrated in order to save many more lives.
MSH believes that in order to effectively combat the rise of C-NCDs — and turn the tide against HIV and AIDS — we must strengthen current health systems while leveraging existing platforms and ensuring access at an affordable cost in the context of UHC.
For a more in depth discussion on this topic, watch the webcast of MSH’s recent panel at the International AIDS Conference (via Kaiser Family Foundation).
Gloria Sangiwa, MD, is Management Sciences for Health’s global technical lead for chronic non-communicable diseases and the director of technical quality and innovation in MSH’s Center for Health Services.
Tuesday’s (July 24) session at the XIX International AIDS Conference kicked off with a plenary session on HIV & AIDS “Challenges and Solutions”.
The first three presenters, Javier Martinez-Picado (Spain) from the AIDS Research Institute IrsiCaixa and ICREA; Dr. Nelly Mugo (Kenya) of the University of Nairobi and Kenyatta National Hospital; and Dr. Bernhard Schwartländer, (Switzerland) the Director for Evidence, Innovation and Policy at UNAIDS, each spoke about the possibilities for ending AIDS. Dr. Howard Koh, Assistant Secretary for Health for the US Department of Health and Human Services described US efforts to end AIDS.
A cure or eradication is necessary
Dr. Martinez-Picado launched the session with a list of reminders why a cure or eradication is necessary: (1) The HIV virus is suppressed with antiretroviral therapy (ART), and (2) the vast majority of patients who adhere to treatment will live long, healthy lives. However, (3) mortality and morbidity from chronic diseases such as heart disease and cancer is still higher in populations of HIV-positive patients in treatment than in the general population. In addition, (4) stigma and discrimination against people living with HIV continues to plague nearly every community. And (5) the cost of treatment is projected at $22 billion per year for universal access. For all of these reasons, a cure or eradication is preferable to lifelong treatment.
This cure or eradication will require, “a prolonged period of research,” said Martinez-Picado. But he urged the audience not to let that deter our efforts. He presented a series of scientific studies that are showing varying signs of promise for progress toward a cure. Though none of them is a silver bullet, it is clear that progress is being made in HIV science.
Science, Not the Only Answer
Science isn’t the only answer — though an important one — Dr. Nelly Mugo reminded us in her presentation. According to Dr. Mugo, 44 percent of new HIV infections in Kenya are among married or cohabitating couples, and 50 percent of HIV-positive couples are serodiscordant. Often a couple’s desire for children will overshadow their fear of transmitting the virus to their partner, thus preexposure prophylaxis and treatment as prevention are important strategies for keeping partners of people living with HIV free of the disease.
However, adherence to treatment and linking patients with care after testing are still major problems — not only in Kenya, but worldwide. The solution to these problems is not more advances in science, but rather community-based efforts to make sure both HIV-positive clients and their partners understand the necessity of accessing treatment and adhering to it for life. After all, treatment as prevention cannot work if treatment is not accessed.
Another $7 Billion
Neither science, nor social programming is free. And without increased funding, the number of new HIV infections per year will stagnate, said Dr. Bernhard Schwartländer. Though he believes we must “learn how to do more with what we have,” Dr. Schwartländer also urged countries to take ownership of their health and increase domestic funding for health, including HIV services. Though he believes another $7 billion is needed by 2015 in order to halve the rate of new HIV infections, he says that if low- and middle-income countries continue to fund health services at the same rate they are currently funding them, the gap will be closed as these nations emerge from low-income to middle- and high-income status over the next decade.
“None of this will be achieved without a strong activist voice,” Dr. Schwartländer reminded the crowd, and urged us to challenge our governments to rise to the challenge. “The world overall is getting richer,” he said, “We have to make it fairer.”
Dr. Howard Koh presented achievements made during the first two years of implementation of the United States’ HIV and AIDS strategy. He praised the FDA’s recent approval of Truvada for pre-exposure prophylaxis and the provisions the Affordable Care Act will make for HIV care — including ending insurance companies’ ability to cap lifetime care limits and preexisting condition exclusions. The US plans to decrease the number of new infections within our borders by 25 percent by 2015 through cutting-edge research on vaccines and microbicides and increasing the number of people who know their status through innovative programs, such as free HIV testing at the department of motor vehicles.
It is clear from this session that we will not end AIDS tomorrow. But with the vision of our leaders, the voices of our activists, and the hard work of those on the front lines living and working with people living with HIV a future free of HIV is within our reach.
Mary Burket is communications manager in MSH’s Center for Health Services.
Science was at the forefront of the opening event of the XIX International AIDS Conference on day two, but the “dream team” and a rock star also made an appearance, in a rousing plenary session attended by more than a thousand members of the global public health community in Washington, DC.
In an opening presentation entitled, “Ending the HIV/AIDS Pandemic: From Scientific Advance to Public Health Implementation,” Dr Anthony Fauci of the National Institute of Allergy and Infectious Diseases (NIAID) captured more than 30 years of the epidemic’s history in less than 20 minutes, from what he called the “dark years” of the 1980’s to the present day “new dawn of therapeutics.” Recapping the increasing evidence behind biomedical approaches from prevention of mother-to-child transmission, voluntary male medical circumcision, and treatment as prevention, Dr Fauci underscored the fact that those working in the field of HIV today must “marry the biological with the behavioral.” He closed his remarks by saying how proud he was, after attending 18 previous AIDS conferences, to be able to say, “We do have the scientific basis to implement!”
Fauci was followed by Phil Wilson, founder and executive director of the Los Angeles-based Black AIDS Institute, who also applauded the tools and knowledge available today, after 31 years of living with this epidemic. Wilson’s mood grew more sober, however, as he highlighted the dismal reality for black American men who have sex with men: at age 25, their odds are one in four that they will contract the virus; by age 40, 59.3% are infected. Wilson enumerated five steps to end the epidemic, starting with fully implementing the Affordable Care Act and ending with a plea to AIDS organizations to “re-tool” themselves – noting that community based organizations are central to the fight against the epidemic but are not in a position to deliver health services or implement the important, effective biomedical interventions that exist today.
UNAIDS Executive Director Michel Sidibé took the stage briefly, reminding the audience that he had called upon them on the conference’s opening day to “dream big dreams” and think of the opportunity that exists today to end this epidemic. He referred to his own dream team – mentioning President Obama, US Secretary of Health and Human Services Kathleen Sebelius, and US Global AIDS Coordinator Eric Goosby — and then called to the podium the woman that the New York Times referred to a few weeks ago as the “rock star diplomat,” US Secretary of State Hillary Clinton.
As chanting activists tried to drown out her voice, Secretary Clinton opened her remarks with the words, “What would an AIDS conference be without a little protesting?” and moved on, talking about how AIDS is no longer the death sentence that it once was, and highlighting the possibility that we are moving toward an AIDS-free generation.
Clinton spoke enthusiastically about the role that the US government has played in the global fight against HIV, lauding the creation of the Presidents Emergency Plan for AIDS Relief (PEPFAR), as well as the work of the US Centers for Disease Control and Prevention (CDC) and the US Agency for International Development (USAID).
Acknowledging that all the work “only matters if in the end we are saving more lives,” Clinton reiterated the US government’s commitment to the effort to fight AIDS, announcing an $80 million investment to help pregnant women in developing countries receive treatment and prevention services; $15 million in scientific research aimed at specific interventions for key at-risk populations; a $20 million challenge fund to support country-led efforts to target key populations; and a $2 million investment to reinforce civil society organizations’ efforts for those most at-risk.
More than 20,000 health workers, people living with HIV/AIDS, development specialists, and community activists are attending the AIDS conference, which concludes this Friday. For more on MSH’s presence at the event, visit MSH at AIDS 2012.
Elizabeth Walsh is director of communications in MSH’s Center for Leadership & Management.
A cast of seasoned AIDS experts gathered at the Center for Strategic and International Studies (CSIS) on Saturday evening, July 21, to weigh in on the President’s Emergency Plan for AIDS Relief (PEPFAR) on the eve of the XIX International AIDS Conference, dubbed “AIDS 2012”.
The conference is taking place in the USA for the first time in 20 years thanks to President Obama’s lifting of the travel ban on HIV-positive visitors.
“What has been PEPFAR’s strategic significance?”
An illustrious panel including Ambassador Eric Goosby (United States Global AIDS Coordinator), Ambassador Mark Dybul (former United States Global AIDS Coordinator), and Dr Anthony Fauci (Director of National Institute of Allergy and Infectious Diseases, NIAID) discussed the first topic: “What has been PEPFAR’s strategic significance?”
Dr Fauci, who was one of the architects of PEPFAR, talked of the humanitarian and moral responsibility that George Bush felt. He mentioned an African male comment that “PEPFAR is the best thing that ever happened to Africa.”
Amb Dybul, another architect of PEPFAR, reiterated that the “driving force was moral responsibility” but also commented on a “moral visceral reaction” that Pres Bush felt whenever he heard people say that Africans were too poor to take AIDS medicines or that they were too promiscuous. He explained that Pres Bush believed that it “represents the conscience of the US people.” He told a story of how a patient described PEPFAR by saying “it means that Americans care about us.” Amb Goosby commented that Pres Bush created PEPFAR because of the moral imperative and the fact that we could respond. He noted “talk is cheap; actions speak louder than words.”
All three panelists voiced concern about fatigue with respect to humanitarianism and ethical issues, such as HIV and PEPFAR, and warned the audience that we cannot afford fatigue 18 months prior to the re-authorization of PEPFAR. This led to the conclusion that we must shift the message to “we can control AIDS,” “we can fix the problem,” and we can create an “AIDS-free generation.”
The second panel shared their answers to the question “What has PEPFAR taught us, for good and bad?”
Dr. Wafaa el Sadr of ICAP praised PEPFAR as providing as place for innovation, for learning on the ground, for fast translation of science into action followed by enormous scale up, and for problem solving by health care workers and policy makers. She thinks the early perception was that PEPFAR was run by Washington DC and not owned locally, but then argued that PEPFAR could not have achieved what it did without country ownership. Dr el Sadr also described as a tragedy the people who have the courage to have an HIV test, only to test positive, but have a CD4 count above the level eligible for treatment.
Dr Alex Muganzi of Uganda described PEPFAR as “the best things that has happened to Africa with respect to HIV.” He described the early days when medicines were very expensive and health care workers had to choose who would receive them; he equated it to ‘acting like God.” PEPFAR revolutionized HIV treatment, shattered misconceptions that Africans cannot adhere to an HIV medicine regimen, and increased the role of civil society.
Dr Jeff Springer, drawing on his experience in Zambia, noted the prevailing beliefs that patients would not come due to stigma, that labs could not handle HIV tests, that patients could not take medicines … all these preconceptions were blown away, leading to a “paradigm shift about what is possible.”
“What Should PEPFAR look like in five years?
The last panel brought together Dr Chris Beyrer, Dr Kevin De Cock, Dr Tom Quinn and Dr David Serwadda to debate: “What PEPFAR should look like in five years” and in particular, reaching an “AIDS-free generation.”
Dr Beyrer cautioned that HIV prevalence will increase as more people live longer thanks to HIV medicines. He expects declining incidence and lower levels of transmission. He cautioned, however, that HIV epidemiology keeps changing and we “can’t get to an AIDS-free generation without addressing these populations”: sex workers, men who have sex with men, and injection drug users.
Dr De Cock added that the term “AIDS-free generation” also means virtual elimination of mother to child transmission and that all persons with HIV access medicines early with the best available medicines. He questioned why none of the previous panelists mentioned medical male circumcision, to which Dr Quinn commented that it’s “the most cost-effective prevention intervention today.”
Dr Serwadda requested that we look longer than five years. He focused heavily on country ownership, challenged PEPFAR to engage countries more, and insisted that “governments must put their mark on it.” With respect to most at risk populations, Dr Serwadda suggested that countries should look at the epidemiology, identify the new infections and put the money there; he predicts that at some point, “countries will come around and put the money there.”
PEPFAR Featured in Journal of AIDS
The Saturday evening panel discussion coincided with the launch of a special issue of the Journal of AIDS: “PEPFAR: Its Vision, Achievements and New Directions,” highlighting a “decade of data and experience.” Read the special JAIDS issue on PEPFAR.
Sara A. Holtz, DrPH, MPH, is senior technical officer at Management Sciences for Health.
Stop by MSH booth 162 today, Monday, July 23 to say hello, and pick up MSH materials about strengthening health systems to eliminate HIV & AIDS. Booth hours: 10:00 – 18:30 today.
We are the health system!
See you at booth 162!
Up next (tomorrow): Managing pharmaceuticals