Speakers Target Zero at MSH Panel and Reception Event

Invite_Icasa_2_smaller_web3As the world looks to 2015 and beyond, MSH organized a panel and reception at ICASA 2013 highlighting how the global health community can best work together to achieve an AIDS-free generation with zero new infections among adults and children, zero deaths due to AIDS, and zero HIV-related discrimination. The event, entitled “Targeting Zero Together: What will it take?,” brought together experts and audience members from NGOs, civil society organizations, governments, donor organizations, and more, to discuss the steps it will take to meet the current Millennium Development Goals and propose ideas for a post-2015 agenda.

MSH South Africa Country Representative Bada Pharasi shared a brief introduction of

MSH’s work in South Africa as he welcomed everyone to the event and introduced moderator and MSH Global Technical Lead for HIV and AIDS Scott Kellerman.

From left to right: panelists Tracey Naledi (Western Cape Dept of Health), Steven Smith (US Dept of Health and Human Services), Lois Chingandu (SAfAIDS), and moderator Scott Kellerman (MSH). Photo credit: Sharon Gama/MSH

From left to right: panelists Tracey Naledi (Western Cape Dept of Health), Steven Smith (US Dept of Health and Human Services), Lois Chingandu (SAfAIDS), and moderator Scott Kellerman (MSH). Photo credit: Sharon Gama/MSH

Kellerman then opened the session, prompting panelist Lois Chingandu, executive director of SAfAIDS, with the question “How do you define vulnerable populations?” This led to a rich hour and a half long discussion between the three panelists about how we can best reach zero, both in vulnerable populations and overall.

Chingandu’s response was simple: follow the evidence, and the evidence says that the youth, ages 11-19, women of all ages, and men who have sex with men are the most vulnerable to contracting HIV. Panelist Steven Smith, health attaché and regional representative for Southern Africa with the US Department of Health and Human Services, continued the discussion, emphasizing the role of evidence in shaping HIV prevention and treatment. Agreeing with her fellow panelists, Director for Health Impact Assessment with the Western Cape Department of Health Tracey Naledi explained how building upon evidence and increasing the use of geographic targeting has helped South Africa target those who need services the most.

Building upon the importance of evidence-based approaches, the panelists discussed the role of health systems in shaping prevention and treatment interventions. Smith emphasized the management piece of health systems, stating that we must strengthen the capacity of each country’s health system to respond to something new. Relying on past methods and a treatment-side approach no longer works – we must go into the community and promote a prevention-focused approach.

The conversation easily transitioned into the importance of breaking social and cultural barriers to better reach vulnerable populations and reduce stigma. Chingandu explained that only once these barriers are broken and individuals from key populations, such as sex workers, feel comfortable enough to come forward for treatment without fear of stigmatization, only then will we see progress towards reaching zero new infections. She continued, stating that we can no longer have a moral umbrella around HIV – we need to promote the idea that every sexual act you have must be protected, regardless of the act and who you have it with.

An audience member asks the panelists a question during the audience Q&A portion of the event. Photo credit: Bright Phiri/MSH

An audience member asks the panelists a question during the audience Q&A portion of the event. Photo credit: Bright Phiri/MSH

As the event opened up to audience questions, the theme continued to focus on the role of change in our fight to reach zero. One audience member posited the question of how best to implement behavior change communication in HIV interventions. Naledi responded with an example from her work with the Western Cape Department of Health to reduce inter-generational sex. After working with other disciplines, such as communications and marketing professionals, to review posters discouraging inter-generational sex, she and her colleagues found that the department’s posters were conveying a conflicting message and were instead encouraging young women to engage in relationships with much older men. Naledi explained that to best incite behavior change, the global health community needs to work with other disciplines, like the department of health did, to create stronger communications materials and build a stronger message.

Wrapping up the panel portion of the evening’s event, one audience member asked “What

Panelist Lois Chingandu (left) and MSH Director of Policy and Advocacy Crystal Lander. Photo credit: Bright Phiri/MSH

Panelist Lois Chingandu (left) and MSH Director of Policy and Advocacy Crystal Lander. Photo credit: Bright Phiri/MSH

really works? What drives people to seek treatment?” Chingandu’s responded back with, “Why is it that every morning we wear underwear?” She continued, saying, that once we can determine why that is natural to all of us – why we all engage in wearing underwear every morning without thinking twice – then we will know what drives people to change their behaviors and seek treatment.

Click here to listen to the full panel and learn more about how we can work together to target zero new infections in a post-2015 world.

ICASA Presentation on Pediatric HIV Screening Raises Further Questions

By Hloniphile Mabuza
Building Local Capacity for Delivery of HIV Services in Southern Africa Project, MSH South Africa

Earlier this week, I attended a session on monitoring and evaluation, and one of the presentations was on “Analysis of the effect of universal PITC [provider-initiated testing and counseling] of all babies at 18 months of age regardless of history of HIV exposure.” This was a pre/post study conducted in the Ugu district in KwaZulu-Natal, South Africa. The Department of Health in Ugu developed a protocol to test all babies at 18 months when they come for their measles immunization. The study revealed that in the nine months before the protocol was introduced (from October 2011-June 2012), only 18.1% of babies were tested and the HIV prevalence among babies 18 months old was 1.03%. During the nine months after the protocol was introduced (July 2012-March 2013), 42.8% of babies were tested and the HIV prevalence increased to 1.68%. There was no mention if this was statistically significant or not. The study recommended robust implementation of universal HIV testing at 18 months regardless of HIV exposure.

As I listened to the presentation and discussion, more questions came to mind: Is this really the best way to conduct pediatric HIV screening? How much would it cost South Africa to implement this strategy, and is it the most efficient use of funding, considering the HIV prevalence both before and after the study protocol was less than 2%?

Let’s hear other thoughts – reply below to join the discussion.

The Advantages and Challenges of Point-of-Care Laboratory Machines

By Luigi Cicció
Strengthening TB and AIDS Response – Eastern Region Project, MSH Uganda

In yesterday’s ICASA satellite session on “Laboratories and Facilities,” all presenters emphasized that point-of-care (POC) laboratory machines are both useful and possible. Their usefulness was never in question, but their feasibility was.

There are now several laboratory machines that can be used by trained personnel at primary health care level to perform tests that have traditionally been carried out by referral laboratories. They can help in providing cluster of differentiation 4 (CD4) count, viral load (VL) and bio-chemistry tests, all necessary for determining antiretroviral therapy (ART) eligibility and monitoring its effectiveness in the long term. It is an emerging market where companies are investing and competing with one another, thus making costs for purchasing and installing these POC machines more affordable.

Their advantages are evident: they can contribute to scaling up ART services and thus, reach out to more people in need with minimal referral to higher level sites (decreasing losses to follow up). The tests are not complex and can allow for task shifting to a lower laboratory cadre, results can be delivered in few minutes and do not require clients to turn up again, costs of reagents are acceptable, and maintenance is limited. Also, proficiency testing of POC laboratories can be accomplished for quality assurance.

All these programmatic benefits do not come without challenges though.

In rural places with limited (and erratic) availability of power, these machines may not reach their expected efficiency level. Shortage of consumables is another serious obstacle that is often under-estimated along with the logistical chain of ordering, procuring and distributing to remote areas. The increased number of clients attending ART clinics will translate in an increased number of tests and eventually in overburdening the existing laboratory personnel.

Some obvious yet crucial questions remain: according to the new World Health Organization guidelines, the VL is the test recommended for ART patient monitoring. But how acceptable is the performance of our ART sites with POC CD4 machines? How many tests per client per year do they provide? How many new ART clients are enrolled based on their CD4 test? And how many are still enrolled with a CD4 count below 100?

Three of the countries that have started implementing the option B+ approach, namely Malawi, Swaziland and Uganda, shared their recent experiences in a well attended plenary session on “Integrated Service Delivery Models,” where respective Ministry of Health (MOH) representatives described the significant modifications, adaptations, and innovations they had put in place for delivering prevention of mother to child transmission (PMTCT) and early infant diagnosis (EID) services.

In Malawi, the MOH took almost one and half year from policy formulation to actual implementation. This was necessary to plan for resource mobilization, training and procurement; to produce guidelines, training manuals and data tools; to institute a procurement process for antiretrovirals (ARVs); to conduct capacity building, and to initiate mentorship of health workers at all levels.

Their model highlighted the importance of integrating ART into maternal, newborn, and child health (MNCH) care through provision of HIV testing, ART, and clinical follow up of mothers and exposed infants in one setting.

The main threats to retention were found to be: ART initiation on the same day of detection of the HIV positive status; too much information given to mothers (about HIV, PMTCT, drug adherence, need for follow up, etc.); and the fact that many mothers were still healthy to accept lifelong treatment. Also, male involvement was not adequate (how could it be any different, since men need to reach eligibility status to qualify for ARV?). However, option B+ approach was scaled up and Malawi graduated as the pioneer country and their implementation model inspired others.

The Swaziland MOH ensured that PMTCT services were totally free of charge; completed the accreditation process of primary health unit (PHU) clinics to allow the scale up; provided POC CD4 machines in most facilities and recommended task sharing and shifting.

To promote retention, they put in place the following:

  • All services were made available in each facility (no referral)
  • CD4 test results were delivered the same day
  • Mother and infant clinic appointments were synchronized to happen the same day under the same roof (“family day” in ART clinics)
  • Children were discharged from the MNCH care point at 24 months of age (and they are considering to extend this to 5 years of age for continuity)
  • They used SMS technology and community health workers (CHWs) for follow up and tracing of missed appointments

Though the uptake of ART by pregnant mothers and children younger than 15 years of age increased from 45% to 75% and from 55% to 70% in three years respectively, they recognized some challenges:

  1. PHU clinics are becoming overcrowded
  2. Infrastructures are not suitable to accommodate the added services
  3. There is high burn out of CHWs
  4. SMS use is limited by hampered availability of mobile phones
  5. The human resources needed for the follow up are not sufficient

The Uganda presentation described their approach on the demand side and specifically the community engagement. Communities were seen as resources to generate service demand, strengthen linkages, reduce the human resource constraints, and addressing MNCH care bottlenecks like mobilizing people, following up and involving males.

The First Lady stepped in as the ending mother to child transmission of HIV (eMTCT) champion attending all 4 regional launches. People living with HIV/AIDS (PLHIV) networks were also involved; community resource people like village health teams and traditional birth attendants became linkage facilitators; family support groups were instituted in most facilities; and mentor mothers were trained and deployed to assist their peers.

Among the preliminary results, 94% of women attend antenatal care at least once (but only 17% during their first trimester); and last year about 88,000 HIV+ mothers received ART (51,000 option B+, 25,000 HAART and 12,000 option A) out of 120,000 detected cases.

Several challenges still persist: only 50% of facilities have an established FSG, adherence monitoring is limited, men involvement at PMTCT setting is at 15%, and community data collection tools are inadequate to capture all activities taking place.

Surprisingly, none of the presenters quoted any figure on the retention of mothers enrolled into option B+. Nor did they mention data issues as one of the implementation challenges. Yet, this was one of the most sensitive concerns that were cited at a B+ review meeting recently held by the Uganda MOH.

PMTCT data tools in Uganda have been changing much faster than the adapting attitude of health workers. Instructions for data recording have been modified and more indicators added, increasing the complexity of the whole exercise and perhaps compromising the overall accuracy of the data.

Could we simply have not more than 10 indicators for the PMTCT-EID cascade and make an effort to capture them correctly?

MSHers from Around the World Gather at ICASA

Last night, Management Sciences for Health staff from four countries, representing six different projects, met to prepare for a week full of conference sessions, exciting events, and networking with global health and international development peers, donors, and government officials.

MSH ICASA 2013 Staff Picture

MSH staff pose for a group picture at the ICASA 2013 welcome staff meeting.
Photo credit: Michele Alexander/MSH

MSH South Africa Country Representative Bada Pharasi kicked off the meeting, welcoming all MSH attendees while Jackie Sallet from the South Africa Sustainable Response to HIV & TB Services (SA SURE) Project, Global Technical Lead for HIV/AIDS Scott Kellerman, Director of Policy & Advocacy Crystal Lander, and Michele Alexander from Strategic Development and Communications discussed MSH’s goals and messages for the conference.

Jackie Sallet, from the MSH project SA SURE, shares the key messages about MSH's HIV and AIDS work.

Jackie Sallet, from the MSH project SA SURE, shares the key messages about MSH’s HIV and AIDS work.
Photo credit: Bright Phiri/MSH

Overall, the South Africa, Uganda, Zambia, and US-based MSHers shared ways to maximize MSH’s conference presence – most importantly through our exhibit booth, #21, and our panel and reception event on Monday, December 9 from 6-9PM (click here for more details and to RSVP).

Global Technical Lead for HIV and AIDS Scott Kellerman takes a look at the MSH ICASA Orientation Book.

Global Technical Lead for HIV and AIDS Scott Kellerman takes a look at the MSH ICASA Orientation Book.
Photo credit: Crystal Lander/MSH

ICASA Kicks Off with High Level Speakers

The conference kicked off with artistic performances followed by high level speakers from civil society, government, and international organizations. Some of these are included below:

Titica, Angola’s first prominent transgender artist, opened the evening.

Titica, Angola’s first prominent transgender artist, opened the evening.

Scottish singer and activist Annie Lennox complimented South Africa on its progress in the response to HIV and AIDS but cited the need for more action and accountability, especially in the fight to end sexual violence. Photo by Johanna Theunissen.

Scottish singer and activist Annie Lennox complimented South Africa on its progress in the response to HIV and AIDS but cited the need for more action and accountability, especially in the fight to end sexual violence.

"78 countries still condemn same-sex relationships," shared Cyriaque Ako, an HIV-positive activist from Cote D'Ivoire. He emphasized the need for the global community to advocate for marginalized communities.

“78 countries still condemn same-sex relationships,” shared Cyriaque Ako, an HIV-positive activist from Cote D’Ivoire. He emphasized the need for the global community to advocate for marginalized communities.

"The solution to the [HIV and AIDS] epidemic lies with women," said Her Excellency Christine Kaseba-Sata, first lady of Zambia, as she stressed the need to integrate HIV and AIDS services with family planning and reproductive health services.

“The solution to the [HIV and AIDS] epidemic lies with women,” said Her Excellency Christine Kaseba-Sata, first lady of Zambia, as she stressed the need to integrate HIV and AIDS services with family planning and reproductive health services.

Acting Global AIDS Coordinator Deborah von Zinkelnagel shared PEPFAR's vision for the future and its achievements in the areas of ART, PMTCT, and VMMC.

Acting Global AIDS Coordinator Deborah von Zinkelnagel shared PEPFAR’s vision for the future and its achievements in the areas of ART, PMTCT, and VMMC.

Executive Director of UNAIDS Michel Sidibé advised delegates: "do not be scared of shaping our future - where no one is left behind" and called for the inclusion of the epidemic on the post-2015 agenda and an end to AIDS by 2030.

Executive Director of UNAIDS Michel Sidibé advised delegates: “do not be scared of shaping our future – where no one is left behind” and called for the inclusion of the epidemic on the post-2015 agenda and an end to AIDS by 2030.

Concluding the evening, Deputy President of South Africa Kgalema Motlanthe stated the importance of investing in health as an essential part of development. “We have the tools necessary, all we have to do is deploy them” to reach our goals.

Concluding the evening, Deputy President of South Africa Kgalema Motlanthe stated the importance of investing in health as an essential part of development. “We have the tools necessary, all we have to do is deploy them” to reach our goals.

All photos credit of Johanna Theunissen/MSH.