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.

Opportunities Abound at ICASA

Most of my time at ICASA has been spent behind our exhibition booth. Before you start to feel sorry for me, however, I need to tell you that I have probably met more people from a wider variety of countries and contexts than most other delegates. It has given me a greater appreciation of the incredible array of individuals and organizations involved in all aspects of the HIV response in Africa. ICASA is providing a unique opportunity for all of these people to come together to share, network, and learn.

Johanna Theunissen and fellow MSH South Africa staff member Corry van der Walt at the MSH booth. Photo credit: Michele Alexander/MSH

Johanna Theunissen (right) and fellow MSH South Africa staff member Corry van der Walt at the MSH booth. Photo credit: Michele Alexander/MSH

To engage with those passing by the booth, I frequently open with asking people where they are from and what they do, to better gauge their interest and tools/products we have which may assist them. This has been fascinating and educational – people are responding to the needs of specific population groups in unique ways. Many of those I have met work at very high levels – people it would be hard to access under different circumstances. Yet, every delegate I have met has been friendly and open (and willing to listen to me trying to convey the breadth of what we do in two sentences).

I also have an enhanced perspective of my own organization, Management Sciences for Health (MSH). Working on a specific project in our regional office in Pretoria, South Africa, I vaguely knew that MSH was working in many countries around the world, but I have now experienced firsthand people from Ethiopia, Kenya, Nigeria, and Uganda, among others, sharing how they have partnered with MSH in their countries or know of our work there. All of the feedback has been positive.

We are having MSH staff attending ICASA work in shifts at our booth, and this has provided opportunities for those of us from different projects and countries to mix together in ways we haven’t before, building relationships that I believe will bear fruit in the future. We don’t have the most prominent booth location, but this has enabled us to enter into deeper and more meaningful conversations with people.

Johanna Theunissen is a Senior Communications Associate with MSH’s Building Local Capacity for Delivery of HIV Services in Southern Africa Project in South Africa

Remembering Nelson Mandela at ICASA

The first of Nelson Mandela’s memorial services was held yesterday in Johannesburg with more than 100 heads of state and dignitaries and tens of thousands of South Africans in FNB Stadium. I saw it much like the rest of the world – from the TV – since I am in Cape Town for the International Conference for AIDS and STIs in Africa (ICASA), conference where more than 5,000 people from all over the world come to discuss the latest developments in the field of HIV and AIDS. But, mostly, ICASA is a conference for people to get together, to meet old friends and make new ones, to advocate for a particular cause that you are passionate about and have people in the audience support you, to protest injustices that are happening throughout the world, and, most of all, to be together in solidarity for the fight against this debilitating, deadly disease.

Photo credit: NMF Photo/Matthew Willman

Photo credit: NMF Photo/Matthew Willman

This has also been a week of remembering the father of South Africa and probably the greatest statesman that I will see in my lifetime. To share stories of how Madiba touched our lives, how his sacrifice and then his tolerance and forgiveness really did heal a nation. And for me personally how his foresight to call for reconciliation, forgiveness, and a peaceful transition has led to me living in South Africa. I probably would not have decided to work in South Africa if apartheid had continued or if a bloody civil war had taken place. He and so many others involved in the struggle have made it possible for me to meet my partner – who is South African/Indian from Durban. During apartheid it would have been illegal for us, as a mixed race couple, to be together.

All of the flags are at half-mast and there are flowers laying at each small statue of Nelson Mandela or on the streets that are named after him – or where people have memories of meeting or seeing Madiba.

As we begin the process of saying goodbye to this tremendous leader I hope that we can all remember what he stood for and asked of all of us.

Kathryn Reichert is the Associate Project Director and Director of Monitoring, Evaluation and Communications of MSH’s Building Local Capacity for HIV Delivery Services in Southern Africa Project in South Africa

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?

Join and follow us in Cape Town!

Please join MSH and our partners at the 17th International Conference on AIDS and STIs in Africa (ICASA) December 7 – 11 in Cape Town, South Africa, for a special talk-show style event on targeting zero in the post-2015 world on December 9, abstract and poster presentations by MSH staff, an interactive conference booth, and much more.

ICASA Event InviteTargeting Zero Together: What Will It Take?
Join us for a special talk-show style panel and reception at Southern Sun The Cullinan Hotel, located across the street from the Cape Town International Convention Centre (CTICC) in South Africa on Monday, December 9, 2013, from 6 to 9 pm. RSVP requested: Facebook or email.

Monday, December 9, 2013

6:00 pm – 9:00 pm
Southern Sun The Cullinan Hotel
Protea 1 & 2

Speakers include:

  • Lois Chingandu, Executive Director, SAfAIDS
  • Scott Kellerman, Global Technical Lead HIV/AIDS, Management Sciences for Health
  • Tracey Naledi, Director of Health Impact Assessment, Western Cape Department of Health
  • Steven T. Smith, Health Attaché and Regional Representative for Southern Africa, U.S. Department of Health and Human Services
  • …and more special guests!

RSVP requested: on Facebook or by email.

Refreshments provided.

MSH Presentations

Poster Sessions

Saturday, December 7

  • Session 1, Track E:
    New Evidence, New Thinking: HIV Prevention Communication Training Bridges the Gap from Research to Practice. Paul Waibale, Building Local Capacity for Delivery of HIV Services in Southern Africa (BLC) Project.

Sunday, December 8

  • Session 1, Track B:
    Understanding the Factors Influencing the Duration of First-Line Regimens in an Ageing Antiretroviral Treatment Programme. Stephanie Berrada, Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program.
  • Session 1, Track D:
    Comparison of Sexual Risk Behaviour Between HIV Positive Men and HIV Negative Men in Gauteng and the Western Cape. Hloni Mabuza, BLC Project.
  • Session 1, Track E:
    Improving HIV Management in Botswana Hospitals Through the Quality Improvement and Leadership Program: The Case of Mahapye and the Scottish Livingstone Hospitals. Katie Reichert, BLC Project.
  • Session 2, Track D:
    The Role of Small Grants in Enhancing and Aligning HIV Prevention Activities in Resource Constrained Rural Communities of the Zululand District, Kwazulu-Natal. Bright Phiri, SIAPS Program.

Tuesday, December 10

  • Session 2, Track B: A Systematic Review of Demand-Side factors Affecting ART Initiation and Adherence for Pregnant an Postpartum Women Living with HIV. Sarah Konopka, African Strategies for Health (ASH) Project.
  • Session 2, Track B: Erik Schouten, MSH Malawi, A Systematic Review of Interventions to Reduce Mortality Among HIV-Infected Pregnant and One-Year Postpartum Women (Presented by Scott Kellerman and Jackie Sallet)
  • Session 2, Track D: Christopher Colvin, ASH Project, A Systematic Review of Health System Barriers to and Enablers of ART for Pregnant and Postpartum Women with HIV

Abstract Sessions

Monday, December 9, 17:00

  • Assessing the Progress of HIV and AIDS Indicators: Can Regional Level Results from Household Surveys Be Used for Program Monitoring? Luigi Ciccio, Uganda Strengthening TB and AIDS Response – Eastern Region (STAR-E) Project.

Tuesday, December 10, 16:45-18:15

  • Scale-Up of Cervical Cancer Screening and Integration with STI Services: The Experience from Eastern Uganda. Jennifer Acio, Uganda STAR-E Project.

Visit us at Booth 21

Meet MSH staff at our booth (21) in Hall 1 and pick up free materials during exhibit hall hours. MSH staff will highlight different areas of our HIV & AIDS work each day.

Hours and Themes:

  • Saturday, December 7: 10am-1:30pm; MSH in Africa and Inside Story
  • Sunday, December 8: 10am-7pm; Health systems, HIV, and other health issues
  • Monday, December 9: 10am-5:30pm; Pediatric AIDS
  • Tuesday, December 10: 10am-7pm; Building Local Capacity Project
  • Wednesday, December 11: 10am-4pm; Pharmaceutical Systems and Services

Join the #ICASA2013 conversation

MSH will be covering the conference through blogs and social media. On Twitter use hashtag #ICASA2013. Join the global #ICASA2013 conversation!

Special Supplement on Pediatric HIV & AIDS for the journal AIDS

Scott Kellerman, MSH’s Global Technical Lead for HIV and AIDS, co-edited a 12-paper special supplement on pediatric HIV & AIDS for the journal AIDS, with co-editors Dr. Nandita Sugandhi from CHAI and Dr. Rami Yogev from Northwestern University Department of Pediatrics. The series was initiated last year because of concerns that key issues in pediatric HIV and AIDS were being overlooked. MSH co-authors included Theresa Feely-Summerl, Helena Walkowiak, Jon Jay, David Mabirizi and Erik Schouten. READ SUPPLEMENT FOR FREE

World AIDS Day: Getting to an AIDS-Free Generation

This piece is cross-posted from the MSH Global Health Impact Blog{Photo credit: Warren Zellman}Photo credit: Warren Zellman

I remember attending the Durban international AIDS conference in 2000, my first. That was the one where everything was going to turn around and we were going get a handle on the epidemic. Nelson Mandela spoke at that one, in a hall that was the size of three football fields. And the crowd was joyous, raucous, the noise was deafening and it was one of the most memorable days of my life.

Before Mandela took the stage, a choir made up of kids—none more than 9 or 10 years of age and many much younger—took the stage to sing tribute to the great man and those of us gathering there.

It was charming and sweet. Everyone had a huge grin on their faces. And then I realized that this group of kids was special, maybe overheard someone nearby or perhaps the MC say that this, “was THAT group.” All were infected with the virus, and as I watched these gorgeous children singing so strong, moving and smiling and clapping with everyone, I knew, knew inside, that they probably wouldn’t live much longer.

We are indeed a far cry from where we were then. And yet with all of our incredible advances, we see essential challenges in starker relief. What we’re discovering is just how hampered we remain in delivering care to those who need it most. It’s not that we don’t know how to deliver life-saving care to adults and children. The problem is that the health systems in many places still struggle to offer basic services. Our focus moving forward must be on strengthening health systems to decentralize to the most local unit, integrate with other key clinical services and ensure that programs are sustained.

A FUTURE FOR HIV POSITIVE CHILDREN

When I was in medical school, the reason why I chose pediatrics was because kids get better for the most part. There are tragic exceptions, of course, but most kids bounce back from illness and recover. They get to be kids. They grow up to be adults.

That’s not the case with pediatric HIV, or at least it hasn’t always been so. At each point in the cascade of care for infected children, there are barriers that until very recently were not really being talked about, and still are not being fully addressed.

Through my work at MSH, I became involved in the Interagency Task Team for the Prevention of Mother to Child Transmission, co-sponsored by UNICEF and WHO, and focused on advocating for improved HIV responses for children.  About a year ago, I was asked to co-chair the Child Survival Working Group within the IATT—a group made up of nearly 60 professionals representing nearly 30 organizations all dedicated to thinking about pediatric HIV issues. When I took over as co-chair, I asked the members for ideas on creating something lasting, something that can highlight what we should be thinking about improving HIV care for children.

STRENGTHENING THE HEALTH SYSTEM AT ALL LEVELS FOR ALL AGES

We all agreed: the existing primary response to pediatric HIV has been to further strengthen Prevention of Mother to Child Transmission (PMTCT) programming.  But in truth, a lot of kids are missed by PMTCT. Even with an absolutely perfect PMTCT system that captures every infected mother presenting for ante-natal care, there will still be a sizable proportion of women who never make it in to antenatal care, are never seen by a nurse or midwife, or a doctor during their pregnancy. They never get a chance to be tested for HIV during pregnancy and understand their HIV status—and their children will never have a chance to be protected from acquisition of the virus from their mothers. Thus hundreds of thousands of children continue to be born with HIV because PMTCT is predicated on women actually showing up at an antenatal care clinic and getting tested.

Our thought was to write a series of papers addressing all aspects of the care cascade for children born infected or affected by HIV. We wanted to highlight areas that have not received the type of attention needed—including case finding of infected children, linking these children to care and treatment, retaining them in care, ensuring adherence to medicine and addressing the myriad issues these children face.

Through our collection of essays, we show among other things, that the infrastructure and the health systems that are responsible for caring for kids are really suffering as well. It comes right down to health systems strengthening, not only for adults but also for pediatric care systems which are separate from those for adults and are often much less resourced.

We undertook this project to try to identify the areas that must be addressed in order to strengthen the care response across the life cycle of infected kids. This series became a reality through the generous support of UNICEF and the multiple organizations who participated in writing and reviewing this series of 11 papers, and through the financial support of the Canadian Department of Foreign Affairs, Trade and Development (DFATD).

GETTING TO AN AIDS-FREE GENERATION: ADVOCACY IN DC AND ABROAD

Advancing a health systems strengthening approach to HIV & AIDS for both adults and children requires more advocacy and education of decision makers: many current legislators were not in office for the passage and earlier reauthorization of PEPFAR; we therefore continue to educate lawmakers on the gains and the work left to be done—such as we are doing this week on December 2 in Washington, DC, at our event, Getting to an AIDS-Free Generation: Overcoming Remaining Challenges.

At the upcoming 17th International Conference on AIDS and STIs in Africa (ICASA), from December 7–11 in Cape Town, South Africa, we will continue highlighting the importance of addressing the epidemic, through capacity building and working in partnerships.

Getting to zero is only possible through:

  • building strong health systems
  • responding to the evolution of the epidemic
  • building local capacity

In honor of World AIDS Day and its theme of HIV and adolescents, the makers of Inside Storyhave made the film available to watch online for free on their website, starting December 1. Inside Story is a powerful film about an HIV-infected soccer player in South Africa (and a film for which I was honored to serve as technical director). Please join us in viewing the film and sharing it with others.