Articles tagged as "Global / multilateral and bilateral responses"

Global Multilateral, Bilateral Responses

Changing global essential medicines norms to improve access to AIDS treatment: lessons from Brazil. Nunn A, Fonseca ED, Gruskin S. Glob Public Health. 2009;4:131-49.

Brazil ’s large-scale, successful HIV treatment programme is considered by many to be a model for other developing countries aiming to improve access to HIV treatment. Far less is known about Brazil’s important role in changing global norms related to international pharmaceutical policy, particularly international human rights, health and trade policies governing access to essential medicines. Prompted by Brazil’s interest in preserving its national HIV treatment policies during World Trade Organisation trade disputes with the USA, these efforts to change global essential medicines norms have had important implications for other countries, particularly those scaling up HIV treatment. This paper analyses Brazil’s contributions to global essential medicines policy and explains the relevance of Brazil’s contributions to global health policy today.

Abstract : 1

Editors’ note: This interesting chronological narrative traces the far-reaching impact of Brazil’s efforts to preserve its domestic HIV treatment policies, which are based on legal commitments to provide universal access to antiretroviral drugs to its people, and yet recognise intellectual property rights. Brazil acted through the United Nations Commission on Human Rights, the United Nations General Assembly, the World Health Assembly, and the World Trade Organisation to improve access to essential medicines. Improved transparency about drug prices, generic drug use to address public health needs, incorporation of antiretroviral drugs into the WHO Essential Medicines List, strengthened TRIPS flexibilities for developing countries, and the defining of access to medicines as part of the human right to health can all be traced to a strong Brazilian influence in shaping global policy.

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Monitoring and Evaluation

Bendavid E, Bhattacharya J. The President’s Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes. Ann Intern Med. 2009 Apr 6. [Epub ahead of print]

Since 2003, the Unites States President’s Emergency Plan for AIDS Relief (PEPFAR) has been the most ambitious initiative to address the global HIV epidemic.  However, the effect of PEPFAR on HIV-related outcomes is unknown. Bendavid and Bhattacharya set out to assess the effect of PEPFAR on HIV-related deaths, the number of people living with HIV, and HIV prevalence in sub-Saharan Africa. Comparing trends before and after the initiation of PEPFAR’s activities they examined data from 12 African focus countries and 29 control countries with a generalized HIV epidemic from 1997 to 2007 (451 country-year observations). The intervention they were assessing was a 5-year, $15 billion program for HIV treatment, prevention, and care that started in late 2003. Outcome measures were HIV-related deaths, the number of people living with HIV, and HIV prevalence. Between 2004 and 2007, the difference in the annual change in the number of HIV-related deaths was 10.5% lower in the focus countries than the control countries (P = 0.001). The difference in trends between the groups before 2003 was not significant. The annual growth in the number of people living with HIV was 3.7% slower in the focus countries than the control countries from 1997 to 2002 (P = 0.05), but during PEPFAR’s activities, the difference was no longer significant. The difference in the change in HIV prevalence did not significantly differ throughout the study period. These estimates were stable after sensitivity analysis. The selection of the focus countries was not random, which limits the generalizability of the results. After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ. Assessment of epidemiologic effectiveness should be part of PEPFAR’s evaluation programs.

Editors’ note: The criteria for selecting PEPFAR focus countries appear to have been burden of disease, the country government’s commitment to responding to HIV, administrative capacity, and a willingness to partner with the US government. Nearly half of PEPFAR resources were spent on treatment and only one-fifth on prevention, of which one-third were earmarked for abstinence-only programmes for which the evidence base is questionable. It is not surprising then that mortality reduction rather than HIV prevalence declines appears to be the significant health-related outcome of PEPFAR from 2004 to 2007. The estimated 1.2 million deaths averted through improved treatment and care of people living with HIV in focus countries is nonetheless laudatory. In July 2008, a 48 million USD budget over 5 years was authorised for the next phase of PEPFAR and it includes a broader emphasis on strengthening health systems.

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Collins C, Coates TJ, Szekeres G. Accountability in the global response to HIV: measuring progress, driving change. AIDS. 2008 Suppl 2:S105-111.

Accountability implies that institutions and individuals are answerable for their commitments and responsibilities. The concept of accountability is highly relevant in the global response to HIV because governments, donors and other actors have often failed to keep their commitments to expand funding and service delivery levels. Many governments have not been held accountable for failing to address the HIV-related needs of their populations adequately. Accountability is about more than passing judgement. Effective accountability mechanisms can be powerful tools to improve service delivery by providing constructive assessments and motivating decision makers to avoid negative external critiques. An impressive variety of HIV-related accountability projects have emerged over the past few years, the most prominent being the ongoing monitoring of government compliance with the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment. Other accountability efforts are essential in order to capture perspectives and priorities outside of governments and aid agencies. Many civil society-based accountability projects are now tracking HIV policy, service delivery and funding levels. Collins and colleagues make several suggestions to increase the impact of accountability efforts, including connecting accountability to sustained advocacy, holding multiple actors accountable, continually assessing what measures of success will be most powerful in driving improved outcomes, and supporting and building the capacity of civil society monitoring efforts. They also suggest exploring how the International AIDS Conferences could serve as an expanded platform for accountability.

Editors’ note: Accountability means measuring progress toward goals, commitments, and responsibilities for action at all levels: Accountability is a powerful tool to improve the quality, accessibility, and equitable delivery of services. Thus, accountability is an important social justice issue in the response to HIV. More robust accountability efforts, which build capacity for and stimulate constructive dialogue between health consumers and policy makers while measuring the appropriateness of programme choices, require increased financial and technical support. They are well worth the investment.

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Moghimi M, Marashi SA, Kabir A, Taghipour HR, Faghihi-Kashani AH, Ghoddoosi I, Alavian SM. Knowledge, attitude, and practice of Iranian surgeons about blood-borne diseases. J Surg Res. 2008 Feb 1. [Epub ahead of print]

Perhaps more than any other healthcare worker, it is the surgeons who are at an increased risk of exposure to hepatitis B (HB) virus, hepatitis C virus, and human immunodeficiency virus. The aim of this study was to evaluate surgeons' concerns regarding risk awareness and behavioral methods of protection against blood-borne pathogen transmission during surgery. A 31-item questionnaire with a reliability coefficient of 0.73 was used. Of 575 surgeons invited to participate from three universities and one national annual surgical society between May and July 2007, 430 (75%) returned completed forms. Concern about being infected with blood-borne diseases was more than 70 (from a total score of 100). Only 12.9% of surgeons always used double gloves. Complete vaccination against HB was done in about 76% of surgeons and only 56.8% had checked their HB surface antibody (anti-HBs) level. Older surgeons never used double gloves (P = 0.001). Iranian surgeons are not aware of the correct percentage of infected patients with and seroconversion rate of blood-borne diseases, do not use double gloves adequately, do not report their needlestick injuries, vaccinate against HB, and check anti-HBs after vaccination. Educational meetings, pamphlets, and facilities must be provided to health care workers, informing them of hazards, prevention, and postexposure prophylaxis to needlestick injuries, vaccination efficacy, and wearing double gloves.

Editors’ note: These middle-aged surgeons with relatively high surgical experience have not translated their concerns about the risk of blood-borne transmission into highly effective protection strategies. Double gloving, which increases protection by providing a second barrier, is more common among younger surgeons who need to encourage this practice as a surgical norm among their elders, along with masks and protective glasses.

PLoS Medicine Editors. PLoS Med. 2008 Aug 26;5(8):e182. A crucial role for surgery in reaching the UN Millennium Development Goals. Recent efforts to bring surgery into the global health conversation have focused on arguments that surgical conditions should be considered as “neglected diseases” that disproportionately affect the world's poorest people. There are at least five important reasons why providing surgery services should be considered a global public health priority. First, surgical conditions constitute a substantial global burden of disease, led by injuries, followed by malignancies, congenital anomalies, pregnancy complications, cataracts, and perinatal conditions. Second, surgery is a global public health issue because of global disparities in surgical care: 30% of the world's population receives 73.6% of the estimated 234.2 million major surgical procedures performed worldwide each year, with the poorest third receiving only 3.5%. Third, surgery can be remarkably cost-effective when compared with some of the interventions that are considered the building blocks of global public health. Fourth, building surgical services, which requires infrastructure, supplies, and human resources, may in turn help to build health systems and to strengthen primary care. Finally, it is feasible to deliver surgical services even in the most resource-constrained settings. Surgery could play an essential role in meeting many of the 2015 United Nations Millennium Development Goals. For example, trauma care, obstetric surgery, and general surgical services are essential components in reaching goal 4 (reducing child mortality) and goal 5 (improving maternal health). Surgery can play a role in tackling infectious diseases (goal 6): male circumcision may reduce the risk of men acquiring HIV through heterosexual sex by 60%. With foresight and planning, the impending scale-up of male circumcision services in Africa could help to provide the infrastructure to build surgical services more generally. The authors argue that there is even a link between surgery and goal 1, the goal of halving the number of people living in poverty. A survey of patients at the Aravind Eye Hospital in Madurai, India found that 85% of men and 58% of women who had lost their jobs as a result of blindness from cataract regained those jobs after surgery. “Improving surgical capacity at district hospital level” was among the top 30 solutions at this year's Copenhagen Consensus meeting of distinguished economists to the question of how best to advance global welfare, especially the welfare of the developing world. The authors conclude that surgery is beginning to outgrow its status as the “neglected stepchild of global public health”.

Editors’ notes: If this open-access article sensitises surgeons around the world to the potential that their skills can play in achieving human development goals and if the skills of those who are motivated, culturally sensitive, and willing to learn from their national counterparts can be channelled by locally led teams into effective and high quality surgical services for the underserved, then surgery will no longer be a ‘neglected disease’.

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Basic science

Bernstein A. AIDS and the next 25 years. Science. 2008 ; 320(5877):717.

Since HIV was discovered as the cause of AIDS a quarter century ago, over 60 million people have been infected with the virus and over 25 million people have died. These numbers make the result of two “proof of concept” vaccine efficacy trials—the STEP and Phambili trials—extremely disappointing. These results reflect our still-limited knowledge of HIV, its interactions with the human immune system, and the formidable, unprecedented challenges that it poses. But evidence of immunological protection in certain experimental models of HIV in nonhuman primates, and the intriguing observation that a small proportion of HIV-infected individuals (“elite controllers”) can completely suppress the virus for years, suggest that a vaccine may be achievable. More, not less, basic and early-stage clinical research is needed. We need to understand the role of both the innate and adaptive immune responses during HIV infection. We need to make it much more attractive for young researchers, including those from other fields, to enter the HIV vaccine field. And the continued engagement of industry is essential if we are ever to have a vaccine. We know from experience with other pathogens that a vaccine is the best way to stop a virus. The only end for a journey that began 25 years ago should be the development of a safe and effective HIV vaccine.

Editors’ Notes: Disappointment can lead to sober reflection and taking stock of what should remain a firm foundation and what can and should be challenged and changed. HIV has a high degree of sequence diversity and is a phenomenal foe, striking the very cells needed for an effective immune response. The stakes are high- this is not the time to walk away.

Walker BD, Burton DR. Toward an AIDS vaccine. Science. 2008; 320(5877):760-4.

A quarter century of scientific discovery has been applied to developing an AIDS vaccine, yet this goal remains elusive. Specific characteristics of the virus, including the extreme genetic variability in circulating viral isolates worldwide, biological properties of HIV that impede immune attack, and a high mutation rate that allows for rapid escape from adaptive immune responses, render this a huge challenge. However, evidence of protection against AIDS viruses in animal models and control of HIV in humans under certain circumstances, together with scientific advances in understanding disease pathogenesis, provide a strong rationale and objective paths to continue the pursuit of an effective AIDS vaccine to stem the global epidemic.

Editors’ Notes: This review explains how the vaccines that work do so, before address ing the unique challenges for the development of an HIV vaccine. These include failure thus far to generate an immunogen to elicit effective neutralising antibodies and to identify the nature of T cell responses that could best contribute to vaccine protection against HIV. Nine critical issues and recommendations for immediate attention are laid out along with a call to pursue an HIV vaccine with greater passion than ever.

Rossi JJ, June CH, Kohn DB. Genetic therapies against HIV. Nat Biotechnol. 2007; 25(12):1444-54.

Highly active antiretroviral therapy prolongs the life of HIV-infected individuals, but it requires lifelong treatment and results in cumulative toxicities and viral-escape mutants. Gene therapy offers the promise of preventing progressive HIV infection by sustained interference with viral replication in the absence of chronic chemotherapy. Gene-targeting strategies are being developed with RNA-based agents, such as ribozymes, antisense, RNA aptamers and small interfering RNA, and protein-based agents, such as the mutant HIV Rev protein M10, fusion inhibitors and zinc-finger nucleases. Recent advances in T-cell-based strategies include gene-modified HIV-resistant T cells, lentiviral gene delivery, CD8(+) T cells, T bodies and engineered T-cell receptors. HIV-resistant hematopoietic stem cells have the potential to protect all cell types susceptible to HIV infection. The emergence of viral resistance can be addressed by therapies that use combinations of genetic agents and that inhibit both viral and host targets. Many of these strategies are being tested in ongoing and planned clinical trials.

Editors’ note: The plot thickens! Gene therapy could be a stand-alone approach or an adjuvant to drug regimens. However, most people living with HIV today are in settings with insufficient infrastructure to support such technology and viral escape will confound even gene therapy approaches. Several clinical trials testing gene transfer strategies are underway, but don’t hold your breath- this will take some time.

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Global, multilateral, and bilateral responses

Gorik Ooms, Wim Van Damme, Brook K Baker, Paul Zeitz, Ted Schrecker. The 'diagonal' approach to Global Fund financing: a cure for the broader malaise of health systems? Globalization and Health. 2008;4(1):6 [Epub ahead of print].

The potentially destructive polarisation between ‘vertical’ financing ( aiming for disease-specific results) and ‘horizontal’ financing ( aiming for improved health systems) of health services in developing countries has found its way to the pages of Foreign Affairs and the Financial Times. The opportunity offered by ‘diagonal’ financing ( aiming for disease-specific results through improved health systems) seems to be obscured in this polarisation. In April 2007, the board of the Global Fund to fight AIDS, Tuberculosis and Malaria agreed to consider comprehensive country health programmes for financing. The new International Health Partnership Plus, launched in September 2007, will help low-income countries to develop such programmes. The combination could lead the Global Fund to fight AIDS, Tuberculosis and Malaria to a much broader financing scope. This evolution might be critical for the future of AIDS treatment in low-income countries, yet it is proposed at a time when the Global Fund to fight AIDS, Tuberculosis and Malaria is starved for resources. It might be unable to meet the needs of much broader and more expensive proposals. Furthermore, it might lose some of its exceptional features in the process: its aim for international sustainability, rather than in-country sustainability, and its capacity to circumvent spending restrictions imposed by the International Monetary Fund. Ooms and colleagues believe that a transformation of the Global Fund to fight AIDS, Tuberculosis and Malaria into a Global Health Fund is feasible, but only if accompanied by a substantial increase of donor commitments to the Global Fund. The transformation of the Global Fund into a ‘diagonal’ and ultimately perhaps ‘horizontal’ financing approach should happen gradually and carefully, and be accompanied by measures to safeguard its exceptional features.

Editors’ note: The pendulum between vertical and horizontal financing has swung back and forth for decades. Diagonal financing proponents think funding for AIDS treatment and prevention could be the driving wedge for urgently needed increases in the overall level of resources available for health. Such a strategy could seriously affect sustainability of antiretroviral treatment programmes and undermine HIV prevention efforts unless accompanied by significantly increased long-term resource commitments. Otherwise, as the authors suggest, like the rabbit-in-a–hat track, without the rabbit this strategy will fail.

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Global, mulitlateral and bilateral responses

Shiffman J. Has donor prioritisation of HIV/AIDS displaced aid for other health issues? Health Policy Plan. 2008 Mar;23(2):95-100.

Advocates for many developing-world health and population issues have expressed concern that the high level of donor attention to HIV is displacing funding for their own concerns. Even organizations dedicated to HIV prevention and treatment have raised this issue. However, the issue of donor displacement has not been evaluated empirically. This paper attempts to do so by considering donor funding for four historically prominent health agendas - HIV, population, health sector development, and infectious disease control - over the years 1992 to 2005. The paper employs funding data from the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee, supplemented by data from other sources. Several trends indicate possible displacement effects, including HIV's rapidly growing share of total health aid, a concurrent global stagnation in population aid, the priority HIV control receives in US funding, and HIV aid levels in several sub-Saharan African states that approximate or exceed the entirety of their national health budgets. On the other hand, aggregate donor funding for health and population quadrupled between 1992 and 2005, allowing for funding growth for some health issues even as HIV acquired an increasingly prominent place in donor health agendas. Overall, the evidence indicates that displacement is likely occurring, but that aggregate increases in global health aid may have mitigated some of the crowding-out effects.

Editors’ note: Although this study considers only aggregate donor funding, does not evaluate national health funding in depth, and does not account for factors influencing funding for other health issues, such as disease burden and effectiveness of advocacy, it will definitely start you thinking. We can only imagine how funding flows might have evolved in a world without AIDS, the so-called ‘counterfactual’ of which economists speak. More in-depth studies are needed to examine the politics of aid provision in high-income countries, interactions among donors themselves, and dynamics in low- and middle-income countries in the context of donor harmonization initiatives and the Three Ones principles that place countries squarely in the driver’s seat.

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Lejars M, Pitigoi D, Teleman M, Nicolaiciuc D, Reintjes R. Implementing a second-generation HIV surveillance system in Romania: Experiences and challenges. Wien Klin Wochenschr 2007;119(7-8):242-247.

Romania is a low prevalence country for HIV. Nevertheless, a special epidemiological situation is evolving because of the high percentage of children who were infected by nosocomial transmission between 1986 and 1991 and the consequent increasing number of sexually transmitted cases in adults, in addition to new cases among injecting drug users. In this particular context and with regard to Romania’s accession to EU membership, second-generation surveillance (SGS) systems were to be implemented. Following a SWOT analysis of the existing surveillance system, a National conference, monthly working groups and a workshop for training were organized with concerned people from central level and from six pilot districts. Specialists in epidemiology, infectious diseases, dermato-venerology and health promotion were involved in the process of developing the survey methodologies, which were based on standard protocols. Methods of testing and legal and ethical issues were discussed, especially for illegal or stigmatized behaviours. Based on the specific HIV epidemiology of each district and also for practical reasons, the surveys developed and implemented were: serological and behavioural surveillance at dermato-venerology clinics in two of the selected districts, serological surveillance among patients aged 15-24 admitted to general hospitals in four districts, and behavioural surveillance among high school pupils aged 15-19 in five districts. While implementing SGS, financial and human resource constraints encountered in the development and implementation of the surveys at each location need to be taken into account. One of the most important lessons learnt during this project was the importance of teamwork and co-operation between the epidemiologists and clinicians involved in HIV surveillance. The lessons learned in Romania could be valuable for many regions in Europe.

Editors’ note: Low HIV prevalence countries face a “know your epidemic” challenge which calls for tailoring second generation surveillance strategies. Romania’s approach included a national conference, working groups, and training workshops. Involving members of populations at higher risk of HIV exposure in programme design, implementation and monitoring will be key to ensuring not only that human rights are respected but also that appropriate strategies for reaching out to marginalised populations are designed and implemented.

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Policy development

Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet 2007 Jun 2;369(9576):1883-9.

WHO regulations, dating back to 1951, emphasise the role of expert opinion in the development of recommendations. However, the organisation’s guidelines, approved in 2003, emphasise the use of systematic reviews for evidence of effects, processes that allow for the explicit incorporation of other types of information (including values), and evidence-informed dissemination and implementation strategies. Oxman and colleagues examined the use of evidence, particularly evidence of effects, in recommendations developed by WHO departments. The authors interviewed department directors (or their delegates) at WHO headquarters in Geneva, Switzerland, and reviewed a sample of the recommendation-containing reports that were discussed in the interviews (as well as related background documentation). Two individuals independently analysed the interviews and reviewed key features of the reports and background documentation. The authors found that systematic reviews and concise summaries of findings are rarely used for developing recommendations. Instead, processes usually rely heavily on experts in a particular specialty, rather than representatives of those who will have to live with the recommendations or on experts in particular methodological areas. The authors interpreted in this that progress in the development, adaptation, dissemination, and implementation of recommendations for member states will need leadership, the resources necessary for WHO to undertake these processes in a transparent and defensible way, and close attention to the current and emerging research literature related to these processes.

Editors’ note: This article received a lot of attention in public health circles. Although there are often difficulties in trying to obtain international consensus, it is clear that guidelines from normative agencies such as WHO need to be adapted by countries to their own epidemiological circumstances. For the record, the recommendations from the WHO/UNAIDS convened consultation on male circumcision and HIV in March 2007 were definitely anchored in the results of the three randomised controlled trials in Orange Farm, South Africa; Kisumu, Kenya; and Rakai District, Uganda but other evidence and information also came into play and influenced the recommendations (please see the UNAIDS website or WHO website).

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Lalonde B, Wolvaardt JE, Webb EM, Tournas-Hardt A. A process and outcomes evaluation of the international AIDS conference: who attends? Who benefits most? MedGenMed 2007;9:6.

The objective of the study was to conduct a process and outcomes evaluation of the International AIDS Conference (IAC). Reaction evaluation data are presented from a delegate survey distributed at the 2004 IAC held in Thailand. Input and output data from the Thailand IAC are compared to data from previous IACs to ascertain attendance and reaction trends, which delegates benefit most, and host country effects. Outcomes effectiveness data were collected via a survey and intercept interviews. Data suggest that the host country may significantly affect the number and quality of basic science IAC presentations, who attends, and who benefits most. Intended and executed HIV work-related behaviour change was assessed under 9 classifications. Delegates who attended 1 previous IAC were more likely to report behaviour changes than attendees who attended more than 1 previous IAC. The conference needs to be continually evaluated to elicit the required data to plan effective future IACs.

Editors’ note: For those of you who attended the Bangkok International AIDS Society Conference, were you a “behaviour changee”? Or were you just more used to being asked about your work-related HIV behaviour? If it takes three years to analyse the data then Mexico 2008 won’t benefit from the Toronto 2006 delegate survey. Find a way to channel your own views and advice for improvement while there is still time!

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