Articles tagged as "Global / multilateral and bilateral responses"

Partnerships

Kamau EM. Roll Back Malaria and the new partnership for Africa’s development: Is there potential for synergistic collaboration in partnerships? Afr J Health Sci 2006;13:22-7.

This synopsis seeks to highlight and promote the enormous potential that exists between these two initiatives that seek to address closely related issues and targeting the same populations at risk within a fairly well defined geographical setting. It also attempts to argue that malaria control, just like HIV control, be given high priority in the New Partnership for Africa’s Development (NEPAD) health agenda, as current statistics indicate that malaria is again on the rise. While much attention and billions of dollars have rightly been given to HIV research, treatment and prevention, malaria, and not HIV, is the region’s leading cause of morbidity and mortality for children under the age of five years. This is the bad news. The good news is that unlike HIV, malaria treatment and prevention are relatively cheap. In addition, there is a payback to fighting malaria; support aimed directly at improving health, rather than poverty reduction, may be a more effective way of helping Africa to thrive. Robust and sustained growth may come to Africa through a mosquito net, Artemisinin-based Combination Therapies (ACTs) or a malaria vaccine, rather that a donor’s cheque for economic development initiatives.  

Editors’ note: We need to get out of our silos, strengthen health systems and look holistically at how we can best address malaria, tuberculosis, and HIV to improve Africa’s development prospects.

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TB/HIV

Wang Y, Collins C, Vergis M, Gerein N, Macq J. HIV/AIDS and TB: contextual issues and policy choice in programme relationships. Trop Med Int Health 2007;12:183-94.

Tuberculosis (TB) and HIV affect each other closely. Given the rapid spread of the HIV-driven TB epidemic worldwide, the case for establishing some form of relationship between control activities for HIV and TB is clear. However, the question ‘how’ has not been resolved satisfactorily. TB and HIV programmes have traditionally maintained their own management, supervision, funding flows and specialist boundaries. This article explores opportunities and challenges for collaboration between the two, through drawing on the expertise in organization and management, policy analysis and disease control of both TB and HIV. Based on an extensive literature review, the article investigates how contextual issues affect the design of a collaboration; what the organizational options are; and what impact a collaboration would have. A universal model for organizational change is unlikely and changes may present as both solutions and contradictions. Careful planning and consultation are required before implementing the changes, in order to avoid jeopardizing the function and effectiveness of both disease control programmes and the health service system.

Editors’ note: The need for close collaboration rather than isolation or even competition in the public health arena has been highlighted in several issues of HIV This Week. March 24th is World TB Day, a good opportunity to highlight collaborative actions at country, regional and global level!

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International initiatives

Simon C, de Lemos G. [UNITAID: an innovative and collective financing system for the fight against malaria, AIDS and tuberculosis]. Med Trop (Mars) 2006;66:583-4.

Malaria, AIDS and tuberculosis cause more than 6 million deaths a year in developing countries. And yet medicines allowing effective treatment either exist already or could be designed in forms adapted to the populations most severely affected by these pandemics (e.g., pediatric antiretroviral formulations suitable for developing countries). Simon and de Lemos describe how by providing sustainable predictable revenues, UNITAID promises to be a powerful tool to respond to the specific needs of developing countries in terms not only of leveraging price reductions but also of developing appropriate drug forms and diagnostic techniques not currently on the market. Stable financing as well as negotiation of large-volume procurement programs for several countries will make it easier for manufacturers to predict requirements and avoid shortages. UNITAID is an independent structure that complements the existing organizations involved in the fight against these pandemics. It intervenes only at the request of beneficiary countries using local human resources and logistics and works to improve the infrastructure facilities whenever necessary.


Bor J. The political economy of AIDS leadership in developing countries: An exploratory analysis. Soc Sci Med 2007 Feb 2; [Epub ahead of print]

The commitment of high-level government leaders is widely recognized as a key factor in curbing national AIDS epidemics. But where does such leadership come from? Bor presents a quantitative analysis of the determinants of AIDS leadership in 54 developing countries, using the 2003 AIDS Program Effort Index "political support" score as an indicator of political commitment. Explanatory variables include measures of political institutions as well as economic development and integration. Models developed in the author’s analysis explain over half of the variation in commitment across the countries in the sample. In particular, the author concludes press freedoms, income equality, and HIV prevalence stand out as determinants of political commitment.

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HIV/ Malaria/ TB

Slutsker L, Marston BJ. HIV and malaria: interactions and implications. Curr Opin Infect Dis 2007;20:3-10.

Slutsker and Marston summarise accumulating evidence of interactions between HIV and malaria and implications related to prevention and treatment of coinfection. HIV-infected persons are at increased risk for clinical malaria; the risk is greatest when immune suppression is advanced. Adults with advanced HIV may be at risk for failure of malaria treatment, especially with sulfa-based therapies. Malaria is associated with increases in HIV viral load that, while modest, may increase HIV progression or the risk of HIV transmission. Cotrimoxazole prophylaxis greatly reduces the risk of malaria in people with HIV; the risk can be further reduced with antiretroviral treatment and the use of insecticide treated mosquito nets. Increased numbers of doses of intermittent preventive (malaria) treatment during pregnancy can reduce the risk of placental malaria in women with HIV. The author concludes that interactions between malaria and HIV have important public health implications. People with HIV should use cotrimoxazole and insecticide treated mosquito nets. Malaria prevention is particularly important for pregnant women with HIV, although more information is needed about the best combination of strategies for prevention. In people with HIV, malaria diagnoses should be confirmed, highly effective drugs should be used for treatment, and possible drug interactions should be considered.

Editors’ note: Less attention has been focused on HIV and malaria than on HIV and tuberculosis but, as this article underscores, interactions can contribute to morbidity and mortality. Preventing malaria and effectively treating it in people living with HIV is important on both the individual and community levels.


Zachariah R, Harries AD, Manzi M, Gomani P, Teck R, Phillips M, Firmenich P. Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport. PLoS ONE 2006;1:e121. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1762339

Zachariah and colleagues analysed data on newly registered HIV-positive tuberculosis (TB) patients systematically offered ART in a district hospital in rural Malawi in order to a) determine the acceptance of ART b) conduct a geographic mapping of those placed on ART and c) examine the association between "cost of transport" and ART acceptance. The authors performed a retrospective cross-sectional analysis on routine programme data for the period of February 2003 to July 2004. Standardized registers and patient cards were used to gather data. The place of residence was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient's residence. Of 1290 newly registered TB patients, 1003 (78%) underwent HIV-testing of whom 770 (77%) were HIV-positive. 742 of these individuals (pulmonary TB = 607; extra-pulmonary TB = 135) were considered eligible for ART of whom only 101(13.6%) accepted ART. Cost of transport to the hospital ART site was significantly associated with ART acceptance and there was a linear trend in association between cost and ART acceptance (X2 for trend = 25.4, P<0.001). Individuals who had to pay 50 Malawi Kwacha (1 United States Dollar = 100 Malawi Kwacha, MW) or less for a one-way trip to the Thyolo hospital were four times more likely to accept ART than those who had to pay over 100 MW (OR 4.0, 95% CI 2.0-8.1, P<0.001). The authors conclude that ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital based ART site. Decentralizing the ART offer from the hospital to health centres that are closer to home communities would be an essential step towards reducing the overall cost and burden of travel.

Editors’ note: Even with antiretroviral treatment and laboratory testing free, out of pocket expenses can have a major impact in hindering uptake of life-prolonging therapies.

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TB/ HIV

Corbett EL, Bandason T, Cheung YB, Munyati S, Godfrey-Faussett P, Hayes R, Churchyard G, Butterworth A, Mason P. Epidemiology of tuberculosis in a high HIV prevalence population provided with enhanced diagnosis of symptomatic disease. PLoS Med 2006;4(1):e22. 10.1371/journal.pmed.0040022

Directly observed treatment short course (DOTS), the global control strategy aimed at controlling tuberculosis transmission through prompt diagnosis of symptomatic smear-positive disease, has failed to prevent rising tuberculosis incidence rates in Africa brought about by the HIV epidemic. However, rising incidence does not necessarily imply failure to control tuberculosis transmission, which is primarily driven by prevalent infectious disease. Corbett and colleagues investigated the epidemiology of prevalent and incident tuberculosis in a high HIV prevalence population provided with enhanced primary health care. Twenty-two businesses in Harare, Zimbabwe, were provided with free smear- and culture-based investigation of tuberculosis symptoms through occupational clinics. Anonymous HIV tests were requested from all employees. After two years of follow-up for incident tuberculosis, a culture-based survey for undiagnosed prevalent tuberculosis was conducted. A total of 6440 of 7478 eligible employees participated. HIV prevalence was 19%. For HIV-positive and -negative participants, the incidence of culture-positive tuberculosis was 25.3 and 1.3 per 1,000 person-years, respectively (RR 18.8, 95% CI 10.3-34.5: population attributable fraction = 78%), and point prevalence after 2 years was 5.7 and 2.6 per 1,000 population (OR 1.7; 95% CI 0.5-6.8: population attributable fraction = 14%). Most patients with prevalent culture-positive tuberculosis had sub-clinical disease when first detected. The authors conclude that strategies based on prompt investigation of tuberculosis symptoms, such as DOTS, may be an effective way of controlling prevalent tuberculosis in high HIV prevalence populations. This may translate into effective control of tuberculosis transmission despite high tuberculosis incidence rates and a period of sub-clinical infectiousness in some patients.

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Capacity building

Nu'man J, King W, Bhalakia A, Criss S. A Framework for building organizational capacity integrating planning, monitoring, and evaluation. J Public Health Manag Pract 2007;13(Suppl 1):S24-S32.

HIV prevention organisations are increasingly adopting more intensive and evidence-based strategies with the goal of protecting targeted populations from HIV infection or transmission. Thus, capacity building has moved to the forefront as a set of activities necessary to enable HIV prevention organizations to plan, implement, monitor, and evaluate prevention programs and services. Cost-effective approaches to the provision of capacity building assistance traditionally use strategies that compromise efficaciousness and more intensive approaches can be cost prohibitive. In addition, traditional approaches treat programme planning and implementation and programme monitoring and evaluation as two separate entities, even though they are interdependent aspects of an efficient and effective service delivery system. Nu’man and colleagues describe a framework for building sustainable organisational capacity that combines high- and low-intensity approaches; integrates programme planning, monitoring, and evaluation; and focuses on building understanding of the value of appropriate organisational change. The authors used the described framework over a 3-year period with 52 community-based organisations funded by the Centers for Disease Control and Prevention (CDC) and organizations funded by CDC-funded health departments. The authors describe lessons learned and make recommendations for building long-term sustainability, organisational change at various levels, and the need to develop standardised indicators to measure changes in organisational capacity.

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Conspiracy Theory

Bogart LM, Thorburn S. Relationship of African Americans' sociodemographic characteristics to belief in conspiracies about HIV/AIDS and birth control. J Natl Med Assoc 2006;98:1144-50.

Although prior research shows that substantial proportions of African Americans hold conspiracy beliefs, little is known about the subgroups of African Americans most likely to endorse such beliefs. Bogart and Thorburn examined the relationship of African Americans' socio-demographic characteristics to their conspiracy beliefs about HIV and birth control. Anonymous telephone surveys were conducted with a targeted random-digit-dial sample of 500 African Americans (15-44 years) in the contiguous United States. Respondents reported agreement with statements capturing beliefs in HIV conspiracies (one scale) and birth control conspiracies (two scales). Socio-demographic variables included gender, age, education, employment, income, number of people income supports, number of living children, marital status, religiosity, and black identity. Multivariate analyses indicated that stronger HIV conspiracy beliefs were significantly associated with male gender, black identity and lower income. Male gender and lower education were significantly related to black genocide conspiracy beliefs, and male gender and high religiosity were significantly related to contraceptive safety conspiracy beliefs. The set of socio-demographic characteristics explained a moderately small amount of the variance in conspiracy beliefs regarding HIV (R2 range=0.07-0.12) and birth control (R2 range=0.05-0.09). The authors conclude that findings suggest that conspiracy beliefs are not isolated to specific segments of the African-American population.

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Politics and Prevention

Laperriere H, Zuniga R. Sociopolitical determinants of an AIDS prevention program: multiple actors and vertical relationships of control and influence. Policy Polit Nurs Pract 2006;7:125-35

In every country, health and prevention "come down" from the authorities responsible for this mission by way of planners, local authorities, and peer educators until it reaches the target population. International and national systems function on the premise of a top-down transmission, with little room for integrating local information that might provide a better understanding of the implementation process. This analysis is based on an empirical evaluative research of HIV prevention projects with sex workers in a remote area of northern Brazil. It illustrates how nursing socio-political analysis can reveal how political interests can have perverse effects by contaminating the group's internal relations and with established partnerships, thereby weakening the impact of prevention programmes. These effects can seriously affect community relations and social practices, far beyond the technical division of work and political hierarchies in the socio-sanitary network.

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Policy Coordination

Sepkowitz KA. One disease, two epidemics - AIDS at 25. NEJM 2006; 354:2411-2414.http://content.nejm.org/cgi/content/full/354/23/2411

UNAIDS/Y. Shimizu
UNAIDS/Y. Shimizu
During the first two decades of the HIV epidemic, the epidemiology and clinical presentation of the disease were established, and potent ART were developed — for use in patients who could afford them. The progress of the past five years has been less dramatic. Indeed, the most salient change was a widening of the gap between the haves (developed countries) and the have-nots (developing countries), so that today a single virus is responsible for two distinct public health calamities. Kent Sepkowitz laments in this perspective article that for the past 25 years, the lessons learned about HIV prevention and control in one country have failed to inform decisions in others. As a result, the world has witnessed a slow-motion domino effect, as the disease overwhelms country after country. Typically, locals place the blame on foreigners and foreign behaviour — just as the French once called syphilis "the Italian disease" and the Italians considered it "the French disease." This sort of buck passing has delayed the control of AIDS in every country. By the time the scale of the problem is finally appreciated, a mature epidemic is in place, and the cost in lives and money has increased exponentially. We can only hope that the years ahead will be characterized not just by better drugs, new vaccines, and improved prevention methods, but also by the adoption of the humility necessary to control a disease that is transmitted through sexual activity and drug use — two of “proper” society's least favourite topics. Sepkowitz categorically states that the prime mover of the HIV epidemic is not inadequate antiretroviral medications, poverty, or bad luck, but our inability to accept the gothic dimensions of a disease that is transmitted sexually. Only when we cease to dodge this fact will effective HIV-control programs be established. Until then, Sepkowitz concludes, it is no exaggeration to say that our polite behaviour is killing us


Merson MH. The HIV–AIDS pandemic at 25 – the global response. NEJM 2006;354:2414-2417. http://content.nejm.org/cgi/content/full/354/23/2414

AIDS is now the leading cause of premature death among people 15 to 59 years of age. In the hardest-hit countries, the foundations of society, governance, and national security are eroding, stretching safety nets to the breaking point, with social and economic repercussions that will span generations. This crisis demanded a unique and truly global response to meld the resources, political power, and technical capacity of wealthy countries with the needs and capacities of developing countries. Such a response would have required policymakers to address taboos concerning sexual behaviour, drug use, power relations between the sexes, poverty, and death. Instead, Michael Merson argues in this perspective article, AIDS often engendered stigma, discrimination, and denial, because of its association with marginalised groups, sexual transmission, and lethality. The result was two decades of a slow, insufficient, inconsistent, and often inappropriate response. A quarter century into the pandemic, the global response stands at a crossroads. More new infections and deaths occurred in 2005 than ever before. A year ago, the G8 and the UN World Summit embraced the goal of the goal to get as close as possible to universal access to prevention, treatment, care, and support by 2010. Attaining this would require more resources – an estimated US$18.1 billion in 2007 and US $22.1 billion in 2008. As AIDS becomes a chronic disease, this funding must be used in part to strengthen fragile health care systems. The progress of the past five years provides a solid foundation on which to build the comprehensive and sustainable response vital to ultimate control of this pandemic. Without this response, Merson conludes, many millions more will die of AIDS or be catastrophically affected by its consequences.

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