Articles tagged as "National responses"

Politics of Disease

Elizabeth M. Prescott. The Politics of Disease: Governance and Emerging Infections. Journal of Global Health Governance 2007 Jan;[online]. http://diplomacy.shu.edu/academics/global_health/journal/PDF/Prescott-article.pdf

 Infectious disease outbreaks demand a timely and proportional response. The responsibility for this action falls to those with the power to harness the processes and systems by which a society operates in order to effect the changes necessary to limit transmission of an illness. Controlling emerging and re-emerging infectious diseases can require extreme actions and coordination between many national and international actors making the ability to respond a reflection of the capacity of a governing system. In the absence of good governance, opportunities are created for disease to emerge, while at the same time, an aggressive response is often hindered. Failures in governance in the face of infectious disease outbreaks can result in challenges to social cohesion, economic performance and political legitimacy. Overall, the need for coordination of actions despite a high degree of uncertainty and high costs makes curtailing infectious disease a challenge in the absence of good governance.

Editors’ note: Whether speaking of an acute infectious disease outbreak or a chronic, endemic, eroding disease, it is clear that good governance, coordination, and harmonisation are the keys to an effective response. The Three Ones have relevance for far more than HIV!


 Wiig K, Smith C. An exploratory investigation of dietary intake and weight in human immunodeficiency virus-seropositive individuals in Accra, Ghana. J Am Diet Assoc 2007;107:1008-13.

In Africa, the human immunodeficiency virus and acquired immunodeficiency syndrome complex is commonly referred to as “slim disease” because, as the disease progresses, food intake and metabolism are altered, leading to visible body weight loss. In this descriptive, cross-sectional pilot study, 50 HIV-seropositive adults attending the Korle Bu Teaching Hospital in Accra, Ghana, were interviewed during the late spring of 2003. Demographics, medical HIV history and current status of their HIV disease, food safety, and food security information were collected. One 24-hour dietary recall was completed, height and weight were measured, and body mass index (BMI) was calculated for each participant. Results show that women participants had a higher mean BMI and maintained it through disease progression compared with men (P<0.02). The majority of the participants cited cost as a barrier in purchasing adequate amounts of food (92%). Fruit and vegetable intake was low overall (<three servings/day). The foods contributing most to daily energy intake were fried fish, white rice, kenkey, white bread, and fufu. In fighting the global HIV epidemic, registered dietitians must consider barriers to achieving optimal nutritional status in a cultural context to enhance feasibility and ensure the effectiveness of dietary interventions.

Editors’ note: Caloric needs increase with advanced HIV disease, exacerbating the potential shortfall. BMI or body mass index (weight divided by height squared) is a quick measure of obesity or underweight. Why women would be better able to maintain BMI than men in this Accra population is unclear. What is known is that poor nutritional state can mean a higher probability of HIV disease progression. However, this is a concern not only for dieticians but for programme planners, anti-poverty advocates, and development partners who must consider the barriers, particularly that of cost, to maintaining adequate nutritional intake among people living with HIV in resource-constrained settings.

National responses
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Country responses

Harries AD, Schouten EJ, Makombe SD, Libamba E, Neufville HN, Some E, Kadewere G, Lungu D. Ensuring uninterrupted supplies of antiretroviral drugs in resource-poor settings: an example from Malawi. Bull World Health Organ 2007;85:152-5.

Drug procurement and distribution practices are weak in many resource-poor countries, and are a major reason for lack of access to medicines. With many countries scaling up antiretroviral therapy (ART), it is vital to avoid interrupted drug supplies, which would lead to drug resistance and treatment failure. Malawi has adapted a model, based on that adopted by the country’s Tuberculosis Control Programme, to allow rational antiretroviral drug forecasting. The model includes a focus on one standardized first-line ART regimen; a “push system” and “ceilings” for first-line ART drugs for facilities; use of starter pack and continuation pack kits; quarterly monitoring of patient outcomes and ART drug stocks at facility level; provision of a three-month buffer stock of ART drugs at facility level; and use of a procurement and distribution system outside central medical stores. The focus on a single first-line regimen, “ceilings” for first-line ART drugs and quarterly data collections to calculate drug needs (for new and follow-up patients, respectively), as well as the use of an independent procurement facility, allow drug orders to be made 6-9 months ahead. These measures have so far ensured that there have been no ART drug stock-outs in the country.

Editors’ note: Malawi is a best practice example of a well designed system of checks and balances using standardized regimens and effective supply side management to avoid drug stock-outs. Malawi’s treatment success rate will be followed with interest, along with the results of drug resistance surveys, as these indicators are the potential favorable outcomes of uninterrupted supplies.


Campbell C, Nair Y, Maimane S. Building contexts that support effective community responses to HIV/AIDS: a South African case study. Am J Community Psychol 2007 Apr 20; [Epub ahead of print]

In this paper Campbell and colleagues discuss their conceptualisation of a ‘health-enabling social environment’, and some of the strategies they are currently using to build social contexts most likely to support effective HIV management in southern Africa. In developing these ideas, the authors draw on our on-going collaboration with residents of Entabeni, a remote rural community in South Africa where 43% of pregnant women are HIV positive. The aim of this collaboration is to facilitate contextual changes that will enable more effective community-led HIV management in an isolated area where people have little or no access to formal health or welfare support, and where HIV is heavily stigmatised. The authors give an account of the three phases of collaboration to date. These include research; the dissemination of findings and community consultation about the way forward; preliminary project activities (skills training for volunteer health workers; partnership building and a youth rally) as a way of illustrating six key strategies for facilitating the development of ‘AIDS-competent’ communities: building knowledge and basic skills; creating social spaces for dialogue and critical thinking; promoting a sense of local ownership of the problem and incentives for action; emphasising community strengths and resources; mobilising existing formal and informal local networks; and building partnerships between marginalized communities and more powerful outside actors and agencies, locally, nationally and internationally. The authors discuss some of the triumphs and trials of this work, concluding with a discussion of the need to set realistic goals when working at the community level in highly conservative patriarchal communities to tackle problems which may be shaped by economic and political processes over which local people have little control.

Editors’ note: Mobilising communities to actively engage in responding to HIV is key to overcoming stigma and other barriers to becoming “AIDS-competent”. Social change to create the healthier and more equitable gender norms that are essential to turning the epidemic around will take much longer and need to be supported by structural and legal changes at higher levels.

National responses
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Monitoring and evaluation

Allen C, Manyika P, Jazayeri D, Rich M, Lesh N, Fraser H. Rapid deployment of electronic medical records for ARV rollout in rural Rwanda. AMIA Annu Symp Proc 2006;840.

While most people with AIDS do not yet have access to antiretroviral drugs, large antiretroviral treatment (ART) programmes are being rolled out in many areas in sub-Saharan Africa. ART programmes have substantial data management needs which electronic medical record systems are helping to address. While most sophisticated electronic medical record systems in low-income regions are in large cities, where infrastructure and staffing needs are more easily met, Partners In Health has pioneered web-based electronic medical record systems for HIV and TB treatment in rural areas. Allen and colleagues deployed the HIV electronic medical record system developed in Haiti in two Rwandan health districts starting in August 2005. The authors report that addition of new features and adaptation to local needs is happening concurrently with the rapid scale-up and evolution of the medical programme itself.

Editors’ note: Electronic medical records, in systems which respect patient confidentiality and ensure record security, are being discussed and implemented in various settings following pilots such as these in operational research programmes.

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Open Access Publications

Eysenbach G. Citation advantage of open access articles. PLoS Biol 2006;4:e157. http://biology.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pbio.0040157

Open access (OA) to the research literature has the potential to accelerate recognition and dissemination of research findings, but its actual effects are controversial. This was a longitudinal bibliometric analysis of a cohort of OA and non-OA articles published between 8 June 2004 and 20 December 2004 in the same journal (PNAS: Proceedings of the National Academy of Sciences). Article characteristics were extracted, and citation data were compared between the two groups at three different points in time: at "quasi-baseline" (December 2004, 0-6 months after publication) and in October 2005 (10-16 months after publication). Potentially confounding variables, including number of authors, authors' lifetime publication count and impact, submission track, country of corresponding author, funding organization, and discipline, were adjusted for in logistic and linear multiple regression models. A total of 1,492 original research articles were analyzed: 212 (14.2% of all articles) were OA articles paid by the author, and 1,280 (85.8%) were non-OA articles. The average number of citations of OA articles was higher compared to non-OA articles (April 2005: 1.5 [SD 2.5] versus 1.2 [SD 2.0]; P=0.002; October 2005: 6.4 [SD 10.4] versus 4.5 [SD 4.9]; P<0.001). In a logistic regression model, controlling for potential confounders, OA articles compared to non-OA articles remained twice as likely to be cited (OR 2.1, 95%CI 1.5-2.9) in the first 4-10 months after publication (April 2005), with the odds ratio increasing to 2.9 (95%CI 1.5-5.5) 10-16 months after publication (October 2005). Articles published as an immediate OA article on the journal site have higher impact than self-archived or otherwise openly accessible OA articles. We found strong evidence that, even in a journal that is widely available in research libraries, OA articles are more immediately recognized and cited by peers than non-OA articles published in the same journal. OA is likely to benefit science by accelerating dissemination and uptake of research findings.

Editors’ note: Open access journals have a novel business plan compared to the standard model for medical and other scientific journals to which only paid-up subscribers have access. Successful authors who have passed stringent peer review pay to have their articles published using funds usually from their institution or research grants. Open access articles can be from an open access journal or a subscriber-only access journal. They are placed, without embargo, in at least one widely and internationally recognized open access repository (such as PubMed Central). The author(s) or copyright owner(s) irrevocably grant(s) to any third party, in advance and in perpetuity, the right to use, reproduce or disseminate the research article in its entirety or in part, in any format or medium, provided that no substantive errors are introduced in the process, authorship is attributed and correct citation and bibliographic details are given. As you can see in this study, open access journals and articles, get your message out. More widespread knowledge dissemination is more likely to influence research, policy, and programmes.

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AIDS Response

Horton R. A prescription for AIDS 2006–10. Lancet 2006;368:716-718.http://www.sciencedirect.com/

In a commentary today in the Lancet, Richard Horton, the editor, describes the Toronto AIDS Conference: Fresh science brought attention to a new class of antiviral agent, the integrase inbibitors. An extremely drug-resistant strain of tuberculosis was described. A visible shift took place in the terms of engagement with HIV – from treatment to prevention. Male circumcision, pre-exposure prophylaxis with antiretrovirals, microbicides, and vaccines were all discussed vigorously. Women were centre stage. Routine testing for HIV provoked furious debate, with proponents arguing that it was one of the few practicable ways to expand treatment. Opponents said it would undermine essential liberties. In sum, there was much to reflect on: narrowly defined, a success. But the opportunity to produce a roadmap to reach the 2010 target of universal access was squandered. Rarely has there been a meeting that felt so disengaged from a global predicament of such historic proportions. The agenda in Toronto was unfocused, giving prime air time to celebrities, such as Bill Gates and Bill Clinton, while largely ignoring Africa. Horton argues that the global action to defeat this pandemic has stalled. A veneer of achievement - 1·6 million people taking antiretroviral drugs, together with the existence of powerful financing mechanisms, such as the Global Fund, PEPFAR, and the Gates Foundation – has bred complacency. He admonishes those who lead the AIDS community to ask these 10 difficult questions that failed to get the answers they deserved at the conference: 1. Why do we refuse to admit that there is still no genuine global commitment to scale up our response to AIDS? 2. Why are the wider health, economic, social, and cultural contexts of AIDS still being ignored? 3. Why does our definition of science still seem to include only the laboratory experiment and the clinical trial? 4. Why do we see biology, medicine, epidemiology, social science, and policy making as parallel, mutually exclusive “tracks” at the International AIDS Conference? 5. After 25 years of AIDS, why are children still largely ignored? 6. Why do health agencies and programmes still base their prevention messages on the outdated and scientifically corrupt idea of abstinence? 7. Why are civil society and NGOs still not being given the credit they deserve as vital levers in the global AIDS response? Why do we still not see the community as a means for societal change? 8. Why is stigma—of gay men and women, indigenous peoples, migrants, refugees, internally displaced persons, drug users, sex workers, and prisoners—still not the concerted focus of the AIDS response? 9. Why do so many of those committed to defeating AIDS prefer to lecture one another about what each is doing wrong, instead of working harder to find meeting points of dialogue and partnership? 10. The most damning question of all: why is the world's response to AIDS failing? He concludes that the grip of AIDS will only be broken by effective programmes at country level. This exclusive country focus should be the purpose of the International AIDS Society's conference – a global accountability mechanism to monitor country progress, to hold all parties responsible for the part they play in defeating AIDS, and to set specific, measurable objectives for the succeeding 2 years. In Mexico in 2008, the international AIDS community will reconvene to take stock of this unprecedented pandemic and to review progress towards the 2010 goal of universal access. Horton concludes that the litmus test for Mexico's success will be the degree to which the conference can be transformed from a scientific meeting and global beacon for AIDS, to a coordinating mechanism to drive advances in prevention, treatment, and care at country level.

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Three Ones

Whyms D, Huijts I, Jensen SL. Coordinating HIV control efforts. Lancet 2006;368:446. http://www.sciencedirect.com/

Photo credit: UNAIDS/Y. Shuimizu
Photo credit: UNAIDS/Y. Shuimizu
In a Lancet article published on 27 May 2006 (Lancet 2006;367:1786–89), Roger England criticised the current structure and functioning of national AIDS commissions (NACs). He suggested radical changes to the planning, coordinating, and monitoring of national HIV control efforts. He went further to propose that NAC functions be put out to tender and provided by a private organisation; contracted by and reporting to a steering committee of donors, UNAIDS, and representation from the presidency and the health ministry, overseeing a funding basket and held together with a joint memorandum of understanding. Whyms and colleagues agree that Roger England is right to press for more accountability and a stronger focus of resources on priorities. But they argue that he is inconsistent in laying the blame for many of the missed priorities and wasted efforts on NACs, when in reality the bulk of resources do not go through the hands of NACs at all. He seems to point the finger of blame only at the failure of national public institutions, and not see the challenges posed by the practices of international partners in a crowded institutional landscape. Privatisation as suggested by England in low-capacity countries does not guarantee better performance. Whyms and colleagues suggest that what is needed is for national AIDS authorities to develop prioritised and costed AIDS plans that are aligned with national development plans, with the goal of scaling up towards universal access to prevention, treatment, care and support. Civil society and vulnerable groups should be fully engaged in developing national plans, and countries should ensure the accountability of all partners through transparent peer review mechanisms for monitoring processes and targets. At country level, the AIDS response is often complex and fragmented. Thus, Whyms and colleagues conclude, without a clearer focus on harmonising the disparate players and resources, and aligning these behind the single national response, simply contracting out the NAC functions will not address this fragmentation, and will impede our aspiration to most effectively scale up towards universal access.

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Advocacy for a Sustained Strategic Response to HIV

Piot P. AIDS: from crisis management to sustained strategic response. Lancet 2006; 368:526–30. http://www.sciencedirect.com/

Photo credit: UNAIDS/R. Bowman
Photo credit: UNAIDS/R. Bowman
AIDS has become one of the make-or-break forces of this century, as measured by its actual impact and potential threat to the survival and wellbeing of people worldwide. Peter argues that the only other global problems that are in the same league as AIDS are extreme poverty and deprivation as a whole; climate change; and the potential risks posed by nuclear war, chronic armed conflicts, or a sustained breakdown of international finance and trade. But quite beyond the devastation that it has set in motion already, the epidemic is exceptional in terms of the scale of future threats it poses. Although it is not possible to predict its probable length, it is prudent to recall that the epidemic has continually outstripped the worst-case global scenarios, that national HIV prevalence has risen far beyond what was ever thought possible, and that we are witnessing multiple waves of HIV spread even in countries where incidence has peaked, especially when HIV prevention programmes do not continue to receive adequate support. The exceptional characteristics of AIDS mean that only an exceptional response, going far beyond the usual public-health parameters of epidemic control and technological interventions, can succeed in checking the epidemic. For much of the first quarter century of AIDS, the response remained business as usual. However, the narrative of the AIDS response is now increasingly one of momentum and achievement. Almost everywhere, and on almost every front, there is today a qualitative difference in the AIDS response. The fundamental challenge we face is to sustain a full-scale AIDS response over at least another generation. To have real success against this crisis, rather than the piecemeal progress of recent years, requires us to anticipate the future, not just in terms of years, but of decades. It requires us to challenge ourselves to meet not only the needs of today on an emergency footing but to take on additional responsibility for sustaining the response at increasingly high levels. An agenda for a response commensurate with the challenges posed by the epidemic cannot be realised if we do not maintain the exceptionality of AIDS. We need to put action on AIDS at the core of social and economic development and leverage mainstream instruments and practice, such as by including AIDS funding in long-term national financial planning, progress on AIDS as a key indicator for national development, and priority consideration of AIDS in poverty reduction strategies and medium-term expenditure frameworks. If we agree to surrender the exceptionality of AIDS, we will come to regret our decision millions of deaths later. Peter concludes that we must now collectively take the response to AIDS to this exceptional level so that we are indeed planning and acting for eventual success. Faced with an unprecedented crisis, we have no choice but to act in exceptional ways. AIDS has rewritten the rules; to prevail, we must too.

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Country Response

Chandrasekaran P, Dallabetta G, et al. Containing HIV/AIDS in India: the unfinished agenda. Lancet Infect Dis 2006;6:508-21. http://www.sciencedirect.com/

India's HIV epidemic is not yet contained and prevention in populations most at risk of HIV exposure (high-risk groups) needs to be enhanced and expanded. HIV prevalence as measured through surveillance of antenatal and sexually transmitted disease clinics is the chief source of information on HIV in India, but these data cannot provide real insight into where transmission is occurring or guide programme strategy. The factors that influence the Indian epidemic are the size, behaviours, and disease burdens of high-risk groups, their interaction with bridge populations and general population sexual networks, and migration and mobility of both bridge populations and high-risk groups. The interplay of these forces has resulted in substantial epidemics in several pockets of many Indian states that could potentially ignite sub-epidemics in other, currently low prevalence, parts of the country. The growth of HIV, unless contained, could have serious consequences for India's development. India's national response to HIV began in 1992 and has shown early success in some states. The priority is to build on those successes by increasing prevention coverage of high-risk groups to saturation level, enhancing access and uptake of care and treatment services, ensuring systems and capacity for evidence-based programming, and building in-country technical and managerial capacity.

Editors’ note: UNAIDS uses the expression ‘populations at higher risk of HIV exposure’ or ‘most at risk populations (MARP)’ in preference to the old stigmatising term ‘high risk groups’.

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Country Response

Slutkin G, Okware S, Naamara W, Sutherland D, Flanagan D, Carael M, Blas E, Delay P et al. How Uganda Reversed Its HIV Epidemic. AIDS Behav 2006 Jul 21[Epub ahead of print]

http://www.springerlink.com/media/f0llqlwqrlp1f0guubex/contributions/7/0/2/4/7024v857p67q0220.pdf

Slutkin and colleagues focus on Uganda as one of only two countries in the world that has successfully reversed the course of its HIV epidemic. There remains much controversy about how Uganda's HIV prevalence declined in the 1990s. The authors describe the prevention programmes and activities that were implemented in Uganda during critical years in its HIV epidemic, 1987-1994. Multiple resources were aggregated to fuel HV prevention campaigns at multiple levels to a far greater degree than in neighbouring countries. The authors conclude that the reversed direction of the HIV epidemic in Uganda was the direct result of these interventions and that other low- and middle-income countries could similarly prevent or reverse the escalation of HIV epidemics with greater availability of HIV prevention resources, and well designed programmes that take efforts to a critical breadth and depth of effort.

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4 for everyone?

Okie S. Fighting HIV — Lessons from Brazil. N Engl J Med 2006;354:1977-81

Okie x-rays Brazil’s experience in providing access to HIV prevention, treatment, care and support to those in need of these services. The government-funded treatment programme, which has improved the health system and extended the survival of tens of thousands of Brazilians, has saved the country an estimated US$2.2 billion in hospital costs between 1996 and 2004, and inspired similar efforts elsewhere — including PEPFAR. In addition, Brazil’s persistent and aggressive efforts to prevent new HIV infections have probably played an equal or greater role in slowing the spread of the virus and containing the country’s epidemic. At the beginning of the 1990s, the epidemics in Brazil and South Africa, both middle income countries, were at a similar stage, with a prevalence of HIV infection of about 1.5 percent among adults of reproductive age. But by 1995, the year before Brazil’s treatment program was established, the HIV epidemic in South Africa had begun to explode; with a prevalence already greater than 10 percent, whereas the infection rate in Brazil had declined by half.

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