HIV & AIDS

From Alima Twaibu’s village in Nhkotakota district, it is 10 km to the nearest Health Center or 16 km to the District Hospital. With more than 80% of the population living in rural areas, the majority of Malawians experience similar challenges to accessing care. People have to walk long distances to receive services when they are sick. And when time away from work or paying for transport competes with other basic expenses, the decision to seek preventive services like family planning and HIV testing and counseling (HTC) is even more difficult. Fortunately for her neighbors and surrounding communities, Alima is an experienced Community-Based Distribution Agent (CBDA).

Mother and children, Salima, Malawi, April 2011

Malawi leads the developing world as the first to propose an approach to prevention of mother to child transmission (PMTCT) of HIV that addresses the health of the mother. Recently my MSH colleague Erik Schouten and his colleagues in Malawi wrote a commentary in the Lancet about Malawi’s innovative, public health approach to PMTCT. Malawi calls its model “B+” because it complements the World Health Organization’s (WHO) B option, whereby a mother’s CD4 cell count, a measure of the volume of HIV circulating in her blood, determines her eligibility for lifelong antiretroviral therapy (ART).

In June 2011, the CSIS Global Health Policy Center asked bloggers around the world, Do you think it's possible to create a unified social movement for NCDs, akin to the movements that already exist for individual chronic diseases?  If so, why?  If not, what initiatives can we implement in the place of an effective social movement to move an NCD agenda forward? Dr. Jonathan D. Quick was one of our four finalists.

For three years, Lucy Sakala has counseled people seeking HIV tests at a District Hospital in Malawi. A year ago, she was diagnosed with uterine cancer. She has had chemotherapy and surgery, which are sometimes painful and tiring, but are extending her life.

During the counseling sessions, she sometimes tells her patients about her illness: “I tell them they should live positively. There are several conditions more serious than HIV. I tell them I have cancer. It’s difficult, but I live positively."

The day before she said this, she had journeyed seven hours to the nearest city to see her doctor. He told her he had no more chemotherapy and she must buy it in a pharmacy. The cost was roughly $180. Insurance would only pay half.  The remaining half is a month’s salary, which she didn’t have.

Frackson Machilika and Grace Bonongwe

Grace Bonongwe is a grandparent. She comes from Zovuta Village T/A Nsamala in Balaka, about 10 kilometers from the nearest health facility. Of the nine children she has given birth to, only one lives to this day. The rest have died over the years from different diseases.

Grace is no stranger to disease and affliction considering she has gone through the pain of losing eight of her children. So when her husband fell ill, she dismissed it as a normal occurrence that would eventually lead to his demise. But he did not die, instead, his illness recurred on and off for a prolonged time.

Monday at the International AIDS Society conference in Rome, an expanded session featured information on the HPTN 052 study, the Partners PrEP Study, and the Centers for Disease Control’s TDF2 study presented in a joint session titled Treatment Is Prevention: The Proof Is Here, on Monday. The results of these trials will fundamentally change the way we think about HIV prevention and treatment, although implementation of these approaches will likely prove as challenging as ever.

HPTN 052, sponsored by the HIV Prevention Trials Network, was the first randomized clinical trial to definitively indicate that an HIV-infected individual can reduce sexual transmission of HIV to an uninfected partner by beginning antiretroviral therapy sooner. The study involved 1,763 HIV-serodiscordant couples at 13 sites across Africa, Asia, and the Americas. The trial results were initially released in May 2011 on the recommendation of an independent data and safety monitoring board (DSMB) and Monday’s session was the first full presentation of the trial data.

I’d like to call attention to an important set of articles in the recent HIV/AIDS themed issue of The Lancet. Erik Schouten of Malawi Basic Support for Institutionalizing Child Survival (BASICS) has published a commentary (free registration required) about Malawi’s push to be the first country to implement a “B+” approach to reducing mother to child transmission.

In 2006, Jamila, a 24 year old Guyanese waitress, took the opportunity to work in a store overseas with the hope of building a better life for her children. But her dreams were dashed when she arrived in the new country and realized the only job available was as a commercial sex worker. She had no money, nowhere to stay, and no one to turn to, so she became a sex worker to survive.  Jamila eventually earned enough to pay for her airfare back to Guyana, where she had left her children with her grandmother.

After her return to Guyana, she was encouraged by a friend to take an HIV test, but though the test was positive, Jamila did not believe it, as she was healthy at the time.

Jamila sought employment at a local logging company as a plywood grader. However, the challenges of her job eventually took a toll on her health and she repeatedly became ill. She thought her illness was a result of the hard work and sought alternative employment. She eventually found work as a caregiver at Guyana Responsible Parenthood Association (GRPA), one of the organizations supported by the USAID-funded, Management Sciences for Health-led, Guyana HIV/AIDS Reduction Program (GHARP II).

Thirty years ago, we learned of a disease that began with a few cases and quickly transformed into an epidemic the world had not seen before. We were not exactly sure what it was, how it was spread, or how to care for people who had it. HIV & AIDS has had a dramatic impact on the world – and especially on people in low and middle income countries. Over the past 30 years, AIDS programming responses have changed due to developments in public health science, politics, economics, and organizational capacity.

As we look through the past thirty years, there have been three distinct generations of AIDS responses and programming. In the 1980s, what we refer to as the Zero Generation, there was no effective response. Little was known and little was done about HIV & AIDS. Prevention was rudimentary, treatment nonexistent, and funding limited.

By 1990, the epidemic was already showing signs of spiraling out of control. The First-Generation programs were characterized by limited funding, a focus on prevention, continued denial in many parts of the world, and—as before— essentially no treatment in low- and middle-income countries.

The theme of this year’s Global Health Council annual conference was Securing a Healthier Future in a Changing World. As populations are shifting, so are their health priorities. Increasing urbanization has led to more people living in and around cities, creating a series of problems that are new to public health professionals. Nutritional challenges, the need for improved water and sanitation infrastructure, and addressing the issue of unregulated health care providers are all problems facing governments, ministries, NGOs, donors, and populations. In addition, non-communicable diseases (NCDs), including cancer, diabetes, cardiovascular conditions, and mental illness, are adding a new strain to many already resource constrained health systems. Of course, immunization, malaria, pneumonia, diarrhea, and maternal death are all still very serious challenges in many of these systems and remain key priorities.

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