Getting to Zero: HIV by the numbers

• 25 million: number of deaths caused by HIV/AIDS since 1981
• 2.5 million: number of HIV-related deaths averted by antiretroviral treatment (ART) in low- and middle-income countries (LMICs) since 1995
• 34 million: number of people living with HIV worldwide at the end of 2010
• 3.4 million: number of children under 15 years living with HIV
• 68%: percentage of HIV-positive persons living in sub-Saharan Africa
• 2.7 million: number of new HIV infections worldwide in 2010, a 21% decrease from 1997
• 50%: worldwide percentage of HIV-infected persons who aware of their status
• 96%: reduction in sexual transmission of HIV between serodiscordant partners with antiretroviral therapy observed in the HPTN052 trial

• 61%: percentage of new HIV infections in the United States occurring among men who have sex with men (MSMs) as of 2009
• 44%: percentage of new HIV infections in the United States occurring among Blacks as of 2009
• 2%: Adult HIV prevalence in Baltimore city in 2009; adult HIV prevalence in Haiti in 2009
• 5%: Adult HIV prevalence in Baltimore zip code 21205, directly northeast of the Johns Hopkins medical campus, in 2009; adult HIV prevalence in Gabon in 2009
• 37.5%: HIV prevalence among MSMs in Baltimore city; the proportion of new HIV infections among MSMs in Baltimore has increased to nearly the same levels as in 1985
• 76.9%: percentage of HIV-infected MSMs in Baltimore city who are unaware of their status
• 312: Median CD4 count at HIV diagnosis in the Baltimore-Towson metropolitan area (current guidelines recommend initiating ART at CD4 counts 350-500)
• 6,411: Number of HIV-positive people in the United States currently on AIDS drugs assistance program (ADAP) waiting lists

• 6.65 million: number of HIV-infected people currently receiving ART in low- and middle-income countries
• 3.3 million: number of people currently receiving ART through Global Fund grants
• $2.2 billion: unfulfilled pledges to the Global Fund to fight AIDS, TB and Malaria
• 2: number of countries (USA and UK) that have honored their pledges to the Global Fund

• ZERO: number of new grants that will be awarded by the Global Fund for the next two years in response to budget shortfall; UNAIDS goal by 2015 (0 new infections, 0 discrimination, 0 AIDS-related deaths)

Training to What End? Neonatal Mortality and HIV/AIDS in Ghana

The Ministry of Health in Ghana recently hosted a training session for community health nurses, midwives, and traditional birth attendants under the Neonatal Survival Project Program. Neonatal mortality remains a large problem in Ghana at 28 per 1,000 live births, according to the 2009 WHO statistics. To contrast, the neonatal mortality rate of the United States is 4 and the rate in Sweden is 2 per 1,000 live births. This training focused on recognizing danger signals before, during, and after delivery, as well as training on more general health issues, such as hygiene.

I spent a year living in Ghana before coming to Hopkins. While there, I got my MPH with a focus on preventing mother to child transmission (PMTCT) of HIV. I specifically studied the proper breastfeeding guidelines for HIV-positive mothers and how well these women (and their healthcare providers) understood these guidelines as a way to minimize both risk of HIV transmission and risk of infection. In resource poor settings, it is often not feasible or safe for HIV-positive mothers to use breast milk substitutes, as many women in developed countries do, to prevent transmission of HIV to their baby. Unhygienic preparation of these substitutes leads to high rates of morbidity and mortality in infants, especially from diarrheal diseases. Furthermore, many women simply cannot afford to buy their infants these substitutes. The WHO recommends that in these situations, women practice exclusive breastfeeding for 4-6 months, followed by prompt weaning. As with all health guidelines, there are exceptions, which need to be explained clearly and thoroughly to HIV-positive mothers. As expected (sadly), many healthcare providers do not themselves understand these guidelines; even if they do understand the guidelines, they often lack the time needed to counsel HIV-positive women; and there are numerous cultural barriers these women face in acting upon these guidelines. The result is high rates of infant morbidity and mortality, as well as mother to child transmission of HIV.

In researching my project, I attended many sessions held jointly by the Ghana Health Service and the National AIDS Control Program that focused on training various health professionals on counseling and treatment guidelines for people living with HIV/AIDS. By sitting in on these sessions, I was able to witness the limits of this training system. While I believe it is essential that these training programs, such as the Neonatal Survival Project Program, are taking place and that resources are being devoted to these causes, what truly lacked in the sessions I saw was a way of strategizing for and tackling the practical barriers that inhibit lasting change. I noticed that the HIV/AIDS training programs gave outlines on the fact that HIV-positive mothers should breastfeed exclusively if they cannot afford substitutes, yet they did not tell trainees what “exclusive breastfeeding” meant. Upon speaking with these trainees after sessions, I discovered that the majority of them had erroneous ideas of what exclusive breastfeeding actually meant, which increased the likelihood that their child would contract HIV and/or a bacterial infection. Training programs for health professionals, especially in such needed areas as neonatal mortality and PMTCT, are a crucial step in improving health outcomes. However, we need to strive to make sure trainees are being empowered with all the knowledge they will need to make true change in their communities.

“Co-producing” Health

Ever since the United States boldly asserted its influence over the international arena in the post-World War II era, the topic of its role in the development and progress of foreign countries has long been debated. This question reaches the U.S. medical profession today as we seek to better understand our role as healthcare providers in a time of growing global interconnectedness. One way of assessing our own international involvement is to evaluate our characterization of the presumed “target population.” Our view of the needs and responsibilities of those we treat abroad dictates our approach to global health.

We often preoccupy ourselves with the logistics of our own medical resources—how many doctors and supplies can we allocate, and how many clinics can we build? Moreover, we too easily view the population at hand as a model of a single disease or condition. We simply declare that we are going to “help HIV patients in Africa” and that becomes our singular goal. Yet this ignores the very social capital and means that are possessed by the persons we seek to help. We overlook the fact that health is not an isolated state of being, but that it is regulated by a series of social, cultural, and even political levers. As such, we should understand people as integral participants in their personal health maintenance and as key components of a larger social network. Earlier this year, Dr. Julio Frenk, Dean of the Harvard School of Public Health as well as the former Minister of Health of Mexico, wrote about expanding our view of global health systems through understanding a person in five different roles: patient, consumer, taxpayer/financier, political citizens, and co-producers of individual and societal health (Frenk, PLoS, 2010). If we do not see global health populations in these contexts, we not only provide an inadequate service but we miss the opportunity to build sustainability and self-sufficiency within the developing society. Such a sentiment is reflected in recent calls to action to develop an “International Health Service Corps” in which health care workers would engage in medical service and capacity-building partnerships abroad as an act of diplomacy (Kerry et al, NEJM, 2010).

Global health involvement of the U.S. is not a question of whether or not we should be involved. In a globalized age, international communication and exchanges are inevitable and necessary. The question is about the particular way in which we are going to partner with the local communities to implement the most effective health interventions and systems possible.  Global health is about how we can make something better overseas than if we had not been involved at all. More importantly, however, it is about how the people abroad can make something better than if they had not been involved at all.

 

International AIDS Conference

The 18th International AIDS Conference began yesterday in Vienna. A great opportunity to take a step back and reflect upon the road ahead in the context of stagnant funding and ever greater challenges in the prevention of transmission. If you can’t afford the flight, there are live webcasts on the Kaiser Family Foundation website.

Microbicides–When will they deliver?

The AP recently reviewed current research on the effectiveness of vaginal microbicides, gels that provide prophylactic protection from HIV infection.

These gels promise to be an amazing tool in the fight against HIV, especially in areas of the world where condoms are 1) not easily accessible/available 2) not allowed to be used for a variety of reasons (religious edict, cultural taboo/condemnation, et cetera). Consequently, vaginal microbicides, like the female condom, have promised to provide a “women-controlled protection” believed to be key in fighting the HIV/AIDS epidemic.

However, trials of numerous microbicide continue to end in disappointment, baffling researchers and frustrating activists looking for another preventive measure in their armamentarium against HIV:

“Frankly, blocking transmission of the virus appears to be a lot harder than anyone understood it would be at the beginning,” says meeting co-chair Dr. Sharon Hillier of the University of Pittsburgh and a principal investigator of the Microbicide Trials Network.

Similar trials looking at rectal microbicides have been equally disappointing.

As things stand now, I cannot help but ask “when will the research deliver?” On the Global Campaign for Microbicides website, they have a section describing how microbicides work. Yet, as you read, you get the impression no one knows how they work…because they don’t. There have been no proof-of-concept studies, there has been little date supporting the effectiveness of any of the trials. Essentially, the research seems to be driven by the ideal of a microbicide, by the idea of “how great it would be if we had a preventive gel.” I can’t help but be a little cynical as more and more research dollars are pumped into a preventive measure that continues to not only prove ineffective but also puts people at increased risk of HIV infection.

So, again, I ask, “when will they deliver?” Or perhaps a better question is to ask, “will they ever deliver?”

At some point, we will need to step back, look at the basic science of the immune response and that data that continues to pour in from microbicide trials and see that maybe microbicides won’t be the next magic bullet against HIV. We need to package HIV prevention and not hope for one great prevention.

South Africa Expands HIV Testing, Treatment and Circumcision

http://www.nytimes.com/2010/04/26/health/policy/26safrica.html?ref=africa

It’s interesting to see how tables are turning in the global AIDS epidemic  As mentioned in a previous post, Uganda, former poster child, is struggling.  And South Africa, infamous for having some of the highest prevalence rates in the world and a former president who denied that HIV caused AIDS, now has one that is publicly being tested for HIV (Zuma is also not the lowest risk man, given his polygamy and extramarital affairs

Interesting points from this article are the embrace of these efforts by key political stakeholders – from President Zuma to Goodwill Zwelithini, the king of the Zulus, who is endorsing circumcision.  But on the flip side, I skeptically wonder how much of a rapid scale-up their health infrastructure can withstand and how much of this intense beginning will translate into lasting change.   But it is encouraging that South Africa is no longer in denial and could go on to become a trendsetter rather than lagging behind.

AIDS Joke Fail.

via Jezebel.com

Senator Evan Bayh doesn’t think AIDS is a laughing matter. Or does he?

Bil Browning at The Bilerico Project caught the whole thing on camera. Here’s the joke:

So I’m walking through the airport and people were kinda being nice and making eye contact and a couple come up and say hello. This one person runs up all excited and I’m prepared to say “Hello,” and he says, “Senator Bayh! Senator Bayh!”

I said “Well, yes?” and he looked at me and said, “Do you have AIDS?”

[audible gasps]

I said, “Huh?”

He said, “Yeah. Do you have AIDS?”

I was dumbfounded. I didn’t know what to say.

He said, “I’ve got a letter I want to give you, do you have someone I can hand this to? Do you have an aide with you?”

[laughter]

So you never know what people are going to say.

Browning followed up with a question to Bayh. Here’s what he got:

No. Look, I’ve voted for AIDS funding and all sorts of things. And I’ve been for all sorts of things in terms of equality and lifestyle and that sort of thing. I’m sorry they took offense to that. It was certainly not intended.

As Megan at Jezebel writes, the problem with Bayh’s joke and follow-up is that “it’s predicated on the idea that someone like Evan Bayh couldn’t possibly have AIDS” and that “he voted for AIDS funding and supports ‘equality’ (though, notably, not marriage equality) and their “lifestyle,” so he’s entitled to make AIDS jokes.”

More seriously, comments like Bayh’s epitomize just the sort of retrograde thinking that has hindered HIV/AIDS education, treatment, and funding. I’m not saying that one off-color joke by a junior senator is the biggest obstacle to the war against AIDS, but…it’s irritating. In his response, he tried to over-compensate by asserting his support for “AIDS-related issues” and ended up offending even more people (who weren’t upset by the joke in the first place). You just can’t win, can you, Senator?

Setbacks on the HIV front: A case for sustainability, capacity building, and a comprehensive approach to global health

Once touted as a shining example in the battle against HIV in Africa, Uganda was featured two days ago as the first–but not the last–example of “how the war on global AIDS is falling apart” in a New York Times series highlighting the shortfall in funding, the US’s (diminishing?) contributions, the failures of scientific efforts to develop vaccines and microbicides, and the behavioral/cultural factors that make it so difficult to control the spread of HIV.

Although Uganda had once managed to decrease its HIV incidence rates, it appears that new infections are on the rise again, caused in part by a recrudescence of unprotected sex due to enduring social patterns of transactional sex, poor education,  and a general lack of female empowerment, among other issues. This is particularly problematic at a time when funding is drying up due not only to Wall Street’s shenanigans but also to donor fatigue. As the article reports, hope soared in the last decade as efforts by MSF, the Clinton Foundation and others led to dramatic falls in the prices of drugs, presenting a tremendous opportunity for international donors to make an impact by making available  the life-extending drugs that hade been available for years in developed countries but remained out of reach for the vast majority of HIV patients.

This “golden window” is now closed; some of the funding initiatives and grants that helped to open clinics  are coming to an end, and no new money is coming in to increase the availability of treatment, at least not at the pace needed to seriously curb the epidemic. The result? HIV patients in Uganda are now being turned away from clinics. There is justified fear that this “Kampala situation” will only spread to other countries and set us back to where we were in the 90s, when so many died without any hope for treatment. This is particularly alarming in the case of the HIV epidemic, with success being heavily dependent on not only maintaining already existing treatment slots but also increasing treatment availability rapidly. The situation is alarming, but I hope that the alarm bells will lead not to panic but rather to a serious examination of the mistakes that have been made and a reformulation of how we practice global health.

Losing battles, but have we lost the war?

Dinavance Kamukama, 28, front right, with her cousins in Kampala, Uganda. She is on a waiting list for AIDS medication. Photo courtesy The New York Times

This was a distressing headline to read: “In Uganda, AIDS War is Falling Apart.” Uganda, long the poster child for successful HIV/AIDS prevention and treatment, is now suffering. Dire lack of public and private funds has left thousands without ARV access and highlighted the cracks in Uganda’s “ABCs” program–Abstain, Be faithful, Contraception.

Will the global recession spell the end of the war against HIV/AIDS?

The soft power of global health diplomacy

We think a lot about global health diplomacy from the U.S. or western European perspective — foreign aid, development, and so on. Much of the international health movement has been structured along these lines: top-down interventions created in Geneva, formalized as WHO (and other) guidelines, and implemented by clusters of dedicated professionals. On the other hand, grassroots organizations work with community leaders and health workers in developing countries to build upward. And then there are those renegade MSF people, who get in there and provide the sheer grit, skill, and manpower to save lives, day to day, through wars and natural disasters. All of this has led to some amazing outcomes.

Why, then, this lingering sense that global health efforts represent a black hole of time and money? Foreign aid is never quite enough, workforce restructuring never fully realized (“brain drain”, I would argue, often takes an unfair share of the blame for this; yes, it’s a problem, but aren’t there others?), and a significant portion of the world’s population remains without access to basic nutritional and medical care.