Thursday, 19 November 2015

HIV/AIDS STILL DESERVES THE FUNDING IT GETS!

What does a disease deserve?
  1. Jocelyn Kaiser
Pressure from AIDS groups such as ACT UP, protesting at the White House in 1987, propelled Congress to begin earmarking research funding for HIV/AIDS. 
PHOTO: © BETTMANN/CORBIS
 
In the early 1990s, as the deadly HIV/AIDS epidemic marched across the United States and the world, lawmakers in Congress and top officials at the National Institutes of Health (NIH) reached an unusual understanding: Roughly 10% of the NIH budget would be dedicated to fighting the devastating disease. Since then, the steady flow of research cash—some $3 billion this year—has helped transform HIV infection from a death sentence to a manageable disease for many people, and some researchers believe they are getting closer to developing a vaccine that could halt new infections.
That special arrangement is now under fire. Health policy experts, lawmakers, and even NIH officials have wondered why, 2 decades after AIDS death rates began dropping dramatically in the United States, the disease still gets a lion's share of NIH resources. As questions have arisen about how HIV/AIDS funds are spent, NIH has also resolved to refocus AIDS money on ending the epidemic. Some voice a broader critique: that NIH's spending on a disease often doesn't align with how much suffering it causes. They note that diseases imposing a relatively small burden on U.S. society, such as AIDS, can get a larger share of NIH funding than those that cause greater harm, such as heart disease (see graph, p. 901). NIH's spending priorities can be “out of whack” says Senator Bill Cassidy (R–LA), a physician who serves on a panel that helps set NIH's budget.
Recently, while responding to pointed questions from Cassidy about the issue, NIH Director Francis Collins said the agency is ready to abandon the 10% set-aside. If Congress follows through on proposals to give NIH a hefty funding boost for 2016, its HIV/AIDS portfolio need not necessarily grow in “lock-step” with the increase as it has in the past, Collins said at a 7 October hearing. At the same time, NIH is taking a broader look at disease spending. Next month officials are expected to release an agency-wide strategic plan that they say will address how disease burden should influence the allocation of research dollars.
The ferment worries AIDS research advocates. “HIV/AIDS research could shrink as a percentage of the total [NIH budget] for the first time” in more than 2 decades, laments Kimberly Miller of the HIV Medicine Association in Arlington, Virginia, which represents health workers who treat HIV-infected patients. Long-time NIH observers also wonder whether the developments signal a re-emergence of the sometimes fierce disease funding wars of the past, when advocates for breast cancer research and other diseases battled for a bigger share of the NIH pie. Already, Cassidy has proposed shifting some AIDS spending to neurodegenerative diseases such as Alzheimer's. 
Some in the biomedical research community, however, welcome these developments. “I'm glad the questioning is happening no matter how annoying it may be to some people,” says Claiborne Johnston, a stroke researcher at the University of Texas, Austin, who has studied disease funding trends. “I hope ultimately that we figure out a way to truly address, through our research and our care, some of these conditions that definitely are neglected.” 
FROM ALMOST THE VERY beginning, NIH's AIDS earmark has created tensions. After activists helped persuade Congress to ramp up HIV/AIDS funding in the 1980s, lawmakers agreed to cap it at 10% of NIH's budget, but keep that proportion year after year. NIH officials argued that AIDS deserved a special allocation because it was a new disease, was still spreading, and had become the leading cause of death for U.S. adults between 25 and 44 years old. Key lawmakers were convinced, and since then AIDS research, which NIH has treated as its own distinct pool of funding, has essentially expanded in sync with the agency's overall budget.
It wasn't long before the deal inspired advocates for breast cancer and several other diseases to publicly argue that those fields, too, deserved large budget increases. Those 1990s campaigns ultimately met with mixed success in Congress. But the so-called disease wars did stir tensions within the large coalition of university, patient, and science groups that advocate for greater biomedical research spending. Those allies traditionally try to present a united front, for fear that internal divisions could fragment and endanger political support for overall NIH spending increases.
Now, that uneasy alliance has again come under pressure as the threat of AIDS has faded domestically. As new drugs made the disease more manageable, the number of deaths directly attributed to HIV plummeted in the United States from 45,000 per year in 1995 to 7000 in 2013. At the same time, some patient groups have recently helped persuade some lawmakers that they should be concerned about the much higher toll of other diseases, such as stroke and diabetes, and the staggering projected costs of caring for Alzheimer's patients. Representative Andy Harris (R–MD), another physician who has taken an interest in NIH policy, noted at a hearing last March that NIH spends 100 times less per U.S. heart disease death than it does per AIDS death. The “stunning” discrepancy “needs to be justified,” he said.
A matter of proportion CREDITS: (GRAPHIC) A. CUADRA/SCIENCE; (DATA) NIH
Many AIDS research advocates and NIH officials continue to defend the earmark, arguing that the global AIDS death rate remains high, and that researchers are making strides toward a vaccine. “I'm looking forward to a time when … we have ended the AIDS epidemic and there won't be any argument about what you want to do with the money, because you won't need the money,” said Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases (NIAID), which oversees about half of NIH's AIDS spending, during a hearing this past April. Robert Eisinger, acting director of the NIH Office of AIDS Research, also notes that the billions spent on AIDS research have produced “numerous crossover benefits” for other diseases—new drugs that treat hepatitis B infection came out of AIDS research, for example.
Yet congressional support for the AIDS set-aside has begun to crack. In a report accompanying the 2015 spending bill for NIH, House of Representatives and Senate appropriators omitted some oft-repeated instructions telling NIH to keep AIDS at 10% of its budget. The omission signaled their desire for NIH to abandon the earmark, says Chris Meekins, a staffer for Harris.
WITHIN NIH, top officials are also scrutinizing AIDS spending, about half of which is doled out by institutes and centers that don't focus primarily on infectious disease. Last year, Collins ordered a sweeping review of the AIDS portfolio. One pilot analysis by NIH staff found a surprise: 15% of grants did not have HIV/AIDS in the title or abstract, suggesting they were only remotely connected to AIDS. That finding added to existing concerns, both within and outside of NIH, that requiring institute directors to spend their dedicated AIDS money can encourage them to look far afield for projects to fund, or force them to lower their standards. At NIH's National Heart, Lung, and Blood Institute, for example, 42% of AIDS grant proposals received funding in 2012, compared with just 18% for non-AIDS projects, Cassidy noted at the October Senate hearing. “They're getting too much money for HIV/AIDS,” Cassidy said. “Can we move money out of that area?”
NIH's new AIDS research priorities
High priority
Vaccines, new therapies, cure strategies, HIV-associated diseases, related basic research
Medium priority
Basic research and projects on health and social issues that “meaningfully” include HIV/AIDS and “will advance HIV treatment or prevention” 
Low priority
Epidemiology of diseases that occur with HIV/AIDS and basic studies on copathogens that are not in the context of HIV infection, behavioral studies where HIV/AIDS is only one outcome 
This past August, in a bid to tighten controls on AIDS spending, Collins announced a revised set of research priorities (see box, right). Vaccines and potential cures are at the top; at the bottom are studies of diseases that sometimes co-occur with AIDS, such as malaria, and basic virology and immunology work that doesn't necessarily include HIV. Also at risk of losing new AIDS funding, the memo suggests, is behavioral research that doesn't focus specifically on AIDS, such as studies of risky sexual behaviors and drug abuse. Although exactly how the new priorities will influence NIH's funding decisions is uncertain, many behavioral researchers are “very nervous,” says epidemiologist David Celentano of Johns Hopkins University in Baltimore, Maryland.
At some NIH institutes, directors have found that disbursing the AIDS money is a distraction from their main mission. Thomas Insel, who stepped down last month as director of the National Institute of Mental Health (NIMH), says he was surprised to realize 3 years ago that the $180 million his institute was spending on AIDS research (12% of NIMH's budget) nearly matched its spending on disorders such as anxiety and schizophrenia. Insel shifted some of the AIDS grants and his HIV/AIDS program staff to NIAID, to ensure better coordination with that institute's bigger AIDS program.
In Congress, some lawmakers are taking direct aim at the earmark. This past summer, during a Senate spending panel debate on NIH's 2016 appropriation, Cassidy proposed taking $235 million out of NIAID's AIDS budget and giving it to other institutes studying neurodegenerative diseases.
The proposal dovetailed with a major push by patient groups to increase NIH funding for Alzheimer's disease, which has helped produce a 30% funding leap for Alzheimer's over the past 4 years. But Robert Egge, chief public policy officer for the Alzheimer's Association, and George Vradenburg, chair of the influential group UsAgainstAlzheimer's, say their organizations did not ask Cassidy to offer his Alzheimer's proposal. 
In the end, Cassidy's measure failed. Still, the move shook the AIDS research community. “To find more money for Alzheimer's you have to cut HIV/AIDS, [that] makes no sense,” says Miller, who is part of a coalition of AIDS groups now lobbying to preserve AIDS funding.
THE DEBATE over how much NIH's spending priorities should reflect disease burden goes back to at least the late 1990s, when The New England Journal of Medicine published an analysis suggesting that NIH wasn't spending enough on certain high-burden conditions, such as peptic ulcers and pneumonia. In a 2011 study revisiting the issue in PLOS ONE, Johnston and co-authors found that diseases with strong advocates (breast cancer, for example) enjoy relatively robust funding, whereas spending lags on those that carry a stigma, such as depression, alcoholism, and lung cancer, despite the higher burden they impose on society. Although “you can't expect a perfect correlation” with funding, says Johnston, “the clearest take-home message is: Some conditions below the line are those where we blame the victim.”
This past summer, for the first time, NIH published its own comparison of health burden and spending. It confirmed that AIDS and cancer receive relatively generous funding, whereas others, such as migraine and chronic obstructive pulmonary disease, receive disproportionately little. An agency official commented on a blog that “we're looking forward to using these analyses as a jumping off point for a larger conversation about priority setting.” And Collins has said in hearings that a new NIH-wide strategic plan due out in December will address disease burden.
Some observers are skeptical that the new plan will have much influence, given the many factors that influence spending, from tight budgets to the power of certain disease groups. And NIH officials caution that, in the end, disease burden data, which have limitations, can't alone be the basis for funding allocations. Institutes must consider the scientific quality of proposals, as well as the need to balance basic and clinical research. They note that it makes sense to spend relatively more on rare diseases that otherwise would be neglected, because they can shed light on common diseases. And infectious diseases can't be funded strictly based on the number of U.S. cases, because it's not possible to predict when viruses such as Ebola and severe acute respiratory syndrome—which have had little impact in the United States—might flare up and cross borders. At the same time, pouring new money into a disease just because it imposes a high social cost can be misguided, NIH insiders say. If the field lacks a critical mass of researchers, or promising research avenues, the money could be wasted.
Johnston and others who call for more attention to disease burden don't buy that. “It's a circular argument,” he says. “Scientific promise happens when you have investments in an area. … If you fund the science, there will be more promise in that area.”
Insel agrees, to a point. He says that when he did a disease burden analysis of NIMH and NIH spending on mental illnesses compared with other diseases, he was struck by how every mental illness was “under the line,” or appeared to get short shrift. This year he shored up funding for the two areas that lagged the most—suicide prevention and eating disorders—in order to stimulate fresh approaches. A decision NIMH made a few years ago to ramp up autism research—amid a push from activists—had convinced him that doing so wouldn't be a waste of dollars where there is “scientific traction.” After the infusion of new funding into autism, he says, “we saw better proposals.” 
Whether that kind of redistribution catches on across NIH remains to be seen. But some AIDS researchers are already resigned to losing their special status, whether the initiative comes from Congress or NIH itself. “For a long time we were the golden child. … We had a 30-year run,” Celentano says. But now, “I think we need to justify better why we should be at the table.”

Wednesday, 18 November 2015

Aligning USAID Funding Targeting Adolescent girls and Young Women; Cues For Local Government Councils In Uganda


SUMMARY:

Local government officials can present over 25 performance indicators below following the use of USAID funds:

1) focus on the poor; 2) improve engagement of the private-for-profit sector; 3) enhance efficiency; 4) strengthen stakeholder coordination; 5) improve service quality; 6) stimulate consumer-based advocacy for better health;  7) programming in maternal; 8) newborn and child health; 9) immunization; 10) family planning and reproductive health; 11) nutrition; 12) health systems strengthening; 13) water/sanitation/hygiene; 14) malaria; breaking cycle of transmission of HIV; 15) pediatric HIV care and treatment; 16) increase in numbers of women attending at least one antenatal care visit with a health care provider; 17) Opportunities for women to deliver their babies with a skilled attendant present will increase; 18) planning meetings on targeted health themes;  19)  identify key persons to contact as far as HIV/AIDS, Adolescent girls and Young Women issues go; 20) develop a community health information management system with vital statistics, targets for treatment, prevention and anti-discrimination; 21) lists of partnerships such as schools, villages, faith-based organizations and traditional healers involved in promoting health;  22) existence of strategic plans at different levels of governance reflecting needs of communities;  23) realizable PEPFAR engagement and an expanded capacity to use Ambassador’s Small Grant Program for advocacy, community mobilization;  24) generating disaggregated statistics giving insight into population demographics and;  25) lists or action plans by Village Health Teams.


Local governments in Uganda can design systems that promote the health and life of adolescent girls and young women (5-24 years). A mental, sexual and reproductive health plan targeting adolescent girls and young women, can be effective if it is integrated with other activities. At a three percent (3%) population growth by 2025, a young population and a high total fertility rate, Uganda’s high population rate will continue to drive health expenditures upwards. Local Governments in Uganda are entities that can mobilize for action through planning and partnerships. This is captured in the Health Sub-District concept bringing essential health services-especially basic surgical and obstetric care closer to the communities. The attendant staffing, infrastructure, equipment and operating costs become resources for promotion of health. A  comprehensive WHO review of Uganda’s Health System conducted in 2011, found that whereas significant efforts are being implemented to qualitatively and quantitatively improve health in Uganda, more needs to be done to a) focus on the poor; b) improve engagement of the private-for-profit sector; c) enhance efficiency; d) strengthen stakeholder coordination; e) improve service quality; and f) stimulate consumer-based advocacy for better health. At local government level there are opportunities to conduct local health assessment and devise community health improvement plans. These local government entities are in a better position to tap into, say, the USAID funding if a focus on quality of care, service integration, and equity are to become a reality. The generated mechanisms and resources at an initial phase may be costly but these costs are reimbursed under the inbuilt cost of doing the U.S. government’s PEPFAR Business (CODB). The critical fiscal space thus created is an opportunity to increase government expenditure on health.  This will in turn create a standardized service delivery across all local government regions. Uganda has a Maternal mortality ratio of 435/100,000 live births. By end of 2015, Uganda needs to reduce that figure to 131/100,000. Poor access to quality maternal care services, is a significant barrier to improving maternal mortality in Uganda. “HIV/AIDS, malaria and respiratory infections are the top three causes of overall disease burden in terms of Disability-Adjusted-Life-years (DALYs) lost,” (Fiscal Space For Health In Uganda).


There are two documents I hope local government planners can use. One is the Country operational plan guidance document provided by USAID, with focus on eradicating HIV/AIDS. It is a comprehensive tool that local council members in Uganda can find useful as they try to utilize PEPFAR funds in a bid to align money in prevention investments. At the local government level, planned and costed investments are called votes, e.g., providing insecticide-treated mosquito nets to a given number of households. In a bottom-up planning, promoted by decentralization, it is possible to harmonize targets for treatment, prevention and anti-discrimination at Local Council I, II, III, IV, V, Town Council, Municipality, Division and district. There are two outcomes that come to mind. One, it will strengthen an existing local public system that ensures health promotion and prevention of diseases. Two, it will critical forces of change at community level with health promotion and prevention of diseases at the planning core.


The second document is the:The Maternal and Child Survival Program (MCSP). MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment. The Program places greater emphasis on key cross-cutting issues such as innovation, e/mHealth, equity, quality, gender, public-private partnerships, and involvement of civil society, community approaches and behavior change interventions. While maintaining focus on the technical high impact interventions, MCSP works toward sustainable scale up to include strengthening the health systems that deliver these interventions. (http://www.mcsprogram.org/). “It is at the heart of improving maternal-newborn health services globally: ensuring care is patient-focused; integrating programs to better serve the needs of mothers and babies; and extending innovative health services to the poorest and most socially vulnerable mothers and babies,” (Bliss, K. 2015). This USAID funding will help local governments mobilize for action through planning and partnerships where a woman in Uganda can seek appropriate counseling and maternal care services in any facility. There will be an increase in number of women attending at least one antenatal care visit with a health care provider. Opportunities for women to deliver their babies with a skilled attendant present will increase.


The health sector at the district and sub district level in Uganda is governed by a district health management team (DHMT). The DHMT is led by the District Health Officer (DHO) and consists of managers of various health departments in the district. The heads of health sub districts (HC IV managers) are included on the DHMT. The DHMT oversees implementation of health services in the district, ensuring coherence with national policies. A Health Unit Management Committee (HUMC) composed of health staff, civil society and community leaders is charged with linking health facility governance with community needs (http://gov.ug/ministry/ministry-health).


USAID funding into a local government budget plan will cause: 1) planning meetings on targeted health themes including national and district indicators (UBOS, 2010)  2)  identify key persons to contact as far as HIV/AIDS, Adolescent girls and Young Women issues 3) develop a community health information management system with vital statistics, targets for treatment, prevention and anti-discrimination 4) lists of partnerships such as schools, villages, faith-based organizations and traditional healers involved in promoting health 5) existence of strategic plans at different levels of governance reflecting needs of communities 6) realizable PEPFAR engagement and an expanded capacity to use Ambassador’s Small Grant Program for advocacy, community mobilization 7) generating disaggregated statistics giving insight into population demographics and 8) lists or action plans by Village Health Teams as a continuum of response who bridge the gap and increase equity in access to health services ( http://www.pathfinder.org/). With the above it is more likely to have information on: voluntary medical male circumcision (VMMC), Test and treat, Viral load, TB/HIV, virology suppression, children health, pregnant women receiving B+, adults on life-saving anti-retro viral treatment, health needs of groups that are higher risk than total population, identified community resources  that support the public health system in promoting health and improving quality of life. A list of themes would be developed, which in turn could be used to assess community health status and community themes. 


Form a team amongst you and check with the US Embassy to see how your local government entity qualifies. A devolved institutionalized public health service is possible in Uganda. Turnock (2015) in “Essentials of Public Health” lists outcomes of deliberate community health improvement plans. I have chosen some points from the long list that I feel would be further outcomes of using USAID funds at a local government level. These are some of the further outcomes: 1) working with policy-makers, promote partnerships, educate, inform, develop policies and plans that support individual and community health efforts and plans 2) Social-community level activity plans 3) Social marketing and targeted media public 4) joint health education programs with schools, churches, Faith-based Organizations, cultural organizations and other entities 5) undertaking health improvement planning e.g., preventive screening, rehabilitation and support programs 6) building coalitions drawing from a wider range of potential human/material resources to improve community health.

REFERENCES:

1. Bliss Katherine (2015). http://www.smartglobalhealth.org/
2. Fiscal Space For Health in Uganda. World Bank Working Paper No. 186 Africa Human Development Series 
3. Government of Uganda, Ministry of Health. http://gov.ug/ministry/ministry-health
4. National Village Health Teams (VHT) Assessment In Uganda. 2015. http://www.pathfinder.org/
5. Statistical Abstract. Ministry of Health. 2010. http://www.ubos.org/
6. Turnock, B. J. (2016). Essentials of public health (3rd ed.). Burlington, MA: Jones & Bartlett.
7. USAID (2015). Country Operational Plan Guidance 2016 – Draft
8. USAID (2015). http://www.mcsprogram.org/our-work/ 

Sunday, 15 November 2015

Important Public Health Pre-occupations in the 21st Century USA

The main role of public health in the 21st Century will be to protect us from various diseases or life threatening conditions deriving from: climate change; emerging diseases; bioterrorism; racism; stigma; prejudice; and political dilemmas. Public health practitioners of the 21st Century must be in position to understand the complexities of cultural diversity, e.g.,different generational, economic, professional, ethnic, religious, linguistic background, gender, gender identity, sexual orientation, stereotypes, prejudices, physical status, conscious bias, unconscious bias, structural bias, enjoyment of access to resources, access to opportunities, access to options, safety from violence,  affordability of housing, civil rights, access to food, access to jobs, opportunities for job trainings, access to recreation and readiness to be  a compassionate provider. Many clients and communities face bias and discrimination when they attempt to access health and social services and , as a result, receive fewer services and services of poorer quality (Berthold, T. 2009). In order to provide public health services, government has concrete plans such as enacting laws, enforce laws, provide financial support and oversight to ensure promotion of health, prevention of diseases and instituting a preparedness mechanism.The most important new or expanded roles for public health occupations in the 21st century will include:

1. Strengthening the public health activities framework that is interlinked by a network of federal, state and local public health agencies with emphasis on referral mechanisms and oversight processes.

2. Ensure a reporting mechanism that dovetails into the overarching design where: the contribution of USA to international health-related interventions continues; the legal foundation gives gives primacy for health concerns to states; allows the federal government to promote consistency and minimum standards across the 50 diverse states; and a practical foundation of LHDs serving as the point of contact between communities and the three-tiered government.

3. Shifting mobilization tasks to advocacy entities at community level as a means of having a pulse on changing needs, resource needs and meeting public expectations.

4. Investing in early warning mechanisms for threats from fires to bio-terrorism. There will be need to have a contingency for fire hazards now that the globe is getting warmer. This will mean wildfire-prone geographical zones like Mid-Western and California will have more established fire departments. The quarantine points at border entry points, airports and ports need to be strengthened now that there is more likelihood for bio-terrorisms, hostility and acts of sabotage against the U.S. or any other nation by terrorists and enemies (www.nytimes.com). 

5. Public health practitioners reaching out to the indigent or marginalized. This will rely on the work of local health agencies. These will in turn report to second tier government levels and different organizations that form the backbone through which the power to protect the public’s health is possible.

6. Providing training and promoting competencies for public health professionals in the 21st century mostly in these areas: conducting essential public health services; legislation; regulation; policies; and the ability to negotiate,  justify public funding for many public health initiatives. For public health to be perceived, such essential services as are relevant: monitoring the health status of the population; diagnosing and investigating problems deemed hazardous to the public’s health; educating the population on health issues; mobilizing communities to act on their own health issues; developing policies; enforcing laws and regulations that protect the public; linking people to health services; ensuring a competent healthcare workforce; evaluating the effectiveness, access and quality of health services and researching to continue progress and innovation in healthcare (Turnock, B. J. (2016). Essentials of public health (3rd ed.). Burlington, MA: Jones & Bartlett).

7. Use of Technology, which will enable complex research to be translated into action in a faster and flexible way. Technology can be used in many other forms as well. One way is establishing a centralized health management information templates that can be used to report for instance compliances to the Healthy 2020 vision and mission. Events in which equity and equality are addressed can be captured at local, state, regional and federal levels. Racial biases are shown to be a part of the social structure of medical practices at both macro and micro levels (Centre for excellence in health care journalism). Use of web-based platforms to share information can help improve on coverage of what works and who is served. Public health will be a means for America to deal with the hot topics that focus on: race, culture, ethnicity, lifestyle, health status and health care in America. This might be the great quest of technology as well. Through technology it will be possible to level the health care playing field. Socioeconomics, individual racism, and institutional racism that represent the three predominant pathways to differential treatment for diseases will be targeted and redress provided. Reporting mechanisms will provide common indicators used to gauge quality of life for women and men irrespective of their gender, sexuality, race and social status.  Compiling reports into a format that can be disseminated to all concerned is another good use of  print technology and the world-wide web. In this format the media can be relied upon to make information available or the applicability of the information by society in form of case reports/studies or any format that is reliable for dissemination. However, newsprint, radio and TV tend to tap into our anxieties focusing on trivia. “The CDC has had to contend with bogus reports of imported banana carrying flesh-eating bacteria, drug addicts placing HIV-infected needles in pay coin-return boxes, virus soaked sponges arriving with the mail,” (Drexler, M. 2010). 

8. Understanding the need for post trauma stress counseling and care arising from the link between terrorism, massacres and resultant traumas. A global nightmare envelopes the world every time wars, genocides and terrorist attacks occur anywhere in the world. The rallying call that brings together nations ready to do rescue activities is to profess solidarity with the suffering nations. Rescue efforts are made by nations. This was seen after September 11, 2001, in UK, in Uganda, in Tanzania, in Kenya and most recently in the 10th district of Paris where the most recent attacks have occurred. The San Francisco editorial has this to say, “France’s loss is our loss. Its grief is our grief. And its fight to counter the forces of inhumanity is our fight”  (San Francisco Chronicle, Editorial, November 14th, 2015). 

9. The effects of political pronouncements such as the recent debate on mass deportations sends trauma shocks to those who are  not documented yet they many have lived in USA all their life and some are employed. These people may end up not attending social services for fear of being hounded and put on hot lists.

 10. Establishing a structure of international partnership to deal with climate change, neglect, poverty and famine  at a global level which in turn make humans and in some cases livestock vulnerable to influenza, Legionnaires’ disease, Lyme disease, toxic shock syndrome, E. Coli 0157:H7, STDs, Ebola virus, AIDS, severe acute respiratory syndrome (SARS), H1N1 influenza (Drexler, M. 2010). 

11. Understanding the increasing relation of chronic low-level inflammation, wide range of common debilitating disorders, stealth infections, deadly sepsis, how to balance use of antibiotics and inflammatory-quashing steroids. Research findings recommend Mediterranean style diet for those suffering from inflammatory disorders (Sachs J.S., 2007).

In the 21st Century, stigma discrimination, bias and prejudice will be the issues that need addressing. This in turn will clear the way for addressing neglect, poverty and famine. In situations where equality, respect and dignity are promoted, proper protection of life and ensuring individual well-being will be achievable.



REFERENCES:

1. Berthold, T. 2009. Foundations For Community Health Workers. San Francisco, MA: Jossey-Bass.
Centre For Excellence in Health Care Journalism. 2006.

2. Drexler M., 2010. Emerging Epidemics: The Menace of New Infections: H1N1 Flu, SARS, Anthrax, E.Coli.Penguin Books.

3. http://www.nytimes.com/2015/11/15/world/europe/strategy-shift-for-isis-inflicting-terror-in-distant-lands.html?emc=edit_th_20151115&nl=todaysheadlines&nlid=60949333&_r=0

4. Sachs, J.S. 2007. Good germs,Bad Germs: Health and Survival in a Bacterial World. New York, NY: Hill and Wang.


6. Turnock, B. J. 2016. Essentials of public health (3rd ed.). Burlington, MA: Jones & Bartlett. 


Saturday, 14 November 2015

Interpreting Health Metrics From a Public Health Perspective; Case of USA and Uganda

All countries have a Public Health Provision Model that combines maximizing individual positive outcomes as well as minimizing adverse collective outcomes. The countries promote population-based activities, monitor health status, investigate health problems and hazards, inform and educate people about health issues, mobilize communities, develop policies and plans, enforce laws and regulations for the wellness of their citizens.

To promote public health practice, medical health practice and long term care practice that in turn ensure quality life, these countries invest money of different amounts. They commit resources which cause health outcomes. However, the social-ecological factors in these countries make it a unique framework within which to provide public health and medical health services. Biologic, environment, behavioral, social, cultural and health services available in a given country in turn affect the well-being of the citizens.  These in turn affect the impact of the strategies or interventions. 

The US has a population total of 320,051,000. Its total expenditure on health as a percentage of GDP for the year 2013 was $ 17.1, a total expenditure on health per capita for 2013 at $ 9,146 and life expectancy of males at 76 and females at 81 (www.who.int/countries/en/).  It has committed over 15 million workers in the Public Health workforce and $ 3.0 trillion in resources. The public health needs presently facing the US include: slowing population goeth rate, and older population, increasing diversity of population, changes in the family structure, a persistent lack of access to needed health services for many Americans and relative prevalence of particular diseases (Turnock, B. J. 2016).

On the other hand, Uganda has a population total of about 37, 579,00, its total expenditure on health as a percentage of GDP for the year 2013 was $ 9.8 a total expenditure on health per capita for 2013 at $ 146 and life expectancy of males at 57 and females at 61 (www.who.int/countries/en/). faced with lukewarm commitment in funding the health sector. The funds keep vacillating below or above $294,117, 000 as in the case of 2011. This amount is far below what the international ceiling ( e.g., Abuja Declaration) calls for.  Uganda still battles parasite infestation e.g., malaria-causing mosquitoes.  Plans to commit to eradicate malaria are half hearted pronouncements made at electoral campaigns most of the time. “The Government also committed itself towards developing and implementing a comprehensive strategy to eradicate malaria and strengthen its prevention, diagnosis and treatment. It also committed itself to reduce morbidity and mortality from the major causes of ill health and premature death,” (www.newvision.co.ug).

In order for public health to be a collective effort that promotes quality health outcomes, countries need to back public health initiatives with a funding commitment and not just lip service. Public Health Provision can be effective if it combines maximizing individual positive outcomes as well as minimizing adverse collective outcomes. 

REFERENCES:

http://www.who.int/countries/en/
Turnock, B. J. (2016). Essentials of public health (3rd ed.). Burlington, MA: Jones & Bartlett.  


Thursday, 12 November 2015

Campaigning and Elections in Uganda November 2015- April 2016

Quick Facts About Uganda Following the On-going Election Campaigns 2015-April 2016



1. Four major candidates have the logistics to move around Uganda: Incumbent/President Yoweri Kaguta Museveni NRM Flag-bearer; Colonel( Ret.) Dr. Kiiza Besigye FDC Flag-bearer; Former Prime Minister, Amama Mbabazi TDA Flag bearer and Dr. Abed Bwanika PDP Flag bearer

2. Four other candidates are still having problems moving around the country: Mr. Mabirizi J.,  Ms. Kyaalya Maureen, Major ( Ret.) Benon Biraro and Professor Barya Venansius.


For more read:

http://www.elections.co.ug/new-vision/election
https://en.wikipedia.org/wiki/Amama_Mbabazi
http://www.elections.co.ug/new-vision/election/1408157/kyalya-left-sh300m-job-contest-presidency

Enjoy!!

Monday, 26 October 2015

There is a relationship between Mental Illness, stigma and discrimination and productivity in the workplace; lessons for Uganda


Mental illness is a human condition caused by factors such as: trauma, accidents, racism, subjugation, lopsided laws, inequity, inequality, torture, criminalization and social structures (homelessness and treatment of women). Mental illness affects productivity due to: the different diagnosable mental disorder and how they are treated; work-defined disability; employer-defined disability; utilization and access of workplace rehabilitation facilities. Mental illness is a health condition that has been the trigger of stigma and discrimination.  

To locate how productivity and mental illness affect each other one has to first understand how productivity at the workplace is nested as well as how mental illness is perceived in society today.  Productivity at the workplace involves a multitude of baseline factors. The factors are: human resource; shelter; economic status of people;  the money invested to establish the job, the level of qualifications, skills, competency, assets; and job description. The jobs range: army, intelligence, banking, law, government, Non Government Organizations, Faith Based Organizations, education, hospitality, service industry, transport, post, telecommunication, administration, media, broadcasting, artisanship, architecture, engineering, construction and publishing. At a minimum, a job requires one to match the job requirements, appear on time at work, stay at work for the requisite duration, have the ability to interpret and transform all work processes into performance. To be good at a job, one has to have values such as: must be able a team-player, dependable and responsible. Human-resource related factors depend on health status of an individual. The way one is treated at work or in society has repercussions on performance. Cognitive levels directly affect  safety behavior, workplace accidents and level of conscientiousness (Wallace, 2003).

Privilege, class, racism, levels of sophistication and the striation due to patriarchy or matriarchy directly affect the way societies produce materials. In today’s world, one has to appreciate the presence of social, cultural and behavior values that are different. One has to also appreciate that some values in one culture may be ridiculed by another. Whole races have had to be subject to denigration by others. Many examples abound. This is seen in the service, education, banking, government, law and health-care. For the purpose of mental illness and productivity in the workplace, the way diagnosis of mental illness need to be tailored to the client who presents the illness. Follow up care should be tailored to that person’s cultural background.  Historically, western social and behavioral scientists have focused largely on the individual as a major source of psychological and social dysfunction or impaired mental health. This tends to ignore the role of social structures that certain cultures depend on.  There is power in social structures and practices and their impact on individual behavior. This needs to be in-built in the rehabilitation path of one with mental illness. Addressing minority issues in the US calls for this (Dorothy, 1990). 
Women have borne the brunt of mistreatment and many end up with mental illness. In the workplace, a woman may choose to keep secret the way she is treated by her husband or men in her life. This can affect her workplace productivity. Women’s struggle for equality is impeded by over 800 pieces of blatantly sex-discriminatory law currently on the US statute books. In most states women cannot co-sign for a loan even though property is jointly owned. In rape cases, a woman with prior sexual experience is less likely to be believed if she claims she was raped. To an extent, a woman is still seen as “property” to be controlled and owned by men( Chambliss, W.J., 2011).

Mental illness, unfortunately has been used as the reason to discriminate and stigmatize those suffering from it. There is potential in many who are labelled and stigmatized as mentally ill. Because of this many isolate themselves and never seek opportunities available to them to rehabilitate as well as be of service to their communities. In this, they are depriving society of taxable incomes. By the year 2020, depression arising from mental illness will emerge as one of the leading causes of disability globally (WHO). Mental illness in and by itself affects workplace productivity. Mental illness arises when social economic opportunities are absent; combined with substance abuse; low socioeconomic class; differential family structure; poor performance in school;  and antisocial behavior of parents (Williams, 1986). Under diagnosed mental illness in a culturally diverse setting from the stand point of stereotyping may perpetuate the very illness it is supposed to treat. Multicultural context approach e.g. transcultural, inter-cultural, cross-cultural, anti-racist and feminist are forms of counseling needed if one is to deal with minority groups. These have sound theoretical base, value and effectiveness if beneficiaries participate in them (Moodley, 1999).

In the US, 75%-85% of people with severe mental illness are un employed and in UK they are 61%-73%. Just because they have severe mental illness, it should not be a reason for them to be denied employment.  There are compelling ethical, social and clinical reasons  for helping people with mental illness to work. From an ethical stand point, the right to work is enshrined in the Universal Declaration of Human Rights 1948. From a social stand point, high un employment rates are an index of the social exclusion of people with mental illness, which the US and UK governments are committed to reducing. From a clinical stand point, employment may lead to improvements in outcome through increasing self esteem, alleviating psychiatric symptoms, and reducing dependency (Crowther, 2001).

  A given percentage of employed people with diagnosable mental disorders are employed. Employees with mental disorders need to be cared for and this costs money. Canada loses $ 4.5 billion attributed to work-related productivity losses due to depression (Dewa, 2004). Mental illness contributes to absenteeism and disability days. This in turn contributes to decreased productivity. Mental illness is also associated with short term and long term disability, which in turn is often related to insurance coverage. Mental illness accounts for 30% of disability clams, at a cost of $ 15- $ 33 billion annually (Dewa, 2004). 

Mental illness affects productivity due to the different manifestations such as: co-morbid disorder; mental disorder (major depressive disorder, mania disorder); anxiety disorder ( social phobia, agoraphobia, panic); affective disorder; substance dependence (alcohol dependence, illicit drug dependence). Work-defined disability is defined as any restriction or lack of capacity to perform an activity in a manner or within a range considered normal (Orme and Costa e Silva, 1995). Employer-defined disability, on the other hand is defined as that which accounts for the additional administrative costs the employer incurs as a result of the sick day or the cost of finding a substitute for the absent worker (Dewa, 2004). 

Workplaces that anticipate providing employee rehabilitation need to have a responsive  environment. The responsive environment through which workplaces provide rehabilitation cost money. Achieving employment for people with mental illness involves focusing on individual enhancement. This builds behavioral coping skills and task ability. The individual is able to manage symptoms and the job is able to increase diversity at the workplace (Akabas, 1994). 

 Depressive disorders have the largest medical plan costs of all behavioral health diagnosis in US. There are implications for the medical benefit plan design, disability plan management, and occupational health professionals’ training (Conti et al, 1994). Depression adversely affects work productivity in form of work absence and reduced performance while at work (Stewart et al, 2003). 

Litigation due to discrimination cases is another means through which mental illness affects productivity. Work is a major determinant of mental health and a socially integrating force. To be excluded from the workforce creates material deprivation, erodes self confidence, creates a sense of isolation and marginalization and is a key risk factor for mental disability.  This in turn may be the cause of stigma and discrimination experienced by people with mental disabilities. Stigma is both a proximate and distal cause of employment inequity for people with mental disability who experience direct discrimination because of prejudicial attitudes from employers and workmates and indirect discrimination owing to historical patterns of disadvantage, structural disincentives, against competitive employment and generalized policy neglect. There are multiple attitudinal and structural barriers that prevent people with mental disabilities from becoming active participants in the competitive labor market (Stuart, 2006).

In talking about the relationship of mental illness and productivity one has to also explore the nesting ground in which mental illness thrives. Addressing mental illness in the workplace is just a tip of the iceberg. the issue of stigma must be addressed at policy, program and community level. We have seen that mental illness is a human condition caused by factors such as: trauma, accidents, racism, subjugation, lopsided laws, inequity, inequality, torture, criminalization and social structures (homelessness and treatment of women). Mental illness affects productivity due to: the different diagnosable mental disorder and how they are treated; work-defined disability; employer-defined disability; utilization and access of workplace rehabilitation facilities. Mental illness as a health condition triggers off stigma and discrimination.  The treatment of women as second class citizens, discrimination and stigma should be given extra attention wherever they rear their ugly heads.

REFERENCES: 
Akabas, Sheila H. 1994. Psychosocial Rehabilitation journal, Volume 17 (3), 91-101. http://dx.doi.org/10.1037/h0095572

Chambliss, W.J. et al. 2011. Criminology: Connecting Theory, Research and Practice. McGraw-Hill Higher Education.

Conti, Daniel J. and Burton Wayne.1994. The Economic Impact of Depression in Workplace. The American College of Occupational and Environmental Medicine.

Crowther, R et al. 2001. Helping People with Severe Mental Illness to obtain Work: Systematic Review. BMJ 2001: 322 doi: http://dx.doi.org/10.1136/bmj.322.7280.204.

Dewa C. et al, 2004. Nature and Prevalence of Mental Illness in the Workplace.

Dorothy Smith Ruiz.1990. handbook of mental Health and Mental Disorder Among Black Americans. Greenwood Publishing Group.

Moodley, R. 1999. Challenge and Transformations: Counselling in a Multicultural Context. International Journal For The Advancement of Counselling. Volume 21, Issue 2, pp 139-152. DOI: 10.1023/A:1005347817892.

Stewart, F. et al . 2003. Cost of lost productive Work Time Among US Workers With Depression. JAMA. 2003: 289 (23): 3135-3144. doi: 10:1001/jama. 289.23.3135.

Stuart, H. 2006. Mental illness and Employment Discrimination. Lippincot Williams and Wilkins, Inc.

Wallace, J.C. et al. 2003. Workplace safety performance: Conscientiousness, cognitive failure, and their interaction. Journal of occupational Health Psychology, Volume 8(4), October 2003, 316-327. http://dx.doi.org/10.1037/1076-8998.84316.


Williams, Donald. 1986. The Epidemiology Of Mental Illness in Afro-Americans. 

Tuesday, 24 February 2015

The article below still rings true for Africa!

BY FESTUS MOGAE AND STEPHEN LEWIS, 12 JULY 2012
In Uganda and across Africa, HIV continues to prey on women, sex workers and men, who have sex with men.

http://allafrica.com/stories/201207131147.html

It is clear that to end the HIV epidemic, we must protect and support these groups. Yet, our country and others enforce bad laws and customs that disempower these groups and make them more likely to be infected with HIV. We cannot hope for an HIV-free generation when we have laws that marginalize and punish those most vulnerable to the disease.

A global commission of legal, human rights and HIV leaders recently released a report that showed punitive laws were standing in the way of effective AIDS responses. Archaic laws and customs make women and girls more vulnerable to HIV. Legally condoned violence and oppression - including genital mutilation, sexual violence, denial of property rights and early marriage - undermine the ability of women to protect themselves.

Laws urgently need to protect women, who are often the ones left to care for the sick, tend to the family and till the fields. In addition, many countries have punitive laws that criminalize sex workers. However, these laws drive sex work underground and put sex workers at greater risk of HIV.

Police violence and the threat of arrest disempower sex workers, making them more vulnerable to abuse and HIV transmission. Many are unable to access prevention and care because of the stigma they face, even from healthcare workers. In contrast, sex workers who are not harassed by the police and who have access to services have lower HIV rates and more economic power.

Laws across the continent also criminalize homosexuality, yet punishing men who have sex with men forces them into secrecy. They are unable to access counseling and testing, making it almost impossible for HIV prevention and treatment interventions to reach them.

In 2008, when the Senegalese government jailed nine gay HIV outreach workers under a law prohibiting "acts against nature," health workers went into hiding, advocacy groups disbanded and HIV treatment sites were shut down.

The time has come for African leaders to take action against bad laws that stifle our HIV response. We must challenge societal values rooted in fear and prejudice and implement laws based on human rights and sound public health. This starts with recognizing the rights of women and decriminalizing homosexuality and voluntary sex work, which is vital to protecting the health and dignity of these groups.

Voluntary sex work should not be confused with human trafficking, which remains an abhorrent human rights violation. Change will not come easy. It will require us to challenge tradition and deeply held personal values. It will mean confronting religious beliefs and antiquated practices that endanger our citizens.

Leaders will face shock, anger and opposition. But change is essential if we hope to slow the spread of HIV. Many leaders have refused to confront this reality. Instead, they opt to hide behind religion and the veneer of morality. But other leaders have demonstrated the courage needed to use laws as a powerful response to HIV.

In May, Malawi President Joyce Banda announced she would make efforts to repeal Malawi's laws that criminalize homosexual acts. "As leaders, especially in this part of the world (Africa), which is the epicentre of the epidemic, we need to harness our efforts in confronting antiquated beliefs based on fear and misinformation that are codified in our laws and engraved in our cultures," said President Banda.

In 2010, Rwanda Secretary of Health Agnès Binagwaho called for human rights-based policies that empower sex workers to negotiate safe sex and protect their health. Botswana enacted a law in 2008 to protect survivors of domestic violence and another in 2004 to establish equality of spouses. In recent years, 8,000 communities across the world, including in 15 African countries, banned genital mutilation.

Leaders in Uganda and across Africa must embrace change and follow these examples. We have a tremendous opportunity to accelerate the end of HIV. We must reverse laws and practices that stand in the way of effective HIV responses and replicate those that protect the human rights and health of our citizens.

Evidence-based, humane HIV responses will not only help shield us from HIV, they will also help build a more prosperous African continent. Africa's leadership must boldly rise to the challenge. Together, we can turn the tide against HIV.

Mr Festus Gontebanye Mogae and Stephen Lewis are members of the Global Commission on HIV and the Law.

Mogae is the former president of Botswana. Lewis is the co-director and co-founder of AIDS-Free World and was formerly the United Nations special envoy for HIV/AIDS in Africa.

Brian Kanyemba| Desmond Tutu HIV Foundation
Research Assistant/AVAC Advocacy Fellow 2011
Men's Research Division
(t) 021 4471025
(e) brian.kanyemba@hiv-research.org.za
skype: brian.kanyemba

As we move towards "HIV undetectable" take note of the message in this abstract!

Estimating the range of potential epidemiological impact of pre-exposure prophylaxis: run-away success or run-away failure?.
Cremin, Íde; Hallett, Timothy B.
Supplemental Author Material
Published Ahead-of-Print
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Abstract
Objective: To investigate the influence of potential interactions between key aspects of a pre-exposure prophylaxis (PrEP) intervention on projections of epidemiological impact and cost-effectiveness.
Methods: A mathematical model representing the HIV epidemic and intervention context in Nyanza province in Kenya was developed. We consider a scenario whereby a fixed annual budget is allocated to a PrEP intervention. A standard projection of impact is generated, assuming that the unit cost of PrEP, adherence to PrEP and the ability of the programme to direct PrEP to those at high risk, all stay constant. The influence of dynamic assumptions and possible interactions between PrEP intervention assumptions is then assessed in comparison.
Results: The cumulative impact of a PrEP intervention could be increased approximately two-fold, relative to the standard projection, if positive interactions (between coverage and cost, coverage and adherence, prioritization and time) are assumed, whereas negative interactions between these factors could almost entirely negate the preventive benefit of the PrEP intervention. The corresponding estimates of cost per infection averted span a wide range from $2060 to $36 360.
Conclusions: Multiple potentially interacting factors will determine the impact of PrEP. Model forecasts should reflect that uncertainty and programmes should focus on these factors and measure them, to maximize the impact of programmes.
Copyright (C) 2015 Wolters Kluwer Health, Inc.

new data on oral PrEP and vaginal tenofovir microbicide gel

February 24, 2015

Dear Advocates, 

Today at the Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle, new data on oral PrEP and vaginal tenofovir microbicide gel emerged that have implications for HIV prevention worldwide. We’ve collated the press releases and statements from groups involved in the research, as well as links to relevant webcasts—which become available 24 hours after presentation. Click here to view these resources; read on for a summary of the news.

Three oral PrEP trials presented at CROI provided additional evidence for use of the pill Truvada (TDF/FTC) for prevention. All three trials had very high rates of consistent use and very high rates of protection against HIV infection, specifically:
  • The Partners Demonstration Project among discordant heterosexual couples (where one partner is HIV-positive and one is not) in Kenya and Uganda showed that a program that delivers both PrEP for HIV-negative partners and/or antiretroviral treatment (ART) for HIV-positive partners reduced the risk of HIV infection by 96 percent. These results highlight the potential impact of combining PrEP and ARV treatment to slow the HIV epidemic. 
  • The PROUD Study among high risk men who have sex with men (MSM) in the UK showed that daily oral PrEP reduced the risk of HIV infection by 86 percent when delivered in existing public health clinics.
  • IPERGAY, a French study, was the first to examine the efficacy of “event-driven” PrEP – in this case, a three-day dosing strategy involving four pills around the time of sex – among high risk MSM who reported frequent sex. Overall, PrEP reduced the risk of HIV infection by 86 percent in the trial. Based on reported pill use by men in the trial, the regimen that most participants took amounted to at least four doses a week. Previous studies of daily oral PrEP have shown that this may be enough to be protective. However, it is not clear how well the event-driven regimen would work for men who have less frequent sex than the men in the trial. 
Also at CROI, researchers presented results from a trial of a tenofovir-based vaginal microbicide gel to be used before and after sex among young women in South Africa.
  • FACTS 001 was a trial of a tenofovir-based vaginal microbicide gel to be used before and after sex among young women in South Africa. FACTS 001 found no effect for vaginal tenofovir gel overall in the trial. While it appeared that most of the participants used the product at some point, there was not enough correct and consistent use in the trial to provide significant levels of protection. There was a trend of modest protection among the small proportion of women in the trial who appeared to have used the product consistently. This was similar to trends seen in previous studies of tenofovir gel among women, but not enough to change the overall outcome of the trial. 
AVAC will be working with partners to convene webinars and in-country discussions in a range of locations to talk through the implications of all of these data. We will announce the schedule in the coming weeks; if you have a specific question or would like support in organizing around these data, please contact us. Our recently released AVAC Report: Prevention on the Line provides background and analysis that anticipates and contextualizes these developments.

AVAC’s press release on these developments states:
 
“Today’s results add to a powerful body of evidence that ARV-based prevention works when it is used correctly and consistently. But they’re also a reminder that with nearly every prevention option available today, from condoms to PrEP to HIV treatment, correct and consistent use is both critically important and a real challenge.

The evidence tells us that we need a two-pronged approach. We should develop ambitious programs to roll out existing, proven options, including daily oral PrEP, around the world to those who can use them.  At the same time, we must continue to develop and test newer methods that others at risk will actually want, demand and use.

There’s growing demand for daily oral PrEP, and the data suggest that there might be other ways to use this strategy that can provide benefit,” Warren said. “For the sake of clarity and impact, providers, advocates and end users need to work together to develop clear, consistent messages that explain what’s known and not known about levels of protection in the context of different types of sex and different patterns of use.

The women in the FACTS 001 trial, the youngest group to date in any ARV-based prevention trial, have contributed so much to our understanding of the challenges and complexities of HIV prevention. The data suggest that these young women truly did want a product they could use to reduce their risk, but that this particular product did not fit into the realities of their daily lives.

Researchers, advocates and donors must keep working with young women at high-risk of HIV to find products that will make sense in their lives. We know that we need a range of safe and effective options for different people at risk. It is clear that no single option can possibly for work all people all of the time.”


Best,
AVAC

Thursday, 19 February 2015

Zimbabwean HIV Positive Feminist Martha Tholanah Wins 2015 David Kato Vision & Voice Award


Renowned Ugandan activist Frank Mugisha will present Martha Tholanah with the award on stage at the prestigious Teddy Awards ceremony in Berlin this Friday.

11 February 2015 [Berlin] – The David Kato Vision & Voice Award (DKVVA) is proud to announce that the 2015 award will go to HIV Positive activist Martha Tholanah from Zimbabwe. Martha risks her life everyday to support lesbian, gay, bisexual, transgender, and intersex (LGBTI) people across the country. Her activism is a powerful example of a straight ally standing in solidarity with LGBTI people despite threats to her own safety and security.

Martha also demonstrates extraordinary leadership on behalf of other marginalized communities, fighting for women’s rights, disability rights and sex worker rights both locally and internationally. She will receive the award on stage this Friday, at the prestigious Teddy Awards ceremony which is part of the Berlin International Film Festival.

“I am incredibly honored to be given this award that to me symbolizes my struggle against injustice in Zimbabwe and across the globe,” said Martha. “By honoring my work we recognize the human dignity and spirit of every person.”

Inspired by the life and work of David Kato, the human rights activist murdered in his home of Kampala, Uganda in January of 2011, the DKVVA recognizes the leadership of individuals who strive to uphold the human rights of sexual minorities worldwide, particularly in challenging circumstances and unsupportive policy environments. The award provides winners with a global media platform and a $10,000 grant to support their efforts.

The DKVVA is supported by a Secretariat based at the Global Forum on MSM & HIV (MSMGF). The MSMGF advocates for equitable access to effective HIV prevention, care, treatment, and support services tailored to the needs of gay men and other MSM, including gay men and MSM living with HIV, while promoting their health and human rights worldwide.

“Community-led efforts play a central role in securing LGBT rights,” said Micah Lubensky, Program Manager of the award and Community Mobilization Manager at MSMGF. “Yet so often these crucial efforts go unrecognized and unfunded. Through the David Kato Vision & Voice Award, we are able to provide activists with a platform to elevate the issues that are affecting their communities, as well as much needed funding to sustain and expand their work.”

As a trained family therapy counselor qualified in medical rehabilitation, Martha has established and headed health programs for Gays and Lesbians of Zimbabwe (GALZ) and the Network of Zimbabwean Positive Women (NZPW+). She currently serves as Chairperson of the Board for GALZ, an organization that has been a long time partner and contributor to MSMGF’s work.

She is currently facing two charges with the Zimbabwe Government linked to her involvement with LGBTI activism. Despite these challenges she remains deeply committed to her efforts and continues to represent GALZ in legally challenging state-sanctioned homophobia and violence.

Martha is also a proud feminist fighting to eliminate sexism in Zimbabwe. She works to make women living with HIV - young women and LBT women more visible in a male-dominated political and social landscape.

"I have been on a long journey to accept myself as an HIV positive African woman. I fight for others to overcome the stigma and discrimination in their lives so that they can find self-love and acceptance too,” Said Martha. “This award strengthens my work with organizations such as GALZ and NZPW+. On the day I receive this award, my wish is that the violence and discrimination in Zimbabwe finally stop, and that all people will come together to end discrimination against marginalized communities worldwide.”

Frank Mugisha, Chair of the David Kato Vision & Voice Award and Executive Director of Sexual Minorities Uganda (SMUG), will present Martha with the award on stage at the Teddy Award ceremonythis Saturday in Berlin.

“Martha’s voice and vision inspire hope for a world where injustice toward any and all marginalized communities is no longer tolerated,” said George Ayala, David Kato Vision & Voice Award Advisory Committee Member and Executive Director of MSMGF. “As we celebrate her life and work, we commemorate David Kato’s legacy and recognize the often dangerous efforts of individuals like David and Martha, who demonstrate what human rights and equality really look like.”

Media Contact
Micah Lubensky
+1.510.849.6437
mlubensky@msmgf.org

Read more about Martha Tholanah’s life and work here.

The David Kato Vision & Voice Award (DKVVA) recognizes and supports the work of leaders who strive to uphold the human rights and dignity of lesbian, gay, bisexual, transgender, and intersex (LGBTI) people around the world. More information about the DKVVA can be found at http://www.visionandvoiceaward.com .

The Teddy Award is an award given at the Berlin International Film Festival, celebrating films and individuals that communicate queer themes and content on a large scale and contribute to more tolerance, acceptance, solidarity and equality in society. Learn more athttp://news.teddyaward.tv/en/ .
 

No improvements in CD4 count at diagnosis in African patients in last decade

Can be accessed from: Gus Cairns
Published: 04 February 2015

A study by Harvard Medical School has found that the average CD4 count in sub-Saharan African people who are diagnosed with HIV has not risen since 2002. Neither has the average CD4 count on initiation of treatment, which remains well below the AIDS-defining limit of 200 cells/mm3.  The authors call for far more active HIV  testing and facilitated referral programmes, and continued global financial support for HIV testing and treatment.

A second study of a number of different prevalence and incidence surveys conducted by the International AIDS Vaccine Initiative (IAVI) among selected populations in the region shows that annual HIV incidence ranges from zero to 19% according to the population studied, indicating that specific groups should be the subject of testing and referral initiatives. Groups with especially high incidence included the negative partners in sero-different couples, female sex workers (FSWs), men who have sex with men (MSM), young women in certain locations, and specific communities such as fisherfolk on Lake Victoria. Equally, however, surveys of some similar groups in different locations reported low incidence, showing that it may change rapidly and that regular studies should track incidence hotspots.

It was notable that the incidence rate in most populations with high rates fell two- to threefold after the first three months of being included in an incidence survey, showing that clinical referral and monitoring is itself a useful HIV prevention measure.

CD4 count at diagnosis and at start of treatment

The Harvard study looked at CD4 count on diagnosis and at initiation of antiretroviral therapy (ART) in 127 different studies covering over half a million patients between 2002 and 2012. Only six studies looked at CD4 count at both HIV diagnosis and ART initiation in the same patients.

It found that the average CD4 count at HIV diagnosis was 250 cells/mm3 in 2002 and 309 cells/mm3 in 2012. This increase – amounting to a 5.8 cells cells/mm3 increase per year – was not statistically significant.

The average CD4 count at ART initiation actually decreased very slightly, from 152 cells/mm3 in 2002 to 140 cells/mm3 in 2012, well below the AIDS-defining limit of 200 cells/mm3. This decrease was also not significant.  There was no change in CD4 count at initiation after the issue of the World Health Organization’s 2009 treatment guidelines, which changed the recommended CD4 count at which to start ART from 200 to 350 cells/mm3.

There were exceptions to these CD4 figures. When ART was given to pregnant women for the prevention of mother-to-child transmission, the CD4 count at diagnosis and at ART initiation were 395 and 313 cells/mm3 respectively. 

More significantly in terms of general testing and treatment policy, CD4 counts were a lot higher at both diagnosis and ART initiation in so-called ‘active HIV screening’ programmes. This means initiatives such as community-wide screening, community-based combination prevention programmes that include testing, home-testing and home-based testing by visiting health workers.  In active programmes, CD4 counts at diagnosis and initiation were 405 and 268 cells/mm3 respectively. However, only 3.3% of all the people whose CD4 counts were included were involved in studies of such programmes.

South Africa is the one country that had higher CD4 counts on diagnosis in 2012 than 2002: its year-on-year increase in average CD4 count at diagnosis of nearly 40 cells/mm3 a year would appear to be an endorsement of that country’s HIV awareness strategy. However this has not been matched by an increase in CD4 count at ART initiation, which at 123 cells/mm3 averaged over the whole decade is the second-lowest among countries surveyed after Ethiopia.

The researchers comment that there is a relative lack of data post-2010, with only 14% of studies reporting figures from beyond that year: this is because some multi-year studies do not report till the end, so recent improvements in CD4 count at diagnosis and ART initiation could be missed.

HIV prevalence studies

Meanwhile a series of observational studies conducted by IAVI document extremely high HIV prevalence and incidence rates in some populations and surprisingly low ones in others. IAVI runs a project called the African HIV Prevention Partnership that conduct observational studies in different parts of Africa to uncover populations in particular need of prevention intervention. This is work preparatory to creating an African HIV Clinical Research and Prevention Trials Network similar to HPTN in the US.

Their paper looks at three prevalence and ten incidence studies in varied populations in the countries of Uganda, Rwanda, Kenya, Zambia and South Africa.

In the prevalence studies, a variety of populations in Uganda and Kenya were studied including rural communities, clinic attendees, a random whole-area population sample, and in Nairobi female sex workers (FSWs) and their clients.

Groups in which there was particularly high HIV prevalence includes FSWs (20% - in their clients it was 7%), and divorced and widowed people (as opposed to single or married ones), where prevalence was 28% in a Kenyan study, and 22% in a Ugandan one. HIV was also more common in urban versus rural populations: it was 9% urban versus 2% rural people in a Kenyan study, and, in a Ugandan one, 16% versus 10% for people who lived near a highway versus people whose homes were only accessible by foot.

Peak prevalence age was 30-34 in two studies (16.5% in Uganda and 24% in FSWs) and in the non-FSW studies women had higher prevalence than men (in women, 10% and 13% in two studies versus, in men, 5% and 9%).

Condom use, especially irregular use, was actually associated with higher HIV prevalence than not using them at all, but possibly because it was associated with casual sex. In Nairobi FSWs and clients, prevalence was 17.5% in condom users versus 10% in non-users. In Masaka, Uganda prevalence was 10% in people who never used condoms, and also in people who used them more than half the time: but it was 15% in people who used them only occasionally. Prevalence in people with one steady partner was lower (8-11% across studies) than in people who had more than one (14-17%).

Genital ulcer disease (herpes, syphilis and the like - GUD) were associated with 2.5 to four times the prevalence than in people who did not have GUD.

HIV incidence studies – very high rates in some groups

But it was the incidence studies that found continuing high, and in some cases extraordinarily high, rates of ongoing HIV infection in some communities and groups – and low rates in seemingly similar ones.

One of the easiest and most important populations in which to conduct incidence is serodiscordant couples. In most but not all studies of serodiscordant couples annual HIV incidence was higher where the female partner was the initially HIV-negative one. Very high rates were observed in Lusaka, Zambia (9% a year in female partners, 7% in male) and Ndola in the same country (11% in women and 6% in men).

The ‘real-life’ effect of placing the positive partner on ART was documented in one study in Masaka, Uganda where annual HIV incidence in serodiscordant couples was 4% in male partners and 5% in female but only 1% in partners of either gender when the HIV-positive partner was on ART.

In the latter case particularly, much of this continued HIV infection may have come from outside the main relationship: IAVI genotyped all viruses in the HIV positive partners and found that from 20% to 33% of the infections in their studies came from someone other than the main partner, with one exception on Uganda where there were no ‘unlinked’ infections.

Other groups in which very high incidence was found were MSM, with annual incidence rates of 7% and 6% at two places in Kenya and 9.5% at Rustenberg in South Africa;  women in ‘peripheral communities', i.e. irregular housing in Rustenburg (9%) and members of fishing communities in Lake Victoria (10% in women in one Ugandan location and 5% in men).

And yet, at the same time, some groups with very high prevalence did not have a high rate of ongoing HIV infection. Even though HIV prevalence in Nairobi FSWs was high (see above), annual incidence was very low: in rural communities in Masaka where HIV prevalence was 10%, ongoing HIV incidence was so low in the general population that the team shifted their incidence survey to serodiscordant couples and fishing communities. And in one study in Kenya there were no infections observed within discordant couples at all (this study is unpublished so there is as yet no explanation for this).

One striking and near-universal finding was that enrolment into an HIV incidence study brought down incidence in itself. There were astoundingly high HIV incidence rates among some people in the first three months of their involvement in incidence studies: 15% and 19% in HIV-negative women in Zambian serodiscordant couples, 16% in Kenyan MSM, 12% among women with casual partners in South Africa. In all cases, although incidence remained high, it fell 1.5 to 4-fold after the first three months of being in the survey. This phenomenon has been seen in HIV prevention studies before and may be due to regular monitoring and the attention and counselling of healthcare workers.

HIV prevalence in sub-Saharan Africa has been in decline throughout the period of these studies and access to ART has expanded hugely. However what these two studies show is that the HIV epidemic is still very much an ongoing one in some groups in Africa.

The IAVI writers comment that their findings "provide valuable data for prevention trial design and conduct, prevention planning, and service delivery," especially in key affected populations where  there is high HIV incidence "despite regular HIV testing and counselling."

References

Siedner MJ et al. Trends in CD4 count at presentation to care and treatment initiation in sub-Saharan Africa, 2002-2013: a meta-analysis. Clinical Infectious Diseases, e-pub ahead of print: pii: ciu1137. 2014.

Kamali A et al. Creating an African clinical research and prevention trials network: HIV prevalence, incidence and transmission. PLoS One, Doi:10.1371/journal.pone.0116100. 2015.

Paul Semugoma MD. (MSM Technical Expert - Health4Men | Anova Health Institute | semugoma@anovahealth.co.za | Tel +27214472844 | Fax +27214472887 | Mobile +27765705942)
Ivan Tom's Center for Men's Health, Victoria Walk, Woodstock, Cape Town 7925
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