Challenges of antiretroviral treatment in resource-poor settings

In a 2001 U.S. Congress Hearing, Chief U.S. Aid A. Natsios publicly stated that if Africa was given antiretroviral treatment (ART) for its HIV/AIDS epidemic, its citizens wouldn’t know how to take the pills on time because they measured the hour by the sun.

“Africans do not know what watches and clocks are,” said Natsios. “They do not use western means for telling time. They use the sun. These drugs have to be administered during a certain time during the day and when you say 10:00, people will say ‘what do you mean by 10:00?’”

But contrary to Natsios’ statement, the complication of administering ART in Africa has nothing to do with the sun. Antiretroviral treatment has a possibility of serious side effects and it requires a high level of adherence on a daily basis. The drugs have been labeled as “unforgiving” in many medical studies if they are not used properly, and resistance may develop in patients that could compromise the entire treatment. For medical clinics, the cost of ART together with the cost of monitoring patients taking these drugs poses a major financial challenge to public health programs, particularly in developing countries where a lack of medical infrastructure and human resources could limit the access to professional and safe ART.

The overall goal of antiretroviral treatment is to better the life of people living with HIV/AIDS, as there is no known cure or vaccination for the virus. But scientists and medical practitioners have debated for years on the best time to start treatment to prevent immunologic damage and adverse side effects from drug toxicity. Cost of treatment, too, must be factored into the argument, as some resource-limited countries must give priority treatment to patients with obvious immunologic damage before moving on to the less urgent cases.

Dr. John A. Idoko, Department of Medicine at the University of Jos, spoke about the benefits of early antiretroviral treatment in Nigeria this week at the annual Harvard-PEPFAR conference on HIV/AIDS prevention. According to Idoko, a delay in initiating ART increases the risk of toxicities—such as skin rashes and bloated stomachs—in a majority of patients. Thus he proposes that medical staff initiate ART when patients have a CD4 level of +350 mm3.

“Firstly, there’s an issue of toxicity. Toxicity is the number one reason that patients stop adhering to their drugs—and the lower the CD4 count when given medication, the higher the toxicity rate,” said Idoko. “Secondly, those who die from HIV/AIDS usually start their medication at lower CD4 counts. Thirdly, the medication given for higher CD4 counts is stronger, less toxic, and more convenient.

“So with all these factors, why not start medication later?”

Nigerian government health guidelines state that patients must have a CD4 count of below 350 and show symptoms of HIV/AIDS before they can receive antiretroviral treatment. But many patients with a CD4 count of between 200 and 350 don’t show symptoms, said Idoko, and cannot receive their needed treatment because of these guidelines.

In the United States, the government changed their health guidelines in less than one year to reflect recent studies and to state that medical facilities can treat patients with 350 CD4 count and monitor patients at lower levels. Dr. Idoko advocates that the Nigerian government follow in the U.S.’s footsteps and make earlier ART part of national health policies and guidelines.

“We want to be suppressing the virus as much as possible,” said Dr. Idoko.

Apart from finding the perfect time to administer ART, enforcing patients’ adherence to ART is always another challenge in resource-poor settings. If a bus driver cannot afford to miss work, he will find it extremely difficult to trek to the clinic each month and wait several hours to pick up his medication. Or, if a mother has to choose between feeding her six children and buying antiretroviral treatment for herself, she will likely pick her family over her own health.

This financial reality stirs up big problems for patient adherence, but many clinics and hospitals in Nigeria are working their way around it. The Jos University Teaching Hospital provides inpatients with transportation to and from the hospital to lower their financial burden. The hospital also encourages local governments to support their HIV-positive staff with transportation to the hospital, and encourages their HIV/AIDS support groups to approach the government for grant money. According to Idoko, “the government does help with funding when it can, but overall it’s not doing enough.”

In addition, the Jos University Teaching Hospital assigns treatment partners to each patient to not only provide financial support, but also emotional, psychological, and physical support. And though the challenge of providing ART to patients in Nigeria and other resource-poor settings continues, scientists, researchers, and doctors have shown that the solutions lie in adherence, access, and support, and not in clocks or the sun.

*Reported by Amanda Hale

Micronutrients in Africa: Cheap, life-saving, and completely underestimated

In developing countries where malnutrition and lack of clean water are common, pregnant mothers—especially those living with HIV/AIDS—often face birth complications such as pre-term births, fetal deaths, and low fetal birth weight, simply because their bodies lack the basic nutrients to bring another life into this world.

Tragedies like this are easily prevented through the distribution of micronutrients like multivitamins, vitamin A, vitamin B, vitamin C, and vitamin D. Each of these vitamins has numerous benefits to the human body and reproductive system: vitamin A increases T-cell counts, vitamin B increases antibody count, and vitamin E increases antibody response to T cell dependent vaccines, to name a few of the perks.

In a presentation on micronutrients and child health, Dr. Ramadhani Mwiru of Tanzania’s Harvard-PEPFAR program explained how micronutrients can change the future of childbirth in Africa. A 2002 study in Malawi showed that HIV-positive pregnant women who took vitamin A throughout their pregnancy significantly improved their baby’s birth weight and lowered their risk of anemia. Micronutrients also reduced the risks of mother-to-child-transmission via breastfeeding.

But despite these life-saving factors, micronutrients haven’t yet been incorporated into many African national health policies. Medical clinics aren’t required to hand out micronutrients to pregnant women; and as a result, many clinics don’t provide the necessary nutrients needed to mothers who lack vitamins in their systems.

Rural clinics are the least likely to give out multivitamins or supplements to pregnant women in their care, according to Mwiru. “It’s something that needs to change. Medications for malaria and anemia are routinely given out to patients as part of hospital protocol, so why aren’t micronutrients?” said Mwiru.

A 1999 study in Dar es Salaam, Tanzania, showed that the use of multivitamins on HIV-negative pregnant women reduced the prevalence of fetal death; multivitamins also reduced low birth weights and the number of severe pre-term births. With studies proving that micronutrients have positive effects on both HIV-positive and HIV-negative women at very low costs (vitamin A therapy costs about 0.35 USD per patient), Mwiru is hopeful that the Tanzanian government will integrate micronutrients into its national health programs and hospital policies soon.

“There are challenges to making this happen—policy-making involves so much beuracracy. You really have to push for change,” said Mwiru. “But if you have dedicated people working with you who can push, then it can work.”

*Reported by Amanda Hale

Training nurses to dispense ARV treatment in Botswana

Abuja, Nigeria—In Botswana, the reality of medical care in most clinics is an overwhelming lack of pharmaceutical officers to administer anti-retroviral treatment for AIDS patients. This means that if you are a person living with HIV/AIDS, you are often forced to trek to towns or large villages to receive anti-retroviral services, waiting in long lines and spending your entire month’s savings to receive a package of life-saving drugs.

Because of this reality, nurses in Botswana are now the backbone of Harvard-PEPFAR’s health care systems. Harvard-PEPFAR trained its nurses how to order and manage ARV drugs, how to quantify treatments, how to conduct quality storing of ARV drugs, and how to monitor adverse drug reactions among patients.

So far 86 nurses have been trained to administer ARV drugs, and among these nurses most are able to assist pharmaceutical officers if needed. The challenges they’ve faced have ranged from inadequate space to store medications, inadequate human resources (including an overall lack of pharmaceutical officers) and inadequate counseling for patients who collect ARV treatment from the nurses.

But Dr. Joyce Kgatlawne of Botswana’s National Program of Nurses Dispensing ARVs is confident that the training program will overcome these obstacles if constant monitoring and evaluation of nurses is enforced. According to Kgatlawne, “Nurses can be the future of ARV treatment, but the training and mechanisms to monitor and supervise the practices are essential.”

*Reported by Amanda Hale

Experts from Nigeria, Tanzania, and Botswana shared successes and challenges of Harvard-PEPFAR program in Africa

Abuja, Nigeria--In Nigeria three million people currently live with HIV/AIDS. Of these three million, 305 new infections occurred only last year.

This rapidly growing number of HIV infections in Nigeria motivated the APIN Plus-Nigeria program (Harvard-PEPFAR), an initiative started in 2003 to address AIDS prevention and intervention methods in Nigeria, to continually develop its technology and improve Nigeria’s HIV labs and pharmacies.

According to Ernest Ekong, National Clinical Coordinator for APIN Plus-Nigeria, the program uses data management to develop treatment response graphs to monitor biological failures in patients who are not responding well to their ARV treatments. When this occurs, doctors start resistance testing with patients and change the patients’ drugs accordingly to improve their biological response to ARV treatments.

‘The ability to graph biological failures is an important tool for medical staff to address adherence issues for patients,’ said Ekong. ‘It makes a huge difference in the lives and health of people living with HIV/AIDS.’

Since 2003, APIN has operated on 17 sites across the country—11 of which are research facilities, and six of which are primary health facilities. After their steady progress in data management and treatment response, the APIN Plus-Nigeria program plans to continually use data to give HIV/AIDS patients the quality care they deserve in Nigeria.


Tanzania:
Tanzanian and US Governments support Harvard-PEPFAR’s expansion of renovated medical sites

In the past two months Tanzania’s Harvard-PEPFAR program received visits from three government figureheads to inaugurate the grand opening of its two renovated medical clinics in Amana and Mwana, Tanzania.

The Tanzanian president, the Tanzanian Minister of Health, and the U.S. Secretary for Human Health Services visited the sites to mark an important commitment between government officials and civil services to expand medical centers and build better infrastructures for people living with HIV/AIDS in Tanzania.

On September 5, 2007, the number of AIDS patients enrolled in the Tanzanian Harvard-PEPFAR program was 30, 915. With two new medical clinics available to provide space for patients, Dr. Guerino Chalamilla of Harvard-PEPFAR said that patients’ quality of life and drug adherence are the next big focus.

Patient tracking, a process in which four to six nurses at each medical site document patients’ phone numbers and physical addresses after their first visit, allows nurses to follow up with patients that have missed visits, provided abnormal lab results, or failed to pick up their ARV treatments.

Patient tracking encourages constant communication between nurses and patients and pushes patients to adhere to their ARV treatments—a very important aspect of living healthily with HIV/AIDS. Formal adherence is a crucial aspect of Tanzania’s program according to Chalamilla, as patients’ adherence rates are checked through self reporting and rate counters checked by pill counting.

‘If patients are taking less than 95 per cent of their pills, then medical staff must provide counseling to address the barriers to effective ARV treatment,’ said Chalamilla.

Critical attention to patient care marks Tanzania’s program as one committed to continually serving people living with HIV/AIDS. Since the late 1980s, the Harvard School of Public Health has worked in Tanzania to develop an internationally recognized clinical and vaccine based research program and a research study on the role of micronutrients in reproductive health and HIV/AIDS.


Botswana:
Harvard-PEPFAR program takes key step towards master training and patient care

In Botswana’s Harvard-PEPFAR program, people are often said to be valued more than numbers. Though this seems a positive statement, it raises imminent challenges for providing endless needs assessments for patients and staff members and to ensure complete satisfaction with PEPFAR treatment.

But Botswana is taking on the challenges with gust. Nurses now implement exit interviews, in which patients are asked questions about how satisfied they were with their visit, how long they had to wait for medical attention, and if they were seen by a nutritionist before they left the medical clinic. The administrators and staff also measure the success and impact of their program by carrying out quality of life studies for every patient.

‘Our program is quite simple,’ said Dr. Tendani Gaolathe of the Harvard-PEPFAR program in Botswana. ‘Our mandate is for training staff to care for patients, and we try to be very people focused, always.’

As for overcoming challenges, there is always more to be done. Space is always a major concern at Botswana clinics, and according to Gaolathe, limited manpower and expensive equipment servicing has caused some issues in the past.

“But we are learning our lessons,” said Gaolathe, such as making sure to establish service contracts for every piece of equipment they buy so as to avoid paying expensive repair fees in the future. And though the Botswana program is scheduled to officially end in February 2009, Gaolathe is confident that they will obtain another PEPFAR grant and continue to increase the level of patient care and staff treatment in Botswana.

*Reported by Amanda Hale

U.S. GOVT TO DOUBLE PEPFAR INITIATIVE TO $30b

Abuja, Nigeria--The United States of America has announced its plans to double the amount ear-marked for implementing the President’s Emergency Plan for AIDS Relief (PEPFAR) program, from $15b to $30b for the next phase 2009 -2014. This pronouncement was made yesterday by Ambassador Robert Gribbin, Charge D’Affaires, United States Embassy, Nigeria, at the star studded opening banquet of the 3rd Harvard PEPFAR Tri-country conference taking place in Abuja, Nigeria. To this end, the administration of President George Bush, is seeking to reauthorize the PEPFAR bill at the United States Congress the bill backing the PEPFAR initiative
.
In his speech, Amb. Gribbin extolled the importance of Nigeria in the global arena; being a principal actor in ensuring peace in the troubled spots of Dafur, Sudan and the West African block and also a force within the petroleum producing nations in the world. To this end, he said there was the need to ensure that people living with the HIV/AIDS in Nigeria are also helped in everyway possible.

Commenting that the opening ceremony coincided with the remembrance of the terrorist attack on the World Trade Centre (9/11) six years ago, Amb. Gribbin said ‘While the victims of the 9/11 terror attack cannot be brought back to us, we intend to make sure that the people who without the help of good treatment, care and support, would have become victims of HIV/AIDS epidemic would be brought back to the productive and qualitative life they had always known.’

He commended the Harvard PEPFAR team of medical researchers for the level of work they had done since the inception of the initiative in Nigeria and urged that the conference should be an opportunity for them to share experiences on the work done in the area of on promoting AIDS awareness, second-generation HIV and STD surveillance, intervention in high-risk populations, prevention of mother to child transmission, and the socio-economic impact of HIV/AIDS in their countries and to learn from this experiences to fashion out a best practice that can be adopted to suit the individual country.

This Tri-country conference from September 11 to 15, 2007 is the third in the series with partners from Botswana, Nigeria, Tanzania, and the Harvard University teams based in Boston and Chicago, United States. The Harvard School of Public Health (HSPH), in partnership with governmental and non-governmental agencies and universities, initiated the APIN program in 2001. Since then, the APIN-Harvard Nigeria program has supported over 30 projects in Lagos, Oyo, Plateau, and Borno States. These projects focused on promoting AIDS awareness, second-generation HIV and STD surveillance, intervention in high-risk populations, prevention of mother to child transmission, and the socio-economic impact of HIV/AIDS in Nigeria.

The Harvard-PEPFAR conference promises to cover all of these issues in great detail as delegates from around the world gather to discuss, debate, and share their current projects and visions for HIV/AIDS awareness and prevention.

*Reported by Nnenna Ike

Harvard-PEPFAR Tri-Country Conference: Researchers enjoined to build capacity and learn from each other

Abuja, Nigeria--Over 200 scientists, health workers, government officials, non-governmental workers, and media from around the world gathered to kick off this year’s Harvard-PEPFAR Tri-Country Conference, themed “Building Sustainable Partnerships in HIV/AIDS Programming,” on September 11th in Abuja, Nigeria. Among the speakers were the Honourable Minister of Health for Nigeria, the United States Ambassador for Nigeria, the Nigeria Country Director for Harvard School of Public Health and the Director General for the National Agency for the Control of AIDS in Nigeria.

Though building partnerships was one of the key points stressed by the speakers at the opening banquet, saving lives of people living with HIV was the main focus of the discussion. Providing the best high quality services for Nigerians infected with HIV, as well as providing information, education, and prevention methods, were stated as the main objectives of the three Harvard-PEPFAR programs in Africa. Manpower development, as well, is another factor that greatly contributes to preventing HIV/AIDS, according to Senator Iyabo Obasanjo-Bello of the Senate Committee on Health in Nigeria.

Learning from each country’s project successes and failures was also a prominent theme of the opening ceremony. Senator Obasanjo-Bello stated that ‘We usually know more about our colonial masters than we do about our own neighbouring countries, which is something that needs to be changed if African countries are to learn from each other’s experiences fighting HIV/AIDS.’ The conference is meant to encourage such cross-fertilization of ideas, projects, and challenges faced by creating an open forum for experts from Africa and international delegates to discuss HIV/AIDS relief.

She concluded that the impact of the program was not only being felt by the people living with the virus, but also on the care givers and researchers as there has been tremendous increase in manpower capacity building. Her words, ”The capacity building of our people is what makes the greatest impact. The increased capacity to do the job well and maintain the international standard for treatment, care and support is something that will always remain with us, and for that we are grateful.”

Though messages of congratulations and thanks abounded in each speaker’s welcome remark, John Vertefeuille, Chief of Party, United States Centres for Disease Control and Prevention (CDC) Nigeria was careful to remind delegates that more work needed to be done and more challenges needed to be overcome in the future.

“Though I thank you all, I want to ask you for your next commitment,” said Vertefeuille. “Our road has not yet come to an end.”

To date, the Harvard-PEPFAR program has provided life saving ART to over 59, 000 AIDS patients—12,000 from Botswana, 19, 000 from Tanzania and 28, 000 from Nigeria. The program was launched shortly after the President’s Emergency Plan for AIDS Relief in 2003, when one of the requirements for the application to the first Track multi-country PEPFAR programs was to have a minimum of 3 years experience in at least 3 of the PEPFAR focus countries.

*Reported by Amanda Hale

Harvard-PEPFAR Tri-Country Conference Begins!

Over 200 research scientists and experts arrived today in Abuja, Nigeria for the annual Harvard PEPFAR (President’s Emergency Plan for AIDS Relief) Tri-Country Conference being hosted in Nigeria for the first time by AIDS Prevention Initiative Plus (APIN+), the Nigerian arm of the Harvard PEPFAR program.

The conference, themed “Building Sustainable Partnerships in HIV/AIDS Programming” is taking place at the Abuja Sheraton and Towers from September 11 to 15, 2007 and features delegates and partners from Botswana, Nigeria, Tanzania and the Harvard University teams based in Boston and Chicago, United States. Already delegates are
filling the lobby of the Abuja Sheraton and Towers as they prepare for the opening ceremony, which commences tonight at 7:00 PM.

Each year for the past two years, experts come together to share progress, lessons learned, and to promote best practices across the PEPFAR Program. The two previous conferences were held in Botswana and Tanzania respectively and allowed in-depth review and visits to PEPFAR supported sites in the host country.

The Harvard School of Public Health (HSPH), in partnership with Nigerian governmental and non-governmental agencies and universities, initiated the AIDS Prevention Initiative (APIN) program in 2001. The APIN Harvard-Nigeria program has supported over 30 projects in Lagos, Oyo, Plateau and Borno States. These projects focused on promoting AIDS awareness, second-generation HIV and STD surveillance, intervention in high-risk populations, prevention of mother to child transmission, and the socio-economic impact of HIV/AIDS in Nigeria.

Since 2001, APIN, an initiative funded by the Bill and Mellinda Gates Foundation, have developed human and institutional capacity in several areas to support Nigeria’s response to the epidemic. The project had a substantial impact on AIDS prevention and care and became the foundation for the Harvard-PEPFAR project, known as APIN-Plus, when Harvard University was awarded a grant in February 2004 by the US government under the PEPFAR program, with the goal of providing treatment to 8000 people living with HIV/AIDS per year. The program currently provides ARV treatment, care and support for thousands of Nigerians.

Overall, the Nigeria-PEPFAR program has demonstrated significant progress, having provided very high quality ART treatment and monitoring to more than 23,000 adult and paediatric patients. Additionally, the program has cared for more than 36,000 HIV infected individuals. PMTCT is a significant component of the APIN-Plus program, providing full PMTCT services to over 40,000 pregnant women in 29 sites across the country. The conference will cover all of these issues in great detail as delegates from the three countries and around the world gather to discuss, debate, and share their current projects and visions for HIV/AIDS awareness and prevention.

Development Communications Network will be providing daily reports from the conference for the media in Nigeria and across Africa. Stay tuned for our update on the conference's opening ceremony, which takes place at the Abuja Sheraton and Towers tonight at 7 PM.

*Reported by Amanda Hale

APIN Tri-Country Conference, Abuja, Sept 11-15

On September 11-15, Development Communications Network will attend the AIDS Prevention Initiative Nigeria (APIN) Tri-Country Conference in Abuja. The conference hosts journalists, NGOs, government officials, non-profit organizations, and health workers from Nigeria, Botswana, Tanzania, and other countries to come together and discuss current HIV/AIDS initiatives in Africa.

The Harvard School of Public Health (HSPH), in partnership with Nigerian governmental and non-governmental agencies and universities, initiated the APIN program in 2001. Since then, the APIN Harvard-Nigeria program has supported over 30 projects in Lagos, Oyo, Plateau, and Borno States. These projects focused on promoting AIDS awareness, second-generation HIV and STD surveillance, intervention in high-risk populations, prevention of mother to child transmission, and the socio-economic impact of HIV/AIDS in Nigeria.

The APIN conference promises to cover all of these issues in great detail as delegates from around the world gather to discuss, debate, and share their current projects and visions for HIV/AIDS awareness and prevention. Development Communications Network will join the conference to share its current collaborative project with APIN, which is a collection of four HIV/AIDS documentaries focusing on positive living, nutrition, treatment and adherence, and prevention of mother-to-child transmission. Additionally, Devcoms will send journalists from Lagos to cover the conference and create awareness of HIV/AIDS issues in the Nigerian media.

Please stay tuned for updates from the conference!

Welcome to Development Communications Network

Development Communications Network is a media-development, capacity-building non-governmental organization coordinated by experienced development journalists. The organization is a product of series of development projects on media (both print and broadcast – including filming and radio production) health promotion, advocacy and capacity building in the Nigerian mass media and the civil society sector from 1995 to date.

Our vision is a society that is literate about science and public health issues. Our mission is to ensure public understanding of science and public health-related research through promotion of excellence in science and public health journalism. We develop appropriate communication strategies for health promotion, scientific literacy, policy development and program implementation.

Development Communication Network's mission is implemented through three approaches: capacity building for journalists; fostering linkage between the media, scientists, civil society and development sector; and public health education promotion.

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