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Caroline Ryan is the author of this post. Ryan is Director of Program Services and Chief Technical Officer in the Office of the U.S. Global AIDS Coordinator, or the PEPFAR program.
Here is some information from the rapporteur session at the end of 2009 HIV/AIDS Implementers’ Meeting. It covered 59 sessions and 255 presentations in addition to selected posters.
Here are some highlights from each of the sessions:
1. Women and Children –
The CIDRZ research group from Zambia presented an evaluation of PMTCT (prevention of mother-to-child transmission) prophylaxis at the population level in four African countries which found that less than half of HIV exposed mother infant pairs received a full course of single dose NVP. In order for PMTCT to work, each mother-infant pair must negotiate a complex cascade of events. Failures occur along each step of this pathway and should be systematically targeted. Fixing the “coverage problem” would prevent as many infant HIV deaths as would rolling out more effective regimens – and should be taken just as seriously.
The number of adolescents living with HIV is growing because there has been limited expansion of PMTCT programmes, there is increasing access to ART and increased survival of perinatally infected children, and new heterosexual infections among adolescents are continuing. Parents, guardians, health providers and health services are ill prepared to meet the diverse needs of adolescents living with HIV. At this conference, we heard of a program in Uganda that empowers parents to communicate with infected adolescents. This is an approach that should be scaled up. From Cote d’Ivoire, we heard about the N’zrama program developed and implemented by youth. The lesson learned is that adolescents must be given explicit information on HIV, sexuality and reproductive health. We can also learn from existing programs for adults and children and adapt these to meet the needs of youth. Youth want and can contribute to this response.
Moderator for the Women and Children track was Dr. Dorothy Mbori Ngacha (CDC/Kenya)
2. Evolving Challenges in Treatment, Laboratory, Care and Support Services –
It was noted that the current trend is to start ART earlier, use less toxic drugs and promote more lab monitoring. ART scale up will cost more irrespective of the regimens or criteria adopted. In a time of global economic pressures, it is increasingly important that national programs, funders and other stakeholders have a sound understanding of the costs, social policy choices and tradeoffs inherent in their decisions. We have to look at opportunity costs and balance continued treatment scale up with investments in prevention and systems strengthening. Final messages in this session included:
• Treatment: Be realistic and aligned to your context but continue to push for inspirational targets
• Laboratory: Strengthen lab services, but don’t permit absence of lab tests to be a barrier to access treatment and care
• Care: Try to be simple, not simplistic
• Support: Promote efficient access to care and treatment with and for PLWH, and prioritize people most in need.
Moderator for the Evolving Challenges in Treatment, Laboratory, Care and Support Services — Dr. Marco Vitoria, WHO
3. Responding to Challenges in HIV Prevention:
This rapporteur session covered male circumcision, multiple concurrent partnership, combination prevention, youth prevention, prevention in mobile and uniform services, positive prevention (now referred to as Positive Health, Dignity, and Prevention), blood safety, and injection safety and waste management. The report out on infection safety and waste management highlighted some unique programs. In Uganda, routine HIV counseling and testing generates huge volumes of medical waste. Twelve million tests per year creates 384 tons of waste with a cost of managing this waste of $1.68 million. Establishing volume and cost of managing medical waste helps management and planning for injection waste. Interestingly, more waste was generated because of peoples’ suspicion of results from finger stick tests and preferred to be retested with a venous blood draw, generating more waste. In Botswana, the Botswana Defense Force (BDF) and Corps of Health Services (CHS) had an innovative approach to the problem of waste transport and dealing with the dangers of open van transport. Their novel solution was the construction of trailers to transport medical waste. There was a substantial cost savings between the trailers and compacter trucks ($5000 vs. $56,000). In Rwanda, recycling plastic hospital wastes significantly reduced the volume of infectious waste. Sustainability is ensured through the sale of plastic bags resulting from the recycling process.
Moderator for Responding to Challenges in HIV Prevention track was Ms. Eda Lifuka (PEPFAR DoD team Zambia)
4. Effective HIV Prevention, Treatment, Care and Support Programs for MSM/Transgender, Drug-Users, Prisons and Sex Workers:
Noted promising practices were:
Application of cell phone technology and helpline counseling was associated with stigma reduction and dramatic increases in clinical service uptake among MSM in Ghana
Personalized contacts with 15-24 year old sex worker-client networks facilitated high acceptance of HIV/STI testing and prevention services in Kenya
Methadone maintenance in China appears to have reduced not only HIV incidence but also social harms including crime, unemployment, demand for heroin
Use of peer educators increases access to MARPs and buy-in/acceptance/participation among MARPs
Rigorous approaches to assess behavioral and biological impacts of programs for populations facing multiple HIV risks need to be pursued (e.g. IDU and SW).
Moderator for the Effective HIV Prevention, Treatment, Care and Support Programs for MSM/Transgender, Drug-Users, Prisons and Sex Workers track was Dr. Sanjay Kupur USAID/India
5. Performance Based Programming and Systems Strengthening:
This report covered: governance and planning; performance based financing; engaging the private sector; human resource issues and solutions; and strategic information. The report closed with a review of how to achieve program efficiencies. Some ways to gain efficiencies include: improved planning and governance; performance-based programming; engaging the private sector; and finding creative solutions to resource constraints. To achieve efficiencies, successful programs identify optimal designs that are responsive to the problem and relevant to customers’ needs. In addition, they create incentive structures that promote efficient implementation and increase quality, and use information to provide useable and pertinent measures of performance.
Moderator for the Performance Based Programming and Systems Strengthening track was Dr. Norbet Forster, MOH Namibia
6. Cross- Cutting:
This session covered: Counseling & Testing (CT); Mental Health and HIV; Community Engagement and Monitoring; Knowledge Translation and HIV Incidence Measurement: “Modes of Transmission (MoT)”; Strengthening Linkages between Sexual and Reproductive Health, Human Rights, and HIV; Engaging Men; and Combating Stigma. The way forward for counseling and testing was highlighted:
• Improve referrals both to prevention and care/treatment programs
• Continue efforts to bring men into counseling and testing through targeted campaigns, door-to-door, and community-based counseling and testing, perhaps while linking to gender programs
• Ensure that counselors receive both extensive training and supportive supervision to ensure capable couples counseling (perhaps learn from the MC model)
• Continue task-shifting to lay counselors to increase sustainability
• When evaluating desired outcomes, it must be considered that PITC identifies patients late in the natural history of their disease. Other forms of CT may identify patients at an earlier disease stage and thus may decrease morbidity and mortality and reduce costs over time.
Mental health care should be integrated into HIV/AIDS services and vice versa. It was noted that there is need for investment in mental health care for OVC and PLHIV. We were encouraged to view that food is a health product. It was noted that food and nutritional programs should be part of a comprehensive package that includes nutritional assessments, counseling, specialized food, micronutrient supplements, and water purification to maximize health impact.
Moderator for the Cross-cutting track was Dr. George Tembo, UNAIDS.