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Posts Tagged ‘Kenya’

The Interagency Youth Working Group worked with USAID to sponsor a meeting yesterday entitled “Protecting and Empowering Adolescent Girls: Evidence for the Global Health Initiative.”  The meeting featured a series of presentations from leaders in the global health field, which aimed to identify factors contributing to girls’ vulnerability to HIV and reproductive health risks, as well as to share effective programmatic approaches and research that address such risks.  In one of the panels, entitled “Empowering Adolescent Girls,” panelists spoke of their respective organization’s projects in developing countries, aimed at empowering young girls as a strategy to deal with the HIV/AIDS epidemic. 

Facilitator Victoria Collins, of Cardno Emerging Markets, discussed the need to invest in the development of young girls as a way to uplift entire communities.  Investing in young girls not only empowers them but empowers their families and ultimately, their whole communities.  Young girls and women in developing countries are often unable to negotiate sex on their terms and ensure their sexual safety, and are particularly vulnerable to being infected by HIV/AIDS as a result.  As HIV/AIDS is the leading cause of death among women of reproductive age worldwide, it is imperative that young women are equipped with the power and knowledge to protect themselves from being infected by the disease.

Worknesh Kereta, of Pathfinder International, spoke of her organization’s women and girl’s empowerment program in Ethiopia, in which they reached over eight million young girls and women with information about sexual and reproductive health, as one part of their multifaceted model to equip girls with the information, skills, and knowledge needed to empower themselves and their communities.  One of their aims is to reduce the prevalence of STI’s and HIV, and they plan to achieve this by spreading awareness of the disease. 

At the end of the program in 2009, 52 percent of women participating in the program had been tested for HIV, a 26 percent increase from the baseline.  In addition, 35 percent of the women were using modern contraceptives at the end of the program, up from 25 percent in 2007.  Kereta also emphasized the importance of reaching out to young boys before attitudes discriminatory towards women were formed as a way to promote gender equity in the future.

Betty Ochieng of Family Health International (FHI) discussed their “House-Girls Health and Life Skills Project” in Nairobi, Kenya, in which community development workers reached out to domestic workers, commonly known as “house-girls”, with the aim to equip these often illiterate and vulnerable young people with the skills and knowledge needed to ensure their sexual and reproductive health.  Of the 277 young women who directly participated in the program, half were sexually active, 12.5 percent had sex in exchange for money in the past, and seven percent had faced sexual violence.  

Because house-girls are often only allowed enough free time to attend church once a week, the program was implemented through churches, with congregation members acting as lead trainers.  In addition to the 277 that were reached through the program directly, 910 more were reached through 22 trained peer educators, and an estimated 27,830 were reached through media efforts.  HIV/AIDS and STI awareness greatly increased as a result of these efforts.

These projects illustrate how simple it can be to equip young women with the tools they need to empower themselves and consequently protect themselves from being infected by HIV/AIDS, and other STIs.

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The Center for Strategic and International Studies yesterday unveiled  a new “must-read” report for global health advocates, “Smart Global Health Policy.” While a panel at the Congressionally-chartered Institute of Medicine, made up primarily of scientists, issued recommendations on US global health policy last year, the CSIS panel is the first to involve high-level business leaders and sitting members of Congress.

The report drew on observations made during a study trip to Kenya, but it is unclear if consultation in developing countries went beyond that, for instance to include global representatives of affected communities and of developing country civil society, such as those on the boards of UNITAID and the Global Fund.

The report and the webcast of the launch event are available online.  Here are a few highlights:

The report makes a strong case that it is in the interest of the United States to continue and increase  our investment in global health and that the issue should matter to all Americans. It calls for keeping funding for AIDS, TB and malaria on a “consistent trajectory,” doubling spending on maternal and child health to $2 billion a year, forging a collaborative response to emerging heath threats, establishing strong coordination of global health policy across US agencies, and increasing support for multilateral efforts.

In 2009 there was a massive drop off in the expansion of treatment by US programs, and the report notes that AIDS advocates are “particularly anxious” at the slowing growth rate, a stalling that could also impact health systems.  The report suggests that funding is a concern for treatment advocates, yet, in fact, HIV prevention advocates have also been quite alarmed at the essentially flatline funding picture.

Despite World TB Day (March 24) being just a few days away, no mention is made in the report of immediate tuberculosis funding concerns, lowered TB targets in the 6-year Global Health Initiative or USAID’s role in responding to TB.  Instead, the report includes TB within a much longer timeframe, stating that “we can accomplish great things in the next 15 years:  We can cut the rate of new HIV infections by two thirds, end the threat of drug-resistant tuberculosis, and eliminate malaria deaths.”

In terms of overall funding, the report calls for less spending in the near term than either the IOM panel or the Global Health Initiative coalition did; instead, the CSIS document endorses the President’s proposed funding of $63 billion by 2014.  While the IOM called for specific increased funding levels on AIDS, TB and malaria consistent with Lantos-Hyde, the CSIS report does not delve into specific funding levels, with the exception of maternal and child health.  Instead, taking the long view, it calls for $25 billion in annual spending by 2025.

One exciting aspect of the CSIS report is that it endorses innovative financing as a means of raising funds for global health.  The report does not touch on the concept of innovative taxation for health, recently championed by maternal health advocates at Family Care International and many other groups. However, it identifies some specific mechanisms, such as borrowing the money needed through an international finance facility, and it urges the US National Security Council to review the most promising ideas on innovative financing and develop a US position.

Admiral William J. Fallon kicked off the launch event, stating that global health is a “bipartisan enterprise… which can unite US citizens in collective action.”  He stated the importance of maintaining forward momentum, noting that “we do not want to coast or slide backward.”  Helene Gayle said that global health efforts are showcasing the American spirit of generosity and said “we need forward momentum even in a period of constrained resources.”

Jack Lew, the top State Department official developing the US Global Health Initiative, spoke about the Administration’s goals in developing the new strategy. He said that the Administration’s aim was to “challenge a way of doing business by moving beyond a primary focus on disease treatment.”  He said the goal was “not to do harm to existing programs.”

Advocates for effective HIV prevention have felt stymied in recent weeks by the lack of specific HIV/AIDS guidances from the Administration to the field and have noted that Kenya’s Partnership Framework with the US even appears to rule out family planning integration.  Family planning came up at the event when Dr. Michael Merson, of Duke University, criticized the Canadian government’s rejection of the inclusion of family planning as a part of its maternal health initiative.

But Lew’s presentation did not delve into details — and there was no opportunity at the event for questions from the floor.  He stated that program integration was crucial to meet the needs of women, and he commented on the importance of having family planning and HIV/AIDS services in one location.

The report is particularly noteworthy for the very strong focus on measurement for accountability in delivering services. Business leaders at the event decried the reporting burden on health programs and, along with Dr. Merson, called for a common set of impact indicators.

Rajeev Venkayya, Director of Global Health Delivery at the Bill and Gates Melinda Foundation, said that measurement matters because it allows us to maximize efficiency and stretch dollars while identifying what works and what doesn’t.  In addition, measurement allows us to hold accountable institutions, organizations, and even individuals, which in turn allows for greater project improvement.  Exxon Mobil Chairman and CEO Rex Tillerson agreed, and cited a Lancet article which said that evaluation must be a top priority for global health.

Robert Rubin, former US Treasury Secretary and former head of Citigroup and Goldman Sachs, told the audience that global health leaders “face wrenching choices” as a result of US fiscal problems.  He asked two members of Congress, Rep. Keith Ellison and Senator Jeanne Shaheen, whether global health is an issue that can “break through the mire” on Capitol Hill.

Senator Shaheen said that the issue can succeed, but it is crucial to explain to Americans that international affairs spending is only a tiny fraction of the US budget, much less than people realize.   She said it was cheaper to spend on global health than on war, noting Bill Clinton’s recent statement about the appreciation of PEPFAR expressed by Muslim residents of Tanzania.  She also said the current committee structure in Congress is an impediment and endorsed the recommendation included in the report for a consultative body that would work across committees.

Congressman Ellison also voiced strong support for greater US action on global health, stating that “infectious diseases know no borders.”  He said that while in Kenya, he made good progress in persuading Kenyan leaders of the necessity of stepping up their own contributions.  He suggested that by reducing US spending on outmoded weapons systems the US could improve its budget outlook and make global health spending easier.

Gayle Smith, the NSC official leading the development of the US Global health Initiative, was the concluding speaker at the event. She said global health was a bipartisan issue and that in fact President Obama specifically directed that the achievements of the previous Republican Administration be recognized.  She praised the CSIS report, and said that its ideas were remarkably congruent with those of the Administration.

She said the Administration’s commitment to fighting global HIV/AIDS was “absolute” and, she added, “this will grow over the life of the initiative.” She said the Administration’s plans for the Global Health Initiative “include an ambitions set of targets in terms of outcomes.”

She did not respond to concerns submitted to the Administration by the Global Center, TAG, the Global Health Council, and the GHI Working Group that the Administration’s targets regarding tuberculosis contradict a directive from Congress approved in 2008 as a part of Lantos-Hyde.  In fact, it was surprising that the event unfolded without  reference  to the consultative process which numerous NGOs have engaged in regarding the US Global Health Initiative or to the detailed analyses these groups have submitted to the Administration.

There were a range of reactions from health NGOs to the event.  Eric Friedman at Physicians for Human Rights noted the “surprisingly little attention in the report to human resources for health and health systems, and no mention of including civil society in the development of country compacts.” He praised the report for “proposing that the Administration develop a long-term, 15-year framework for making progress in and committing the United States to improving global health, a good idea so long as it does not set the stage for underambition, and is flexible to respond to changes in the years ahead. ” He also would have liked to see “a recommendation that the United States should deliberately integrate a right to health approach throughout U.S. global health programs, including the consistent focus on equality, accountability, and participation that this entails.”

Matt Kavanagh at Health GAP praised what he heard from the report, which included an emphasis on keeping up the fight against HIV/AIDS, especially important for the health of African women. But he noted with concern that “some of the Administration comments that seemed to favor prioritizing ‘cheap’ interventions that do not work in the long term, such as single dose nevirapine instead of treatment for HIV positive mothers, an approach abandoned long ago as ineffective in wealthy nations.”

The American Medical Students Association’s Farheen A. Qurashi said that the report “takes a bold, but necessary, approach to U.S. global health planning by insisting upon a 15-year comprehensive plan.”  She said, “Unfortunately, the Commission’s report does not appear to specify the need for scaling-up of PEPFAR investments versus the dangers of flat-funding, and instead uses language that suggests that a continuation of current levels of funding without annual growth is sufficient.”

On health systems, she said that “though integration and health systems strengthening is mentioned in general terms, and the need for training and retention of health care workers is noted, there is no detailed analysis of the measures, funding, and support necessary to establish and retain adequate numbers of health professionals and other health care workers.”

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Kevin M. De Cock, MD, has been tapped to lead a new center focused on global health at the U.S. Centers for Disease Control and Prevention. A longtime leader in international health, Dr. De Cock has been at the forefront of the battle against the HIV/AIDS epidemic for more than a decade. As director of the World Health Organization’s Department of HIV/AIDS from 2006-2009, he oversaw all of WHO’s work assisting low- and middle-income countries to scale up treatment, prevention, and support programs. He is now finishing up a stint as Director of CDC’s Kenya office before he moves to Atlanta to launch the CDC’s new Center for Global Health. In this Q&A, he talks about the vision for this new center and the challenges ahead.

 Q: You are about to take the helm of a new center within CDC that will amplify the agency’s work on global health. Why did CDC leaders feel this new center was needed and what are the objectives?

A: When the CDC’s director, Dr. Tom Frieden, took up his functions in the middle of last year, he did two things. Firstly, he defined global health as one of CDC’s core priorities. And I think the significance, the symbolism, of that is considerable. Although CDC has done international work since its inception, it’s really the first time a CDC director has so explicitly named global health as one of his priorities. And to match that rhetoric, he also decided CDC’s work in global health should be consolidated and therefore created a new center.

The creation of the new center does mean that CDC has to think more ambitiously and more strategically about its role in the world, in the hugely changed international diplomatic environment that is so different from just ten years ago. We will be thinking about science and public health priorities and how best to do our work in the 40 or 50 countries where we are engaged. We will work to get a better impact, a more measurable impact, and one that can be communicated more clearly. 

Kevin DeCock who lead a new Center for Global Health at the CDC

Q: You have a long history of working on the global HIV response both in Kenya with CDC and with the WHO.  Many of us are concerned that the Administration’s Global Health Initiative, with its welcome expanded reach, will in fact come at the expense of the robust response envisioned for HIV and TB through the Lantos-Hyde Act.  Already we see evidence of this in less than ambitious treatment targets for HIV and TB.  What is your own assessment of this? Are you concerned about a loss in momentum toward HIV treatment targets that you helped craft, such as Universal Access by 2010? 

A: I think that’s a very relevant question. I have no doubts about the commitment of the Administration to building up the impact of PEPFAR I. And as far as PEPFAR II is concerned, the funding remains huge and the targets remain ambitious and the work is very extensive.

Now at the same time, there’s no doubt that we have to look to the longer term future and begin to think more deeply about how does the long-term global response get funded? It’s unrealistic for one country to fund the whole response to the pandemic, which is likely to stretch into decades to come.

Actually, it’s a coincidence that you asked this, because we’ve been discussing these sorts of questions for Kenya yesterday and today. And I think we’re okay for the time being. But obviously with 33 million people infected with HIV, and with around 4 or 4.5 million on therapy right now and others waiting to become treatment eligible, the costs of HIV/AIDS are going to increase and we do need to think about innovative methods of financing—sharing the burden more broadly; getting other donors involved, such as emerging economies; getting affected countries themselves to take up some of the costs, which some of them could; and making the response more efficient and effective. I’m not so worried about the immediate short term, but I certainly think some deep thinking is required about the longer term.

Q: Similarly, the tuberculosis treatment targets detailed in the Administration’s GHI consultation document was considerably lower—roughly half—of the goals laid out in Lantos-Hyde. Do you have concerns about a pullback on fighting TB, particularly with the rising threat of multidrug-resistant TB (MDR) and extensively drug-resistant TB (XDR-TB)?

A: I think tuberculosis is always at risk of getting forgotten. The history of TB funding has always been cyclical. It rises when TB seems to get out of control, then the response is funded, the cases come down, and then people’s attention gets drawn elsewhere. That’s been a phenomenon, including in the US, over many years. So I do think there’s a need to continually remind people about tuberculosis. And although I think we’ve done reasonably well addressing TB within the context of the AIDS epidemic, there’s still enormous work to do.

As far as MDR and XDR, these are very important issues. We need better surveillance data, but XDR has been most severe in a limited number of places and MDR also is not a huge problem everywhere. The real answer to drug-resistant TB is prevention and better functioning programs, since it is poorly functioning programs that are at the root of MDR and XDR TB.  I think the response under the GHI is fairly robust, but tuberculosis does need continuous advocacy to ensure it’s kept on the front burner and policymakers continue to pay attention to it.

Q: What role will the CDC play in the Global Health Initiative?  We noted last week the appointment of Amie Batson as the point person for the GHI at USAID, but certainly our physician members see CDC as a critical player in global health.  Will there be a similar liaison from the CDC? And if not, how will the agency ensure that its voice is heard in this new approach to global health?

A: The discussions are ongoing about the governance of the GHI–those discussions are unfinished. But let me reassure you that the director of CDC, Dr. Frieden, is paying the utmost attention to this issue and has been intimately involved … And as this new center is stood up, he’s been paying extraordinary  attention himself to global health issues and these Washington discussions. The CDC will be represented at the highest levels.

Q: Some advocates have argued that CDC has suffered as an agency because it is far from Washington’s reach in Atlanta.  What plans do you have to engage with the Washington community of policy makers, program implementers and advocates on global health?

A: That question has some validity, but there are some advantages also to being in Atlanta. One of the original reasons CDC was put in Atlanta was to deal with malaria in the southern United States in the early 1940s. Two advantages of not being in Washington are 1) it has allowed the agency to develop a very strong technical focus and identity, because being away from the political spotlight, I think an emphasis has been put on its technical work and 2) it’s allowed the agency to grow and occupy more physical space, which in D.C. frankly might have been quite difficult.

On the other hand, meetings in Washington get called, sometimes on short notice, and there isn’t always someone to fly up from Atlanta and so we miss out on discussions. We do have an office in Washington, with a Washington-based director. There’s a deputy for the agency for policy in Washington, who has just been appointed. And for global health, we also have a deputy director for policy and communications position that will be Washington based. We are recruiting as we speak.

Q: There was new evidence presented at CROI last month about the benefits of HIV treatment as prevention. How do we educate policymakers about the broader community benefits of HIV treatment, including the reduced transmission of HIV and TB?

A: Policymakers pay attention to data if they are explained to them in the right way, and we are beginning to see pretty persuasive data on HIV treatment as prevention, especially with discordant couples, where one person is infected and HIV treatment prevents the second person in the couple from becoming infected. To my mind, there’s only one direction this debate is  going—it’s towards early treatment and more widespread treatment. It is giving a biological and biomedical justification for the aphorism that treatment and prevention are inseparable. It’s a very important and emerging theme in HIV/AIDS work.

The role of HIV treatment as prevention, the impact at the community level of widespread treatment on HIV transmission, and the question of when to start treatment for the individual, and the impact that would have on individual health and on TB at the community level–these allied questions are, to my mind, the most important research priorities in HIV medicine today.

Q: On drug-resistant TB, there’s a lot of excitement about new diagnostics in the pipeline that could lead to faster, better tests for drug-resistant strains of TB. If such a vital tool comes to market soon, will the US have the resources to help get it out widely to the field?

A: If new tools become available, such as diagnostics, that are shown through research to improve outcomes or to make interventions more effective, more efficient, then they do get adopted and sometimes remarkably quickly. We’ve certainly see that within HIV medicine. You have to be impressed with the scale of up therapy and rapid HIV testing. There is also a movement in programs in lower and middle-income settings towards laboratory strengthening and an interest and emphasis on point-of-care tests, be they for malaria , TB or HIV. But the technology has to be developed first, has to be refined, and has to be evaluated.

Q: You haven’t officially transitioned into your new job yet and are wrapping up things in Kenya as we speak. What kinds of successes has the CDC seen in Kenya and what challenges remain for your successor there?

A: CDC has had a very interesting history in Kenya. It was in 1979 that the first D.C. assignee arrived here and he was sent to initiate collaborative malaria research.  And up to and until the early 2000s, the agenda was almost exclusively research, which CDC always tries to link to policy development and programs.

But with the advent of PEPFAR, and subsequently our work in emerging infectious and global disease detection, we’ve become much broader. Our research has had direct impact on health policy. For example, malaria research on the efficacy of insecticide-treated bed nets was extremely important. In HIV, the clinical trial of HIV treatment to prevent mother-to-child transmission through breastfeeding contributed to a change in international guidelines.

As for what comes next, we have been very infectious-disease oriented. It is time that we begin to extend our work—and this is mandated actually through the GHI—to non-communicable disease priorities, including tobacco use, salt intake, hypertension, diabetes and injuries. And we have to address maternal and child health and extend our work to neglected tropical diseases. These will be the challenges moving forward.

Q: When you get to Atlanta, what will the new center’s structure look like and what will its portfolio include?

A: It will be structured like other centers within the CDC, with an office of the director that has central functions like policy and communications. Currently there are 4 operational divisions in the new center. The first one is the division of global HIV/AIDS, the operational arm of the CDC for PEPFAR implementation. A second division is focused on parasitic diseases and malaria. Third, there’s a division called global disease detection and emergency response, which does international work on emerging infectious diseases, response to outbreaks, international surveillance and response to humanitarian emergencies. And fourth, a division that deals with health system strengthening and is well known for its work in field epidemiology training. We will have to work towards better integration of all CDC’s work in global health.

There is of course a great deal of work in other aspects of public health with global implications done in other parts of the agency, for example our work on immunizations. Whether those will move into the new center is under discussion, but the important point is that the new center will  do all it can to support all of CDC’s international work.  And perhaps that summarizes the identity we seek – a global public good for public health.

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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

It’s been almost 3 years since the World Health Organization developed its recommendations and goals for male circumcision. As Kim Dickson, MD, an AIDS expert with the WHO, outlined in a presentation at CROI today, scale-up has not been speedy or simple.

In her talk, Dickson noted that the WHO identified 13 priority countries for scale up, especially those with high prevalence, generalized heterosexual epidemics, and low levels of circumcision.  All of the countries are in eastern and southern Africa. The goal: reach 80 percent of adult males and newborns by 2015 in the target countries. 

This intervention could prevent more than 4 million adult HIV infections over 15 years, but millions of circumcisions would have to be performed during this time period. The approximate cost of the procedure in these settings is $50. 

 Advocacy has been vibrant at all levels, and there have been multi-stakeholder consultations in all countries including various groups. A number of funding agencies have made money available for male circumcision-related activities, including PEPFAR, the Global Fund, and the Bill & Melinda Gates Foundation.  Male circumcision policies have been developed in Lesotho, Namibia, South Africa, Swaziland, Uganda and Zimbabwe. Kenya has developed actual guidelines.  Most countries are focused on so-called “catch-up” strategies to reach adult men, but longer term neonatal strategies are under consideration in Botswana, Swaziland and Zambia.  Provider training programs have been implemented in almost all 13 countries.

The bottom line question, however, is how many circumcisions have been done?  (more…)

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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

The evidence for scale-up of home-based testing is straightforward and compelling. In Africa, an estimated 17 million people with undiagnosed HIV infection are responsible for 90 percent of infections. Testing rates remain low in many sub-Saharan African countries, but home-based testing has proven to overcome many obstacles that keep people from finding out their HIV status in clinics.

Peter Cherutich, with the national AIDS program in Kenya, detailed the promise of home-based testing in a talk at this week’s CROI meeting in San Francisco entitled “HIV Prevention and Care through Door-to-Door HIV Testing and Counseling:  Opportunities and Challenges.”

He began by reminding us all that testing is the foundation of HIV prevention and that knowledge of serostatus is effective in reducing risk behavior.  A survey in Kenya found that HIV-infected persons who knew their status were 15 times less likely to engage in unsafe sex than those who do not.

And reticence to getting tested remains high. For example, a review of testing rates across a number of sub-Saharan African countries found the highest rates in South Africa, where 28.7 percent of women and almost 20 percent of men reported testing in the last year.  This is in part because the model of voluntary counseling and testing is client-driven, requiring clients to self-identify as at risk. There are also challenges with health care facility-based testing, including the burden of transportation.

 Home-based testing and counseling overcomes the obstacles of cost and transportation.  It also encourages discussion within families and ensures that consent and confidentiality are protected.

There are basically two types of home-based testing and counseling (HBTC): door-to-door testing of the general population and targeted testing of household members of HIV-infected persons in care and treatment.  Home-based testing is most effective and a wise use of resources in countries with high HIV prevalence, generalized epidemics, high density urban or rural areas, and sizeable populations on ART.  Uganda, Kenya, Malawi, Zambia, Swaziland, and Lesotho all have robust HBTC programs.  Uganda and Zambia have data showing that people are much more likely to be tested in a home context.  (more…)

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Dr. Luis Sambo, the WHO’s regional director for Africa, sought to draw attention this week to the growing threat of drug-resistant strains of HIV, tuberculosis and malaria on the continent, calling for aggressive action “before the situation gets out of hand.”

Sambo made his comments during the 59th session of the WHO regional committee meeting in Kigali, with Rwanda getting some praise for progress in improving its health services. But more broadly, Sambo said African countries needed to respond forcefully to the emergence of virulent new strains of TB and other deadly diseases. He called for a nine-point plan that includes developing human resources, strengthening lab capacity, and bolstering drug supply chains, among other steps.

All those concepts go to the very core of health-system strengthening, a fresh point of focus in the US, where the Obama Administration is reshaping US global health priorities. On that front, there was this very interesting blog post on the Center for Strategic and International Studies’ website today about broader benefits of the US global AIDS program in Kenya to that country’s health system. (more…)

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This is a guest blog post by Buck Buckingham, who has been the PEPFAR country coordinator for Kenya since 2003, when the program began.

Buck Buckhingham blogs about a panel he moderated today at the HIV/AIDS Implementers' Meeting in Windhoek.

Buck Buckhingham blogs about a panel he moderated today at the HIV/AIDS Implementers' Meeting in Windhoek.


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I’m happy to see the 2009 HIV/AIDS Implementers’ Meeting break new ground by beginning to unpack subjects that either policy makers, or activists, or funders considered off limits for far too long.

We’re talking about value for money, not just more money, for AIDS programs. Unheard of until now.  I also hear people talking about our prevention shortcomings with almost as much energy as they’re talking about highly-effective interventions like male circumcision.

This morning I moderated a panel that focused exclusively on the needs of men who have sex with men (MSM) in Africa, a first for this conference.  MSM – like intravenous drug users or sex workers – have been particularly underserved or overlooked in Africa because their behavior is criminalized and highly stigmatized in most corners of the continent. (more…)

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