Posts Tagged ‘TB’

The Center’s Rabita Aziz describes a visit to Livingstone General Hospital’s antiretroviral therapy (ART) ward in Zambia during a recent Congressional delegate trip to Africa.

In a dark room so small and cramped that the door won’t even close, Ndabila Singango, a provincial clinical mentor employed by the Center for Infectious Disease Research of Zambia (CIDRZ), tests and counsels HIV/AIDS patients at the Livingstone General Hospital. The hospital, built more than 60 years ago and used only by white colonists before Zambia gained independence, is the only hospital in all of Southern Province, which has a population of 1.6 million. With an HIV prevalence rate of 30 percent in Livingstone, it is not surprising that 80 percent of admissions to the hospital are HIV-related.

Gertrude, an HIV positive mother with newborn twins, explained that the lesions on her face appeared two weeks ago.

The ART ward of the hospital sees an average of 70 patients daily, and provides ART to 3500. When we met one such patient, Gertrude, she was breastfeeding one of her three-month old twins while the other – strapped to her back – slept peacefully.

Gertrude learned that she was infected with HIV/AIDS three years ago when she felt ill and was advised to take an HIV test. She had not disclosed her HIV status to her husband as she feared reprisal from him and the community. Like many African women, Gertrude was unable to negotiate the terms of sex, and therefore did not use protection.

When she started ART in November of 2008, Gertrude’s CD4 count was at 129. Six months of therapy later, it rose to just 130. (more…)

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Ezekiel J. Emanuel, center, White House global health advisor

Ezekiel J. Emanuel, head of the Department of Bioethics at The Clinical Center of the National Institutes of Health and a breast oncologist, is on extended detail as a special advisor for health policy to the director of the White House Office of Management and Budget.

But that doesn’t speak to his impact. He is one of the architects of the Obama administration’s Global Health Initiative, and he has been a lightning rod of criticism for activists who want a much more vigorous global AIDS response from the administration.

Emanuel spoke to John Donnelly on Saturday about how the Obama administration now needs better ideas for making global health programs more efficient, and how he won’t shy away from taking on AIDS activists. “I have two brothers and all we do is disagree,’’ he said.

Q: You haven’t been shy in pushing back on criticism from AIDS activists about the Obama administration’s smaller increases in the global AIDS budgets than under the Bush administration. What really upsets you?

A: We can have disagreements about the right policy, which way we are going forward, but we can’t have a disagreement about the facts – the facts of the budget. A number of advocates are saying we are cutting the PEPFAR budget. The fact is funding for HIV and our work on PEPFAR is going up – in 2009 2010 and 2011. That is matter of fact. You may not like the allocation we have made, or not like the pot we are putting it in, but (saying we are) cutting the budget is wrong.

The second thing is [the notion] that somehow I am `anti-HIV,’ or `anti-work-we-are-doing-on-HIV,’ is absolutely wrong. This development of the [Global Health Initiative (GHI)] is building on everything we have done, using what our work in HIV and malaria has shown us. One of the things that we have shown is that you can take complicated medical interventions, get them working in rural areas — including sophisticated techniques like measuring T cell and viral loads — and monitor people. A lot of what we have put into the GHI is built on the foundation of PEPFAR. We want to broaden it.

And (another thing) is that we have a moral obligation to the people we are trying to help that if we are spending money on things that are not efficient, we have to be more efficient. There is a moral obligation from the community (working in AIDS issues) not to just ask for more money, but to say, `We have this pot of money, how are we going to do the most with it?’

We’re not doing this because we are green-eyeshade, no-morals people. It’s because we want to save lives and spend money most efficiently.

Q: Still, Ambassador Eric Goosby told Science Speaks this week that even with efficiencies, there will be a `mismatch’ between funds and the need.


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A crucial milestone was passed this week in the effort to get increased funding levels approved for global health programs, including PEPFAR, USAID and the Global Fund. The State and Foreign Operations Subcommittee of the House Appropriations Committee, led by Rep. Nita Lowey (D-NY), approved some increases for these programs relative to FY 2010, despite having less money overall to work with.

The Subcommittee divides up an overall amount of money that is only about 1.4% of the total US budget.   But, this total was $4 billion less than what President Obama requested, due to a cut imposed by the Chair of the Appropriations Committee, Rep. David Obey.  In fact, it was the international affairs account that bore the brunt of the cuts to the President’s budget proposal.

All of the global health programs in this bill were increased over FY 10 enacted levels.  Tuberculosis, family planning, and the Global Fund received increases above the President’s request.  Advocates had requested specific, higher levels and have sent a letter to both the House and Senate raising concern about HIV/AIDS funding.

These are the amounts approved for a few areas of interest, drawing on info from the Global Health Council:

The Global Fund — the Subcommittee rejected the Obama proposal to cut the US contribution below the FY 2010 level.  Instead, the Subcommittee approved $825 m,  a boost of  $75 million for the Fund above FY 2010. (President’s Request: $700 m; FY10: $750 m).  However, it remains to be seen whether the portion of the US contribution that comes through the Labor Health and Human Services budget will be provided in full.

Bilateral HIV/AIDS — the Subcommittee provided a boost of $91 million over the FY 2010 level, approving $5.050 b (President’s Request: $5.150 b; FY 10: $4.959b).  This is about half of what President Obama had requested.  Obama had proposed using half of his requested increase for PEPFAR to help finance technical and management assistance for the GHI Plus Countries, and we hear that the report language accompanying allows this.  That means  that about $50 m of the boost for PEPFAR will go to this purpose and only $41 m will be available to expand access to direct services, such as prevention, care and treatment.

USAID’s TB program —  The Subcommittee gave this program a boost of $15 m over the FY 2010 level, approving a total of $240 m (President’s request was $230 m; FY 10: $225 m)

In other decisions, the Subcommittee provided the full amount requested for the Peace Corps, giving it a boost of $46 m over 2010.  And it approved a $71 m increase for Embassy Security, Construction and Maintenance, $114m above the Obama request.

The panel considered an amendment offered by Rep. Rehberg that would have reduced most of the bill’s spending levels by 7.27 percent and reduced multilateral assistance by 31.85 percent.  But, this was voted down along party lines.

There are still many hurdles yet before the funding levels are finalized.  The Senate’s State and Foreign Operations Subcommittee is expected to consider the International Affairs budget sometime in July.  Then a conference committee would have to iron out any differences. Finally, the bill would have to be approved by the full Congress, which could be significantly delayed by the fall elections.

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Below is our (now weekly) reading list for you. All thoughts welcome, as usual!

  • As you may already know, the Women Deliver conference was held in in DC this week. Alanna Shaikh has an interesting post at UN Dispatch summarizing a panel on a “combination therapy” approach to HIV prevention. She says that this new approach “might be the change we need.”
  • The Global Fund to Fight AIDS, Tuberculosis and Malaria announced yesterday that 2.8 million people with HIV have received ARV treatment thus far in 2010. This is a 22 percent increase from the same time last year. (more…)

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Below is a sampling of reading material here at Science Speaks that you might find interesting. Let us know your thoughts!

  • A study released this week found that the mining industry may be a driving force in the TB epidemic in Sub-Saharan Africa.  From lead author Dr. David Stuckler of Oxford University: “It’s well known that miners have the highest risk of tuberculosis of any occupational group in the world, especially in sub-Saharan Africa.  But the striking finding of our study was that not just miners are at risk…these risks are spread to their families, communities and entire countries.”

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This post is by Center Director Christine Lubinski, who is in Almaty, Kazakstan this week for a meeting of the HIV/TB core working group of the Stop TB Parternship.

We visited an NGO run by the International Federation of the Red Cross with an on-site HIV clinic.  The small staff, consisting of two social workers, a coordinator, a lawyer and a psychologist, was joined by a number of clients of the group who welcomed the opportunity to tell us about the challenges they face in Kazakhstan.  They also made it clear that this site provides a safe haven where they feel respected and supported and where the clinical staff also treat them well.

There are approximately 15,584 persons living with HIV infection in Kazakhstan, with about 1100 persons receiving HIV therapy. There are fewer than 130 on ART in Almaty, this city of 2 million people.  Sixty-percent of HIV cases are among injection drug users. 

The group provides services for 120 clients co-infected with HIV/TB and 500 injection drug users living with HIV infection.  Many of the individuals receiving services here were formerly incarcerated, adding to the stigma and barriers they face to accessing services.

The challenges facing this population are numerous.  One huge hurdle is a requirement that they report to the authorities every six months to register their “permanent residence.”   No certificate of residency means no services, including medical care such as TB treatment, HIV treatment, or drug treatment.  TB treatment is supposed to be free to all, notwithstanding residency status, but those without adequate paperwork are nevertheless denied care by many clinics.  Many of the marginalized individuals living with HIV infection cannot establish permanent residency; they don’t have appropriate paper work for a variety of reasons.  The lawyer spends a great deal of her time advocating for this group.  When one member of our group asked what options individuals who cannot establish residency have, one of the clients replied: “Prison or the cemetery.”

Drug treatment is largely religious in nature , in other worlds controlled by Christian or Muslim groups, and it is frequently not free. There are very few 12-step programs and methadone is not available in this part of the country. Currently only 50 persons have access to substitution therapy nationally.  Finally, a number of drug treatment centers refuse to admit persons with HIV infection.  Advocating for HIV infected clients with these treatment programs is one of the activities of this client-centered NGOs.

Gainful employment can be virtually impossible for this population.  Despite laws that prohibit such discrimination, it is commonplace for prospective employers to require job applicants to provide documentation from the office of the prosecutor showing that they have no criminal record, and documentation from a physician certifying their TB and their HIV status.  Even though this practice is patently against the law, law enforcement authorities have no interest in taking action against these employers.

Tuberculosis, including MDR-TB, is a much bigger problem in Kazakhstan than HIV infection, although the numbers of individuals who are co-infected is growing. A visit to a TB clinic illustrated the very different approach to TB treatment in this region.  Twenty percent of all cases of tuberculosis in Kazakhstan are drug resistant and the percentage of retreatment cases that are MDR is 45 percent.  Generally speaking, tuberculosis is treated on an in-patient basis, requiring patients to spend very long periods of time in the hospital.  The average length of stay is 103 days for drug-susceptible pulmonary TB. This is not likely to change soon, since budget allocations for TB are based on numbers of hospital beds occupied.  However, there is a growing acknowledgement that this treatment of TB in congregate settings has real implications for infection control and for perpetuating high MDR-TB rates.  One government representative noted that while laws specify inpatient treatment for tuberculosis, they do not specify length of stay, providing some opportunity to reduce inpatient stays under current regulations.  Those with MDR can be hospitalized as long as two years. 

All patients with TB are automatically tested for HIV infection.  Persons with HIV infection without active tuberculosis are placed on isoniazid preventive therapy (IPT) for 6 months.

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Starting today, we here at Science Speaks are going to try something new: Every Wednesday, we are going to feature stories from around the blogosphere and elsewhere that we have been reading – and that we believe will be of interest to you.

Because this is something new for us, any feedback you have would be much appreciated. And please do not hesitate to make suggestions for future posts!

  • The new issue of The Lancet features a number of stories on TB, including some focusing on HIV/TB coinfection, XDR-TB, and tactics for addressing the epidemic. (more…)

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