Beginning in the mid 1980s, East Africa became an important stop along international drug trafficking routes, introducing heroin in the region – not only as a transit hub, but also as a place for consumption. Currently, an estimated 533,000 opiate users live in eastern Africa.
Tanzania has been particularly impacted, with injection drug use, primarily of heroin, spreading in Dar es Salaam. It threatens to become a major driver of the HIV epidemic. Current estimates suggest up to 50,000 people in Tanzania inject drugs, and in Dar es Salaam, 42% are estimated to be HIV–positive compared to 9% overall in the city.
In 2009, the Tanzanian Drug Control Commission, Ministry of Health and Social Welfare, Muhimbili University of Health and Allied Sciences, and Zanzibar AIDS Control Program approached Pangaea to provide technical assistance with developing a national response to Tanzania’s HIV epidemic among people who inject drugs (PWID). The program is funded largely by the US Centers for Disease Control.
To date, harm reduction services have been provided to over 10,000 people who use drugs in the country, including needle exchange, and nearly 2,000 people who inject drugs accessing methadone treatment. The country has developed gold-standard expertise in developing and sustaining harm reduction services.
The program is now expanding to ensure that life saving services reach more people in need. In December, Pangaea appointed Dr. Haneefa Saleem to provide in-country coordination of our technical support to the program.
Dr. Ayoub Magimba from the Tanzanian Ministry of Health and Social Welfare said, “With support from Pangaea, we are poised to drive harm reduction services for people who inject drugs to the next level, through developing innovative models of methadone delivery and a one-stop-shop clinic for clients to access culturally relevant treatment services.”
Take-Home Methadone Dosing
A key component of this innovation and scale up will be take-home dosing of methadone. Pangaea is working with partners, including existing and former methadone clients, on the best way to deliver these services. Dr. Barrot Lambdin, who heads up Pangaea’s work in Tanzania says, “Currently, all clients are expected to come every day to the clinic to receive their methadone dose, disrupting their ability to go to work and be with their families. It is also unnecessarily burdensome on health facilities. Take-home methadone dosing will allow clients to re-establish themselves in their homes and their community and will allow clinics to reduce resources needed to attend to each client, allowing more people to initiate treatment with the same staffing and clinic structure.”
Improving Access for Women
Another priority is to make services more accessible for the clinics’ women clients. Enrollment criteria are being adapted to allow women to begin treatment more rapidly. We are seeing a very significant uptake of services as a result, and will report data at the upcoming IAS conference later this year.
Improving Linkages to HIV Care
Within the next six months, Pangaea and partners will implement an integrated strategy for clients who are HIV positive, including on-site HIV testing, point-of-care CD4 screening and immediate linkage to HIV treatment, with distribution of ARVs through the methadone clinic.
Many clients are both infected with HIV and Hepatitis C, and the question of how to treat their HCV infection has been a major challenge. We are in advanced discussions with the developers of new oral treatments for HCV to implement trials to demonstrate the utility of these treatments for clients in resource-limited settings.
Barrot Lambdin comments, “Far from ignoring the issue or criminalizing people who inject drugs, Tanzania is showing that innovative public health leadership that provides compassionate, evidence based care with respect for the rights of clients can have a major impact. It is leading the way across East Africa and the region more broadly.”
After over a decade of being at the forefront of the Bay Area’s response to the global AIDS epidemic, Pangaea will be holding its first Global Health Leadership Dinner on May 12th 2015 in downtown Oakland’s Rotunda building, with excellent road and BART links.
We will be honoring the following local and global heroes who have made a significant difference, saving lives and preventing new HIV infections around the world:
How You Can Help
By supporting the Global Health Leadership Dinner, you will be helping Pangaea continue to help hard-hit countries establish HIV prevention and treatment programs that have literally saved hundreds of thousands of lives. We hope you will join the Dinner’s Host and Honorary Committees, as well as the Board and Staff of Pangaea, to celebrate the victories of the last decade and to rededicate ourselves to the fight ahead of us.
Tables of ten seats each are available at the following levels:
This World AIDS Day is a promising one with several new HIV prevention interventions for young women on the horizon.
It is in Zimbabwe's best interest to prepare for these emerging strategies now. Just last year, HIV prevalence among pregnant women aged 15-24 in Zimbabwe was a startling 10.4 percent. This number is indicative of a larger trend in southern Africa where adolescent women are up to eight times more likely to become infected with HIV than young men.
Young women's high rates of HIV are due in part to biological, social and economic factors making them more susceptible. Because efforts to promote abstinence, monogamy and the use of male condoms have not been enough to stop HIV among girls and young women, researchers have been working to develop women-initiated biomedical prevention interventions. Years of scientific exploration here in Zimbabwe and around the world are finally starting to pay off. PrEP (pre-exposure prophylaxis), microbicide gels and rings are three methods that could potentially turn around the endemic rates of HIV in young women.
Some microbicides are gel-like substances that could be used in the vagina and/or rectum to reduce the risk of IDV infection during sex. A South African microbicide study is testing whether a microbicide gel containing the antiretroviral drug tenofovir is safe and effective at reducing women's risk for HIV or genital herpes. Study results are expected in early 2015 (next quarter!). South Africa is planning for success by preparing rollout in the communities that would need new interventions most. Zimbabwe should prepare too.
There are also twin studies to determine if a monthly vaginal silicone ring with the antiretroviral dapivirille could prevent HIV in women. These studies are ongoing ill eastern and southern Africa, including right here ill Zimbabwe, conducted by the University of Zimbabwe/University of San Francisco Collaborative Research Programme. Results are expected in 2016.
If results show either the gel or ring are safe and effectively prevent HIV the world could possibly have one or more new woman-controlled methods that could help decrease HIV incidence rates and protect more women from HIV. The time is now for civil society to create demand, and for policy and regulatory bodies to consider how they could rapidly introduce new interventions.
In the meantime, there is a proven HIV prevention strategy that Zimbabwe's Ministry of Health and Child Care could begin to implement now. PrEP (pre-exposure prophylaxis) is a proven HIV prevention method that reduces risk of HIV in women and men. Those who are negative take the antiretroviral pill Truvada once a day to prevent HIV. When taken as prescribed, Truvada can reduce chances of acquiring HIV by more than 90 percent. Studies in Botswana, Kenya and Uganda have proven that PrEP can work in women. Demonstration studies are underway in several countries, including Zimbabwe, to understand the best way to rollout this new intervention and bring down high rates of new infections in young women.
Ensuring timely access to PrEP for women, will pave the way for microbicide gels and rings. Let's hold our leaders accountable: They must ensure Zimbabwe policy lives up to scientific promise.
Source: Standard issue of Sunday the 14th
Since 2011, with funding from the Bill & Melinda Gates Foundation, the Pangaea Global AIDS Foundation has supported the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) to make effective and efficient use of the best available HIV treatment tools; drugs, diagnostic tests and health care delivery systems. A final consultation in the series, held in Washington, DC from May 20-21, 2014, reaffirms the centrality of leadership by the affected communities—in this case men who have sex with men (MSM) who are living with HIV—in responding effectively to AIDS. The meeting was held in close partnership with the Global Forum on MSM & HIV (MSMGF).
Meeting participants included 30 global MSM leaders, predominantly from lower- and middle- income countries, many of them living with HIV and all of them longstanding experts in HIV among MSM the field. They gathered to inform the programmatic and research agenda on increasing engagement in the HIV treatment cascade for gay men and other MSM in lower- and middle-income countries. This included optimizing provision and mitigating barriers to services, with an emphasis on legally and socially constrained environments and providing evidence of good practice.
A retrospective cohort study led by Dr. Barrot Lambdin of Pangaea has been published in Clinical Infectious Diseases. Read below for the abstract and click the link below to access the full text.
Background : People who inject drugs (PWID) in Dar es Salaam, Tanzania, have an estimated human immunodeficiency virus (HIV) prevalence of 42%-50% compared with 6.9% among the general population. Extensive evidence supports methadone maintenance to lower morbidity, mortality, and transmission of HIV and other infectious diseases among PWID. In 2011, the Tanzanian government launched the first publicly funded methadone clinic on the mainland of sub-Saharan Africa at Muhimbili National Hospital.
A study led by Dr. Barrot Lambdin of Pangaea has been published in PLoS One. Read below for the abstract and click the link below to access the full text.
Introduction : Current estimates suggest an HIV prevalence of 42% among people who inject drugs (PWIDs) in Dar es Salaam, while HIV prevalence is estimated to be 8.8% among the general population in the city. To address the HIV epidemic in this population, the government of Tanzania began establishing HIV prevention, treatment and care services including outreach and medication assisted treatment (MAT) for PWIDs in 2010. We assessed gender inequities in utilization of outreach and MAT services and evaluated differences in HIV risk behaviors between female and male PWIDs.
HIV and drug abuse are serious inter-related health problems around the world. Recent estimates indicate that there are 16 million people who inject drugs (PWID) throughout 148 counties, among which three million (range 0·8—6·6 million) are living with HIV. In most countries, the prevalence of HIV among PWID is higher compared to the general population due injection-related and sexual risk behaviors associated with drug use. Despite increased HIV risk among PWID, harm reduction and HIV prevention programs among this group are limited, especially in resource-constrained countries.
Supported by the Bill and Melinda Gates Foundation, the consultative meeting on “Optimal Models of Care for People who Inject Drugs” was organized to identify best practices and models of care that provide comprehensive, evidence-based interventions, promote successful linkage to HIV testing, care and treatment, and integrate collaborative TB and HIV services for people who inject drugs. Recommendations from this meeting are intended to inform the World Health Organization’s (WHO) 2014 consolidated treatment guidelines for key populations (KP).
In the mid-1980s and the early 1990s, East Africa became an important stop along international drug trafficking routes, thereby introducing heroin in the region. In 2009, 40-45 tons of opiates were trafficked into Africa, most entering through the eastern countries by air and sea, and 34 of those tons were consumed in the region, highlighting it only as a transiting hub, but also a place for consumption. Currently, an estimated 533,000 opiate users live in eastern Africa.
Pangaea is relieved to learn that Dr Paul Semugoma has been released by the South African Ministry of Home Affairs at Oliver Tambo International Airport Johannesburg, and has removed the threat to deport him to his native Uganda where he is at risk of persecution under the country's anti-LGBT legislation. We are enormously grateful to the South African AIDS Council Civil Society Sector, Treatment Access Campaign, Health4Men and other South African, Pan African and international groups for leading the campaign for his release.
Pangaea is launching a new program to identify and document effective HIV treatment programs across East- ern and Southern Africa emphasizing programs that link the best in medical services with community-based organizations.
In the November issue of Current Opinion, Charles Flexner (John Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA), Ben Plumley (Pangaea Global AIDS Foundation, Oakland, CA. USA) and David Ripin (Clinton Health Access Initiative, Boston, MA, USA) provide a comprehensive overview of current activities aimed at optimizing global HIV treatment. HIV treatment optimization is a process intended to enhance the long-term efficacy, adherence, tolerability, safety, convenience, and affordability of combination ART. The ultimate goal of this process is to expand access to well tolerated and effective lifetime treatment to all those in need.
Two recent conferences, the first and second Conference on Antiretroviral Drug Optimization (CADO), brought together experts from academia, governments, foundations, the pharmaceutical industry, and community activists to develop a global HIV-treatment research agenda for the coming decade focused on better therapies and how to make them accessible to a broader population of people living with HIV. Important recommendations included a focus on more efficient process chemistry for antiretroviral drugs, investigation of antiretroviral dose reduction as a possible optimization strategy, recognition of the increasing importance of concurrent infections and comorbidities especially tuberculosis and aging-related diseases, and identifying a highly effective and affordable nontoxic, once-daily fixed-dose combination regimen for first-line treatment.
To access the full article for free, please click here.
The HIV Treatment Optimization website is also providing a comprehensive overview of past and current activities for global HIV Treatment.
Budgets for global HIV treatment and prevention in resource-limited settings will continue to be pressured, and, because the need for treatment scale-up is urgent, the emphasis on value for money has become an increasing priority.
The first CADO in 2010 focused on developing a research agenda to optimize the doses and combinations of existing approved drugs, including through role of process chemistry, and recommended a research development agenda for HIV drug optimization. The conference identified a portfolio of projects with the potential to significantly optimize treatment while achieving major cost reductions. Projects included improvements in process and formulation chemistry and dose reductions as intermediate technologies with an imperative to focus future resources on developing better regimens and formulations.
The goals and objectives of CADO2 were to identify and facilitate the development of novel, affordable, optimized drug regimens in resource-limited settings, within a public-health approach. CADO2 participants looked further into the future, to review drugs in the development pipeline, and to highlight gaps in drug development programs. Underpinning the meeting was the commitment to a single global standard for the equitable treatment of everyone, in both resource-rich and resource-poor settings. Potent, durable and affordable drug regimens are needed to sustain the contribution of universal access to HIV treatment to reversing the global AIDS epidemic.
Integration of HIV Care and Treatment in Primary Health Care Centers and Patient Retention in Central Mozambique: A Retrospective Cohort Study
A retrospective cohort study by Dr. Barrot Lambdin of Pangaea has been published in the Journal of Acquired Immune Deficiency Syndromes (JAIDS). Use the link below to access the study, and read below for the abstract:
Background: In 2004, the Mozambican Ministry of Health began a national scale-up of antiretroviral therapy (ART) using a vertical model of HIV clinics colocated within large urban hospitals. In 2006, the ministry expanded access by integrating ART into primary health care clinics.
Methods: We conducted a retrospective cohort study including adult ART-naive patients initiating ART between January 2006 and June 2008 in public sector clinics in Manica and Sofala provinces. Cox proportional hazards models with robust variances were used to estimate the association between clinic model (vertical/integrated), clinic location (urban/rural), and clinic experience (first 6 months/post first 6 months) and attrition occurring in early patient follow-up (≤6 months) and attrition occurring in late patient follow-up (>6 months), while controlling for age, sex, education, pre-ART CD4 count, World Health Organization stage and pharmacy staff burden.
Results: A total of 11,775 patients from 17 clinics were studied. The overall attrition rate was 37 per 100 person-years. Patients attending integrated clinics had a higher risk of attrition in late follow-up [hazard ratio (HR) = 1.75; 95% confidence interval (CI): 1.04 to 2.94], and patients attending urban clinics (HR = 0.57; 95% CI: 0.35 to 0.91) had a lower risk of attrition in late follow-up. Though not statistically significant, clinics open for longer than 6 months (HR = 0.71; 95% CI: 0.49 to 1.04) had a lower risk of attrition in early follow-up.
Conclusions: Patients attending vertical clinics had a lower risk of attrition. Utilizing primary health clinics to implement ART is necessary to reach higher levels of coverage; however, further implementation strategies should be developed to improve patient retention in these settings.
LINK: click here
On Thursday November 29, Secretary of State Hillary Rodham Clinton commemorated World AIDS Day 2012 and unveiled the PEPFAR Blueprint: Creating an AIDS-free Generation that provides a roadmap for how the U.S. government will work to help achieve an AIDS-free generation. Secretary Clinton will be joined by Ambassador Eric P. Goosby, U.S. Global AIDS Coordinator.
Secretary Clinton was joined by:
Ambassador Eric P. Goosby, U.S. Global AIDS Coordinator
Michel Sidibe, UNAIDS Executive Director
Dr. Nkosazana Dlamini-Zuma, Chairperson of the African Union Commission
Florence Ngobeni-Allen, Ambassador for the Elizabeth Glaser Pediatric AIDS Foundation
The PEPFAR Blueprint is available here: http://www.pepfar.gov/documents/organization/201386.pdf
This month, Pangaea published a paper in a preeminent journal of women’s health, Reproductive Health Matters. This paper summarizes data from Pangaea’s SHAZ! Project, a study working to increase access to HIV services and improve health outcomes for adolescent women living with HIV in Zimbabwe. Findings highlight the complex and critical nature of disclosure of HIV status among this age group to achieve good HIV and reproductive health outcomes. Programs and services must do more to help young women living with HIV negotiate the complexities of disclosure in the context of achieving desired fertility.
Abstract: In the Shona culture of Zimbabwe, a high regard for childbearing contributes to strong pressures on women to have children. For young women living with HIV, consequently, disclosure of HIV status
can be a central strategy to garner support for controlling fertility. This paper reports findings from
qualitative interviews with 28 young women aged 16–20 living with HIV in urban Zimbabwe and discusses
how these findings can contribute to better policies and programs for this population. Regardless of their
current relationship status, interview participants described disclosure as a turning point in romantic
partnerships, recounting stressful experiences with major ramifications such as abuse and abandonment
on the one hand, and support and love on the other. All but one participant had been in a committed
relationship, and most had disclosed to a previous or current partner, with about half of disclosure
experiences resulting in adverse reactions. Findings suggest that sexual and reproductive health services
must do more to help young women living with HIV negotiate the complexities of disclosure in the context
of achieving desired fertility. © 2012 Reproductive Health Matters
Full article available at: www.rhm-elsevier.com
Pangaea is launching a new report, “The Leadership of Affected Communities in Delivering HIV Prevention, Testing and Treatment”, with recommendations from two consultations held in Zimbabwe and Thailand organized with the World Health Organization (WHO), UNAIDS, the Zimbabwe Ministry of Health and Child Welfare, and the Asian Network of People Living with HIV (APN+). These recommendations have been presented to WHO for consideration as it develops new consolidated HIV treatment guidelines for release in 2013. The report distills lessons learned from HIV treatment community organizations from over 30 countries.
What is a Shadow City?
"A city, municipality or other jurisdictional area that is overshadowed, and thus overpowered by a larger city that is global in nature and possesses more resources such as expertise, enterprise, money, and national government investment."
— Marsha Martin (2011), Get Screened Oakland, an initiative of the Office of the Mayor of Oakland
Dr. Barrot Lambdin, Pangaea's Director of Implementation Science, was lead author of "Local Residents Trained As 'Influence Agents' Most Effective In Persuading African Couples On HIV Counseling And Testing," published in Health Affairs in August of 2011.
Dr. Barrot Lambdin, Pangaea's Director of Implementation Science, was lead author of Patient Volume, Human Resource Levels, and Attrition From HIV Treatment Programs in Central Mozambique published in JAIDS in July 2011.
Lambdin, Barrot H PhD, MPH; Micek, Mark A MD, MPH; Koepsell, Thomas D MD, MPH; Hughes, James P PhD, MS; Sherr, Kenneth PhD, MPH; Pfeiffer, James PhD, MPH; Karagianis, Marina MBChB; Lara, Joseph MPH; Gloyd, Stephen S MD, MPH; Stergachis, Andy PhD, MS
JAIDS Journal of Acquired Immune Deficiency Syndromes:
1 July 2011 - Volume 57 - Issue 3 - pp e33-e39
Implementation and Operational Research: Epidemiology and Prevention
Full text of article available here.
Pangaea researchers have led the development of SHAZ! (Shaping the Health of Adolescents in Zimbabwe) – an HIV prevention intervention and research study in Zimbabwe that empowers adolescent female orphans to avoid sexual risk behaviors by improving economic opportunities and linking them to life skills-based HIV education and clinical care. As a resource for others in the field, Pangaea is pleased to be able to make available the SHAZ! Facilitator's Guide.
Pangaea convened an expert consultation in July 2009 in Cape Town, South Africa on behalf of the Office of AIDS Research (OAR) at the National Institutes of Health (NIH), aimed at addressing the growing imperative for analyses to inform and improve uptake of proven interventions and to scale up HIV/AIDS programs.
HIV Prevention Among Injection Drug Users: Strengthening U.S. Support for Core Interventions, CSIS Global Health Policy Center, April 2010
This report examines data on the burden of HIV among IDUs and access to and receipt of MAT, needle and syringe programs (NSP), and ART services in 14 countries.