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In it to Save Lives: Scaling Up Voluntary Medical Male Circumcision for HIV Prevention for Maximum Public Health Impact

Emmanuel Njeuhmeli is the Senior Biomedical Prevention Advisor in the USAID Office of HIV/AIDS.

“Male circumcision can be done anywhere, and if you don’t believe me, I’ll prove it to you during this meeting.”

These were my last words during my first presentation at the 2011 PEPFAR Annual Meeting in Johannesburg this past May. Needless to say, there were a lot of raised eyebrows, a few laughs and a couple of questions as to whether I had a male circumcision tent set up in one of the breakout rooms.

But no – the goal, of course, was not to perform a medical procedure on my USG colleagues. It was to heighten their understanding of a cost saving and effective form of HIV prevention that, despite the science and clinical findings, still does not get the recognition and broad support it should.

Soon after the World Health Organization released findings from three randomized trials that showed  male circumcision prevents 60% of new HIV infections in men who have heterosexual sex, countries in Eastern and Southern Africa  with technical and financial support of PEPFAR, BMGF, WHO, UNAIDS began scaling up efforts around voluntary medical male circumcision (VMMC).

PEPFAR, through USAID, CDC, DOD, Peace Corps, and NIH, has continually supported country governments in their VMMC efforts. Kenya’s program is one worth noting. In two short years, the national program has reached 66 percent of its VMMC goals. This means – based on USAID and UNAIDS estimates that Kenya is on its way to averting 47,000 adult HIV infections between 2009 and 2025, and can save $247 million along the way. This is no small feat.

Now, working to support other countries in Africa, such as Swaziland – which is scaling up VMMC services through the Soka Uncobe, an accelerated saturation initiative – we are confident VMMC has the potential to avert more than 4 million adult HIV infections in Eastern and Southern Africa in the next 16 years.

That is what PEPFAR is all about: making smart investments to save more lives.

After our meetings, I felt my colleagues were more inclined to return home and explain VMMC to their country governments in a compelling and effective way. They saw the value of VMMC as a critical HIV prevention tool – one that can be done in a safe medical environment and rolled out on a wide scale in almost any community.

But, to reach our ultimate target – the decision makers and communities in country – we knew we had to go beyond the presentations. So, with the help of AIDSTAR One, we teamed up with Lisa Russell, an award-winning filmmaker, to create In It to Save Lives: Scaling Up Voluntary Medical Male Circumcision for HIV Prevention for Maximum Public Health Impact.

The film examines the expansion of male circumcision as an HIV prevention intervention and tells the story of how governments and communities in Kenya and Swaziland have embraced VMMC in their countries. The goal of the film is to show that VMMC services can be replicated and expanded to reach the critical mass needed for maximum public health impact.

Now, 30 years into the epidemic, there are roughly 34 million currently living with HIV/AIDS, with another 7,000 new HIV infections each day. With numbers like these, it’s more important than ever to focus on reaching those most in need with prevention, treatment, care and support messages and programs.

Through a variety of prevention interventions, including VMMC, we hope to turn the tide of the HIV epidemic.

Watch the video and download additional resources at AIDSTAR-One.

Mobile Clinics in India Take to the Road: Bringing HIV Testing and Counseling and STI Services to Those Most at Risk

Ed Scholl, AIDSTAR-One Project Director, John Snow, Inc. AIDSTAR-One is funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID’s Office of HIV/AIDS, and provides rapid technical assistance to USAID and U.S. Government (USG) country teams to build effective, well-managed, and sustainable HIV and AIDS programs, and promotes new leadership in the global campaign against HIV.

Sanjay takes his lunch break on his construction job near the city of Nagpur in the state of Maharashtra, India.  He migrated here in search of work from his home in the northern state of Madhya Pradesh.  He’s 23 and single and hopes to earn enough to get married, start a family, and help his parents back home.

During his break, Sanjay (not his real name) decides to visit the big van parked near the construction site, where an outreach worker told him he can get free HIV and sexually transmitted infection (STI) testing.  He’s curious and a bit concerned about his HIV status, since he knows that visiting sex workers back in town, as he and his fellow workers occasionally do, puts him at risk for HIV.  He enters the van and is greeted by the counselor, who explains how HIV and STIs are transmitted and what he can do to avoid them. Sanjay then gives his consent for an HIV test.  The counselor shares some pamphlets that give him additional information about HIV and STI prevention.  Before she leaves, she demonstrates how to use a condom and offers him some.

Next, he visits the doctor, who goes through a checklist of STI symptoms and provides a physical exam.  Finally, he goes to the lab, where blood is drawn. He is told to come back for the results in four hours.  At the end of his shift, he returns to the van and the counselor tells him, much to his relief, that he is HIV-negative and does not have an STI.  She reminds him how he can stay healthy and avoid HIV and STIs and answers all of his additional questions.

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30 Years of HIV/AIDS: A USAID Historical Perspective

On June 5, 1981, the Morbidity and Mortality Weekly Report reported that five seemingly healthy young gay men were diagnosed with an infection that would typically affect only individuals with substantial damage to their immune system. As similar cases cropped up, national and international attention soared, and the scientific and public health community mobilized to ascertain the scope and root of this anomaly. Eventually, the causal factor was given the name AIDS.

This month marks 30 years since the first cases of AIDS were reported in the United States. After scientists identified and isolated HIV, and confirmed it caused AIDS, the U.S. Agency for International Development (USAID) began its HIV/AIDS development program. Starting in 1986, USAID’s work in this field has been ambitious and cutting edge, showcasing the best of American scientific ingenuity and demonstrating core American values.

In the 1980s and 1990s, we launched prevention, care and treatment programs through our missions around the world using approaches that fit within the social context of each country and targeted the most vulnerable populations. The proliferation of the disease across sub-Saharan Africa prompted us to intensify our focus on this region. In 2000, USAID convened the first agency-sponsored international meeting on male circumcision and HIV prevention. We also began some of the first prevention of mother-to-child transmission programs with the Elizabeth Glaser Pediatric AIDS Foundation.

We quickly realized fighting this disease would require more than just new medication and care. In 2001, we forged a partnership with the International AIDS Vaccine Initiative (IAVI) to invest in research and development for an effective vaccine. To date, IAVI has made a number of groundbreaking discoveries, including several potent new antibodies to HIV, adding more vitality to this game-changing effort. In the same year, USAID commenced three pilot trials of antiretroviral treatment in Kenya, Rwanda, and Ghana.

In 2003, President Bush announced an unprecedented initiative to ramp up the U.S. Government’s commitment to HIV/AIDS in the developing world. Today, the President’s Emergency Plan for AIDS Relief (PEPFAR) continues to be the largest bilateral AIDS program in the world, touching millions of lives through prevention, care, and treatment. Through our global network of missions and partners, USAID currently implements more than half of all PEPFAR programs.

Through PEPFAR, USAID has contributed to saving lives through a variety of voluntary prevention interventions, counseling, testing and care programs. Today, more than 3.2 million people receive lifesaving treatment through the support of the American people.

Building on the strength of PEPFAR  and other successful US global health initiatives, USAID is working at an interagency level to ensure President Obama’s Global Health Initiative replicates and amplifies the success of our HIV/AIDS programs through a continued focus on health system strengthening and investments in innovation. Our award-winning Supply Chain Management System project has provided more than $750 million in HIV/AIDS commodities and saved $700 million by pooling procurements of generic AIDS drugs. We also funded the CAPRISA 004 Trial, which was completed last summer and provided the first-ever proof of concept that a microbicide can reduce risk of transmission from men to women.

Our work is far from done. We have a shared responsibility as a global partner to save lives by focusing on smart investments. The generosity of the American people has made sustained progress against this deadly disease possible. Closing the chapter on HIV/AIDS will require a steadfast focus on remaining gaps and challenges as we chart the way forward.

The Other Half of the Family Planning Equation

As Father’s Day approaches I look back to when my wife and I first decided to have children. We married fairly late, both in our early 30s, so we planned to have our first child just a couple years after we married. It was an exciting time; much thought went into planning our family. We are now proud parents of two healthy and happy girls. It’s normal in the U.S. for both men and women to play an active role in planning their families; however, in much of the developing world that is not the case.

Involving men in international family planning programs is an uphill battle. There is a lack of information among men on the importance of delaying first birth, of spacing births, and of avoiding high parity births for the health of the woman and the child. Family planning saves lives and improves maternal and child health. In the developing world, an estimated 90 percent of infants whose mothers die after childbirth will die by their first birthday.

Men play an essential role as they are the gatekeepers in many countries to what women can and cannot do: whether women can use contraception or whether family resources should go to pay for other methods. A number of USAID’s programs address gender issues, focusing on improving male participation in family planning.

We are making progress. Twenty years ago in Kenya, 10 percent of women who were not using or planning to use family planning said that their husband’s disapproval of family planning was the main reason. Today, this percentage has been reduced to 6 percent. Meanwhile, countries like Nigeria have 10 percent of these women attributing non-use of family planning to husband’s disapproval. So while we have seen improvements, there is still much work to be done.

Educating men on the importance of family planning and birth spacing is only part of the equation. There should also be a greater emphasis on male methods, including condoms and vasectomy.

The challenge is many men around the world don’t have good health seeking behavior so we must get creative in our opportunities to reach men. For example, now that there is incontrovertible evidence that male circumcision significantly reduces acquisition of HIV by men, there are male circumcision programs for adult men blossoming all over sub-Saharan Africa. We should make sure there are no missed opportunities to speak to men about other health issues, including planning for their families.

This Sunday, as we celebrate fathers everywhere, let us not forget that men’s participation in planning for their families will result in better health and improved lives.

Photo blog: If countries lead will donors follow?

Originally posted on the Ministerial Leadership for Global Health (MLI) Blog

All five MLI countries were represented Thursday afternoon at the MLI event, “If Countries Lead Will Donors Follow?” at the Global Health Council’s annual conference in Washington, D.C. Delegates spoke on a panel moderated by John Donnelly in The Ambassador Room, sharing stories about how country leadership has advanced health outcomes in their countries.

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The Health Professional Crisis: A Personal Perspective

Phetogo Phoi, Lab Logistics Advisor, Supply Chain Management System (SCMS)

Botswana, like many countries, struggles with a limited amount of health workers, especially personnel qualified in the area of lab management.  In Botswana, this challenge is compounded by a limited number of graduate and undergraduate health programs. Professional courses, especially in the health area, are not offered here. Like many, I went abroad to the United States and the United Kingdom for my undergraduate and graduate degrees.

In the absence of a comprehensive health education infrastructure, the technical assistance provided by President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID to enhance the skills of the health workforce plays a critical role in strengthening the health sector. In the area of lab logistics, lab commodity management ensures that tests and other supplies are available when a doctor or nurse needs them. This field of study is often the furthest thing from a laboratory scientist or pharmacist’s mind when they enter the workforce.

In my work as a Lab Logistics Advisor for the Supply Chain ManagementSystem (SCMS), a project under PEPFAR and administered by USAID, I train health workers, mainly lab personnel, on laboratory commodity logistics management. One thing I’ve learned:  lab supplies are critical to health programs. Someone will visit a clinic and be tested for HIV. If they test positive, based on their CD4 count, they are placed on lifesaving treatment. Health workers then monitor the patient’s treatment regimen and most importantly, their health.

If a lab isn’t properly tracking its inventory, there is an opportunity for stockouts of test kits, which could lead to very sick people going without treatment because they never learned their status.  By learning to better manage their inventory of medicines, test kits and laboratory supplies, health workers can ensure their facilities are well stocked and the products they need are available for patient diagnosis and treatment.

I’m working with laboratory staff to help them implement the systems they didn’t learn about in their university studies or other pre-service trainings. I try to focus staff on addressing challenges and identifying how the system should look. Systems are more important than some may think. Without a system, there are many challenges in managing a health facility. But even with all the complaints and finger pointing, there was no structured system to resolve challenges.

Every day, I see the difference PEPFAR and USAID and the Centers for Disease Control and Prevention are making in this area.  I used to visit one of the facilities we work with, and it was a painful sight to find everything so mixed up. Pharmacists and laboratory officers were unable to find the supplies they needed or were unable to use them before they expired. Now, I go to facilities where I’ve trained people and just smile to see so much changing.

There is still much to do. Change doesn’t happen overnight, but I believe that with more investment in training and technical assistance we can help build a public health workforce we can all be proud of.

Renewed Commitment to Global Vaccines and Immunizations Will Save Lives

Originally posted on the White House Blog

During a time when we all – including the federal government – need to live within our means and find places to cut spending, any investments made by your government need to meet the test of whether it is an effective and efficient use of taxpayer dollars.

Immunizing children from preventable diseases meets that test. As USAID Administrator Raj Shah announced in London on Monday, by making a multi-year commitment to the Global Alliance for Vaccines and Immunizations (GAVI), the US is able to get the most from our investment – leveraging a pledge of $450 million over three years more than eight-fold into billions of dollars in commitments from other donors, including the UK, the Gates Foundation, Norway and others.

Together, these commitments will help save the lives of 4 million children over the next five years, by getting more vaccines to more children and by helping to ensure the quantities of vaccines needed to lower the prices for new vaccines such as those that protect against pneumonia and diarrhea, the world’s two most potent childhood killers. All in all, we will be able to immunize more than 250 million children and prevent more than four million premature deaths.

Investments in vaccines are one of the best and most cost-effective life-saving investments for the world’s children, which is why we’ve made tough choices and trade-offs within our current global health portfolio to make this commitment.  As Administrator Shah said: “In this fiscal climate, a multi-year pledge is an extremely difficult commitment to make. But we have made tough reallocations across our portfolio in order to make that commitment because only a multi-year pledge will ensure the highest possible return for every taxpayer dollar.

Not only will our commitment inspire the generosity of other donors, it will help drive economies of scale that lower the cost of vaccines, allowing us to save even more lives. Just last week, GAVI reached an agreement with GlaxoSmithKline to cut the cost of the rotavirus vaccine by 67%. That kind of reduction is only possible with the guaranteed demand a multi-year pledge provides.”

In the lead up to GAVI’s conference, the White House received thousands of phone calls, emails, and signed petitions calling for continued U.S. support for GAVI.  The ONE Campaign issued a statement of support following our announcement, including praise from Bono who noted the President was “in it to win it.”

The U.S. has played a lead role in GAVI since its inception, and is a world leader in support of every aspect of the vaccines value chain, including research, development, vaccine affordability, delivery systems, and policy coordination.

Gayle Smith is Special Assistant to the President and Senior Director for Development and Democracy for the National Security Staff

Day of the Child: 250 Million Kids to Receive Life-Saving Immunization

Compiled by Chris Thomas, Ryan Cherlin

“The most transformative technology at our disposal, vaccines ensure protection against killer diseases whether children are immunized by pediatricians in the U.S. or by health workers in rural clinics in Africa,” said USAID Administrator Dr. Raj Shah.

Yet, vaccine-preventable diseases are still estimated to cause more than 2 million deaths every year in developing countries. The global effort to expand the coverage of existing vaccines and introduce new vaccines against pneumonia and diarrhea got a powerful shot in the arm Monday.

At a first-ever pledging conference for the Global Alliance for Vaccines and Immunization (GAVI), donors committed US$ 4.3 billion, exceeding the $3.7 billion target. The funding will immunize more than 250 million of the world’s poorest children against life-threatening diseases by 2015, and prevent more than four million premature deaths.

Dr. Shah announced a $450 million commitment from the United States over three years (subject to Congressional appropriation). With the pledge, the United States surpassed $1 billion in commitments to GAVI for the purchase of vaccines.

GAVI is a public-private global health partnership, created in 2000, to save children’s lives and protect people’s health by increasing access to immunization in the world’s poorest countries. The alliance funds childhood vaccines against diseases such as pneumococcal pneumonia, Haemophilus influenzae type b, or Hib disease, diphtheria, pertussis or whooping cough, meningitis, yellow fever, tetanus, and rotavirus.

Because infectious disease knows no borders, investment in this area is also one of the most cost effective ways to protect the global community from outbreaks that take an economic and physical toll on previously uninfected populations. In February, the largest outbreak of measles in the U.S. this year was linked to an unvaccinated child who recently travelled to Kenya. The cost in lives and money spent to contain and prevent further infection caused an unnecessary and avoidable burden on local health systems.

The U.S. has long recognized the moral imperative and the inherent economic value of vaccines and immunization, which is why we played a lead role in founding and supporting GAVI.

The first-ever pledging meeting convened prime ministers, ministers and high-level officials from donor and developing countries, leaders of UN Agencies, CEOs from private companies and senior civil society officials and philanthropist Bill Gates.

Dr. Shah also offered to organize a high-level meeting in a year’s time in Washington, D.C., so GAVI, donors and all immunization partners can review progress and impact.

At the conference, it was announced that a record 50 GAVI eligible countries have applied for vaccine funding from the Alliance in this latest application round. The number of countries is nearly double the previous record in 2007 when 27 countries requested support to introduce new or underused vaccines.

The increased demand highlights how developing countries are increasingly prepared to expand routine immunization programs and introduce new vaccines to save the lives of children and protect against illness and disability.

In studies in the Health Affairs and The Lancet journals, public health experts and scientists projected 6.4 million child deaths could be prevented in the next decade, which could save $6.2-billion in treatment costs and $145-billion in lost productivity if vaccine delivery were expanded in 72 low- and middle-income countries.

Picture of the Week

A young girl gets typhoid/diptheria vaccination at a medical clinic at Petionville golf club on July 13, 2010, in Port-au-Prince. USAID/OFDA funds 12 mobile and static International Medical Corps clinics that target rural and displaced populations in and around Port-au-Prince, Petit Goave and Leogane. Photo by Kendra Helmer/USAID

New USAID Report Highlights Achievements in Egypt’s Health Sector

Yesterday I joined former USAID Administrator Peter McPherson, Egypt Embassy Counselor Motaz Zahran, and more than 100 members of the Egyptian diaspora and global health communities to launch USAID/Egypt’s Health and Population Legacy Review (pdf, 1.5mb).

The report demonstrates impressive long-term results of USAID health sector assistance in Egypt over 32 years.  For example, over the past three decades, there have been declines in maternal mortality by more than 50 percent and in infant mortality by more than 70 percent, as documented by Egypt’s regularly released Demographic and Health Surveys. Medically assisted deliveries increased from 35 percent in 1988 to almost 80 percent in 2008.

I served in USAID’s Egypt mission from 1976 to 1980 and again from 1984 to 1988, and I have seen with my own eyes the remarkable progress that has been achieved.  When I left Cairo in 1980 oral rehydration therapy was not part of Egypt’s health program.  When I returned in 1984 it appeared to me that there was an oral rehydration center in every neighborhood of Cairo and every village throughout the country.

The Egypt Health and Population Legacy Review attributes the success of programs like this to the duration of assistance and to robust funding and staffing levels.  Because USAID was a reliable partner with the Ministry of Health and Population over a 32-year period, it allowed not only for introducing new programs, but also for seeing them through various stages of program evolution. The substantial level of funding over the decades also helped ensure that programs were implemented on a large enough scale to achieve significant impact.

Despite the accomplishments, much work remains to be done.  And in many ways, the moment is ripe.  This has been a historic time for the people of Egypt and the Middle East.  And now, more than ever, it is vital that we use studies like these to learn from the past.

U.S. Ambassador to Egypt Margaret Scobey said it best:

The emergence of a new political order in Egypt sets the stage for even greater improvements in the lives of Egyptians. The accomplishments, the institutional strengthening, the data and policy analysis, and – most important – the many new Egyptian health professionals and leaders, are a solid platform from which to launch new initiatives and innovations of many kinds.  In the Egyptian health sector, the past can inform the future.

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