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Archives for Global Health

Making TB Personal: An Ancient Disease and the Need for Innovative Solutions

By: Christy Hanson, Chief of Infectious Disease Division, USAID

When I began my career working with Tuberculosis twenty years ago, the outlook for future progress against this biblical disease looked very different than it does today.  From 1990 to 2009, the TB community has made tremendous progress—TB related deaths have declined by more than one-third, and incidence is declining globally. The emergence of new diagnostic technologies has made it easier to quickly detect multi-drug resistant TB.

Today, the global incidence rate is falling slowly, and 5 of the 6 regions of the world are on track to meet the UN Millennium Development Goal target to halve TB prevalence and deaths by 2015. We are now looking beyond this goal and are focusing on providing universal access to TB care. This is an effort that will require engaging all providers in the public and private sector, people in communities, and TB patients themselves.

It gives me pause to think this is the same disease that has plagued mankind as far back as the ancient Roman civilization. To understand how this disease has survived for millennia, it is important to know how it works.

This is a disease that is inextricably linked to the socioeconomic realities of the impoverished. TB is activated when an individual’s immune system is weakened by any number of causal factors: old age, malnutrition, pregnancy, HIV, and other concomitant illness, such as diabetes. It is estimated that more than one-third of the population in the developing world who are exposed to these conditions are infected with the disease.

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U.S. and World Bank Strengthen Water Partnership on World Water Day

On March 22nd, Secretary of State Hillary Clinton and World Bank president Robert Zoellick signed a Memorandum of Understanding (MOU) committing to a stronger partnership on water issues.  The agreement, signed at a World Bank ceremony on World Water Day, will bring the U.S. government and World Bank together to work on global water and sanitation challenges.

The need for a combined effort on water issues could not be clearer.  An estimated 880 million people lack access to an improved water source.  More than 5,000 people—most of them women and children—die every day from causes linked to unsafe water, sanitation, and hygiene.  The current outbreak of cholera in Haiti is a stark reminder of this reality.  Beyond health, water is central to a number of development challenges, such as climate change, food security, conflict, energy, and gender.

Secretary Clinton providing remarks at the MOU signing with the World Bank. USAID’s Deputy Administrator Don Steinberg and World Bank President Zoellick looking on. Photo Credit: State Department

The work promised at the signing has already begun: USAID and the World Bank have started to develop a prize to stimulate the development of new technologies related to drinking water and sanitation.  The World Bank is also working with NASA to provide remote sensing technologies around the world.  As speakers at the ceremony emphasized, this type of cooperation is necessary because water issues cannot be confined to just one area.

“The water crisis is a health crisis, it’s a farming crisis, it’s an economic crisis, it’s a climate crisis, and increasingly, it is a political crisis,” Secretary Clinton noted.  “And therefore, we must have an equally comprehensive response.  Now our experts in the United States Government are working on water issues at nearly two dozen agencies – of course, from State and USAID, but also the Millennium Challenge Corporation, NASA, NOAA, EPA, Treasury, and so much else.”

As a result, the United States is one of the largest bilateral donors on water and sanitation; USAID and the Millennium Challenge Corporation together invested more than $770 million in the water sector and on sanitation-related activities in developing countries in fiscal year 2009.

Secretary Clinton highlighted several USAID projects launched since her speech at last year’s World Water Day, which are representative of the new direction set for the U.S. government water program:

-       In Indonesia, USAID has begun a five-year, $34 million water, sanitation, and hygiene project to reach more than 2 million of Indonesia’s urban poor.  USAID also launched a project in Haiti to teach women about sanitation and hygiene so they could better take care of their households.  In India, USAID is supporting a project to provide slum dwellers in eight states with municipal water and sanitation systems.

-       USAID and the Qatar National Food Security Program convened representatives from 17 water centers in 10 countries across the Middle East and North Africa to create a regional network to share technical knowledge to solve the complex water challenges they face.

-       In Kenya, USAID is working with local water utilities, a local cell phone company, and a local microfinance institution to create new ways for poor people to pay for water. They receive a microloan to cover the initial cost of connecting their homes with water systems, then they repay those loans using micro-banking services on their cell phones.

-       In the Philippines, Japan and the United States have worked together to establish a water revolving fund to leverage private investment to improve water and sanitation for more than 100,000 people in 36 villages. Last year, the first USAID guaranteed loan for $2.5 million was granted.

-       To promote science and technology, USAID is working with NASA to use satellite images to monitor and forecast ecological changes in the Himalayas, including the monitoring of glacial melt. USAID has also worked with the private sector to open a ceramic water filter factory in Cambodia.  With ceramic filters, people no longer need to boil water to make it safe to drink, so they don’t need to burn as much wood or charcoal, which in turn reduces greenhouse gases.  The plant has even applied to receive carbon credits for future sales.

At the 2010 World Water Day event, Secretary Clinton stressed the U.S. government’s commitment to strengthening its partnerships; the MOU with the World Bank is reflective of that commitment.

Under the new agreement, the United States and the World Bank will work together in a number of areas, including rehabilitating wetlands, improving irrigation practices, and mobilizing public-private partnerships and private capital to support water projects around the world.

Progress in these areas depends upon the efforts of numerous organizations.  NGOS, private industry, foundations, and international bodies were all represented at the event.  Many of them have ongoing projects with USAID and the World Bank across the globe.  As USAID Deputy Administrator Donald Steinberg emphasized, “our presence here today reflects a basic truth in the development challenges we face: no single government, international institution, civil society group, or private corporation has a monopoly on good ideas, dedicated commitment, or ground truth.”

Our Common Fight – TB in Eastern Europe and Eurasia

Several weeks ago, I visited the Central Tuberculosis Research Institute (CTRI) of the Russian Academy of Medical Sciences in Moscow. It plays a central role in Russia’s battle with tuberculosis (TB)  as the country’s top TB treatment hospital, research center, and medical training facility. Russians with the most difficult multi-drug resistant (MDR) – TB  and extensively drug-resistant  (XDR) -TB are treated there. I was struck by the determination of the Russian doctors in the face of the continued threat of MDR-TB and XDR-TB and I am glad that USAID counts them as partners in our common fight.

As we commemorate World Tuberculosis Day on March 24, it is important for all of us to recognize that Eastern Europe and Eurasia continue to have the highest rates of MDR-TB and XDR-TB infections in the world.  According to the World Health Organization (WHO), 12 countries have reported proportions of MDR-TB of 6% or more among new TB cases: all of these countries are in Eastern Europe and Eurasia. Five countries report MDR-TB proportions of 50% or more among previously treated cases: all of these countries are also in Eastern Europe and Central Asia. The WHO estimates that in Russia, 42.4% of previously treated TB cases are MDR-TB; in Azerbaijan, 55.8%; in Georgia, 27.4%; and in Ukraine, 44.3%.

A TB patient receives care at the Central Tuberculosis Research Institute of the Russian Academy of Medical Sciences in Moscow, an institute dedicated to treating Russians with MDR and XDR-TB. Photo Credit: David Grout/ USAID

In our interconnected planet where people constantly cross borders and millions of people fly every day, not only are U.S. citizens travelling abroad vulnerable to MDR and XDR-TB, but Americans from Georgia to Maine could face this threat at home. Therefore, we have a national security interest in stopping TB around the world and we need the grit of those dogged Russian doctors I met in Moscow.

Tuberculosis is curable but potentially deadly. It is spread through the air and is second only to HIV among infectious killers worldwide. Tuberculosis exacts an enormous personal and economic toll, often striking people in their most economically productive years.  MDR-TB and XDR-TB are major risks to effective TB control. MDR-TB is resistant to the two most important first-line drugs used in the treatment of TB. XDR-TB is resistant to additional drugs. The usual six-month treatment with first-line TB drugs is not effective for MDR-TB and XDR-TB. The treatment for MDR-TB and XDR-TB is more expensive, less effective, with greater side effects, and it requires two years to complete—if that form of TB is treatable at all.

MDR-TB and XDR-TB arise due to a number of controllable factors, such as high patient treatment default rates, late diagnosis, irregular treatment, easy access to first and second line drugs in private sector pharmacies without prescription, and, in some cases, population displacement due to unrest. Therefore, it is possible to prevent and control MDR-TB and XDR-TB.

USAID missions through the Eastern Europe and Central Asian regions are working with host countries to combat MDR-TB and XDR-TB.  There is hope. For example, USAID in Georgia supported the National TB Program and provided technical assistance to create DOTS spots—special TB outpatient centers located inside of the general urban outpatient clinics. As a result, in the capital city of Tbilisi, the clinics reduced treatment defaults from 23% in 2003 to 9% in 2008. With lowered treatment default rates, the risk of MDR and XDR-TB are lessened.  With USAID-supported technical and financial assistance, MDR-TB reported cases decreased in the Balkans from 14.4% in 1996 to less than 9% in 2003. In Ukraine, USAID assisted implementation of laboratory quality control procedures in 8 regions, resulting in 92% of USAID-supported laboratories demonstrating high proficiency in laboratory-based TB diagnosis. These successes show that USAID support is yielding results and helping to control MDR and XDR-TB.

USAID is helping to save thousands of lives and showing the goodwill of the American people.  Together with the people of Europe and Eurasia, we must continue to fight MDR and XDR-TB for their sake and our own national interest. Let us not lose focus, take decisive action and curb the spread of MDR-TB and XDR-TB. It is the right thing to do morally, economically, and for our national security.

USAID Official Featured as Voice of America’s “American Profile of the Week”

Ellyn Ogden, USAID’s worldwide polio eradication coordinator, immunizes a child during a festive kick-off event for a polio vaccination campaign in Kabul, Afghanistan.

USAID’s Worldwide Polio Eradication Coordinator, Ellyn Ogden, has devoted her career to eradicating polio and advocating for children’s health.

Read more about her life and work in this week’s VOA profile.

A Look Ahead to World Water Week 2011

Written by Christian Holmes, USAID’s Global Water Coordinator

As we enter World Water Week 2011, it is a good time to reflect on the significance of this vital resource that we often take for granted here in the United States, but is such a precious commodity in many other parts of the world.

Children Washing Hands at School Handwashing Station in Pahuit, Guatemala Copyright: Water For People/Nancy Haws

For me, World Water Week most importantly and fundamentally is about the harsh reality of life and death.  It is staggering, almost beyond comprehension, that each day approximately 6,000 people, most children under five, die from preventable diarrheal diseases and that diarrheal disease remains the second leading cause of death in children worldwide.  Yet, that is the case. These children die in a world where over 800 million people lack access to an improved water source and more than two and a half billion people lack access to sanitation. This is the world we have to change.

But change is possible.  This is also a world where individuals and organizations have the skills and resources to make extraordinary differences in the lives of others. A great many of these people have come together in Washington this week to express their commitment to saving and improving lives and to helping sustain the environment in which people live and on which they are dependent. In so doing, much of the week involves important activities related to sharing and learning about approaches which will improve our ability to reduce the loss of life and human suffering.

I’ll be participating in a number of events which I’m convinced will help lead to change.

On March 22 I’ll be at a World Bank World Water Day Cross Sectoral Working Group on WASH and Healthy Ecosystems: Advancing Freshwater Management Through Integrated WASH Programming.

Also on March 22, Secretary of State Hillary Clinton will join World Bank president Robert Zoellick to sign a Memorandum of Understanding between the Bank Group and the US Government to expand and enhance our collaboration in the water sector. USAID Deputy Administrator Don Steinberg will also participate, and the event will be webcast live.

On March 23, I’ll join NGO colleagues on the Hill as part of World Water Advocacy Day.

I look forward to sharing thoughts and impressions of these events with you as the week progresses.

Developing Kenya through AIDS Vaccine Research

I was very glad last month to hear Administrator Rajiv Shah describe USAID’s deep commitment to sustainable development and building country-led health systems. These principles characterize USAID’s impact in Kenya, where USAID has supported the Kenya AIDS Vaccine Initiative (KAVI) through our partnership with the International AIDS Vaccine Initiative (IAVI).

Dr. Omu Anzala of the Kenya AIDS Vaccine Initiative (KAVI) during an interview for the 2007 documentary HIV/AIDS: the search for a vaccine. The documentary originally aired as part of BBC World’s “Kill or Cure?” series. Credit: KAVI

Here in Kenya, our people and our resources have been drained by three decades of HIV/AIDS.  We are grateful for all that PEPFAR and the Global Fund have done to make antiretroviral drugs (ARVs) accessible and affordable in our country. At the same time, the existing prevention, treatment, and care available are simply not enough to stop the epidemic.  We need new and more effective prevention strategies, and, more fundamentally, we need to build a sustainable, national response to HIV specifically and to grow our country’s capacity to develop scientific solutions to our health problems more generally.  We are accomplishing all of this with the assistance of USAID.

In 1999, we established KAVI with IAVI, the University of Nairobi, and the UK Medical Research Council. KAVI ran the first clinical trial of an HIV vaccine candidate in Kenya, and another four early-stage clinical trials since then. We participated in the study that led to the discovery of broadly neutralizing HIV antibodies—an advance which is crucial to AIDS vaccine research.

But our work has not only contributed to the development of a desperately needed HIV vaccine, which is the only way to stop AIDS once and for all.  It has also strengthened our country in many ways.  Working closely with the Kenyan government and with support from USAID through IAVI, we have built state-of-the-art laboratories and clinical facilities and trained first-rate Kenyan scientists and technicians.  As a result, KAVI-KNH (Kenyatta National Hospital) was among the first laboratories in Africa to win the stringent Good Clinical Laboratory Practice (GCLP) accreditation.  We have increased our capacity for basic research in HIV immunology.  IAVI provided a liquid nitrogen production plant and helped train teams to produce this frozen gas that is essential to process and analyze samples on site.  At Kilifi, we constructed a family clinic that provides ARVs for HIV-positive individuals and at Mtwapa free counseling and support services.  Volunteers in our clinical trials receive healthcare and family planning services. The Expanded Community Outreach program supports vaccine and research literacy, and trains peer leaders to inform their communities about HIV prevention and AIDS vaccine development.

What USAID invests in building country-led health systems can produce not just extraordinary breakthroughs in health research but also independence, sustainable capacity, and opportunity in the world’s poorest countries. Administrator Shah’s commitment to “advancing science, technology and innovation aimed directly at improving human welfare” will yield a healthier, more secure world.

Professor Omu Anzala is Programme Director of the Kenya AIDS Vaccine Initiative (KAVI) at the University of Nairobi, which recently began enrolling participants in two clinical trials examining the safety and immunogenicity of HIV vaccine candidates. He is also Chair of the University of Nairobi’s Department of Medical Microbiology and an advisor to the African AIDS Vaccine Program (AAVP), the African Childhood Vaccine Program, and the National Polio Eradication Expert Committee.


Bangladesh: Maternal Deaths Decline by 40 Percent in Less Than 10 Years

Bangladesh is on track to meet the 2015 deadline for U.N. Millennium Development Goal 5 (50 percent reduction in maternal deaths).   The Bangladesh Maternal Mortality and Health Service Survey [PDF] jointly funded by the Government of Bangladesh, USAID, Australian Aid (AusAID) and the United Nations Population Fund (UNFPA) found that maternal deaths in Bangladesh fell from 322 per 100,000 in 2001 to 194 in 2010, a 40 percent decline in 9 years.

The decline in direct obstetric deaths is most likely the consequence of better care seeking practices and improved access to and use of higher-level referral care.  The decline in total fertility rate due to the successful family planning program has reduced exposure to high risk pregnancies and has thus prevented a large number of maternal deaths.

USAID’s program in Bangladesh has historically been very strong in family planning through the world’s largest social marketing program for non-clinical contraceptive methods and through the public sector for long-acting permanent methods.  We can confidently say that our long and unwavering investments in family planning have had direct impact in lowering the total fertility rate, and thus the maternal mortality rate, in Bangladesh.  Over the past five years, USAID has also invested in scaling up active management of the third stage of labor to prevent postpartum hemorrhage in the public and NGO sector.

The USAID program has also long invested in promoting and providing antenatal care through the NGO sector which linked women to the health system thus contributing to increased awareness and care-seeking for obstetric complications. USAID and CDC’s long term commitment to the in depth training of local scientists has resulted in the creation of Bangladesh’s premiere research institute, the International Center for Diarrheal Disease and Research, Bangladesh (ICCDDRB) which has the capacity to effectively guide valid and reliable research efforts such as the 2010 Bangladesh Maternal Mortality and Health Care Survey (BMMS).

USAID supported and provided technical leadership in implementation of the 2001 and 2010 BMMS to monitor the performance of the overall maternal health program. Without these two surveys it would not be possible for Bangladesh to monitor its progress towards achieving the MDG 5 goal.

Amanda Glassman, Director of Global Health Policy and a research fellow at the Center for Global Development, wrote “the results are also a good reminder that investments in family planning and girls’ education drive much of maternal health outcomes, and that USAID investment in social marketing of family planning and health seems to be paying off in improved health (see blog post).”

The Bangladesh Ministry of Health and Family Welfare is scaling up emergency obstetric care and active management of the third stage of labor; the Ministry has also recently approved distribution of Misoprostol tablets to all pregnant women shortly after delivery to prevent postpartum hemorrhage. There is also increasing availability of Magnesium Sulphate for management of pre-eclampsia. The predominance of hemorrhage and eclampsia deaths and deaths after delivery indicate a need to strengthen access to treatment for these two conditions, improve referral systems, and improve referral level care.

Every year, USAID provides basic health care services to nearly 20 million Bangladeshis, including provision of low-cost, quality family planning services and maternal and child health care. With USAID and international support, under-five mortality rates have declined by more than 50 percent in Bangladesh since 1990. USAID has trained and mobilized community health workers to provide critical maternal and child health care to supplement broader health interventions and support country-level capacity. Bangladesh already received a country award from the United Nations for significant progress in reaching MDG 4 (reducing child mortality) during the MDG Summit in New York on September 19.

The Government of Bangladesh and the United States jointly rolled out President Obama’s Global Health Initiative in Bangladesh on November 23. GHI in Bangladesh will focus on providing quality services to reduce maternal and child mortality, resuscitate family planning programs, improve nutrition status among children under age five, and strengthen overall health systems over the next five years.

Calling All Probem Solvers: Help Make Birth Safe

This blog is cross posted from the OSTP blog.

The birth of a child is a momentous event anywhere in the world.  In many countries, though, the occasion is not just one of joy, but one of fear – fear for the life of the mother and the newborn baby.  The time between when a woman begins labor and 48 hours after the birth of a baby is a high-risk period during which millions of newborn babies and new mothers die each year.

US Agency for International Development(USAID) Administrator Rajiv Shah delivers remarks at the launch of a Global Partnership on Maternal and Child Health on March 9, 2011 at the Ronald Reagan Building in Washington, DC. US Secretary of State Hillary Clinton introduced a new partnership between the US Agency for International Development, the Government of Norway, The Bill and Melinda Gates Foundation, Grand Challenges Canada and The World Bank that will seek innovative solutions to reduce maternal and child mortality in developing countries. Photo Credit: Chris KLEPONIS/AFP

That’s why today the U.S. Agency for International Development (USAID) is leveraging the collective resources of our partners—the Bill & Melinda Gates Foundation, Grand Challenges Canada, the Government of Norway, and The World Bank—to launch Saving Lives at Birth: A Grand Challenge for Development. This grant-based program will seek groundbreaking prevention and treatment approaches for pregnant mothers and newborns around the time of delivery in rural, low-resource settings.

This extraordinary partnership underscores the fact that saving lives at birth is one of the most critical challenges facing people in developing countries.  Finding new technologies, such as low-cost infant resuscitation devices or incubators, and new approaches to improve birth outcomes for mothers and newborns would not only alleviate suffering, but would also have a significant impact on public health and economic productivity.

It would also accelerate progress toward achieving the Millennium Development Goals 4 and 5, which call for a two-thirds reduction in under-five mortality, a three-quarters reduction in maternal mortality, and universal access to reproductive health services.

Saving Lives at Birth is the first in a series of Grand Challenges for Development that will be announced by USAID in the coming years to mobilize focused attention and resources around the most pressing obstacles to achieving our development goals.  These Grand Challenges for Development are definable, quantifiable goals that address some of the largest solvable problems poor countries currently face.  USAID will partner with other funders and encourage others to invest in finding innovative solutions to these Challenges that are sustainable, scalable, easily adopted, and that build on and utilize 21st-century infrastructure and technology.

These Challenges also reflect President Obama’s commitment to game-changing innovation as a powerful and cost-effective instrument for achieving development goals.  The President’s Policy Directive on Global Development focuses on sustainable development outcomes by placing a premium on broad-based economic growth, democratic governance, sustainable systems, and the creation and application of game-changing innovation to transform longstanding development challenges into solvable problems.

We believe that these Grand Challenges can address key priorities, catalyze innovations that drive economic growth, spur the formation of multidisciplinary teams of researcher and multi-sector collaborators, bring new expertise to bear on important problems, strengthen the ‘social contract’ between science and society, and inspire students and non-development experts to get involved in problem-solving for development.

USAID and its partners cannot solve the Grand Challenges for Development alone.  We hope that the effort to meet these challenges will be taken up by non-governmental organizations, the private sector, governments, and individuals around the world.  We know there are millions of people and organizations around the world who want to help but don’t know how to start.  This is a place to start.

For more information on the Challenge and application process, visit here.

Dr. Rajiv Shah is the USAID Administrator and Tom Kalil Deputy Director for Policy for the White House Office of Science and Technology Policy and Senior Advisor for Science

USAID Partner Hosts Scientific Writing Program for African AIDS Researchers

During his fellowship from September 2010 to March 2011, Mr. Randy Kaja, a Pfizer Global Health Fellow based at the International AIDS Vaccine Initiative (IAVI) Regional Office in Kenya, has been coaching IAVI-partner scientists to develop and publish scientific articles from their research results. This effort is a part of the ongoing training and support of USAID partner IAVI, to build capacity of African AIDS researchers in the field, while in the pursuit of an HIV vaccine.

Late in the summer of 2009, IAVI held a scientific abstract writing course for staff from Ugandan clinical research centers.  The course was designed to develop the skills and confidence of the research teams to independently construct complete, concise and clear scientific abstracts for submission to conferences.  Fourteen staff from the Uganda Virus Research Institute (UVRI) in Entebbe and the Medical Research Council (MRC) in Masaka participated in the program.  The program was a success; following this training, abstracts from two program participants were accepted for presentation at major international scientific conferences this year:

  • “Innovations in Addressing Communication Gaps in HIV Prevention Research: Experiences from a Lake Victoria Fishing Community.” Submitted by Simon Sigirenda and presented as a poster at the 2010 International AIDS Conference held in Vienna.
  • “Comparison of HIV Prevalence among Study Participants Screened for an HIV Vaccine Preparedness Cohort and VCT Clients in a Ugandan Fishing Population.” Submitted by Annet Nanvubya and presented as a poster at the 2010 AIDS Vaccine Conference in Atlanta.

In May 2010, IAVI hosted a more comprehensive scientific writing training for clinical research scientists in eastern and southern Africa.  Staff from six organizations, including UVRI, the MRC, the Kenya AIDS Vaccine Initiative in Nairobi and the Center for Geographic Medicine Research-Coast in Kilifi, Kenya participated in the six-day course, which covered the detailed process of drafting a scientific paper, editing it, and submitting it to a journal. The curriculum addressed abstract preparation, mastery of writing styles, essentials of editing, the structure of a scientific paper, preparing tables and illustrations, and an overview of the publishing process.

Mr. Kaja saw early results as well. An article titled “Reasons for Ineligibility in Phase 1 and 2A HIV Vaccine Clinical Trials at Kenya Aids Vaccine Initiative (KAVI), Kenya” by Dr. Gloria Omosa-Manyonyi et al. was recently published in the journal PLoS ONE. More papers are currently in various stages of drafting.

In addition, Mr. Kaja, in collaboration with IAVI staff in Kenya, delivered comprehensive workshops on scientific writing early this year, covering a range of essential topics, such as overcoming writer’s block, language usage, choosing a journal, research ethics, and authorship. Sixteen research staff from Kenya and 13 from Uganda and Rwanda have benefitted from these workshops. The participants, around 60% of them women, have ranged from medical researchers to community liaison officers involved in IAVI-sponsored studies.

More about IAVI:

IAVI is a global not-for-profit, public-private partnership whose mission is to ensure the development of safe, effective, accessible, preventive AIDS vaccines for use throughout the world.  USAID and IAVI formed a partnership in 2001 to hasten development of an AIDS vaccine.

Women Shouldn’t Have to Be Sneaky to Get the Family Planning They Want

Yes, I said it. But it’s not my word. I’m just the messenger, relating to you what I heard: sneaky.

According to health care providers I interviewed recently in Western Province, Kenya, sneaking is exactly what women feel they need to do if they want to avoid or postpone pregnancy. Their male partners, for the most part, do not want them limiting the number of children they bear. Many men share the traditional attitude that the primary role of women is to give birth. Others believe that family planning makes women “promiscuous” or that certain contraceptive methods produce deformed children. So, faced with men’s resistance and socially disempowered, many women don’t tell their male partners about the contraception they use.

But family planning is more than a UN-recognized right for a woman “to decide freely and responsibly on the number and spacing of [her] children.” It’s also a powerful HIV prevention strategy, part of a comprehensive approach to prevent mother-to-child transmission of HIV (PMTCT). Each year, HIV-positive women in sub-Saharan Africa avert almost 175,000 HIV-positive births by using contraception, a figure that would nearly double if all HIV-positive African women were able to use family planning services.

Programs that integrate family planning and HIV services—such as the USAID-funded AIDS, Population, and Health Integrated Assistance II (APHIA II) Western Project—enable women to postpone pregnancy or avoid unintended pregnancy, which, in the case of HIV-positive women, decreases mother-to-child HIV transmission. Such programs also increase the number of community members who get tested, as well as the number of women and men enrolling in HIV care, support, and treatment programs.

How does APHIA II Western work? On the most basic level, if you are a woman going to a clinic for an HIV service—maybe a CD4 count—the provider will ask you if you are pregnant, if you are using a family planning method, and, if not, whether you would like to learn about the methods available. If the answer is yes, you will get counseling on family planning and either receive the contraceptives immediately (free of charge) or be referred elsewhere for them. Likewise, if you arrive and are seeking a family planning method, the provider will ask if you have been tested for HIV and, if not, whether you would like to be. The HIV rapid test is also free.

In fact, no matter what brought you to the clinic, providers will ask you these questions—and more.

So far, so good—but what about the sneaking?

Despite an abundance of contraceptive methods available at the clinics, women always have to consider what might happen when they go home. So, many opt for “sneaky” contraceptives, such as the injectable Depo-Provera, that can be used without their partners’ knowledge. Depo-Provera is an effective contraceptive, but it must be re-injected every three months, and it does not protect against HIV. In fact, the only contraceptive methods that can help prevent HIV transmission are male and female condoms—both of which require either the male partner’s involvement or knowledge.

So how can family planning programs and policies bridge that wide gap between men’s attitudes and women’s contraceptive and HIV prevention needs? The short answer is that male norms and behaviors must change so that men learn to support women’s contraceptive choices and to participate in family planning themselves. This is not news: In 2009, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) advocated that HIV prevention, treatment, and care and support programs address male norms and behaviors.

One way to do this is to increase men’s interactions with the health care system, especially with programs that protect the health of their partners and children. APHIA II Western Project accomplishes this by holding “male clinics” on weekends, where men learn about PMTCT and other reproductive health topics, some of which are considered taboo for men to discuss. To attract participants, these male clinics do not focus exclusively on HIV, a subject that is raised only toward the end of the session, but also cover broader health issues that are important to men, such as high blood pressure. During each clinic, the men are given the option to be tested for HIV and asked to spread the message by returning the following week with a friend. By bringing men together in this way and around PMTCT, the project is tackling some of the norms that force women to feel sneaky about seeking care.

The program also encourages male involvement by sending PMTCT clients accompanied by their male partners to the front of the service queue. This policy has decreased loss-to-follow-up and offers an opportunity to enroll additional men in the male clinics.

If you work in the field of public health, you may already know about the value of integrating services. But the success of APHIA II Western’s efforts shows that it is important to not only integrate services but also to incorporate strategies that address gender inequity.

It is time for all the sneaking to stop. Instead, women and men should be proud to exercise their right to family planning. With support from gender-sensitive health programs, the mothers and fathers of Kenya can lead the effort to end vertical HIV transmission.

For other programs addressing male norms and behaviors, see the Gender Compendium.

AIDSTAR-One is managed by USAID’s Office of HIV/AIDS, and provides rapid technical assistance to USAID and U.S. Government country teams to build effective, well-managed, and sustainable HIV and AIDS programs and promotes new leadership in the global campaign against HIV.

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