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USAID Book Club: A Farewell to Alms

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As part of USAID’s Fall Semester, we will host an online book club for our readers this fall. The Impact Blog will post suggestions from our senior experts at USAID to suggest a book on important issues in international development.  We’ll provide you and your book club with the reading suggestions and discussion questions, and you tell us what you think! Our fall reading list will  explore solutions to the most pressing global challenges in international development—mobile solutions, poverty, hunger, health, economic growth, and agriculture.

This week’s choice comes from: USAID Administrator Rajiv Shah

Dr. Rajiv Shah serves as the 16th Administrator of USAID and leads the efforts of more than 8,000 professionals in 80 missions around the world.

Dr. Rajiv Shah serves as the 16th Administrator of USAID and leads the efforts of more than 8,000 professionals in 80 missions around the world.

Book: A Farewell to Alms: A Brief Economic History of the World, by Gregory Clark

Synopsis: The source of human progress has long been a subject of debate. What makes rich countries rich, and poor countries poor? In the this book,  University of California, Davis, Economist Gregory Clark offers a provocative take on the age-old question, arguing that it was culture—rather than geography, natural resources or centuries of exploitation—that left some parts of the globe behind.

According to Clark, relative stability and effective workforces enabled certain societies to take better advantage of the Industrial Revolution’s new technologies and opportunities. Those countries with lax systems or undisciplined workers lost ground, and stayed there.

Clark’s book is skeptical of whether the poorest parts of the world will ever achieve real progress. For development professionals, it offers up a challenge to the belief that outside intervention can help bridge the vast economic divide between rich and poor.

Review:  This book impacted me because it shows how for hundreds, or even thousands, of years basic economic progress was largely stagnant. You didn’t have rapid compound increases in living standards until the Industrial Revolution when some countries and some societies got on a pathway towards growth – towards better health, longer life expectancy, higher income per person and more investment in education. Others remained on a slower-moving pathway.

That great divergence, and the study of it, is at the core of development. It is that divergence that we try to learn from and correct for. We define success in development as helping communities and countries get on that pathway towards improved health and education, and greater wealth creation.

I didn’t choose this book because I think it is the definitive story on development, but rather because I share its focus on core economic growth as the driver of divergence.

I disagree where Clark concludes that some societies failed to take advantage of the availability of modern technology because their cultures were antagonistic to development. With the right conditions in place, you can unlock a formidable work ethic from a range of different cultures and communities. The last 50 years have shown us that. By investing in local capacity and local institutions, we can leave a legacy of economic infrastructure, strong and capable leadership, and transparent, effective public and private sector institutions.

USAID’s partnerships in Latin America helped country after country develop strong institutions. The same can be said for South Korea. Unfortunately, there have been examples where aid and assistance have been provided in a manner that was not as sensitive to building lasting local capacity and institutions. This is true for all partners, not just our Agency. That’s why we’ve launched a program called USAID Forward, to refocus on working in a way that will create durable and sustained progress.

Administrator Shah is on Twitter at @rajshah. You  can also “Ask the Administrator” your questions on Crowdhall

Discussion Questions

1. Do you agree with Clark that some societies failed to take advantage of the availability of modern technology because their cultures were antagonistic to development?

2. The Nobel prize-winning economist Robert Solow has said Clark does not take into account how institutional factors, such as cronyism, inequitable taxation and ineffectual government cripple development. What role do you think these institutional factors play?

3. Clark challenges how effective outside intervention can be in helping poor nations progress. Do you agree?

4. Regardless of why some nations have fallen behind, how do you think they can bridge that gap today?

5. Has your world view changed after reading this book and how?

Get Involved: Use the comments section of this blog post to share your answers, or tweet them to us at #fallsemester

Water, Sanitation, and Hygiene Help Fight Disease

Guest Author Lisa Schechtman is the Head of Policy and Advocacy for WaterAid in America.

Earlier this year, I attended a meeting of the Alliance for Global Elimination of Trachoma. I was there to represent safe drinking water, sanitation and hygiene (WASH), which are critical to the global strategy to eliminate blinding trachoma, the leading cause of preventable blindness. Partnerships such as these, which bring those from the water, sanitation and hygiene sector together with other health professionals, are vital in developing a holistic approach to tackling the root causes of trachoma, and other diseases known collectively as Neglected Tropical Diseases (NTDs).

Worldwide, one billion people are affected by one or more NTD, many of which are linked to lack of access to high-quality water, sanitation and hygiene. For example, poor hygiene allows flies, attracted by dirty faces, to spread trachoma, or skin-to-skin contact to spread yaws. Sanitation and waste management could help control spread of these diseases in the first place.  Schistosomiasis (also known as bilharzia), and guinea worm, also NTDs, are spread by infected snails or fleas that live in water contaminated due to a lack of sanitation.

While crucial to preventing NTDs, hygiene promotion takes targeted work with individuals and communities; it is not often prioritized and even less often measured and evaluated. Sanitation is one of the farthest off-track of all Millennium Development Goal targets, with 2.5 billion people still needing access to even a basic pit latrine. We still have a long way to go to reach universal access to WASH; yet, if we don’t address these neglected issues, we won’t succeed in addressing the consequences.

Neglected Topical Diseases have that name for a reason. They affect the most marginalized and forgotten members of our global community—those who live in extreme poverty, in rural areas “off the grid,” already affected by disabilities, chronic illness and other challenges.  Though unknown to most Americans, these diseases can cause blindness, physical disabilities, impaired cognitive development, heart failure, and a host of other consequences, including death. Yet with holistic development and global health programs targeting the poorest people, NTDs can be prevented and ultimately eradicated as they have been here in the United States.

Eradication of NTDs requires focused responses in affected localities, to promote hygiene or control disease vectors such as flies and mosquitoes, but also broader attention to infrastructure basics, such as latrines. This requires political will, coordination, and innovative partnerships to challenge business as usual

From the U.S. President’s Global Health Initiative driving integration across sectors at the highest political levels, to partnerships between WaterAid and other national and international NGOs that ensure the right expertise is available for household-based sanitation drives, coordination of WASH and NTD control efforts is part of what makes progress possible.

An added value of focusing on Neglected Tropical Diseases is that it requires us to consider equity, dignity, and the most basic needs of the people most often left behind. In order to really eradicate many of these diseases, equitable WASH access must be a shared goal. Together, we must maintain—and accelerate—momentum, keep our promises, and forge new relationships to be sure we’re reaching those most at risk of preventable illness and death. After all, the primary value of doing this work is simple indeed: we do it to save lives.

The END7 Campaign Unites!

Guest author Dr. Neeraj Mistry is the Managing Director of the Global Network for Neglected Tropical Diseases.

The work to control and eliminate neglected tropical diseases (NTDs) is one of the greatest examples of the power of innovative public-private partnerships.  Endemic country governments, development partner governments such as the United States, non-profit organizations, pharmaceutical companies, the World Health Organization, the World Bank, and many others have come together in an unprecedented way to demonstrate support for populations affected by these terrible diseases.

In spite of this progress, though, we noticed that a crucial population was missing: the general public.

That’s why in January 2012, the Global Network for Neglected Tropical Diseases launched END7, the only public awareness campaign focused exclusively on NTDs.  END7 is a compelling digital campaign that relies on a variety of social media channels and visual communications to get the word out about NTDs and rally mass appeal around our goal of eliminating the seven most common NTDs by 2020.

So far, we’re thrilled with the response.  Since January of this year, we’ve grown to a community of more than 20,000 supporters and we’ve enlisted the help of big names in the music and entertainment industry in spreading the word far and wide.

But even more than the reach, we’re excited about the two-way engagement that we see taking place on Facebook, Twitter and YouTube.   We recognize that disease names like onchocerciasis and schistosomiasis don’t exactly lend themselves to casual conversation, so the active level of participation evident on these channels is a certain sign that our supporters both understand the problem and want to be part of the solution.

As we continue into year two of the campaign, we will continue to create buzz around NTDs. We know that by doing so, we’re helping to promote our partners’ terrific work in the field and enticing new supporters and partners to join us.

For those not yet acquainted with the END7 campaign, we encourage you, your colleagues, and your friends to visit our website and join us on Facebook and Twitter!

Together we can see the end!

The Next Chapter in the Fighting Neglected Tropical Diseases

Guest Author Rachel M. Cohen is the Regional Executive Director of DNDi North America.

Research and Development to Address Urgent Patient Need for New Tools 

The United States government and its country partners should be commended for the tremendous achievements in the fight against neglected tropical diseases (NTDs) as part of the U.S. Agency for International Development (USAID) NTD Program. When it comes to research, the US government also plays a major role in NTDs: the National Institutes of Health is by far the largest funder of basic research for NTDs. The commitment to NTD implementation programs and research has spanned several presidential administrations, receiving widespread bipartisan support from both sides of the Congressional aisle.

However, not all NTD research is created equal. Beyond basic research, much more research and development (R&D), including late-stage product development, for new drugs, vaccines, and diagnostics is urgently needed for those NTDs where adequate tools do not exist. Without such new tools, disease control and elimination will not be possible for certain NTDs – greater investments in research are urgently needed.

For example, when it comes to the filarial parasitic-worm diseases of river blindness (onchocerciasis) and elephantiasis (lymphatic filariasis), which together infect over 150 million people, the standard treatment of ivermectin, alone or in combination with albendazole, can lead to brain damage or death in people co-infected with loiasis (Loa loa, also called African eye worm). Also, current drugs kill only juvenile and not adult worms, which continue to infect, requiring repeated mass drug administrations. The Drugs for Neglected Diseases initiative (DNDi) – a not-for-profit R&D organization – is looking to develop a new macrofilaricide (a drug targeting adult worms) to address this gap in NTD treatment.

Of the 17 NTDs defined by the World Health Organization, DNDi focuses most of its attention on the three with the highest case fatality rates – African sleeping sickness, Chagas disease, and kala azar (visceral leishmaniasis, or black fever). These diseases are not yet included in the USAID NTD Program.

Although cases of African sleeping sickness (human African trypanosomiasis) have dropped over recent years, this fatal disease continues to infect people in remote, conflict-ridden pockets of the Democratic Republic of Congo, among other hotspots. Diagnostic tools are inadequate – painful lumbar punctures must be performed – and the current treatment requires hospitalization and intravenous infusions, which are difficult in unstable, resource-poor settings. DNDi is therefore aiming to develop an easy-to-take oral pill for sleeping sickness, which can treat both stages of the disease and do away with the need for painful lumbar punctures. This would go a long way in helping eliminate the disease once and for all.

While continuing to provide existing medicines for NTDs, greater commitment to developing new NTD treatments and other tools is sorely needed if disease control or elimination is to be achieved. Patients infected now with these neglected afflictions are anxiously waiting.

Child Survival: Did You Know?

America’s legacy in child survival is a proud one: With strong bipartisan support, U.S. support of global health has saved many millions of lives. 

Nearly 30 years ago, the United States Agency for International Development (USAID), and the United Nations Children’s Fund (UNICEF), with the support of the U.S. Congress, launched a “child survival revolution” aimed at reducing the number of deaths among young children in developing countries.  At the time, an estimated 15 million children under age 5 in the developing world died from common preventable diseases each year.  Without reduced rates of mortality, the number of deaths today would be about 17 million each year. Instead, the latest estimates indicate that there are fewer than 7 million child deaths globally, still far too high but clearly indicating great progress.

Thirty years ago 46,000 children died every single day. Today that number is less than 19,000.

But a child dying anywhere in the world is a tragic loss and undermines peace and stability.  This year, the United States co-hosted a Child Survival Call to Action that challenged the world to reduce child mortality to below 20 child deaths per 1,000 live births in every country by 2035. Assuming countries already on track continue to make progress at their current rates, achieving this target will save an additional 5.6 million children’s lives every year. That means 50 million more children will survive and thrive.

Past USAID investments led to innovations that now reach millions, saving lives throughout the developing world.

For decades, USAID has played a vital role in the development and delivery of low cost, high impact health interventions that can reach children in poor countries to prevent or treat the most important causes of child death – pneumonia, neonatal conditions, diarrhea, and malaria.  Innovations include safe injection technologies like auto-disable syringes and vaccine vial monitors, a diagnostic test for anemia and for vitamin A deficiency, safe birth kits and other products that are now used in countries throughout the developing world.

Helping children reach their fifth birthdays and beyond has brought about happier parents, smaller, more prosperous households, and children with much brighter futures.

Improving child survival brings a demographic dividend through fertility declines, reduced mortality, and increased economic productivity Reduction in child mortality can result in billions of dollars in direct economic savings –life-saving vaccines alone could save 6.4 million lives and $231billion in lost productivity by 2020.

Why We’re Celebrating Global Female Condom Day

Today is the first-ever Global Female Condom Day, and women and men around the world are celebrating. They’re also speaking out for increased recognition of a prevention method that is too often overlooked.

An educator demonstrates female condoms with students from the University of Yaoundé, Cameroun. Photo Credit: Association Camerounaise pour le Marketing Social (ACMS).

Those of us working on the frontlines of reproductive health are excited about the potential of this powerful tool for protection. Female condoms offer women—and men—dual protection from unintended pregnancy and sexually transmitted infections (STIs), including HIV. Female condoms are easy to use and can afford women greater control over safe sex negotiation – an especially important benefit in countries where women’s risk of contracting HIV is high. Some have argued that female condoms are too expensive, but mathematical modeling shows they can be a cost-effective public health intervention when offered as part of a well-planned STI and pregnancy prevention program.

But even with all of these advantages, female condoms don’t get the attention they deserve. The first female condom was introduced two decades ago. Yet today, awareness and availability remains too low in too many places, including areas with high rates of HIV infection and unmet need for family planning.

We have a technology available right now that gives women the power to save and enhance their own lives. Will we let two more decades pass before making it fully available to them?

Global Female Condom Day gives us the chance to publicly renew our commitment to achieving universal access to female condoms. The good news is that we are making progress toward this goal:

  • Female condom distribution is on the rise. According to the United Nations Population Fund (UNFPA), global distribution of female condoms tripled from 2005 to 2009.
  • Female condom commodity and program support has been expanding, thanks to the leadership of international donors including UNFPA and the US Agency for International Development (USAID). Meanwhile, new initiatives including the Universal Access to Female Condoms Joint Programme (UAFC) are bringing large-scale female condom programming to more countries.
  • Female condoms are getting a boost from new advocacy initiatives. UAFC, the Center for Health and Gender Equity’s (CHANGE) Prevention Now! Campaign, and the recently launched US National Female Condom Coalition are galvanizing female condom supporters in theUnited States and worldwide to advocate for increased access.
  • New types of female condoms are becoming available, expanding options for dual protection.

Different types of female condoms were on display at the Condomize! booth at the XIX International AIDS Conference in Washington, DC. Photo Credit: Kimberly Whipkey, PATH

One new type of female condom is the Woman’s Condom, developed in part with funding from PEPFAR through USAID. PATH, CONRAD, and our research partners in several countries developed the Woman’s Condom using feedback from women and their partners. Their input helped us design a female condom that’s easy to insert, secure during use, and comfortable for both partners. Through our Protection Options for Women Product Development Partnership, we are now working to bring the Woman’s Condom to market inChina and sub-SaharanAfrica.

So, let’s celebrate these encouraging advances on this first Global Female Condom Day. And, let’s also renew our efforts to make sure that women everywhere have access to the tool we’re toasting.

Patricia S. Coffey leads the  Maternal, Neonatal, and Reproductive Health Technologies Group at PATH.

Empowerment, Not Pity: HIV Prevention Programs for People with Disabilities

Ed Scholl, of John Snow, Inc., is the AIDSTAR-One Project Director. AIDSTAR-One is funded by USAID’s Office of HIV/AIDS. The project provides technical assistance to USAID and U.S. Government country teams to build effective, well-managed, and sustainable HIV and AIDS programs.

The messages were familiar, but the delivery was not. The classroom was filled with high school students learning about HIV, sexually transmitted infections, and pregnancy prevention.  But instead of a teacher lecturing, or using a flipchart or video, a blind man spoke to the class, with a sign language interpreter communicating his words to deaf students who attend the Dominican Republic’s National School for the Deaf in Santo Domingo. I watched as the deaf students carefully followed the interpreter’s hand motions and quickly responded in sign language to the questions posed by the facilitator.

Students at the National School for the Deaf in the Dominican Republic respond to questions about HIV. Photo Credit: Ed Scholl,JSI

The blind facilitator is one of 30 persons living with disabilities trained by the Dominican PROBIEN Foundation to communicate HIV information to others living with disabilities. Two other PROBIEN facilitators, one who is also deaf and another whose leg was amputated, simultaneously led discussions about HIV and reproductive health in other classrooms at the school. These efforts to bring HIV information and education to persons living with disabilities and their families are supported under a grant provided by the AIDSTAR-One project, with funding made available by the U.S. President’s Emergency Plan for AIDS Relief through the U.S. Agency for International Development (USAID)/Dominican Republic. Through AIDSTAR-One, USAID is providing financial support and technical assistance to build the capacity of twelve Dominican NGOs, including the PROBIEN Foundation, working in HIV prevention, care and treatment for most-at-risk and vulnerable populations.

Persons with disabilities make up an estimated 15 percent of the world’s population.

Wheelchair basketball players in the Dominican Republic are among the HIV promoters trained by the PROBIEN Foundation. Photo Credit: Ed Scholl,JSI

They are considered to be a population at risk of HIV, unintended pregnancy, and sexual abuse, yet they are often overlooked when it comes to programs and services. Why is this so? PROBIEN Director Magino Corporan explains that much of society doesn’t want to acknowledge the human rights of people living with disabilities. They may be objects of pity and charity, but they don’t enjoy the same opportunities for education, employment, health care, and rights that others enjoy. People living with disabilities are also often considered to be sexually inactive, so they rarely receive sexual and reproductive education, contraceptives, and access to services.

Recognizing the value of peer education, PROBIEN trains people with disabilities to provide education about HIV, sexually transmitted infections, and reproductive health to other people with disabilities, and to their families. One PROBIEN promoter, who lost both legs in a traffic accident, directs a community radio program and shares information about HIV with his listening audience once a week. Two other promoters play in a wheelchair basketball organization and share HIV messages with their teammates. When I interviewed them recently, they invited me to sit in a wheelchair and play a practice game with them. Needless to say, this one-time basketball player was humbled in the extreme!

PROBIEN also works at the policy level and, in 2008, played an instrumental role in getting the Dominican Government to include persons living with disabilities as beneficiaries of national health insurance (along with persons living with HIV).

Thanks to the work of PROBIEN and its volunteer promoters and the support of USAID,  many more people with disabilities and their families in the Dominican Republic are receiving messages about HIV and sexual and reproductive health and taking action to protect themselves and live healthy lives.  Efforts to protect this often neglected at-risk population not only empower people living with disabilities to take control of their own health but also serve as a powerful example of a truly inclusive and human rights approach to HIV programming.


Reflections and Impressions from AIDS 2012

Last month, nearly 24,000 participants from 183 countries –  including over half from the U.S. – attended the 2012 International AIDS Society Conference (IAC) “Turning the Tide Together” in Washington, D.C. Thanks to President’s Obama’s lifting of the ban on visas for people living with HIV/AIDS, the conference was held for the first time in the U.S. in over 20 years – presenting a remarkably unique platform for the United States to highlight its accomplishments under PEPFAR and vision for an AIDS Free Generation.

President Obama’s video address at the opening ceremony re-affirmed the U.S. commitment to fighting HIV/AIDS. Secretary Clinton electrified the audience with her keynote address — highlighting PEPFAR’s progress, legacy and vision for the future. She announced increased funding to eliminate mother-to-child transmission of HIV and laid the groundwork to develop a blueprint for achieving an AIDS-Free Generation.

Other high profile notables, including President Clinton, bipartisan congressional leaders, including House Minority leader, Nancy Pelosi and Rep. Barbara Lee, former First Lady Laura Bush, and celebrities including Elton John, Annie Lenox, Deborah Messing and Whoopi Goldberg were also present — making their continued support and commitment to fighting AIDS loud and clear.

All in all, AIDS 2012 was an all-star event and an extraordinary opportunity for the vastly diverse participants to hear about game-changing scientific discoveries and state-of the-art technical updates, and to experience the lively booths and personalities at the global village.

USAID was visible throughout the week. Agency leadership, staff and partners contributed to satellite sessions, posters and abstracts. The Agency’s flagship Emerging Issues in Today’s HIV Response Debate Series – cosponsored with the World Bank – held its seventh and final debate on ‘Funding Allocations for HIV/AIDS’. Administrator Shah made multiple high profile appearances.  Alongside World Bank president Jim Kim and former Botswana President Festus Mogae, Dr. Shah opened the debate with commitments of future collaboration. In a symposium on Country Ownership alongside Minister of Health Dr. Kesete Berhan Admasu of Ethiopia, the Administrator explained USAID Forward.  At an elegant session at the Museum of American Women Art – alongside Ambassadors Melanne Verveer and Eric Goosby, GHI Executive Director Lois Quam, CDC Director Tom Frieden and Zimbabwe’s Deputy Prime Minister, Thokozani Khupe – he spoke about gender.

My Takeaway

Eight million people are now on treatment and the goal for 15 million by 2015 seems within reach. There has been so much progress; 30 years ago HIV was considered a death sentence, but now the life expectancy of a person living with HIV who adheres to treatment is similar to a person with a chronic illness, similar to diabetes. We now have a broad range of tools for prevention, including those we have been using – like circumcision, condoms, and PMTCT – and new ones that have just been introduced – like treatment for prevention and possibly future interventions like Pre Exposure prophylaxis (PrEP). A vaccine is closer to development. Costs have continued to decline: ARVs are less expensive and programs increasingly efficient. Treatment in many African countries now costs around $200 per year.

Country ownership is growing as lower and middle income countries are picking up increasing shares of the financial burden. The launch of the new PEPFAR guidance on Orphans and Vulnerable Children provides updated coverage for households, communities and social services.

Challenges still lie ahead.  There is an estimated $7 billion funding gap over the next three years. Incidence is declining, but the rate of decline is not sufficiently steep. To move the needle, we need to close the treatment gap, scale up access to voluntary male circumcision, and enroll more expecting mothers with HIV in PMTCT programs. And, while we have a broad range of tools, we must work with country leaders to apply them appropriately given the epidemic and the local context.

Recent microbicide and PrEP trials have underscored the challenges of adherence and retention, and the need to work outside as well as inside facilities to influence changes in behavior. Key populations are stigmatized and often have alarmingly high infection rates and limited access to critical services. Middle income countries with concentrated epidemics feel they are losing support as donors increase focus on high prevalence, low income countries.

The epidemic is aging. By 2015, in North America and Western Europe, half of the HIV population will be over 50 and new approaches to care and support will be needed – especially as those infected at birth become young adults and those in their 20s and 30s become senior citizens.

With all that lies ahead, the future looks bright – and USAID, as witnessed during the conference – will continue to be a leading technical force in the fight against HIV/AIDS. Our commitment to global health and HIV/AIDS, as seen since the beginning of the epidemic and over the past 30 years, will continue to lead to major contributions and progress in the field.

The 500 Pound Gorilla: Addressing the Structural Drivers of HIV

AIDSTAR-One is funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development (USAID), 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.

During the recent International AIDS Society Conference in Washington, DC, exciting breakthroughs in HIV prevention, treatment, and care—even a possible cure—took center stage. But despite recent advances, many men and women remain at risk of HIV as a result of structural issues that fuel and have an impact on the epidemic. Structural Interventions reduce individual HIV-related vulnerability by creating conditions that enable people to adopt safer behaviors. Addressing gender inequality, poverty, stigma, and other social, economic, cultural, and legal factors is necessary to create an “enabling environment” for these promising biomedical and behavioral interventions.

There is increasing agreement worldwide that structural issues are too often overlooked where HIV prevalence remains high. Women who are not empowered to take charge of their sexual lives cannot practice HIV prevention, be it in the form of condoms or pre-exposure prophylaxis. Most-at-risk populations, such as men who have sex with men, will not seek out prevention and care services if they fear stigma or prosecution. Countries that cannot afford an extensive public health network cannot offer voluntary medical male circumcision or antiretroviral therapy to its rural citizens.

Unfortunately, specific operational guidelines, definitions, and evidence to clearly guide implementation of scalable structural approaches remain inadequate. To fill this gap, the U.S. Government and the global HIV community are working toward achieving consensus on how to prioritize which structural interventions. Addressing structural drivers can have a tremendous impact on the epidemic, but bringing promising approaches to scale requires sustained investment, a significant challenge in the face of competing priorities and tightening budgets.

Recent PEPFAR guidance recognizes the importance of addressing structural drivers as part of a comprehensive combination prevention package of services. At the International AIDS Conference, USAID – along with other U.S. Government agency staff, implementers, researchers, and policymakers – discussed the structural issues that impede progress, with the goal of building consensus to move forward.

The challenge is figuring out which structural approaches will achieve the maximum impact within different contexts. Implementers at the community level know that addressing structural drivers—which are deeply entrenched in social, economic, and political systems—requires sustained investments with strategies tailored to local contexts. Identifying what works is also difficult. Although there is increasing evidence that supports the links between these factors and HIV, measuring change can often be hard in relatively short-term project lifecycles. Experts also disagree on which types of evaluation methods are adequate to demonstrate change, and balancing the need to address these factors while also scaling up other proven interventions continues to be a challenge. Because structural drivers are linked to the very fabric of social, economic, and political systems, they often require a broader sector response, unlike more narrow biomedical and behavioral approaches.

Nonetheless, and despite the existence of clear guidance, some countries are making great progress in this area. For example, Zambia is integrating structural approaches into its national HIV framework through a multisectoral response. Key successes in Zambia’s national strategy have been strengthening collaboration and coordination across sectors and investing in a community-driven process. Panelists at a satellite session on the topic at the International AIDS Conference discussed some of these initiatives. For example, the Zambia Land Alliance is working with local authorities to ensure the availability of land for vulnerable populations, which helps address the lack of access to property that increases women’s vulnerability.

The best strategies for lifting structural barriers will be context specific, and will ultimately come from local communities. But to achieve widespread success, the response will also have to be coordinated with and supported  by national and international strategies and—given limited resources—strategically integrated into other combination prevention program areas. Easier said than done, but acknowledging the challenges and building consensus are two positive steps in moving one stubborn gorilla.

Learn more about structural approaches to HIV prevention at AIDSTAR-One.

A Global Partnership for Vaccine Design

When you’re dealing with a global public health crisis, having an international presence isn’t just advisable – it is imperative. This applies as much to the development of new tools to prevent disease as it does to treatment. An AIDS vaccine candidate, for example, must be tested in the people who will eventually use it and against the strains of HIV it is devised to protect them from.

That’s why the International AIDS Vaccine Initiative (IAVI), in partnership with USAID, has worked diligently over the past several years to establish itself as a truly global non-profit partner. Using donor funds, IAVI has created an enviable network of research centers in sub-Saharan Africa dedicated to assessing novel AIDS vaccine candidates in clinical trials and conducting supporting epidemiological studies on HIV. These partnerships have made meaningful contributions to the research capacity of many developing countries—a capability that is now helping local researchers tackle other diseases.

IAVI and its partners are now applying that same model to support the design of a new generation of AIDS vaccine candidates. Today, IAVI and the Translational Health Sciences and Technology Institute (THSTI), an autonomous institute of the Indian government’s Department of Biotechnology (DBT), launched an HIV Vaccine Design Programme near New Delhi. The Programme is dedicated to the large-scale generation and preclinical evaluation of immunogens, the active ingredients of vaccines. It will focus on devising immunogens capable of eliciting antibodies that can prevent infection by a broad range of the circulating genetic variants of HIV.

That challenge, known to researchers as the neutralizing antibody problem, has long stymied progress toward an AIDS vaccine. But recent discoveries of antibodies capable of blocking a number of HIV variants have provided researchers with clues to the design of potentially powerful new vaccine candidates. The HIV Vaccine Design Programme will use these insights to develop new methods to generate large numbers of potential HIV immunogens and rapidly assess their potential for use in candidate vaccines. Much of the work will take place in a laboratory housed within THSTI that is being built and staffed with support from IAVI, DBT and THSTI.

The Programme’s location is no accident. Over the past decade, IAVI has enjoyed a productive partnership for the clinical evaluation of candidate AIDS vaccines with key medical research institutions of the Indian government. Indian scientists have also actively participated in an international consortium of HIV laboratories supported by IAVI to advance HIV vaccine research. The government of India, meanwhile, is in the early phase of its “Decade of Innovation”, a policy that seeks to harness a growing roster of home-grown biotechs, the nation’s deep pool of scientific talent and global research partnerships to boost innovation in a variety of high-tech fields.

The HIV Vaccine Design Programme provides an opportunity to engage an emerging economy in the global quest to develop a vaccine against HIV. For India, it creates an opportunity to address a crisis of significant relevance to Indians.  As importantly, it seeds the kinds of collaborations that often foster scientific and technical innovation and generate ideas that might be applied to address other diseases that have long hampered development.

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