Implementation Research: A Primer More is Needed in Pediatric AIDS Research 24 Bill Gates: great ideas from unexpected places 09 15
Issue 09
winter 2011 $4.95 U.S.
Gaps in Research www.globalhealthmagazine.com —
What will the world’s population look like in 20 years? If current demographic changes continue, the average age will be older in most parts of the world than it is today, more people will live in cities, and population growth will have slowed throughout the world except in Africa. These trends naturally result in changes in the burden of disease, most notably a transition from infectious to non-communicable diseases, from acute to chronic disease.
REGISTER TODAY
Visit www.globalhealthconference.org
Page 1 —
issue 09
contents —
In this issue:
—
06 Gaps in Research
COVER STORY: GAps in research —
15 More is Needed in Pediatric AIDS Research
24 Bill Gates: great ideas from unexpected places
09 Implementation Research: A Primer 11 Moldova: What Happens to MDR-TB Patients? 19 Stigma Research to Build Better Mental Health 22 Why We Need Men to Save Lives
screenshots —
04 the projected effect of an intensified hiv prevention & treatment program 05 Tariffs on Anti-Malarial Commodities
www.globalhealthmagazine.com
—
Page 2
—
Issue 09
—
letter from the editor
Global Health
—
Executive Editor
Tina Flores Web
Winnie Mutch
—
Editorial assistant
Katrina Overland Graphic Design
Shawn Braley E-mail:
magazine@globalhealth.org
gaps in research What are the gaps in global health research? What further knowledge can be gleaned to improve the lives of the world’s 2 billion poorest people living on less than $2 a day? Robert Eiss and Roger Glass of the Fogarty International Center at the NIH outline the broad picture of what needs to be done – from R&D to capacity building, genes to technology – noting that, “The challenges are considerable.” Indeed, the other articles in this edition of GLOBAL HEALTH reflect the spectrum of challenges yet to overcome: How do we eliminate pediatric AIDS? How do men influence the health of their families? How can we address the issue of MDR-TB in resource-poor settings? How do we tackle stigma… and mental health? A recurring theme throughout the magazine is the need for greater implementation research. How do we efficiently and effectively scale up programs? David Nicholas, who directs the Translating Research into Action Project, USAID’s new implementation research program, offers a primer on it. The Bill & Melinda Gates Foundation has embraced unanswered questions with the Grand Challenges in Global Health program. The foundation is catalyzing scientific discovery while fostering new ideas and largely unknown talent. The magazine and its blog features essays by Bill Gates, Chris Wilson, director of the foundation’s Global Health Discovery Program, and three grant recipients. We hope you enjoy this issue of GLOBAL HEALTH. As always, we welcome your comments online at www.globalhealthmagazine.com.
The Editors
ISSUE 09 winter 2011
—
Global Health Council Board of Directors
Joel Lamstein, SM, chair William Foege, MD, MPH, chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Christopher Elias, MD, MPH Elizabeth Furst Frank, MBA Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Patricia McGrath Reeta Roy Jeffrey L. Sturchio, PhD, President and CEO Global Health is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members. Learn more about the Council at www.globalhealth.org
Page 3 —
issue 09
—
C
online exclusives
go to www.globalhealthmagazine.com for further reading
—
C Field Notes
A Day in the Life of a Health Worker: Francine Uwimana, Rwanda
C Dim Sum Family Secrets: Risking Reproduction in Central Mozambique
AIDS – Taking a Long-Term View
Photo Contest Women, Girls and Global Health Be part of the magazine
www.globalhealthmagazine.com
—
Page 4
—
Global health statistics
screenshots —
the projected effect of an intensified hiv prevention & treatment program*
status quo
New HIV Infections
intensified program
(15-49 Years old) 3.0
Millions
2.5 2.0 26 Million Infections Averted
1.5 1.0 0.5 0.0 1975
1980
1986
1990
1995
2000
2005
2010
2015
2020
2025
2030
Number of Adults Infected (15-49 Years old) 22.00
Millions
16.5 33% 11.0 5.5 0.0 1975
1980
1986
1990
1995
2000
2005
2010
2015
2020
2025
2030
*Data from 22 countries
ISSUE 09 winter 2011
—
Source: AIDS - Taking a Long-Term View - AIDS2031 constortium
Page 5 —
Tariffs on anti-malaria commodities in africa
Source: Malaria Taxes and Tariffs Advocacy Project
Click on the source at C www.globalhealthmagazine.com
Page 6
—
By Robert Eiss and Roger Glass
—
Gaps in Research Over the past decade the global response to diseases of poverty has altered dramatically. Driven by what Gates Foundation Senior Fellow Dr. Bill Foege has called “spectacular inequities,” global initiatives have been directed at improving access to effective interventions for AIDS, TB and malaria, and broadening access to vaccines and health information. Deficiencies in health systems and trained personnel are persisting challenges on the ground, but we are also confronted with substantive gaps in knowledge about how to deliver new and proven interventions in impoverished settings – the subject of the emerging field of implementation science – as well the need for more effective tools. Both represent substantial research agendas.
How can we bring to scale the training of local scientists, develop and assimilate new knowledge, incorporate new technologies, and monitor impact? How can we help ensure that as responsibilities for large intervention programs are increasingly borne by national governments, adequate human resources in biomedical science and locally relevant knowledge are developed in-country? The challenges are considerable. But as the architect Daniel Burnham famously remarked, “Make no small plans, they have no magic to stir men’s souls.” Burnham’s aphorism has much relevance for those engaged in global health research, given its potential to transform lives and livelihoods. Trends and Transitions An instructive starting point in assessing global research challenges is the distribution of the burden of disease. As Harvard School of Public Health’s Dr. Barry Bloom has noted, we are increasingly confronted with a global convergence of health problems. In large part due to the control of childhood infectious diseases,
ISSUE 09 winter 2011
—
childhood mortality has declined in most regions of the world. As a result, many countries are now undergoing an epidemiological transition, resulting in a marked shift in the global pattern of disease. By 2020 adult conditions such as cardiorespiratory diseases, cancers and other chronic conditions are expected to eclipse communicable diseases as leading health burdens. The global epidemic of type 2 diabetes is indicative of the shift. An estimated 150 million are affected with diabetes worldwide, with the number projected to double by 2025. Rapid demographic changes, including higher density settlements, also hold implications for patterns of infectious disease transmission. The emergence of new infectious agents such as severe acute respiratory syndrome (SARS) and the influenza A (H5N1) virus exemplify the persistent threat posed by novel organisms. In addition, the indiscriminate use of antibiotics, both in community and hospital settings, has encouraged the emergence of resistance. In many developing countries, these trends are accelerated by the use of single antimicrobial agents when combinations would be less likely to generate resistant strains. Looking Ahead: From Molecular Medicine to Global Health Against this complex social and demographic backdrop, the biomedical sciences are converging on a common set of approaches to address disease burdens: making use of generic tools of genomics and cell biology, integrating research with innovations in clinical care, and creating highly disciplinary teams to achieve scale and complexity. These advances have profound implications for addressing global health priorities – from the classical tropical cluster of infectious and parasitic diseases to the insidious rise of chronic and
Robert Eiss is a senior public health advisor at the Fogarty International Center at the National Institutes of Health. Roger Glass MD, PhD, is the director of the Fogarty International Center at the National Institutes of Health.
Page 7 —
One of the most progressive developments in global health R&D over this past decade is the creation of product development partnerships, non-profit ventures that have revitalized the neglected disease drug pipeline. degenerative diseases. Some of the major scientific opportunities and needs surrounding the global health enterprise include: Genomics, molecular epidemiology and diseases of poverty Among the benefits of genomic science is the fact that we are increasingly more able to quantify disease risks that gene variants confer, for both chronic and acute conditions. These advances hold profound implications for the most intractable global health burdens. For example, within a relatively short period of evolutionary history, a diverse set of gene families has been modified in response to selective drive associated with malaria, involving the immune system and other biologic factors. Using the tools of genomics, studies are being pursued to identify susceptibility factors and conceive new therapeutic and preventive strategies. These types of analyses are extending to mycobacterial disease – tuberculosis and leprosy – chronic liver disease and hepatocellular carcinoma associated with hepatitis B infection. To help capture these potentials the NIH, Wellcome Trust and African partners launched the Human Heredity and Health in Africa Project (H3 Africa). The initiative takes leadingedge research forward into the complex interplay between environmental and genetic factors in disease susceptibility and variable drug response in African populations. Diagnostics, global health and the new “omics” The accelerating pace of bioengineering, proteomics and digital technologies is giving rise to a new era of “lab on a chip” diagnostics. These tools are enabling sensitive analysis of complex fluids with efficiency and speed in remote settings and at point-of-care. Emerging diagnostic platforms hold the potential to significantly alter the quality of health care where infrastructure is limited. For example, a diagnostic test to identify bacterial acute respiratory infection that enables greater
treatment access and requires minimal laboratory infrastructure would save an estimated 400,000 lives per year. In the past, diagnostics rarely developed or adapted for developing country needs. However, led by the Bill & Melinda Gates Foundation and others, multiple efforts are now underway to create low-cost diagnostics suited to the medical needs and social contexts of the developing world. Progress will require us to meet several complex challenges. Chief among these is the matching of technological capabilities with well-defined clinical and community needs, with these needs guiding device design early in the development process. Constructing the pipeline: clinical trial and regulatory needs Among priorities to accelerate drugs, vaccines and diagnostics for global health burdens, a key systemic need is to enhance physical sites, scientific and management skills, and ethical review capacities to support clinical trials in low- and middle-income countries. With several hundred products for neglected diseases in development globally, trial capacity is lacking to support the current pipeline. Institutional support for centers of clinical excellence in disease endemic regions is required to create a more durable and adaptable base of trial sites capable of undertaking a variety of intervention studies. Several organizations are now dedicating resources to strengthening clinical trial infrastructure, among them the European Developing Countries Clinical Trials Partnership, which has launched regional networks to broaden clinical capacity, train staff in ethics, clinical practices and regulatory issues. A related systemic need is a harmonized approach to product registration and approval at the global level. Regulatory capacities in countries most affected often are limited or reflect different thresholds and interpretations. A number of recent attempts have been made to resolve this issue – including WHO’s efforts to expand its prequalification system – to develop technical standards earlier in the approval process and to expand the availability of reference reagents. The emergence of product development partnerships One of the most progressive developments in global health R&D over this past decade is the creation of product development partnerships, non-profit ventures that have revitalized the neglected disease drug pipeline. Numerous business models now exist, such as the
www.globalhealthmagazine.com
—
Page 8
—
Medicines for Malaria Venture and the TB Alliance. According to an empirical review by Mary Moran of PolicyCures, product development partnerships now manage two-thirds of identified drug development projects for neglected diseases. As these new ventures mature, there is a need to identify and promulgate public-private sector best practices that encourage commercial development while obtaining the broadest public benefit. Universities and progressive corporations increasingly pursue creative practices to stimulate product development while helping to ensure that products reach populations in need. These include commitments to humanitarian licensing and emerging collective actions to reduce upstream burdens on the potential to share enabling discoveries or technology platforms, for example, through patent pooling. Other actions that would assist these new ventures include access to small molecule chemical libraries in the private sector under appropriate legal arrangements and market analyses such as estimates of demand to engage corporate interest. Integrating research into the design and implementation of health interventions One of the neglected links in the R&D continuum is what has been termed implementation science, or the study of health interventions in practice. As a means to improve prevention and treatment outcomes, numerous groups have called for the establishment of set-aside funds for program-relevant research, as an operational tenet in health intervention projects. The concept first was proposed by the influential Commission on Health Research and Development in 1990, and more recently by the WHO Commission on Macroeconomics and Health and the grouping of ministers of health, science and education that created the “Bamako Declaration.” The rationale for such allocative schemes is compelling. Public health experience demonstrates that the uptake of proven interventions, especially in resourcepoor settings can be a torpid process. Intervention projects require on-site research to identify factors that affect delivery and capture attributes of successful implementation. To cite a topical example, the scaleup of programs to provide treatment regimens for HIV require both qualitative and quantitative studies to tell us what types of infrastructure and stratagems yield the most effective treatment, limit resistance, and ultimately are sustainable and cost-effective.
ISSUE 09 winter 2011
—
Improving Capacities in Disease Endemic Countries Research capacity in disease endemic countries may be the single most important rate limiting factor to achieving solutions to current priorities in global health. It is a too common phenomenon that institutions in low-income countries lack a critical mass of faculty and researchers, adequate facilities and access to health information, and experience intellectual isolation. Perhaps the most pressing and foundational need is to reverse brain drain and the persisting diaspora of talented scientists from sub-Saharan Africa and other impoverished regions. In addition to the well-recognized need for adequate compensation and professional tracks for research, several measures would strengthen the capacity of institutions to retain talented staff. These include the promotion of skills necessary for technology transfers and the marketing of scientific products; encouraging contacts and collaborations with the industrial and service sectors when such activities advance the social mission of the university; and promoting international linkages, including the creation of expatriate communities of academics as collaborative partners and supportive networks. This requirement cannot be overstated. Recently, a small delegation from the Department of Health and Human Services visited sub-Saharan Africa to observe progress achieved through the President’s Malaria Initiative and other intervention programs. In Zanzibar a nearly complete reduction in the incidence of malaria was achieved within one year through indoor residual spraying, distribution of insecticide treated bed nets and use of artemisinin-based combination drugs. The Minister of Health, commenting on the success, noted wistfully that the achievement represented yet the third occasion that malaria had been controlled in Zanzibar in past decades, only to resurge with increased severity once the prior internationally-led efforts were discontinued. The episodic control of malaria in Zanzibar is something more than a representative commentary on losing ground to a difficult parasite. It is an object lesson on the relationship between research capacity and sustainability – on the need to train local scientific staff to monitor, develop and evaluate intervention strategies that empower local communities to can gain greater control over the disease. GH —
C View references online at www.globalhealthmagazine.com
Page 9 —
by David D. Nicholas —
Implementation Research: A Primer It is well known in the international health community that there are a large number of proven, evidence-based interventions that are not being implemented or scaled up in many developing countries. Often these are low resource countries with the highest maternal, newborn and child mortality rates and as a result, millions of lives are being lost and MDG goals are not being achieved. For example, the Active Management of the Third Stage of Labor (AMTSL) is an accepted intervention that can significantly reduce post-partum hemorrhage, the leading cause of maternal mortality in many developing countries. In 2006, Niger had yet to implement this intervention. However, in that year, it used a form of participatory action research, the improvement collaborative, to introduce and expand the use of AMTSL. Facility teams in 33 sites studied their labor and delivery processes and tested ways to effectively incorporate AMTSL into their practice. Within two years, AMTSL had been spread to cover 32 percent of total facility births in Niger with a reduction in post partum hemorrhage of 75 percent.
Jon Hrusa/EPA
Implementation Research: A Definition A useful definition of research is that it is the advancement of knowledge by the systematic collection of data and information to test hypotheses or solve problems. It can range from theoretical to experimental to applied research. In the health sector, translational research focuses on moving laboratory discoveries into widespread use of new drugs and treatments in everyday practice. It includes efficacy research, which uses very controlled experimental designs to study the
David D. Nicholas, MD, MPH is the project director of the USAID-funded Translating Research into Action Project, TRAction, led by University Research Co. LLC, in collaboration with the Harvard University School of Public Health.
efficacy of these new drugs or other interventions, and effectiveness research, which tests these drugs and interventions in real world situations. Implementation research focuses on studying and developing approaches to effectively and efficiently implement and scale up proven interventions. Clearly, there is some overlap in the terminology and definitions of these types of research. Among the many things that program managers need to know to effectively and efficiently implement and scale up interventions are: • Why do programs fail/succeed? • How can we better assure success? • What are the best ways to design programs? • What are the options for program designs? Can modeling help evaluate the possible options and identify the most cost-effective design? • What epidemiologic information is needed for program design? • What policies need to be implemented or changed? • What is the best marketing approach? • What behaviors will need to change and what are the best approaches for achieving the needed behavior change? • How should health workers be compensated and motivated? • What is the most cost-effective training program for the health workers and supervisors? • How must the supply system be changed to meet the program’s needs? • How must community and client participation be addressed? • How should the program’s inputs, processes, outputs and impact be monitored? • How can continuous improvement of the program be assured? Implementation research is eclectic and may use a variety of methods during the course of a study or a program roll out, including:
www.globalhealthmagazine.com
—
Page 10
—
There has been critical analysis of the assumptions about published experimental research and concern that effective interventions are not reaching those who need them .
• • • • •
Effectiveness research and comparative effectiveness research Policy analysis and prospective policy research Marketing and behavioral research Quality Improvement Modeling
There are also a number of types of research designs that may be employed, including: • Operations research for problem solving • Quasi-experimental designs (including plausibility & probability designs) • Adequacy studies Gaps in Implementation Research In the last decade, there has been active debate about the nature and expectations of research, the value of different kinds of research, and the most effective ways to acquire knowledge to improve people’s lives. There has been critical analysis of the assumptions about published experimental research and concern that effective interventions are not reaching those who need them. There has also been a greater recognition for the use of mixed methods in public health, both qualitative and quantitative, and of the need for “customization” of the research design and methods used that are most appropriate for the context in which the research will be carried out. “Democratization of research” such as that fostered by quality management, where the research is embedded into programs, and the research is carried out by program staff and providers themselves is needed. Outside researchers may or may not be asked to provide assistance, depending on the needs. This usually results in the identification of innovative solutions to problems, better understanding of work processes and better commitment to achieving program goals. Participatory Action Research is a well-known approach to involving providers and communities in setting priorities, implementing programs and overcoming barriers. Yet, this form of research is greatly
underutilized because it has not been in the mainstream of health research, skepticism of the validity of the data and results and fear that the community may change priorities. Finally, there is increasing recognition that health systems, even at the local level, are complex adaptive systems, with multiple interdependencies and feedback loops. Introducing a new program may have many unpredicted effects. The application of complexity science as applied to health care and health research is in its infancy but a number of researchers are working to find out how it can be best applied to health research so that programs can better understand the systems in which they work, develop more simple work rules that function better in complex systems, and re-adjust to uncertainties and unexpected barriers and effects. If these efforts are successful, it could result in a “quantum leap” in health research and in the impact of health programs. Because of this need to design and assure effective programs for the scale up of proven interventions and save many more lives, more resources must be devoted to implementation research. The Translating Research into Action Project (TRAction) works to close the gap between the development of effective interventions and their implementation on a large scale. Its current priority implementation research topics include: 1. The Integrated Community Case Management of Childhood Illness – policy, costs and financing, and embedded implementation research. 2. Targeting key maternal and newborn interventions to high-risk populations. 3. The integration of maternal, neonatal and child health services. 4. The effect of performance-based financing on access and quality of maternal, neonatal and child health services. 5. Improving the community recognition of neonatal illness and complications, referral and case management at facilities. 6. Reducing abuse and disrespect during facility childbirth. 7. The combined and complementary use of indoor residual spraying and long-lasting insecticidal nets for malaria vector control. There is great ferment, debate and creativity in the field of research in general and of implementation research in particular. We are hopeful that this will lead to the quantum leap in knowledge that will help close the gap between what we know and what is being done. GH —
ISSUE 09 winter 2011
—
Page 11 —
Moldova
What Happens to MDR-TB Patients? Story and photos By David Rochkind
GH
—
C click on the source at www.globalhealthmagazine.com
—
Page 12
—
●
Moldova TB Incidence Rate: 154 cases/ 100,000 people
●
25% of all new TB patients are infected with MDR-TB
●
43% of all TB patients are infected with MDR-TB
Moldova has one of the highest rates of multi-drug resistant tuberculosis (MDR-TB) anywhere in the world. This deadly strain of the disease can emerge as a result of low quality health systems, poor quality drugs, lack of accessibility to treatment, and when a patient intermittently takes his medicine or fails to complete his treatment. After the fall of the Soviet Union, Moldova faced a huge economic shortfall, which exacerbated all of these conditions. The health care system crumbled, poverty rose and the country became more vulnerable to the emerging TB crisis. It is now estimated that 44 percent of all TB patients in the country are infected with MDR-TB.
As hospitals closed down and jobs became scarce, very few social programs were put in place to help manage the myriad of problems that the country’s population was now facing. In essence, TB patients were left on their own to deal with the consequences of being infected with a contagious disease they knew very little about. Over the past 10 years the country has begun to implement new programs focusing on TB, but there is still very little education about the disease and even fewer resources to help treat and prevent it. TB seems to take a back seat to other social and health issues, evidenced by the fact that there are only four organizations in the country that work on tuberculosis.
ISSUE 09 winter 2011
David Rochkind is a photojournalist whose work in Moldova was sponsored by the Pulitzer Center for Crisis Reporting.
—
Page 13 —
Between 1995-2000, Moldova only had resources to treat 20%-30% of all TB patients
5,000 TB cases are detected annually
While the overall TB numbers have dropped or stayed stagnant in recent years, the number of MDR-TB patients has risen, showing that Moldova’s infrastructure is currently incapable of dealing with the complex problems that TB treatment and prevention present. Speranta Terrei is a small NGO that works in Balti, a town in northern Moldova that has one of the country’s highest TB incidence rates. The organization is the only one in the city that works on TB; it is underfunded and staffed mostly by volunteer community health workers. Their admirable work falls short in the fight against TB not because of a lack of knowledge or will,
C Read David’s blog from Moldova and his mulitmedia piece on www.globalhealthmagazine.org.
www.globalhealthmagazine.com
—
Page 14
—
but rather due to a lack of funding and resources. They consistently work to spread awareness about the disease, and provide patients with home health care that helps them correctly adhere to their treatment, but their staff constantly strains to reach patients on such a small budget. Likewise, Balti’s TB hospital suffers from a lack of resources and consistently operates 10 to 20 percent above its capacity of 200 patients. In 1999 the old TB hospital in Balti was closed as the government looked to make budget cuts and, according to local doctors, determined that the size of Balti did not warrant such a
large TB hospital. The new hospital is smaller, has fewer resources and faces daily struggles to meet the needs of the city’s TB patients. Balti has more than 50 people who have a form of TB that does not respond to any medication – meaning the patients have no treatment options. What was once a treatable disease has produced lethal strains that leave some patients with no options but to try to stay comfortable while they wait for the inevitable. If proper measures are not taken, MDR-TB could spread to more of the general population in Moldova and beyond. GH —
10.8% of all TB patients in Moldova default on their treatment ISSUE 09 winter 2011
—
C EPIDEMIC: TB in the Global Community is a free online education program on tuberculosis. Visit it at http://www.tbepidemic.org/.
Page 15 —
By laura guay
—
We’ve Made Great Strides but
Photo by Jon Hrusa/ EGPAF
More is Needed in Pediatric AIDS Research
When the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) was established in 1988, most AIDS research was focused on adults, not on the unique pathways of transmission to children or the distinct medical challenges facing HIV-positive children. Elizabeth’s tenacity in fighting for her own children helped ensure that all children were not forgotten as scientists tackled the mysteries of HIV and AIDS. Since then, the scientific and medical advancements in the field of preventing mother-to-child transmission and HIV care
Dr. Laura Guay serves a dual appointment of vice president of research for the Elizabeth Glaser Pediatric AIDS Foundation and as research professor at The George Washington University School of Public Health and Health Services.
and treatment have been extraordinary. Scientifically, we know how to prevent transmission of HIV from mothers to their children. The UNAIDS 2010 report on the global AIDS epidemic reflects increased momentum toward the elimination of pediatric HIV and AIDS worldwide, and documents significant progress in increasing access to services to prevent mother-to-child transmission (PMTCT) of HIV, reducing new infections in children, and providing treatment for children (Figure 1). Despite this success, there were still an estimated 370,000 new
www.globalhealthmagazine.com
—
Page 16
—
our failure to achieve virtual elimination of pediatric HIV and AIDS, and universal access to care Photo by Jon Hrusa/ EGPAF
and treatment for mothers and children globally is a failure not of science, but of implementation.
figure 1
pediatric HIV infections in 2009 – more than 1,000 preventable infections every day. Pediatric research remains essential to ensuring the survival and well-being of HIV positive children, and ultimately achieving the goal of eliminating pediatric HIV and AIDS. The pediatric AIDS research agenda encompasses critical basic science, as well as clinical and operational research questions (CTable 1). Many priority research questions are unique to infants, children and adolescents, hence it is vitally important that research resources be devoted specifically to this population.
global access to arv drugs for pmtct pregnant women receiving arvs exposed infants receiving arvs 60%
47% of pregnant women not receiving pmtct drugs
50%
45%
40%
35%
30% 10%
10%
ISSUE 09 winter 2011
15% 18%
2004
2005
35%
20% 65% of hiv-exposed infants not receiving pmtct drugs
12% 6%
With critical support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health has announced that it will fund a pediatric specific leadership group in the upcoming re-structuring of the National Institute of Allergy and Infectious Diseases HIV clinical trials networks. The proposed areas of focus for this research network include the testing of vaccines to prevent HIV infection in adolescents and infants born to HIV-positive women, which cannot wait until a vaccine is found to be effective in adults (CTable 1). Just as antiretroviral drugs (ARVs) were shown to provide significant protection against mother-to-child transmission of HIV long before studies of similar regimens showed protection against heterosexual HIV transmission in adults, an HIV vaccine may protect breastfeeding infants even if it is not effective in adults with sexual or intravenous exposure.
—
32%
24%
20%
0%
53%
2006
2007
2008
2009
WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2010
With known HIV exposure from a single identifiable source for a limited duration, studying mother-infant pairs with and without HIV transmission provides a unique opportunity to answer basic immunology, virology and neonatal immunity questions that can advance our scientific knowledge about HIV transmission. The new 2010 WHO guidelines for the use of ARVs for the prevention of mother-to-child transmission and antiretroviral therapy (ART) for treatment of infants and children represent significant changes and progress in the prevention of infection and treatment of those living with HIV. Implementation of these new guidelines must be accompanied by additional clinical research as several recommendations are based on extrapolation
C See Table 1 online at www.globalhealthmagazine.com
Page 17
Photo by Mia Collis/EEGPAF
Photo by Jon Hrusa/ EGPAF
—
Photo by Jon Hrusa/ EGPAF
Photo by Mia Collis/EEGPAF
of data from clinical trials, without a strong evidence base. For example, clinical trials are underway to address the safety and efficacy of extending maternal or infant ARV prophylaxis during breastfeeding from the previously studied six months period to the currently recommended 12 months, however additional data are needed on the long-term safety of in-utero exposure to ARVs. Determining the cost effectiveness of the new regimens and their impact on HIV- free survival in infants will allow more effective decision-making for program scale-up. Identifying HIV- positive pregnant women who require ART for their own health is a critical component of the PMTCT guidelines, however this is challenging in settings with limited access to CD4 cell counts. The development and testing of inexpensive, simple pointof-care CD4 testing that can be performed in the lowest level health facilities, as well as point-of-care early infant diagnosis (EID) and viral load monitoring, will significantly advance HIV prevention, care and treatment efforts for infants and adults. Similarly, research is needed on innovative ways to use new technologies, such as mobile health initiatives, to improve the effectiveness of PMTCT and treatment programs. Since approximately half of untreated children with HIV infection will die
Photo by Georgina Goodwin/EEGPAF
before their second birthday, identifying strategies to maximize early HIV diagnosis and rapid initiation of ART with appropriate drug formulations in infected infants is key to improving child survival. Although there are important basic and clinic research questions remaining, our failure to achieve virtual elimination of pediatric HIV and AIDS, and universal access to care and treatment for mothers and children globally is a failure not of science, but of implementation. The translation of results obtained in clinical trials into routine health services in the field has been met with considerable barriers. The PEARL study, conducted in facilities with PMTCT services in four African countries, demonstrated progressive drop-out at every step in the PMTCT cascade. When combined with the number of women who never access antenatal services, the effectiveness of PMTCT programs is substantially reduced. The transition to the most effective regimens for PMTCT will make little overall difference in national transmission rates unless the challenges of limited health service delivery, access and uptake that prevent large numbers of HIV positive pregnant women from receiving any ARV are addressed. Research is crucial
www.globalhealthmagazine.com
—
Page 18
—
to provide health ministries, funders and implementing staff evidence-based, innovative, effective and scalable interventions with demonstrated impact on overcoming current barriers to effective PMTCT programs. In response to the critical need for operations and implementation research, UNICEF, WHO and UNAIDS, in collaboration with The George Washington University and EGPAF, held an expert technical consultation on operations research. The goal of the consultation was to identify the highest priority operations research questions to promote the rapid national scale-up of PMTCT and pediatric HIV care support and treatment (CST) programs. Attendees identified 20 priority research questions in the areas of PMTCT, Pediatric CST, integration of PMTCT and MNCH services, and health
systems (CTable 1). The International AIDS Society held a parallel consultation that included generation of priority clinical research questions for PMTCT and pediatric treatment (CTable 1). These consultations provide a research framework to guide governments, researchers, and funders in prioritizing pediatric HIV activities. In summary, while significant progress has been made in the field of pediatric HIV and AIDS globally, considerable research gaps remain. We cannot afford to lose the momentum of the last decade as we enter a new one. Continued strong advocacy for resources to ensure the pediatric HIV/AIDS research agenda is addressed as a high priority is required until we achieve an HIV-free generation. GH —
Membership at the Global Health Council The Global Health Council is the world’s largest membership alliance dedicated to saving lives by improving health throughout the world. If you would like more information about membership, go to www.globalhealth.org to review our a list of our benefits and sign up for membership or contact us at membership@globalhealth.org.
ISSUE 09 winter 2011
—
C View references online at www.globalhealthmagazine.com
Page 19 —
By Rebecca G. Palpant
—
Photos courtesy © Eugene Richards
Bridging the Gap in Stigma Research to Build Better Mental Health
Today, we can map the course of a seizure as it travels across the brain or pinpoint where memories exist in the inner recesses of the mind. We have medicines that are so technically advanced they target specific types of neurons. The genetic and biological causes of some mental illnesses have been identified after
decades of research. Despite all of this progress and the tremendous growth in availability of cost-effective treatments, we still know so very little about how to prevent or reduce the stigma against mental illnesses, which can be as damaging to a person’s health and well-being as the illness itself.
Rebecca G. Palpant, MS is assistant director of the Rosalynn Carter Fellowships for Mental Health Journalism, The Carter Center Mental Health Program.
www.globalhealthmagazine.com
—
Page 20
—
Stigma, a mark or label that leads to discrimination, remains one of the greatest barriers to people seeking treatment worldwide. Stigma against mental illnesses is linked with heinous forms of discrimination and human rights abuses, with some of the most disturbing violations taking place in psychiatric hospitals. In both developing and wealthy nations, mental health services and institutions are chronically underfunded and understaffed, functioning largely as crumbling warehouses for the suffering rather than providers of rehabilitative care. Mental illnesses are some of the most expensive and disabling conditions – they represent five of the top 10 leading causes of disability worldwide for men and women in their prime. Stigma and discrimination often define the barriers that prevent so many from accessing less costly and effective early interventions critical to maintaining a productive and meaningful life. If millions of people in both developed and developing countries could access appropriate mental health treatment without fear of labeling or discrimination and remain as productive and contributing members of the community the economic benefits to communities would be countless. The Movement for Global Mental Health, BasicNeeds and The Carter Center, among many other mental health groups, are working to identify innovative ways to address the barriers to providing evidence-based treatments where mental illnesses are highly stigmatized and discrimination is pervasive. In Liberia, for example, approximately 40 percent of the population is believed to suffer from a range of mental health disorders, including post-traumatic stress disorder (PTSD), after a long and brutal civil war. The Liberian Ministry of Health and Social Welfare has committed to improving mental health in the nation but faces many challenges not the least of which, according to preliminary research conducted by The Carter Center, are prevailing myths on the causes of PTSD. For example, there is a belief that PTSD is caused by having committed a crime or wrongdoing during the war, and that those who suffer from it deserve such a punishment. In developing countries, stigmatizing attitudes are more widespread across various illnesses and not necessarily associated with just mental health. But the myths and misunderstandings about mental illness are just as concerning in developed nations. In many parts of the developed world, violence and serious mental illnesses are perceived as inextricably linked, perpetuating the stereotype that people with mental illnesses are to be feared with very little evidence to support a significant relationship. In fact, data indicate that people with
ISSUE 09 winter 2011
—
mental illnesses are far more likely to be violated than those without the experience of mental illness. Great strides have been made in the field of mental illness stigma research over the past decade through the efforts of many people that have devoted their careers to this issue. But much more needs to be done. We are learning a great deal about how to increase knowledge and understanding of mental illnesses – more people now believe in the effectiveness of treatments. Progress, however, in the area of changing attitudes and behaviors has been challenging. Finding ways to advance quantitative research in the area of stigma research could advance the field in new and bold ways. More work is needed to build outcome measures for methods to address the intractable problem of stigma and discrimination associated with mental health problems. Millions of dollars and the hard work of untold numbers of consumers and advocates continue to drive wide-reaching anti-stigma campaigns in many countries. We must do better in providing the evidence to support anti-stigma messages and initiatives not only to validate their effectiveness, but also to ensure that they aren’t doing more harm than good. Recent findings indicate that touting mental illnesses as
Page 21 —
brain diseases – “a disease like any other” – in some cases has inadvertently encouraged the belief that there is nothing one can do to prevent these diseases. The impetus behind the approach was to help people understand the physical component of mental health using general health terminology, but instead, it led people to believe that the illnesses are permanent, leading to the notion that nothing should be done to change unsupportive social and physical environments that adversely affect mental health (e.g., lack of good parenting skills; poverty; living in conflict/war-prone areas). Gaps in the Research The field of mental health stigma research is in its infancy, and only recently has research begun driving a comprehensive and well-defined agenda to improve our knowledge base on this issue. Of paramount importance is the development of consistent measures endorsed by the field. Critical to the success of these endeavors is the establishment of an outlet for information exchange of projects that select a problem, define it, determine how to measure it, create a program to address the problem, and measure the results and outcomes. The Carter Center is an affiliated organization with the journal Stigma Research and Action, launched in January 2011, that provides one of the first such formal venues to share this information. The future directions for the field should center on a demonstration of cause and effect relationships. By changing knowledge and attitudes about mental illnesses, can behavior consequently be changed? Additionally, how might positive behaviors be enhanced instead of focusing on stopping negative ones? The most pressing question is how to address the perceived connection between mental illnesses and violence, which is one of the most significant causes of stigma and discrimination against these disorders. The media play a key role in perpetuating these stereotypes and more work should be done on how best to inform them about inaccurate depictions as well as going further to encourage sensitivity and balance. The Rosalynn Carter Fellowships for Mental Health Journalism is an ongoing initiative to encourage journalists to explore a timely mental health topic over
C View references online at www.globalhealthmagazine.com
the course of a year and complete a major media project connected to their work. The field could benefit from the evaluation of other mental health and media initiatives to assist in guiding further development of these important programs. Those with the lived experience of mental illness can provide critical “on the ground” information and insights that are invaluable, but not often sought by the field. This sizeable gap provides a major barrier to progress, and mental health consumers must inform future thinking and directions in the field. Their voices can be the best guides in identifying targets for stigma research as well as desired outcomes. Future Directions Critical to the success the field of mental illness stigma research has achieved over the past decade have been the key partnerships and coalitions formed globally. There are lessons to be learned from other stigmatized health conditions and public health campaigns, and they should be shared in a structured and consistent process. The field holds substantial professional opportunities for the next generation of bright and innovative researchers if they can be engaged and their interest cultivated. Other areas for further exploration include an examination of the contribution of mental health professionals on perpetuating or reducing stigma, exploration of attitudes of children, and increase in evaluation research. The field could benefit from further exploration of the use of direct observation in research methodology. The next decade of mental illness stigma research has the potential to be the guiding force in measuring and re-shaping stubborn attitudes and behaviors that have been intractable for generations. The knowledgebase has been laid, partnerships have been cultivated and developed, and key measurement tools have been identified. With these critical factors in place, it would be unconscionable if the field does not leverage the opportunity at this critical point to propel stigma research forward and ultimately to make a difference in how people with mental illnesses are perceived and treated within their communities. GH —
www.globalhealthmagazine.com
—
Page 22
—
By Koki Agarwal
—
Photo courtesy of the Maternal, Newborn and Child Health Integrated Program.
Why We Need Men to Save Lives
An interesting aspect of working on women’s health in the developing world is that it is often the men who hold the keys to improving maternal health. In many lowresource settings, men are the primary decision-makers for the family – from determining the number of children to the timing of pregnancies, and even whether women can seek health care for themselves or their children. We have been hesitant, in many cases, to engage men in what has traditionally been seen as a women-centered issue. But to improve maternal health outcomes in
developing countries, men must be considered equally important to reach as women.
ISSUE 09 winter 2011
Koki Agarwal directs USAID’s flagship Maternal, Newborn and Child Health Integrated Program.
—
Our program work shows that males can become valuable allies in addressing health issues. Time and time again we have seen maternal health programs benefit from the positive roles men play within their communities. Educating and empowering men to become more involved in maternal and health issues not only improves outcomes for the mother and baby,
Page 23 —
The care and support of an informed husband can go a long way, not only within his own family unit, but also within the community at large. but can mean the difference between life and death in cases of complications, when women need immediate medical care. However, men also need to see the advantages for themselves and be key contributors to the dialogue. When equipped with the right knowledge and information, men can begin to understand the role they can play as a leader in the community, the societal benefits of a healthy family and the resulting economic growth that can be achieved. The care and support of an informed husband can go a long way, not only within his own family unit, but also within the community at large. In Northern Nigeria, for instance, men are encouraged to take an active role in their partners’ pregnancies in an effort to reduce maternal deaths. As a result, even in a region where women have little access to education, are predominantly confined to domestic activities, and have few economic opportunities, their husbands’ permission to form the Mothers Savings and Loans Clubs has dramatically improved the handling of emergency health problems for pregnant mothers and their newborns. Comprised of women of reproductive age and older, members of these clubs engage in group lending to support each other’s needs. Members of the clubs operate and maintain two major savings portfolios every week on a regular basis. The first savings is collected for paying small interest bearing loans to their members to engage in small scale businesses and the interest charged ranges from 5 to 20 percent. The second savings is collected for emergency obstetric and newborn care and does not attract an interest because it is meant to solve emergency health problems for pregnant mothers and their newborns. Any member of the club that needs financial assistance for emergency obstetric and neonatal care makes her intention known during regular meetings. The activities of the loan clubs showed that women – with the support and encouragement of their male
family members – can contribute significantly to reducing complications associated with pregnancy, labor and delivery. And much of the success of these clubs can be attributed to the use of male birth spacing motivators, who are community volunteers trained in communications, to help local men achieve their vision for a healthy community. Men in Northern Nigeria have embraced the Mothers Savings and Loans Clubs initiative because they found that it was financially empowering their wives and indirectly reducing demands on husbands. Furthermore, because of the financial benefits derived from the program, men have not objected to the educational messages being delivered during the meetings such as recognition of danger signs in pregnancy, during and after child birth and in newborns. They also did not object to messages on healthy timing and spacing of births and family planning. In short, the clubs have served as an appropriate vehicle for getting maternal and newborn health messages across to women. And this is not unusual: we have seen better outcomes in our programs throughout the world when we and our colleagues engage men. In other parts of Africa – such as Kenya, Tanzania and Malawi – this includes teaching women to prevent HIV transmission to their children and encouraging them to bring their male partners to clinics for follow-up treatments. In Asia, the trend is the same. Afghanistan has projects that train community midwives with the help of the local council of male village elders, who have consented to let the women attend training and assist in births when they return to the community. And in the conservative eastern region of Bangladesh, male groups are trained to deal with the unexpected complications that can arise during pregnancy. As a result, in a setting where less than 10 percent of the women have facility births, Bangladeshi men have set aside funds for transportation to hospitals in case of maternal emergencies, something that would have been impossible without their allowance. Engaging men means reaching out to community elders, leaders and religious groups, but there are challenges in reaching men, who are often away at work. We need to continue to work to reach them where they are – mosques or job sites, such as the mines in South Africa – knowing that a 75 percent reduction in global maternal deaths by 2015 is only possible with their involvement in the countries that need it most. We have definitely seen better outcomes in health programming when we engage men in our programs and as a result, have seen women become agents of change themselves. We must continue to do our part to recognize the importance of their role in saving the lives of women and children across the globe- and encourage our colleagues to do the same. GH —
www.globalhealthmagazine.com
—
Page 24
—
By Bill Gates
—
Great Ideas from Unexpected Places Photo courtesy of the Bill & Melinda Gates Foundation.
I have always been interested in the scientific discoveries underlying health advances in developing countries. The benefits of such breakthroughs are substantial, with the potential to save hundreds of thousands of lives. And the challenges are great, often involving issues that no one has been able to solve before. Grand Challenges Explorations – part of the Foundation’s Grand Challenges in Global Health initiative – funds bold research ideas that have the potential to create breakthroughs in global health solutions. Launched two years ago, Grand Challenges Explorations (GCE), is aimed at encouraging researchers with promising and sometimes unconventional ideas for improving health to apply for $100,000 grants. That may not seem like a lot of money for scientific research. But by funding a larger number of smaller grants and encouraging applications from a wider range of individuals – including those with little or no experience – Grand Challenges Explorations can fund initial research into potentially innovative concepts that might not otherwise ever be explored. In October of last year, nine previous grant recipients were awarded next-stage grants of up to $1 million. This funding will allow projects that have shown outstanding progress and great promise to move forward. For example, Dr. Mark Davis, professor and director of the Stanford Institute for Immunology, Transplantation and Infection, is working on a new technique to measure vaccine efficacy, a tool that could shorten the time required to test new vaccine candidates. Dr. Pradip Rathod, a professor of chemistry at the University of Washington, is trying to develop a mechanism that could help prevent drug resistance from developing
during malaria treatment. Dr. Dan Feldheim, professor at the University of Colorado is exploring how gold crystals could be tailored to block many viral and bacterial drug resistance mechanisms. And Dr. Szabolcs Marka, an experimental astrophysicist at Columbia University who specializes in gravitational waves, is applying his expertise to malaria prevention. He’s working on a device that will use light fields to create barriers to deter mosquitoes from humans and prevent malaria transmission. I had a chance to meet these researchers and other GCE grantees and I found their passion and creativity inspiring. Some, perhaps many, of these ideas may not pan out. But if even one of these projects is successful, it will have been well worth the investment. GH —
ISSUE 09 winter 2011
—
Bill Gates is co-chair and trustee for the Bill & Melinda Gates Foundation.
Page 25 —
C
On the BLOG
By chris wilson —
C engaging the best minds to
tackle global health challenges
One hundred years ago the mathematician David Hilbert formulated a list of important, unsolved problems that has encouraged innovation in mathematical research ever since. Seven years ago, inspired by Hilbert’s example, we at the Bill & Melinda Gates Foundation identified 14 major global health challenges that, if overcome, could lead to breakthrough advances for those in the developing world. Supported by our strong partners in the Foundation of the National Institutes of Health, the Canadian Institutes of Health Research and the Wellcome Trust, we formalized this concept as the Grand Challenges in Global Health (GCGH) program. In 2005, we gave 45 grants totaling $458 million to research projects involving scientists in 33 countries. To me, GCGH was an experiment. We brought together creative minds from across scientific disciplines – including those who have not traditionally taken part in
health research – and encouraged them to take risks in pursuit of transformative health solutions. I watched the program grow, initially as an outsider, and beginning this year as director of Global Health Discovery. Last year marked the conclusion of the first round of Grand Challenges projects. We have learned that these investments not only catalyzed critical scientific research, but they also drew more attention to the importance of global health and engaged a greatly increased number of creative scientists to attack these critical problems. We learned that the questions we ask must be carefully framed to address scientific barriers in the context of real world needs and realities so that progress achieved has the greatest potential for translation into useful global health solutions. And for promising projects, we need to help foster their transition into product development to ensure that new solutions lead to impact. In 2008, to expand the pipeline of ideas and possibilities, we launched Grand Challenges Explorations, an initiative that awards smaller grants to test even more creative, high-risk concepts.
C Read the full blog on www.globalhealthmagazine.com
By dan feldheim
By dr. keith jerome, md, phd
—
—
C the golden treatment:
C slicing hiv dna from
Staying one step ahead of drug resistance
In the 1930s, a common disease called childbed fever went from killing 3 out of every 4 women who contracted it during childbirth to less than 1 in 20. This miraculous shift in the trajectory of an infectious disease resulted from Gerhard Domagk’s 1931 discovery and isolation of the first safe antibiotic drug called prontosil. A few years later, penicillin was isolated, and the remarkable success of both of these drugs prompted many scientists and doctors worldwide to proclaim the end of all infectious disease.
infected human cells
Great strides have been made in the development of drugs to manage HIV infection. Yet significant challenges to treatment remain – especially in resource-poor settings where HIV infection rates are among the highest in the world. Lifelong treatment is expensive, even when low-cost generic drugs are available. Additionally, if resistance arises, there is little opportunity for access to second-line therapy. Social, economic and political factors can also interrupt access to drugs at any time, putting patients at risk. C Read the blog on www.globalhealthmagazine.com
C Read the blog on www.globalhealthmagazine.com
www.globalhealthmagazine.com
—
1111 19th st. nw suite 1120 washington, dc 20036 www.globalhealthmagazine.com
Bellagio Center Residency Program The Rockefeller Foundation Bellagio Center, through conferences and residency programs, supports the work of scholars, artists, thought leaders, policymakers and practitioners who share in the Foundation’s pioneering mission to promote the well-being of humanity. The Bellagio Residency program offers a serene setting conducive to focused, goal-oriented work, and the unparalleled opportunity to establish new connections with fellow residents, across a stimulating array of disciplines and geographies.
Deadline for scholars and creative artists is May 1, 2011 Applications for practitioners are accepted on a rolling basis. To learn more about the program, please visit: www.rockefellerfoundation.org/bellagio-center
Non-Profit Org US Postage PAID Permit #1 Putney, VT