A WHITAKER GROUP PUBLICATION

JANUARY-FEBRUARY 2009

AFRICA HEALTH NEWS
HIV/AIDS

PEPFAR REPORT HAILS SUCCESS OF PARTNERSHIPS
The President’s Emergency Plan for AIDS Relief (PEPFAR) is successful in large part because of the public-private partnerships (PPPs) the US government has developed with host country governments, NGOs, faith and community-based groups and the private sector, said PEPFAR’s outgoing Coordinator, Ambassador Mark Dybul, in January. “We have the resources, but the leadership, the brilliance, the real success, is of the people and the countries,” he said at the release of PEPFAR’s annual report. “That’s really one of the geniuses of this program...that leads with country ownership, that pushes good governance, results-based approaches, all sectors being engaged.” In today’s resource-constrained world, PPPs are the key to sustainability. In addition, they help facilitate increased interventions and leverage private sector resources to multiply impact. PEPFAR supported eight large-scale, multi-country PPPs in 2008, as well as an array of country-level PPPs and workplace programs with local private sector entities. Two such initiatives mentioned in the report are the Partnership

PEPFAR ACHIEVEMENTS 2004-2008
☑ Supported treatment for more than 2.1 million people, saving nearly 3.28 million adult years of life. ☑ Increased the share of those receiving treatment who are children from 3% in 2004 to 8% in 2008. ☑ Supported care for more than 10.1 million people affected by HIV/AIDS, including more than 4 million orphans and vulnerable children. ☑ Supported HIV counseling and testing for nearly 57 million people. ☑ Supported tuberculosis treatment for more than 395,400 HIV-infected patients through September 2008. ☑ Reached an estimated 58.3 million people to prevent sexual transmission of HIV through the ABC approach. ☑ Distributed more than 2.2 billion condoms. ☑ Supported prevention of mother-to-child HIV transmission during nearly 16 million pregnancies, providing antiviral prophylaxis for nearly 1.2 million HIV-positive pregnant women, allowing nearly 240,000 infants to be born HIV-free. ☑ Partnered with 2,667 organizations, of which 86% were local. ☑ Supported an estimated 3.7 million training and retraining encounters for health care workers.

for an HIV-Free Generation, a global PPP initially piloted in Kenya to advance youth-focused HIV prevention, and the creation of a Wellness Center in Uganda in partnership with Becton, Dickinson and Company and the International Council of Nurses. The center will serve 29,000 health workers in Uganda and their families. In 2008, PEPFAR continued to expand its partnerships, working with 2,667 organizations up from 1,588 in 2004, of which 86% were local. PEPFAR has also worked with PHOTO: EJ MUNOZ its international implementing partners to develop strategies A baby receives care at a PEPFARfor handing over programs as funded clinic in Addis Ababa, local organizations increase Ethiopia. their capacity to work directly with the US government. Goals for future PPPs, the report stated, include expanding private health insurance options and strengthening health systems, including human resource capacity and expanding information communications and technology offerings. Ambassador Dybul also emphasized that PEPFAR investments are building Africa’s health care capacity across the board and ultimately strenthening democracy by building accountability frameworks. “People feel a sense of accountability and development that we haven’t had before,” he said. Launched by former President George Bush in 2003, PEPFAR has so far spent $18.8 billion and exceeded its goal of supporting anti-retroviral therapy (ART) for two million people by 2008. As of September 30, 2008, the initiative has provided ART for more than 2.1 million people worldwide, of which the great majority are in the 12 focus countries in sub-Saharan Africa. These include Botswana, Côte d’Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia. In July 2008, the US Congress reauthorized PEPFAR with $48 billion in funding through 2013. The initiative also includes funding for tuberculosis and malaria. Between 2009 and 2013, PEPFAR plans to work in partnership with host nations to support treatment for at least three million people, prevent 12 million new infections, and care for 12 million people, including five million orphaned and vulnerable children. It also plans to support training for at least 140,000 new health workers. PEPFAR is expected to receive strong support from the new US Administration because both President Barack Obama and Vice President Joseph Biden were sponsors of the PEPFAR reauthorization. The funding, though authorized, is still to be appropriated by Congress.

PAGE TWO BUILDING CAPACITY COLLABORATION

NEW PARTNERSHIP SEEKS TO STRENGTHEN TANZANIAN HEALTH WORKFORCE
Tanzania’s Muhumbili University of Health Allied Sciences (MUHAS) announced in January that it will partner with the University of California, San Francisco (UCSF) to develop and implement strategies to enable MUHAS and other African institutions to meet their countries’ health workforce needs. The project, funded by a $7.5 million grant from the Bill & Melinda Gates Foundation, seeks to harness the resources of the two universities to develop an institutional partnership that can be replicated in other low-resource settings. Faculty from MUHAS and the MUHAS School of Public Health will work with their counterparts at the UCSF schools of medicine, nursing, pharmacy and dentistry to share curricula and educational technologies, and develop collaborative research programs. “Through this collaboration, MUHAS will recruit and train faculty, strengthen the academic environment for education and research, and revise undergraduate and postgraduate curricula in order to increase its output of health professionals to serve the needs of the country,” said MUHAS Vice Chancellor Professor Kisali Pallangyo. The partnership builds on an already established relationship between the two universities, which are both public health institutions that train doctors, nurses, pharmacists, dentists and allied health professionals.

NEW INITIATIVE TO IMPROVE HEALTH OUTCOMES IN UGANDA
Uganda’s Makerere University has launched a new partnership with the Johns Hopkins University in Baltimore to improve health outcomes in Uganda by extending the education capacity of Makerere’s College of Health Sciences. The first phase of the project, made possible by a $4.97 million grant from the Bill and Melinda Gates Foundation, focuses on aligning Makerere’s education and research with the Government of Uganda’s national health goals and priorities, as well as identifying strategies to ensure the long-term sustainability of the university’s efforts to address evolving health priorities and health manpower needs. Working with the Johns Hopkins Center for Global Health, Makerere will develop and test effective teaching, research and practice strategies with a focus on translating research into policy implementation. “We see this project as a major stepping stone to ensure that Makerere will be the hub for capacity building and influencing the health sector to improve lives in Uganda and the East Africa region for years to come,” said Dr. David Peters, Associate Professor in the Department of International Health at Johns Hopkins Bloomberg School of Public Health. The project will be led by Dr. Peters and Dr. George Pariyo, Head of the Department of Health Policy, Planning and Management at the Makerere University School of Public Health. One of the early focus areas for the initiative will be to reduce neonatal and maternal mortality by removing constraints on women giving birth in hospitals. “We want to test strategies to reduce the barriers for maternal mortality like reduction in hospital fees. We are proposing that we test out ways of subsidizing costs, for example, through vouchers,” Dr. Pariyo told the Monitor newspaper. Dr. Ibingira Charles, Dean of the School of Biomedical Sciences at Makerere, described the project as a bridge between students and the community. “Students have been learning but there has been a disconnection between them and the community through integrating learning and service delivery,” he said. “We hope to impact communities by looking at how we can translate research into policy. Once we are able to do this, it will be easier to directly impact the lives of Ugandans.”

Student dentists training at Muhimbili University in Tanzania

REGIONAL COOPERATION

GLIA PROGRAM TO PROTECT LONG HAUL TRUCK DRIVERS FROM HIV SHOWS RESULTS
The Great Lakes Initiative on AIDS (GLIA), a regional collaboration between six East African governments ratified by treaty in 2005, is starting to see the results of its program to educate long distance truck drivers about the dangers of unprotected sex and the need to be tested for HIV infection. Working with National HIV Coordinating Commissions and truck and workers’ unions, in 2007 GLIA helped launch the program among its member states - Burundi, Democratic Republic of Congo (DRC), Kenya, Rwanda, Tanzania and Uganda - to address the problem of HIV infection in a highly mobile and vulnerable population. A key facet of the program is to encourage the truckers themselves to ‘know their epidemic’ and plan and institute their own response. Since then, the results have been impressive: ■ In Kenya, more than 11,000 truckers have undergone voluntary HIV testing and counseling, many at a well-equipped truck stop on the well-traveled Mlolongo Road. ■ In Rwanda, 60% of truckers now know their HIV status. ■ In Uganda, workers’ unions have distributed condoms, carried out voluntary counseling and testing and held behavioral change sessions. ■ In Tanzania, truckers living with HIV have openly declared their status and formed a support and advocacy group. One spillover effect is that sex workers at truck stops have begun to use condoms more consistently. ■ In DRC, truck drivers report they are having fewer sex partners and increasing condom use. To support this progress, GLIA has contracted with an international NGO, Constellation for AIDS Competence, to educate leaders of trucker networks on HIV response and to encourage them to pass the training on. GLIA is funded with a $20 million grant from the World Bank. Its objective is to implement HIV/AIDS interventions regionally to add value to individual country efforts.

PAGE THREE GUINEA WORM DISEASE ERADICATION LOCAL PRODUCTION

GLOBAL PARTNERS BEGIN FINAL PUSH TO ERADICATE PARASITE
The Bill & Melinda Gates Foundation and Britain’s Department for International Development (DfID) announced in December that they were jointly committing $55 million to the effort led by the Carter Center to finally eradicate Guinea worm disease. “Guinea worm is poised to be the second disease eradicated from Earth, ending needless suffering for millions of people from one the world’s oldest and most horrific afflictions,” said former US President Jimmy Carter, whose Atlanta-based center has been working for more than two decades on the eradication effort. He said that cases of Guinea worm disease reached an all-time low in 2008 with less than 5,000 cases reported in six African nations, down from 3.5 million cases in 1986 in 20 nations in Africa and Asia. In the first 10 months of 2008 only 4,410 incidents of Guinea worm were reported in Ethiopia, Ghana, Mali, Sudan, Niger and Nigeria. It is already suspected that the last cases have been reported from Nigeria and Niger, according to the Carter Center. The Gates Foundation is contributing $40 million as a challenge grant to the Carter Center. It includes an outright contribution of $8 million and encourages other donor organizations and individuals to provide an additional $32 million that the Gates Foundation will match one-to-one. The British government has pledged about $15 million. The funds will be shared equally between the Carter Center and the World Health Organization (WHO). Guinea worm disease will be the first disease to be wiped out without a vaccine or medicine. Interventions include health education, free cloth filter distribution and larvicide applications. To date, about $225 million has been invested in the eradication effort. “The drive to eradicate Guinea worm disease is one of the world’s most impressive global health success stories,” said Dr. Regina Rabinovich, Director of Infectious Diseases Development at the Gates Foundation.

EAST AFRICA NOW A KEY SUPPLIER OF ARTEMISININ
East Africa has become the third most important growing region in the world for Artemisinin, the active ingredient in the most effective antimalarial, the United Nations (UN) reported in January. Until recently, almost all Artemisia annua plants, native to Asia, were grown in China and Vietnam, but in 2002 a handful of Kenyan farmers contracted with the local company Botanical Extracts EPZ Ltd. (BEEPZ) to plant 40 hectares of the plant. Artemesia annua cultivation now supports at least 40,000 smallholder farmers growing 4,000 hectares of the crop in Kenya, Tanzania and Uganda. Commercialization of the plant was made possible by grants from Britain’s Department for International Development (DfID) and the Swiss pharmaceutical company Novartis. BEEPZ pays between $550 and $600 per metric ton. One hectare can produce up to two metric tons of dry leaves. Cultivation of the plant in Africa is considered critical to ensuring a less expensive supply of the drug that has taken over from the older quinine-based medicines no longer considered effective against several forms of malaria. According to the UN, the Kenyan government buys about 17 million doses of Artemisinin drugs annually at a cost of $24 million for free use at government clinics. At private pharmacies, the cost per dose ranges from about $5.50 to $8.20. In 2006, BEEPZ paid out $1.7 million to farmers. The company completed an Artemisinin extraction plant in 2007 and now supplies Novartis with enough Artemisinin for more than 22 million doses of the drug.

DIABETES

NOVO NORDISK TO SUPPLY AFFECTED CHILDREN WITH FREE INSULIN
Danish bio-pharmaceutical company Novo Nordisk announced in December that it would provide diabetes care and free insulin to 10,000 children in the Democratic Republic of Congo, Guinea-Conakry, Tanzania and Uganda beginning in 2009. The five-year program, called “Changing the Future for Children with Diabetes,” will be based on a hub-and-spoke concept with satellite centers around existing hospitals and clinics. With an estimated cost of $25 million, it is aimed at building sustainable solutions for improving availability, accessibility, affordability and quality of diabetes care for children with type 1 diabetes. An estimated 38,000 African children have type 1 diabetes, the majority of whom die within a year of diagnosis due to lack of access to insulin. While still relatively rare in Africa, type 1 diabetes is on the rise due to increased urbanization and changes in dietary and exercise habits. “The premature death of a child caused by lack of insulin is unacceptable, when a life-saving solution is available,” said Dr. Jean Claude Mbanya, President-elect of the International Diabetes Foundation (IDF). “We must work together across borders to keep these children from dying. This is why I welcome this new program being launched by Novo Nordisk.” The bio-pharmaceutical company aims to collaborate with as many local partners as possible, including governments and diabetes associations, and regional chapters of the IDF. In addition to providing free insulin, it will focus on helping to improve the health care infrastructure of the host countries. “This project will not only provide insulin free of charge to an extremely vulnerable group, it is also designed to build long-term solutions for insulin distribution and sustainable diabetes care for all people with diabetes in the world’s poorest countries,” said Mr. Lars Rebien Sǿrensen, President and CEO of Novo Nordisk A/S. Novo Nordisk hopes to expand the program beyond the initial four participating countries.

Workers cultivate Artemisia annua plants in Tanzania

PAGE FOUR AIDS OUTLOOK/09 LEADERS IN HEALTH

Fewer people in the world are becoming infected with HIV, fewer are dying from AIDSrelated illnesses and more of those infected with HIV are receiving treatment, a new UNAIDS report states. New infections have declined from three million in 2001 to 2.7 million in 2007, the number of children becoming infected through mother-to-child transmission has dropped to 370,000 in 2007 from 450,000 in 2000, and an estimated two million people died from AIDSrelated illnesses in 2007 - down from 2.2 million in 2005. A total of three million people in the developing world are now receiving antiretroviral therapy (ART), 10 times more than were being treated in 2002. But, the report cautions, the total number of people living with HIV is increasing due to new infections, the longer life span of those receiving treatment and population growth. It estimates that about 33 million people worldwide are infected, of which 22 million are in sub-Saharan Africa. Despite improvements in treatment, the report stated, only 25% of those in need of ART receive it and 88 out of 113 developing countries reported that fewer than half of mothers received services to prevent the transmission of HIV to their children. Seventy-five percent of all AIDS-related deaths worldwide are in Africa. The report, entitled “AIDS Outlook/09,” highlights progress made in several African countries with high prevalence rates in lowering new infections and enabling more of those who are infected to gain access to treatment. According to the report, changes in sexual behavior in Rwanda and Zimbabwe have led to a decline in the number of new HIV infections, while young people in Burkina Faso, Ethiopia, Ghana, Malawi, Uganda and Zambia are waiting longer before becoming sexually active. Increasingly, the report states, African governments are making greater efforts to understand and respond in a targeted way to the particular dynamics of the disease in their countries. In 16 sub-Saharan countries - Benin, Botswana, Burkina Faso, Côte d’Ivoire, Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Nigeria, Senegal, Swaziland, Tanzania, Uganda and Zambia - national HIV experts have just produced, or will soon produce, transmission analyses that pinpoint how HIV infection oc-

UN REPORTS PROGRESS ON FIGHT AGAINST HIV/AIDS EPIDEMIC

DR BABATUNDE OSOTIMEHIN: MINISTER OF HEALTH, NIGERIA
When Nigerian President Umaru Yar’Adua appointed Dr. Babatunde Osotemehin his new Minister of Health last December, it was a signal that he was making HIV/AIDS the top priority in his country’s health agenda. An eminent research scientist in sexual and reproductive health, Dr. Osotemehin was most recently the DirectorGeneral of Nigeria’s National Agency for the Control of AIDS and the Project Manager of his country’s HIV/AIDS Program Development Project. He was also the Coordinator of the Social Sciences and Reproductive Health Research Network in Ibadan, Nigeria, and a Professor of Clinical Pathology at the University of Ibadan’s College of Medicine. In an interview with SciDev.Net, a London-based NGO that provides information on science and development to developing countries, he said his priorities would be “research for evidencebased healthcare,” increased rollout of anti-retroviral drugs to fight HIV/AIDS, community health insurance and a greater emphasis on routine immunization, especially for polio, which has seen a resurgence in Nigeria in recent years. “We have to improve the capacity of the ministry to deliver quality service to the Nigerian people,” he told SciDev.net. “That capacity is not limited to physical access, but includes competence through training and financing.” Dr. Osotimehin, who earned medical degrees from the University of Birmingham in Britain and the University of Ibadan, did post-doctoral study at Memorial Sloan Kettering Cancer Center in New York and the Harvard Center for Population and Development Studies in Cambridge, Massachusetts.

Couples counseling and testing is increasingly being adopted curs in their countries. One example cited in the report is that of Uganda, where transmission analysis showed that approximately 43% of new HIV infections occurred among ‘low risk’ couples in which one partner was HIV positive and one HIV negative. An estimated 44% of new infections came from those with multiple sex partners, including their regular partners, and about 11% were related to sex work. Based on these findings, the Government of Uganda is focusing prevention efforts on people in marriages or long-term relationships. Prevention strategies include promoting couples counseling and testing, efforts to reduce the number of sexual partners and emphasis on consistent condom use for couples in which one partner is HIV positive and one HIV negative. “A number of things are happening with those couples in long-standing relationships. First, they don’t use condoms. Second, they do not test as much. We need to encourage them to test - and not only to test, but also to disclose to their partner,” said Professor Fred WabwireMangen, the team leader of the Uganda modes of transmission study and Associate Professor of Infectious Disease Epidemiology at the Makerere Unversity School of Public Health in Kampala. Lesotho, which has one of the highest infection rates in the world, is also reformulating its national strategy based on its transmission analysis. “With this information we have fine-tuned our behavioral change and communication strategy and future programming of prevention interventions,” said Mr. Keketso Sefeane, CEO of the Lesotho National AIDS Commission.
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Dr. Babatunde Osotimehin

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