The Global Pulse Journal Blog

The World Bank and USAID are hosting a series of debates exploring emerging issues in global responses to HIV/AIDS and worldwide evolving approaches to development aid, .  The debates attempt to lay out the best evidence and information available to assist world governments, civil society organizations, and other development organizations in interpreting and responding to the shifting dynamics of the epidemic and our collective responses to the challenges it presents.

This global discussion series began this past May with a debate entitled “Test and Treat: Can We Treat Our Way Out of the HIV Epidemic?” which looked at testing and treating strategies with a focus on their role in Africa.

In June, a debate on “Behavior Change in HIV Prevention” took place looking at dynamics involved in behavior change approaches and their past ineffectiveness.

Check out these past debates and the ones still to come including theis week’s August 26th debate on “Discordant Couples and HIV Transmission” and continue to follow this debate series for future conversations.

In today’s guest post, recent medical graduate Laura Janneck, MD, MPH reflects on an elective course in social medicine she took in Uganda. Dr. Janneck is an AMSA alum, and now a resident in Emergency Medicine at Brigham & Women’s Hospital, Boston. For further information about the course, see details below.

Over the course of my involvement in global health during medical school, I began to narrow my interests toward humanitarian assistance and global health delivery in post-conflict settings. Last year, during my fourth year of medical school, I participated in a new course on social medicine being taught in Gulu, northern Uganda, a region that is recently recovering from a 20 year civil conflict. This course, called Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness was very well organized, with didactics on a range of topics from the health consequences of internal displacement, to the portrayal of Africans in the Western media. We also were able to spend time on the wards seeing patients with a range of diseases and syndromes common in the region. The keystone of this course, however, is the international student body. Half of the medical students study at Gulu University and hailed from around Uganda. The other half were American and European. This enabled fantastic discussions with different perspectives on the issues we were studying, and planted the seeds of long-term friendships between colleagues from around the world. I enjoyed my time there so much that I went back to Gulu for another clinical rotation later that semester.

If you have any questions about the course or are interested in applying, please email the course directors at: social.medicine@yahoo.com. Applications are due July 30, 2010.

Figure 1.

For the first time in the 15 year-long search for an HIV prevention method that women can control, a vaginal microbicide gel called Viread has been shown to decrease the risk of HIV infection by as much as 54%.  Even though the microbicide does not prevent transmission in every woman who uses it, this is the first promising tool that women are able to use without the cooperation of the male partner.  This is an important consideration most of the new HIV infections in women living in Africa were acquired through forced sex with infected men who refuse to wear condoms. Women and girls represent 60 percent of the 22 million people infected with HIV living in Africa.

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Despite being one of the world’s poorest nations, Rwanda has had national health insurance, know as health mutual, for the past 11 years. With two dollar a year premiums, an overwhelming 92 percent of the nation’s 9.7 million people are currently covered. While the coverage is not extravagant, it covers the major causes of illness and death in the region including diarrhea, malaria, pneumonia, malnutrition and infected wounds. Further, this basic health insurance provides access to local health centers which usually have all the medicines on the World Health Organization’s list of essential drugs as well as laboratories providing routine blood and urine analyses, in addition to tuberculosis and malaria tests. This access to health care has had a measurable impact on average life expectancy, which has risen from 48 to 52 years of age since the introduction of health mutual despite a continuing AIDS epidemic.

In order to achieve such coverage for only two dollars a year, the government of Rwanda must receive supplemental help from outside organizations such as Partners in Health, The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US government. Additionally, the plan requires co-pays which can be cost prohibitive for many patients. For example, a Caesarean section requires a five dollar co-pay which many patients cannot afford.

For more on this issue check out the New York Time’s recent article, this info sheet from the World Bank and this article in the bulletin of the World Health Organization.

From Science Speaks, an excellent blog from the staff of the Infectious Diseases Center for Global Health Policy, comes an interview with Dr. Eric Goosby, the U.S. Global AIDS ambassador.

Q: Roxana Rogers, USAID’s South Africa health team leader, said recently in South Africa that, “US government funding is going to come down dramatically over the next five years.” True?
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For the past seven years, the United States has supported and expanded its program to fight HIV/AIDS in developing nations, underwriting almost half of the world’s AIDS relief. But some are concerned by recent setbacks in the global campaign to fight disease in the developing world. At a time when the numbers of people infected with HIV is beginning to increase after stabilizing in countries like Uganda and the number of people in need of treatment is rapidly expanding, the US funding has not kept pace. With updated World Health Organization guidelines, the number of HIV-infected people eligible for treatment has expanded to 14 million, a large increase from the only 4 million people current in treatment.

In the face of this expanding pool of people in need, US government funding seems to be staying stable. For example, at the same time that the Obama administration has announced plans to expand HIV treatment to at least 4 million by 2013, they have also signaled no increases in funding budgets through fiscal 2011. Defending the administrations commitment to fight the global pandemic, Eric Goosby, the President’s AIDS czar, stated that “our commitment to universal coverage hasn’t wavered.”

For more on the global fight on AIDS and particularly the fight in Uganda, check out the Wall Street Journal’s January 30th article and slideshow.

According to recent data from the WHO and UNAIDS, the number of people infected with the HIV virus has remained relatively stable, around 33 million around the globe, for the last two years. The data suggests that the number of cases probably peaked in 1996 with the disease stablizing in most regions since then.  The WHO/UNAIDs report suggests that their were 17% fewer new infections worldwide in 2008, compared with 2001. A notable exception is the number of HIV infections in many parts of Africa which remains alarming. Although the rate of new infections has decreased worldwide, only two out of five of those newly infected begin treatment. While around 4 million people were receiving antiretroviral medications at the end of 2008 compared to 3 million in 2007, an additional 5 million people in need of antiretrovirals were not receiving treatment.

It has long been established that high adherence to antriretroviral therapy is associated with slowed progression of HIV infection and increased survival, but a recent study by researchers at the Johns Hopkins Bloomberg School of Public Health suggest that high antiretroviral therapy adherence is also associated with lower health care costs. Their study suggests that improved health outcomes associated with high adherence to HIV therapy results in an overall median monthly health care cost savings of $85 per patient in a cohort of 6,833 HIV-infected adults in South Africa. A large component of this cost savings resulted from a decreased need for hospitalization in patients with high adherence to antiretroviral therapy. These results suggest that effective, practical strategies are needed to encourage and actively monitor antiretroviral therapy adherance in order to improve patient outcomes and, in the process, save much need health care resources.

More details on the study can be found in the January 5, 2010 issue of Annals of Internal Medicine.

This is a guest post by Leah Bevis and Alison Hayward, MD for Uganda Village Project, an IFMSA transnational project. There are many ways to get involved with UVP, including through summer internships. – Sujal Parikh

Naigaga Florence lives in Bulumwaki Village, a small, extremely rural community in eastern Uganda. A thin, toothless, but smiling old woman, we first sighted her at a village outreach – in her arms was the most malnourished child that any of us had ever seen. The child’s eyes were dull, his hair a few blondish wisps on a dry skull. His tiny limbs were mere bones draped in shriveled skin, and his head lolled on his neck as if about to fall off completely. His name was Alfred, and he suffered from severe malnutrition, since his mother had died and was unable to breastfeed him. Without breastmilk’s protection, babies in the rural villages of Uganda face a grim prognosis. They are fed a thin gruel of flour and water which provides hardly any calories, or the protein they need to grow.   Read the rest of this entry →