Currently, over 215 million women worldwide want but do not have access to family planning tools. “We’ve made a lot of progress in putting maternal health on the global agenda; now we must call on leaders to put family planning on their to-do list. Every individual deserves this – women, men, and young people,” said Jill Sheffield, President and Founder of Women Deliver.

These speakers reinforced the importance of the demographic dividend – the concept that health and social development, enabled by full access to contraception, are inextricably linked with strong economic growth. They provide examples of success in Asia, where declining fertility, spurred by rising contraceptive use, have led to increased education, improved health, and market-driven economic policies which have allowed for significant income growth.  With an expanded world population of over seven billion, “Now is the time to prioritize family planning – as a strategy to reduce maternal mortality, to improve the lives of women and their families, and ultimately, to enable broad and enduring economic development,” said Dr. Amy Tsui, Director of the Gates Institute for Population and Reproductive Health, Professor at Johns Hopkins Bloomberg School of Public Health, and a lead conference organizer.

To proceed into the future, investments must be made in the health sector maintaining adequate numbers of midwives, OB/GYNs, facilities, etc. and examining past successes around the globe. As Hon. Stephen O’Brien stated, “having a child should bring joy” not dying in childbirth and women must be able to plan for the future. Family planning is smart and cost-effective. As Dr. Osotimehin stated, we must empower young people to take control of their futures along with the future of their countries and make sure that economic and social justice drives this process. Issues of family planning are issues of human rights.

According to Judy Manning from USAID, their priorities include: 1) Improve existing methods to make them more acceptable, easier to use and more affordable like injectable forms of contraceptives. 2) Develop new contraceptives to fill gaps such as duration of effectiveness between 3 month injectables and 5 year inserted rings. 3) Develop technologies that simultaneously prevent pregnancy, HIV & other STDs like the silk diaphragm which delivers tenofovir.

Clearly there is an immense need for family planning access, affordability, and effectiveness. Fortunately, there are also attainable solutions. Meetings such as ICFP brings together a wealth of scientific knowledge, family planning experience, and critical discussions to help ensure that universal access to family planning becomes a reality.

World AIDS Day is a time to renew our commitment to the 34 million people living with HIV/AIDS worldwide and the recent developments revolving around HIV, including several scientific breakthroughs in HIV prevention research and Secretary Clinton’s recent remarks declaring that it is possible to reach an AIDS-free generation, make this an especially exciting time to reflect on the epidemic.

According to Dr. Bertozzi, the strategy of the Bill & Melinda Gates Foundation includes both decreasing new infections and improving quality of life of those currently infected. A large focus of this strategy is on the delivery of current strategies in large part through the Global Fund as well as smaller national programs.

Despite the proven effectiveness of existing prevention approaches, there are limitations. For example, many women are not in a position to insist that their partners wear condoms and daily adherence to prophylactic treatments is difficult. The development of a vaccine and other new prevention options is critical for successfully fighting the epidemic, especially in developing countries. The largest investment in newer technologies is currently in trying to develop a HIV vaccine. As such, a focus is on the success of the RV144 HIV vaccine trial, which recently showed encouraging results in Thailand and advancing that to the next generation of the vaccine with hopes of increased efficacy.

They are also investing heavily on products that can be used by individuals to protect themselves either topically in the vagina or systemically. While daily use of vaginal microbicides has shown mixed results, many reasons may contribute to this, especially lack of adherence which is a common problem with daily use products. To address these challenges, they are working on products which are less dependent on adherence such as a vaginal ring which slowly releases the antiretroviral compound dapivirine and can be left in for up to a month.

Another strategy is systemic daily antiretroviral prophylaxis which has also had mixed results and faces problems with adherence, but looks promising. They are focusing on injectables which can be injected every 1 to 3 months, decreasing the need for adherance. The Gates Foundation is currently supporting clinical trials to evaluate the effectiveness of Pre-exposure prophylaxis (PrEP) such as this for HIV prevention.

Images from the Bill & Melinda Gates Foundation

Additional efforts are on enhancing the delivery of male circumcision and scaling up these programs with fewer resources. Despite three clinical trials demonstrating the protective benefit of the procedure, donors and countries have been slow to invest in voluntary male circumcision for HIV prevention. The foundation is investing in advocacy efforts to encourage more rapid scale-up of male circumcision for HIV prevention and funding research on new technologies and methods for performing male circumcision safely and less expensively. This strategy is so cost effective that it costs more money to NOT implement such programs due to the future treatment savings.

The Gates Foundation is also working towards improving the delivery and effectiveness of current programs. With decreasing funding in a faltering global economy, scale up of treatment has continued at the same pace by improving efficiency of programs. Fortunately this has been happening in HIV treatment. Continuing efforts to reduce the cost of drugs, design and implement more efficient delivery systems and further task shifting and sharing among health providers is needed without compromising care and can even lead to improved quality of care.

Stay tuned to Global Pulse Blog for more views on this monumental speech and its implications.

Yesterday, Secretary of State Hillary Rodham Clinton declared the U.S. government’s intent to create an “AIDS-free generation.” Secretary Clinton outlined a bold plan to reduce new HIV-infections, globally, including the eradication of pediatric HIV by 2015. This new strategy builds upon the success of the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. program that addresses HIV/AIDS in resource-limited settings.

A notable feature of Secretary Clinton’s “AIDS-free generation” initiative is to strengthen healthcare systems in sub-Saharan Africa. Clinton stated:

“We know we can’t create an AIDS-free generation by dictating solutions from Washington. Our in-country partners — including governments, NGOs, and faith-based organizations — need to own and lead their nation’s response. So we are working with ministries of health and local organizations to strengthen their health systems so they can take on an even broader range of health problems.”

Strengthening African healthcare systems is a view echoed by many eminent voices in the global health community. Last year, the Institute of Medicine (IOM) of the National Academy of Sciences authored a report entitled: “Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility.” The IOM report recommended the urgent need to increase African healthcare workforce capacity to address the HIV epidemic.

I offer Secretary Clinton a solution to assist African healthcare workforces and ensure the success of the “AIDS-free generation” initiative. Last year, in an editorial in The New England Journal of Medicine, Vanessa Kerry, Sara Auld, and Paul Farmer reintroduced the idea of enacting a Global Health Service Corp (GHSC). The GHSC, compromised of U.S. healthcare professionals, would provide medical education and technical assistance to enhance the healthcare workforces in low-income countries. The GHSC’s goal would “go beyond that of filling a human resource void to focus on infrastructure development, knowledge transfer, and capacity building.” The GHSC could also offer partial student loan forgiveness for U.S. corps members who engage in service abroad for a specified time period similar to the loan forgiveness offered by the National Health Service Corp.

To address the African healthcare workforce shortage, I encourage Secretary Clinton to adopt the principles of the GHSC. The success of the “AIDS-free generation” initiative depends on the availability of skilled healthcare workers in African resource limited settings. Additionally, the eventual transition from a U.S. to African led HIV/AIDS response requires the U.S. to teach and train healthcare personnel in recipient countries through collaborative partnerships that eventually lead to African ownership of their domestic healthcare needs.

Some may argue that enacting the GHSC, especially in the era of U.S. government austerity measures, is not prudent. However, the funding for the GHSC already exists. In addition to HIV/AIDS prevention and treatment, PEPFAR’s congressional mandate requires the program to “strengthen partner government [healthcare] capacity to lead the response to this epidemic and other health demands.” Last year alone, PEPFAR committed over $734 million in healthcare capacity building initiatives.

Global health is the moral litmus test of our time. As Secretary Clinton asserted: “An AIDS-free generation would be one of the greatest gifts the United States could give to our collective future.” The U.S. should enact the GHSC to ensure the success and sustainability of the “AIDS-free generation” initiative.

-Anand Reddi, The Huffington Post

If you are interested in supporting the Global Health Service Corp please sign the petition to show your support. http://www.globalhealthservicecorps.org/index.php/petition/

Additionally, the Medical Student Section of the American Medical Association is considering a resolution endorsing the GHSC at its 2011 Interim Meeting in New Orleans, Louisiana.

Some of the most incredible health research is taking place in Kenya right now. Because of this work, we are on the cusp of the most exciting new tools in global public health in recent years—the first ever malaria vaccine, gels women can use to protect themselves from HIV, new drugs for neglected diseases that affect the poorest of the poor. Kenya is also rolling out an array of lifesaving new health products that research has already made available, like HIV/AIDS drugs, vaccines to protect children from pneumonia, and insecticide-treated wallpaper that prevents malaria inside people’s homes.

During the GHTC’s recent trip to Kenya, I was fortunate to visit several of these global health research projects, most of them run by our dedicated coalition members like the Drugs for Neglected Diseases initiative (DNDi), PATH, the International Partnership for Microbicides (IPM), Aeras, and the International AIDS Vaccine Initiative (IAVI).

We also saw firsthand how the US is making a huge impact in health research in the country, through the work of agencies like the US Agency for International Development (USAID), Centers for Disease Control and Prevention (CDC), and the Department of Defense (DoD).

3935 – Siaya, Kenya – Kayla Laserson is the Director of the KEMRI/CDC Field Research Station . Photo: Evelyn Hockstain/PATH.

Although we visited a range of projects, I was left with the lasting impression that much of this research is so close to producing new health tools that can lead to amazing innovations in public health. “We are on the verge of breakthroughs in malaria and in TB and in other diseases,” Kayla Laserson, director of the CDC/KEMRI Field Research Station in Kisian, said. “What we really need is continued support so we can get the job done, we can finish it, we can show the impact, we can save hundreds of thousands of lives here and globally.”

We also saw how past commitments to research are already saving lives. For example, research that led to the development of antiretroviral drugs is one of global public health’s biggest success stories.  Rister Kageha, a woman living with HIV close to the town of Kakamega, told us how these drugs had not only saved her life, but also prevented her daughter Sylvia from contracting HIV. Because of these drugs, “I expect to live long,” Rister said, adding that she also hopes for a long life for Sylvia due to the drugs that kept her daughter HIV-negative.

Rister Kageha says antiretroviral drugs saved her life. Photo: Evelyn Hockstein/PATH.

And while past research has led to some health tools already in use, and current research is producing breakthroughs we could see in next five years, other innovations aren’t as far along down the research pipeline. This is why continued US support is critical to sustain the momentum around these new tools, from discovery to delivery. US support for microbicides, for example, has been vital to recent research successes, and must continue while the research continues over the next several years.

A microbicide “is one of the tools that gives us the opportunity that we could actually end the epidemic,” Elizabeth Bukusi, deputy director at the Kenya Medical Research Institute (KEMRI) who works with IPM, said. “I think we can move towards a complete AIDS-free generation that will completely stop the epidemic in its track using microbicides as part of the armament.” She added that the “US has been a critical partner in providing catalystic funds and also in funding a large number of the trials that have looked at microbicides. So US funding is absolutely critical to moving this agenda forward.”

The same can be said of US support for all global health tools, not just microbicides. Fortunately, if Kenya is any indication, the US has a long history of supporting research for health products like vaccines and drugs.This long history should not end anytime soon. It’s imperative that this historical leadership continues, so the groundbreaking research the GHTC saw in Kenya can produce the next generation of lifesaving health tools.

-Kim Lufkin, GHTC

During the week of October 10-14, 2011, the Botswana-UPenn Partnership celebrated its ten year anniversary with events highlighting the past, present and future of the program. Check out the archives to learn more about this program, its history and where it is going!

By Jenna LeMieux, PIH Director of Programs

	Construction on Neno District Hospital in 2007.
	Construction of staff housing in Neno, Malawi.

When I began working for Partners In Health in January of 2007 as a program manager, I thought I had a good sense of the scope and responsibilities of the position I had accepted. I was to help launch the new PIH-supported site in Malawi, Abwenzi Pa Za Umoyo (APZU). I spent about two months in Boston before I moved to Malawi, and during that time was able to make valuable connections to colleagues with expertise in finance, procurement, and human resources. Little did I know how valuable those connections would become.

Looking back now, I am amazed by the complexity and volume of work that awaited our team. I had no idea how varied and lengthy my “to-do” list would be. Partnering with the Ministry of Health, we wanted to immediately begin supporting and improving the care available to patients in Neno District. We set to work on substantial renovations at several health centers, with the goal of providing dignified and well-equipped settings in which patients could receive care. We began planning for the construction of a brand new, two-story district hospital. And we began constructing 26 housing units for the Ministry of Health staff and ourselves.

We hired cleaners, guards, nurses, cooks, and administrative staff. We worked with Village Headmen to identify community health workers. We partnered with local community-based organizations to understand grassroots activities already taking place to educate people about HIV transmission and prevention, and to understand how we could support those activities. We established relationships with hospital equipment and supplies vendors in the nearest large city, and began to renovate a large building that would serve as a warehouse.

Explore the Guide

Our long list of goals was informed and shaped by my colleagues at PIH who had engaged in similar start-up activities in Rwanda and Lesotho, among other places. Their collective experience and wisdom guided our work, and helped us prioritize among a dozen urgent and competing demands. When I first began working in Neno, I was fortunate to have access to individuals who could answer the dozens of questions I had on a daily basis. Their advice and counsel was invaluable, and the Program Management Guide represents our effort to share that collective experience with others.

My work in Neno was supported by a robust network of experienced professionals willing to offer their time and expertise to help guide our work. Those same individuals have pored over this guide, adding the content and stories, sharing their knowledge and advice, which is rooted deeply in PIH philosophy and based on decades of field experience. We hope it will serve as a practical and useful tool for program managers, and for others engaged in this work around the globe.

Check out PIH’s new Program Managment Guide.

Malawi’s Neno District Hospital today.

Short videos of previous courses can be viewed by clicking the desired year: 2010:
http://www.youtube.com/watch?v=gLHGpY4EDwg&feature=related and 2011:
http://www.youtube.com/watch?v=Z2UCUFcXAas.

If you have any questions or are interested in applying, please email
social.medicine@yahoo.com.  Applications are due July 31, 2011.

Field workers in Macha Zambia capture mosquitoes with traps.

Image from JHSPH website

According to the study’s senior author George Dimopoulos, PhD, “We’ve previously shown that the mosquito’s midgut bacteria can activate its immune system and thereby indirectly limit the development of the malaria parasite. In this study we show that certain bacteria can directly block the malaria parasite’s development through the production of free radicals that are detrimental to Plasmodium in the mosquito gut.”

This finding suggests that mosquitoes of the same species and strain sometimes have different resistance to the Plasmodium parasite. Scientists hope that this discovery could lead to new methods to reduce the spread of malaria, for example, by exposing mosquitoes in the wild to this bacterium.

For more on malaria and recent developments in the fight against this global killer, check out our recent blog posting on World Malaria Day.

Johns Hopkins Bloomberg School of Public Health offers several resources for reflecting on the global impact of malaria.

• A debate on eradication of malaria

• The life cycle of malaria

• Nobel laureate Peter Agre’s reflections on achievements and priorities in the struggle to conquer malaria
• Malaria Research News
• The Quest to Develop New Antimalarials
• Malaria History

During a recent Duke Global Health Institute talk as part of Global Health Week 2011, Ugandan physician and HIV/AIDS pioneer Peter Mugyenyi gave a talk on the unresolved AIDS crisis in Africa. In his talk, Mugyenyi reiterated that, although progress has been made in the fight against HIV/AIDS, the epidemic is far from over. He emphasized that the implementation of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have played large roles in saving the lives of millions around the globe. For example, Mugyenyi directs the Joint Clinical Research Center in Kampala, which receives funding from these organizations to bring life-saving antiretroviral therapy to hundreds of thousands of Ugandans. In the following video of Mugyenyi’s talk at Duke, he shares his thoughts on the role of universities in the fight against HIV/AIDS and his hopes and concerns for the future.

Peter Mugyenyi: The Unresolved AIDS Crisis in Africa

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.

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.

The gel was developed by Conrad, a nonprofit organization based in Arlington, Virginia, and funded by the U.S. and South African governments under royalty-free license from Foster City, California-based Gilead, the world’s biggest maker of AIDS medicines. The Bill Gates Foundation also helped fund the trial.

In the clinical trial, coordinated by scientists at the Centre for the AIDS Program Research in South Africa (CAPRISA), the use of the microbicide was compared to a placebo in a group totaling 889 women located in either the urban setting of Durban or the  rural setting of Pietermaritzburg in the KwaZulu-Natal province of South Africa.

The main active ingredient of Viread was a 1% vaginal gel formulation of the nucleotide reverse transcriptase inhibitor tenofivir. The pill form of tenofivir is already used in combination with other antiretroviral agents for the treatment of HIV and works  by slowing HIV’s spread through a patient’s body.  The secret to tenofovir’s success as a topical agent may be that it absorbs into the vaginal wall and into the cells targeted by HIV. Other gels have had to be sufficiently spread around and present in the vagina during intercourse in order to work.

Participants of the clinical trial were instructed to apply the gel 12 hours before and up to 12 hours after intercourse. Participants were told that the gel was experimental and were also counseled to use condoms or another means of HIV prevention. According to the trial results, when compared with the placebo group, women in the tenofovir group showed 39 percent fewer HIV infections. Within the tenofovir group, women who used the gel more than 80 percent of the time had 54 percent fewer infections than women who used the placebo gel .  For women who did not use the gel regulalrly ( less than 80 percent of the time) there was a 28 percent reduction.

Some theories as to why the gel did not perform better:

The net impact seen in the study reflects the combined effect of many variables, only one of them the action of tenofovir, which penetrates into the vaginal tissue, protecting the cells that HIV targets for infection. Other variables include the prevalence of HIV infection in the male population; the number of sexual partners a woman had; the amount of AIDS virus (“viral load”) in an infected man’s semen; concurrent use of condoms; and, most important, the consistency with which a woman used the gel.

For that reason, the researchers said, it’s impossible to say how much protection this microbicide might afford any woman.

“We can only approximate it,” said Salim Abdool Karim of the University of KwaZulu-Natal in Durban, South Africa, who helped lead the study. “What you see is a mixture of the efficacy of the product mixed with the ability to use the product. It is fundamentally dependent on human behavior.”

Other scientists speculated that some women who became infected despite using the tenofovir gel might have been exposed to men with very high HIV load (which occurs soon after infection).

“My most likely explanation is that you have to go up on the dose,” said Anthony S. Fauci, who heads the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. “You may have maxed out on 1 percent,” he said, meaning a more concentrated gel might produce greater protection.

Over the past 15 years, six other microbicides were tested in 11 clinical trials, with none showing a protective effect.  Previous gels relied on drugs that weren’t specifically designed to target HIV.

Another important finding in the trial was that the gel prevented the transmission of genital herpes (caused by the herpes simplex virus-HSV) by 51%.  A genital herpes infection increases the susceptibility to HIV infection because the HSV virus can cause open lesions to form.

If further development and testing continues to be successful, more potent formulations combined with marketing that makes the product more appealing to women could lead to increased prevention of HIV transmission.

A product could be ready as early as 2013 if the results are confirmed by a second study known as Voice that is enrolling patients.

Gilead, which donated the active ingredient in the gel, won’t participate in the commercialization of the product in developing nations. They are unsure of whether or not will market the gel in the U.S. and Europe. Conrad gave the rights to manufacture the gel to the government of South Africa to get the product to women in the country most affected by the disease as quickly as possible.

The findings of the study were described at the 18th International AIDS Conference in Vienna, Austria and the research article was published in Science magazine.

For More Info:

1. Sciencenews
2. Businessweek
3. WashingtonPost

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.

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?

A: No, it’s not true. Every year there’s been an overall increase in funding for PEPFAR, and we’ve also not been in a situation where we’ve had a decrease in any country, certainly not in South Africa. Our funding for South Africa is over a half billion dollars a year. Our resources that go into South Africa are having a huge impact, and I’m not understanding that (comment by Rogers).

We also committed to $120 million recently over two years to specifically address an unexpected shortage of funding for antiretroviral drugs in South Africa in nine provinces. The South African government asked us to be silent (about it during that time.) … It made a lot of sense for us to fund it for the simple reason that we not allow services to be interrupted and allow South Africa to respond to the increase in demand.

Roxana’s statement is based on the fact – I think – that she was used to PEPFAR funding that went up in huge increments every year — so much so they scrambled to find meaningful applications to use the funding for programs. Now we are in an economic crisis, with nowhere near the increase in funding like that, so on a relative level it may feel like a drop in funding.

Q: What happened in South Africa’s shortfall of funding for treatment?

A: PEPFAR has not run out of any antiretroviral drugs in any country, including South Africa. .. But for multiple times we’ve been asked to bail out a country for one or two months (because of drug shortages in the national program or funding shortages). South Africa had run out of resources to pay for the medication in nine provinces, starting in November. It was a significant outlay of resources for us and a real example of cooperation. In addition, we were able to work with the government to ensure their Treasury picks up the bill thereafter, so it doesn’t happen again.

Be sure to read the entire interview.

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.

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.  

For 9 thousand Ugandan shillings – about five dollars –we provided Alfred with one large cup of milk every day for a month. Naigaga scrapes together enough money to buy millet, soy, and maize porridge, and a bit of oil, to mix in with the milk after it is boiled. Alfred grew stronger, became the brown color he ought to have been, gained tiny layer of flesh over his bones. His eyes began to focus. His grandmother Naigaga showed up at every single Uganda Village Project event, greeted our staff with hugs and dancing, and thanked us profusely, over and over again, for saving her grandson’s life. Though he is infinitely more healthy than he was, Alfred’s life is still fragile – propped up, as ridiculous as it seems, by five dollars worth of milk every month.

The majority of Ugandan village children are malnourished. Almost all suffer from mild kwashiorkor, caused by protein deficiency and presenting with a distended stomach, thinning and blonding hair, edema, inadequate growth, and edema. Some suffer from iodine or iron deficiencies, many suffer from Vitamin A deficiencies (which causes a prevalence of eye problems), and the children of very poor families suffer from marasmus (protein and carbohydrate deficiency, basically starvation).Twenty percent of Ugandan children are underweight for their age, and this rate is certainly much higher in the rural villages where Uganda Village Project works.

Malnutrition in children can be deadly on its own, but more often it weakens the immune system, causing a higher incidence of malaria, typhoid, skin infections, respiratory infections, and tuberculosis. Malnourished children who escape death often suffer from reduced physical and mental capacity, and may do poorly in school or be less able to provide for their families in the future.

We are working to prevent and treat child malnutrition in a number of ways, including education, subsidized vegetable seeds for villagers, and training for planting small, water-efficient vegetable gardens. We are also providing emergency aid to severely malnourished babies like Alfred by paying for a cup of milk a day.

While Ugandan children face a variety of challenges, both in health and otherwise, malnutrition is one of the most cross-cutting and deeply rooted of these challenges. By working to prevent malnutrition in rural Iganga, we are working for a better future for the children, and a better future for their society as a whole.

This is an important effort given the impact of mother-to-child transmission of the virus.

• Currently, over 45% of HIV-infected pregnant women receive ARV prophylaxis (up from 10% in 2004)
• Only 15% of children born to mothers infected with HIV in reporting low- and middle-income countries were tested for the virus within the first two months of life
• Only 38% of the over 730,000 children in low- and middle-income countries in need of ARV treatment in 2008 received these medications

For more on these efforts, see press coverage of the Global Fund’s World AIDS Day activities.

Past trials investigating HIV vaccines broach many ethical dilemmas. Several controversial experiments of HIV vaccines have taken place around the world. In 1987, an experimental HIV vaccine was given to healthy children in Zaire before any animal trials had been completed, based on an argument that this was justified given the gravity of the local circumstances. In another trial, researchers conducting a placebo-controlled preventative HIV vaccine trial in Thailand failed to provide intravenous drug using subjects with clean needles, the best proven method for preventing HIV in this population, and did not provide antiretroviral therapy to subjects who became infected during the course of the trial, arguing that this was the standard of care the subjects would have received had they not been enrolled in the trial. Not only does this trial raise concerns about relativising standards of care and exploiting vulnerable populations, but it also brings up the concept of therapeutic misconception. Inevitably many trial subjects, believing that the vaccine trial is therapeutic, will become newly infected with the HIV virus.

While advances and innovations in modern medicine build out of a foundation of clinical research and these advances lead to medical treatments to benefit many, it is important to scrutinize the path which brings these interventions into mainstream scientific medicine. The growing practice of taking clinical trials abroad to developing countries raises several important questions which must be thoughtfully discussed and addressed. Is it appropriate to apply the same regulatory standards and ethical guidelines employed for clinical trials conducted within the United States to trials taking place in developing nations, a decidedly diverse context? How do factors which shape the nature of the health care delivery systems of developing nations impact the conduct of clinical trials in these nations? How do the socioeconomic, cultural, ecological and genetic environments of the subject population affect the results of clinical trials and impact whether this data is generalizable to populations where the treatment will be most commonly utilized? What are the unique ethical challenges which arise when clinical trials are conducted abroad, enrolling vulnerable subjects from developing nations? Reflective, professional, responsible action is needed to address these questions, ensure ethical, quality research conduct and protect vulnerable populations.

Part four of this series introduces telemedicine technology and one application of such technology, teledermatology.

What is Telemedicine?

Telemedicine allows health providers in remote areas to transfer information for medical consultation anywhere in the world and serves to support local health workers through discussion and access to pertinent educational materials. Many nations in the developing world have a dire shortage of doctors and other needed health care resources. Therefore, affordable, easy-to-use technologies are imperative for providing care and much needed educational opportunities as well as reducing the limitations imposed by scarce resources.

There are numerous benefits to telemedicine technology including improving patient access to medical care, empowering providers by serving as an educational tool and allowing for more efficient use of health care resources.

Capturing a clinical photograph for use in a mobile teledermatology consultation from Botswana

The most common form of telemedicine is store-and-forward technology which allows for information capture and transfer to a distinct consultant for review and feedback at a later time. International Teledermatology can be utilized via a standard internet-based service which is currently being used at several urban centers in Africa and around the world or using mobile-phone-based technology.

Teledermatology in sub-Saharan Africa: The Teledermatology Africa Project

One telemedicine project which serves providers and patients in sub-Saharan Africa is The Teledermatology Africa Project, a teleconsultation service and electronic learning program which strives to link medical centers in Sub-Saharan Africa with more specialized dermatology services in Europe and the US. Primary collaborating institutions include Departments of Dermatology, Medical University of Graz, Austria under the director of Dr. Steven Kaddu, and University of Pennsylvania, USA under the direction of Dr. Carrie Kovarik. Since its founding in January 2007, medical centers in Botswana, Eritrea, Malawi, Mozambique, Kenya, Liberia, Lesotho, South Africa, Swaziland, Tanzania and Uganda have utilized the service to receive feedback on dermatologic care. Additionally, the Africa Teledermatology Project provides a valuable educational resource for participants, with a curriculum of educational materials covering general and HIV-related skin diseases, case-based presentations and information on how to participate in the program and perform common dermatologic procedures.

The Africa Teledermatology Project Website

Mobile-phone based technology is increasingly being utilized for transfer of information for teleconsutaltion. Not only is mobile teledermatology an accurate diagnosis tool, it also allows for rapid information exchange and eliminates the need for a computer and internet service, allowing for increased access to teledermatologic consultation services. It also has economic benefits, significantly reducing the need for referrals to dermatologists and reducing the support staff needed. This simple and efficient technology allows the user to capture information and photographs to be sent to a remote dermatologist for consultation and advice regarding diagnosis and management. The user simply gathers and record patient information in the phone, uses the mobile phone to take clinical photographs of the patient, text-records any additional symptoms and submits the consultation to a remote clinician via the mobile phone.

Click Diagnostics, in conjunction with Carrie Kovarik, MD, are developing and validating the use of mobile telemedicine in areas where medical assistance is critically needed, including the diagnosis of cervical cancer, HIV, and skin diseases in rural areas of developing countries.

Botswana has two parallel health systems—the public system and private system—each with its own hospitals, clinics, and physicians. Care in the public sector, including laboratory testing, hospitalization and medications, is free for all Batswana (citizens of Botswana are known as Batswana).

The Princess Marina Hospital

The Princess Marina Hospital (PMH) in the capital of Gaborone is one of the two main public hospitals in Botswana. Patients are commonly referred from smaller district hospitals and outreach clinics to PMH for specialized or complicated care.

In-patients are cared for in medical wards, divided by gender. Spaces are open with many windows to allow for natural ventilation.

The Mathubudukwane clinic in Kgatleng district of Botswana near the Zimbabwe border. Remote clinics like this one provide the majority of care for people living outside of the major cities of Gaborone and Francistown. Everything from pediatric primary care to a basic pharmacy to a delivery room are available at these remote clinics.

Patient laundry drys on bushes in a courtyard of Princess Marina Hospital.

In addition to public and private westernized medicine, there is an important third “health system,” involving traditional medicine and delivered by traditional healers. As a medically pleural society, it is very common for most Batswana to receive health care from both traditional healers and the public system.

Nurses, medical students and local physicians round in the wards of PMH.

Botswana’s first medical school was formed only recently. The first pre-med class began in August 2008.

Botswana started its first internship program in January 2007; prior to this time, all Batswana medical students received their clinical training at hospitals outside Botswana.

Teaching rounds at PMH join local housestaff, attendings and visiting students, residents and attendings to discuss patient cases.

Due to the recent establishment of formalized medical education within the country, around 90% of the physicians in the public hospitals are from outside Botswana. There is a nursing school at the University of Botswana, in the capital Gaborone, so most nurses are Batswana; the rest come from other countries in Africa, China, and Cuba.

Several American universities have developed programs in Botswana. The University of Pennsylvania-Botswana Partnership began in 2001 and UPenn has been working at the public hospital in Gaborone, Princess Marina Hospital, since 2004 and at Nyangabgwe Hospital in Francistown since January 2006. UPenn is also collaborating on the design and implementation of expanded clinical and medical training in Botswana.

The Botswana–Harvard School of Public Health AIDS Initiative was founded in 1996 and has since continued research studies including mother-to-child transmission; mutation rates for Clade C HIV and other biological features of Clade C Virus; Clade C vaccine studies; and several drug studies. This branch of the Harvard AIDS Institute in Botswana is located in the research laboratory at Princess Marina Hospital in Gaborone.

Baylor's Clinical Center in Gaborone

Baylor College of Medicine plays a very important role in outpatient pediatric HIV care and medical education at Princess Marina Hospital. They have maintained a large research and clinical facility, the Botswana-Baylor Children’s Clinical Center of Excellence, at Princess Marina Hospital since the spring of 2003, making a significant contribution to both outpatient and inpatient pediatric care and teaching.

See the International Institute for Health Promotion for more on the healthcare system of Botswana.

And stay tuned for the next part of the series!

Botswana is a landlocked country about the size of Texas located just north of South Africa in southern Africa.

The majority of the 1.84 million population are Setswana (or Tswana) and are concentrated along the eastern part of the country due to the largely uninhabitable Kalahari Desert which occupies most of the rest of the territory. 35% of the population are 0-14 years old; 61% are 15-64 years old; and only 4% of the population is older than 65 years.

70% of people living in Botswana are Christian, 7% have indigenous beliefs, and 20% have no religion. While English is the official language, Setswana is still widely spoken and many older Batswana only speak Setswana.

Formerly known as the British colony of Bechuanaland, Botswana gained independence from the British in 1966, but has a long history of democracy through the tribal meetings of the kgotlas. The country is now a stable democratic parliamentary republic and has a market-based economy among the strongest in Africa. Most of Botswana’s wealth comes from diamond mines most of which are co-owned by DeBeers and the Botswana Government. Beef exports and tourism also contribute to the economy. Despite this socio-economic stability, poverty remains a concern with a large gap between rich and poor existing and unemployment remaining close to 40%. Education and healthcare are free, and the national literacy rate is greater than 80%.

For more general information about Botswana, check out the Botswana Tourism Board and check back for more entries!