Dr. Rebeca Plank is the Principal Investigator of a new clinical trial, Infant Male Circumcision in Gaborone, Botswana, and Surrounding Areas: Feasibility, Safety and Acceptability. Plank is an Infectious Disease and HIV specialist who trained at the Brigham and Women’s Hospital in Boston. She recently spoke with Martha Henry, Editor of Spotlight Continue reading
Introduction by: Pamela Barnes, President and CEO, Elizabeth Glaser Pediatric AIDS Foundation
Edited by: Richard Marlink, MD, Senior Advisor, Medical and Scientific Affairs, Elizabeth Glaser Pediatric AIDS Foundation and Professor of Public Health, Harvard School of Public Health; Sara Teitelman, MPH, Senior Technical Editor, Elizabeth Glaser Pediatric AIDS Foundation
Format: From the Ground Up consists of three softcover volumes presented inside of a hardcover slipcase. The full content of the book is also available as a searchable CD-ROM.Description: From the Ground Up is a three-volume collection of best practices and lessons learned by 320 distinguished HIV/AIDS professionals from around the globe, with a special focus on sub-Saharan Africa. This groundbreaking publication is being produced by the Elizabeth Glaser Pediatric AIDS Foundation with support from the “A Day in the Life of Africa” AIDS Education Fund, the U.S. Centers for Disease Control and Prevention, Harvard University, and others. In an unprecedented move for a publication of this size and quality, the Foundation is offering the book free of charge in the hope that it will reach the widest possible audience, especially those doing program implementation work “on the ground” in resource-limited settings.
Content: Each volume is named after an essential step in HIV/AIDS program implementation. Volume one, “Laying a Strong Foundation,” highlights the key elements that should be in place prior to program initiation. Volume two, “Establishing a Framework for Success,” touches on both scientific and practical considerations for the provision of HIV-related care, treatment, and prevention services. Volume three, “Developing Pathways and Partnerships,” looks at ways in which implementers, once programs have been established, can ensure that services reach those who need them most. Chapters in each volume are grouped together by topic area, making the publication an easy-to-navigate, comprehensive summary of practical considerations for HIV/AIDS programs in the 21st century. Volumes also feature several profiles of extraordinary individuals on the “front lines” of the pandemic, ranging from a community health nurse in western Kenya to the first African religious leader to publicly disclose his HIV-positive status. These profiles include color photographs taken by award-winning photojournalist Dominic Chavez (formerly of the Boston Globe) and words by John Donnelly (also formerly with the Boston Globe).
Contributor Affiliations: Contributors to this publication are affiliated with many well-known institutions, including: AIDS Support Organization (TASO) Uganda, Baylor College of Medicine, Brown University, Centers for Disease Control and Prevention, Cheikh Anta Diop University in Senegal, Chiang Mai University in Thailand, EngenderHealth, Family Health International, François-Xavier Bagnoud Center, George Washington University, Global Network of People Living with HIV, Harvard Medical School, Harvard School of Public Health, International Council of Nurses, International Rescue Committee, John Snow Inc., Johns Hopkins Bloomberg School of Public Health, Mailman School of Public Health at Columbia University, Kings College London, Makerere University in Uganda, Management Sciences for Health, Ministries of Health (Botswana, Cambodia, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe), Nelson Mandela School of Medicine at the University of KwaZulu-Natal in South Africa, Northwestern University, Pangaea Global AIDS Foundation, Stanford University, UNAIDS, University of Alabama at Birmingham, University of California Los Angeles, University of California San Francisco, University of Cape Town in South Africa, University of Jos in Nigeria, University of Maryland, University of North Carolina at Chapel Hill, University of Washington, University of the Witwatersrand in South Africa, Vanderbilt University, World Bank Institute, World Health Organization, and many others.
Volume I Contents
Richard G. Marlink and Sara J. Teitelman
Pamela W. Barnes
Pamela W. Barnes
Leadership Profile: Mara Banda
Introduction to Volume I: Laying a Strong Foundation
Leadership Profile: Daniel Ongayi
Estimating Health Workforce Needs for Antiretroviral Theraproviral Therapy
Andrew M. Fullem & Lisa R. Hirschhorn
9 Sidebar: Task Shifting in Botswana: Equipping Nurses to Manage and Dispense Antiretroviral Drugs
Overcoming Human-Resources-for-Health Challenges at the Service Delivery Level
Stephen N. Kinoti and Nigel Liveley
23 Sidebar: Task Shifting Guidelines in the Era of HiV Program Expansion
Francesca Celletti, Badara Samb, Anna Francesca Wright, Alan Greenberg, and Joan Holloway
Caring for Caregivers: Lessions Learned in Addressing the Needs of Health-Care Workers Affected by HIV/AIDS
Michael Vitols, Dorothy Gillian Ngoma, Olive Ngandu, and Isaac Sulwe
Popular Training Methodologies and Applications
Elizabeth McCarthy, Anne Sliney, and Megan O’Brien
42 Sidebar: The Development and Application of a Distance Learning Tool for HIV Care and Treatment
Fransje van der Waals
Curriculum Development and Training for Comprehensive HIV Care
73 Sidebar: Training and Treating at the Same Time: Experiences with National HIV/AIDS Training in Nigeria
James C. Shepherd, Abdulrazaq Habib, and Patrick Dakum
Supporting National ART Scale-Up in Botwana through Standardized, Multiphased Training
Christine Bussman, Ndwapi Ndwapi, Tendani Gaolathe, Hermann Bussmann, C. William Wester, Patricia Ncube, Ava Avalos, Madisa Minda, Daniel Baxter, Elang Mabe, Patricia Burns, Joseph Makhema, and Richard Marlink.
Development and Implementation of Training Packages for PMTCT and Pediatric HIV Care
Linda S. Podhurst, Mary Jo Hoyt, Farai Dube, Nomfundo Nhlapo, Lucy Connell, and Robert Ayisi
Training and Clinical Mentorship to Support the Scale-Up of Pediatric HIV CAre: Lessons Learned from Uganda
Developing National Training Materials for PRevention of Mother-to-Child Transmission of HIV: The Zimbabwe Experience
Agnes Mahomva, Anna Miller, and Rumbidzai Mugwagwa
Expanding the Roles of Nurses and Advanced Practice Nursing in HIV/AIDS Care
142 Sidebar: The UCSF ASPIRE Nurse Training Program
Catherine Lyons, Project ASPIRE, University of California, San Francisco
144 Sidebar: Expriences and Challenges among Nurses in Malawi
Evelyn B. Chilemba, Kamuzu College fo Nursing, University of Malawio
LABORATORY AND PHARMACY SERVICES
Challenges in Developing Laboratory Capacity and Infrastructure to Support HIV/AIDS Care Programs
John. N. Nkengasong, Deborah Birx, and Jean-Louis Sankale
Developing Laboratoreis to Support HIV0RElated Service and Research Activities in Sub-Sarahan Africa
Wendy Stevens and Deborah K. Glencross
Managing Medicines and Supplies for HIV/AIDS Program Scale-Up
Helena Walkowiak and Doublas Keene
HIV/AIDS Drug Procurement and Supply Chain Management
Yasmin Chandani, Eric Takan, Claudia Allers, and Collen McLaughlin
Lower-Cost Laboratory Monitoring for CD4 T-Lymphocyte Enumeration, HIV RNA Quanititaion, and Drug Resistance
Seble Kassaye, Cybele Renault, and Dennis M. Israelski
Expanding the Role of Pharmacy Staff in Antiretroviral Therapy
Helena Walkowiak and Douglas Keene
MONITORING, EVALUATION, AND QUALITY OF CARE
The Third One: Monitoring and Evaluation of HIV Programs
John Puvimanasinghe, Wayne Gill and Eduard Beck
The Third One in Practice: Monitoring and Evaluation of the Botswana National HIV Response
John Puvimanasinghe Wayne Gill and Eduard Beck
The Importance of Standard Operation Procedures for HIV Care
Leine Stuart, Eric van Praag, Babajide Keshinro, and Mukadi Ya Diul
Wuality Management in HIV Care
Lisa R. Hischhorn and Bruce D. Agins
Achieving and Maintaining Quality in HIV Care: Lessons Learned from Zambia
Mary Morris and Nicole M. Quiterio
HUMAN RIGHTS AND HIV CARE
Universal Access: Are National Strategic Plans SEnsitive to Human Rights?
Daniel Tarantola and Sofia Gruskin
Human Rights and Women’s Empowerment in the Context of HIV and AIDS
Overcoming Obstacles to Care and Treatment for Women Living with HIV
Deloris Dockrey and Lynde Francis
386 Sidebar: Transforming Male Gender Norms to Address the Root Causes of HIV and AIDS
Adopting Human Rights Standards int he Scale-Up of HIV/AIDS Care: Lessions Learned from Argentina, Botswa, and Thailand
Shyami Puvimanasinghe, Christine Stegling, Karyn Kaplan, Mabel Bianco, and Paisan Suwannawong
HIV Care, Treatment, and Prevention in Conflict Settings
Susan Purdin, Wendy Venter, and Roxanne Saucier
Barriers to HIV/AIDS Prevention, Care, and Treatment for Men Who Have Sex with Men
Vasu Reddy and Theo Sandfort
Volume II Contents
Introduction: Establishing a Framework for SuccessMichel Kazatchkine
Leadership Profile: Sam Phiri
SCIENCE AND TREATMENT OF HIV INFECTION
Biology and Variation in HIV-2 and HIV-1
Phyllis J. Kanki and Seema Thakore Meloni
Immunology of HIV Infection and the Host Response
Desmond J. Martin
Immunology of HIV-1 and the Host Response in Children
Sibyl Greelen and Debbie van Baarle
Fundamentals of Antiretroviral Therapy
Antiretroviral Treatment Failure, Drug Resistance, and Management of Therapy-Experienced Patients
Babafemi Taiwo and Robert Murphy
Drug-Drug Interaction in HIV Disease Management
Hermann Bussmann and Kimberly K. Scarsi
Recognition and Management of Antiretroviral Toxicities in Adults
C. William Wester and Hermann Bussman
Immune Reconstitution Inflammatory Syndrome
Lewis J. Haddow, Phillippa Easterbrook, and Mahomed-Yunus S. Moosa
Injecting Drug Users and HIV: Issues in Care and Treatment
Eric P. Goosby and Deborah von Zinkermagel
Sidebar: Compassionate Care for Injecting Drug Users
Timothy P. Planigan and Josiah Rich
HIV/AIDS and Nutrition in the Era of Antiretroviral Therapy: Programmatic Implications for Care and Treatment
Julia L. Finkelstein, Ferdinant M. Mugasi, Saurabh Mehta, and Wafaie W. Fawzi
HIV Postexposure Prophylaxis: General Recommendations and Lessons Learned from Jos University Teaching Hospital, Nigeria
Raphael Onu Ojoh, John Idoko, Bitrus Badung, Patricia Agaba, and Oche Agbaji
OPPORTUNISTIC INFECTIONS, CANCERS, AND COINFECTIONS
An Algorithmic Approach to the Diagnosis and Management of Headache and Visual Loss in People Living with HIV
Andrew D. Kambugu and Juliet Otiti Sengeri
Treatment of HIV-Associated Kaposi’s Sarcoma
Gastrointestinal Conditions in People Living wtih HIV
Iris De Ryck, Seilavath Ros, Lut Lynen, and Robert Colebunders
Identification and Management of Cutaneous Manifestations of HIV in Adults and Children
Anisa Mosam and Avumile Mankahla
Chronic Hepatitis B and HIV
Debika Bhattacharya, Norah J. Shire, and Emmet B. Keeffe
Prevention and Management of Malaria Infection in People Living with HIV
Paula E. Brentligner and Christpher B. Behrens
Diagnosis and Management of Sexually Transmitted Infections and Considerations for Women Living with HIV
Anjali Sharma, Jack DeHovitz, Elizabeth Mbizvo, and Francis Ndowa
Human Papillomavirus and Cervical Dysplasia in Women Living with HIV
Cynthia S. Firnhaber
Building a Cervical Cancer Prevention Program into the HIV Care and Treatment Infrastructure in Zambia
Goesbeck P. Parham, Mulindi Mwanahammuntu, Krista Pfaendler, Gricelia Mkumba, Vikrant V. Sahasrabuddhe, Michael L. Hicks, Edith Welty, and Jeffrey S. A. Stringer
PREVENTION AND MANAGEMENT OF TUBERCULOSIS
Diagnosis, Treatment and Prevention of Tuberculosis in People Living with HIV
Steward E. Reid and Micheal E. Kimerling
Diagnosis, Treatment, and Prevention of Tuberclosis in Infants and Children Living with HIV
Alwyn Mwinga and Carolyn Bolton Moore
Approaches to Prevention and Management of Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis
Sheela Shenoi, Anthony Moll, and Gerald Friedland
Expanding the Role of Nurses in TB Prevention, Care and Treatment
Building Laboratory Capacity for Rapid Detetion and Diagnosis of Tuberculosis
Integration of TB and HIV Care in Large, Urban Primary Health Centers: Lessons Learned from Lusaka, Zambia
Hennifer Hrris, Kelly Randels, Nzali Kancheya, Bushimbwa Tambatamba Chapula, and Steward Reid
Integrating TB and HIV Care: Lessons Learned from Rwanda
Livinus Bangendanye, Martin Ngabonziza, Blaise Karibushi, Dominique Rwakunda, Usabinema Agathe, Jean Batiste Sahaha, Eric van Praag, Deborah Murrah, and Mukadi Ya Diul
HIV PREVENTION, COUNSELING, AND TESTING
Rethinking Approaches to HIV Prevention
Sidebar: Anti-HIV Microbicides: Paving the Way Forward
Jeremy Nuttall, Saul Walker, Caroline Galbreath, Pamela Norick and Zeda Rosenberg
Positive Prevention in Africa: A Plan for Action
Rebecca Bunnell, Rachek King, Nafuna Wamai, Esther Agali, Jaco Homsy, and Jonathan Mermin
Public-Health Interventions for HIV Prevention: Treatment of Sexually Transmitted Infections and Adult Male Circumcision
Vikrant V. Saharabuddhe, Laura E. Tharpe, Katherine L. Allen, and Sten H. Vermund
HSV-2 Treatment Interventions to Control HIV: Hope for the Future?
Sinead Delany-Moretlwe and Connie Celum
Theory and Practice of HIV Counseling and Testing
Claudes M. Kamenga and Gloria Sangiwa
Routine HIV Testing: The Botswana Experience
Sheri D. Weiser, Lisa M. Butler, Vincent I. Iacopino, and Shyami Puvimanasinghe
Sidebar: Provider-Initiated HIV Testing and Counseling an Human Rights: Reflections on the Botswana Experience
Shyami Puvimanasinghe and Uyapo Ndadi
Couples HIV Counseling and Testing as and Entry Point to HIV Care
Anchilla Mary Owor, Andrew Mujungira, and Linda Kavuma
PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV
Issues in Mother-to-Child Transmission of HIV: Breastfeeding Transmission
Dhayendre Moodley and Hoosen Coovadia
Overview of Prevention of Mother-to-Child Transmission of HIV
Isaac Adewole and Solomon Sagay
A Review of Clinical Efficacy Trials and Guidelines for the Prevention of Mother-to-Child Transmission of HIV during Pregnancy, Labor, and Delivery
Special Considerations for the Administration of Combination Antiretroviral Therapy during Pregnancy
Elizabeth M. Stringer and Benjamin H. Chi
Drug Resistance following the Use of Antiretrovirals for Prevention of Mother-to-Child Transmission of HIV: Prevalence and Implications for Treatment Response
The Evolution of Prevention of Mother-to-Child Transmission: From Simple to More Complex Regimens
Sphie Le Coeur, Suparat Karnjanavanit, Nipunporn Voramongkol, Siripon Kanshana, Somsack Pattarakulwanich, Virat Klinbuayam, Suporn Koetsawang, and Marc Lallemant
Prevention of Mother-to-Child Transmission as an Entry Point to Care and Treatment
Gonzague Jourdain, Intira Collins, Federica Fregonese, Sarakij Bhakeecheep, Chureeratana Bowonwatanuwong, Prapap Yuthavisuthi, Jullapong Achalapong, Guttiga Halue, and Sophie Le Coeur.
PEDIATRIC AND ADOESCENT HIV CARE
Approaches to Early Infant Diagnosis of HIV
Wendy Stevens and Gayle Sherman
Diagnosis of HIV Infection in Infants and Children: Lessons Learned from Johannesburg, South Africa
Gayle G. Sherman
Early Diagnosis and Care of HIV-Exposed Infants: Lessons Learned from Thailand
Intira Collins, Pranee Leechanachai, Wasna Siriungsi, Tassana Leusaree, Sorakji Bhakeecheep, and Nicole Gno-Giang-Huong
Simplified Approaches to Pediatric HIV Screening
Anniek J. De Baets, Jose Ramet, and Philippe Lepage
Improving Identification and Follow-Up of HIV Exposed Children in Zimbabwe
Agnes Mahomva, Rufaro Madzima, And Anna Miller
Principles of Pediatric Antiretroviral Therapy
Tammy Meyers, Heather Jaspan, Helena Rabie and Mark Cotton
Follow up and Adherence Management for Children and Adolescents Living with HIV
Sidebar: Bringing Children Affected by HIV and AIDS Back from the Brink: The Maddox Chivan Children’s Center for the Cambodian Health Committee
Marie-Pierre Fernandez, Sok Thim, and Anne E. Goldfeld
Nutrition, HIV and Antiretroviral Therapy in Infants and Children
Katherine A. Krasovec, Wafaie Fawzi, and Nigel Rollins
Treatment and Prevention of Opportunistic Infections in Children Living with HIV
Maxensia Owor, Mary Glenn Flowler, Heather Jaspan, Helena Rabie, Mark Cotton, and Philippa Musoke
Programming Considerations for Youth-Friendly HIV Care and Treatment Services
Smita Kuma, Kristin Mmari and William Barns
Sidebar: Meeting the Psychosocial Nees of Children and Adolescents Living with HIV through Health Worker Training
Volume III Contents
Introduction: Developing Pathways and Partnerships
Leadership Profile: Syprose Adhiambo Oduor
ROLLING OUT AND SCALING UP
Principles and Experiences in National Antiretroviral Therapy Roll-Out
Alfredo E. Vergara, Americo Assan, And Sten H. Vermund
Cost and Cost-Effectiveness of Antiretroviral Treatement Delivery
Sydney Rosen, Lawrence Long, and Ian Sanne
Implementing the Continuum of Care for HIV: Lessons Learned from Tanzania
Eric van Praag, Rowland Swai, Gottlieb Mpangile, an Feddy Mwana
The MTCT-Plus Initiative: Engaging Women and Families in Care through PMTCT Services
Elaine J. Abrams, Patricia Toro, Deo Wabwire, Robin Flam, Philippa Musoke, and Wafaa El-Sadr
Scaling Up Antiretroviral Therapy in Malawi: Achievements and Challenges
Anthody D. Harries, Smon D. Makombe, Erik J. Schouten, and Kelita Kamoto
Implementing a National Pediatric Antiretroviral Therapy Program: Lessons Learned from Mozambique
Paula Vas, Giberto Manhica, Carlo Giaquinto, and Stephane Blance
Implementing Comprehensive Care for Children Living with HIV at the District Level
Anniek J. De Baets, Philippe Lepage, and Jose Ramet
Youth-Friendly Services for HIV Prevention, Treatment, and Care: The Tuungane Youth Project, Kenya
Kawango Ago and Jacob Odhiambo Onyango
Pediatric Antiretroviral Therapy Roll-Out: Lessons Learned from KwaZulu-Natal, South Africa
Integration of HIV Care for Pediatric Populations
Joseph I. Harwell, Elizabeth Dufort and David Pugatch
Sidebar: Addressing the Hunger Needs of the Family and Communicty: A Nutrition Initiative within and HIV Care Program
Elizabeth Durfort, Winstone Nyandiko, and Joseph I. Harwell
Sidebar: The Mondol Mith Chuoy Mith Center and the Cambodian Continuum of Care
Bunna Kim, Mean Chhi Vun, Joseph I. Harwell, and David Pugatch
The Role of Social and Behavior Change Communication in Combating HIV/AIDS
Susan Krenn and Rupali Limaye
Communications Strategies for HIV/AIDS in Africa: Lessons Learned in Ethiopia and Senegal
Collins O. Airhihenbuwa, Fekerte Belete, Khadidiatou Ndiaye, and Cheikh I. Niang
The Growing Importance of Community-Based Care
Joia S. Mukherjee and Fernet Leandre
Principles of Adult and Pediatric Palliative Care
Kimberly Green and Carla Horne
Provision of Palliative Care in South Africa: Lessons Learned from the Hospice Palliative Care Association
Kath Defilippi and Sue Cameron
Peer Education in HIV/AIDS Care and Treatment Programs
Sidebar: A Peer Educator’s Story: Experience Working in HIV/AIDS Program Management and Advocacy as an HIV Peer Counselor in Nigeria
Mobilizing the Community to Expand Access to HIV Testing, Care, and Treatment: Lessons Learned
Peter Mugyenyi, Cissy Kityo, Francis Ssali, and Augustin Muhwezi
Sidebar: The Creativity Initiative: Empowering People Living with HIV to Become “Change Agents”
Keith PWJ McAdam, Andrew Kambugu, Leah Thayer, Penny AS McAdam, and Caleb
The Use of Midwives and Traditional Birth Attendants in HIV Care
Freddy Perez and Tih Pius Muffih
The Role of Traditional Healers in Comprehensive HIV/AIDS Prevention and Care in Africa: Untapped Opportunities
Rachel King, Dorothy Balaba, Bwira Kaboru, Donna Kabatesi, Anastasia Pharris, and Jaco Homsy
Use of Laypeople to Scale Up HIV Testing and Antiretroviral Therapy in Uganda
Michael Etukoit, Christine Nabiryo, and Alex Coutinho
Principles of Adult and Pediatric Home-Based Care: Lessons Learned from Thailand
Wilawan Senaratana, Pikul Nantachaipan, and Chomnard Potjanamart
LEADERSHIP AND PARTNERSHIPS
Surveying the Global HIV/AIDS Landscape
Rose McCullough and Lior Miller
Clinical and Community Provision of Care and Treatment for Children Living with HIV in Zimbabwe: National Policy and Strategy Development
Matthews Maruva, Jo Keatinge, Anna Miller, Geoff Foster, and Filda Bwakura
Part of the Solution: Faith-Based Responses to HIV and AIDS in Africa
Sidebar: World Health Organization Studies Show Faith-Based Organizations’ Engagement in HIV/AIDS Care Is Extensive and Crucial
The Case for Integrating Reproductive Health and HIV/AIDS Programs
Approaches to Linking HIV Prevention, Care, and Treatment with Sexual and Reproductive Health Services
Michael T. Mbizvo
Expanding Access to HIV Care and Prevention through Successful Public-Private Partnerships: Lessons Learned from Botswana
Joan Sullivan, Lesego Busang, L.R.G. Manthe, and Themba L. Moeti
Public-Private Partnerships: From Theory to Practice
R. Sebastian Wanless, John Damonti, Phangisile Mtshali, and Patricia Doykos
Leadership Profile: Gideon Byamugisha
FAQs From the Ground Up
Q: Why did the Elizabeth Glaser Pediatric AIDS Foundation decide to create this publication?
A: The rapid scale-up of HIV/AIDS care programs now underway in many countries signals a pivotal point in the global response. The Foundation led this project to broaden our own base of knowledge about the current state of HIV/AIDS program implementation, and to encourage the consideration of these lessons by others in our field.
Q: Where did the funding for this publication come from?
A: The project began with a seed grant from “A Day in the Life of Africa” AIDS Education Fund. Additional support was received from the U.S. Centers for Disease Control and Prevention (CDC) as part of the Foundation’s Project HEART initiative (Cooperative Agreement U62/CCU123541), as well as in-kind support from Harvard University and other institutions.
Q: How many authors contributed to the text and how were they selected?
A: Over 320 authors contributed to this text. Authors for each chapter were selected based on their established expertise in a given area of practice. Other contributors to the publication included a team of section editors and expert technical reviewers responsible for content review and a scientific advisory board, consisting of respected authorities on international HIV/AIDS care.
Q: Were the authors paid to participate in this effort?
A: All authors volunteered their time for this collaboration. Each will receive a complimentary copy of the book as remuneration for their contribution.
Q: Is all of the information in the book officially endorsed by the Elizabeth Glaser Pediatric AIDS Foundation?
A: The views, opinions, and recommendations in each chapter are those of the authors alone and do not express the official views of the Foundation, its partners, or its financial supporters.
Q: Is this book a “how-to” manual?
A: From the Ground Up is not a “how-to” manual. Rather, it is a collection of many different viewpoints and experiences, each as unique as its authors. These experiences, together with the scientific and programmatic evidence on which they are based, form the backbone of what is sometimes referred to as the “science of implementation.” Readers will be enriched by learning what professionals in a range of disciplines have been able to accomplish in this diverse field, with these lessons providing a rich context for guidelines and standard operating procedures found elsewhere.
A: Orders for booksets and CD-ROMs containing the full content of the print publication may be placed by visiting at: http://www.pedaids.org/pages/contact-us. The book is being provided free of charge to individuals; shipping and handling fees may apply.Q: How can I order a copy? How much will it cost?
Q: Where did the photos on the covers come from?
A: The images appearing on the cover of each volume are from a social arts initiative entitled “The House is Small but the Welcome is Big” led by the California-based Venice Arts organization. This project aims to explore the impact of the AIDS epidemic as seen through the eyes of women and youth affected by HIV and AIDS. For more information on this project, visit http://thehouseissmall.org.
Q: Will this book be translated into other languages?
A: There are no current plans to translate the book into other languages, but this may be considered in the future if there is sufficient demand.
Q: Who can I contact for more information about this publication?
A: General inquiries may be sent to firstname.lastname@example.org.
On November 25th, 2009, Harvard President Drew Faust spent a day in Botswana, touring the clinics and lab of the Botswana–Harvard AIDS Institute Partnership. She met with doctors, researchers, and students to learn about AIDS research being conducted in southern Africa as part of Harvard’s growing commitment to global health.
When the United Nations presented their 2009 Progress Report on HIV/AIDS in late September, there was good news. Over a million people in the developing world began treatment with antiretroviral drugs (ARVs) last year. Tremendous strides have been made in preventing mother-to-child transmission of HIV. Yet the news was tempered by the fact that 2.7 million people became newly infected in 2007, the last year for which estimates exist. Preventing new adult infections has been a losing battle in Africa and elsewhere.
Only by preventing new infections in sexually active teenagers and adults will we begin to see a true end to the AIDS epidemic. The Mochudi Project is designed to address exactly this problem.
Mochudi, a village of about 40,000 people in southern Botswana, is the site of a new research project by the Harvard AIDS Initiative. The village has an adult HIV prevalence of 25%. The Mochudi Project will take a comprehensive, community-based approach to HIV prevention. It combines established prevention methods, along with several innovative methods that will be tested for the first time.
Treating Acute Infection
The Project will emphasize the detection and treatment of acute (recent) HIV infections. When a person is infected with HIV, his or her viral load (the amount of HIV virus in the body) climbs steeply in the first weeks of infection. In the usual course of HIV infection, the body’s immune system brings the viral load under control after several weeks or months, dramatically reducing the level of HIV for a number of years. When viral load drops, the risk of transmission also drops. Yet until this happens, a person with acute infection is more likely to infect others, especially if he or she is involved in more than one relationship.
An added concern is that about 25% of people infected with HIV-1C, the virus of southern Africa, seem to have high viral loads that are prolonged for up to one or two years after infection, much longer than others. This subset of highly infectious people may be responsible for the majority of transmissions, making them an important group to reach with prevention programs. This is a hypothesis that researchers will test.
By identifying men and women recently infected with HIV and starting them on antiretroviral treatment to reduce their viral load, we hope to prevent new adult infections. This “test and treat” strategy is similar in principle to the successful strategy of giving pregnant women ARVs to prevent them from passing the virus to their infants. By targeting therapy to the most infectious individuals, we hope to significantly reduce the rate of new infections in the village.
Contact Tracing and Viral Sequencing
We will also use new tools in genetics to map how HIV spreads within a community. By comparing viral genetic sequences of new infections, we will be able to tell how closely related they are to each other. Comparing viral sequences will help us investigate the tendency of people with new infections to group together in what is known as a Transmission Cluster. In effect, we will be able to draw an anonymous map of how HIV actually spreads within a village. This information will be crucial in helping to adapt prevention efforts to what is actually happening in Mochudi.
Using What Works
Though the Project will evaluate several promising new strategies for HIV prevention, it also incorporates interventions already in use, including Voluntary Counseling and Testing (VCT), condom use, male circumcision, and education about risk reduction with respect to number of sexual partners. Recent studies about the effect of circumcision have been promising. Three randomized trials in sub-Saharan Africa designed to measure the impact of male circumcision on HIV infection among heterosexual men showed a strong protective effect, with about a 60% reduction in the risk of infection.
Another important component of the Mochudi Project is to quantify the effectiveness of several different prevention methods being used at the same time. To accomplish this, mathematical models will be developed to identify synergies among prevention methods. Evaluation of the cost-effectiveness of combined methods will also be performed.
Ambitious in scope, the Mochudi Project combines the best of what we already know about HIV/AIDS prevention with promising new methods. The ultimate goal of the Project is to evaluate prevention interventions that could be scaled up for Botswana and southern Africa. The more local goal is to slow and eventually stop the spread of HIV/AIDS in one village in Botswana.
The Mochudi Project has received initial funding from the National Institutes of Health (NIH) to demonstrate the feasibility and acceptability of the program. We are seeking additional funding to carry the program through to completion.
Dr. Stephen Lagakos, an international leader in biostatistics and AIDS research and professor of biostatistics at the Harvard School of Public Health (HSPH), died in an auto collision on Monday, October 12th in Peterborough, New Hampshire. He was 63 years old. His wife, Regina, and his mother, Helen, were also killed in the daytime accident, along with the driver of the other car. Continue reading