Kaisernetwork.org (Washington, DC)
25 November 2008
Global Challenges
Kenya Launches Male Circumcision Program
[Nov 25, 2008]
The Kenyan Ministry of Health on Monday launched a voluntary male circumcision program as part of the country's national HIV prevention strategy, the Kenya Broadcasting Corporation reports.
The ministry has allocated one billion Kenyan shillings, or about $13.2 million, for the program over the next two years (Achienga, Kenya Broadcasting Corporation, 11/24). In addition, Family Health International has received an $18.5 million, five-year grant from the Bill & Melinda Gates Foundation to establish the Male Circumcision Consortium in partnership with the Kenyan government, the University of Illinois at Chicago and EngenderHealth. The President's Emergency Plan for AIDS Relief also is supporting the program. The consortium will conduct research and training on the safest and most effective ways to provide male circumcision as part of an HIV prevention strategy.
The consortium's members have consulted officials from the World Health Organization to ensure the consortium's objectives are in line with WHO and UNAIDS recommendations on male circumcision. The consortium will support the Kenyan government and local partners to develop and implement the national male circumcision strategy. It also will expand a research and training center in Kisumu, Kenya, to train providers, increase capacity of health facilities and monitor outcomes. In addition, the consortium aims to address misunderstandings about male circumcision (FHI release, 11/24).
The program will be launched in six districts in Kenya's Nyanza province before being expanded to the rest of the country (Kenya Broadcasting Corporation, 11/24). The initiative aims to reduce HIV prevalence in Kenya by 60%, Public Health and Sanitation Minister James Gesami said Monday at the program launch. Gesami also emphasized the importance of ensuring that all circumcisions are performed in sanitary conditions. "Traditional circumcisers should use septic techniques by not using one knife on several individuals," he said.
WHO Country Representative David Okello said that circumcision should not be seen as an excuse to practice risky behaviors. "Circumcision should be promoted along with other HIV prevention strategies including safer sex, reduction in the number of sexual partners, plus the correct and consistent use of condoms," Okello said (Ndong'a, Capital News, 11/24).
Gesami added that the health ministry will provide no-cost counseling to couples on the benefits of male circumcision to prevent HIV transmission as part of the program. According to the Daily Nation, two-thirds of HIV-positive adults in Kenya are married or in a relationship, and one spouse is HIV-positive in 10% of marriages. Peter Cherutich, head of the national task force on circumcision, said that counseling is critical for couples and that women "have to be involved for the full benefits [of the procedure] to be felt" (Ngirachup, Daily Nation, 11/24).
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Bill To Implant Microchips in 'Sexually Aggressive' HIV-Positive People in Indonesian Province Generates Support, Criticism
[Nov 25, 2008]
An Indonesian bill that includes a bylaw requiring "sexually aggressive" people living with HIV/AIDS to be implanted with microchips is causing debate between some lawmakers, who argue that the bill is necessary to curb the spread of the virus, and advocates, who say the bylaw is discriminatory and a violation of human rights, the AP/Minneapolis Star Tribune reports. According to John Manangsang, a lawmaker who supports the bill, authorities would be able to identify, track and punish people living with HIV/AIDS in the country's province of Papua who intentionally spread the virus with a $5,000 fine or up to six months in jail. In Papua, the HIV prevalence is 15 times the national average at 61 cases per 100,000 people (Karmini, AP/Minneapolis Star Tribune, 11/24).
According to Reuters, Manangsang said the microchip is "a simple technology. A signal from the microchip will track their movements and this will be received by monitoring authorities" (Anjani, Reuters, 11/22). According to the Jakarta Post, the microchips would only be implanted in people living with HIV/AIDS who are labeled as "aggressive." Manangsang said, "Aggressive means actively seeking sexual intercourse" (Flassy, Jakarta Post, 11/22). According to the AP/Star Tribune, a committee would be created to establish which HIV-positive people should be implanted with microchips and to monitor their behavior. The technical and practical details of the bill are still being decided by lawmakers. The provincial parliament of Papua has given its full support to the measure, which will be enacted next month if it receives the expected majority vote (AP/Minneapolis Star Tribune, 11/24). Manangsang said the program is "one way to protect healthy people" and that "real action" must be taken "because 47% of (the country's) HIV/AIDS (cases) are in Papua."
Critics of the bill say it is discriminatory toward people living with HIV/AIDS and a violation of human rights, the Post reports. Constan Karma, executive director of the Papua AIDS Commission, said the law "will violate the rights of people living with HIV/AIDS because they will be implanted with microchips." Gunawan -- a liaison officer of the West Papua chapter of Save Papua -- said that people living with the virus "do not always have sex, especially those with AIDS." He also questioned how officials would measure aggressiveness. Although reported incidents of discrimination against HIV-positive people in Papua have declined, Enita Rouw -- coordinator of the Papua branch of the Indonesian Network of People Infected with HIV -- said that "stigmatization is still there. So please don't use microchips. We are humans, not animals" (Jakarta Post, 11/22). Tahi Ganyang Butarbutar, an advocate in Papua, said that increased funding for sex education and condom promotion would be more effective for addressing the HIV/AIDS epidemic in the region. He also said the people living with the virus "aren't animals; we have to respect their rights" (AP/Minneapolis Star Tribune, 11/24).
Weynand Watari, a lawmaker who supports the bill, said the region's "health situation is extraordinary, so we have to take extraordinary action." According to the AP/Star Tribune, the HIV epidemic in Indonesia is one of the fastest-growing in Asia, with as many as 290,000 cases in the country's population of 235 million. HIV/AIDS in Indonesia primarily is spread through commercial sex work and injection drug use (AP/Minneapolis Star Tribune, 11/24). According to Reuters, the rapid spread of HIV/AIDS in the Papua region primarily is because of inadequate education programs, lack of condoms and partner swapping rituals that take place in the region (Reuters, 11/22). According to the Post, Manangsang said that people should not concentrate solely on the bylaw but should focus on the entirety of the bill, which requires universal HIV testing "so that preventative measures can be taken early on." He also said that "if we respect the rights of the people living with HIV/AIDS, then we must also respect the rights of healthy people" (Jakarta Post, 11/22).
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Nigerian, Ugandan First Ladies Pledge To Work Jointly on HIV/AIDS Issues
[Nov 25, 2008]
Ugandan first lady Janet Museveni and Nigerian first lady Turai Umaru Yar'Adua last week pledged to work together to address HIV/AIDS in their countries, the New Vision/AllAfrica.com reports. The pledge was made in the Nigerian capital of Abuja during Museveni's four-day official visit to the country. Yar'Adua and Museveni were speaking with members of the Nigerian National Women Coalition on AIDS.
According to Yar'Adua, Nigeria and Uganda share several factors that contribute to the spread of HIV, including the fact that poverty, famine, malnutrition and other diseases are widespread in both countries. She added that addressing such issues jointly would work to the advantage of both nations. Yar'Adua also committed to working with Museveni through the Organisation of First Ladies of Africa Against AIDS.
In addition, Museveni said that more serious HIV/AIDS strategies are needed in Africa, with a focus on prevention. "HIV/AIDS has continued to thrive because we have failed to protect ourselves and our children," she said, adding, "We have failed to exercise self control, say no to premarital sex and live faithfully in marriage as embodied in our cultures" (New Vision/AllAfrica.com, 11/21).
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Guardian Examines Continued Challenges in Fight Against HIV/AIDS in Zambia, Uganda
[Nov 25, 2008]
Despite successful efforts to reduce its HIV/AIDS prevalence, Zambia, which "has weathered one of the world's most devastating assaults by" HIV, continues to face obstacles to effectively fight the disease, London's Guardian reports. The country's HIV/AIDS prevalence rate has decreased from about 30% in the 1990s to 14.3% this year, but an estimated 300 to 500 Zambians still contract HIV every day, according to the Guardian. Transmission remains high in the country's urban centers and industrial copper belt, and rural communities are especially affected because of a lack of access to health facilities, chronic shortages of trained health care workers, and cultural stigma and discrimination associated with HIV/AIDS.
According to the Guardian, the European Union-funded Antiretroviral Treatment Community Education and Referral program, run by the International HIV/AIDS Alliance Zambia, since 2004 "has been trying to bridge this gap between health care services and local communities" by building networks of support groups for people living with and affected by HIV/AIDS. "The idea is that these groups will play an active role in shaping and delivering HIV/AIDS treatment and services to their local communities, by encouraging the uptake of treatment and testing," the Guardian reports. More than 200 HIV-positive volunteers also have been trained as treatment support workers and community mobilizers and now provide in-clinic services such as counseling and outreach programs, including home-based care services to complement existing antiretroviral programs. The Guardian reports that the program is so successful that it has been adopted by the International HIV/AIDS Alliance Uganda, where there are now more than 1,200 volunteer "network support agents" working in more than 400 health facilities across 40 districts.
Nevertheless, the Guardian reports that an increasing reliance on volunteers in Zambia has caused concern among some government officials. Albert Mwango, national antiretroviral treatment coordinator at the Ministry of Health, said, "The health system and donors have discovered that these volunteers are a very useful resource to plug the chronic staff shortages we have in our national health system," adding, "Just as the volunteers get dependent on their small monthly stipend, so local health staff end up depending on volunteers. But when they burn out or leave because there is another better paid volunteering job somewhere else, the system suffers."
Following the government's 2005 decision to provide antiretrovirals at no cost, there are now 220,000 Zambians receiving treatment, compared with 15,000 in 2004, the Guardian reports. According to the health ministry, there are an additional 150,000 HIV-positive people who should be on antiretrovirals but cannot be reached because of deficits in trained health care workers who can run drug distribution programs (Guardian [1], 11/24).
In related news, the Guardian reports that although Uganda's battle against HIV/AIDS is regarded as "one of Africa's success stories" since its prevalence rate decreased to about 6% from a peak of 30% in the 1980s, the country's new National HIV/AIDS Strategic Plan "bleakly states the country is some way off beating the epidemic." According to the Guardian, the number of HIV-positive Ugandans is expected to increase from 1.1 million in 2006 to 1.3 million in 2012.
Elizabeth Namagala, senior medical officer for HIV care and treatment at Uganda's Ministry of Health, said, "I think there has been a certain complacency that now we have [antiretrovirals], AIDS isn't the death sentence it once was. Maybe we have taken it for granted that people would still be absorbing the prevention messages." She added, "The situation at the moment is that for every one person we're getting on treatment, there are another five new incidences. Seventy percent of medical admissions are HIV-related, yet we're already facing chronic health care staff shortages. So it's going to be a serious challenge to contain this over the next five years." Milly Katana, country director at AIDS Alliance Uganda, said, "Unfortunately, we are not winning the war against this pandemic at the rate at which we are fighting it," adding, "New infections are increasing and this is an indication that ground is being lost. It's going to take a lot more investment in our health service and a commitment to keep funding the network model of community participation if we want to have a chance of beating it" (Guardian [2], 11/24).
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Across The Nation
Funding, Management Problems Lead Baltimore HIV/AIDS Organization To Close
[Nov 25, 2008]
Baltimore is set to lose its oldest and largest HIV/AIDS service provider, the Baltimore Sun reports. According to the Sun, the Health Education Resource Organization -- which provides services to as many as 3,000 people annually and was once considered a model for international groups -- will close on Wednesday because of funding and management problems.
The Sun reports that private donations to HERO have decreased as HIV/AIDS has become a more manageable disease. In addition, although the organization used to be the only one of its kind, there are now about one dozen or more similar clinics and organizations in the city. The Sun reports that a financial scandal five years ago "left questions about the organization's management practices, further impeding its ability to raise money."
About one year ago, HERO stopped providing clinical services, and employees have been leaving at a steady pace, according to the Sun. It was also revealed this summer that HERO sometimes failed to make payroll and pay its subcontractors. According to the Sun, the city Health Department earlier this month concluded that the organization "was in such dire shape that its federal grant money should be pulled, leaving it all but penniless." The Sun reports that HERO's grant money and clients will be diverted next month to places such as Total Health Care, Women Accepting Responsibility, Chase-Brexton medical clinic and Johns Hopkins Hospital. Baltimore Health Commissioner Joshua Sharfstein said, "The concern was that HERO would just shut down one day and leave clients with nowhere to go. We had to get people into other programs before that happened." However, Alta Cannaday, president of HERO's board of directors, questioned whether other organizations are capable of treating HERO's former clients. "The clients we serve are often homeless. Some are recovering from substance abuse. Everybody doesn't do a great job handling this population. There is no other agency in place to provide that kind of service to people," Cannaday said (Bykowicz, Baltimore Sun, 11/24).
Related Editorial
HERO for years "was one of the most active, best-funded clinical support groups for people with HIV/AIDS in the country," a Sun editorial says, adding, "It provided counseling, medical care, a place to gather and a sympathetic ear to patients who often had nowhere else to turn at a time when AIDS was poorly understood and its victims often stigmatized as unworthy of help." According to the editorial, HERO's "collapse is a sad coda to the contributions of a once-revered local icon," and "past and present HERO clients are shocked and saddened by the news" of its closure. "Aside from its medical, legal and counseling services, HERO gave a lesson in compassion to a city that would become a center of the epidemic," the editorial says, concluding, "And as soon as effective treatments became available, HERO began saving lives. It is likely the epidemic here would have been far worse if not for HERO's courageous, pioneering work. For that, Baltimore always will owe it a debt of gratitude" (Baltimore Sun, 11/25).
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Opinion
Lancet Publishes Opinion Pieces on HIV Prevention, Epidemic in China
[Nov 25, 2008]
The Lancet on Saturday published two editorials about HIV prevention and China's HIV/AIDS epidemic. Summaries appear below.
Merson et al., Lancet: According to Michael Merson of the Duke Global Health Institute and colleagues, HIV prevention cannot be limited to just "one or two stand-alone" measures such as male circumcision or partner reduction. Although such prevention measures are effective and important in the fight against HIV/AIDS, they must be used in combination with other measures, and prevention efforts must "address immediate risk settings as well as social norms and regulatory environments," the authors write, adding, "No quick fix can substitute for the sustained political will needed to ensure these populations are not dehumanized." According to the authors, "Our call to action to fully implement combination prevention is framed in terms of accepting its complexity: neither paralyzed in the face of vast social inequities nor tempted by magic bullet solutions. A revitalized HIV prevention movement needs to move beyond its fixations about whether any specific intervention is more important than the other while ignoring how to achieve them." The authors write, "If we really want to advance the effectiveness of HIV prevention, we have to disabuse ourselves of the notion that the epidemic can be conquered by a single best intervention." They conclude, "Rather, we must focus on scaling up combination efforts and on building the evidence base for which mixes produce maximum effect in which settings" (Merson et al, Lancet, 11/22).
Zhang et al., Lancet: Kong-Lai Zhang of the Institute of Basic Medical Sciences in Beijing and colleagues detail the measures they believe can prevent and treat HIV/AIDS in China, where the disease largely affects low-income and marginalized groups. According to the authors, there is a need for promotion of condom use, needle-exchange programs, and local clinics and laboratories that can provide second- and third-line antiretroviral drugs, as well as specialized expertise. HIV-positive people also must be taught the importance of adhering to antiretrovirals, and those at risk of contracting the virus -- such as men who have sex with men and commercial sex workers -- should be taught proper prevention measures. The authors write, "To stop the spread of the epidemic, additional changes to HIV/AIDS policies, as well as better coordination and implementation of programs, need to be made. HIV/AIDS prevention and care need to be incorporated into routine practices in health care, public health programs, and medical and nursing education to guarantee an effective, efficient and sustainable response. China also needs to mobilize and engage civil society in the fight against HIV/AIDS and to encourage interdisciplinary approaches for HIV research, treatment, care and prevention." They conclude, "We are confident that China will continue to meet the challenges" (Zhang et al. Lancet, 11/22).
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