“We abandoned chloroquine when it failed to cure one in four patients and was available everywhere,”…..“We now have a drug that cures 100% of patients but is not available in one in four clinics.”

That is a quote taken from a recent Editorial by the Editors of the PLoS Medicine journal who are calling for what they call a “third wave” in malaria treatment advocacy.

According to the authors of this editorial, the first wave of malaria activism brought to global attention the disparity between the burden of malaria and the amount of money spent on the disease by the international community. Successes during this period include the establishment of the Global Fund and other major new fund raising mechanisms for the disease.

The second wave highlighted the fact that although money was rushing it, much of it was not being spent on the most efficacious malaria treatments, namely ACTs. We have now seen the establishment of the Affordable Medicines Facility for Malaria (AMFm) and much more attention to this issue globally.
Now the big problem, they argue, is that despite the fact that there is money available for treatments and commitment to spend them on the best drugs, the medicines are still not always making it to the patients who need them, largely due to stock-outs of medicines in facilities. They see this as perhaps the biggest barrier to expanded treatment coverage.

This finding should not be terribly surprising, big global solutions tend to start at the top and only when they realize that things are not working do they look one level down to see why the solution did not work (parallels can be drawn with HIV and health human resources). But how is this nitty gritty operational problem going to be solved? It will all depend on health systems, and solutions are likely country specific, but will need to be resolved if global targets are to be met.

A friend of mine, Jeremie Gallien, a brilliant operations researchers at MIT, who normally devotes his energy to figuring out how to get parcels from warehouses to people’s doors or how to get the latest fashions on store shelves as fast as possible, is now working on this problem in Zambia, and I can’t wait to find out what he has learned.

I know that there are lots of other really smart folks out there also working on this important problem, it is just too bad we always have to start at the wrong end of a problem to identify the most important barriers or to foresee them in advance. Perhaps an operations researcher would have said that all along!

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Another big win for the NTDs

On December 8, 2009, in neglected tropical diseases, public health, by Karen Grepin

Last evening I a lecture on the Neglected Tropical Diseases (NTDs) in my Global Health Policy course at NYU-Wagner. One of my students asked whether the many NTD control programs that had sprung up over the years to address these diseases were in fact sustainable – an excellent question. My response was “who ever said they should be?”.

Later that evening I learned some excellent news on the NTD front. After nearly 20 years of tireless work, and thanks in a large part to the help of the Carter Center, Nigeria – once the country the most afflicted by Guinea Worm – is on the verge of declaring victory in the war on the scourge. Guinea Worm – a worm that enters into your body and can grow as long as 3 feet before getting bored and exiting your body in a painful and debilitating way – is among the group of helminthic NTDs and is among what I consider to be the yuckiest diseases on the planet.

The strategy to eradicate this disease is a slow but effective one – all patients infected with the worm are identified, treated, and educated in such a way so that they do not risk spreading the worm to others. The strategy works, it just takes time. Since the mid-1980s, when the Carter Center waged a war against the disease the number of people infected has fallen from a few million to a few thousand, an impressive and significant global health achievement.

Which brings me back to the question of sustainability. Guinea Worm control program, along with other NTD control programs that aim for elimination or eradication, when successful will eventually work themselves out of a job. That is the point. Some NTD programs are likely to be even more short-lived than Guinea Worm control. Therefore, it is not clear that sustainability of these programs should ever be an important goal. Not all diseases, however, share these characteristics.

Plus, some functions of NTD control, for example ongoing disease monitoring and surveillance, are likely to be needed for years after eradication or elimination are achieved and therefore these programs should be integrated into existing health system infrastructure, this is a lesson that has been learned from onchocerciasis elimination and elsewhere. But this is one example of how vertical programming, when well targeted and well implemented, can be a good thing. The NTD community is years ahead of many other disease control programs in terms of their experiences and their learning. It is great when we can learn from great successes such as this one.
For those that can stomach it, here is an excellent video from the NYTimes Science Times from a few years back, with the mandatory views of Guinea Worm extraction.
Photo credit: Vanessa Vick via the NYTimes

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Earlier this week, I attended a symposium entitled “HIV Scale-Up and Global Health Systems” hosted by Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP). During the panel moderated by Stephen Lewis, which included former US President Bill Clinton, the moderator stopped the discussion to make the point that his organization does not use the term “mother-to-child” transmission of HIV because that places to much blame on the woman. Instead, they use the term “vertical transmission” – between generations. I found his emphasis humorous, not because I don’t agree with the idea of not blaming women, but because he was making such a big deal out of what I assumed was essentially the only way children acquired HIV.

Yesterday, Kim Yi Dionne on her blog haba na haba made me aware of a debate that apparently has been brewing under the radar in the HIV community for some time, one that seems to have a small number of ardent supporters, but one that is not readily accepted by the mainstream research community.
It turns out that there are many out there who believe that non-sexual transmission may account for a substantial fraction of HIV infections in some Sub-Saharan African countries, including among children.

A Telegraph article suggests that up to 1/5. Given that we generally assume young children to be sexually inactive, the authors speculate that blood exposure, through needles or through other forms of contamination is to blame. A whole edition of the journal “International Journal of STDs and AIDS” was recently devoted to a review of the research on this topic.

The primary form of evidence that exists to support this view is that a number of sero-prevalence studies have found rates of HIV infection among children to be too high to be explained by vertical transmission alone (I am not quite sure what is a normal rate) as well documented cases of HIV infected children born to HIV negative mothers. There are also qualitative surveys that have asked about all exposure risks and have relatively high rates of reported blood exposures in different populations and that people living in Africa may have much greater exposure to injections and vaccinations than in other parts of the world – partially due to injections for malaria. Together, these studies have been taken together to argue that blood exposure may account for a substantial fraction of transmission in Africa and that it has not received enough attention as it deserves from the prevention community.

I read through some of the research papers and thought some of them made strong inferences from rather limited data (e.g. the 1/5 figure came from a study of children in Swaziland, of which there were only 50 in the sample, and only 11 of which reported to be sero-discordant from their parents. Other issues, such as remarriage, false positives and false negatives, small sample size, and other potential explanations were not given enough discussion) but just the same I found the idea perplexing and interesting. PEPFAR has focused a lot of attention on blood safety in many developing countries, but perhaps more emphasis also needs to be placed on other injections and needle use as well.

Anyone out there know more about this issue that they would be up for sharing?

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