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Archive for the ‘Population & Reproductive Health’ Category

Microbicides – Where are they Now? How much have we spent?

I was just sent this information (thanks to Becky!) about a new round of funding for microbicides, which comes on the heels of promising results from a trial of the PRO2000 microbicide candidate. We covered this a couple of years ago and at the time I said – the potential of this drug is revolutionary. With microbicides there was great excitement and hope, then there was failure and now there is some maturity. Okay, maybe I am overstating the case, the take home point is that we still don’t have a product and this is not cheap, easy, or quick. Developing a drug is complicated, involves huge risk, can take decades and is highly uncertain. Let’s review the drug development time line again for those of you not familiar – the graph below gives the most simplistic picture:


The early microbicide discussions took place almost 15 years ago (International Working Group on Vaginal Microbicides, source). Over half that amount of time, from 2000-2007, $1.1 Billion has already been invested in microbicide R&D! It takes anywhere from $200M to $1 Billion to bring a single novel drug to market. Let’s hope one of these compounds works and makes it through phase III. But how much will we have spent? $2 Billion, $3 billion? If it works, it will have been worth the money, however, we must ask if we took the most efficient financial route to get to the end point and if there were better financial models – that is a valid question.

Maternova: Life Changing Technology for Women and Children

Cat Laine over at AIDG alerted me to Maternova…After a little bit of effort I think I finally figured out what they are up to, and the potential is exciting. From what I can tell, Maternova is acting as a clearinghouse and agent to spur the production of low cost life changing technologies in the area of maternal and child health. They are building a portfolio of innovative projects and products. What they are doing is critical for many reasons, one is that they are filling a major gap by coordinating and organizing in one particular area. There are many individuals and groups working globally on similar issues, however attempting to bring some of these ideas together under one umbrella is much more powerful than those projects standing alone.

Here is an introduction to 2 of their several products:

“Embrace is a $25 incubator designed to save premature and low birth weight babies. The product’s mission is to help the 20 million vulnerable babies born every year around the world, who can’t access traditional incubators that cost up to $20,000.  It is not yet on the market.”


“Study findings show the use of a neoprene suit can save the lives of women suffering from obstetrical hemorrhaging due to childbirth. Hemorrhaging accounts for about 30 percent of the more than 500,000 maternal deaths worldwide each year due to childbirth…”

I read on the Maternova website that they are thinking about linking up with mothers in the US as one funding stream. This seems like a great idea, especially if it is to get high volume low cost donations (e.g. <$10-$20). Part of the sales pitch could include an appeal to our global community – today we truly live in a global community and are inextricably linked to one another. Our fates are intertwined like never before. I could see making a pitch like this to appeal to new grandparents, parents, uncles and aunts to make donations in the name of their newborns. I’ll follow up with more information on Maternova…

Written by Aman

November 16, 2008 at 9:11 pm

Global Health Council 2: “Small is beautiful, but big is necessary”

Yesterday’s plenary session The First Mile: Setting the Framework for Effective Community Health Systems was a global health conference experiment.  The session linked the Global Health Council Conference (Washington, D.C.) to the Geneva Health Forum by video conference.  Keep in mind these were sessions attended by hundreds of people on both sides.  Louis Loutan, who modertated from Geneva, a self-professed “technical skeptic”, was so impressed by the technical success of the video conference that he proposed it as a model that we need to consider for future meetings.

Both meetings had complementary themes this year: “Community Health” and “Strengthening Health Systems and the Global Health Workforce”, respectively.  This session brought together these themes in the context of community health systems. 

Here’s who was involved from each side:

  • Sigrun Møgedal, HIV/AIDS Ambassador, NORAD, Ministry of Foreign Affairs, Norway
  • Frank K. Nyonator, Director, Policy, Planning, Monitoring, and Evaluation Division, Ghana Health Service, Ghana  
  • Halfdan Mahler, Former Director-General WHO, Switzerland
  • Moderator: Louis Loutan, MD, Head, Service of International and Humanitarian Medicine, Department of Community Medicine of Primary Care, University Hospitals, Geneva, Switzerland
Washington, D.C.:
  • Fazle Hasan Abed, Founder and Chair, Bangladesh Rural Advancement Committee (BRAC)
  • Gretchen Glode Berggren, MD, MScHyg, Consultant, International Health and Nutrition
  • Molly Melching, Founder and Executive Director, Tostan
  • Moderator: Nils Daulaire, MD, MPH, President and CEO, Global Health Council

I’m really happy that I attended this session because of the shift in thinking that it seems to represent.  Key quotes from each of the 6 people on the panels (tried to get quotes verbatim, but will be off by a few words):

  • “Health must not only be seen as a whole internally, but also externally as an integral part of social and economic development.” -Mahler [he had a beautiful metaphor involving kaleidoscopes, but I didn’t capture it – he also quoted Mark Twain and Niels Bohr]
  • “Maybe we can’t do great things, but we can do small things with great love.” -Berggren, quoting Mother Teresa who said this at the Global Health Council Conference in the 1980’s
  • “Doing holistic healthcare was hard, it was messy … it lost its energy” -Møgedal
  • “We need someone nearby, who tells us what’s wrong, what to do, and where to go.” – Nyonator, quoting an opinion leader from a community in Nigeria describing what is needed in terms of healthcare workforce
  • “If 10 people dig, and 10 people fill, we have plenty of dust, but no hole.” -Melching, citing one of her favorite African proverbs
  • “Small is beautiful, but big is necessary.” -Abed, describing BRAC’s village health worker system in Bangladesh

There were five themes throughout the session that stood out to me:

  1. Revisiting Alma-Ata
  2. Collective impatience
  3. Listen to the people
  4. Changing social norms
  5. Community health workers
The issue of food security was a recurrent one throughout.  The overall message was that there needs to be an increased emphasis on holistic primary healthcare using community resources, that understanding social norms was critical to success in improving health, and that this will take time.
Revisiting Alma-Ata
  • Why it came up: the WHO Declaration of Alma-Ata (PDF) is celebrating its 30th anniversary in September, Dr. Mahler directed the creation of the declaration, the WHO has recently recommitted to strengthening primary health care, and the theme of both conferences and this session were very relevant to Alma-Ata
  • There was a “total betrayal of Alma-Ata within months” because structural adjustment programs (e.g. FMI) “sapped energy” from health systems and “made it impossible for developing countries to conduct experiments necessary to test the recommendations achieved by global consensus” -Mahler
  • At the time, one of Mahler’s colleagues told him “It is not doable. We must only do what is doable.”
  • Alma-Ata is about “bottom-up” approaches and “social justice” -Møgedal
  • “It’s not about convincing your adversaries that they’re wrong, but it’s about uniting with your adversaries at a higher level of insight.” -Mahler
Collective impatience
  • “It takes time.” “We suffer from ‘Instant Coffee Syndrome’.” -Berggren
  • Møgedal spoke of an impatience that we have in addressing the problems of global health in the context of a “broad-based global health push”.
Listening to the people
  • “Let’s go back and listen to the people.” “Everyone deserves a home visit.” “We must return to be more in touch with people.” -Berggren
  • We need to think “where people are” and “what makes a difference to people” -Møgedal
Changing social norms
  • “We must change social norms.” -Nyonator
  • Melching spoke of the role of social networks and testimonials (not her words) in effecting behavior change in FGC (female genital cutting) with Tostan in West Africa.  She called this the “organized diffusion approach”.  The goal was “widespread change of social norms.”
  • We need “change agents and fieldworkers.” -Abed
Community health workers
  • “How come we keep talking about community health workers without talking about the support that they need?” “Work at each problem … solution in each context.” -Møgedal
  • “Community-based health workers need extra arms and legs.” “We must work with groups.” -Berggren

Written by Jaspal

May 28, 2008 at 9:54 am

Experts Call for Rethinking AIDS Money

This week’s KaiserNetwork report just hit the two hottest topics for me on HIV right now: male circumcision (Rwanda now has a formal program) and the flattening of vertical HIV funds into primary care, 30 years after the Alma Atta conference had called for a universal primary care package.

“In the two decades since AIDS began sweeping the globe, it has often been labeled as the biggest threat to international health. But with revised numbers downsizing the pandemic — along with an admission that AIDS peaked in the late 1990s — some AIDS experts are now wondering if it might be wise to shift some of the billions of dollars of AIDS money to basic health problems like clean water, family planning or diarrhea.”

“If we look at the data objectively, we are spending too much on AIDS,” said Dr. Malcolm Potts, an AIDS expert at the University of California, Berkeley, who once worked with prostitutes on the front lines of the epidemic in Ghana.

Read the full story at the KFF.

P.S. The CGD blog (Is donor spending on AIDS a “Gross Misallocation of Resources”?) highlights findings from a recent paper on global health funding for HIV, population, infectious disease control, and broad health sector support. Two key points:

  • donor support for AIDS has grown from around 5% of total health commitments in 1992-3 to about 30% in 2003-5, a six-fold increase of AIDS’ share, but
  • funding for general health sector support is the fastest rising category in absolute terms in the years 2003-5

Written by Ben

January 24, 2008 at 11:00 pm

First year improvements in Uganda OBA clinic utilization and claims quality

This piece is cross-posted from the Uganda output-based aid (OBA) site which just got a major under-the-hood overhaul in its move to a blog format. The Uganda OBA project contracts private clinics to see qualified patients for complaints of suspected sexually transmitted infections (STIs). Patients who buy a subsidized voucher from local drug shops and pharmacies are entitled to seek care for themselves and their partner at any of the contracted clinics. Clinics are reimbursed on a negotiated fee-for-service schedule.

The following report (“VSHD, 2007, Assessment of OBA Clinic Utilization”) is an evaluation of the OBA program’s first year impact on utilization at participating clinics (July 2006 to June 2007).  The study, led by Berkeley graduate students Richard Lowe and Ben Bellows, was undertaken June to August 2007 and required an extensive review of thousands of handwritten lab and outpatient entries at OBA facilities. Records were kept differently at many of the clinics and,at several clinics, data were simply not available. However, we have information from 7 of the 16 clinics and they indicate a strong patient uptake and program improvement in the first year of OBA. One of the more dramatic findings is that the total number of patient visits at contracted clinics increased 226% in the first year of OBA compared to the year before OBA.

It does not appear that patients who have attended OBA clinics simply substituted the OBA voucher for their own out-of-pocket spending. Taking all seven clinics together, the number of non-OBA patients seeking STI treatment actually increased in the first year of OBA. One likely reason is that social marketing stimulated greater demand for STI treatment beyond the voucher-using population.

Program adherence also appears to be improving over the first year of OBA as the number of fully paid claims increased from 30% of all submitted claims in July/August 2006 to 70% of all claims in June 2007. Although it should be stressed that claims quality varied significantly between providers.

There is some concern about the quality of lab testing at participating clinics. Lab technicians could benefit from better on-site follow-up and incentives for high quality diagnoses. However, the percent of positive gonorrhea tests more than doubled, indicating increased awareness of this infection in the community and at provider clinics.

The report paints a detailed picture of the participating clinics in their first year of OBA and it is hoped that findings can be used for program improvement as the expansion is planned.

Our many thanks go to both Microcare and MSI who graciously assisted with our many requests for supplemental data and assistance reaching clinic providers. Many thanks as well to the KfW Development Bank and the Bixby Program at UC Berkeley for funding the research.

Written by Ben

January 16, 2008 at 3:09 am

Thailand approves production of patented HIV, cardiovascular drugs

The titles of these two articles – Thailand to break AIDS, heart drugs patents from ETNA (Thailand) and Thailand backs patent drug copies from the BBC – suggest different actions on behalf of the Thai government, but they both report on the same: Thailand has approved production of patented HIV and cardiovascular pharmaceuticals.  The drugs in question are Kaletra, an antiretroviral protease inhibitor produced by Abbott Laboratories, and Plavix, an anti-clotting agent from Sanofi-Aventis and Bristol-Myers Squibb.

From the ETNA article:

BANGKOK, Jan 30 (TNA) – The Thai Public Health Ministry confirmed Monday that it has issued compulsory licenses for the production of two drugs, one for the treatment of HIV/AIDS and another for a cardiovascular drug, paving the way for immediate production and imports of lower-cost generic versions.


[Thai Public Health Minister Dr Mongkol na Songkhla] said the decision to break the patents was not taken lightly but the move was necessary to ensure that the affected Thai patients have access to cheaper generic versions of the life-saving drugs.

He added that generic production of Plavix, for instance, would reduce the cost from about 70 baht (US$2.06) a pill to less than six baht (18 cents).

This is the second time Thailand’s military-backed government has broken an international drug patent in the interest of the health needs of the country’s poor.

In November it introduced Thailand’s first compulsory licencing for Merck’s Efavirenz anti-retroviral AIDS treatment.

HIV/AIDS Awareness and Prevention Through Animation-Based Curriculum

Interactive Teaching Aids, Learning ScaffoldingPiya Sorcar, of the Learning, Design and Technology Program at Stanford University is leading Interactive Teaching AIDS (ITA), an initiative to develop “an animation-based curriculum to teach HIV/AIDS awareness and prevention strategies.” There are currently two versions of the application in development, one for India and one “general Asian version”.

I had the opportunity to speak with Piya about her work:

Why cartoon animations?

When I started this project last year, as part of my research I interviewed dozens of people on this subject. I couldn’t understand why so much misinformation was out there about a virus which many organizations have tried to combat through strong dedication and millions of dollars. After many interviews and running an IRB-approved study in India, I realized that people averse to discussing HIV/AIDS because of the stigma associated with its connection to discussing sexual practices. The educational materials are actually quite simple, it is getting the education to the people that is hard. Fighting stigma is not easy and we know this because people are so embarrassed and frightened of asking simple questions that in the long run might save their lives. I wanted to use cartoons to make the subject less embarrassing, to enhance learner comfort. When I originally ran the IRB-approved study in India, I gauged the comfort of students in learning HIV/AIDS material with various illustrations. People were most comfortable with simple graphics and actually, the simple graphics seem to get the points across just fine. It was important to me that individuals learn about this subject while feeling comfortable. I felt that cartoons accomplished this mission.

Why emphasize the biology of HIV/AIDS?

HIV/AIDS is a difficult subject to talk about. There are schools that won’t teach the prevention strategies because of its close ties to sexual practices. What we often forget is that HIV is just a virus, and we study viruses in biology classes all the time. By bringing the subject back to the basics, we can discuss it more openly and clearly. In order to prevent the spread of the virus, it’s important to build a coherent conception of where it lives, how it works and how it is transferred. In order to fully understand this, it’s important not to merely memorize a list of safe actions but to understand why a virus spreads.

What is the underlying pedagogy of this initiative?

There are many pedagogical principles utilized, but I would say the most important is based on the cognitive theory that it is important to create a coherent conception in the mind of the individual learning the material. Since in many countries there are few, if any, requirements for students to learn about HIV/AIDS in educational institutions, they tend to learn about it from mass media campaigns through television, billboards and radio. Although there are strong efforts to disseminate HIV/AIDS information in India (among other countries), because of the nature of the aforementioned education strategies, individuals must make sense of short, out-of-context pieces of information on their own. This often leads to misunderstanding as well as the memorization of random fragmented data, which doesn’t build a clear conceptual map. Interactive Teaching AIDS provides calculated learning steps to provide scaffolding for learners, allowing them to develop a coherent conception of basic biology, bodily fluids, transfer of bodily fluids into the human body, and their application to various actions or scenarios. In addition to building on a cognitive approach, we relied on other learning techniques including the use of mnemonic devices as well as Vygotsky’s scaffolding techniques. [See also: ITA Learning Theory & Rationale]

What is the current status of the projects in India and Korea? What makes those initiatives different from one another?

The Asian version of Interactive Teaching AIDS was fully funded by the Medical Research Information Center in Korea, which is funded by the South Korean government. The storyboard, which was developed at Stanford University, was animated by a professional development team and now needs to be translated into several different languages. We plan to test the production version of the project early next year. The prototype for the Indian version is complete and we have just received funding from a couple donors to create a more industry-ready version. Once that is complete we plan to test it throughout India. We hope the testing will provide us with useful data so we can iterate and make the project more effective. Finally we hope to give it away for free to various AIDS control societies, schools and eventually port to mobile devices so the information can truly be viewed in the privacy of one’s home. We are hoping also to partner with various organizations who are interested in the same goal as us – to promote awareness and prevention methods to people all over the world.

What is the overall assessment plan?

As I mentioned earlier, we hope to test this project with many students in Asia in order to inform our design and create a more effective learning tool. We hope to compare and contrast our work to other AIDS and general health education materials.

What are the key challenges ahead? (development, deployment, adoption, behavior change)

I would love to see the educational content available on all mobile devices across Asia. Perhaps governments and mobile service providers would be interested in partnering with us in order to either make this content freely available to download online or better yet, be preinstalled on the buyers cell phone or PDA. In terms of development the challenge is, of course, to develop something that is fairly short yet still gets the message across using limited screen real-estate. Once we have tested this project widely, hopefully we will have a better idea of what works and what doesn’t work and this will inform us in designing a mobile version of the project. Secondly, since there is no universal platform for cell phones, it will be challenging (not to mention expensive) to develop the animation using various scripts. When I ran the study in India, I was appalled that so many college-educated students were misinformed. The number one question was whether there was a cure for AIDS. My goal right now is to inform masses about the virus and prevention strategies. I think we have a huge problem if the population of the country with the greatest number of HIV/AIDS cases in the world doesn’t have a general understanding of how the virus spreads. Once the goal of educating people has been met, this will hopefully lead to behavior change.

Written by Jaspal

December 26, 2006 at 10:58 am

Male circumcision reduces risk of HIV

Yesterday the National Institutes of Health announced the halt of two randomized control trials on male circumcision for HIV prevention. To continue the studies, the investigators believed, would be unethical. From the NIH news release posted on Politics and Policy of HIV/AIDS*:

The trial in Kisumu, Kenya, of 2,784 HIV-negative men showed a 53 percent reduction of HIV acquisition in circumcised men relative to uncircumcised men, while a trial of 4,996 HIV-negative men in Rakai, Uganda, showed that HIV acquisition was reduced by 48 percent in circumcised men.

More from the NIH press release

“Many studies have suggested that male circumcision plays a role in protecting against HIV acquisition,” notes NIAID Director Anthony S. Fauci, M.D. “We now have confirmation—from large, carefully controlled, randomized clinical trials—showing definitively that medically performed circumcision can significantly lower the risk of adult males contracting HIV through heterosexual intercourse. While the initial benefit will be fewer HIV infections in men, ultimately adult male circumcision could lead to fewer infections in women…

Scaling the intervention will be interesting, to say the least. The procedure can be conducted safely on infants, boys and young men in a clean field clinic setting. Risk of minor adverse events is low, though present. It is low cost; one South Africa study estimated the average cost to be $55 per patient and considering that it’s a one-time procedure with an estimated 50-60% reduced rate of infection, it’s likely to be highly cost effective in populations with a high prevalence of HIV.

However, in my own limited time in East Africa, questions about circumcision for HIV prevention raises mixed responses among colleagues. It’s a topic weighted with ethnic and religious identities. Yet, Culture should not be overplayed especially in light of the incredible potential implied by the recent findings. The early response in southern Africa to a similar study finished in Orange Farm last year (see “Swaziland to endorse male circumcision“) suggests that the intervention, given its solid science and policymakers’ strong endorsement, can quickly gain public interest and save lives. A detailed mathmatical model published last July (“Potential impact of male circumcision on HIV in sub-Saharan Africa“) estimates that 1.1 to 3.8 million lives can be saved in the next ten years if male circumcision is scaled quickly across sub-Saharan Africa.

*full disclosure: I help run the Politics and Policy of HIV/AIDS blog and the link and NIH news quote are from a post I made Dec 13th when the MC news was first released.

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Written by Ben

December 14, 2006 at 2:26 pm

Reproducing Inequities (in Haiti)

Last week in Berkeley, I had the chance to hear Catherine Maternowska speak about her new book, Reproducing Inequities. In the book, she reflects on 12 years of fieldwork in Cité Soleil, Haiti, developing a political economy framework to explain the causes of inequities in reproductive health services in an urban slum of Port-au-Prince. In part, what makes it interesting is that she worked in a very dangerous part of Haiti during tumultuous times. Just last week, two Jordanian UN Peacekeepers were shot dead in Cité Soleil (BBC News).

Related to the concerns of technology, health, and development were her observations regarding clinical studies. At one time in Cité Soleil, 22 simultaneous studies were being conducted, including one for Norplant, a subdermal contraceptive. Here is some info from a Population Research International report on the Norplant study:

USAID has carried out Norplant testing in Cite Soleil, one of the poorest communities in Haiti. Norplant insertions were done without the informed consent of the women concerned. Norplant removals were denied or delayed, even to women who suffered extremely severe side effects such as bleeding extensive enough to cause anemia or paralyzing headaches.

Needless to say that the realities of informed consent on-the-ground were very different than the policy of the foreign managing organizations.

Written by Jaspal

December 1, 2006 at 1:46 pm

“The Right to Sutures” – Paul Farmer’s keynote address at APHA

apha-2006.jpgPaul Farmer gave the second of two keynote addresses at today’s opening of the APHA (American Public Health Association) Annual Meeting – the first was from Helene Gayle, now President and CEO of CARE International. In reporting on his address, I have quoted him as directly as possible, and where appropriate.

The theme of this year’s conference is “Public Health and Human Rights”, and as it is in one of Paul Farmer’s backyards (Boston), he was a well-suited speaker. The overall message was an extension of his 1999 article “Pathologies of power: rethinking health and human rights” (American Journal of Public Health, Vol 89, Issue 10 1486-1496). In short, he argued “prevailing orthodoxies” in public health center around the “crude” concepts of sustainability and cost-effectiveness, while the focus should be on social and economic rights. “[Sustainability and cost-effectiveness] are tools we need, not religion.”

The more practical message was that we need to address more immediate, material concerns, such as food, clean water, drugs, and medical supplies – much of which can be considered “wrap around services”.

“There should be a right to sutures. There should be a right to sterile drapes. There should be a right to anesthesia … We will need gloves, sutures, drapes, and hot, clean water. This is uncharted territory for human rights groups. We here are ready to talk about gender inequality, but to few of us are ready to buy generators, sutures, or [operating room] lamps … [This] may not seem sexy to people commenting on health and human rights.”

I was delighted to hear his talk touch on such “unglamorous” issues as supply chain and procurement.

He is still very committed to his ideology of providing equivalent technology to poor people. While this is certainly the most effective and ethical approach in many cases – as he has demonstrated to the rest of the world – it is unclear that this is always in the best interests of poor people. I argue not from the point of “cost-effectiveness”, but rather of “effectiveness”. Take for example his advocacy for clean water and infant formula in Rwanda. A colleague who is an expert on breastfeeding reported that people at this year’s International AIDS Conference were highly critical of this approach because of the increased potential for infant deaths from diarrheal diseases. Significant, comparative research over the last few years has shown that while formula is effective for PMTCT (prevention of mother to child transmission) of HIV, breastfeeding results in fewer overall infant deaths. One key is the lack of access to clean water, which results in diarrheal disease, while another is the protective nature of the breastmilk itself. Farmer’s response, no doubt, would be that Partners in Health will provide all the clean water necessary. Achieving this for small communities will be difficult, but not impossible – achieving it at a large scale will take considerable time. In the short-term, breastfeeding seems to be a much safer bet.

Several nursing colleagues and I went to dinner in Chinatown, where we discussed Farmer’s talk. The consensus was that Farmer often makes it seem as if nothing positive is being done in the sphere of international health.

Despite some concerns about his ideology, he provided a strong, persuasive, and needed message. His quote from a young Kenyan doctor, lamenting about working conditions and supplies, sums it up best: “I did not go to medical school to become a mortuary attendant.”

Written by Jaspal

November 5, 2006 at 8:18 pm