Release Type: News Article

Based on new evidence assessing benefits and risks, the WHO recommends the use of the HIV drug dolutegravir (DTG) as the preferred first-line and second-line treatment for all populations, including pregnant women and those of childbearing potential.

Initial studies had highlighted a possible link between DTG and neural tube defects (birth defects of the brain and spinal cord that cause conditions such as spina bifida) in infants born to women using the drug at the time of conception. This potential safety concern was reported in May 2018 from a study in Botswana that found 4 cases of neural tube defects out of 426 women who became pregnant while taking DTG. Based on these preliminary findings, many countries advised pregnant women and women of childbearing potential to take efavirenz (EFV) instead.

New data from two large clinical trials comparing the efficacy and safety of DTG and EFV in Africa have now expanded the evidence base. The risks of neural tube defects are significantly lower than what the initial studies may have suggested.

The guidelines group also considered mathematical models of the benefits and harms associated with the two drugs; the values and preferences of people living with HIV, as well as factors related to the implementation of HIV programmes in different countries, and cost.

DTG is a drug that is more effective, easier to take and has fewer side effects than alternative drugs that are currently used. DTG also has a high genetic barrier to developing drug resistance, which is important given the rising trend of resistance to EFV and nevirapine-based regimens. In 2019, 12 out of 18 countries surveyed by WHO reported pre-treatment drug resistance levels exceeding the recommended threshold of 10%.

All of the above findings informed the decision to update the 2019 guidelines.

In 2019, 82 low- and middle-income countries reported to be transitioning to DTG-based HIV treatment regimens. The new updated recommendations aim to help more countries improve their HIV policies.

As for any medications, informed choice is important. Every treatment decision needs to be based on an informed discussion with the health provider weighing the benefits and potential risks.

WHO also stresses the importance of providing information and options to help women make an informed choice. To this end WHO has convened an advisory group of women living with HIV from diverse backgrounds to advise on policy issues related to their health, including sexual and reproductive health. WHO highlights the need to continually monitor the risk of neural tube defects associated with DTG.

Image: Dr Robert Paulino-Ramirez (centre)

Director of the Institute for Tropical Medicine and Global Health at Universidad Iberoamericana (UNIBE), Dr Robert Paulino-Ramirez, presented on the Dominican Republic’s experience of piloting Pre-Exposure Prophylaxis (PrEP). Dr Paulino-Ramirez made his presentation during the session titled, ‘It’s time for PrEP in Latin America and the Caribbean’ at the 10th International AIDS Society Conference on HIV Science which is being held in Mexico City, Mexico from 20-24 July. Following an 18-month pilot, PrEP implementation is being expanded from 15 July 2019 to two extra sites. Of the 849 persons who were assessed for PrEP, 32 percent (271) started. Acceptability was high among persons targeted. Dr Paulino-Ramirez emphasized the importance of mental health interventions and behaviour change modifications in the delivery of PrEP. The pilot was a collaborative effort by the Ministry of Public Health, DIGECITSS (Dirección General de Control de Infecciones de Transmisión Sexual y VIH/SIDA [Division for Controlling STIs and HIV], PAHO and UNIBE.

Director of PANCAP, Mr Dereck Springer, in an intervention from the floor, shared that The Bahamas and Barbados had led the Caribbean in implementing PrEP. Mr Springer informed the audience that PANCAP, with funding from the Global Fund, had convened a PrEP Share Fair on 16-17 July in Barbados. Eleven countries participated in the event and had the opportunity to learn from The Bahamas and Barbados’ experience through interactive presentations, site visits and stories from clients who are receiving PrEP. He explained that countries also developed action plans, identified support needs and committed to advocating for PrEP’s implementation. The Caribbean is therefore poised to accelerate implementation.

Image: Dr Clarissa Etienne, PAHO Director (centre) 

The PAHO Director, Dr Clarissa Etienne, suggested the need for change in the legislative framework to facilitate the integration of HIV into general health systems. The Director was speaking at the Global Fund Dialogue among leaders on mobilizing and promoting better use of HIV and health investment convened at the 10th International AIDS Society Conference on HIV Science which is being held in Mexico City, Mexico from 20-24 July.

Dr Etienne explained that this requires a legal and institutional framework. She stated that HIV prevention in care should be included in health packages and that emphasis on comprehensive care can reduce cost and improve efficiency. The second priority should be decentralizing of HIV services and strengthening of health care services at the first level of care and referral systems. Thirdly, countries should adopt principles of the primary health care approach – participation, people centeredness, multidisciplinary team, and address stigma and discrimination.

Image: First Lady, Kim Simplis-Barrow, first from left

First Lady of Belize, Kim Simplis-Barrow, called for empowerment of women and girls as a priority for achieving universal health coverage and HIV targets.  The First Lady was speaking at the Global Fund Dialogue among leaders on mobilizing and promoting better use of HIV and health investment convened at the 10^th International AIDS Society Conference on HIV Science which is being held in Mexico City, Mexico from 20-24 July.

Ms Simplis-Barrow emphasized that there is a critical need to address human rights and stigma and discrimination, gender inequality, violence against women and girls and poverty that place them at higher risk. All these issues serve as barriers to access to services. She lauded PANCAP and other partners’ support to Belize in the development of an Anti-Discrimination Legislation. She noted that Spouses of Caribbean Leaders have influence in bringing about an enabling environment.

The First Lady also called for a successful Sixth Replenishment of the Global Fund, which she believes would allow for the global financing mechanism model to continue. She reminded the audience that the Global Fund’s model is client-centred and addresses the holistic health needs of individuals and communities.

PARIS – Sir Elton John joined French President Emmanuel Macron to call on the world to raise at least US$14 billion for the Global Fund to save 16 million lives over the next three years. The two addressed supporters of the Solidays music festival after President Macron presented Sir Elton the Légion d’honneur, France’s highest award, for his lifetime contribution to the arts and the fight against HIV.

“The fight against AIDS has been my passion for many, many years,” said Sir Elton. “We have made such incredible progress, but we cannot become complacent. A fully replenished Global Fund is essential if we are going to consign this disease to history. I commend President Macron for his leadership in this effort.”

Sir Elton was joined by President Macron, who called on the world to step up the fight to save 16 million lives through a successful Replenishment of the Global Fund. Watch the full remarks here.

President Macron presented the award to Sir Elton at a ceremony this afternoon at the Élysée Palace in Paris, in the presence of global health leaders including Peter Sands, Executive Director of the Global Fund and Lelio Marmora, Executive Director of Unitaid.

“Sir Elton John has been one of the most steadfast and outspoken supporters of the fight against HIV, and France is a world leader in rallying support, funding and research to end AIDS,” said Peter Sands, Executive Director of the Global Fund. “This award acknowledges Sir Elton’s lifetime contributions in music, as well as his work to support millions of people living with HIV and AIDS around the world.”

Under President Macron’s leadership, France will host the Global Fund’s Sixth Replenishment pledging conference in Lyon 10 October 2019. The Global Fund seeks to raise at least US$14 billion for the next three years to help save 16 million lives, cut the mortality rate from HIV, TB and malaria in half, and build stronger health systems by 2023.

The Elton John AIDS Foundation, established in 1993, was one of the early groups providing lifesaving treatment and dignified care and support for people living with HIV. Today, the foundation partners with the Global Fund to provide treatment and support to millions of people around the world.

About the Global Fund: The Global Fund is a partnership designed to accelerate the end of AIDS, tuberculosis and malaria as epidemics. As a partnership between governments, civil society, the private sector and people affected by the diseases, the Global Fund mobilizes and invests nearly US$4 billion a year to support programs run by local experts in more than 100 countries. By challenging barriers and embracing innovative approaches, we are working together to better serve people affected by the diseases.

Information on the work of the Global Fund is available at www.theglobalfund.org

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PANCAP convened a Consultation with Faith Leaders in Jamaica on 6 June 2019 at the Bahai Centre, Mountain View, Kingston.  The meeting was held in partnership with the Religious Group Steering Committee (RGSC) and representatives of religious leaders as a follow up to a consultation held in 2017.

The forum was chaired by Rev. Canon Garth Minott, Chair of the Regional Consultative Steering Committee and PANCAP Champion, who announced a new initiative of the Religious leaders in partnership with the Ministry of Health and Wellness, Jamaica. The Jamaica Council of Churches (JCC) has signed an agreement with the Ministry as a sub-sub-recipient of the Global Fund Grant for intervention in human rights advocacy with special focus on reducing stigma and discrimination within religious organizations generally and among religious leaders in particular. A mapping exercise, which is an integral part of the project will assist in identifying religious agencies offering services for healthy living which will serve to enhance the directory of services offered by the National Family Planning Board.

Rev. Canon Minott reported that the RGSC has formed valuable partnerships with the AIDS Healthcare Foundation (AHF), the Joint United Nations Programme on HIV/AIDS (UNAIDS), Ministry of Health and Wellness, the United Theological College of the West Indies (UTCWI) and the Jamaica Theological Seminary (JTS).  He further stated that there has been a meeting with five parliamentarians which resulted in an agreement to focus on providing sensitisation on issues related to sexual health and the role parliamentarians can play as leaders in society.

In his remarks, Dereck Springer, Director of PANCAP shared that significant progress has been made in responding to the HIV epidemic. However, there is still more work to be done to achieve the UNAIDS 90-90-90 Target by 2020 and to end AIDS as a public health threat by 2030. He stated that the national consultations build upon the work that is being done at the regional level and noted that it is at the country-level that the real work is done to address stigma and discrimination that impede individuals’ access to prevention, treatment, care and support services. He lauded the work that is being done by the RGSC in supporting the national response through increased partnership with the Ministry of Health and Wellness, Civil Society Organisations (CSOs), development partners and the private sector. He acknowledged the presence of two persons who are living with HIV and noted that their input is critical for shaping the faith community’s response.

Ms Karlene Temple-Anderson, Grants Manager, Ministry of Health and Wellness, commended the Religious sector’s contribution to Jamaica’s efforts to achieve the UNAIDS 90-90-90. She shared that at the end of 2017, there was an estimated 34,000 People Living with HIV (PLHIV) in Jamaica and 26,426 were diagnosed. However, only 12,908 were on treatment and 7,315 were virally suppressed.   The national prevalence of HIV is 1.8% while the prevalence in Men who have sex with men (MSM) was 29.6% and transgender people 51%.  Female sex workers were 2.0%. As at April 2019, Jamaica now purchases all its anti-retroviral drugs and laboratory reagents and consumables. She noted that partnership with the faith community was helping to fill gaps in the response and that the Faith-Based Organisations (FBOs) are involved at every level of the response including on the Country Coordinating Mechanism for the Global Fund Grants.

Ms Temple-Anderson challenged faith leaders to focus on gender norms and practices that support vulnerability of women and girls, violence against women and girls, norms of masculinity that support poor health-seeking behaviours among men; abstinence, fidelity and partner reduction; elimination of intimate partner and domestic violence, cross-generational relationships between older men and young girls and the need to remove the perception that the Faith community is a place of exclusion rather than a refuge. She also encouraged faith leaders to develop social marketing and mass media campaigns to address prevention, benefits of treatment and retention in care.

Ms Manoela Manova, UNAIDS Country Coordinator for Jamaica stated that there is a public role for FBOs in the response.  She posted that FBOs can overcome obstacles through partnerships and that they have a role to play in creating an enabling environment, increasing testing and retention on treatment and care.  She further stated that FBOs have the power to influence and therefore have a pivotal role in policy and legislative reform and in the development of the national strategic plan for HIV and AIDS.   She advocated for the inclusion of FBOs in developing strategies and policies for vulnerable groups.

Outcomes

Faith leaders agreed to address stigma and discrimination within the faith community, facilitate a dialogue with the community of PLHIV around the benefits of disclosure and to focus efforts on policy, partnership building and training of faith leaders.  They also reached consensus on utilizing knowledge synthesis to disseminate educational material as well as feedback on progress received from the faith community.

National AIDS Programme Managers and Civil Society Organisations are tasked with using innovation for HIV messaging, community/public education and employee training and capacity building. Brainstorming ideas and capturing those new concepts is not an easy task using “old school” text on a whiteboard or recorded minutes.  For your next idea-generation meeting, try “visual notetaking”.

Visual notetaking or “sketchnoting”  is a process of representing ideas non-linguistically (That’s a fancy way of saying, “drawing pictures”). Visual notetaking can include concept mapping but also more artistic ways of visually capturing and representing ideas.

On the simpler side of the visual notetaking continuum, visual notes can be used to create narrated art. On the complex end of the spectrum, some visual notetaking applications support the creation of narrated “sketchnotes” (whiteboard animation videos) which include audio narration synchronised to screencasts of drawings. Visual or graphic facilitation can be used at meetings to summarise presentations and guide discussions. Whether simple or complex, visual notes can be used to more deeply process information as well as communicate it to others with images.

For example, Knowledge Management Coordinator, PANCAP Knowledge for Health Project, Dr Shanti Singh-Anthony introduced Visual Notetaking to the PANCAP Advisory Group on Resource Mobilization in February 2019 to capture the group’s ideas for a marketing approach to PANCAP’s resource mobilisation.  Illustrated below are the results:

The technique proved ideal for concisely capturing the meeting’s ideas for target audiences,  key messages, marketing collaterals and other critical elements of a marketing plan for PANCAP. Dr Singh-Anthony recommends visual note-taking for any activity where ideas must be captured and communicated succinctly.  She posited “The old English adage – a picture is worth a thousand words applies nicely to visual note-taking. Visual note-taking allows you to capture and present complex ideas in ways that are easily understood and remembered. I have found this tool to be extremely useful as a student and professional and highly recommended it!”

To learn more about visual notetaking and some of the other ideas shared in our article, view Rachel Smith’s 18 minute TEDx talk, “Drawing in Class,” which provides an excellent overview about the “what and why” of visual notetaking.

To learn more about how PANCAP utilises Knowledge Management for learning and sharing, click here.

With the support of Gilead Sciences Inc., Spouses of Caribbean Leaders Action Network (SCLAN) partnered with the Ministry of Health, Belize and the Anira Foundation in Guyana to implement the project, “Transforming Lives Through Innovation: Implementation of high-impact prevention programmes for adolescents, young women and men.”

The goal of SCLAN’s project in Belize is to expand access to HIV prevention and treatment to 600 females and 400 males, particularly the high-risk population ages 15-24 years in Dangriga Town, Stann Creek District.

Stann Creek district has the second highest rate of infection and the highest HIV-related mortality. With this information, it was important to begin the project with consultations with various stakeholders working in HIV and sexual and reproductive health.

The sessions were productive and positive feedback was received on effective ways to engage youth and collect essential baseline data to inform an effective peer education programme. Baseline data is a powerful tool to create meaningful policies, strategies and projects.

A community mapping was also completed to determine the target population, which will be exposed to a sexual behaviour survey that will measure knowledge and attitude on sexual practices, gender-based violence as well as other sexual and reproductive issues.

The next steps will involve the creation of peer education target groups, along with a peer education curriculum and public awareness campaign.
For more information on this initiative, contact Judy Waight, Programme Officer, SCLAN at jwaight@sclan.org

Image: Facilitators and participants of the Caribbean Sex Work Coalition (CSWC) capacity building initiative

The Caribbean Sex Work Coalition (CSWC) recently trained 15 members from six of its member countries. Sex Workers from Belize, Barbados, Guyana, Jamaica, Republic of Trinidad and Tobago and Suriname participated in a three-day Sex Worker Implementation Tool (SWIT) workshop followed by a  two-day Organisational Management Training aimed to build the capacity of sex workers to manage their civil society organisations efficiently.

According to Co-chair and Coordinator, CSWC, Miriam Edwards, three days of training were dedicated to building the capacity of sex workers to monitor and evaluate their progress in following the guidelines specified by the SWIT.  The SWIT offers practical guidance on effective HIV and STI programming for sex workers. It provides evidence for the necessity of decriminalisation of sex work, the involvement of sex workers in developing policy, and the empowerment and self-determination of sex working communities as a fundamental part of the fight against HIV.  SWIT was created by the World Health Organization (WHO) and is based on WHO’s 2012 recommendations on HIV and Sex Work.

The SWIT training was supported by the Robert Carr Civil Society Networks Fund (RCNF).

Following the SWIT training, participants were involved in two days of capacity building focused primarily on Financial Management and the Principles of Good Governance. Participants were exposed to the basics of financial management through several practical exercises that included preparing budgets for their organisations, creating vouchers for payments, distinguishing between an invoice and a quotation, understanding the importance of accountability as well as the need for correct documentation for payments.

The Principles of Good Governance and Board Development were also critical elements of the training course. Participants had the opportunity to take part in several leadership exercises. This initiative was funded by the Caribbean Coalition for Vulnerable Communities (CVC).

Written by Lisa Tarantino, Principal Associate | International Development Division | Abt Associates

The process of transition from donor support to country ownership of an HIV response is a daunting challenge for development partners, organisations and countries. If managed well, it can be an opportunity for countries to strengthen their HIV response and improve health system performance. Across the globe, governments, private-sector health care providers, civil society, communities, and development partners are making the transition to a more sustainable HIV approach. The global health community knows the well-documented components of a sustainable HIV response. The President’s Emergency Plan for AIDS Relief’s (PEPFAR) Sustainability Index Dashboard defines them according to the following themes: Governance, Leadership, and Accountability; National Health System and Service Delivery; Strategic Investments, Efficiency, and Sustainable Financing; and Strategic Information.

We have learned by experience that if some of the ingredients of sustainability are missing or inadequate, then the whole response will suffer. Like a cake that falls flat because you forgot to add the eggs, for example, donor transition can fail without a sufficiently robust and engaged civil society.

But a recipe is more than a list of ingredients. The actual amounts, timing and (baking) techniques are vitally important. Technical assistance (TA) could address all the right ingredients and still be ineffective if some are provided too late in the process. As in the example, if you add eggs too late in the process, then the cake could sink later. Similarly, development partners and local stakeholders should address as soon as possible foundational elements that secure the HIV response into full country ownership, such as financing, governance, and institutionalised engagement of non-government actors. Even civil society organisations (CSOs) that provide quality HIV services will flounder without donor funding in the absence of domestic funding, a supportive policy environment, performance monitoring and management capacity. What’s critical is managing the process with a long-term time horizon, political and programmatic engagement and communications, and monitoring and evaluation of the transition’s impact. All of this will help hold the shape of the HIV response together and continue to reduce the incidence of new infections and HIV deaths during the process.

Barbados is in the midst of what looks to be a successful transition from PEPFAR support. The country has been increasing its ownership of the response to HIV over the last 10 years. I have had the (unbelievably) good fortune of working on PEPFAR-funded programs in Barbados and in nine other Caribbean countries during their transition processes. I marvel at the bumpy but doggedly determined process by which Barbados and its development partners have strengthened the country’s HIV response while increasing country ownership with strengthened health financing, multi-sectoral capacity building and engagement, and collaborative stewardship. The TA ingredients came together at roughly the right time and in the right measure to:

•    Strengthen CSO capacity
•    Build private sector engagement and contracting capacity
•    Emphasise a health financing approach
•    Coordinate development assistance
•    Promote regional cross-learning and shared resources
•    Support internal champions in the Government of Barbados
•    Draft a sustainability strategy that reflects a health systems approach

Drawing from the lessons of countries in the Caribbean, here are seven ways that development partners and country stakeholders can ensure this happens:

Develop a clearly communicated long-term transition strategy, with political signalling of the transition by international and national parties and a plan for gradual, planned withdrawal.

Stakeholders and development partners need to coordinate, collaborate and be strategic, avoiding duplication. Country stakeholders should be engaged in this process.

Take a systems approach as early as possible in the transition process.  The HIV response needs to be integrated into a wider, well-functioning system to be sustainable.

Build capacity for institutionalised multi-sectoral engagement. CSOs and the private sector must have a sustainable role within the broader system.

Develop country strategies to sustain the HIV response beyond donor support that are realistic with successful transition as one objective.

Strengthen governance to ensure inclusivity and access. We need a clear-eyed approach to this crucial issue. Development partner-established mechanisms rarely survive. What will be the new or adapted governance structure?

Implement domestic resource mobilisation strategies. Start with data, build capacity for collecting it, obtain adequate funding, and allocate it effectively and efficiently.

Transitioning from donor support is not as easy as baking a cake. Innumerable factors impact whether a transition process succeeds. Development partners can mitigate risks with well-designed and delivered TA: the right ingredients, in the right amount, at the right time, put together and delivered with care.