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Outlining the economic and social toll HIV and AIDS continues to take on workers around the world, the International Labour Organization (ILO) called on Thursday for an “urgent effort” to improve treatment, step up testing and ensure healthier and more productive workplaces.

Prepared in collaboration with the UN agency dedicated to tackling the virus, UNAIDS, The impact of HIV and AIDS on the world of work: Global estimate, examines the past and future effects of the HIV epidemic, and development of antiretroviral therapy (ART), while assessing the economic and social impact on workers and their households.

The report shows that workers’ deaths attributed to HIV and AIDS are projected to fall to 425,000 worldwide in 2020, from 1.3 million in 2005; with people in their late-30s the most affected.

“This is the age workers are normally at the peak of their productive life,” said Guy Ryder, ILO Director-General.

“These deaths are totally avoidable if treatment is scaled up and fast-tracked,” he added.

In addition to the toll on lives, the report indicates that the disease costs billions of dollars in lost earnings – largely due to the hundreds of thousands of preventable HIV- and AIDS-related deaths.

Although the lost earnings have declined substantially from almost $17 billion in 2005, they are still projected to amount to $7.2 billion in 2020.

The good news is that ART is keeping employees healthy and productive, causing the number of workers living with HIV, either fully or partially unable to work, to drop dramatically since 2005.

The total number of those estimated to be fully unable to work is expected to decline to about 40,000 in 2020 from a 2005 level of about 350,000 – an 85 percent decline for men and a 93 percent drop for women.

The report recommended that treatment be scaled up and stressed the need to produce better-integrated health data with social and economic components to capture the full impact of AIDS-related diseases.

The Impact of HIV also looked at “hidden costs,” such as those being exacted on household members.

It predicts that in 2020, some 140,000 children will carry what ILO refers to as the “child-labor level chore burden”, while an additional full-time equivalent of 50,000 workers will perform unpaid care work.

It also shows that the number of workers living with HIV increased from 22.5 million in 2005 to 26.6 million in 2015 and is projected to rise to some 30 million in 2020, even if ART is scaled up.

“Mere scaling up of treatment is not enough,” stressed Mr. Ryder.

“Testing and HIV prevention measures also need to be stepped up if we are going to end AIDS. This makes human sense. And this makes astute economic sense,” he concluded.

The “CCAS EXPERT SUMMIT: From Care to Cure – Towards the Elimination of HIV”, will bring together an array of experts who have been selected not only for their international reputation but also for the vision they bring to their work. The summit is being described as an exciting juncture in the HIV field.  Discussions will focus on the state-of-the-art advances in HIV treatment as practitioners shift the paradigm from care to cure.

The summit will review the dramatic advances in antiretroviral therapy and the public health benefits accruing from treatment as prevention. The Caribbean is LEADING THE WORLD in eliminating mother-to-child transmission, with seven (7) Caribbean countries certified by the UN to have eliminated transmission of HIV from infected pregnant mothers to their infant.  The event will be held at the Coco Palm Hotel, Saint Lucia from 26 – 30 August 2018.

To register, click on the following link: http://www.ccasexpertsummit.org/ 

Image: Participants at SASOD’s Ninth Annual HIV and AIDS Candlelight Memorial

Even though the availability of treatment for HIV and AIDS has increased in Guyana over the years, Programme Manager of the National AIDS Programme (NAPS), Dr. Rhonda Moore has bemoaned that pervasive stigma and discrimination continue to hinder the fight.

Speaking at the ninth annual HIV and AIDS Candlelight Memorial organized by the Society Against Sexual Orientation Discrimination (SASOD) and held at the organization’s Lamaha Springs office, Dr. Moore stressed the need for greater societal involvement in tackling the disease.

According to her, Guyana has made strides in approving the accessibility of treatment for Human Immunodeficiency Virus infection and Acquired Immune Deficiency Syndrome (HIV/AIDS) and making this treatment affordable, even free of cost, yet persons are unable to access these services. “The elephant in the room continues to be stigma and discrimination,” the Programme Manager said.

Adding to her sentiments was Managing Director of SASOD, Joel Simpson, who spotlighted the fact that while persons are discriminated against for having HIV/AIDS, the Lesbian Gay Bisexual Transgender (LBGT) community continues to be further discriminated against and marginalized.

While the provision of medical services is critical, Dr. Moore also posited that cognizance of people’s rights regardless of their sexual orientation, ethnicity, creed or other attributes is tantamount.

Dr. Moore nevertheless noted that persons living with HIV, though discriminated against and are marginalized, are “the greatest teachers” in the efforts to reduce the scourge.

“Without the involvement of persons living with HIV, policymakers will never understand what needs to be done,” she noted.

And despite dwindling donor funding internationally to reduce the HIV/AIDS-related cases, Moore assured that the government remains committed to funding treatment and testing through its National Health Strategy.

The overarching international goals that Guyana has aligned itself with include the elimination of AIDS by 2030 and the achievement of the United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 target of diagnosing 90% of all HIV-positive persons; providing Anti-retroviral Therapy (ART) for 90% of those diagnosed; and achieving viral suppression for 90% of those treated by 2020.

“All Guyanese have a right to quality care,” Moore highlighted but stressed, “This can only be achieved through working together.”

On a macro-level, a Sustainability Oversight Steering Committee has been established by the Public Health Ministry to guide the sustainability plan for continuing the gains already made vis-a-vis the goals outlined. The Committee is chaired by Public Health Minister, Volda Lawrence and includes Junior Health Minister, Dr. Karen Cummings; Dr. Moore; representatives from civil society organizations; representatives from faith-based organizations; and representatives from government ministries, among others.

SASOD has been the local organizer for the annual AIDS Candlelight Memorial in Guyana since 2010. Also in attendance at the Memorial was UNAIDS Country Director, Dr. Martin Odiit; UN Resident Coordinator and UNDP Resident Representative for the Cooperative Republic of Guyana, Mikiko Tanaka; and members and supporters of SASOD.

UNAIDS’ 90-90-90 targets focus on three global goals to be achieved by the year 2020: 90 percent of all people living with HIV will know their status, 90 percent of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90 percent of all people receiving antiretroviral therapy will have viral suppression. To successfully reach this goal, key populations (KPs) most at risk for HIV – including men who have sex with men, people who inject drugs, sex workers, and transgender people – need to be at the center of prevention, care, and treatment programs.

Tracking KPs’ successful access to these services is an essential part of the process of reaching 90-90-90. This is achieved by using a systematic approach to data collection and analysis through a strategic information (SI) system. SI is designed to support and shape long-term strategies for program planning and implementation, responding to stakeholder’s needs, and supporting innovations. More specifically, SI in KP programs generates data so that the decisions made in planning clinical, behavioral, and structural interventions are rooted in evidence.

SI in KP programming

HIV programs that focus on KPs require a specialized SI system to monitor the changes that occur within each population during a program’s implementation. KPs face special challenges in accessing HIV prevention, care, and treatment including their legal status, stigma and discrimination, and the influence of power structures. The information generated by an SI system can be used to identify and manage structural barriers to service uptake and understand the dynamic nature of KP individual’s behavior.

With an SI system, data are collected to ensure that KP programs are monitored from all fronts. Ideally, the system collects information beyond the standard PEPFAR indicators to ensure that data are helping shape program strategies. In the LINKAGES project, an SI system is used to collect data relating to structural interventions, including activities related to violence, stigma and discrimination, advocacy, sensitization, and peer navigation for HIV-positive KPs to ensure improved adherence to care and treatment. It also tracks activities that affect KPs in their day-to-day life and influence their behaviors. This SI system can be further customized based on country or regional needs. The SI system helps program teams with routine monitoring of the quality of their services along the HIV cascade and their progress toward reaching 90-90-90 targets.

The SI system for any KP program includes carefully tailored monitoring tools used to collect data at the grassroots level and subnational level and track the trends and gaps within a program. Data are then aggregated and used for analysis at the national level. The SI system also includes simple analytical tools that show site-level statistics on the various services provided to KPs, including behavioral, clinical, and structural interventions. SI provides the evidence needed to establish and maintain a program-wide approach to data collection, data analysis, data use, and action-oriented program planning processes.

Resources on SI

Many efforts are underway to ensure that SI systems being developed are KP-friendly and help KP-specific programs make effective use of data for strategic planning. Listed below are resources that can be used for systematic monitoring of KP programs through an SI system:

• Monitoring guide and toolkit for key populations HIV prevention, diagnosis, treatment, and care programs
• Operational guidelines for monitoring and evaluation of HIV programs for sex workers, men who have sex with men, and transgender people: Vol. I, national and sub-national levels (2013, UNAIDS/PEPFAR/Global Fund)
• Operational guidelines for monitoring and evaluation of HIV programs for sex workers, men who have sex with men, and transgender people: Vol. II, service delivery providers (2013, UNAIDS/PEPFAR/Global Fund)
• Use it or lose it: How Avahan used its data to shape its HIV prevention program in India (2008, Bill & Melinda Gates Foundation)
• ACQUA: Aastha Continuous Quality Assessment (FHI 360/Aastha, India)

Image: A member of Brothers for Life in Cote d’Ivoire

Written by: Stephanie Desmon

Director of Public Relations and Marketing, Johns Hopkins Center for Communication Programs

Not enough men in Cote d’Ivoire, a coastal nation with the highest HIV prevalence in West Africa, are being tested for HIV.

Getting tested is the first step to being treated, and treatment is a vital step in reducing the spread of the virus. People who are tested can almost immediately receive treatment here – for free. But Johns Hopkins Center for Communication Programs researchers and others have long known that fear is keeping men from learning their HIV status.

“The question here is: Why are men so afraid?” says Danielle Naugle, PhD, a research and evaluation officer at CCP. “Our new research has given us an answer: Being diagnosed with HIV threatens everything men hold dear. You’d be hard-pressed to find something that threatens them on so many levels. Some say they would rather die of AIDS than be tested and know they have HIV.”

Research conducted in late 2016 in Cote d’Ivoire with nearly 300 HIV-positive men, men who don’t know their status and health workers found that the masculinity of men, their sense of self, hinges on five domains: Family, social status, sexuality, work and health. And all of these can be impacted if a man is diagnosed with HIV. For example, if others learn about a man’s HIV diagnosis, he fears the serious stigma associated with the virus, including the potential loss of a job, the worry that future children could be infected, the loss of freedom to pursue multiple sexual partners – all of this without even thinking about the actual impact of being sick.

The most recent data, from 2012, found that 75 percent of men in Cote d’Ivoire had never been tested for HIV compared to 62 percent of women.

In many instances, men in Cote d’Ivoire aren’t tested until it’s the last resort, until after they are showing signs of illness. Naugle says that men are often making what can be considered “rational calculations,” that the loss of these other domains outweighs the potential upside of seeking treatment for the benefit of their health.

“If you know your status, there is the potential for other people to know and the potential that the news spreads and threatens these other aspects of your life,” Naugle says.

Said one young man in a focus group in Bouake, Cote d’Ivoire’s second-largest city: “I would not be respected like before and I could not bear that.”

“It is obvious why people hide,” said one young man from the southwestern port of San Pedro, “Because we know that it is a shameful disease, we know how it is caught.”

The antidote to this, Naugle says, is that antiretroviral treatment is available at no cost and that it can restore most people to the picture of health. HIV is no longer a death sentence and people are living longer and healthier lives. “But many men have images in their head of 30 years of fear-based messaging,” she says. “It’s hard to compete with that.”

This information collected by CCP under its former Health Communication Capacity Collaborative (HC3) project is being used to inform programming being undertaken in Cote d’Ivoire by CCP’s new USAID-funded Breakthrough ACTION project. Breakthrough ACTION is overseeing a support group called Brothers for Life that brings together at-risk men to discuss issues including HIV. The curriculum has been tweaked to address some of the team’s findings on masculinity and the threats posed to it by HIV.

Preliminary evaluations of these tweaked programs have shown that some men, learning that HIV is not the life-threatening virus it once was, are being tested after attending Brothers for Life, says Natalie Tibbels, MSPH, a senior research assistant at CCP.

“When I take the treatments, it gives me the strength to go about my business,” a man living with HIV in San Pedro told researchers. Said another from the capital Abidjan, the country’s main urban center: “With treatment, I feel normal, as if I did not have the disease.”

Naugle says she hopes the new insights she and her colleagues have made into the fear men have about testing can be used to make the process much less threatening.

“We want to be able to develop messages that can help men feel comfortable knowing and acting upon their HIV status,” she says.

Image: Ms. Laura A. Griesmar, Deputy Chief of Mission of the U.S. Embassy in Barbados, the Eastern Caribbean and the OECS, Barbados Minister of Health Honorable John D. E. Boyce, M.P., Honorable Midori de Habich, Former Minister of Health of Peru, Julia Henn, Director, Health and HIV/AIDS Office, USAID/Eastern and Southern Caribbean, Lisa Tarantino, Principal Associate, Governance Specialist, Eastern & Southern Caribbean Region, HFG Project/Abt Associates, Dr. Marty Makinen, Health of Health, HFG Project/Results for Development and health finance officials from Ministries of Finance and Health of Barbados, Guyana, Suriname and Trinidad & Tobago AND leaders of respective National AIDS Programs, national coordinating bodies, PAHO/WHO, UNAIDS, and USAID

Recently, the Health Finance and Governance Project (HFG) organized a two-day workshop to support policymakers from Ministries of Health (MOH) and Ministries of Finance (MOF) in preparing concrete strategies for mobilizing domestic resources for health, with a specific focus on HIV programming. Representatives of Country Coordinating Mechanisms and National AIDS Coordinating Committees also participated. The workshop convened thirty-two health and finance experts from Barbados, Guyana, Suriname, Trinidad and Tobago, Peru, the United States, and various global and regional institutions in Bridgetown, Barbados.

Over the course of the workshop, MOH and MOF participants identified commons priorities and objectives related to HIV programming sustainability and heard presentations from global experts on strategies to achieve domestic resource mobilization (DRM).

Three key priorities were identified as foundational to the implementation of sustainable DRM plans to achieve goals for HIV programming:

Prioritizing and allowing sufficient time for quality communication between health and finance agencies is essential to building sustainable, long-term plans. This means starting resource planning early and developing strategies to adapt to an evolving resource environment. When discussing health sector outcomes, it can be helpful to adopt a medium-term planning mindset to set realistic expectations for how investments in health will be realized. The former Minister of Health of Peru, Honorable Mrs. Midori de Habich advised participants to always have a well-developed back-up plan to quickly absorb any funding that becomes available. Proactive and timely planning were important themes that underscored many of the goals and milestones discussed.

Implementing strategies to improve shared understanding between Ministries of Health and Finance, as these two institutions don’t always speak the same “language”. A lack of common indicators, nuanced dialogue, and infrequent opportunities to cross-collaborate increases the divide between the Ministry of Health and Finance. Bringing these two institutions together—through personnel exchanges for brief secondments or by investing in personnel with backgrounds in cross-disciplinary learning, can help establish a common foundation of understanding on which to base resource planning.

Building on existing political will can allow teams to strategically position resource mobilization efforts for health to address the gaps that exist, and will arise, in HIV programming. Workshop facilitators and participants discussed the unique opportunity created by this funding transition period to bring the topic of resource mobilization for HIV to the forefront of public and political conversation. Maintaining a dialogue at high-levels while engaging with the public about issues most meaningful to them are two important tactics to driving long-term, sustainable change. Simple, key messages and the need for continuous feedback were two strategies outlined to build on, and sustain, political will.

Barbados Minister of Health, Honorable John D. E. Boyce, called upon the workshop attendees to “play an important role in creating advocacy messages that put health at the top of our governments’ agendas… continued improvements rest on the responsibility of us as stakeholders to make change happen.” He emphasized the importance of demonstrating how DRM for HIV connects to overall health system strengthening as a way to ensure that political will is cultivated and sustained. By the end of the workshop, each country team presented a thorough and ambitious action plan, incorporating one or more the tools they learned about, and made commitments to work towards implementing these actions.

Image: Ms Terianna Bisnauthh of SWAG makes a presentation to a representative of the Night Shelter, Georgetown Guyana. 

As part of its community service efforts to support vulnerable women, the Society Against Sexual Orientation Discrimination: Women’s Arm Guyana (SWAG) concluded its feminine hygiene and sexual health drive by presenting 30 gift bags to the women of the Night Shelter in Georgetown, Guyana on Thursday, May 10, 2018, ahead of Mother’s Day celebrations.

SWAG representatives distributed the gift bags to both the female residents and staff at the 24-hour homeless shelter. Aimed at promoting body safety, good hygiene, and healthy lifestyles, the gift bags contained feminine hygiene products, sexual and reproductive health commodities and informational brochures.

Gift items were donated by Massy Distribution Guyana Inc., Terianna Bisnauth, Dr. Nastassia Rambarran and Her Excellency, First Lady of the Cooperative Republic of Guyana, Mrs. Sandra Granger. The sexual health commodities and brochures were provided by the National AIDS Programme Secretariat of the Ministry of Public Health.

Established in 2017, SWAG seeks to work towards the equality, safety, and protection of lesbian, bisexual and transgender women and other vulnerable women.

Image: Ms. Victoria Nibarger, PEPFAR Coordinator, Caribbean Regional Programme

The PANCAP Newsletter is one of the first digital publications to interview Ms. Victoria Nibarger, the new PEPFAR Coordinator for the Caribbean Regional Programme based at the Office of the Global AIDS Coordinator and Health Diplomacy (S/GAC), U.S. Embassy Kingston, Jamaica. 

Here, Ms. Nibarger discusses the new PEPFAR direction for HIV and AIDS in the Caribbean and the significant changes occuring within the programme.  The following is an in-depth conversation with Ms. Nibarger and the Editor of the PANCAP Newsletter.

Editor: PEPFAR is on a new course of redefining its presence within the Region. Can you provide details on the new PEPFAR direction?

Victoria Nibarger:  This is a time of transition for PEPFAR efforts in the Caribbean.  At present, our PEPFAR Caribbean Regional Program covers our bilateral assistance in Barbados, Guyana, Jamaica, Suriname, and Trinidad & Tobago.  To better position ourselves to address the higher HIV burden in Jamaica, we have moved our regional headquarters from Barbados to Jamaica.  Over the next two and a half years, we will wind down our bilateral programs in Barbados, Trinidad & Tobago, Suriname, and Guyana.  At the same time, we will continue to provide regional technical assistance from Jamaica.  In terms of bilateral country programming, after fall 2020 we will focus on the HIV response in Jamaica, where there is a greater prevalence and incidence of HIV.  This will help PEPFAR maximize its efforts at controlling the HIV epidemic in the region.

Editor: Can the region expect any significant changes from PEPFAR?

Victoria Nibarger: As mentioned above, our program is changing significantly.  Change is never easy, and we understand that our decision-making on PEPFAR affects many others, including government partners, NGOs, multilateral organizations, and of course, the people living with HIV throughout the region.  While we will not be able to provide bilateral assistance to each country in the regional program, we have started planning for regional assistance that could be offered from our new home in Jamaica.  For example, I am excited about possibilities to use existing PEPFAR-supported technological platforms to support clinicians by providing continued training and in turn, help ensure people living with HIV have access to high-quality medical care.

Editor: As your tenure begins, what is your vision for PEPFAR’s contribution to achieving the International targets for ending AIDS including the 90-90-90 Targets and the Sustainable Development Goals 2030 Target?

Victoria Nibarger:  I am new to the PEPFAR world, and I feel fortunate that I am joining the team at a time when globally, we have the best practices for reaching the 90-90-90 targets and achieving epidemic control.  I believe we can fine-tune our approach in the Caribbean and inch closer to the goals.  In Jamaica, while the majority of people know their HIV status, less than 40 percent are on antiretroviral treatment (ART) and around 20 percent are virally suppressed.  In Jamaica and in the region, I envision our PEPFAR support as strategically helping the governments to bring more patients from key populations into care, retain them on treatment, and achieve viral suppression. To do so, we must continue to spread awareness of the policy shift to Treat All, so that every person who tests positive will rapidly initiate ART – ideally that same day.  We must also combat stigma and discrimination, so that HIV/AIDS is treated as other ailments such as diabetes, cancer, the flu.  All are health issues, not moral ones.

Editor: How does PEPFAR intend to collaborate with the region on resource mobilization in the context of declining external support?

Victoria Nibarger:  Sustainability is at the heart of our transition planning. We are working with the goal of responsibly turning over PEPFAR-supported activities to host governments, civil society partners, and other donors.  We have a tool called the “Sustainability Index Dashboard” that offers a sort of snapshot of a country’s sustainability landscape; this and other analysis is helping to inform our discussions.  For some countries, we have funded stakeholder planning meetings, and more are scheduled.  We are also trying to enhance donor coordination at a regional level, where entities such as PANCAP will continue to play key leadership roles.

Editor: How important is the role of civil society in achieving the 90-90-90 Targets?

Victoria Nibarger:  Civil society is absolutely critical to achieving epidemic control in the Caribbean, and I am heartened to see so many incredible organizations working to affect positive change.  The epidemic is localized in a few key populations, and these groups face serious stigma and discrimination.  In my view, civil society’s role is essential on two main fronts:  1.) to help patients safely initiate treatment and stick with their regimens; and 2.) to promote policy change and government support to ensure equal rights and equal access to healthcare.  Jamaica AIDS Support for Life (JASL) is doing remarkable work in Jamaica, and I understand that its model is now being replicated throughout the wider region.  Simply put, PEPFAR assistance could not have the impact that it does without our civil society partners.

Editor: Do you have any further thoughts you would like to share with the Partnership?

Victoria Nibarger:  It is a pleasure to once again be working in the Caribbean, this time in a regional capacity.  I am grateful for the warm welcome I have received from those involved in the region’s HIV/AIDS response, and I look forward to meeting as many colleagues as possible in the coming months.  I am a career U.S. diplomat, meaning I move every few years to a new country and topic of assignment; my prior assignment entailed work related to the armed conflict in eastern Ukraine, for example.  To be back in the Caribbean, working on HIV/AIDS policy issues that I studied as a graduate student, is an unexpected, and most welcome, “full circle” moment for me.

PANCAP extends congratulations to Ms. Nibarger and wishes to express sincere gratitude for her insight into the new PEPFAR pivot and other essential information highlighted in this interview.  The Partnership anticipates further successful collaborations with Ms. Nibarger.

Click here to read the original congratulatory message from Mr. Dereck Springer, Director, PANCAP on Ms. Nibarger’s appointment.