GAIA Vaccine Foundation

This article is from the New York Times. Pregnancy and childbirth kill more than 536,000 women a year, more than half of them in Africa, according to the World Health Organization.

In April 2009, GAIA volunteer Rebecca Gerber brought an ultrasound machine to Mali. GAIA VF is Part of the Solution. We Take Action.

Where Life’s Start Is a Deadly Risk
By DENISE GRADY

BEREGA, Tanzania — The young woman had already been in labor for two days by the time she reached the hospital here. Now two lives were at risk, and there was no choice but to operate and take the baby right away.

It was just before dawn, and the operating room, powered by a rumbling generator, was the only spot of light in this village of mud huts and maize fields. A mask with a frayed cord was fastened over the woman’s face. Moments later the cloying smell of ether filled the room, and then Emmanuel Makanza picked up his instruments and made the first cut for a Caesarean section.

Mr. Makanza is not a doctor, a fact that illustrates both the desperation and the creativity of Tanzanians fighting to reduce the number of deaths and injuries among pregnant women and infants.

Pregnancy and childbirth kill more than 536,000 women a year, more than half of them in Africa, according to the World Health Organization.

Most of the deaths are preventable, with basic obstetrical care. Tanzania, with roughly 13,000 deaths annually, has neither the best nor the worst record in Africa. Although it is politically stable, it is also one of the world’s poorest countries, suffering from almost every problem that contributes to high maternal death rates — shortages of doctors, nurses, drugs, equipment, roads and transportation.

There is no single solution for a problem with so many facets, and hospital officials in Berega are trying many things at once. The 120-bed hospital here — a typical rural hospital in a largely rural nation — is a case study in the efforts being made around Africa to reduce deaths in childbirth.

One stopgap measure has been to train assistant medical officers like Mr. Makanza, whose basic schooling is similar to that of physicians’ assistants in the United States, to perform Caesareans and certain other operations. Tanzania is also struggling to train more assistants and midwives, build more clinics and nursing schools, provide housing to attract doctors and nurses to rural areas and provide places for pregnant women to stay near hospitals so that they can make it to the labor ward on time.

But there is a shortage of Emmanuel Makanzas, too. As he began to operate, he said he should have had another pair of skilled hands to assist him. But, he said, “we are few.”

He made a quick, vertical cut, working down from just below the navel, through one layer at a time: skin, fat, muscle, the peritoneal membrane. Within three or four minutes he had reached the uterus, sliced it open and wrestled out a limp, silent baby boy exhausted by the prolonged labor and knocked out by ether. It took a nurse 5 to 10 minutes of vigorous resuscitation to get him breathing normally and crying.

There are many nights like this at the hospital here, 6 miles from the nearest paved road and 25 miles from the last electric pole. It is not uncommon for a woman in labor to arrive after a daylong, bone-rattling ride on the back of a bicycle or motorcycle, sometimes with the arm or leg of her unborn child already emerging from her body.

Some arrive too late. In October, a mother who had been in labor for two days died of infection. In November and December, two bled to death. Doctors say they think that more deaths probably occur outside the hospital among the many women who try to give birth at home.

A few minutes’ walk from the hospital is an orphanage that sums up the realities here: it is home to 20 children, all under 3, nearly all of whose mothers died giving birth to them.

“You can never get used to maternal deaths,” said Dr. Siriel Nanzia Massawe, an obstetrician and the director of postgraduate studies at Muhimbili University of Health and Allied Sciences in Dar es Salaam, the country’s largest city. “One minute she’s talking with her husband, then she is bleeding and then she is gone. She’s gone, very young. You cannot sleep for one week. That face will always come back to you. Too many die, too young. But the people in power, they have not seen it. We need to make them aware.”

Over the course of several days at Berega, the difficulties became clear. At times, Mr. Makanza performed one Caesarean after another, sometimes in the middle of the night. One mother was only 15. Another had already had two Caesareans, adding to the risk of this operation or any future pregnancies, but she declined Mr. Makanza’s recommendation to be sterilized.

Others had hoped to speed their labor by taking herbal medicine but were suffering dangerously strong contractions. Hospital staff members struggled to keep up with the operations, handwashing bloodstained gauze and surgical drapes in basins and mopping blood from the floor between cases.

Two women had severe problems from high blood pressure. One came to the hospital after giving birth at home and having a seizure. Another delivered a full-term infant who had died in her womb at least a week before; her only other pregnancy had ended the same way.

A mother in the maternity ward had arrived in labor with twins, one already dead. A Caesarean had saved the second.

The Global Perspective

Women in Africa have some of the world’s highest death rates in pregnancy and during childbirth. For each woman who dies, 20 others suffer from serious complications, according to the W.H.O. “Maternal deaths have remained stubbornly intractable” for two decades, Unicef reported last year. In 2000, the United Nations set a goal to reduce the deaths by 75 percent by 2015. It is a goal that few poor countries are expected to reach.

“Why don’t we have a global fund for maternal health, like the one for TB, malaria and AIDS?” Dr. Massawe asked.

Tanzania has reduced its death rate for young children, but not maternal mortality. The Ministry of Health says its maternal death rate is 578 per 100,000 births, but the World Health Organization puts the figure at 950 per 100,000. By contrast, the health organization estimates the rate in Ireland, the world’s lowest, to be 1 per 100,000.

The women who die are usually young and healthy, and their deaths needless. The five leading causes are bleeding, infection, high blood pressure, prolonged labor and botched abortions. Maternal deaths from such causes were largely eliminated nearly a century ago in developed countries. In poor countries a mother’s death leaves her newborn at great risk of dying as well.

Experts say that what kills many women are “the three delays” — the woman’s delay in deciding to go to the hospital, the time she loses traveling there and the hospital’s delay in starting treatment once she arrives. Only about 15 percent of births have dangerous complications, but they are almost impossible to predict.

A Medical Emergency

A case in the Tanzanian city of Moshi late last year reveals how suddenly a seemingly normal labor can turn into an emergency in which every second counts. Hawa Khalidi, 36, who had five normal births, gave birth to her sixth child a few hours before dawn on Nov. 19 at a health center staffed only by nurses in one of the poorer sections of the city.

Then she began to hemorrhage, and by daybreak she was dead.

An autopsy found that Mrs. Khalidi bled to death because the nurse who delivered her baby failed to perform one basic task, essential to prevent deadly bleeding: removing the placenta after she gave birth.

Normally, pulling on the umbilical cord will extract the placenta. But the autopsy revealed that the cord broke off. The nurse apparently did not know how to reach into the womb to remove the placenta. She sent Mrs. Khalidi to a hospital, but by then Mrs. Khalidi had lost so much blood that doctors could not save her.

In an interview, Mrs. Khalidi’s husband said nurses at the clinic had scolded her because she was too poor to bring her own “delivery kit” containing gloves, clamps and other supplies. Some maternity wards are so crowded that women sleep two or three to a bed, or lie on the floor, along with their newborns. Although the government has promised to build more clinics and to put one within three miles of every village, it cannot even fully staff the clinics it already has. Health workers — overworked, underpaid and sometimes poorly trained — often become demoralized and resigned to the high death rates.

Women lack education and information about birth control, and some become pregnant too young to give birth safely. Husbands and in-laws may decide where a woman gives birth and insist that she stay at home to save money. Malnutrition, stunted growth, malaria and other infections, anemia and closely spaced pregnancies all add to the risks.

In rural areas, many women use traditional birth attendants instead of going to the hospital. The attendants usually have no formal training in medicine or midwifery. Many doctors blame them for high rates of maternal death and complications, saying they let labor go on for too long, cannot treat complications and fail to recognize emergencies that demand hospital care. But many women are loyal to them. For one thing, the price is right. Around Berega, they charge about $2 per birth. A normal birth at the hospital costs about $6, an emergency Caesarean $15.

Dr. Jeffrey Wilkinson, an obstetrician from Duke University who is working at the Kilimanjaro Christian Medical Center in Moshi, pointed out that other African countries, like Niger, had even higher maternal death rates. Despite the many obstacles in Tanzania, “there is hope here,” he said.

A Hospital’s Shortages

Even though it serves an area with about 200,000 people, the hospital in Berega has no obstetrician or pediatrician. It has only one fully trained doctor, Dr. Paschal Mdoe, 31, who became the medical director in August, fresh out of medical school.

Like most hospitals in Tanzania, the one in Berega tries to compensate for the doctor shortage by relying on assistant medical officers like Mr. Makanza to perform many Caesareans and a few other relatively simple operations like hernia repairs. Although such assistants eventually become quite adept in such operations, most other countries do not recognize their credentials and so do not try to lure them away, a big plus for Tanzania, which loses doctors and nurses to Botswana and other countries that pay more.

Periodically, visiting surgeons repair fistulas, a severe childbirth injury that causes incontinence in the mother. Other outside experts like Dr. Wilkinson have also taught staff members how to resuscitate newborns and treat obstetrical emergencies like hemorrhages and severe high blood pressure.

To persuade more women to give birth at the hospital instead of at home, the hospital is sending health workers with that message to marketplaces, churches, village elders and religious leaders.

In addition, the hospital is creating a “maternity waiting home” so that pregnant women who live far from the hospital can travel to Berega before labor starts and have a place to stay until it is time to give birth. Officials are also negotiating with the government to cover all fees for pregnant women and children, and to acquire an ambulance. (The hospital, a mission institution supported partly by the Anglican Church and the government, does not receive enough money to cover its costs, so it charges fees to make up the difference.)

But there is a long way to go. Only 20 percent of women in the area give birth at the hospital, and many do so only when they need Caesareans. Many women say they simply cannot afford the hospital. More than 50 percent stay home to give birth, and the rest go to local clinics that cannot handle emergencies or perform Caesareans.

“We lost four or five babies this week,” the Rev. Isaac Y. Mgego, an Anglican priest and the hospital’s director, said in an interview in January. “Our doctors have to play with two bad things, to save the mother or save the child.”

It is not easy to lure doctors and nurses to Berega, where most people live in mud huts with no electricity, flush toilets or running water. Malaria is common.

To attract staff members, the hospital provides concrete houses with access to a pump. The church “tops up” government salaries for doctors and nurses, and Dr. Mdoe successfully lobbied church officials to give his staff a raise. A nursing school is being built, with the hope that it will draw local students who will want to remain in Berega.

The hospital has four nursing officers, 10 midwives and 2 other workers known as clinical officers, a total of 16.

“We used to have 34,” Mr. Mgego said. “People leave. We are struggling to retain them. They don’t want to live in villages. Some go without saying goodbye. Those who are committed, they are working tirelessly.”

It costs about $200,000 a year to run Berega Hospital, Mr. Mgego said. He said he hoped the hospital would find ways to prevent the serious problems that required mercy missions and visiting surgeons from groups like Amref, the African Medical Relief Foundation, also known as the flying doctors.

“Coming here to cure people is good, but what can we do to prevent this?” Mr. Mgego asked. “So that one day we can say, flying doctors, you can come, but we have only one patient, or nobody, around here.”

Since 2005, GAIA VF has been providing Mother to Child HIV Transmission Prevention in Mali, West Africa.
This is the simplest, most direct means of preventing HIV. It is also incredibly low cost.

GLOBAL: Group Says Infants Needlessly Get HIV
Boston Globe (05.22.09) - Friday, May 22, 2009
Marilyn Chase, Bloomberg News

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Mother-to-child HIV infections have been almost eradicated in the global North, but prevention interventions are not accessible for the vast majority of HIV-positive women who will become pregnant in the developing world, according to an international coalition of HIV/AIDS advocates.
Just 33 percent of HIV-positive pregnant women have access to antiretroviral prophylaxis to prevent vertical HIV transmission, the International Treatment Preparedness Coalition (ITPC) said in a new report. “At least three- quarters of HIV-positive pregnant women in 61 countries, including Cameroon, Ethiopia, India, and Nigeria, are still not receiving this intervention,” the report found.

ITPC blames the gap on poor coordination by government and global health groups, lack of funding, and the value of “wealthy women over poor.” “Donors talk the talk, but don’t walk the walk,” said Gregg Gonsalves, ITPC’s leader.

“Overall coverage is still very low for this proven, inexpensive intervention,” said Michel Sidibe, executive director of UNAIDS, who agreed with many of the report’s findings.

Even among pregnant women who do receive antiretroviral treatment to prevent vertical transmission, most get single- dose nevirapine, according to ITPC’s report. While the treatment can reduce transmission risk by 40 percent, it also increases the chance of sparking drug-resistant HIV in the mother, ITPC said. Only 8 percent of women receive a triple- drug combination, which is more effective, less apt to provoke drug resistance, and costs less than $100 per patient per year, Gonsalves said.

To access the report, visit http://www.aidstreatmentaccess.org/mtt7_final.pdf.

January 25, 2009

Friends of GAIA and friends of Mali -

It is true that GAIA is one of many foundations that finds itself in crisis at the present time, especially since promised funds from major foundations have failed to materialize, and it is true that the financial crisis is suppressing donations, and that as a result - despite our amazing progress and our ability to meet our goals - we don’t have enough money to see out six months - - but we are full of joy and optimism about our work in Mali. Why? Because we remain convinced, that we can do so much with so little. We will find a way, because there must be a way to do what needs to be done - to give a future to children who would otherwise have none, and to give hope for survival to their parents, AIDS patients who, without the simple meals and the medications we provide, would have given in, and given up, many months ago.

We at GAIA are full of joy because - there is nothing quite like the sun setting through the red dust in Bamako – nor, for that matter nothing like the sight of a small boy wearing shredded shorts and a filthy shirt who sits proudly on a stack of treadless truck tires – or like the the flock of sheep stopping traffic in mid town – or the 10 foot Tuareg on the 15 foot camel right on main street doing some afternoon shopping. . .

There is nothing quite like the vision of carrots piled high like so many orange sputniks topping heads – nor the push carts next to donkey carts next to the Mercedes at the stop lights in Bamako – or the flutter of a well fitted “pagne” over intricately hennaed feet – and there is nothing quite like the joy of dancing until you drop, the gentle back and forth of greetings and farewells, all this, all of this and more, is Mali.

Beyond what can be seen in Mali, there is still so much more that invites joy. There is the pride of doing, the engagement, and the partnership that GAIA has with the community. There is Allou Sylla, head of the national AIDS organization (CSLS), who opens his arms wide and embraced GAIA’s mission and sustains us, promising refrigerators and training and even a motorcycle- for our HIV clinic in the CSCOM, and he asks, “What are we waiting for?”

We met with him yesterday, and in addition to these wonderful promises of direct aid to our HIV clinic, once we start HIV care on site, he promises to support the conference that we’d like to do with local non profits, and he said that he is going to organize the National HIV conference, and he’s going to make sure that it happens when we are in town!

He said, in addition, that we have done things exactly as should be done - we came to work with Malian scientists to bring a globally relevant and globally accessible HIV vaccine to trial in Mali, and we made no bones about that, but while we work on developing the vaccine, we have partnered with our colleagues in Mali on HIV prevention and improving access to care. He says EVERY scientific partner should follow this model - building infrastructure, reinforcing capacity, and then bringing in the clinical trials.

And so, he gives us his blessing for the work we wish to do –opening the first ever HIV clinic in a village in Mali, and so does the chief of the village, who brings his strength and powers of persuasion to the mix, and so does Haby Bengal, our first HIV patient from so many years ago- who is just fine thank you-and who now has a new donkey, thanks to a church in Cumberland, and so does Mahamane Maiga, director of “CAMS”, whose homeless children now will have a place to go for HIV care. And Madame Diallo of the regional department of health gives us her blessing too. She patiently steered our fragile ship away from disaster on more than one occasion. She sat beaming in her office the other day when I finished giving her an update on our work. She could not be more proud of the progress. She will come see the clinic to see our doctors providing HIV medication to patients on site, and she knows that she contributed to making that dream come true.

We are at this point thanks to her guidance, and to help from Sounkalo Dao, HIV doctor to thousands of Malians - - he sends us his young specialists and is the source of the new pharmacist who will give out HIV medications in our clinic. Lest we not forget we should also mention Malick Sene and his adjunct Tounkara at the HCNLS, and Ousmane Koita, who has always believed that we will some day have the vaccine in our hands, and who works tirelessly, guiding us, listening to us, helping us in a myriad of ways to move that hope forward. And so, too, we are helped by Ben Aboubacar, the director of the Millennium Village Project programs in health for West Africa - who found Karamoko Tounkara, our director (another blessing) and has patiently provided Kara with direction and directives when I cannot because I am so far away.

In truth, if Paradise could have AIDS, then this would be Paradise on Earth, because - despite the dust, and the desperate poverty, there is so much hope, and so much optimism for something better, and so much desire to reach out and help - each one contributing something to obtain that distant, but achievable goal, a vaccine against HIV that is globally accessible, and, in the far distant future, a world without AIDS.

Here is just one small example – a mural being created by San Francisco muralist Eduardo Pineda, who traveled to Mali, inspired by the GAIA message of Hope for Access, to lend his hand and inspiration by painting the wall outside the HIV clinic in Sikoro, Bamako, the epicenter of AIDS in West Africa.

In celebration of World AIDS Day, the Global Alliance to Immunize against AIDS (GAIA) Vaccine Foundation will honor the humanitarian work of seven noted HIV/AIDS advocates.
This year’s award recipients are:
• Daniel Halperin (Harvard University), for uncovering the connection between lack of circumcision and AIDS transmission and for advocating family planning and access to care as a low-cost means for stemming the spread of AIDS.
Dr. Halperin has conducted epidemiological and ethnographic research for over thirty years on a number of health and sociocultural issues in Latin America, sub-Saharan Africa and other developing regions. Since completing his doctoral training in medical and cultural anthropology at the University of California, Berkeley in 1995, his work has mainly focused on the heterosexual transmission of HIV and other sexually transmitted infections. He has had extensive involvement in the design, management and evaluation of prevention, care and other HIV-AIDS programs, and continues to be actively engaged in collaborative endeavors with UNAIDS, WHO, CDC, UNICEF, Gates Foundation and other international partners in developing and disseminating policy-setting technical consultations, guidance documents, etc.
• Doctors Frederick Altice (Yale University School of Medicine), David Paar (University of Texas Medical Branch), Joe Bick (California Medical Facility), David Thomas (Nova Southwestern) and David Wohl (University of North Carolina-Chapel Hill), for their pioneering work in the fight against AIDS in U.S. prisons.
These physicians all specialize in infectious disease, with a special focus in HIV/AIDS medication adherence and access to care, and have worked for many years among incarcerated inmates with HIV infection. They have fought for simple HIV prevention measures such as increased testing, access to HIV care, and distribution of condoms with some degree of success. Despite significant institutional resistance in most states, these doctors have succeeded in raising the standard of care for a group with one of the highest national rates of HIV infection: incarcerated individuals.
• Jesse Creel, grassroots AIDS advocate who has long championed the development of an HIV/AIDS vaccine, is a self-taught AIDS vaccine expert. Jesse is relentless in his pursuit of information about HIV vaccines and HIV treatments, scrutinizing each new piece of information as it is published for its relevance to individuals who are at highest risk of HIV and who, because of lack of education, poverty or distance, have no voice in the development of the vaccine. His email updates have garnered Jesse a devoted following among HIV vaccine researchers and developers, from the top echelons of the NIH to the front lines of the epidemic. His first pre-Katrina forays into AIDS research were enabled by a keyboard connected to a TV screen (WebTV). His most recent efforts are carried out in post-Katrina safety, on donated laptops (from EpiVax). He is self-taught, fearless, and tireless. His insights are at times startling, at times shocking, and always on point.
Past recipients of the “Hope is a Vaccine” award include: Judy Lieberman, Senior Investigator at the CBR Institute and Professor of Pediatrics at Harvard Medical School, and Leigh Blake, Founder of Keep A Child Alive (KCA), which provides vitally needed anti-retroviral medicine to children and families with AIDS in the developing world (www.keepachildalive.org); Jeff and Sonia Sachs of the Millennium Village Project; Jose Esparza, MD, and AIDS expert who works with the Gates Foundation; and Peggy Johnston, Ph.D., Associate Director of the Vaccine and Prevention Research Program in the Division of AIDS at the National Institutes of Health.
On World AIDS Day, December 1, 2008, the Joint United Nations Programme on HIV/AIDS (UNAIDS) will release new data on the global HIV epidemic. According to that report, more than 33.2 million people are living with HIV throughout the world. Of these, 22 million live in sub-Saharan Africa. In 2007 alone, there were 2.7 million new HIV infections – the equivalent of about five persons every minute. The global rate of new infections exceeds the number of deaths by 700,000 persons per year, which underscores that the epidemic is continuing to expand, unabated.
The mission of GAIA Vaccine Foundation is Global Vaccine, Global Access. It is the goal of GAIA to distribute the HIV vaccine developed as a result of this project at no profit in developing countries. Initial studies of the GAIA HIV/AIDS vaccine are being carried out by Dr. Annie De Groot, who was recently named the Director of the Institute for Immunology and Information at the University of Rhode Island, in collaboration with Dr. Mickey Lally and Dr. Ken Mayer at the Miriam Hospital and Bill Martin at EpiVax, a Rhode Island based bioinformatics company.
The Global Alliance to Immunize against AIDS (GAIA) is working hard to curb HIV infections on a global scale. GAIA’s mission is to promote the development of a globally relevant and globally accessible vaccine against AIDS. However, since the development of such a vaccine is years away, GAIA also coordinates HIV education, prevention and access to care programs in Providence and Bamako, working to stop HIV until a vaccine is developed.
In keeping with these objectives, GAIA has built the Hope Center Clinic, a new HIV treatment center in Sikoro, Mali. Sikoro is one of the poorest neighborhoods of Bamako, the capital city of one of the poorest countries in the world, and consequently has very high HIV prevalence when compared to the rest of the city. This center will serve tens of thousands of people who currently have no access to HIV testing and treatment. GAIA is doing its part to provide the poorest people of Bamako with access to HIV prevention, education and treatment programs.

GAIA’s 6th Annual “Hope is a Vaccine” Award Gala will take place at the Federal Reserve Restaurant, located at 60 Dorrance Street in Providence on Thursday, December 4th at 6:30 p.m., and For more information about the GAIA Vaccine Foundation and the “Hope is a Vaccine Awards,” please visit www.GAIAVaccine.org

Knowledge, Attitudes, Practices and Willingness to Participate in HIV Vaccine trials among urban residents of Bamako, Mali, in West Africa

Karamoko Tounkara1, Yssouf Kone2, Ben Aboubacar1, Ousmane Koita1, Sankare Moussa3,
Dolo Ibrahima3, Siby Fanta3, and Anne S. De Groot4

1Fondation GAIA Mali, 2CSCOM de Sikoro and 3Direction Regionale de la Santé, Bamako, Mali
and 4GAIA Vaccine Foundation, Providence RI

Introduction The objective of this study was to evaluate baseline levels of HIV knowledge and practices prior to a more extensive intervention, and to evaluate willingness to participate in an HIV vaccination trial among residents of the periurban slum of Sikoro, located within the city limits of Bamako, Mali, where the GAIA Vaccine Foundation has established an HIV care center.
Methods A random sample of 200 households from six sectors of Sikoro was selected to participate in an oral survey. Over a two-month period, trained interviewers of matched age and gender surveyed members of these households who gave their oral consent and recorded their knowledge of HIV, HIV transmission, and HIV prevention on a standardized form. The participants’ history of previous vaccination and willingness to participate in trials of vaccines was also assessed. The survey was voluntary, confidential and anonymity was maintained.
Results: 399 residents of Sikoro who were between 15 and 50 years old agreed to participate in the survey, of which 186 (47%) were women and 213 (53%) were men. 95% of the participants had heard about HIV and HIV infection, 93% knew at least one mode of transmission; 91% knew at least one means of preventing HIV tranmission; 72% knew where to get tested; 78% knew how to be tested; 85% were aware that the government of Mali provides HIV treatment for free; 54% knew where treatment was available. Among HIV prevention methods, 87% mentioned condoms; 60% mentioned fidelity; 50% mentioned abstinence. 73% felt “pity” towards people living with HIV and felt that HIV seropositive persons should not be excluded from activities of daily living. Participants were also relatively well informed about causes of sexually transmitted infections (STIs); 65% identified gonococci as a cause of STIs, 41% mentioned “yeast” infection, 25% mentioned syphilis and leucorrhea but 18% refused to talk about STIs. 94% of participants said they had been vaccinated at least once, and contrasting with our previous results , , more participants (78%) indicated that they would be willing to participate in a trial of an HIV vaccine (WTP), whereas 65% would participate in a trial of a malaria vaccine and 61% would participate in a trial of a TB vaccine. Women were slightly more likely to say that they would participate in a trial: 80% would, compared to 76% of men.
Conclusions: HIV knowledge is high, except for knowledge about MTCT, and there was a high level of willingness to participate in vaccine trials, among men and women participating in this survey. This is the third study performed by GAIA Vaccine Foundation to date that indicates a high level of WTP among residents of the capital of Mali, in West Africa.

Key words: HIV/AIDS/STI Prevention, Vaccination, Agreement to test a new vaccine.

World AIDS Conference 2008 Mexico City
WAC Abstract STI Sikoro
Published as poster abstract in “CD accompanying WAC brochure”
August 2008

Abstract title: Increased HIV and STI testing in Bamako, Mali using a push/pull intervention
Abstract number: CDC0368

This number will be your abstract’s reference number on the CD-ROM.

Increased HIV and STI Testing in Bamako, Mali using a Push/Pull Intervention

Karamoko Tounkara, Youssouf Kone, Ben Aboubacar, Flabou Bougadougo, Ousmane Koita, Anne S. De Groot

GAIA Mali, ASACOMSI, Millennium Villages Project, University of Bamako, GAIA Vaccine Foundation (USA),

Background: We developed a street-outreach peer education program that uses a mnemonic based on the five fingers of the hand to teach illiterate residents of a peri-urban slum in Mali about sexually transmitted diseases, HIV testing, HIV treatment and prevention. Here we report the impact of peer education intervention on the uptake of sexually transmitted infection testing and HIV testing at the local infirmary-style community clinic (the ASACOMSI).

Methods: Beginning in February 2007, 11 peer educators provided HIV education and distributed condoms in street-based outreach sessions. Initial projections were that the Hêré Bolo program would reach 440 people per month or approximately 5,000 individuals in its the first year. At the same time, HIV testing was provided at the local infirmary at no cost.

Results: STI and HIV testing information was collected from clinic records. The program was formally initiated in February 2007. The 11 peer educators made 7242 contacts with community members from 2/2007 to 11/2007. During this period, 7941 condoms were distributed. STI testing requests at the ASACOMSI increased by 81% over the same period in 2006; and HIV testing requests increased four fold over the course of the year. From January-June the rate of HIV testing requests was 7/mo.; from June to September, the rate of testing was 27/mo.

Conclusions: Community-based clinics serve as a portal of entry to the HIV care system. We used a push/pull model to increase HIV testing: increasing demand through peer education and reducing the barrier to testing by making HIV tests free. This combined intervention increased the rate of HIV testing four-fold over a period of two years. In the next phase of the program we will make testing for STI’s free to all comers and provide free treatment for STIs. This intervention is easily adaptable to other settings in Sub Saharan Africa.

Patient adherence to HIV treatment and prevention in the Centre de Santé Communautaire de Sikoro, Bamako, Mali

TOUNKARA Karamoko, KONE Youssouf, KOTY Zoumana, ABOUBACAR Ben, WERWIE Timothy, DE GROOT Anne S.

GAIA Vaccine Foundation (Mali and Providence), Brown Medical School and the University of Rhode Island

Introduction : The Global Alliance to Immunize against AIDS Vaccine Foundation (GAIA) provides financial and technical support to a small infirmary, the Centre de Santé Communautaire (CSCOM) located in Sikoro, Bamako, Mali. The CSCOM is part of a national network that were created to bring health care to residents of Mali. The national HIV prevalence rate is 1.3% but is believed to be higher in Sikoro, where unemployment and illiteracy rates are much higher than elsewhere in the country. GAIA has been supporting access to HIV counseling and testing, to HIV medicine (MTCTP) and to artificial milk for pregnant women attending the Sikoro prenatal care center (Chez Rosalie) since 2005. We evaluated acceptance and adherence among women attending Chez Rosalie during the period January 2007-October 2008.

Results : Chez Rosalie counselors received 2,540 women during the study period. An average of 115 pregnant women were seen each month. All were offered a free HIV test, following pre-test counseling, and 99.8% agreed. During this period, 48 women (1.89%) tested HIV sero-positive and 29 (60.41%) delivered at the CSCOM. Of the 48, only four women did not accept anti-retroviral (ARV) prophylaxis prior to delivery. Following delivery, most (86.5%) of the new HIV-seropositive mothers elected to use artificial milk and 13.5% chose breastfeeding. During this period six children who had reached 18 month of age were also tested for HIV. Of those who were fed artificial milk during the first six months of their life, all (4/4) were negative and 2/2 (100%) of the children who were naturally breastfed were HIV-seropositive.

Conclusion : Enrollment and adherence to the PMTCT program and testing at the CSCOM are increasing, due in part to the CSCOM’s central location, the availability of tests and reagents, and the establishment of trust between patients and clinical staff. Some women still refuse ARV prophylaxis and artificial milk, increasing the risk of HIV transmission. GAIA is working on new methods to destigmatize HIV and PMTCT in Sikoro, and to scale-up peer-education programs that are already in place in Sikoro so as to improve willingness to participate and continue in PMTCT.

Protocol:
We submitted the protocol to Dr. Flabou last wednesday. He emailed back with comments early this week, the most important being that we needed a signature from the Chef de Vilage of Sikoro and the Mayor. Once we fixed it up and got the signatures, Dr. Flabou told us to bring the protocol directly to the Faculty of Medicine (at Point G) which we did today. We met with the guy who seemed to be in charge of the Commite de Etique submissions, and he told us many things that we had not heard before. The two most important being 1.) We need to submit the protocol by Tuesday, in order for it to be seen that Saturday. This means that we will not go to the Committee until next Saturday July 26th. 2.) The cost of submission to the committee (as i think karamoko has written) is $500+. (S#e^%*Fge&^bK)!!!!!

Peer Educators:
We met with them last week, as I had emailed. It was a great productive discussion, that resulted in the decision to have a salary increase for the two month pilot period. We are meeting with them again tomorrow with a few goals in mind: 1.) To let them know that the budget was a go, and salary increase approved. 2.) To go over the curriculum with all 11 educators in French/Bambara, 3.) To go over the logistics of the TB BOLO project (specifically those that make it different from here Bolo, i.e cough questionaire, active screening for at risk patient) 4.) Introduce them to Salimata, from the clinic, who handles all the TB cases in Sikoro. We have asked Salimata to explain to the peer educators the process of a Tb patient in Sikoro, where to get tested, where to get meds, who administers meds, etc.

My thoughts:
- I’m going to ask Karamoko to send the name of the person we spoke with today regarding protocol submission. If we had spoken with him from the outset, we would have known all this extra information regarding the process of presenting to the Commitee and we could have moved faster! This has taken quite a while and I feel frustrated that we can’t get to the committee before the 26th, cause i’ll be gone on the 30th! Also perhaps he can send us a format that we can use for future submissions
- I’m worried about TB Bolo Pilot once I leave, because there will be nobody directly “in charge” of the project. Karamoko can take on this responsibility, but he’s got a lot on his plate (?) also I think it would be better for it to be one of the peer educators. I think that once the peer educators are out in the community, many questions/issues will arise (i.e regarding the protocol for at risk patients, regarding money, etc.) and I think it would be nice to have somebody solid that the peer educators can direct their questions to. Sophie S and I have discussed the possibility of having Ablo (a super motivated, and charasimatic peer educator) be in charge. Again, the issue of time and compensation arises…and here is where the thoughts that Sophie S has been expressing re: Rama come into focus….
- The $500+ is a huge bummer. Paying it strengthens my previous point that we need to make sure we follow through with the TB project. It would be very unfortunate to see it struggle after we’ve put all this time and money into it!!

Okay,phew!
-Binny

PS: Karamoko and I are definitely making way with the French/English barrier. haha, we drove to and from Point G today and it was not in silence! I even taught him how to say Awesome! haha and this morning he greeted me with a “Hi Binny!”

Hello–

Last Monday I went to Point G and “shadowed” Dr. Diallo (so handsome! Haha.) I sat with him in his office as he saw patients for the morning. He’s definitely got a mix of visits. The next day I went back and rounded on the TB floor with the medical students and Dr. Patrice. He’s wonderful, does research (Ousmane is his ultimate boss) on HIV and TB and is looking at cytokine levels at different time points. His English is great, and he was very nice to make sure to explain the important points of each patient to me. In fact, if I was ever out of sight all of a sudden I would hear “Where’s Bin-Tu?” He heads the TB rounds to keep up with clinical medicine. I think he’s a great person to have be connected with GAIA, because he’s a little less busy than the big wigs, he’s much more accessible and willing to help. He spent over two hours with me a few days later looking over the TB curriculum suggesting small but helpful changes (i.e people in Mali don’t know what stress is, therefore they won’t really understand that its connected to active TB, haha.)

Another day at Point G, I was scheduled to shadow to Dr. Patrice, but he was doing informed consent interviews for his research, so I kind of just roamed the halls until somebody picked me up, haha. Low and behold, not much time passed before I heard, “Bin-tu!” and this great doctor, Dr. Tolaba took me to his office. He heads the rounds for the non-TB pulmonary patients, I’m pretty sure he’s a specialist, definitely higher on the hierarchy than Dr. Patrice. Anyway I sat as he saw patients and he did his best to explain some things to me. I’ll send his contact info as well. (he gives me a fresh boisson from his mini-fridge every time I’m at the hospital! Haha.)

Yesterday I also went to Point G and rounded with the med students and Dr. Patrice again. The second time around I was able to follow it a bit more, and this very nice med student from Cameroon (great English) also helped to explain some things that were happening. They have a lot of interesting cases, there are about 28 patients, I know of 2 MDR cases and 1 XDR case, there was also two cases of Potts Disease and two other patients with co TB/Diabetes. I was only made aware of 1 patient with co HIV/TB, but I could have missed another one. Learned a bit about the treatment for MDR TB, and that to do the MDR test they have to send the culture to the faculty of sciences, and it takes about six weeks-two months to get the results back. & I’m pretty sure he said that for XDR cases they have to send cultures to Colorado?! Since it was my second time, I got in on the questions, as in “Bin Tu how many months of treatment for MDR?” 21!

Other than these Point G visits I’ve been working on the protocol with Sophie, which we handed in today for Dr. Flabou to take a look at before the Committee meets on Saturday. It was helpful to go through the protocol step by step, because it helped to organize the course of the pilot program in our minds and also helped to identify factors that we may need to better explain to the peer educators — i.e what is the course of a TB patient through the Sikoro health system, where are tests available, where are meds available, who administers meds, etc.

Also last Friday the 4th, sophie karamoko and I met with all the peer educators again about TB Bolo. Unfortunately about five of them were missing due to the rain, but those that were there were interested/attentive. we delved a bit deeper into the hard to grasp topics, ie. mdr, how to act when a person has tb, etc. sophie and I found a great website with comprehensive and easy to understand TB information in French, so we printed some of it and handed it out to the peer educators as a “booklet” they can keep it on hand when they go out into the community to do sensitization sessions. we were excited about that! anyway, we’ve been having a good time here. unfortunately dr. Patrice is leaving this friday for a month long vacation in southern mali. I’m not sure how best to proceed with the point g visits, bc dr. diallo is pretty busy dont want to get in the way much, but was thinking if i could get in with the med student from cameroon i could hang with her. also annie, how do I get in touch with the hiv docs? also once the protocol is approved, we’re going to proceed with training the five TB BOLO peer educators (karamoko will do a session to make sure they can do it in bambara, and we will also meet with salimata from the asacomsi and hope that she will be able to talk withthem about the TB process.) we will also meet with the tb people at the ces ref, dr. berte, etc. to keep them up to date with whats happening.

Cool,

Binny

Most of the past few days was spent shaping up the TB curriculum and with a lot of sophies help we translated it into French. We decided to lessen the emphasis on co-infection in light of stigmatizing hiv and/or tb patients.

Sophie did a great job of presenting the curriculum to the Peer Educators yesterday. We met with them for approximately an hour (they gather the last friday of every month at the gaia house to get their pay etc.) We had printed out copies for them to share. Sophie engaged one of the peer educators to read the curriculum aloud (& translate into bambara) which was very helpful. Some were more receptive than others, asking questions etc, but everybody seems to have an interest. Karamoko chimed in often to clarify some medical terms (such as resistance, bacteria, etc.) A major question that came up was how kissing individuals with Tb can be allowed. I’m going to do some more research so that we can present this information more clearly. Most took a copy home with them and are going to read it over and prepare any questions that they have, which we will discuss when we meet with them next Friday.

On the radar: Finish up the TB Pilot budget (how much will the asacomsi cover, show it to karamoko), meet with Flabeau, show the curriculum to Salle, decide which peer educators (& how many) will be doing Tb Bolo, figure out how the card system subsidizing the cost of consultation at the asascomsi will work…

Its always interesting to be at the clinic, but with my lack of french/bambara skills, its hard to pick up a lot of whats going on. So I’ve been trying hard to learn some french & Karamoko has been trying to get in touch with Dr. Diallo (who speaks some english) so that I can go to Point G and “shadow” him while he sees patients.

Binny