Geneva Health Forum Archive

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Using Technology and Community Empowerment to Treat Tuberculosis.

Author(s) Shelly Batra1.
Affiliation(s) 1Senior Management, Operation ASHA, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Infectious Diseases
Summary TB is has been declared a health emergency by WHO. Over 9 million people are newly infected with TB and 1.4 million die annually. Incomplete TB treatment has led to an alarming rise in DR-TB (Drug Resistant TB), a man-made epidemic. MDR-TB (Multi Drug-Resistant TB), if not fully treated, leads to the dreaded XDR-TB (Extremely Drug-Resistant TB), causing greater suffering and economic loss. Operation ASHA’s innovative idea is a combination of our comprehensive model and high leverage of low-cost biometric technology, eCompliance. We monitor every dose taken by MDR-TB patients to prevent XDR, because MDR-TB treatment is often left incomplete due to long duration and debilitating side effects.
What challenges does your project address and why is it of importance? TB is an airborne infectious disease, which transcends all socio-economic, cultural and physical barriers. India carries 26% of the worldwide TB burden. Patients are extremely poor, malnourished, living in cramped, ill-ventilated homes. Poor quality coal for cooking creates smoke, choking the lungs, thus making them susceptible to TB. They live on less than $1.25 a day (World Bank) and cannot afford to lose work and wages to access TB care. Although Government provides free diagnostics & medicines, treatment centres are few and far between. Patients find it impossible to adhere to the regimen, which requires 60 centres-visits over 6 months. Even if they start treatment, once they feel better they tend to stop for fear of losing jobs or of discrimination. This leads to various DR-TB strains, which are near to impossible to treat. Each patient infects 10-15 others, increasing the number of DR-TB cases exponentially. Social stigma, fear and misconceptions all explain poor adherence. Out of 600,000 MDR-TB patients globally, 100,000 are in India. XDR-TB is rampant. Mumbai recently reported 12 cases of TDR-TB (Totally Drug-Resistant TB), which has no treatment. DR-TB is serious socio-economic issue causing tremendous economic loss. Thus, treating MDR-TB fully will prevent XDR & TDR-TB.
How have you addressed these challenges? Do you see a solution? Operation ASHA’ (OpASHA) model and eCompliance effectively tackle lingering problems in TB treatment: patient identity fraud, missed doses, data fudging and high treatment cost. OpASHA fosters community empowerment and employs TB treatment providers who are locals from the communities we serve. With their knowledge of the local language and geography it is far easier for the treatment to reach disadvantaged people. Providers gain the community’s trust and help destigmatise TB through comprehensive education. They assure no patient loses their job or is ostracised by their family. We effectively utilise religious and social leaders to ensure patients adhere to their regimen. OpASHA establishes DOT (Directly Observed Treatment) centres within disadvantaged communities that are accessible and open at convenient times so no patient has to miss work and wages. One DOTS centre serves a population within 1.5km radius. To ensure each dose is taken we use eCompliance, which has a fingerprint reader attached to a netbook computer (or android phone). To register in our centre, new patients must provide fingerprints. Afterwards, every time they come for their free TB treatment they provide fingerprints to verify their identity. To decrease missed doses we rely on our providers and eCompliance for follow up. If a patient misses a dose, eCompliance sends an SMS immediately to the Programme Manager & Treatment Provider. Providers must follow up within 48hrs, find the patient, repeat TB education, administer TB medicine and obtain a fingerprint as proof of visit. If patients experience side-effects, providers either treat them or, if severe, refer them to the hospital.eCompliance eliminates data fudging because we use fingerprints for registering patients, rather than rely on manual data entry. The back end EMR (Electronic Medical Record) generates a set of 100% accurate reports, which previously was a time consuming task as our staff did it manually and with errors. eCompliance saves 30% of provider’s time which is now spent on valuable Active Case Finding and Patient Counselling.We recently upgraded eCompliance to follow MDR-TB treatment, thus preventing XDR-TB. We are also installing eCompliance on android phones. This substantially reduced our terminal costs by 40% and the cost of treatment per patient to less than $3. LGT Venture Philanthropy found that “OpASHA’s cost for treating each patient in India is approximately 19 times lower than the nearest other provider."
How do you know whether you have made a difference? OpASHA believes in a measurable impact, thus generating far more detailed reports than the Government. The following shows our achievement thus far:• We serve 6.1 million disadvantaged people in India and Cambodia
• 31,150+ TB patients treated in more than 3,000 rural areas and urban slums
• We have successfully reduced default rates from as high as 36% to as low as 1.5 %, thus minimising the risk of MDR-
• Treating over 70 MDR patients; supporting 2 XDR patients and one TDR patient with medicines and protein supplements.
• Distributed 570,000 painkillers, 780,000 antacid tablets, 315,000 antiemetic tablets, 240,000 iron tablets, 45,000 calcium tablets, 30,000 condoms, 12,000 sachets of Oral Rehydration Salt, 3,500 packets of protein supplements, 5 tons of food and 4000 blankets.
• 24 Female TB patients were provided vocational training to prevent them from being abandoned by families.
• $150/year increased income through reinstated productivity from TB, equivalent to an annuity of $1,877; treated patients have benefited by $56 million, $13,150 saved by economy for each person treated (Annual TB Report 2011: Govt. of India).
• 190 disadvantaged persons provided dignified sustainable full-time work.
• Income of 178 micro-entrepreneurs in disadvantaged localities (Community Partners) enhanced substantially.
• Social return on investment (SROI) of 3217% i.e. for every dollar invested, the society and the economy benefit by $49.3.Apart from the above, we also regularly measure, collate and analyse the following parameters
• User satisfaction metrics
• Access/ utilisation metrics: Detection as a percentage of prevalence; target is 100%
• Cost and sustainability metrics: Monthly expenses, Cost per patient & Cost per
Treatment / DOTS centre
• Achievement of positive health outcomes: Increase in body weight during the treatment.OpASHA has partnered with J-PAL, MIT in USA, which has conducted an RCT (randomised control trial) to assess the impact of OpASHA’s incentive-based salaries. We have received funding from USAID for the second RCT to assess the benefit of eCompliance. This is helping impact policy in India and abroad.
Have you or the project mobilized others and if so, who, why and how? The overarching principle of OpASHA is providing free, quality TB treatment to the doorsteps of the disadvantaged, while at the same time mobilising them to take self-initiative to improve their health as well as their socio-economic lifestyle. We believe OpASHA’s localised model is an efficient way of generating that mobilisation. For instance, in Cambodia all of our employees are locals, except for the Country Director. 80% of our budget is used to generate jobs for the disadvantaged in India and Cambodia. Within 6 years OpASHA became the 3rd largest TB treatment provider worldwide & the biggest in India by using a high-impact/low-cost, scalable & replicable model. In 2012 The Millennium Villages Project & Columbia University replicated our model and eCompliance in Uganda with “staggering improvement” in results. It took only 8 hours of Skype calls to train the master trainer in Uganda, who then trained their local providers. All technology, training and troubleshooting was done remotely from our office in India. Columbia University is now replicating eCompliance in the Dominican Republic.TB is not only a serious medical issue but it also has serious gender-related consequences. In India 100,000 female TB patients are thrown out of their homes each year by their families, left to die of disease and starvation. 300,000 children have to leave school because of TB either as a result of the infection, or because the parents have TB, in which case the child has to work to support the family (Government of India). OpASHA regularly employs women as TB treatment providers, thus reducing gender disparity. In return, not only do they generate income to support their families but they also gain great respect from the communities who treat them as doctors. In addition, at the end of each quarterly report we reward the provider with the most successful rate of active TB case finding.OpASHA’s delivery of effective TB treatment to women and girls, and in general to the “poorest of the poor”, remote and marginalised tribal communities in India, alleviate the adverse medical, social, economic and gender-based effects of TB, both on the individuals and their communities. This will, in turn, improve productivity, raise income, prevent economic loss, provide skills, training and employment for semi-literate providers in those communities, and enable access to services for the deeply marginalised tribes.
When your donor funding runs out how will your idea continue to live? OpASHA’s collaboration with the Indian Government increased our leverage by more than 4 times. They provide us with free TB and MDR-TB diagnostics, physician consultations and medicines for the communities we serve. The government also gives a grant per patient, which we receive 2 years after starting patient’s treatment. At the moment the government grant covers our entire field costs, i.e. cost of operations, thus our fieldwork is sustainable. Nevertheless, the grant still comes 2 years late. This means that in the meantime we need donor funds to help establish and operate those same centres for 2 years, as well as cover administrative expenses. This makes the government grant currently inadequate. As the eradication of TB is one of the Millennium Development Goals and due to rapid proliferation of DR-TB cases, the Indian government is focused more than ever on TB eradication, which has become a priority for politicians and policy makers. Hence, the Government has declared a plan to increase funds for TB treatment by at least 4 times and also to keep pace with the inflation by steadily increasing the funds. It has been decided that the money will also be given upfront to NGOs rather than being delayed for 2 years. Because of that we can use this grant to establish and operate our centres and continue treating patients year after year. Once the new plans come into place our entire programme will truly become self-sustaining and we will no longer be dependent on donor funds at all.The eCompliance initiative comes at a cost of $3 per patient, which is more than offset by increased productivity of our providers and office staff so it does not add to the per patient cost. eCompliance is therefore, self-sustaining from the very beginning.

Population attributable estimates and Risk factors for Hepatitis.

Author(s) Bilal Ahmed1, Tooba Ali2, Huma Qureshi3, Saeed Hamid 4
Affiliation(s) 1Department of Medicine , The Aga Khan Univesity , Karachi, Pakistan, 2Medicine , The Aga Khan University , Karachi, Pakistan, 3PMRC, Pakistan Medical and Research Council, Karachi, Pakistan, 4Medicine, The Aga Khan university , Karachi, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Infectious Diseases
Summary Estimation of population attributable risks indicates the potential for prevention of hepatitis if the exposure to certain modifiable factors could be eliminated.
We estimated the population attributable risks and performed systemetic review of various risk factors for transmission of HBV and HCV ( in 2012) using data from a large nationally representative survey conducted in 2007 across Pakistan.
A substantial number of HBV and HCV infections in Pakistan and other South Asian countries can be prevented by key interventions targeted towards a few selected and modifiable risk factors.
Background Viral hepatitis is a major public health disease worldwide with serious morbidity and mortality. South Asia lies among endemic regions where about 70 to 90% of the population become HBV-exposed before the age of 40, with 8 to 20% of people going on to become HBV carriers.
Objectives Data from Pakistan provides an important opportunity to better analyze and understand the most important attributable risks associated with specific factors for transmission of these infections in order to inform effective prevention and control policies. Previous analyses have estimated the odds ratios of various factors associated with HBV and HCV infection in our population, however these estimates do not provide information about the potential impact on disease occurrence that could be expected by eliminating these risk factors. In the present study we have tried to calculate population attributable risk (PAR) that can provide information as a quantitative assessment of the potential reduction in disease prevalence if the exposure in question were eliminated from our population. This study can potentially be generalized as applicable to other South Asian countries with similar background risks. The present analysis constitutes the first attempt at a comprehensive study of the population impact of risk factors for hepatitis B and C.
Methodology From July 2007 to May 2008, a nationally represented cross sectional survey was conducted in all urban and rural areas of the four provinces of Pakistan. The target population was the local residents of all territories of the country. The sampling frame was designed by the Federal Bureau of Statistics so as to be representative of the country’s population. A multistage sampling strategy was used by classifying cities and towns into well-defined enumeration blocks that constituted the primary sampling units (PSU). Taking population size in each province, and keeping in mind rural/urban proportions, 350 PSUs with 20 houses in each PSU were pre selected. House to house investigation was completed by trained staff based on the sampled household list. Information on demography, ethnicity, socioeconomic status, education, employment and marital status was collected by using standardized questionnaires. Altogether 7000 households were sampled and approximately 47000 individuals were tested for hepatitis B surface antigen (HBsAg) and anti-HCV antibody using rapid tests based on enzyme-linked immunosorbent assays (ELISA). For HBeAg testing a chemiluminescence method was used (CIMA), approved by FDA for field testing for HBV and HCV.
The risk factors under study were frequency of therapeutic intramuscular injections in the past one year, types of syringes used and categorized as new disposable or reused syringes, practice of shaving among males at home or by a barber, tattooing or acupuncture within the last five years, ear or nose piercing among females within the last five years and sharing tooth brush, miswak (herbal twig for dental hygiene) or sharing smoking utensils (hokas, bidi).In the present analysis we calculated the population attributable risk associated with modifiable factors for HBV and HCV in our population. The population attributable risk is defined as the proportion of hepatitis cases that can be related to a given risk factor (or set of risk factors) and is useful in assessing its impact at the population level. Estimation of population attributable risk was obtained by using an approach based on unadjusted logistic regression.
Additionally, a systematic review for the prevalence of modifiable risk factors associated with HBV and HCV from the South Asian region was performed to study the disease dynamics in this region, which could help in designing a holistic intervention strategy for disease prevention.
Results Analysis showed that the odds ratio of HBV infection among those with greater than 10 therapeutic injections in the past one year were 4.5 times higher compared to those who had received no injections, yielding a population attributable risk of 3.5%. Likewise, practice of reuse of syringes was 3.7 times higher compared to those who had received no injections giving a PAR of 2.7%. Another modifiable risk factor i.e. practice of shaving at barbers was 4.1 times higher compared to shaving at home with a PAR of 2.1%. Similarly, the odds of sharing of smoking devices (cigarettes, hokka, bidi) were 2.5 times more associated with the outcome, giving the highest population attributable risk of 4.4%.The odds of HCV infection among those with greater than 10 therapeutic injections in the past one year were 8.1 times higher compared to those who had received no injections, yielding a population attributable risk of 11.3%. Similarly, the practice of reuse of syringes was 6.8 times more associated with the occurrence of HCV giving a PAR of 6.2%. The practice of sharing of smoking (cigarettes, hokas, bidi) was 11.5 times more associated with HCV with a PAR of 5.1%. Odds of HCV among those reporting tattooing are 8.3 times, yielding a population attributable risk of 3.5%.
In the overall study population 34 % of hepatitis cases could be attributed to at least one of the seven well established risk factors. Therefore a substantial number of cases of hepatitis B and C can be prevented by eliminating these risk factors
Findings of systematic review:
We identified approximately 30 full text articles from the south Asian region that focused on the risk factors for transmission of viral hepatitis (see annexure). HBV and HCV epidemiology shows a high variability across the South Asian region, however both viruses bear common risk factors for transmissibility in this geographical region. Majority of these factors are related to health delivery and life style practices and are completely modifiable. Reuse of needles, shaving practices and body piercing are significantly prominent in the region.
We recognize that there are certain limitations to this study. One of the major limitations in the primary study was not using multistage cluster sampling and appropriate sampling weight at the design phase of the study, which limits our external generalizability. Besides this, causality is important for the interpretation of the PAR.
Conclusion A substantial number of HBV and HCV infections in Pakistan and other South Asian countries can be prevented by key interventions targeted towards a few selected and modifiable risk factors. Hence policies specifically targeted at key risk factors for HBV and HCV, such as safe and rationale use of injections prescribed by trained healthcare providers, are urgently needed for countries like Pakistan.This study indicates that about one-third of the hepatitis B and hepatitis C cases in the Pakistani population could be prevented by interventions in a few selected and modifiable risk factors: decreasing the frequency of therapeutic intramuscular injections, stopping the practice of re-used syringes and needles, avoiding shaving at barbers, prohibiting sharing of tooth brushes, razors and smoking utensils like hukka, avoiding tattooing and prohibiting the use of non-sterilized tools for ear /nose piercing.Our results show that about 33% of hepatitis B and C are attributed to the factors identified earlier and at least 67% are still unexplained and might be associated with other factors like blood transfusions, hemodialysis, previous surgery etc, for which the data were not collected in our primary study.The findings of our study have huge implications from public health perspective. Pakistan’s national hepatitis control program is mainly working on providing vaccination against HBV to the newborn and high risk groups, providing treatment for chronic HBV and HCV infection, and raising public awareness about these viruses. Improved surveillance to monitor incidence and prevalence of viral hepatitis, along with creating awareness and utilising low cost interventions among the general public and high risk individuals by media campaigns would help in reducing the burden of hepatitis. Strict policies and regulations for the prohibition of reused syringes and use of unsterilised tools, together with some life style changes, will help curtail the burden of the disease. Strengthening hepatitis B vaccination program is an effective step toward preventing transmission.

Public Responsibility in Research and Development Partnerships

Author(s): Bernard Pécoul1
Affiliation(s): 1Executive Director, Drugs for Neglected Diseases Initiative, Geneva, Switzerland
Key issues: A fatal imbalance exists in the investment in new drugs for neglected diseases, such as sleeping sickness and leishmaniasis, versus diseases prevalent in wealthy countries. From 1975 to 2004, of the 1,556 new drugs marketed only 21 just over one percent were for infectious tropical diseases and tuberculosis, in spite of the huge need. So, not only are the poor in developing countries disproportionately suffering from curable diseases, but their needs are woefully unmet by the existing model of drug development.
Meeting challenges: This disparity is now widely acknowledged and is being addressed by new research as well as new initiatives. Several research initiatives have been set up in the last 5 years to address this issue, e.g., the Drugs for Neglected Diseases Initiative (DNDi), Medicines for Malaria Venture, and TB Alliance. The challenge here lies in procuring full financial and political support from governments so that the initiatives can achieve their goals of developing and delivering desperately needed, new, effective, needs-oriented medicines to neglected patients. Currently, only 16% of funding for these initiatives comes from governments, while almost 80% comes from philanthropic organisations. This is unsustainable. The importance of public responsibility in providing equitable access to these health tools is an essential part of DNDi’s message as a not-for-profit research organisation that works in close collaboration with public and private partners in both developing and developed countries. The need for increased public support of essential innovation for neglected diseases is a growing global concern. Governments are being urged to lose no more time in supporting new funding mechanisms for neglected disease research and development and to create a favourable environment to stimulate R&D. A handful of Innovative Developing Countries such as India, South Africa, Brazil, etc. are becoming more proactive in the field of drug R&D. Yet innovation in drug discovery for neglected diseases remains a critical gap.
Conclusion (max 400 words): This message has recently gained ground at the WHA 2006, which voted to adopt a resolution to establish a global strategy and a plan of action directed at public health, innovation and essential health research. These are positive steps towards addressing the greater problem of R&D for neglected diseases. Much more remains to be done.

Working in Partnership to Improve Child Survival: Red Cross Support to the Ministry of Health During the Mali Integrated Campaign

Author(s): M. M. Erskine1, D. Adama*2, J. Peat1, O. I. Toure3
Affiliation(s): 1Health and Care Department, International Federation of Red Cross and Red Crescent Societies, Geneva, Switzerland, 2Governance Committee, Mali Red Cross Society, 3Ministry of Health, Bamako, Mali

Child survival, Mali, Ministry of Health, Red Cross, integration, vaccination, malaria, civil society, partnership


In 2007, the Malian Ministry of Health worked with its financial and technical partners to plan and implement one of the largest child survival campaigns to date. The Mali Child Survival campaign targeted over 2.8 million children under the age of five throughout the country. In one week, children received vaccination against measles and polio, supplementation with vitamin A, deworming treatment and long-lasting insecticide treated nets for malaria prevention. Together, the integrated package addresses a number of diseases that contribute to a high disease burden among African children.  A central part of the campaign planning was the communications and social mobilization strategy, to ensure that all segments of society were informed and motivated to promote and participate in the activities. One organization that played an important role was the Mali Red Cross Society, which trained 2,500 volunteers in six regions of the country. The partnership between the Malian Ministry of Health and the Malian Red Cross is an example of how civil society organizations can play a supportive role to improve healthcare delivery. The Malian Red Cross continues to play this auxiliary role for community- and household-based promotion of routine health services to work towards sustaining the high coverage rates attained during the integrated campaign.


The objectives of the Integrated Child Survival campaign in Mali were to reach more than 95% of children with measles vaccination and more than 80% of children with all other interventions. Additional objectives included ensuring adequate social mobilization to persuade caretakers of the importance of the campaign, undertaking micro-planning for logistics and management of all campaign supplies and implementing an effective system for monitoring and supervision during the week of activities. The campaign will be evaluated in late January/early February using PDA technology.


Results for this presentation are divided into two components, one related to process and the other related to impact. In terms of process, a strong collaboration and cooperation existed amongst partners, with the Ministry of Health leading and coordinating all activities. Strong relationships with civil society organizations, including the Mali Red Cross, allowed for successful mobilization of parents and organization of sites for the child survival campaign. The role of the Red Cross as a civil society organization is highlighted here to emphasize the need for community-based volunteers to ensure that the most vulnerable, and the most resistant, households receive these necessary interventions. In terms of impact, data were collected daily during the seven days of campaign activities and information was relayed from the health centre level to the national level through telephones, computers and radios. The results of the campaign indicate that all objectives set at the outset of the campaign were not only reached but also exceeded. A cluster survey, using PDA technology, will be used to confirm the daily tally results from health facilities with household level data regarding under fives and their participation in the campaign.

Lessons learned:

The Mali Integrated Child Survival campaign was an enormous undertaking for the country. The importance of partnership, at both international and national levels, is highlighted as a major reason for the success of the initiative. Within the vast country, the contribution of community-based organizations is central, as demonstrated by the role of the Red Cross in mobilizing caretakers before, during and after the campaign. The importance of ongoing messaging to parents to ensure that health facilities are accessed for routine vaccination services, and to contribute to positive behaviour change at the household and community level, are retained as major lessons for sustaining achievements.

Improving Home-Based Use of Coartem for Malaria Management in Children Under Five Years of Age

Author(s): H. A. Oluyedun1
Affiliation(s): 1Sociology, University of Ibadan, Nigeria
Keywords: Home-based, health volunteers, adherence, malaria management

Malaria is the largest cause of health service attendance, hospital admissions and child deaths in Nigeria. Resistances of plasmodium falciparum to chloroquine and sulphadoxine plus pyrimetamine have led to adoption of policy to use Coartem as the first-line drug of treatment. This is an intervention programme at Orile-Odo in Oluyole L.G of Nigeria. It targets the mothers of under-five children with uncomplicated malaria, using 200 households, 20 health volunteers and four supervisors. A cohort (non-experimental epidemiologic intervention) study will be used a multistage sampling technique. The 20 volunteers and four supervisors are to act as community advocates in sharing the knowledge they have acquired and support mother and caregivers in the community in managing simple malaria.


The objectives of the intervention are - to find out the home based practice, to train the health volunteers on the correct usage of Coartem as the first line of treatment in other to improve adherence, to increase the awareness of the mothers and community about Coartem. To ensure accessibility of Coartem in the community health centres and in the drug sellers shops in the community and to ensure early recognition of symptoms and proper administration of Coartem.


The result showed that: (1) prior to the study the patronage of the Health facility in the community is poor, it is as low as 20% due to lack of knowledge and preference for herbal treatment, after the intervention the hospital cannot meet the demand for Coartem because nearly every mothers in the community wanted to enrolled in the programme; (2) The accessibilty to Coartem improved in the community because the record of the drug dealers in the community all improved on the average of 200%; (3) Early recognition and prompt treatment improved by 100% as revealed by the health volunteers and the drug seller; (4) The adherence to dosage regimen was seen in 90% of the mothers; (5) The health Volunteers and the drug sellers in the community after the training were better informed, and the assessment showed that they passed correct information to the mothers.

Lessons learned:

The programme is an innovative approach to malaria control involving community members. The monitoring ensured validity of the evaluation and made it feasible for replication in other areas in order to inform national scale up. The outcomes of the intervention showed improved and correct use of antimalarial (Coartem) in home management, early recognition and prompt action taken in the malaria management, and compliance to antimalarial drug regimen.

A Qualitative Study to Explore Barriers Faced by Patients in Adhering to Antiretroviral Therapy at Lighthouse Clinic


K. R. Chikaphupha*1, F. P. Kachomoza1, L. J. Nyirenda1, G. T. Bongololo1, R. Weigel2, M. Boxshall2, S. Theobald2, I. M. Namakhoma1


1REACH Trust, 2Lighthouse Clinic, Lilongwe, Malawi, 3Liverpool School of Tropical Medicine, Liverpool, UK

Keywords: ART, adherence

The major success of the antiretroviral therapy (ART) depends on maintaining high adherence levels among patients on ART. Lighthouse operates the largest ART clinic in Lilongwe District in Malawi and provides care to more than 4,000 patients on ART.


The objective of the study was first to understand factors that cause patients on ART to stop treatment or miss doses or clinic appointments. Secondly to determine whether or not some groups of patients e.g. women, face more barriers in adhering to ART.


Results:   The study revealed several impediments to ART adherence. Financial problems were reported as a major challenge leading to patients missing appointments or stopping treatment. Patients reported that they sometimes do not have money for transport to travel to and from the hospital. Financial constraints also led to problems in sourcing food in the home hence patients’ failure to strict observation of their dose time and appointment dates. Patients’ financial problems were aggravated as a result of loss of income and employment due to long illness. Travel outside Lilongwe for purposes of business and work for instance truck drivers and business people, also contributed to missing of doses and appointments. Belief that HIV could be cured through traditional medication and prayers caused some patients to stop treatment. Side effects from ARVs and co-infection with TB that demanded an interruption of ARVs to start TB treatment also led some patients not to restart ART.

Lessons learned:

Poverty which leads to lack of food was a major impediment to the retention of patients on treatment. Hence exploring ways of supporting patients with food is necessary to enhance adherence to treatment. The TB/HIV co-infection in patients has implications for the individual and the health system hence need for better ways of addressing the problem. Further, health facilities need to improve on reporting system to curb mis-defining patients as defaulters. Early recognition of risk factors for poor adherence supported by follow up of patients could help to communicate targeted health messages to these groups to encourage treatment adherence and retention in the ART programme. Most of the patients who had defaulted from treatment are willing to continue taking up the therapy.

Malaria Intervention

Author(s): E. Tamakloe1, F.K. Mensah*2
Affiliation(s): 1Aowin Suaman District Hospital, NGO, TCAF-NGO, ENCHI, Ghana

High risk and vulnerable areas, pregnant women, children under five, insecticide-treated  nets, intermittent prevention treatment, IE&C


The National Malaria Control Programme of the Ghana Health service has received five year support from the Global fund on Malaria. This presentation showcases the experience in the Aowin Suaman District in one of the Poorest Regions of Ghana - and the successful partnership between the Government Hospital and TCAF NGO and the free distribution of ITNs and Administration of free anc/IPT for women.


In Ghana malaria is noted to be hyper endemic and is estimated to be a major killer disease in the country, even though it is preventable and curable. Those children who escape death are not untouched by the killer disease. Malaria also hinders the development of those who survive. Malaria accounts for about 40% of all out patient visit to clinics-indeed 50% of all hospital admissions. This affects not only the health but also the socio-economic and developmental strength of the community. With support from the Global fund, the NMCP has succeeded in bringing on board many other players aside the health sector to join in the fight. This has succeeded in creating the needed awareness and drumming home the importance of avoiding the bite of the infected female anopheles mosquito. These successes notwithstanding, many more players are yet to come on board for Ghana to become a malaria free nation. To achieve this, NMCP has embarked on a series of aggressive advocacy and social activities with several players and stakeholders to win their support and also assist with the malaria control effort in the country. The national malaria control drug policy and preventive strategy has been developed and is being advocated and spread nationwide by the National Malaria Control Programme with support from the Global Fund. Unfortunately, highly deprived communities in the Aowin Suaman District in the Western Region are not able to access the malaria interventions fully. Stake holders in this national fight, like NGOs CBOs, CBAs and other community leaders are not involved in the strategy by the Regional Health Administration. It is in line with this that Take Care Africa foundation (NGO) has responded to the invitation by the Aowin Suaman District Health directorate and the NMCP to join in the fight by mobilizing community strengths through education, stake holders/agents workshops towards improving access of households and targets population to various malaria preventive and management interventions.


1 – District Hospital empowered with equipment including vehicles and bicycles to reach excluded and marginalized communities/villages;
2 – Hospital facilities improved;
3 – Hospital personnel and volunteers of Take care Africa foundation (NGO) collaborate effectively to create friendly environment in the hospital and community health post;
4 – 6,000 insecticide-treated bed net distributed free of charge to community members.
5 – 100 ITN Re-treatment centres;
6 – Engaged and assist 100 CBAs/TBAs and community members to promote project in the communities;
7 – Reduce the rate of death resulting from Malaria infections;
8 – Increase awareness of new malaria policy and usage of treated bed net.

Lessons learned:

1 – Health funding and developmental interventions when focused on high risk areas and vulnerable communities become more effective and produces more results;
2– women and children must be empowered and offered free medical care in poor countries, this will enhance the socio-economic status of the affected communities;
3 – Global fund for malaria has enhanced healthcare in Ghana – and the fund has enlightened community members on the need for early detection and reporting /use of ITN.

Equity Assessment and Treatment Outcomes in Accessing Antiretroviral Therapy in Malawi

Author(s): T. I. Chilipaine-Banda*1, I. Makwiza-Namakhoma1, B. Nhlema-Simwaka1, J. Aberle-Grasse2, B. Hedt2,
E. Schouten3
Affiliation(s): 1Research for Equity and Community Health Trust, 2Centres for Disease Control, Malawi, 3Ministry of Health, Malawi
Keywords: Equity, treatment access, treatment outcomes, antiretroviral therapy

In Malawi, HIV prevalence among adults (15-49 years) is estimated at 14 percent. Though the number of people accessing ART is rapidly expanding, the goal of ART provision is to reach only 50% of the population becoming eligible every year. The Ministry of Health recognises the importance of equity in the national ART scale up as highlighted in the World Health Organisation’s Alma Ata declaration. Equity is defined as comprising elements of an assessment of vulnerability, in terms of HIV infection and access to care and treatment or ability to cope with the impact of the illness. Equity monitoring is crucial in ensuring that the disadvantaged and vulnerable populations are accessing treatment.


The study aimed at conducting an equity assessment to analyse who is accessing treatment by age and gender and compare if ART access is in line with HIV prevalence trends. Furthermore, the study established the effect of gender and age on the patient’s treatment outcomes. Data analysis used existing routine ART registers and focus was on all ART patients who initiated treatment in 2006 in the 5 districts of Malawi. Data was collected on the following variables; age, gender, area of location and also patient’s treatment outcomes.


Results show that 10,800 patients were enrolled on treatment in the 5 districts studied in 2006. Treatment access compared with HIV prevalence by gender shows proportionately more females accessing treatment than males. A comparative analysis of the age-sex distribution with HIV prevalence shows that the young age group of 15-19 had more men proportionately on treatment as compared to women. However, HIV prevalence trends show that prevalence in the 15-19 age group is higher in women than men. Also, uptake of treatment in the 30-39 age group showed that there were more women on treatment than men, yet HIV prevalence in this age group is higher in men as compared to women. Disparities in treatment outcomes by gender and age shows that men on ART are at more risk of dying as compared to women by 25% (Odds ratio= 1.25, P-Value=0.003). Furthermore, Men are 1.15 times more likely to default on treatment as compared with women (Odds ratio= 1.15, P-Value= 0.078).

Lessons learned:

In general, men are not accessing treatment as compared to women. Furthermore, there are also age specific differences in access to ART. Particularly, amongst the 15-19 age group for women and 30-39 age group for men. In order to make ART scale up provision equitable, it is imperative to target women in the 15-19 age group and men in the 30-39 age group for counselling and testing and also access to ART. This would enable increase in the uptake of treatment in these age groups. Furthermore, the treatment outcomes by gender suggests that there is need to understand the health seeking behaviour patterns amongst men in order to establish the confounding factors for the higher death rate and default rate in men as compared to women.

Women and HIV/AIDS in Sierra Leone

Author(s): Y. G. Golley-Morgan*1
Affiliation(s): 1Ministry of Health and Sanitation, Freetown, Sierra Leone
Keywords: HIV/AIDS, WLWHA, triple jeopardy, poverty, voice of women, care and support

More than two decades after its identification, AIDS has become far more widespread, affecting all members of society. Women continues to bear the brunt of the epidemic as they are faced with many other health, social and economic issues and has to struggle with the challenges poised by the epidemic. Thus, they carry a triple jeopardy of AIDS, i.e. as people infected with the virus, as mothers of children infected and as carers of partners, parents and orphans with AIDS. This has resulted in further impoverishment, increase in gender-based violence, threat to women’s livelihood, devastation, extra burden of care, and inaccessibility to health services.


Women living with HIV/AIDS in Sierra Leone are increasing. The prevalence rate is 1.7% for ages 15-19yrs (Aug 2006) and the age group most affected is 20-24yrs. Some of the causes of this increase in post war Sierra Leone ranges from lack of autonomy of women, pervasive poverty, sexual violence and gender based violence, illiteracy, ignorance or low knowledge of the virus, unwillingness to change behaviour, cultural norms, and patriarchy and gender inequality. HIV affects both their sexual health and well-being. Addressing the health and other needs of women living with HIV/AIDS is fundamental to women’s wellbeing, their partner and children. Organization and institutions addressing WLWHA are essential in the fight against poverty and contributes in promoting social and economic development.


Increase in the number of services (both community and national) that addresses the sexual, reproductive and other health, social and economic needs of these women. Formation of a sound HIV/AIDS workplace policy that addresses HIV/AIDS issues has resulted in increased support for WLWHA. The ‘Voice of women’ initiative of HIV positive women was set up to empower women living with and affected by HIV/AIDS. 80% of healthcare in the country now has trained personnel for HIV testing, with free ASRV for all HIV positive women that require them. The development of manuals on STDs for healthcare workers and booklets on guidelines on lab diagnostic procedures of HIV infections.

Lessons learned:

Breaking the silence among women needs implementation of sound and collective initiatives from victims themselves and women must be encouraged to be central to the HIV/AIDS response to break the patriarchy trend. Implementation of the principle of GIPA is moving in a rather slow pace as a result of poor partnership and lack of proper strategic framework. Cultural practices, e.g. FGM, early marriage etc., cannot be addressed by HIV/AIDS programmes alone but rather on sound policies and legislation. Well chosen volunteers and family members including traditional healers and leaders are essential for community and home based care. Capacity building through skills training is an important and alternative source of income. Nutritional support is essential for ART adherence. Involvement of existing health institutions in admission and further clinical management of WLWHA have contributed in reducing stigma among health staff and other family members and promote psychological healing.