JULY 2010

Inside ICAP

AIDS Response at a Crossroads: ICAPís Wafaa El-Sadr and Jessica Justman Co-author Editorial in Science Magazine. Available here.

On July 13, ICAP Director Wafaa El-Sadr attended a White House reception. Hosted by President Obama, the reception celebrated the HIV community on the occasion of the launch of the first the U.S. National HIV/AIDS Strategy. The strategy is available here.

About ICAP

ICAP was founded in 2004
at Columbia University’s Mailman School of Public Health. Now a global leader
in HIV/AIDS services, ICAP supports work with more
than 1,200 health care facilities in 14 countries in Africa. More than 962,000 people have received ICAP-supported HIV services, including antiretroviral treatment for more than 480,000 individuals.

For more information about ICAP, visit here.
For more information about ICAP leadership, visit here.

Sponsored by Doris Duke Charitable Foundation, Bill and Melinda Gates Foundation, William and Flora Hewlett Foundation, Robert Wood Johnson Foundation, Henry J. Kaiser Family Foundation, Stephen Lewis Foundation, John D. and Catherine T. MacArthur Foundation, National Institutes of Health, David and Lucille Packard Foundation, Rockefeller Foundation, and Starr Foundation.

© 2010 ICAP

Contributors include Robin Flam, Grace Garnvwa, David Hoos, Anton La Grange, Elizabeth Magomba, and Patricia Toro.

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Much of the effort to confront the HIV epidemic in Africa has focused on generalized epidemics largely affecting heterosexual men and women. Until recently, most at-risk populations (MARPs) have received little attention, such as men who have sex with men and injection drug users (IDU).

Across the world, injection drug use is linked to some of the fastest growing HIV epidemics. It is estimated that roughly 30% of new HIV infections outside of sub-Saharan Africa are linked in some way to drug injection, and that the contribution of injection drug use to HIV transmission in sub-Saharan Africa is poorly understood.

United for Risk Reduction and HIV/AIDS Prevention (URRAP) is an innovative program initiated through ICAP support in 2008. URRAP involves a partnership between national government agencies and three non-governmental organizations (Zanzibar Youth Education, Environment and Development Support Association; Zanzibar Association of Information Against Drug Abuse and Alcohol; and the Zanzibar Youth Forum). The partnership reaches out to injecting drug users (IDUs) to provide them with information regarding HIV prevention, linkage to HIV testing, and for those found to be HIV-infected, access to care and treatment. The five-year program is now in its third year.

A series of islands east of Tanzania, Zanzibar has a 1.2 million population. While HIV prevalence among the general Zanzibar population is much lower than in mainland Tanzania, HIV is concentrated among IDUs. Currently, an estimated 4,000 people on the islands inject heroin. While HIV prevalence in the general population was estimated at 0.6% (in 2002), a 2007 survey from the Ministry of Health and Social Welfare found that up to 16% of IDUs were HIV positive.

When ICAP first embarked on this work in 2008, there were no drug treatment programs for IDUs in Zanzibar. There was no connection between overall HIV outreach efforts and outreach efforts for drug users. Syringe sales to drug users were also discouraged. Some users needed to hide needles in secret locations only known among their injecting partners, which promoted the sharing of syringes. Fear of mistreatment by the police posed an obstacle to outreach efforts

URRAP’s work in Zanzibar involves outreach to heroin users. Educational activities include providing IDUs with bleach and teaching them how to use it to clean syringes and needles to minimize potential infections, including HIV transmission, medical treatment for opioid dependence, informing them of need for use of clean syringes and needles, HIV counseling and testing, referral of those found to be HIV positive for HIV care, and treatment for those eligible. Thus far, a total of 1,700 encounters have been accomplished. Much of the outreach has been conducted by peer workers who are IDUs or former IDUs who are trained to provide support and guidance. In collaboration with partner NGOs, ICAP has supported the establishment of four drop-in centers and 12 recovery centers where IDUs can meet as needed for counseling and support. Through these centers, together with the outreach activities, more than 30 IDUs are in recovery since the start of URRAP. Over time, support for condom distribution has been garnered as well.

URRAP also focuses on training and sensitizing health care providers on issues regarding substance use, the special needs of this population, and how to adapt services to their needs. Pharmacists have been a key group in this training. To date, 218 health care and outreach workers have been trained through the program.

“The stigma that comes with injecting drugs seems even more profound than that associated with HIV,” said ICAP-Tanzania country director Redempta Mbatia. “When we support training for health workers, part of this training focuses on changing provider perceptions of substance use, so that they are able to provide IDUs with the same quality of care as anyone else.”

URRAP has also focused on the issue of heroin overdose. "On a daily basis, injecting drug users see friends die from overdoses" noted Sharon Stancliff, ICAP program advisor. To respond to this concern and build trust with this community, some of the initial outreach and education focused on overdose prevention. A partnership was established with the government in Zanzibar to distribute Naloxone, a drug that enables reversal of effects of drug overdose and can save lives. Naloxone will soon be available at two pilot health care facilities. Since overdoses frequently occur in the community, future efforts will try to make naloxone more widely available.

Mbatia added, “By addressing concerns about overdosing, we’re establishing trust and building on that to introduce the elements of HIV prevention and care. Our goal is to protect these individuals from getting HIV as well as to ensure that those with HIV have access to high quality, comprehensive, and humane services.”

ICAP has also sought the involvement of policymakers, including the Ministry of Health, Board of Pharmacy, Department of Substance Abuse Prevention and Rehabilitation (DSAPR), Zanzibar AIDS Control Program, and the local medical community in this effort. A notable plan is to make methadone treatment available in Zanzibar in the fall of 2010.

Ahmed Awadhi, director of the DSAPR, was grateful for ICAP’s support. He reported, “The ICAP contribution has played a significant role in bringing people with drug dependency closer to health service provision centers through targeted outreach. Capacity building trainings for service providers and peer educators have produced enormous changes and equipped them with better skills to address the problems related to substance abuse and HIV/AIDS.”

The success of the pilot program in Zanzibar, the unique partnerships established, the services provided, and the lessons learned will help inform further development of this work. In addition, these insights will inform the establishment of similar programs in the region, programs urgently needed to respond to the threat of HIV among injecting drug users.


In South Africa, Lay Counselors to Perform HIV Tests

In South Africa, lay counselors can now perform finger-prick HIV tests. Before the new regulations, only nurses were allowed to conduct these tests. Counselors will need to participate in a three hour training before being allowed to perform this test. This represents a landmark decision to help scale up HIV testing in the country.

At the district and sub-district levels, ICAP supports this approach by training facility staff on the new guidelines, and helping supervise implementation. ICAP also supports the provincial departments of health in five provinces with training for community health workers and lay counselors.

Video Artist Captures Patient Experiences in Uganda

A project that started in December 2009 has culminated in several short films produced by video artist Gideon Mendel. The short films are a combination of video, still images, and narratives of families who are part of ICAP's MTCT-Plus Initiative at the MU-JHU Cares HIV Clinic in Kampala, Uganda. The films shed light on some of the challenges that families with HIV encounter, particularly around the issue of disclosing their positive status to other family members.

From 2002–2010, ICAP’s MTCT-Plus Initiative supported programs in 10 countries that enrolled 16,500 HIV-positive pregnant women and their families (including over 6,000 children) in comprehensive services. MTCT-Plus was one of the first multi-country programs established to provided HIV care and treatment.

Videos are viewable HERE.

South Africa Trains Nurses to Manage ART

South Africa has a new slogan: NIMART. Short for “nurse-initiated management of ART,” the strategy helps scale up HIV services and address the shortage of doctors.

To provide the necessary training and refresher courses, the National Department of Health is developing a comprehensive training program called the ICP (integrated common program). Part of this program includes the “PULSA PLUS” methodology, which uses case studies to help nurses diagnose and treat patients. ICAP has trained all of its clinical mentors using this methodology, and provided a refresher course on clinical mentoring.

Kenya Taps Tech Innovation with Mobile Data Entry

Armed with just a laptop, record officer Richard Kabera rides a matatu, a public minibus, through rural Central Province, Kenya. Employed by the Ministry of Health and supported by ICAP, he uses the Roving Electronic Data Entry System (REDES), a pilot program, to ensure that information is complete and up-to-date. With the REDES system, Kabera records patient data while on the road, tracking patients who move from site to site, and centralizes the information in one confidential and secure database.

“REDES allows the tracking of patients who default from one facility to another,” says Dr. Muhsin Sheriff, Director of Monitoring and Evaluation at ICAP-Kenya, who created the system in collaboration with the ICAP Monitoring and Evaluation team . “Before the REDES program, these patients were considered lost to follow-up.”

ICAP-Kenya designed database software known as Comprehensive Care Centre Patient Application Database (C-PAD) to enable this work. Kabera and other record officers travel from facility to facility by matatu, collecting data from low volume facilities that do not have a data clerk or computer system onsite. Record officers enter data from paper records into the C-PAD database, which then enters REDES for more efficient epidemiologic and demographic analysis. The digitized health records system brings major advantages including making the reporting from sites and districts to the Ministry of Health as easy as clicking a button.