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Published on January 16, 2008

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CDN Webcast presentation September 20, 2005 Presenter: Larry Casazza MD MPH Director, ACAM –African Communities Against Malaria :  CDN Webcast presentation September 20, 2005 Presenter: Larry Casazza MD MPH Director, ACAM –African Communities Against Malaria The Impact of Malaria on Health in Africa and its Interaction with HIV/AIDS: The Potential for NGOs to strengthen Civil Society for Sustainable Results Acknowledgement of technical resources:  Acknowledgement of technical resources This presentation is a compilation of information that acknowledges the contribution of CDC, USAID, the CORE Group and the Advisory Board of ACAM. I thank you. Larry Casazza, MD MPH, Director, ACAM E-mail:larrycasazza@earthlink.net Session Goals :  Session Goals Malaria remains a major killer especially in Africa where over 90% of the global malaria deaths occur; meanwhile, HIV/AIDS programs have grabbed the headlines and dominate program emphasis in poor African communities Disease–specific programs can “miss the mark” as the interaction between the these two diseases, namely malaria and HIV/AIDS, in the same host is not uncommon. This is especially evident in HIV/AIDS-affected pregnant women where the fetus is also at risk. The clinical interaction between diseases demands that programs responding to them are not fragmented, but rather integrated in their planning and implementation in the context of a community-based approach. Non-government organizations (NGOs) and Community-based Organizations (CBOs) stand ready to link communities and the national programs for sustainability and ownership at the local levels. Presentation Objectives: By the end of the presentation, participants will have… :  Presentation Objectives: By the end of the presentation, participants will have… Analyzed data concerning state-of-the art information of the Roll Back Malaria Initiative in Africa focusing on the burden of disease on the health system, communities and households Recognized the clinical interaction between malaria and HIV/AIDS infections Examined the critical role of integrated community-based approaches to RBM activities as shared and implemented with assistance from NGOs and CBOs Formulate potential strategies and partners with whom to work for improved collaboration and program effectiveness. Slide5:  1900 1930 1950 1970 1990 2000 0.1 1.0 3.0 2.0 China Asia Central & S.America Annual Deaths from Malaria (millions) (Source: Carter & Mendis, 2002) Malaria Deaths World Impact in Africa:  Impact in Africa Inhibits economic growth in SSA by estimated $12 billion GDP per year SSA excluding Southern tier is 28% of 0-4 yr mortality 57% of 5-14 yr mortality 6% of 14+ mortality 40%+ of household and health system effort Slide8:  MALARIA 101 – clinical syndromes Non-severe Acute Febrile disease Cerebral Malaria Death Why is the malaria problem growing?:  Why is the malaria problem growing? Climate changes Development of drug resistance Complex emergencies (Geopolitical Issues) Development of insecticide resistance Weak health infrastructure to deal with the problem of malaria Limited local resources Human and behavioral factors Malaria: Africa's major parasitic disease:  Malaria: Africa's major parasitic disease Yet Malaria is a curable disease if promptly diagnosed and adequately treated, while prevention methods are relatively cheap and simple. Malaria is a disease of the poor and the world’s poorest people living in rural communities are particularly affected Children suffer an average of five bouts of malaria/year Rural and urban populations affected in new areas where malaria was not a threat previously Things to Recall:  Things to Recall Species: what is the illness? Transmission intensity: who is sick? Who’s affected and how: marginal, central? Adults? Children? Vector: how can we approach their destruction? Human behavior: how do humans encounter malaria? What are the human behavioral factors/ How to respond? Slide12:  MALARIA 101 Human Malaria is caused by one of 4 protozoan parasites: Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malariae Malaria is transmitted through the bite of an infected female Anopheles mosquito Slide13:  Liver stage Malaria Life Cycle Vectors:  Vectors Where do they breed? When do they bite? Who/what do they bite? How ubiquitous are they? How resistant to insecticide are they? Abuja Declaration:  Abuja Declaration By 2005: 60% of children receiving prompt & effective treatment 60% of pregnant women receiving IPT 60% of children and pregnant women sleeping under ITNs Annual needs in LLITNs to protect the most vulnerable groups at risk of malaria in Africa (285 million people):  Annual needs in LLITNs to protect the most vulnerable groups at risk of malaria in Africa (285 million people) Year 1 to year 5: 115 million nets After year 7 (maintenance) 29 million nets/year A vibrant commercial market for ITNs in Nigeria:  A vibrant commercial market for ITNs in Nigeria LLITN Supplies:  LLITN Supplies Mass producers in Asia moving strongly into LLITN New technology from private sector—LL treatment kits for existing nets LLITN transfer to Africa and other producers New products—sheeting, etc Treatment—Artemisinin Combinations or ACTS:  Treatment—Artemisinin Combinations or ACTS Efficacious against resistant P.F strains Potential to reduce transmission Greater cost Delivery throughout health system Challenge: what households can do to improve mortality/morbidity Malaria Treatment:  Malaria Treatment About 70% of expenditure on malaria is out-of-pocket by households Over 50-60% of initial treatment is self-determined outside the formal sector Probably only about 20% at best is quality, effective treatment—dose, timing, drug, quality, follow-up Who Actually Sells?:  Who Actually Sells? Implementing ACTs: the challenge:  Implementing ACTs: the challenge Mobilising resources (GF application) Strengthening the procurement and drug management process Improving access Diagnostic policy Drug regulation Monitoring and evaluation Slide26:  HIV and Malaria Interaction Slide27:  Interaction of HIV and Malaria Malaria Branch Division of Parasitic Diseases National Center for Infectious Diseases Effective Malaria Interventions Include::  Effective Malaria Interventions Include: Providing prompt access to curative treatment Preventing and controlling malaria during pregnancy Promoting the use of insecticide-treated mosquito nets (shown to reduce all-cause child mortality by 20%-25%) Recognition of the effect of HIV on malaria in pregnant women:  Recognition of the effect of HIV on malaria in pregnant women Malawi study (1987-1991): During pregnancy, malaria was more common and of higher density in HIV(+) vs. HIV(-) women These findings were repeated in other studies and countries -Malawi (2 sites), Kenya (3), Rwanda (1) Pregnant women and their fetus/newborn :  Pregnant women and their fetus/newborn HIV does make malaria in pregnancy worse More and higher density malaria, more illness, more anemia, more low birth weight Malaria may make HIV worse Higher HIV viral load ? impact on Mother-to-Child Transmission (MTCT) Effect of HIV on Malaria illness in pregnancy Kisumu, Kenya, 1996-1999:  Effect of HIV on Malaria illness in pregnancy Kisumu, Kenya, 1996-1999 van van Eijk et al, AIDS, 2003 Malaria contribution to HIV-MTCT?:  Malaria contribution to HIV-MTCT? Malawian pregnant women (Bloland, AJTMH 1995) Malaria and HIV co-infection Infants born to dually infected mothers had increased post-neonatal mortality, beyond independent risk associated with exposure to either maternal HIV or placental malaria Increased viral load or altered placental architecture increased MTCT? *MTCT = Mother-to-child transmission Non-pregnant adults :  Non-pregnant adults HIV with immune compromise (CD4 depletion) does make malaria in adults worse More malaria, higher density parasitemia, more illness, more severe disease Reduced efficacy of antimalarial therapy? Malaria may make HIV worse Higher HIV viral load Impact on clinical illness?; survival?; transmission? Impact of HIV on malaria in non-pregnant adults:  Impact of HIV on malaria in non-pregnant adults Advanced HIV immunosuppression is associated with higher density parasitemia and more clinical illness in adults French et al, AIDS 2001; Whitworth et al. Lancet 2000; Francesconi et al, AIDS 2001. Advanced HIV immunosuppression is also associated with poorer response to malaria treatment Shah S et al, personal communication 2004 Summary of Malaria-HIV interactions:  Summary of Malaria-HIV interactions Malaria infection could be an important determinant of HIV disease outcome, and vice versa HIV-associated immunusuppresion increases prevalence and severity of placental malaria Malaria associated with increased HIV replication Co-infections with HIV and malaria lead to increased MTCT, even after controlling for maternal HIV-viral load Implications for Programs:  Implications for Programs Pregnant women attending ANC clinics can be targeted for: Diagnosis of HIV + Malaria at the same visit Effective malaria prevention in HIV+ pregnant women Significance of research:  Significance of research Co-infection of malaria and HIV-1 during pregnancy may have severe consequences for morbidity and mortality of infants, and prevention of these infections during pregnancy is a public health priority. Given that most HIV-infected children acquire infection as a result of vertical transmission from mother-to-infant, if malaria exacerbates MTCT, it could have substantial public health importance and interventions to prevent malaria could play a role in the prevention of MTCT Malaria & HIV program overlap:  Malaria & HIV program overlap Population overlaps Anemic children; pregnant women; adults with CD4 Intervention overlaps Diagnostics Treatments: complexity and costs of Tx, resistance Protease inhibitors block endothelial CD36 binding of malaria-infected red blood cells OI prophylaxis with co-trimoxazole (an antimalarial) HIV-infected persons need malaria prevention Site of activity overlaps GFATM and Country Coordinating Mechanisms Antenatal clinics; under-5 clinics; communities, VCT sites? ARV delivery systems Malaria & HIV program overlap :  Malaria & HIV program overlap Recommendations for coordinated program action Jointly strengthen health service delivery: Laboratories Antenatal and delivery care ITNs & IPT for malaria; VCT & MTCT prevention Child care – anemia prevention Specific Interventions ITN distribution with ARV delivery Use highly efficacious antimalarials in HIV+ persons with malaria infection HIV+ persons on cotrimoxazole for OI prophylaxis who get malaria should receive highly effective antimalarials Malaria and HIV biologic interactions – summary 2004:  Malaria and HIV biologic interactions – summary 2004 HIV-associated immunosuppression contributes to more and worse malaria and it’s consequences in adults, pregnant women, and children. Malaria contributes to stimulus of HIV replication and possibly(?) to its consequences: disease progression, transmission in adults, and MTCT. Co-infection with Malaria and HIV in pregnant women contributes to anemia, low birth weight,and their risk for poor infant survival. Malarial anemia in children too frequently requires blood transfusion and this may lead to HIV transmission Malaria: What Shall We Do?:  Malaria: What Shall We Do? How can we scale–up what we know works? Who can reach those in need? Who can organize for sustainability? Slide42:  From 70 – 90% of all sickness care takes place in the home* (even more so for prevention) Household members, especially mothers: apply the available preventive practices to those most at-risk make the primary diagnoses of illnesses assess the severity and likely outcomes select among available providers and treatment options procure and administer treatments How about disease prevention and sickness care? *Source: WHO, World Health Report 2002. Reducing Risks, Promoting Healthy Life The Household Production of Health :  The Household Production of Health Premise 1. Households are the primary units for the production of health. But the most neglected resource by Medical professionals The Role of NGOs/CBOs:  The Role of NGOs/CBOs Have already established the confidence and trust of households/communities upon which to build Share the national RBM objectives Focus on collaboration, not competition, to strengthen all partners Can harness community participation and ownership Directly engage with communities and households The Key to Sustainability: NGO Collaboration and Organizational Development :  The Key to Sustainability: NGO Collaboration and Organizational Development Coupling Technical Expertise With Management & Implementation Capability Effective Networks for Collaboration Are Critical To Achieving Abuja Targets:  Effective Networks for Collaboration Are Critical To Achieving Abuja Targets Current Condition of NGO Networks Strong implementation expertise Provide focal point for technical input Minimal leadership, management, or administrative capabilities Governments have no clear model of how to work with NGO’s (and vise versa) Four secretariats now under formation What We’ve Learned Effective distribution of aid requires a coupling of technical expertise with management capabilities Secretariats have the potential to be the mechanism for this coupling Ownership and self-management from local organization is critical to scaled, sustainable results Collaboration between NGO’s, CBO’s, and governments is imperative Business best practices exist which can be easily applied to our efforts LQAS measurement methodology Value chain assessment and design Transformational leadership Success stories and models (NicaSalud) What We Need Shared governance framework that creates a clear path for NGO collaboration and coordination Development and implementation of simple business practices to ensure the effective distribution of technical expertise Shared long-term vision that addresses the evolution and maturity of secretariats Working plan that allows secretariats to generate their advocacy voice and ownership of vision and objectives Models for network building Future Condition Scalable, sustainable programs Pro-active secretariats who plan “three moves down the chessboard” Local ownership and voice Enhanced government partnership Enhanced NGO collaboration Heightened community coordination Creating A Basic “Toolbox” For Networks Will Build Capability:  Creating A Basic “Toolbox” For Networks Will Build Capability Building Secretariats To Couple These Capabilities Is The Tipping Point To Success:  Building Secretariats To Couple These Capabilities Is The Tipping Point To Success Effective Scaled Implementation Recommended Next Steps Identify funding and partners for Vision & Strategy pilot program Build support and alignment for approach Select pilot secretariat Identify participants and team members Identify pilot timing Management Capability Technical Expertise Glossary of Terms :  Glossary of Terms Strategy: Simply stated, a strategy is the plan to realize a vision. A strategy for the secretariat would include clearly articulated objectives and metrics, organization model, organization capabilities, and set of prioritized strategic initiatives to realize vision. Roadmap: A roadmap is a Gantt chart showing activities, timing, and key milestones across a defined period. Governance: Governance is the framework for governing an organization. This includes what decisions needs to be made, how they are made, and who makes them. Project management fundamentals: Key fundamentals in the areas of time management, resource planning, Transfer of competency: Transfer of competency refers to the explicit development of specific capability in the secretariat organization. This transfer is done using a defined process of training, shadowing, and coaching. Glossary of Terms- continued:  Glossary of Terms- continued Relationship/ network management framework: Framework for identifying, segmenting, and managing various relationships and networks. Setting up specific accountabilities for secretariat staff and partners would be an outcome of this framework. Frameworks would be established to manage relationships with NGO’s, CBO’s and government ministries/departments. Communication framework: Framework and templates for standard communications (e.g., progress reports) targeted towards specific stakeholders. This would also include establishing a calendar for standard communications. Communication plans: Three-month detailed plan for specific messages, delivery vehicles, development and delivery accountabilities, and feedback collection

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