Global health partners in the fight against malaria welcomed news that the European Medicines Agency last month offered a positive scientific opinion on malaria candidate vaccine RTS,S.
The decision marks a further significant step towards the availability of a vaccine against a disease that causes 584,000 deaths per year, most of them in sub-Saharan Africa.
In a joint blog, Seth Berkley, CEO of Gavi, the Vaccine Alliance, and Mark Dybul, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said the vaccine can potentially save many lives, further reducing the disease’s impact, alongside mosquito nets treated with insecticide, indoor spraying, prompt diagnostic testing and effective anti-malarial medicines.
Dr. Berkley and Dr. Dybul also said the partial protection of the vaccine means that more trials are needed to get clarity on its effectiveness and the issues around a booster dose. “The best way to get any clarity on these issues is to see how the vaccine performs in a real-life setting, in high and low transmission areas, with and without high coverage of other interventions,” they wrote.
The Global Fund partnership will continue to work together with partners to plan for the possible use of a malaria vaccine — if recommended by the World Health Organization and if the Global Fund Board decides to support the vaccine in conjunction with other proven malaria interventions, as part of an integrated approach towards malaria control.
Huge progress has been made against malaria in recent years, with the number of deaths caused by the insect-borne disease declining by 34 percent between 2000 and 2013, the result of a massive increase in domestic and international funding. The Global Fund partnership believes that ending malaria requires a comprehensive approach and continued commitment from all partners.
Risk reduction in Senegal
“The patients here call me ‘she who saves’ because they say that I give them something good.”
Diaba is the head pharmacist at the CEPIAD (Dakar Integrated Treatment Centre for Persons with Addictions) methadone center. She volunteered to do work there when the center opened its doors in February 2015 in a building that is part of the Fann University Hospital.
From her small office, Diaba hands out methadone to the former intravenous drug users who show up every day to get their dose of treatment. There are 44 patients of both genders who take part in the program; the youngest is 27 years old. But the waiting list is long and the demand for a more easily accessible program is high.
“I have a special relationship with them. They tell me about themselves, confide in me and sometimes they bring along their wife or husband. They tell me about what life was like before: life on the street, violence, desocialization and addiction. They tell me what it was like when they couldn’t get any heroin, cocaine or crack. It’s even more difficult for women.”
Drug users are stigmatized and penalized; they are also at higher risk of becoming infected with the HIV virus or developing hepatitis B or C. HIV prevalence in Senegal is estimated at 9.4 percent (21.1 percent for women and 7.5 percent for men) for intravenous drug users as compared with 0.5 percent for the general public.
The center was founded to combat that very stigmatization and discrimination and to provide female intravenous drug users with the same access to treatment and prevention as their male counterparts. Unique in West Africa, the center is also a pilot research and training center for integrated treatment with a focus on respect for human rights, which is a real strength in terms of providing services to intravenous drug users and those with addictions to other substances. The center is a political and financial partnership between the government of Senegal, the CNLS (National Center to Combat AIDS), ESTHER (Network for Hospital Therapy Solidarity), the city of Paris, UNODC (United Nations Office on Drugs and Crime) and the Global Fund.
Diaba sees the center as a source of national pride. “In Senegal, we didn’t know that heroin could do so much damage. We didn’t even know that it existed here in our country. We are a very solid team and we all work together: patients, physicians, psychologists, nutritionists, and social workers. We feel that we are all part of something new, something very motivating. But above all, we know that we are here to save lives.”
In Somalia, a TB Center Brings Hope
Habiq knew something was wrong. Abdi, her eight-month-old baby, could not stop coughing. And then there were the shivers. A local pharmacist told Habiq the baby had pneumonia. But she was afraid it could be something worse.
When she was pregnant with Abdi her husband had been diagnosed with multidrug- resistant tuberculosis, the mutated strain of TB that is resistant to first-line treatment. Doctors at the local hospital confirmed her worst fears: Abdi also had multidrug-resistant TB. The news was a terrible blow for Habiq, who lives with her seven children in a shack made of sticks and blankets in a wind-swept plot in the city of Hargeisa, in northwestern Somalia. Habiq is the family’s sole provider, making US$ 1.50 a day cutting camel meat at a local market. The salary is merely enough to pay off the loan she takes out every day to buy the family’s evening meal.
Treatment for multidrug-resistant is expensive and difficult, and poses severe strains for any health system. Tackling this critical public health issue is even more daunting in a country like Somalia, which is struggling to rebuild after two decades of war and famine and is battling Islamist insurgents.
Yet thanks to global solidarity, Abdi is today a smiling two-year-old on the road to recovery. Abdi is the youngest patient of Somalia’s first multidrug-resistant TB center, which opened in Hargeisa in 2013, defying all the challenges and bringing hope to many families. The center is run by World Vision, a Christian relief organization, in partnership with the Global Fund.
“I can barely afford to provide for my seven children every day, but my husband and child get free multidrug-resistant TB treatment,” Habiq said. The husband’s family has disowned Habiq and her children because she belongs to a different clan. She said they blame her for bringing TB to the family, so she is on her own. “If it wasn’t for this center, I don’t know what I would do. It is all I have. This place and Allah.”
TB remains a public health emergency in Somalia, which has one of the highest burdens of multidrug-resistant TB in the Middle East and North Africa region. According to the World Health Organization, there were an estimated 800 cases of multidrug-resistant TB in 2014. Most cases remain unidentified and continue to spread in the communities. World Vision coordinates all TB programs funded by the Global Fund partnership across Somalia. Hargeisa, in the autonomous region of Somaliland, was chosen as the initial location for the multidrug-resistant TB center, while two more centers will open by the end of 2015, in Puntland and in Mogadishu. Sixty-six health staff have been trained on multidrug-resistant TB. The center has a 30-bed admission ward, and a multidrug-resistant TB laboratory is under construction – a laboratory in nearby Uganda is currently used for diagnosis. By the end of the first quarter of 2015, a total of 126 multidrug-resistant TB patients had been put on treatment.
Francois Batalingaya, World Vision Somalia Country Director, said Somalia’s recent past of violence, drought, floods and mass population movements make it very difficult to provide uninterrupted services and to control multidrug-resistant TB and normal TB in Somalia. The country’s health system and infrastructure has been severely damaged. Stigma associated with TB is another challenge they face, he said. Because of the country’s insecurity, he operates out of neighboring Kenya, with frequent travels to all regions of Somalia. But Batalingaya said the program is making a big difference in people’s lives. “When we began working in Somalia we saw many cases of multidrug-resistant TB, but there was nothing we could do. We are extremely happy to see what this program is doing.”
One of the first patients was an 11-year-old girl named Aisha. She was brought to the center from her hometown 600 kilometers away, severely underweight and suffering from convulsions. Thanks to her discipline in following treatment, she is now is strong enough to catch up on school homework. She said she cannot wait to return to class after she finishes her treatment this August. Aisha has dreams for her future. “I would like to be a doctor,” she said. “I will not stop taking the TB drugs because if I do I will not be able to be a doctor.”
Reaching Out to the Most Vulnerable in Bangkok
Noppadon Rodsalee began injecting heroin when he was 16. The drug was cheap and easily available in Klong Toey, a sprawling slum of shacks and narrow alleys in central Bangkok. The tattoos that cover his entire body from his forehead down to his ankles are a testimony to his eight years in prison, where he contracted tuberculosis. At age 36, Noppadon, who is HIV-positive and too weak to walk, shares a two-room house with his mother, who is a cleaning lady, and his brother, an unemployed truck driver who also has TB and is a former drug user. A community worker from the Raks Thai organization visits Noppadon three days a week to make sure he takes his TB medication. Raks Thai is also helping him sign up for a government-run harm reduction program and start receiving antiretroviral therapy.
Community-based organizations play an essential role in providing health services for marginalized key populations, such as people who inject drugs. Take community worker Prasert Liangrak, for example. He is like a guardian angel for Noppadon and 40 other drug users under his watch in the labyrinthine alleyways of Klong Toey. A former drug user himself, Prasert takes off his shoes respectfully before entering the small cramped living room and sits on the wooden floor next to Noppadon, under the family’s makeshift altar.
“How are you feeling today, Noppadon? Have you taken your medicines? Are your knees any better?” Sometimes Prasert brings along some food, as he knows the family is struggling to make ends meet. He also visits homeless injecting drug users camped out under a nearby freeway under-pass to make sure they have clean needles.
“Most injecting drug users don’t go to government clinics because they find it daunting to deal with all the paperwork, especially those who came out from prison,” Prasert said. “They feel stigmatized and that staff is arrogant and looks down on them because of their tattoos and their drug use.” To deal with this, Raks Thai conducts training of health personnel for friendly services and stigma reduction.
While the HIV epidemic among people who inject drugs has been increasing at a slower pace in Thailand in recent years, prevalence among injecting drug users remains high, at 25.2 percent, according to 2012 data. Shunned by society and cultural attitudes, drug users also face legal and physical barriers to access, including forced detention and other human rights violations. Kritsadakorn Sowtong, coordinator of Raks Thai’s program for people who inject drugs, said the organization conducts regular awareness workshops with community leaders and police so that drug users are not harassed or persecuted by authorities. “We tell them they are humans too and deserve respect.”
During the Partnership Forum in Bangkok last June, civil society groups repeatedly expressed concerns about the role of community organizations and non-governmental organizations in middle income countries after Global Fund support ceases, saying marginalized populations might be left out. This issue resonates beyond Thailand: The majority of people affected by HIV, TB and malaria now live in middle-income countries. “Thailand is a middle-income country but has one of the most unequal societies in the world,” said Paisarn Likhitpreechakul, a field officer from Raks Thai. ” They open a mall in Bangkok every month, but there are a lot of people living in misery.”
Aware of such challenges, Thailand’s Coordinating Country Mechanism is working on a roadmap for a sustainable transition, including setting up a mechanism to allow NGOs to receive government funding. The Harm Reduction Policy launched last year and the registering of Ozone, a service delivery organization run by people who inject drugs, have been important advances. A new health insurance scheme for migrants has made it possible for an increasing number of migrant workers to get affordable medical care, but will require further work to reach its full potential.
Dr. Petchsri Sirinirund, Executive Secretary of Thailand’s Country Coordinating Mechanism, said her country is keenly aware of the importance of a sustainable transition and of making sure that key populations such as people who inject drugs, sex workers and uninsured migrant workers are not left out. “Communities, civil society, NGOs and the government are all working together,” Dr. Sirinirund said. “We have a very clear transitional plan to end AIDS, stop TB and eliminate malaria and we can only do this working with key populations.”