Into Africa
Mailman and P&S Faculty
Bring Hope to AIDS-Torn
Countries

BY MIKE ISBELL
Africa's Map

Africa Collage

CHALINZE HEALTH CENTER, LOCATED JUST STEPS OFF THE BUSY highway that heads north from Dar Es Salaam in Tanzania’s Pwani Region, serves a population of more than 30,000 people. Like many rural health centers in resource-limited areas of sub-Saharan Africa, it is overwhelmed with large numbers of patients suffering a variety of illnesses, including malaria, tuberculosis, and especially HIV/AIDS. An estimated 28 percent of the area’s population is infected with HIV. Until recently, Chalinze lacked the most basic resources needed to care for patients with HIV and had to refer them to the regional hospital nearly 40 miles away. For many with HIV, this was an insurmountable hurdle. But today, because of support from Columbia University’s International Center for AIDS Care and Treatment Programs, Chalinze Health Center provides comprehensive HIV services to hundreds of people living in the seven surrounding villages.
   Since 2004, the Mailman School of Public Health’s International Center for AIDS Care and Treatment Programs — known as ICAP — has helped transform nearly 400 health care facilities and 250 laboratories in 14 countries of sub-Saharan Africa and Asia. This work has included renovating and supplying clinics and laboratories as well as training and mentoring various types of practitioners, all with the goal of building sustainable, high-quality programs. Today, these facilities, from large hospitals to remote rural health centers like Chalinze Health Center, provide HIV care to more than 400,000 people, including life-saving antiretroviral therapy to more than 170,000 people. Only a few years ago, the possibility of providing care and treatment to the millions of people with HIV in the world’s poorest countries could not have been imagined.
   ICAP’s success is rooted in the experiences its leaders had with the HIV epidemic that swept through New York City’s low-income neighborhoods in the 1980s. Witnessing HIV’s devastating effects on families, ICAP Director Wafaa El-Sadr, M.D., MPH, and her colleagues at Harlem Hospital developed a model of care based on a comprehensive, multidisciplinary approach that sought to address the medical and psychosocial needs not only of HIV-positive people, but their families as well. Also distinguishing Harlem’s family-focused HIV program were the partnerships built with community groups and institutions, which became instrumental in helping to bring support services to people with HIV and their loved ones.
   Lessons learned in Harlem have informed the development of ICAP since its inception.
   “I think of the journey from Harlem to ICAP as one continuous arc,” says Dr. El-Sadr, professor of clinical medicine at P&S (Harlem Hospital Center) and professor of clinical epidemiology in the Mailman School. “When I think of the key principles we used when we established the Harlem program and the lessons learned, they are precisely the ones that are guiding our work in Africa.”
   Both in Harlem and in Africa, the most effective model of care has proved to be one that extends well beyond clinical encounters between patients and practitioners. Experts have found that models that take into account the community’s unique cultural and social needs have a better chance of succeeding.

Kenya
Kenya
Lee Goldman and ICAP Director Wafaa El-Sadr, second from right, discuss program plans with ICAP-Kenya program staff, from left, Dr. Mushin Sheriff, Dr. Eliud Mwangi, and Charles Kimani in Nairobi.

   “HIV is not just a medical condition,” says Elaine Abrams, M.D., professor of pediatrics at P&S and professor of epidemiology at Mailman. “HIV is a disease of the family and community. It is also a disease of poverty.”
   In the 1980s, Dr. Abrams and her colleagues at Harlem Hospital were involved in early studies that demonstrated the effectiveness of antiretroviral medications in sharply lowering the HIV transmission risk from pregnant women to their babies. Development of this strategy for prevention of mother-to-child transmission of HIV — pMTCT — represents one of the great success stories of the AIDS epidemic. In the United States, HIV transmission from mother to child has been virtually eliminated. Despite this success domestically, thousands of HIV-infected babies are born every day in developing countries around the world.
   pMTCT was the focus of ICAP’s first program, the MTCT-Plus Initiative directed by Dr. Abrams. MTCT Plus refers to care and treatment services (including antiretroviral drug therapy) provided to women after delivery and their families. In 2002, Mailman School Dean Allan Rosenfield and Dr. El-Sadr, with support from a number of private foundations, launched the MTCT-Plus Initiative to link pMTCT services with comprehensive HIV care and treatment for HIV-infected women and their families. The success of its family-focused, comprehensive approach became the foundation for all ICAP-supported programs.
   In many African countries where ICAP operates, women account for 60 percent of HIV infections. However, despite the success of pMTCT interventions in the developed world, only about one in 10 HIV-infected pregnant women receives preventive services. ICAP-supported programs have been vigorous in addressing this need. In a recent six-month period, nearly 70,000 pregnant women in five countries received HIV counseling and testing. ICAP’s work in support of pMTCT has been particularly successful in Rwanda, where all HIV-positive pregnant women visiting ICAP-supported facilities receive preventive services and, even more importantly, all women who need antiretroviral therapy themselves have it available.
   “The best way to promote pMTCT is to consider it as part of care and treatment for the woman and her family,” Dr. Abrams says. “One element of the effort is to prevent transmission, but that is only one step along the way toward comprehensive care.”

Wafaa El-Sadr “When I think of the key principles we used when we established the Harlem program and the lessons learned, they are precisely the ones that are guiding our work in Africa.”
Wafaa El-Sadr, director of ICAP  

   Key to the success of ICAP-supported programs have been the patients themselves, many of whom take active roles in their own health care and provide support to their peers. This parallels a similar phenomenon that occurred with the rise of the HIV epidemic in the United States: Patients challenged the status quo and tirelessly sought access to high-quality services and new treatments. Training HIV-positive people to become peer educators is an important component of activities at ICAP-supported health facilities. Peer educators support patients in a variety of ways, from providing information about HIV and its treatment to escorting individuals from pMTCT or tuberculosis clinics to HIV care centers. In Swaziland, peer educators are trained as “expert clients” to provide practical and emotional support to fellow patients. In Kenya, peer educators, who lead support groups, can be found discussing diverse topics from how to disclose HIV status to partners to dealing with side effects of medications. In Nigeria, peer educators escort patients who have transportation difficulties to their clinic visits.
   “The empowerment of patients is amazing,” ICAP-Tanzania country director Amy Cunningham says. “I was recently on a visit to one of the clinics we support, and one of the peer workers walked up to me and asked me to assist in creating a place in the clinic where the peers would be able to do their work. Patients aren’t sitting back but are asking for what they need. It’s truly exciting.”
   ICAP receives substantial funding to support its work through President Bush’s Emergency Plan for AIDS Relief — PEPFAR. Initially proposed in 2003, PEPFAR is a five-year, $15 billion effort to bring prevention, treatment, and support services to the countries most severely affected by the HIV epidemic. In 2007, President Bush proposed to double the size of the program over the next five years, and Congress appears poised to grant at least this large an increase when it reauthorizes PEPFAR later this year.
   While ICAP primarily focuses its funding on HIV/AIDS, it strives to achieve the broadest possible impact on health services in general. “HIV has the potential to transform health care systems,” says Dr. El-Sadr. “Because HIV is a chronic disease, health care systems have to evolve from providing acute and sporadic care to systems that emphasize preventive interventions and continuity of care and build strong patient-provider relationships. These changes can only help all patients, not just those with HIV.”
   The scarcity of health care workers is probably the most challenging issue facing health care systems globally, particularly in the poorest countries in the world. Although nearly 70 percent of all HIV-positive persons live in Africa, the region is home to only 3 percent of the world’s health care work force. Thirty-eight countries in Africa fail to meet the minimum ratio of 20 physicians per 100,000 people as recommended by the World Health Organization, and 17 countries have fewer than half the recommended number of nurses.

Tanzania
Tanzania
Lee Goldman surveys renovation work at Chalinze Health Center in the Pwani Region of Tanzania. With extensive support from ICAP, the health center recently began delivering comprehensive HIV prevention and treatment services.

   While recognizing that these shortages will not be rectified overnight, ICAP has supported the training of more than 2,000 physicians, 4,000 nurses, and 100 laboratory technicians. In Ethiopia, South Africa, and Mozambique, ICAP also works with health care systems to train and mentor new groups of health care workers, specifically nurses and medical technicians, to deliver comprehensive HIV services.
   “Expanding the skills of available health care workers as well as building and retaining new cadres of workers are important priorities for ICAP,” says David Hoos, M.D., assistant professor of epidemiology and director of ICAP’s Multicountry Columbia Antiretroviral Program. “This could not be achieved without ongoing intensive mentoring.”
   ICAP’s support for enhanced skills, as well as improvements in working conditions, also helps efforts to combat Africa’s “brain drain.” Doctors and nurses in the developing world, who are often underpaid, frequently emigrate to wealthier countries or abandon the public sector to join private facilities where they can earn more and working conditions are generally better. Providing workers continuous support could encourage more public sector health care workers to remain in their communities and develop their careers.
To date, ICAP has supported the renovation of 66 clinics and laboratories in seven sub-Saharan African countries and outfitted them with equipment, supplies, and medicines necessary for delivering comprehensive HIV services.

   Barnabas Jeruve, a young man who works with great pride as a data manager, received on-the-job training at Tanzania’s Chalinze Health Center. “I previously knew nothing in terms of data management,” he says, “but with the training I received, I am now confident in my new career and can contribute to fighting HIV in my community.”
   Worker morale is also affected by physical improvements to health care facilities. To date, ICAP has supported the renovation of 66 clinics and laboratories in seven sub-Saharan African countries and outfitted them with equipment, supplies, and medicines necessary for delivering comprehensive HIV services. To provide high-quality care, many health facilities have reconfigured space to allow confidential conversations between patients and their providers, accommodate support groups, maintain medical records, and store medications. “Shoring up these facilities benefits both health care providers and patients by providing supportive and comfortable environments,” says Dr. El-Sadr. “Walk into a clinic and you are likely to encounter a multidisciplinary team having its weekly meeting. Counselors and nurses are eagerly contributing to a discussion of challenges facing a family with HIV. Peer workers are intently listening. All are focused on how they can work together to achieve the optimal outcomes for this family with ICAP advisers providing the mentoring and guidance. In many of these settings, cross-disciplinary conversations and multidisciplinary tactics are novel approaches.”

Rwanda
Rwanda
Lee Goldman and pediatricians from Central Hospital of Kigali in Rwanda visit the site for the hospital’s planned Model Pediatric HIV Center, currently under renovation.

   The impact of ICAP’s work on the communities it serves is evident from its work in Tanzania, a country of 35 million people, where one out of every 14 adults has HIV and nearly 1 million children have been orphaned by AIDS. By December 2007, ICAP-supported programs in Tanzania were providing HIV care to nearly 32,000 and antiretroviral medications to more than 11,000 people. By 2009, ICAP plans to increase by six-fold the number of facilities it supports in Tanzania. This success can be attributed to the strong partnerships it has forged with the Tanzanian Ministry of Health and 22 district health authorities throughout the country. During a visit last year to the Mailman School, Tanzania First Lady Mama Salma Kikwete commended this work. “There are no achievements without partnerships,” she noted.
   With the expansion of ICAP-supported programs, the center has launched new educational opportunities for Columbia medical students and graduate students from other schools, including public health, nursing, and non-health related schools. With guidance from in-country ICAP staff and faculty, students will gain experience in international HIV/AIDS prevention, care, and treatment through clerkships, practicums, and women’s health and HIV fellowships, in New York, in sub-Saharan African countries, or both.
   “ICAP’s work in addressing the global HIV epidemic is truly extraordinary,” says Lee Goldman, M.D., executive vice president for health and biomedical sciences, who traveled to Africa in November 2007 to witness ICAP’s work firsthand. “The high-quality, comprehensive HIV programs that ICAP supports save lives and give so many people hope for the future. We take very seriously our role as a global university with a major focus on global health. Opportunities for our students to learn by participating in these programs will enrich their international perspective as physicians and public health leaders who will continue these programs into the next generation.”

Poul Olson, ICAP’s communications manager, contributed to this article.

ICAP: Faculty with Breadth
of Experience in HIV Medicine


ICAP leadership reflects the complexity of multidisciplinary HIV prevention, care, and treatment programs and is comprised of faculty from the Mailman School of Public Health and P&S who have broad academic expertise and experience in HIV-related clinical issues, other infectious diseases, program development, epidemiology, prevention and therapeutic research, laboratory medicine, training, and mentoring, as well as management and administration. In addition, the ICAP staff includes more than 400 New York- and Africa-based professionals with a broad spectrum of expertise and experience.

ICAP leadership includes:
WAFAA EL-SADR, M.D., MPH, Director
P&S (medicine) and Mailman (epidemiology)

THOMAS W. HARDY, MBA, Deputy Director
Mailman (population & family health)

ELAINE ABRAMSs, M.D.
P&S (pediatrics) and Mailman (epidemiology)

ALAN BERKMAN, M.D.
Mailman (epidemiology and sociomedical sciences)

ROBIN FLAM, M.D., DrPH
P&S (medicine) and Mailman (epidemiology)

DAVID HOOS, M.D., MPH
Mailman (epidemiology)

JESSICA JUSTMAN, M.D.
Mailman (epidemiology) and P&S (medicine)

SILESHI LULSEGED, M.D., MSc
Mailman

DENIS NASH, Ph.D.
Mailman (epidemiology)

MIRIAM RABKIN, M.D., MPH
P&S (medicine) and Mailman (epidemiology)

 

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