The World Health Organization recommends countries routinely implement nationally representative HIV drug resistance (HIVDR) surveys among people infected with HIV to measure the level of drug resistance. The results of HIVDR surveys are a critical component of HIV programs and can guide changes to pediatric and adult antiretroviral therapy (ART) treatment regimens, including first- and second-line regimen decisions. I-TECH has been implementing HIVDR surveys in Malawi since 2016.
HIV DR Surveys Conducted Since 2016:
Infant HIVDR Survey: An HIVDR survey was conducted among infants aged 18 months and younger to determine the level of pediatric resistance to nonnucleoside reverse transcriptase inhibitors (NNRTI), nucleoside reverse transcriptase inhibitors (NRTI), and protease inhibitors (PI) ART drugs through exposure during pregnancy and breastfeeding. A total of 232 eligible remnant dried blood spot (DBS) samples from nine early infant diagnosis (EID)-approved laboratories were used for the diagnosis of HIV in infants between June 2016 and December 2017.
Antenatal Care (ANC)/Pregnant Women HIVDR Survey: An HIVDR survey was conducted to measure resistance to NNRTI, NRTI and PI drugs among ANC clients who were found to have a recent HIV infection. A total of 45 DBS samples from women with recent HIV infection were collected as part of the 2016 HIV sentinel surveillance survey and were successfully amplified and sequenced.
The next step in HIV surveillance activity is monitoring HIVDR among pregnant women initiating dolutegravir (DTG)-based regimens, as well as the potential emergence of DTG resistance in infants via mother-to-child transmission. A study of DTG resistance is currently underway in Malawi and will determine the level of DTG resistance in adults who are unable to achieve viral load suppression and DTG resistance in children < 15 years old who are unable to achieve viral load suppression.
The International AIDS Society (IAS) hosted the 12th IAS Conference on HIV Science on 23 – 26 July 2023 in Brisbane, Australia, and virtually. This biennial conference brings together top HIV researchers, experts, and scientists for presentations and discussions on the latest advances in HIV research and practice.
This year, representatives from the International Training and Education Center for Health (I-TECH), I-TECH’s partner network organizations, and the Centers for Disease Control and Prevention (CDC) shared findings from I-TECH-supported programs in India, Malawi, and Zimbabwe. Read the ePoster abstracts below.
Voluntary medical male circumcision (VMMC) decreases the risk of female-to-male HIV transmission by about 60%. I-TECH Network partner the Zimbabwe Technical Assistance, Training, and Education Center for Health (Zim-TTECH) supports innovative VMMC engagement solutions that are tailored to the populations they serve.
Caravans Allow for Mobile Services and Door-to-Door Outreach
Makumbe Hospital in Goromonzi District, Zimbabwe, serves a population of more than 100,000 people, including the rapidly expanding population of surrounding townships. Zim-TTECH-led consortium ZAZIC has run the Makumbe Hospital site since October 2018 and supports the VMMC team there.
This population within the hospital’s catchment area primarily comprises informal traders selling necessities such as groceries, garden produce, or second-hand clothes, while others run at-home small businesses that manufacture furniture, iron and steel products, and other wares.
“It’s difficult for economically active young men to leave their businesses and attend to VMMC at a venue away from their premises or market,” said Lewis Masimba, VMMC Program Manager at Zim-TTECH.
In light of this challenge, the team implemented a mobile caravan, which could increase the number of men receiving circumcisions by taking services out of the medical facility and bringing them closer to the concentrated settlements of Domboshava Showground, Mungate, and Mverechena townships and nearby farm compounds.
The caravan has been in use in the district since January 2023, and it has vastly shortening the period between client engagement and service delivery. In most cases, two mobilizers at a time will engage with potential clients within the townships, while another three will conduct intensive door-to-door visits in residential areas.
Mobilization efforts include one-on-one and small group discussions at market stalls, small businesses, and drinking spots, where mobilizers will answer questions and distribute information about VMMC. Sometimes the caravan is supported by a roadshow van and dancers who disseminate VMMC information through edutainment.
“The caravans have so many advantages,” said Mr. Masimba. “Men are able to access the VMMC services near their workplaces, minimizing disruptions to their daily routines. The caravan has also brought convenience and privacy to those who did not feel comfortable being ferried in program vehicles to and from the hospital.”
Since the site started utilizing the caravan, the number of men who have received VMMC each month has increased from 159 to 233 (Fig. 1).
On the heels of this success, the ZAZIC teams will continue exploring other combination approaches involving engagement activities such as pool/snooker, soccer, and music roadshows to reach hard-to-convince men in their localities.
Peer-to-Peer Learning Takes Center Stage in Performing Arts Program for Adolescents
The performing arts have been used since time immemorial as motivators to rally communities toward common goals, to relieve stress, and as an effective teaching tool across diverse cultures and religious settings. They are a particularly effective method for engaging adolescents both in and out of schools. As teens seek independence from their parents, the influence of peers becomes increasingly important, and performing arts are a fantastic way to employ peer-to-peer learning strategies.
Harnessing these strategies, ZAZIC uses drama in several districts to complement efforts already made by VMMC teams and teachers who have previously used sporting events and lectures to communicate with students.
In a particularly successful case, Hurungwe District chose to use a drama competition to communicate VMMC and other health messages to adolescents. The goals of the competition included effective peer-to-peer learning, outreach to a large audience, and the demystification of VMMC.
Roadshows to promote the competition were held at major townships to create awareness of the event and invite members of the public to attend. Eight secondary schools enrolled in the competition, and teams of adolescents led the process of writing and directing short, 30-minute performances incorporating messages in a provided guide.
The guide emphasized use of appropriate language, the need to double-check facts; and encouragement of uptake of VMMC and related services, such as HIV testing and counseling and cervical cancer screening.
More than 1,000 people attended, including students, parents, and staff from all competing schools.
“Matawu Secondary School ultimately won the drama competition, but all of the schools did a wonderful job explaining VMMC and its benefits,” said Mr. Masimba. “Messaging also emphasized abstinence for adolescents, the importance of the HPV vaccine for girls, and details about the VMMC procedure. The level of accuracy of information was extremely high.”
Importantly, two of the performances highlighted communities that reject medical interventions and stressed the need for participation by all.
A total of 182 VMMCs were attained by adolescents aged 15 to 19 years old immediately after the competition. Those who were not ready were booked for the procedure and will be followed up with by school health masters and community mobilizers.
I-TECH works in collaboration with key stakeholders, including communities, government entities, and the Centers for Disease Control and Prevention (CDC), to strengthen and implement surveillance programs focused on emerging disease threats, HIV recent infection, birth defects surveillance, and hospital acquired infections in sub-Saharan Africa. Eastern Europe, Asia, and South America.
In Malawi, I-TECH has supported the implementation of an active hospital-based birth surveillance system at four high-volume facilities in Malawi since 2016, and beginning in 2019, I-TECH began implementing recent HIV infection surveillance in April 2019.
In Kenya, the I-TECH Kenya office is working with CDC on implementing surveillance for hospital acquired infections (HAI) in low resource settings, with a focus on surgical site infection surveillance.
Data from the International Training and Education Center for Health (I-TECH) program in Malawi were presented during the 2023 Conference on Retroviruses and Opportunistic Infections (CROI). The annual conference took place in Seattle, WA, from 19-22 February 2023, and brought together researchers, academics, and experts to discuss and present on their scientific achievements and new research.
During the “Insights into Prevention and Treatment of HIV in Women and Children” oral abstract session that was held on 20 February 2023, representatives from I-TECH Malawi presented on recent HIV infection surveillance data in breastfeeding women in Malawi:
The Extension for Community Healthcare Outcomes (ECHO) Project® was developed by the University of New Mexico to improve care for underserved populations using a hub-and-spoke approach of knowledge-sharing by video-conferencing technology. The Lighthouse ECHO project provides a platform for sharing critical, timely, and life-saving information and data with health care workers (HCWs) located in different locations and facilitates peer-to-peer interactions among local, regional, and international experts using real-time, video-conferencing technology.
Lighthouse, a long-standing I-TECH implementing partner, is a World Health Organization-recognized clinic for integrated HIV prevention, treatment, and care in Malawi, serving approximately 60,000 antiretroviral therapy patients across the country. Lighthouse is an established HIV education site and has been involved in capacity building in pre- and in-service trainings for staff from the Ministry of Health as well as non-governmental organizations and implementing partners for many years.
Since April 2020, Lighthouse’s Project ECHO has conducted 67 sessions and has served 4,150 participants on COVID-19, HIV, and tuberculosis topics.
Malawi is one of first countries in Southeast Africa to respond to the World Health Organization’s call for robust birth surveillance systems. Routine surveillance is essential for public health monitoring of pregnancy outcomes and birth defects, especially in high-HIV burden settings where women living with HIV initiate the use of antiretroviral therapy before or during pregnancy.
Since 2016, the International Training and Education Center for Health, in collaboration with the Centers for Disease Control and Prevention, has supported the implementation of an active hospital-based birth surveillance system at four high-volume facilities in Malawi. To date, a total of 165,608 of births have been assessed. A subset of women are also enrolled in an ongoing nested case control study to assess associations between external birth defects and maternal exposures such as prior health conditions, medications, and environmental and lifestyle factors.
Anticipated use of these data include:
Establish a baseline prevalence of external birth defects in Malawi
Evaluate the impact of introducing new drugs for the management of HIV (e.g., dolutegravir) on the prevalence of external birth defects
Advocate for investment in programs and interventions to reduce the occurrence of birth defects and adverse pregnancy outcomes.
The International Training and Education Center for Health (I-TECH), under the leadership of Government of Namibia ministries overseeing child welfare and health and in close collaboration with the Namibia Statistics Agency (NSA), UNICEF, and the U.S. Centers for Disease Control and Prevention (CDC), supported the implementation of Namibia’s first Violence Against Children and Youth Survey (VACS).
VACS are national surveys that measure the prevalence and impact of violence on children and youth around the world. The survey results help inform future program decisions and policy approaches to ensure the safety of children and youth. On 28 September 2021, the Day of the Namibian Child, the Government of Namibia published the final Namibia VACS report.
The survey, funded by the U.S. President’s Emergency Plan for AIDS Relief and led by the Ministry of Gender Equality, Poverty Eradication and Social Welfare (MGEPESW), interviewed households with children aged 13-24 years in all 14 regions of Namibia from March 2019 through June 2019.
Survey operations—including data collection by field teams, data generation, and analysis—were carried out by the NSA, the central statistical authority responsible for all official statistics in Namibia. “It has been a pleasure working together with the Ministry of Gender Equality, the University of Washington, I-TECH, and CDC on this important survey,” says Ottilie Mwazi, Namibia’s Deputy Statistician General. “Our team has learned a lot from the process and is very proud to have contributed important data that will help to improve child welfare in Namibia.”
Prior to data collection, I-TECH alongside CDC colleagues hosted a two-week training for 130 enumerators, focused on best practices for data collection, interview techniques, and key aspects of the survey protocols. In addition to supporting VACS training, I-TECH and the Ministry of Health and Social Services (MoHSS) ensured all selected enumerators were trained and certified by the Namibia Institute of Pathology to conduct HIV rapid testing so any survey respondent aged 14-24 years who did not know their HIV status and wanted a test during their interview could immediately be tested.
In total, 5,191 individual interviews among 6,042 households (86.35% overall response rate) and 3,232 HIV rapid tests were conducted as part of data collection. Any respondent testing positive for HIV during the survey was linked to psychosocial and HIV/AIDS care and support in line with well-established MoHSS guidelines and the survey protocol.
Expanding Post-Violence Clinical Care
The survey results have informed important initiatives across Namibia’s wider social welfare and health systems. MGEPESW has moved forward with drafting the National Action Plan on Violence against Children and has accelerated the training of various child welfare stakeholders such as police officers and social workers, while operationalizing the establishment of more child shelters in several regions.
“The data coming out of Namibia’s VACS have really brought home how prevalent and serious violence against children and adolescents really is,” says Helena Andjamba, Director for Child Welfare at MGEPESW. “Having these hard facts readily available has helped greatly during our policy and planning engagement with multiple stakeholders during the past year. We are now moving forward with the Ministry of Justice in drafting a new Child Justice Bill, and at the same time we are engaged with the Ministry of Education on strengthening the National School Safety Framework.”
Following the completion of the survey, the MoHSS convened a technical working group with I-TECH, the World Health Organization, UNFPA, Project Hope, and other stakeholders to coordinate and strengthen first-line post-violence clinical care in primary health care facilities across Namibia. I-TECH also supported the compilation of clinical guidance on emergency care for survivors of sexual violence and its inclusion in the 2021 edition of the Namibia Standard Treatment Guidelines published by the MoHSS.
Much of the focus during the second half of 2021 was on integrating post-gender-based violence (GBV) clinical care in MoHSS HIV/AIDS clinics and antiretroviral therapy (ART) services throughout Namibia. As part of this work, I-TECH conducted a mentorship training-of-trainers for 28 HIV clinical providers, nurses, and testing services staff. These mentors now provide ongoing technical guidance and supportive supervision to frontline health workers through monthly facility visits.
To further improve post-violence care in clinics, I-TECH compiled a GBV care implementation guide for Namibian healthcare providers. This includes elaboration of best practices, as well as a suite of materials including posters, pamphlets, job aids, and a pocket booklet for communities, clients, health workers, and health facility managers, respectively. An intimate partner violence/GBV screening tool to be administered to ART patients with persistent high viral loads is also currently being piloted in ten health facilities.
On World AIDS Day, December 1, staff from the International Training and Education Center for Health (I-TECH) convened with the Ministry of Health (MOH), Columbia University’s ICAP, and other national stakeholders in Malawi to present the results of the 2020-21 Malawi Population-based HIV Impact Assessment (MPHIA). The commemoration, with the theme of “End Inequalities, End AIDS, End Pandemics,” was held at Bumba Primary School grounds in Rumphi District.
Preliminary results of the assessment, led by the MOH and ICAP, show that the national HIV testing program, supported by I-TECH, has achieved a significant increase in the awareness of status among HIV-positive adults—from 77% in 2016 to 90.9% in 2020-21.
Malawi has also made great strides toward reaching the UNAIDS 95-95-95 Fast Track targets, surpassing both the second 95 (results indicate that 98% of those who know their status are initiated on treatment) and third 95 (results indicate 97% of those on treatment are virally suppressed).
The assessment will be critical to informing future programming, says Dr. Rose Nyirenda, Director of the Ministry of Health’s HIV and AIDS Department. “The 2020-21 MPHIA has produced a wealth of information that will be critical for tailoring our services and to refine strategies for closing the remaining gaps,” says Dr. Nyirenda.
The HIV and AIDS Department also exhibited commodities (antiretroviral medications, testing kits, opportunistic infection (OI) and sexually transmitted infection (STI) medicines, condoms, voluntary medical male circumcision kits) that are procured and managed through the Supply Chain and Logistics Unit.
Correction: A previous version of this article misstated the organization that conducted the 2020-21 Malawi Population-based HIV Impact Assessment. This assessment was led by the Malawi Ministry of Health and Columbia University’s ICAP.
In a time of increased barriers, disruptions, and restrictions due to the COVID-19 pandemic, the International Training and Education Center for Health (I-TECH) and its network partners have implemented new approaches and adapted existing programs to support continued access to antiretroviral therapy (ART).
As a result of the pandemic, many organizations and health systems have had to shift to offering virtual care, which allows ART initiation and other HIV services to persist while minimizing patients’ risk of exposure to COVID-19. However, not all patients have access to the technology that makes virtual services possible, and additional approaches are needed to support ART treatment access during this time.
“Globally, the pandemic has generated innovative responses from communities and health systems that are striving to keep people connected to care,” says Dr. Pamela Collins, I-TECH Executive Director. “One challenge is to recognize how (or when) some adaptations increase disparities in access. We’ve learned that the right combinations of technological and no-tech solutions can also be innovative if they help provide the care that’s needed.”
One way I-TECH has helped to provide innovative care during the pandemic is by centering solutions within the affected communities themselves. A few of the community-oriented approaches that the I-TECH network has implemented include decentralized ART centers, community outreach, home delivery, community adherence refill groups (CARGs), and multi-month dispensing (MMD) of antiretroviral (ARV) medication.
Decentralized ART Refill Sites and Community Outreach
Decentralized refill sites have been an essential strategy during lockdown restrictions for I-TECH’s network partners because they allow ART to be distributed at more convenient locations, minimizing travel and treatment interruptions. Some programs have also started providing mobile outreach to improve ART access during the pandemic, at times even providing doorstep delivery to those who are unable to go to a clinic or refill center.
I-TECH’s network partner in India, the UW International Training & Education Centre for Health Private Limited (I-TECH India) launched the ARTMitra helpline in Mumbai, an outreach effort designed to map the location of unreachable PLHIV and aid in planning decentralized ART refill sites. SMS messages were delivered to 13,103 PLHIV who had missed appointments during the pandemic, resulting in the identification of 42 decentralized ART refill centers in Mumbai in 2020. A similar helpline was launched in five districts of the state of Mizoram in partnership with the State AIDS Control Society. In total, I-TECH India, in close coordination with government partners in the PEPFAR states in Northeast India and in Mumbai, has ensured uninterrupted ART delivery through 145 decentralized ART refill sites.
Through outreach efforts, clients were notified about how they could access medication, and which decentralized ART refill site they should visit. Additionally, ART home delivery was provided to 255 PLHIV living in Mumbai who were unable to pick up their medication.
Thank you for calling and informing me about the availability of medicine at the nearby ART Centre, as I had no idea whom to contact and how to collect medicine.
—an ARTMitra client in Mumbai
I-TECH network partner the Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH) has also utilized community outreach to support PLHIV during the pandemic. Zim-TTECH has supported the Zimbabwe Partnership to Accelerate AIDS Control (ZimPAAC) consortium—along with PEPFAR partners, the U.S. Centers for Disease Control and Prevention (CDC) and in close collaboration with national efforts—to provide mobile HIV care, including prevention services and integrated services at ART events. In the Harare District, 8,257 clients were supplied ART during outreach events from 28 March through 17 July 2021.
Community Adherence Refill Groups and Multi-Month ART Dispensing
Through CARGs, a community of PLHIV access treatment more easily by sending a representative to receive ARVs for the entire group. The I-TECH network implements CARGs in a number of countries, using the person-centered approach to simplify HIV care and reduce the need for in-person services. This approach is often used in tandem with MMD, allowing a group to access multiple months of medication at a time.
While ARVs have traditionally been prescribed monthly, MMD allows patients to pick up medication for 2 to 6 months and reduces traditional barriers, such as access to transportation and taking time off work, as well as barriers specific to COVID-19, such as lockdown restrictions and limited capacity of health care facilities. I-TECH and its network partners have scaled up MMD in many programs during the COVID-19 pandemic, effectively minimizing the number of in-person visits and encouraging ART adherence.
In response to COVID-19 and in partnership with CDC, the Ministry of Health and Social Services (MoHSS) in Namibia introduced a new MMD policy in April 2020 for eligible ART patients, making more people eligible for this service than ever before. In addition to policy support, I-TECH Namibia is engaged in technical support to the national HIV/AIDS program through clinical mentors who work in more than half of Namibia’s health districts. This national engagement has contributed to a rapid increase in the number of eligible ART patients who now receive between 2 to 6 months’ supply of ARVs at a time.
‘’As the number of ART patients on MMD increased, waiting areas in Namibia’s health facilities have rapidly decongested, enhancing COVID-19 infection prevention and control measures,” says Dr. Norbert Forster, I-TECH Namibia’s Country Director. “At the same time, our HIV clinicians now have more time to focus their care on patient engagement and on enhancing viral load suppression and other interventions.”
I-TECH’S WORK IN INDIA IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER U91HA06801, THE INTERNATIONAL AIDS EDUCATION AND TRAINING CENTER (IAETC). THE CONTENT OF THIS POST IS THE AUTHOR’S AND SHOULD NOT BE CONSTRUED AS THE OFFICIAL POSITION OR POLICY OF, NOR SHOULD ANY ENDORSEMENTS BE INFERRED BY HRSA, HHS OR THE U.S. GOVERNMENT.