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:
After facing incredible obstacles, three resilient 22-year-old women from Tsholotsho District, Zimbabwe, found their lives intersecting: Sitheni, Clemencia, and Faith are DREAMS ambassadors, equipping adolescent girls and young women with skills to reduce their vulnerability to contracting HIV–and helping them to find their own strengths.
DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) is a PEPFAR-funded program that aims to reduce HIV infections among adolescent girls and young women through not only prevention and treatment, but also a core curriculum that addresses HIV prevention, financial literacy, and gender-based violence (GBV). Participants can also access services such as HIV testing, family planning, pre-exposure prophylaxis (PrEP), counseling, and screening for GBV.
The International Training and Education Center for Health (I-TECH) has been supporting the Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH) and its ZimPAAC consortium to implement the DREAMS program since 2020. To date, nearly 20,000 girls and young women in Zimbabwe have completed the primary DREAMS curriculum, Health for Life.
Sitheni, Clemencia, and Faith were initially enrolled in the DREAMS program as beneficiaries, having turned to transactional relationships (trading sex for money or necessities) to survive poverty amid the deepening economic crisis in Zimbabwe. They now use their own experiences to give back to young women who face similar choices.
Sitheni had to abandon her life-long goal of attending university to support her parents and four siblings; carrying the burden of sole provider for her family took a toll on her. When earnings from her part-time jobs weren’t enough, she became involved in sexual relationships with older, cross-border traders—known as omalayitsha—to make extra money.
Once enrolled in the DREAMS program, she thrived within the Health for Life courses, which cover financial literacy, social asset building, condom education, and violence and HIV prevention. “I encourage young girls in my community not to depend on men, but to use their skills instead of waiting to be given money by men who will abuse them,” Sitheni says.
Training and services are often provided in a safe space such as a school or community center, where participants meet with a mentor trained to deliver the Health for Life curriculum.
“At the moment I mentor 140 adolescent girls and young women aged 15-24 in the district,” says Faith, who also dated older men for money in order to make ends meet. “It is my duty to link adolescents with the district clinical nurse to access services at health facilities and safe spaces. I also encourage women to support people living with HIV/AIDS in the community. I teach them about human rights and encourage them to utilize their talents to make a living.”
Another part of Faith’s job is enrolling and following up on beneficiaries as well as supporting community-based facilitators who teach social asset building. This includes facilitating relationships and connections within DREAMS safe spaces to share encouragement and survival skills.
These safe spaces were critical to providing hope and new options for Clemencia. “After my father passed away, there was no one to pay for my school fees,” she says. “I came to my wits’ end, and I ended up exchanging sex for livelihood. At that time, it seemed the only viable option.”
Clemencia traded sex for two-and-a-half years, placing her among those at highest risk for HIV acquisition in Zimbabwe. “Luckily for me, I did not get infected with HIV,” she says. “Ever since joining DREAMS, I have become empowered, and I know how to protect myself from sexual violence.”
Thanks to what she learned in her financial literacy sessions, Clemencia has started a small business of breeding hens and selling them to community members. “I also sell clothes for extra income,” says Clemencia, who now encourages other young women to complete their financial literacy sessions so they can start their own businesses and become independent.
Faith is thrilled to be able to foster this independence, as well. “Little did I know that I could make an honest living without anyone having expectations from me,” she says. “I am now able to encourage other girls and young women to stop engaging in transactional relationships. I am able to do this because I have been mentored and I have knowledge about HIV/AIDS and violence against women.”
 Chiyaka T, Mushati P, Hensen B et al. Reaching young women who sell sex: Methods and results of social mapping to describe and identify young women for DREAMS impact evaluation in Zimbabwe. PLoS One. 2018 Mar 15;13(3):e0194301. doi: 10.1371/journal.pone.0194301. eCollection 2018.
On April 1, the International Training and Education Center for Health (I-TECH) celebrates 20 years since its founding. It has since grown into the largest center in the Department of Global Health (DGH) and one of the largest centers at the University of Washington (UW).
“We are proud to mark this milestone,” says Dr. Pamela Collins, Executive Director of I-TECH, Professor of Psychiatry and Behavioral Sciences, and Professor of Global Health at UW. “For 20 years I-TECH has helped to save lives through its support of public health systems in the Caribbean, Europe, Africa, and Asia. Over the years, our scope has broadened, but responsive partnerships with ministries of health, collaborating NGOs, and our donors have been central to the work.”
I-TECH comprises a global network, operating in 17 countries, that fosters healthier communities around the world through equitable partnerships in research, training, and public health practice. Its work is rooted in health care training and draws on a culturally rich community that includes UW faculty, global partners, and U.S. and global staff and students. This community of people with diverse backgrounds, experiences, and opinions encourages learning from one another while working toward high quality, compassionate, and equitable health care.
“COVID-19 has reminded me, and many of us, about the critical and life-saving role of health care workers, a group that often lacks proper support,” says Ivonne X. “Chichi” Butler, Associate Director at I-TECH. “At the same time, collectively, we have come to understand the urgent need for stronger and better prepared health systems to respond to the COVID crisis.
“At I-TECH, these concerns have been at the heart of our work for the past 20 years,” she continues. “We have invested–and continue to invest–in health workers and in the systems in which they work. I am proud to be part of a center that has transformed the delivery of HIV care and treatment in so many countries and that truly puts individuals and communities at the forefront to meet their particular needs.”
I-TECH began in 2002 with its first award, the International AIDS Education & Training Center (IAETC) grant. The IAETC was administered by the Center for Health Education and Research (CHER), within the Department of Health Services (now the Department of Health Systems and Population Health). This was one of CHER’s first forays into what would become known as “global health.”
“The IAETC award was the first of its kind at UW,” says Shelly Tonge-Seymour, Associate Director of I-TECH, who has been with the center for 20 years, “the first to translate lessons from the U.S. to improve the training of health care workers and delivery of care globally.”
With the advent of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, I-TECH’s portfolio expanded rapidly, reflecting the evolution of PEPFAR from “emergency” to a longer-term investment in health systems strengthening. I-TECH became an official UW center in 2008, a year after joining UW’s new Department of Global Health at the invitation of Dr. King Holmes, then-chair of DGH. “It became clear that we had grown so large that we needed our own administrative core,” says Tonge-Seymour.
Through its work with PEPFAR, I-TECH’s efforts have contributed meaningfully to the huge advancements in HIV prevention, care, and treatment seen across the globe, with a particular emphasis on groups that have been marginalized or stigmatized.
“I’ve been involved with I-TECH for its entire 20 years, and the most impactful thing for me has been the contribution I-TECH has made in Zimbabwe to supporting the development of lay cadres into primary counselors,” says Abisha Jonga, Senior Program Manager at Zim-TTECH. “This program created a career path for so many, made HIV counseling services more accessible to the general population, demystified HIV testing, and shaped the individuals’ lives.”
Dr. Batsi Makunike, Executive Director of Zim-TTECH, agrees that fostering local connection has been the key to success. “I am particularly proud of the fact that I-TECH has succeeded in nurturing local organizations,” says Dr. Makunike. “Providing full support without competition–that is huge. Without I-TECH, there would be no Zim-TTECH.”
Malawi has seen its health care landscape change dramatically in the past 20 years and is now close to meeting the UNAIDS 95-95-95 targets for the elimination of HIV. Since 2008, I-TECH has partnered with the Malawi Ministry of Health’s Department for HIV and AIDS and helped to generate pioneering policy initiatives such as the 2011 adoption of Option B+ for the prevention of mother-to-child transmission (PMTCT) of HIV. Option B+ provides universal, lifelong ART for pregnant and breastfeeding women. Based on Malawi’s documented success, the World Health Organization formally adopted Option B+ as a global policy in 2013.
“We truly believe that I-TECH has significantly contributed to the prevention of thousands of infant infections and AIDS deaths among children, adolescents, and mums and dads in Malawi,” says Dr. Andreas Jahn, Senior Technical Advisor with I-TECH Malawi. “We have walked this journey with a whole generation of Malawian HIV program colleagues, and we have learned a tremendous amount from each other.”
I-TECH’s funding has grown from $500,000 for its initial award in 2002 to a cumulative total of more than $1 billion. The center currently has 26 awards, harnessing UW technical expertise in multiple technical areas from mental health to electronic health information systems to global health security and emerging health threats.
As I-TECH has adapted to changing needs, at its core remains a commitment to creating equitable partnerships and facilitating knowledge sharing throughout the I-TECH network, which includes I-TECH’s own country offices, independent partner organizations fledged from I-TECH, ministries of health, academic institutions, community groups, and others.
“When I reflect on the success of I-TECH in reaching the age of 20, two observations keep coming up for me,” says Dr. Ann Downer, co-founder and former Executive Director of I-TECH and Professor Emeritus in the Department of Global Health. “One is about the power of unity. I believe that the ability of a diverse group of individuals and teams to hold a common vision and set of values generates resilience. This unity allows I-TECH to continue operating after 20 years with integrity and grace across enormous geographic, linguistic, and cultural borders and despite regular economic and social challenges.
“The other observation is about the importance of encouraging leadership from all parts of an organization,” she continues. “This requires us to embrace the value of humility and results in our ability to listen and learn. Both are critical actions for successful work anywhere but are essential for working ethically on a global stage.”
The I-TECH story continues to unfold. From a modest grant with limited staff to a vital, resilient, and animated worldwide network of more than 1,600 dedicated personnel, I-TECH will continue to work alongside its global partners in its commitment to stronger health systems and safer, healthier communities.
“There’s so much to celebrate and a wealth of lessons to light the way forward,” says Dr. Collins. “In this era of pandemic, war, and fractured communities, our vision for health is needed now more than ever.”
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.
The Government of Ukraine prioritized pre-exposure prophylaxis (PrEP) as part of combination prevention for HIV in 2019.1 Since 2020, I-TECH has focused its programmatic efforts in Ukraine on improving PrEP services uptake and strengthening PrEP delivery at selected stat healthcare facilities.
The International AIDS Society (IAS) virtually hosted the 11th Conference on HIV Science on 18-21 July 2021. The conference also included a “local partner hub” in Berlin, the original host city, for local experts to gather in person. This biennial conference brings together top HIV researchers, experts, and scientists for presentations and discussions on the latest advances in HIV research and practice.
Representatives from the International Training and Education Center for Health (I-TECH) virtually presented the following posters:
Pamela Collins, MD, MPH, is Professor of Psychiatry and Behavioral Sciences and Professor of Global Health at the University of Washington (UW), where she is Executive Director of I-TECH, Director of the UW Consortium for Global Mental Health–a joint effort of the UW Department of Psychiatry and Behavioral Sciences and the UW Department of Global Health–and Associate Director of the UW Behavioral Research Center for HIV (BIRCH). She is a psychiatrist and mixed methods researcher with 25 years of experience in global public health and global mental health research, education, training and capacity-building, and science policy leadership. Prior to her current role she directed the Office for Research on Disparities & Global Mental Health and the Office of Rural Mental Health Research at the National Institute of Mental Health (NIMH) (USA). Dr. Collins has served the field in diverse leadership roles, most recently as a commissioner for the Lancet Commission on Global Mental Health and Sustainable Development, a leader of the Grand Challenges in Global Mental Health initiative, co-lead of the NIMH-PEPFAR initiative on mental health and HIV, a member of the World Economic Forum’s Agenda Council on Mental Health, and the director of the RISING SUN initiative on suicide prevention in Arctic Indigenous communities.
Dr. Collins’s research has focused on social stigma related to mental illness and its relationship to HIV risk among women of color with severe mental illness; the intersections of mental health with HIV prevention, care, and treatment; and the mental health needs of diverse groups in the US, Latin America and Sub-Saharan Africa. She is currently the Principal Investigator of EQUIP Nairobi: a pilot implementation of Trauma-Focused CBT in Nairobi, Kenya, part of a more comprehensive effort to meet the mental health needs of children and adolescents in Nairobi.
Since 2013, the ZAZIC Consortium has been implementing Voluntary Medical Male Circumcision (VMMC) as part of a combination HIV prevention package approved by the Ministry of Health and Child Care (MoHCC) in Zimbabwe. Unlike other VMMC programs in the region, the ZAZIC model uses an integrated approach, blending local clinic staff supported by MOHCC with partner staff. The ZAZIC consortium supports:
Training using MoHCC approved curricula, health workers in the supported districts are trained on the surgical technique as well as on demand creation
Development and implementation of age appropriate demand creation strategies
Support service delivery in 13 districts from consent procedures to post-surgical care and linkage to other services
Comprehensive monitoring and evaluation including continuous quality improvement and operations research
From 2013-2018, ZAZIC performed over 300,000 VMMCs with a reported moderate and severe adverse event rate of 0.3%. The safety, flexibility, and pace of scale-up associated with the integrated VMMC model appears similar to vertical delivery with potential benefits of capacity building, sustainability and health system strengthening. Although more complicated than traditional approaches to program implementation, attention should be given to this country-led approach for its potential to spur positive health system changes, including building local ownership, capacity, and infrastructure for future public health programming. Over 80% of the circumcisions occur in outreach settings, an approach that ensures wide coverage and expanded services in hard-to-reach locations.
Voluntary medical male circumcision (VMMC) safely reduces the risk of female-to-male HIV transmission by up to 60%. Few men have any post-operative VMMC complication. However, current practice in Zimbabwe and throughout most of sub-Saharan Africa requires VMMC patients to return for multiple, in-person post-operative visits. With low complication rates, and severe healthcare worker shortages, these required visits are a burden for providers and patients — threatening achievement of critical HIV prevention targets. A two-way texting model studied by University of Washington researchers in Zimbabwe offers a new way to address this barrier by reducing provider workload while also safeguarding patient safety.
“These visits can be a barrier to male circumcision uptake and expansion in countries with severe health care worker shortages, as well as negatively impacting patients who needlessly pay for transport, miss work, and wait for unnecessary reviews,” said Principal Investigator Caryl Feldacker, PhD, MPH, at the International Training and Education Center for Health (I-TECH) in the University of Washington Department of Global Health.
The study included 721 VMMC patients in two locations in urban Zimbabwe. In the study, patients communicated directly with a health care worker through interactive text messaging for the critical 13 days post-VMMC, rather than returning for required in-person visits. By giving men the option to heal safely at home, or return to care when desired or if complications arose, the method dramatically reduced in-person visits by 85%. Texting also reduced follow-up costs by about one-third while improving the quality of care.
As compared to routine in-person care, the study yielded twice the number of reported complications. “This increased identification and reporting is a positive result that is likely attributable to improved counseling and men’s engagement in care. Through texting, men were empowered to observe their healing and report potential issues promptly, before they worsened,” said Feldacker.
Currently, most text-based health care efforts blast pre-defined messages to many people simultaneously, removing patients’ ability to communicate back with health care workers. In contrast, two-way texting between providers and patients provides interactive care, and the short time frame heightened participation: in the study, 93% of men responded to texts. Both providers and clients reported confidence in the texting option, feeling safe and highly recommending it for scale.
“With the current system, Zimbabwe could perform millions of unnecessary follow-up visits over the coming five years. The workload burden for health care workers and time lost for patients who are healing without complication is a significant burden for health care workers and clients alike,” said Feldacker. “Potential gains in efficiency and reduced costs through using two-way messaging are large.”
With funding from the U.S. Centers for Disease Control and Prevention (CDC), and in partnership with the Society for Family Health, the model will soon be tested in urban South Africa. The new, field-based research will further test two-way texting in a different geographical and patient context to better inform the model for adaptation and widespread scale-up.
Feldacker added that “while our findings are grounded in studies on male circumcision, our results are largely attributable to the methods rather than to a specific disease or condition.
“With minimal adaptation,” she continued, “two-way texting could streamline other post-operative care contexts or be re-configured for other similarly acute, episodic conditions where continuity of care within a short period is critical for patients, such as short-course TB treatment, post-operative healing, post-natal care or early childhood illnesses — diarrhea, pneumonia, malaria — laying the foundation for generalizing to other diseases and contexts.”
For more on the study, see the paper pre-published in the Journal of Acquired Immune Deficiency Syndromes (JAIDS):
The study was led by Caryl Feldacker, and co-investigators are Vernon Murenje (International Training and Education Center for Health (I-TECH), Harare, Zimbabwe); Mufuta Tshimanga (Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe); Scott Barnhart, Isaac Holeman, and Joseph B. Babigumira (Department of Global Health, University of Washington); Sinokuthemba Xaba (Ministry of Health and Child Care, Harare, Zimbabwe); and technology partner Medic Mobile (Nairobi, Kenya).
The Zimbabwe 2wT study was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW010583.