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The fourteen weeks old strike by doctors in Lagos State may have ended. But it left in its wake sorrows, tears and blood. Among the affected communities are people living with HIV and AIDS in the state. According to Ibrahim Umoru, Coordinator of the Network of People living with HIV/AIDS(NEPWHAN)in Lagos, the strike was a nightmare especially as it affected  access to life saving antiretroviral and other quality  monitoring and follow ups.

As the world marks World AIDS Day(WAD), many are celebrating  achievements recorded in the global AIDS response  especially the 2010 Global AIDS Report published by UNAIDS which indicates a reduction in the rate of new infection and as well as access to treatment. But for Lagos state, the death of PLWH during the strike by doctors should be a cause for all to be worried as their death were indeed avoidable.

To mark this year’s WAD,NIGERIAN HEALTH JOURNAL reflects on this seemingly glossed over tragedy in this interview with NEPWHAN’s Ibrahim Umoru.

As someone representing a community that was at the receiving end ,what would you consider the cost of the suspended strike by doctors in Lagos?

Umoru

The cost is enormous to the citizenry generally and particularly heavy to People Living with HIV (PLWH). You will agree with me that in the management of HIV, one gets to see a doctor quarterly. That is for patients who have been on treatment for long and are stable; while those who just started treatment would have to see their doctor say, monthly. It’s so worrisome for our secondary hospitals where our nurses have not been strongly grounded in triaging*. Many people who could not afford private hospitals resorted to taking traditional herbal medicines and those who had no choice actually died.

That means the strike led to treatment interruption for many PLWH…what is the implication of this on AIDS control in the state especially with the likely issues of drug adherence and resistance?

There can’t be anything closer to the truth than this. You know there are various categories of PLWH. Some have vast treatment literacy experience while some were just  initiated into treatment and others were  just about to start treatment . The implication is that those who have been on treatment for a long and time and are experienced and  have become very stable but within the period of the strike there can’t be  any quality evaluation of tests done .Also, there were no consultations for opportunistic Infections(OIs)  just in case any was present. Patients were just coming to pick their drug refills without doctors’ examinations that are routinely done quarterly for this class of patients. However, some are not that experienced and worst of it is OIs could just come up within that period and the only alternative is private hospitals. How well informed are doctors in private hospitals with regards to the management of HIV and AIDS? So, that becomes an issue. I lost a close client to complications resulting from opportunistic infections. I have  another PLWHA who committed suicide that period too. These are some of the numerous painful losses to us in the PLWHA community resulting from the strike.

Is it true that knowing the consequences of a strike on PLWH some doctors in a particular treatment centre tried to ensure that there were no treatment interruption despite the strike?

Yes! Very well yes. I am aware of a particular doctor that took all the risk to be available for some days to PLWH during the strike. This is very commendable as the risk was enormous if his colleagues  had found out. That to me is the height of humanitarianism.

So, what becomes the fate of PLWH who died during this strike? Are you making your case known to Lagos State has that become one of the many casualties of being HIV positive in Nigeria?

Definitely, I am going to make a case to Lagos state as am trying to collate data from the various treatment sites around. At least, we have it on record. But come to think of it, can they bring back those lives again?

What could have been done other wise to prevent these needless deaths even in the face of the strike?

There is great need to improve the skills of nurses in triaging and palliative care. However, our leaders have to be more sensitive and proactive in the welfare of workers generally and health workers particularly. What the doctors were asking for were not out of the moon. They were things they had all negotiated and agreed upon long before now.

Someone has argued that doctors should get a bit more creative when considering a strike action given the implication of a doctors strike. Do you think so?

Our leaders and policy makers should be more creative and compassionate too. The problem is when most of them get there; they care no more about the populace. This should not be so!

So what can be your advice regarding the best way for doctors to strike without downing tools especially when you consider the fact that when their needs are finally met, they cannot bring back the lives that  have been lost?

The underlying fact is we should not allow issues to get to the point of strike at all. A strike that lasted for months is a reflection of the gross insensitivity of the people at the top. They don’t attend these hospitals as they and their families get health care outside the shores of our land. The people need to ask questions. We need to engage our various representatives in the legislative arm of government. The government too need to engage with the populace as they are too far away from the people they govern. These lives as you rightly attest to cannot be brought back. We should be more proactive in leadership and be on ground with the people.

For PLWH on treatment and for AIDS support groups, what lessons have been learnt from this ugly experience bearing in mind that  workers strike in Nigeria is now a way of life and healthcare workers are not left out?

We need to address our positive living lessons more creatively and increase the treatment literacy efforts in the support groups. Most importantly, we need to engage the government particularly in Lagos state to make sure we are heard at the right quarters. To this we have started restrategising to engage with government. You would recall  that the Lagos state government has a law in place protecting PLWH and a section of that law provides for a board and PLWH are supposed to  be part of that board that focuses on fund for drug buffer for people living with HIV. Furthermore, we wish to engage with Lagos State AIDS Control Agency( LSACA) to find out the composition of their board as the law that sets up such agency up to NACA provides for our representation there. That way we can be heard.

 

*prioritization of patients for medical treatment: the process of prioritizing sick or injured people for treatment according to the seriousness of the condition or injury: Microsoft® Encarta® 2009.

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Kingsley Obom-Egbulem, New Delhi

For journalists covering the 2008 Microbicides Conference in New Delhi, India, one session that may remain remarkable for a long time was the media conference held on day two of the conference.

Arguably, the media conference seemed unprecedented.

Check out members of the panel and you can imagine the quality of deliberations: all the M2008 Conference co-Chairs-Dr. Gita Ramjee, Director, HIV/AIDS Research Unit, Medical Research Council (MRC) South Africa, Dr.Nomita Chandiok, Deputy Director of Reproductive Health and Nutrition, Indian Council of Medical Research, (ICMR), Delhi and Dr. Badri N. Saxena,Professor, Centre for Policy Research, New Delhi,India.

Also present were Ms. Lori Heise, Executive Director, Global Campaign for Microbicides(GCM),Dr. Sharon Hillier, professor of obstetrics and gynecology, University of Pittsburgh, USA and Dr. Salim Abdool-Karim, clinical infectious diseases epidemiologist and Pro-Chancellor at the University of Kwazulu Natal, South Africa.

Aside the caliber of speakers that featured, the media conference provided opportunity for candid questions and remarks from the panel and media professionals in attendance on microbicides research development.

Expectedly at such meetings, the quality of engagement and outcomes are usually limited to journalistsunderstanding of the issue. That was exactly the case.Aside two journalists from India and a South African journalist whose questions came from an informed perspective, others simply made the media conference seem more like a media briefing or a monologue.

The event must have been an attempt to update journalists about goings on in the microbicides research clime by creating a platform for journalists/researchers parley for the good of every one waiting earnestly for a safe and effective microbicide.

Was the event appropriate? Certainly yes! Was that the best way to go about it? Of course not!

I think the role journalists can play in the global microbicides research and development agenda needs to be properly articulated and steps taken to incorporate it as part of a holistic efforts not a cut and paste, quick fixapproach, otherwise microbicides researchers may continue to wonder whether or not journalists are friends or foes, says Olayide Akanni Executive Director, Journalist Against AIDS (JAAIDS)Nigeria.

Akanni spoke the mind of a Zambian journalist in Cape Town 2006 who was embarrassed to see researchers and investigators from his country, who would rather die than grant interviews blowing hot at sessions and even blaming journalists for not coming to seek for information.

Most of these researchers only speak at conferences, he says.You see them, you even interview them but as soon as they get back home, they will never pick your calls or reply your emails unless again you meet them at another conference.

The media: Friends of foe, was the title of a track D session that actually tried to examine the roles of journalists, communicators and researchers in the interest of microbicide research efforts. Incorporated into this session was a skills-building opportunity on media engagement for researchers and it featured a lot of what to say, what not to say, how to say it and how not to say it.

I believe the media has a critical role to play if we must succeed in our search for a microbicide but I also believe that only an informed media can play this expected role, and we must engage them, let them know what they need to know without filtering thus improving the quality of their involvement, says Manju Chatani, Coordinator African Microbicides Advocacy Group (AMAG) Accra. Not a few people have argued that journalists are a threat to microbicides research development especially in their coverage of clinical trials.The argument is that journalists can jeopardize the objectives of a trial if they are encouraged to keep the issue in the news. But others believe that journalists can be made to see themselves as partners whose interests such research and clinical trials are meant to serve rather than a distance group of people who must not know what is going on when the trial commences and must keep their mouth shut even if the trial hit the rocks.

It is always better to let the media know when you are starting a clinical trial and communicate your limitations with respect to regular updates and coverage of clinical trials so that they can always be there for you during critical moments and even report from an informed and less sensational perspectives. It has worked for us in Nigeria during one of the trails , says Morenike Ukpong, Coordinator, Nigeria HIV Vaccine Microbicides Advocacy Group (NHVMAG).

Ukpong added that because journalists had been briefed and educated about the trials when it commenced, there was no need for any damage control. They knew what was going, they knew it was a clinical trial and like any trial it would be stopped if anything goes wrong and they knew what could go wrong and when it happened there was no need to report falsehood or sensationalize the issue.

It all started from a pre-conference workshop on Health Advocacy organized by a coalition of microbicides advocacy groups at the India Habitat Centre. The media and its role in microbicides research development was not a core focus of the workshop but thanks to what initially seem like a participants unguarded comments. For about twenty minutes, those comments tilted the discussions and opened up a vista into what the next two years would look like as far as the media and reporting of clinical trials are concerned.

Indeed, the next two years can be said to be critical moments for microbicides research development and research advocacy.

With the outcome of the HPTN 059 trial painting an unprecedented picture of progress and hope, there are indications that ARV-based microbicides may just be the way to go. The HPTN 059 Trial assessed the safety and acceptability of an antiretroviral-based microbicides called Tenofovir gel used daily by 200 sexually active women over a six months period.

Results from the study presented at the New Delhi Conference indicate that the tenofovir gel is safe for use every day.

Also in the next two years, the world would await the outcome of two studies:the Vaginal and Oral Interventions to Control the Epidemic-also known as the VOICE Study as well as the CAPRISA 004 Study.While the VOICE Study seeks to establish the effectiveness of an ARV-based microbicides that women can use everyday instead of at the time before sexual intercourse, the CAPRISA Study being conducted at the Center for the AIDS Programme of Research in South Africa (CARISA) Durban is a Phase 2b trial that seeks to evaluate the dosing strategy and time around sexual intercourse when using the Tenofovir gel.

These are indeed critical moments for global HIV prevention efforts and the media can make a whole lot of difference at this time. What dimension this difference takes and its impact would depend largely on how informed the media is, how much of this research efforts they can buy into and own and the quality of trust, partnership and engagement the scientific world can offer.

First published March 3, 2008

http://www.nigeria-aids.org/eforum/msgRead.cfm?ID=7150

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Kingsley Obom-Egbulem, Delhi,India

Dr. Salim Abdool-Karim can easily be described as a feminist when you consider his zeal and commitment towards microbicide research and advocacy.

“I’m very concerned about women and the issues that affect them especially their health”, he says.

And talking about women’s health, you only need to hear him talk about microbicides research and development to appreciate how deep this mans concern is with regards to the health of women.

A Pro-Chancellor at the University of Kwazulu Natal in South Africa, Dr. Abdool Karim is a clinical infectious diseases epidemiologist whose research interests are in microbicides and vaccines to prevent HIV infection, as well as implementing antiretroviral therapy in resource constrained settings.

Just like his ilk in the Microbicides Trial Network (MTN),Abdol-Karim can’t wait to see the development of an effective, women-controlled HIV preventive mechanism.

One day, there was this woman who came into the hospital where I work with her sick child. The child had thrush and looking at him you could tell he is HIV positive. We conducted a test on him and that confirmed our suspicion. The woman was confused. We advised her to test for HIV too. The test turned out to be positive. As I looked at the confusion on her face, I asked myself, what could have prevented this woman from getting infected? If you tell her to abstain, she will tell you she is married and must satisfy her partner’s need for sex.

“If you tell her to insist her partner uses a condom, she will tell you she needs to have children. The solution lies in a preventive method that is controlled by the woman a solution that does not in any way interfere with her relationship or her desire to have children. That is why we are in this quest for an effective and safe microbicides and we need to get it.

But getting the needed breakthrough in this quest for a microbicides hasn’t been a smooth sail. Its been a catalogue of ups and downs. Amongst these downs is the perception of clinical trials as an avenue for trial participants to get infected with HIV.

Indeed people are likely to sero-convert (i.e, become HIV positive) in the course of a microbicide clinical trial. But can it be said that they got infected because they participated in the trials? Could they have been infected with HIV even if they hadn’t participated in trials?

When people get infected in HIV clinical trials, they got infected not primarily because of the drugs being tried but because they were already vulnerable before coming into the trials, says Abdool-Karim.

In health care, a clinical trial is a comparison test of a medication or other medical treatment (such as a medical device), versus a placebo (ie inactive look-a-like). While undergoing the trial, the agent being tested is called an investigational new drug.

Clinical trials are usually done in three phases.Phase I tests the safety of the treatment on a small number of patients. Phase II assesses the effectiveness of the treatment and usually involves a larger group of people. Phase III provides in-depth information about the effectiveness and safety, by comparing experimental treatment with the standard protocol. Phase III trials usually involve several thousand of people.

Trial participants who volunteered to be part of any clinical trial, tend to exhibit some confidence in the drugs being tried which often increases their vulnerability even though they were already vulnerable to getting infected in the first place, but that is not to say that the product being tried infected them like people are meant to believe, says Dr. Morenike Ukpong of the Nigerian HIV Vaccine Microbicides Advocacy Group, (NHVMAG).

Ukpong believe that the greatest challenge facing any HIV prevention research any where in the world is that of finding a safe ground between a laudable intention of trying to test a potential product that will prevent HIV infection and the ethical and even emotional implications of that quest.

No doubt, we need something that can protect women who have no power to say no to partners who are not faithful and who wont use condom, if there is a product with the potential to protect women from HIV,it certainly has to be tested and testing it comes with a lot of issues which we must deal with as they arise.

Some of these issues are really not clinical but sentimental, ethical and borders about fundamental rights.

The target participants in any microbcides trials are vulnerable people-poor dis-empowered women, sex workers who are daily exposed to the risk of getting infected with HIV due to their work or normal day-to-day life.

Lori Heise, Executive Director, Global Campaign for Microbicides(GCM) lends credence to this notion.

If you have to do microbicides trial, you have to go to where you have women who are very vulnerable, women who do not have the power to control where and when and with whom they have sex and that is not very easy.

Since clinical trials are fundamental hurdles that must be crossed in the quest for safe and effective microbicde that can protect women against HIV infection, how can this hurdle be crossed without reinforcing the guinea pig perception most people have about trial participants?

We need to let these women understand the risk they are taking and also let them understand their rights in relations to such trials, says, Heise

That is definitely one way out. But how easy is it in practice? To what extent do researchers go to translate the care on paper into reality when it is needed?

In 2006,GCM conducted a mapping of standard of care at microbicide clinical trial sites. The exercise looked at the prevention services provided to women enrolled in large-scale microbicide effectiveness trial.

We were actually at trial sites to ensure that what is promised is what being offered in terms of care and our overall, microbicides studies are meeting or exceeding the ethical obligation to provide access to proven prevention interventions, including risk reduction counseling and provision of male and female condoms when requested, says Heise.

It is uncertain if the issue of sero-conversion will ever be addressed considering the emotional perspectives to it. But like Dr. Bode-Law Faleyimu a researcher, gynecological surgeon and a member of NHVMAG puts it, there is a need to ensure we have done what is right for the common good.

There is a way your mind feels when you know you have done what is right before all. This issue is about conscience, it’s about right, it’s about justice and equity, like ensuring that those who were part of the trials and research are among the first beneficiaries, but you know this is not always the case.

Perhaps here lies the challenge for future trials.

The GCM report on Mapping the Standard of Care at Microbicides Trials says, the field of microbicides research is making ethical progress. However the report says local community involvement from the conception of a trial onward is still insufficient. Decision-making on standard of care is often obscured at the top, with ill-defined or inconsistent donor policies that restricts what is considered possible and the ability to meet ethical demands.

Sounds like a corroboration of Faleyimu’s admonitory gesture.

First published March 3, 2008

http://www.nigeria-aids.org/eforum/msgRead.cfm?ID=7149

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Kingsley Obom-Egbulem,Delhi,India

The 4th Microbicide Conference -M2008 kicked of this week in New Delhi, India, with most scientists, researchers and advocates expressing hope in what could be described as a new generation of microbicide products that may redefine ongoing efforts towards developing women-controlled HIV prevention options.

Microbicides are compounds that can be applied inside the vagina or rectum to protect against sexually transmitted infections (STIs) including HIV. They can be formulated as gels, creams, films, or suppositories. Microbicides may or may not have contraceptive effect. Currently, an effective microbicide is not available.

With most compounds that have gone through clinical trials showing little promise of preventing HIV infection in women when applied in the vagina before sexual intercourse, the tilt towards products that have anti-retroviral (ARVs) is seen as the turning point that may lead to the much-expected breakthrough.

ARVs are drugs used for treating HIV and AIDS. They slow down the reproduction rate of HIV. Once the virus is reproducing at a slower rate, it is less able to harm the body’s immune system. The immune system is the body’s defense system against infection. Since ARV’s slow down the damage to the immune system, if they are used properly, they allow one to live a longer, healthier life.

So how does this relate to microbicide research and development?

The thinking is that since we have used the same drugs used in treating malaria and TB to prevent TB and malaria as prophylaxis, it is also possible to use ARVs which inhibits and slows down the progress of HIV in the body, to prevent HIV infection, says Dr Morenike Ukpong, of the Obafemi Awololwo University,Ile-Ife, Nigeria.

ARVs are currently being used as post-exposure prophylaxis (drugs administered to rape survivors or anyone suspected to have been exposed to HIV to prevent infection). Perhaps this makes it even logical to explore the preventive power in ARVs as a mircobicides.

In serving as post exposure prophylaxis, ARVs are administered generally and taken orally. But as a microbicides, we are hoping that it can be applied locally (that is to the vagina since it a major entry point during sexual transmission) and see how well it can protect within that region, says Ukpong who is also the national coordinator of the Nigeria HIV Vaccine and Microbidide Advocacy Group (NHVMAG).

Already, there seems to be some progress in this direction.

Result of a Phase 2 study of Tenofovir gel-an ARV-based microbicides; presented at the conference indicate that the product is safe for HIV positive women to use daily over an extended period.

The study was led by Dr.Sharon L. Hillier, professor of obstetrics, gynecology and reproductive sciences and of molecular genetics and biochemistry at the University of Pittsburgh School of Medicine,USA.

Conducted by the Microbicides Trials Network(MTN) in Pune, India as well as Alabama and New York, in the US, part of the study objectives was to find out if Tenofovir(an ARV) was safe for use every day for six months compared to its use prior to each sex act and if women were able to adhere or follow each regimen.

Researchers found both approaches safe and womens adherence to product use encouraging and most participants willing to apply gel daily if found to be effective to prevent HIV infection.

Based on what we have learned, we can proceed with greater confidence on a path that will answer whether Tenofovir gel and other gels with HIV-specific compounds will be able to prevent sexual transmission of HIV in women when other approaches have failed to do, says Hillier who also is director of the Center of Excellence in Womens Health at the Magee-Womens Hospital of the University of Pittsburgh Medical Center and head of Microbicides Trials Network(MTN)

It is a critical time for us engaged in HIV prevention and I truly believe we are turning corner,Hiller added.

Indeed, this is a critical time and we might not be turning into the right corner if the fears about the use of ARV-based microbicides are not properly addressed top of which is the issue of drug resistance.

The same drugs used for treatment are about to be used for prevention and when there is resistance to these drugs, both prevention and treatment becomes serious issues of concern. There is also the concern that with resistance some people newly infected with HIV may be infected with resistant strains.

These can only happen when a woman using ARV-based gel to prevent HIV eventually becomes infected with HIV.

We are studying the efficacy of ARV-based microbicides to learn how to protect and we have to be careful because if it fails, we will get into a problem where we will have a drug that can’t prevent and can’t treat, say Dr John Mellors, Director, HIV/AIDS Programme, Dept of Medicine, University of Pittsburgh

First published February 26,2008

http://www.nigeria-aids.org/eforum/msgRead.cfm?ID=7148

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