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4 Addressing Continuous Threats: HIV/AIDS, Tuberculosis, and Malaria
Pages 99-132

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From page 99...
... With 2 million new infections, 1.1 million deaths, and 36.7 million people living with HIV in 2015, there is a clear need for heightened attention (UNAIDS, 2015d)
From page 100...
... HIV/AIDS Beginning in the early 2000s, the HIV/AIDS pandemic and the global attention it received resulted in a great deal of funding and research toward finding drugs and other treatments and helping those with HIV improve their quality of life. Because of these concerted efforts by the global community, about 18.2 million people living with HIV now have access to antiretroviral therapy -- a major feat, considering that just 16 years ago, fewer than 1 million people had access (HHS, 2016)
From page 101...
... government's enthusiasm to end the AIDS pandemic has led to the establishment of lofty targets. Current global strategy is guided by the 90-90-90 agenda of the Joint United Nations Programme on HIV/AIDS, which, by 2020 aims to have 90 percent of people living with HIV knowing their status; 90 percent of people with diagnosed HIV infection receiving sustained antiretroviral treatment; and 90 percent of all people on antiretroviral treatment having viral suppression (UNAIDS, 2014a)
From page 102...
... , and halving the adult death rate in PEPFAR-supported countries within 5 years of program rollout, PEPFAR has led to a number of economic benefits for partner countries that improve the prosperity of American businesses and the safety of the American people, including •  3 percent higher employment rates among men in PEPFAR countries 1 than in non-PEPFAR countries; •  three times higher development rate in PEPFAR countries as compared a to non-PEPFAR countries •  n increase in positive opinion of the United States from 40 to 68 percent a by people in PEPFAR countries compared to 40 to 46 percent in non PEPFAR countries between 2007 and 2011; •  n 86 percent viral suppression among those being treated in Zimbabwe, a Zambia, and Malawi, indicating these countries are on the path to control ling the epidemic; •  16 to 20 percent less likelihood of dying of human immunodeficiency a virus/acquired immunodeficiency syndrome (HIV/AIDS) in PEPFAR coun tries as compared to non-PEPFAR countries; •  positive trend toward lower tuberculosis rates for PEPFAR countries.
From page 103...
... . With so many individuals dependent on the PEPFAR program for life-saving treatment and the dangerous potential for regression given the rapid youth population growth in many PEPFAR countries, there is an ethical imperative that PEPFAR be continued.
From page 104...
... In those cases, low-income countries will continue to rely on support from donors like the United States in order to keep HIV infection rates from surging out of control. A range of opinions exists about how to best support national governments in this transition, but many emphasize the need to incentivize and encourage country-driven funding by devising innovative, creative, and flexible financing strategies (Oomman et al., 2007; PEPFAR, 2009; Resch et al., 2015)
From page 105...
... field staff in multiple countries on PEPFAR's successes and challenges.9 Overall, respondents reported that the PEPFAR program was generally well-received in countries and was significantly increasing the number of patients on treatment and decreasing HIV infection rates. Some respondents noted that country leaders understandably appreciated the technical and financial support provided by PEPFAR but wanted a greater degree of responsibility in decision making and prioritizing.
From page 106...
... People who take antiretroviral therapy often encounter food insecurity as a critical barrier to linkage to care, treatment adherence, retention in care, and viral load suppression. Malnourished people living with HIV are two to six times more likely to die within the first 6 months of treatment than similar patients who are not malnourished (UNAIDS, 2015b)
From page 107...
... and Nursing Education Partnership Initiative (NEPI) were created in response to the poor treatment outcomes resulting from the paucity of trained medical professionals in PEPFAR countries in 2010.
From page 108...
... infection in young women. The partnership focuses on young women in high-burden locations of Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe, with a goal of 40 percent reduction in new HIV infections among adolescent girls and young women by the end of 2017.
From page 109...
... Most importantly, as noted previously, nearly half of all people living with HIV are unaware of their status, underscoring the urgency of closing the testing gap. Late diagnosis of HIV infection is the most substantial barrier to scaling up HIV treatment (UNAIDS, 2015c)
From page 110...
... However, the successes achieved should not be taken as a rationale for downscaling PEPFAR. The need for the program remains: Approximately 9.5 million people currently receive antiretroviral treatment through PEPFAR support, while 2.1 million new HIV infections still occur each year (PEPFAR, 2017a)
From page 111...
... • Enhance emphasis on primary prevention through multisec tor efforts, including strong interventions against gender based violence, given that many new HIV infections are occurring in adolescent girls. TUBERCULOSIS TB, an airborne disease, has been historically underprioritized.
From page 112...
... The predominant method for diagnosing TB in LMICs is direct sputum smear microscopy,13 which is quick but limited in its ability to detect pediatric TB,14 drug-resistant TB, and TB/HIV 11  In 2015, an additional 0.39 millions deaths were caused by HIV/TB coinfection. 12  A reason Southeast Asia and Africa rank so high is that China, India, Indonesia, Nigeria, Pakistan, and South Africa accounted for 60 percent of new cases in 2015 (WHO, 2016c)
From page 113...
... 15 (Laurenzi et al., 2007) , adherence outside of these settings is lower due to physical barriers to access and lengthy treatment, which results in average global success rates of about 83 percent (Laurenzi et al., 2007; WHO, 2016c)
From page 114...
... , accounting for 34.45 percent of HIV deaths.19 Coinfection has been found to result in a dangerous interaction in the body, with HIV being linked to the progression of a TB infection and TB being reported to worsen HIV infection (Getahun et al., 2010; Whalen et al., 1995)
From page 115...
... The mainstay of TB treatment is the directly observed treatment, short-course (DOTS) strategy,20 which 20  Though DOTS contains five elements (sustained political and financial commitment, diagnosis by quality-ensured sputum smear microscopy, standardized short-course anti-TB
From page 116...
... . Given the resource intensiveness of directly observed treatment and its relative ineffectiveness compared to self-administration, policy makers need to reconsider TB control strategies and a redirection of resources toward other causes of poor treatment outcomes.
From page 117...
... government, through USAID, started its TB program in 1998. Global TB funding has increased since then, and the United States is now the largest international funder for TB, with its bilateral programs reaching more than 50 countries (KFF, 2017b)
From page 118...
... Further complicating global efforts is a rise in drug resistance, with 3.9 percent of all new TB cases being drug-resistant. Treatment for TB, MDR-TB, and XDR-TB is lengthy and complex, and frequently fails.
From page 119...
... Recommendation 5: Confront the Threat of Tuberculosis The U.S. Centers for Disease Control and Prevention, the ­ ational N Institute of Allergy and Infectious Diseases, and the U.S.
From page 120...
... The United States continues to be the single largest international funder for malaria, accounting for approximately 35 percent of total malaria funding in 2015, including both the President's Malaria Initiative (PMI) and contributions to the Global Fund (WHO, 2016d)
From page 121...
... Both of these programs inform the current global malaria strategy, which uses 2015 as a baseline and has the goal of reducing malaria mortality and incidence by 40 percent and eliminating malaria from 10 countries by 2020. The final target of the global malaria agenda is to reduce malaria mortality and incidence by 90 percent and eliminate malaria from 35 countries by 2030 (RBM, 2015; WHO, 2015b)
From page 122...
... Due to its geographical heterogeneity and the presence of multiple malaria parasites, the region is notoriously complex for malaria control and elimination. As a result, the Greater Mekong subregion is considered to be one of the most dangerous foci of malaria in Southeast Asia (Cui et al., 2012; WHO, 2016a)
From page 123...
... U.S. Commitment: President's Malaria Initiative As noted, the United States is the single largest international funder for malaria, and in 2016 contributed $861 million for global malaria control, with the majority of the activities being conducted by PMI.
From page 124...
... . Unlike PEPFAR, PMI was launched when the global community had already established a framework for global malaria control and strong institutions, such as RBM and the Global Fund, were already in existence.
From page 125...
... Because of the investments by the United States and the global community, HIV is no longer necessarily a death sentence for the poorest in the world, millions of deaths due to TB have been averted, and malaria elimination has become a real possibility for many countries. Maintaining programmatic and financial commitment toward these diseases is vital if these gains are to be sustained.
From page 126...
... As discussed in the previous sections, resistance has created a global emergency for TB and significantly threatens the progress of integrated malaria control. As national borders become more porous and globalization increases global travel, coordination among neighboring countries becomes vital to contain resistance.
From page 127...
... 2008. A new global malaria eradication strategy.
From page 128...
... :290-294. Global Fund (Global Fund to Fight AIDS, Tuberculosis and Malaria)
From page 129...
... directly observed therapy effect on microbiologic failure, relapse, and acquired drug resistance in tuberculosis patients. Clinical Infectious Diseases 57(1)
From page 130...
... Washington, DC: The U.S. President's Emergency Plan for AIDS Relief.
From page 131...
... New York: United Nations International Children's Emergency Fund. University College London Hospitals.
From page 132...
... 2016a. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach.


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