Give us some background on you and WHO.
I joined WHO’s Africa regional office in 1999 and served as deputy regional director, assistant regional director, director of non-communicable diseases, WHO representative for Malawi, and co-ordinator of the Inter-Country Support Team for South and East African countries. Before joining the WHO, I worked with UNAids as Team Leader of the Africa and Middle East Desk in Geneva (1997-1999). I also served as Unicef’s regional health advisor for East and Southern Africa; and with Botswana’s Ministry of Health as a clinician and public health specialist.
You have been vocal about the shrinking donor funding. How can African countries fill in the gaps and sustain progress in healthcare?
It was inevitable that we would get here. Countries are developing, their economies are growing. This means that as countries graduate into middle-income states, they need to smartly invest more of their resources in health. If donor funding is reducing, African countries need to be working on ways to improve their own revenue. While they are trying to seal the gap, they need to work better on areas that need emphasis. It is not as if the money is not there, it may not be getting into the public purse. Therefore, we need to talk about flight of capital and address cases of some international donors not paying taxes to the degree that they should.
At the same time, instead of lamenting and worrying about the flight of donor money, countries need to invest much more effort in getting their own revenue from areas like taxation. I should say, Botswana has done well over the years, government expenditure on health has increased substantially. It is one of the few African countries to have reached the Abuja Target, with 15% of total government expenditure allocated to healthcare.
With a continent that is heavily populated with young people, what is the involvement of youth in an agenda like Universal Health Coverage?
We need to deal with the awkwardness of having old and young people in the room to talk about health or at least engage young people where they are and bring their views and voice into decision-making. At the WHO, we are learning to do this. Our adolescent health programme has not been among the best funded or our strongest and we are deciding that it deserves this added emphasis because it deals with the biggest demographic in the region.
We are therefore recruiting young people to change how we are working and asking our adolescent health programme to work with all the other programmes, so that those working on HIV/Aids, sexual and reproductive health, non-communicable diseases, and health systems development take on board the needs of young people.
Talk about WHO’s renewed approach to dealing with health emergencies and outbreaks.
Lessons from the Ebola outbreak in West Africa revealed critical gaps in WHO’s emergency preparedness. We are therefore adjusting our programmes to have a smart technical focus in line with the region’s priorities, basing interventions on evidence and lessons learned from experience. We have now reformed our Health Emergencies Programme and are part of a global WHO approach of one emergency programme, one workforce, one budget and one line of accountability.
That means, for example, that my director, who is the team leader in Africa, does not need to get permission from me for everything he has to do. One of the big changes we have put in place is that this director can work directly with the executive director in Geneva and the WHO country representative to make decisions.
This is the approach we used to address recent disease outbreaks in Africa such as the yellow fever outbreak in Angola. We are also working with other partners in a structured way and co-ordinating the work that needs to be done between the three levels to provide better support.
How prepared are African countries to deal with emerging issues like antimicrobial resistance and disease outbreaks?
I genuinely think African countries (maybe not all of them) are better prepared on the whole than they were pre-Ebola outbreak.
But I also think we are not quite there yet. Health systems are still very weak. If you look at an objective tool like the International Health Regulations, there are very many gaps in African countries.
With data collected from about 12 of the 47 countries, we have more evidence-based information about the existing gaps and what needs to be done.
Countries have also begun putting together co-ordination mechanisms on the so called emergency operation centres, where you can deal with one of the key problems when something arises:
“How do I have an effective co-ordination nod which directs the actions from investigations, confirmation, response, surveillance and monitoring to see that an outbreak is being brought under control?”
That is one more step to being better prepared. We have also seen improvement in the laboratory capacity to quickly diagnose some of the organisms causing outbreaks. At the end of the day, what needs to happen is that if an outbreak is starting somewhere and the infected person goes to a clinic anywhere in a country, you need to have in the health worker diagnostic capacity to pick up that something unusual is happening, report that and trigger investigations that will conclude what is going on.
Research has not been explored especially when you focus on Africa’s role. How can we see more research by ‘Africa for Africa’?
Africa has paradoxically been quite involved in global health research but much of this has been invested in by outside entities and the agenda of this research has been determined by the funders of the research.
We need our own domestic investment in research which will enable the countries to define their own research priorities and, most importantly, to work with the outcomes of those researches to inform policy and service delivery.
I have seen the private sector becoming more and more engaged in playing its role in healthcare.
And we must admit that there are a lot of opportunities to harness the resources, skills and experiences of private sector. However, I think it needs to be done within a framework of clear alignment with national priorities and for us, because this is the Sustainable Development Goals era, clear alignment with the idea of driving towards equity, better quality services access but also emphasising affordability.
Dr. Emily Shava explains the Antibody-Mediated Prevention (AMP) study
Enrolment is ongoing in the Antibody-Mediated Prevention (AMP) study. Tell us about that. What is AMP and how exactly does it work?
AMP is a multicentre study being conducted in different countries by two global networks known as HIV Prevention Trials Network (HPTN) and HIV Vaccine Trials Network (HVTN). The AMP study in Sub-Saharan Africa is enrolling women and is also known as HVTN 703/HPTN081 Study. Women because in Africa they are among those at highest risk of HIV infection because of their physiology and gender based imbalances. In this study broadly neutralising antibodies (Bnabs) known as VRC 01 are being studied to see to what extent they can prevent acquisition of HIV-1(efficacy) and to what extend VRC01 can be tolerated by participants (safety).
This is a follow up of previous studies which showed that VRC01 is generally safe and well tolerated (HVTN 104).
It is a double blind randomised placebo controlled trial. This means that participants do not choose which group they are to be on. The study has 3 groups, high dose VRC01, low dose VRC01 and a placebo group. They will NOT know which group they are in and the clinicians consulting them will also not know which group the participants are in. Only the site pharmacy personnel are unblended – they know which product is which. This is important to prevent bias. BHP has engaged and continues to engage various stakeholders (including Ministry of Health and Wellness, DHMT, clinics) and communities through the BHP community advisory board since 2015 when we were selected to take part in this important study. The success we are talking about now would not have been possible had the different stakeholders and communities not been on board.
What is your role in the Study?
I am the study coordinator for the project, responsible for day to day running of the study clinic. The person with overall responsible for the study in Botswana is the site investigator, Dr Joseph Makhema.
Who are the participants in the study? How many people are required and how many have you enrolled so far?
The participants are healthy HIV negative women at risk of acquiring HIV, aged between 18 and 40 years and willing to take part in the study. They should not be pregnant or breastfeeding and should be willing to use effective contraception to prevent pregnancy since the effect of VRC01 on pregnancy is unknown. In Sub-Saharan Africa a total of 1900 participants will be enrolled from Botswana, Kenya, Malawi, Mozambique, South Africa, Tanzania and Zimbabwe. 1555 participants have been enrolled as of the end of April. From Botswana a total of 150 participants will be enrolled.In Botswana the AMP study was activated in July, 2016. The first participant was enrolled on August 16, 2016. To date 236 participants have been screened/checked for eligibility to participate in the study and from these, 122 women have been enrolled and are on study as of May 4, 2018.
Willing participants provide written informed consent after discussion of all procedures, and their risks. The informed consent forms together with the protocol (document that explains how the study is conducted) and other pertinent documents for study conduct are submitted for approval by the Ministry of Health and Wellness, Institutional Review Board (IRB) known as Health Research and Development Committee (HRDC). This is the committee responsible for approval of research conducted in country.
What are the fundamental questions about HIV prevention that the AMP Study is designed to answer?
Are people able to “tolerate” the antibody without becoming too uncomfortable? Does the antibody lower people’s chances of getting infected with HIV? If the antibody does lower people’s chances of getting infected with HIV, how much of it is needed to provide protection from HIV?
When did it begin and when is it expected to end?
In Botswana the study started in July 2016.Total duration of study is 5 years. Each participant stays on study for about two years.
What HIV preventive care do volunteers receive and how are you ensuring the safety of study participants?
Participants come for study visits monthly. During these visits, we do what is called “history taking” from the participants to find out how they are feeling and have been feeling. We examine them and we conduct laboratory tests to ensure safety. To prevent HIV infection, we provide risk reduction counselling and HIV prevention package per Botswana Standard of care
What impact will this study have in the future of HIV prevention?
We generally liken HIV prevention options to a tool box. We currently have various behavioural modification options in this tool box, including abstinence, use of condoms effectively and consistently. It is therefore important to also add more biomedical interventions in this tool box. bNabs would then be an important addition if proven to be effective. This would lead to more combination prevention options. The idea of a toolbox with more tools in it is important because we know that when people have more choices, it increases the chances that an individual will find one tool that fits their needs and circumstances. Those decisions can be influenced by many factors – cost, ease of use, availability/easy access, partner agrees to use, etc. –so having more tools will mean increasing the chance of serving more people’s needs for HIV prevention.
How will the findings benefit Batswana?
I would say that it is too soon to say what direct benefit there may be to Batswana. This trial is about proving the concept that bNabs can prevent HIV. More trials will be needed to find the best antibody, or combination of antibodies, how to best administer them as a public health strategy amongst other things.
We know the strides science has made in the war against HIV/AIDS. There are very effective drugs and that is great news. But what do you say to young people that would say to you that it’s no big deal to get HIV and that there are already good drugs to control the disease as if it’s diabetes?
Prevention is ALWAYS better than cure. We are truly grateful for the strides that have been made in science to avail great treatments for HIV treatment. We do not yet have all the answers about the various great treatments available, time generally brings things to light. Additionally, prevention is more cost effective than treatment or a cure. (Note that in the question, diabetes isn’t cured – it is treated as a chronic illness.) That is important to individuals, and to countries/public health systems.
From your experience, do you believe that there will be an effective vaccine and/or cure for HIV in our lifetime? Is that an achievable objective you think?
Please note that in AMP study, the study agent VRC01 is NOT a vaccine but broadly neutralising antibodies (bNabs). This study could help us develop a safe and effective HIV vaccine more quickly. An HIV vaccine developed more quickly because of this study could essentially teach the body to make antibodies like VRC01 (without getting the VRC01-like antibody through an IV/drip). To develop a vaccine like that we need to understand more about how VRC01 may work, and how much is needed to “work” (to prevent HIV infection). This study should help us learn that. My answer on vaccine in our lifetime would be YES. The Thai Trial, RV144, showed us a vaccine regimen could reduce new infections by about 32%. That wasn’t strong enough to license, but it paved the way for a great deal of additional research. There are 2 efficacy trials currently underway in sub-Saharan Africa testing different vaccine strategies (one of which builds on the Thai results), so we have come farther than ever before.There are various international organisations with scientists whose main focus is the development of the HIV vaccine such as the HVTN, International AIDS Vaccine Initiative(IAVI) etc.
I understand that the HI virus lives not in the blood but lymph nodes and some organs. Is there any research
currently being done to try and flush out HIV from these compartments so that it can be killed by the antiretroviral drugs?
To clarify, when a person is on antiretroviral therapy, the amount of virus also known as viral load in blood will reduce. Generally, if a person is not on treatment the viral load will remain high. For people on treatment with low/undetectable viral load, scientists are looking into ways of flushing out HIV from its hiding places like the lymph nodes termed the “shock and kill” strategy.Currently I am not aware of any such study being conducted in Botswana.
HIV was around for decades before it was discovered and diagnosable and infecting humans during that period. Has anything been learnt from that to prevent a recurrence with another type of retrovirus?
This is a difficult question, yes human beings are capable of learning to better themselves in the future, to what extent, time will tell.
What good news can you give readers of this interview who are living with HIV/AIDS?
If someone knows they are living with HIV, it means they have been responsible enough to take the test and know their status. This needs to be commended. Currently we have available in this country potent antiretroviral treatment with minimal side effects, which means that people living with HIV can have improved quality of life, including sexual reproductive health and live longer.
I would also like to take the opportunity to highlight the importance of universal test and treat and for all HIV infected people to be on treatment and to take the treatment diligently. This is important because a persistently undetectable virus is not transmissible.
‘Merck More Than a Mother’campaign coming to Botswana in 2019
Pharmacist and CEO of Merck Foundation Dr RashaKelej, has made it her mission to raise awareness about the discrimination, stigma and ostracism women undergo for their inability to have a child. Here she discusses with SunHealth how her foundation is empowering women across Africa and other developing countries.
Dr Rasha Kelej, you are CEO of Merck Foundation, can you start by introducing the Foundation for us?
Merck Foundation is the philanthropic arm of Merck KGaA Germany. It is non-profit organisation that aims to improve health and wellbeing of people and advance their lives through science and technology. Our efforts are primarily focussed on raising awareness about non-communicable diseases, empowering women and youth, improving access to innovative healthcare solutions in under-served communities, building healthcare and scientific research capacity in the fields of diabetes, hypertension, cancer and fertility care in underserved communities. Our vision is to see a world where everyone can lead a healthy and fulfilling life.
You will be launching the ‘Merck More Than a Mother’ campaign in Botswana in 2019. Can you discuss when this launch is expected to happen and what it will entail?
We will launch in Botswana sometimes in the first quarter of 2019 in partnership with Her Excellency First Lady of Botswana Madam H.E. NEO JANE MASISI, and ministry of health of Botswana. We will first launch the Merck more than a Mother campaign with Her Excellency as the Ambassador with the aim to empower infertile women through information, health and change of mindset.
As part of the campaign we will call for application for media recognition award of Merck more than a Mother. And we will also train media about health reporting and sensitive issues reporting such as infertility. We will also launch the start of producing a song about infertility stigma and sensitising the community to break its stigma.
In addition to providing training to doctors in the fields of fertility care and oncology we will also launch a pilot project called blue points where we will provide one year diabetes diploma to doctors to build Health care capacity in the country. Our vision is to develop a strong platform of specialised doctors to improve access to quality and equatable healthcare solutions in Botswana.
When did this campaign start? … What makes “Merck more than a mother” such a unique campaign and how do you hope it will be embraced by relevant stakeholders?
We started Merck more than a mother campaign in 2015 first in Kenya then Uganda and the rest of 35 countries in Africa and Asia.The campaign is an exponential success, the ambassadors of Merck more than a mother, The First Ladies of many countries, are very active and increasing every year. We have partnered with ministries of health and academia of many countries who are working closely with us.
The social media followers and videos viewers are in millions. Merck Foundation has trained more than 100 fertility specialists over the last two years in more than 30 countries in Africa and Asia. Thousands of women are sharing their stories of suffering every day; African media has started to discuss the issue every day, and we also worked with singers to write songs and produce video clips about infertility and delivering the message to all communities, since in many cultures infertile women suffer discrimination, mistreatment and physical and psychological violence. We have also supported the establishment of first ever Public IVF centres in Rwanda, Ethiopia and Uganda.
The Foundation seems to be so fond of Africa why the interest, many will ask? How do you settle on the choice of health needs or area and the countries that you engage with in Africa?
Prof Frank Stangenberg Haverkamp, the Chairperson of E-Merck KG and Merck foundation is very fond of Africa and believes in its potentiality. Furthermore, there are many challenges in Africa with regards to healthcare and this is our speciality we can help, and this is what we do and we do it well. But we also focus on Asia, we have programmes in many countries such as Sri Lanka, Bangladesh, Nepal, Myanmar and Cambodia; and we will expand to Latin America in 2020.
There was also the first Merck Health Media Training in Kenya to break the stigma around infertility in Africa, may we know the reason behind the focus on infertility and liaising with the media?
According to WHO data 2016, one in every four couples in Africa and developing countries are infertile which means that there are 180 million couples that are infertile. Incidence is much higher than in Europe and developed countries which has around maximum 8% to 9%, very high percentage of infertility due to untreated infectious diseases which result from child marriage, unsafe abortion, unsafe delivery, STDs and genital mutilation. Hence prevention is very important.
More importantly, in many cultures women suffer discrimination, mistreatment and violence due to their inability to bear children, although 50% of infertility cases are due to male infertility, therefore we need to create a culture shift to respect women whether they are mothers or not, encourage men to speak up about their infertility and support their wives through the treatment journey. I strongly believe in the power of art and media.
They are critical partners to address such sensitive topics. We have produced many projects of songs, and now we are going to produce drama (plays and documentaries) with African talents across the continent. It will be the first and we will be creating a culture shift, raising awareness and exploring African talents.
We started “Merck More Than a Mother” campaign in 2015 now it is in 35 countries in Africa and Asia. In partnership with First Ladies who are the ambassadors in their respective countries, academia, ministries of health and international fertility societies, the initiative also provides medical education and training for fertility specialists and embryologists to enable them to help and treat infertile couples in their countries.
Also, part of the campaign is our Merck Embryology & Fertility Training Programme, a three-month hands-on practical course to establish the platform of fertility specialists across Africa and Asia. Merck Foundation provides clinical and practical training for fertility specialists and embryologists in more than 35 countries across Africa and Asia such as: Chad, Niger, Central African Republic, Cote D’Ivoire, Ghana, Ethiopia, Uganda, Kenya, Tanzania, Zambia, Nigeria, Benin, Mali, Burkina Faso, Senegal, Guinea Conakry, Sierra Leon, Liberia, Cameron, Rwanda, Botswana, DR Congo, Congo Brazzaville, Gambia, Nepal, Sri Lanka, Bangladesh, Myanmar and Cambodia. So far more than 80 candidates have taken the training.
How do you envisage the future of health care in Africa and the partnerships that Merck Foundation is forging across the continent?
I think the future will be brighter if we cooperate together. The magnitude of the health challenges are very big to be addressed by one organisation. The secret is in the private public partnership and to really get things done by being hands-on. No time for talking anymore. We need to talk only when we talk about our impact and way forward.
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