Illustration: India 2013 © George Butler

MSF’s HIV/TB Project in Mumbai

MSF invited illustrator George Butler to visit our HIV and MDR-TB project in Mumbai, India to capture our activities there. He returned with images and stories of families affected by multidrug-resistant TB, their care givers, and the MSF team responsible for their treatment.

Photo: An MSF staff member uses a SAMBA tool for rapid viral load monitoring. Malawi 2011 © Nabila Kram

MSF Research Points to Ways to Expand Viral Load Testing for HIV in Developing Countries

“Viral load monitoring—a test that measures the amount of virus in a person’s blood and thus the effectiveness of antiretroviral treatment—is critical in allowing treatment failure to be detected earlier, and ensuring that people receive the support they need to adhere to treatment,” said Dr. Jennifer Cohn, medical coordinator for MSF’s Access Campaign. “It’s a standard part of HIV disease management in developed countries but due to high costs and the lack of suitable technology, this type of virological monitoring is almost non-existent in developing countries. We need to challenge this state of affairs by ensuring there is financial and political support for roll-out of viral load in remote settings as a routine part of decentralized care.”

The two main barriers to roll-out of viral load concern the cost of testing and the difficulties of sample collection and transport. In two studies to be presented at CROI from its projects in Thyolo, Malawi, MSF will show how viral load monitoring can be adapted for resource-limited settings by using novel technologies and strategies to address these barriers.

The first study looked at simplification. Instead of conducting a blood draw, which requires a nurse, MSF was able to acquire blood samples by performing a simple finger-prick in order to prepare dried blood spots, which were then transported to a laboratory with viral load testing capabilities. Because dried blood spots (DBS) are easy to prepare, extremely stable at room temperature, and can even be sent in the mail, the finger-prick method of collecting samples in conjunction with the practicality of using DBS helps to overcome the challenges of health worker shortages and lack of sophisticated sample transportation networks for blood-based samples. This makes access to viral load testing easier for patients in rural areas, who no longer need to travel long distances to reach facilities with testing capacity.

A second viral load study to be presented at CROI looked at overcoming cost barriers preventing routine viral load implementation. MSF evaluated the accuracy and cost-saving of pooling samples of dried blood spots compared to individual viral load testing in a rural district laboratory in Thyolo, Malawi. 

Photo: Blood is drawn for an HIV test at the MSF Dipping Tank community testing campaign at Nhletsheni, in Shiselweleni region. Swaziland 2012 © Giorgos Moutafis

Trying Out New Approaches to HIV Treatment

Thirty years into the HIV/AIDS epidemic and more than a decade since the introduction of antiretroviral treatment (ART) in developing countries, the latest scientific evidence shows that the treatment keeps people healthy and prevents the virus from spreading. MSF is now treating more than 222,000 people for HIV/AIDS in 23 countries and introducing new approaches to treatment including earlier provision of ART to pregnant women living with HIV, expanded testing and treatment programs, and using improving technological monitoring techniques to track patient progress. Here, Micaela Serafini, MSF medical referent, discusses MSF’s efforts to treat HIV/AIDS in Swaziland.

Why is it important to provide antiretroviral treatment to people living with HIV while their immune system is still strong?

Today, we measure the level of an HIV-positive person’s white blood cells [CD4 cells] to determine when to start them on treatment, because this is an indicator of how strong their immune system is. Right now, the World Health Organization recommends starting people on ART when their CD4 cell count drops to 350 cells per mm³ of blood, but asks countries to consider earlier ART for pregnant women and HIV-positive partners in couples where one person is HIV-positive and the other is not, or “sero-discordant” couples. A healthy person’s CD4 count ranges from 800 to 1,200 cells per mm³—the lower the count, the more prone a person is to becoming ill from opportunistic infections like tuberculosis.

In Swaziland, MSF is studying the feasibility and acceptance of the “Test and Treat” (T&T) model, the most radical option of Treatment as Prevention (TasP). It involves providing all HIV-positive people with treatment, regardless of their CD4 count. This approach would allow us to have a maximum impact on reducing illness, as well as transmission of HIV in the community.

We are currently paving the way for TasP in Swaziland with the implementation of a greatly improved treatment protocol for pregnant women in order to better prevent mother-to-child transmission of HIV, or PMTCT, and help keep mothers healthy. The protocol is referred to as “Option B+.” In a nutshell, PMTCT Option B+ is T&T for pregnant women—we aim to start all HIV-positive pregnant women on life-long treatment, regardless of their CD4 count.

This new pilot project is just starting in the south of the country, in the Shiselweni region, which has a population of 208,000 people. We hope to start PMTCT B+ this month and from there put 3,000 pregnant women on ARV treatment every year. In 2013, we will expand this approach to other vulnerable groups and eventually to all HIV-positive adults in the region.

Photo: Young MDR-TB patients in Blue House, a facility in Nairobi where MSF treats TB and HIV. Kenya 2011 © Yann Libessart

New MSF Multinational Study of Pediatric TB/HIV Co-Infection Confirms Crisis of Undiagnosed TB Among Children

Data from the largest-ever multinational cohort of children infected with both tuberculosis (TB) and HIV, released by MSF, definitively shows that there is an urgent need for better TB tests for children. The standard TB test fails to detect the disease in children 93% of the time. 

“When you’re only detecting TB in one out of ten children, you can be sure that many are falling through the cracks simply because they’re not being diagnosed, resulting in unnecessary deaths and the disease spreading to others,” said Dr. Philipp du Cros, head of MSF’s medical department in London. “Most revealing of this sad reality is that until just last month, there was little data on the global burden of pediatric TB.”

One of the main barriers to developing a TB test that works in children has been the lack of a gold standard to assess performance of new diagnostic tools. In a process led by the US National Institutes of Health (NIH), a consensus on clinical case definition and methodological approaches to apply in the evaluation of new TB diagnostic tests in children was developed. This consensus should open the way for academic groups and test developers to work towards better TB tests for kids.

“What we need to see now is test developers showing that children are a priority, and that will mean developing tests that respond to their needs,” said Dr. Grania Brigden, TB Advisor for MSF’s Access Campaign. “We need to move away from having to put children through excruciating procedures to get lab specimens that in the end don’t provide us with a diagnosis.” 

Photo: A child at MSF’s intensive feeding center in Guidam Roumdji, Maradi region. Niger 2011 © Alessandra Vilas Boas

Rotavirus Research Results Show Need to Tailor Vaccines to Improve Their Impact

Cape Town/Geneva/New York, November 8, 2012- Research presented today by Epicentre, the epidemiological research arm of MSF and other African researchers, contributes to the growing body of evidence that the two existing rotavirus vaccines may not be best adapted for use in Africa.

“Vaccine developers have not taken into account the full rotavirus picture in places that are hardest hit by diarrheal illness and deaths caused by rotavirus,” said Dr. Anne-Laure Page, an epidemiologist at Epicentre. “This study adds to the growing body of research that underscores the need to ensure that vaccines are developed that effectively address the needs of developing countries.”

The two available rotavirus vaccines were developed and tested in industrialized countries, and have an efficacy rate of 90 percent against severe diarrhea in these countries, compared to an estimated 50-60 percent in countries in Africa and Asia. The current vaccines are also bulky and have a limited shelf life at room temperature, further making them unsuitable for developing countries that lack adequate refrigeration capacity.

“The fact that currently available vaccines are not easy to use in the places that are hardest to reach contributes to the fact that 22 million children born each year do not receive even the basic vaccination package,” said Elder.

“I’m Going to Tell The Whole World”: An HIV “Expert Patient,” In Her Own Words

In 2001, I tested positive for HIV. At that time, I was 25 years old and in a terrible state. I had lost a lot of weight, I was vomiting, had cold and hot rashes and was saying weird things. My whole body was covered with sores and I was confined to a wheelchair. Literally, I was more dead than alive.

In 2004, I started volunteering for an organization that helped people living with HIV/AIDS in Nhlangano, the capital of Shiselweni region. They asked me to share my experiences, and I told people about antiretroviral treatment and what it had done for me.

When I started seeing MSF cars in Nhlangano in 2009, I became curious and asked around. Someone told me what MSF was doing, and immediately I wrote my application letter and was hired as an “expert patient.” My role is to do pre and post-test counseling and to be there for the patients when they need support.

I really like the work with the patients. I know I give them hope by telling my story. Today I am fine. I have a healthy four-year-old boy who is HIV negative. Before I had him, five children I brought to this world had died, each after six months. My older son is 17, and he is well, too. I know what the patients are going through, and telling them my story and how important it is to stick to the treatment encourages them. The other day a young girl even told me I was her role model. That made me very happy.

Photo: Thembi (right) with her two sons
Swaziland 2012 © Irene Jancsy/MSF

The Need For Urgent HIV and TB Treatment in Myanmar.

Tens of thousands of people living with HIV and tuberculosis (TB) in Myanmar are unable to access lifesaving antiretroviral therapy (ART), a dire situation exacerbated by the recent cancellation of a new round of funding from the Global Fund to Fight AIDS, TB, and Malaria.

“Lives in the Balance,” a report from Doctors Without Borders/Médecins Sans Frontières (MSF), outlines the situation for people affected by HIV and tuberculosis (TB), with a special focus on multidrug-resistant TB (MDR-TB), in Myanmar today. It calls for urgent funding and assistance to be made available by the international donor community to help Myanmar close the devastating gap between people’s need and people’s access to treatment for HIV and TB.

Infographic by Will Owen

Tuesday, MSF marched in the streets of DC with other organizations at the Internetional AIDS Conference. We told pharma to put people before profits. Millions die without access to affordable generic meds, we marched and will continue to march for them.

The Trans-Pacific Partnership (TPP) is a trade agreement for which the U.S. is demanding provisions that would roll back public health safeguards. It would allow pharma companies to patent minor modifications of old medicines, potentially keeping prices high indefinitely, and delaying access to more affordable generic medicines for our patients and millions of others.

Earlier this week, we introduced you to Mqondisi, the 17-year-old boy from Zimbabwe who is living with HIV.
Today, he marched with MSF to the White House in Washington D.C. calling on pharma and the U.S. government to stop undercutting affordable medicines so that we can scale up HIV treatment and stop the virus.

In our satellite at the International AIDS conference this afternoon, we talked about how the market-driven medical research and development system leaves our field teams frustrated because the tools needed for our patients are unsuitable, unavailable, or unaffordable.

Learn more here.