Gaia VF: Our Work in Mali

Global Alliance for the Immunization against AIDS

Because you can't distribute an HIV vaccine in a vacuum, GAIA is building the infrastructure that will be needed to deliver our HIV vaccine. This includes instruction on how to administer a vaccine, provision of safe delivery devices and supporting a network of distribution points.

New mothers await the midwives at the GAIA-sponsored

Chez-Rosalie Mother to Child Transmission Prevention Program.

Why is GAIA Vaccine Foundation involved in clinical care in Mali and West Africa? Africa is home to the highest number of people living with AIDS and is the epicenter of the global epidemic. GAIA VF is involved in setting up a field trial site for the GAIA (not for profit, globally relevant) HIV vaccine. In the meantime, GAIA VF has established a “Prevention Now!” campaign in Mali. GAIA VF believes that active, ongoing collaboration with West African physicians and support for clinical activities in the region will improve the health of West African children and their parents, and foster the development of the type of regional knowledge base and level of care that is needed to pursue ethical implementation of HIV care and future HIV vaccine trials in the region.

HIV Prevalence in Mali The HIV prevalence rate in Mali is 1.9% among adults and at between 170,000 to 400,000 people are living with HIV (including more than 70,000 women). To place the epidemic in perspective, there are almost as many PLWH/A in Mali, a country that is less than two times the size of Texas, as there are in the continental USA. The last HIV survey was performed in 2001 and there is reason to believe that the epidemic is beginning to accelerate: HIV prevalence rates of 5% have been described in prenatal clinics in Bamako and Segou and confirmed in GAIA VF's clinic in Sikoro. HIV treatment is available: in April 2005, the Global Fund awarded $23,483,234 to the Malian government's Haut Conseil pour la Lutte Contre le SIDA (HCNLS) for the coordination of HIV prevention and treatment efforts.

Limited access to HIV care. Despite the recent expansion of access to HIV medications in Mali thanks to the Global Fund award, access to the lifesaving medications is limited. HIV-infected individuals must find a clinic (only 4 ‘Centres de Soin” exist) and pay for clinical tests and for treatment for opportunistic infections, which are not provided by the government. The number of “dispensers” who are allowed to prescribe HIV medications is limited (less than 40) and concentrated in Bamako, the capital city. Experienced HIV providers are isolated in academic centers within Bamako, leaving large numbers of HIV infected individuals in the capital city and rural countryside without care. Furthermore, HIV care and risk reduction efforts are hampered by a severe lack of successful management models, vehicles for the exchange of expertise, defined standards of care, and effective treatment algorithms. As a result of the concentration of Malian HIV expertise in these centers, of the estimated 800,000 Malians who are in need of life-saving ARVs, as of January 2007, only 8,000 are currently receiving treatment.

The Hope Center Clinic

Check out our latest pictures on Hope Center Clinic

As of March, 2008 GAIA has completed the construction of the Hope Center Clinic in Sikoro, a peri-urban impovershed neighborhood of Bamako, Mali. The completion of this construction will allow GAIA VF to continue our effort to become the first “CSCOM” (Community-based clinic or infirmary) in Mali to offer HIV care to villagers. No CSCOM-based HIV care is currently provided in Mali.

The Hope Center Clinic is a 2-floor addition to the existing Regional Health Department clinic of Sikoro. It will be fully equipped with a large infirmary, a pharmacy, a laboratory, exam rooms, and offices. The building also has a meeting room for peer education and a cooking area for the preparation of the GAIA supported weekly meal program. The clinic will have wireless internet, multiple sinks and toilets.

This plan has the support of the local authorities (the CSLS and the Regional department of Health). Should the Hope Center Clinic establish itself as a center for HIV care in this most rudimentary of settings – the village infirmary - it will set an example that the other 785 CSCOMS in Mali will be able to follow, increasing access to government-supported free HIV medication and HIV tests for hundreds of thousands of individuals who currently have no access to care. Thus, the Hope Center Clinic will establish a village-based HIV care model, “setting the standard” in Mali, thereby dramatically improving access to HIV prevention, education and care for all of Western Africa.

Board member Sophie Sprecht-Walsh plays construction manager on her recent trip to Bamako.

The clinic already provides HIV care to more than 65 patients. We anticipate, given the current rate of enrollment of five patients per week, that we will be serving an additional 100 patients by June of this year. We estimate that at least 800 individuals living with HIV are situated in the village of Sikoro. It is our goal to reach out to all of these individuals by the end of 2008. Our CSCOM-based HIV care model will become the ‘standard of care’, increasing access to HIV medications for the estimated 800,000 persons living with HIV in Mali.

While that is 65 patients is a small fraction of the estimated 800 infected children and their parents who are in need of care in this area, we have surmounted a significant amount of stigma and despair to establish that number of patients. Patients are currently arriving for care at the clinic at the rate of five per week: our current goal is to have 100 patients under our care by June 2008. HIV medication is provided at no cost; additional medications are obtained by GAIA VF at no-cost or at reduced cost, using GAIA VF funds to leverage access to life-saving antiretrovirals (ARVs) from the government and treatment for AIDS-related opportunistic infections from pharmaceutical company donation programs.

Why develop an HIV care center in a “CSCOM”? Malians have limited access to these life-saving drugs due to restricted access to HIV testing and the lack of clinics that provide HIV care. The CSCOM is the health care delivery system at the base of the health care pyramid in Mali –the most important means of reaching the average Malian, whether he/she lives in an urban slum or in the most rural area of the country. GAIA VF is motivated to establish this clinic as a model for “communal self-care” that may be replicated in other neighborhoods in Bamako, and the rest of Mali, should this clinic be successful. Thus, future beneficiaries will also include all HIV-infected children and their parents in Mali, West Africa.

GAIA VF’s commitment to stop AIDS through the Hope Center Clinic, our “Prevention Now!” projects, and our on-the groundwork to develop a global vaccine for distribution on a not-for-profit basis remains unflagging.

Hand of Hope
Peer Education for an Illiterate Population, 2007

Previous research has determined that door-to-door HIV education programs are an effective means of teaching about HIV, reducing stigma, and increasing the number of people seeking HIV testing and treatment in sub Saharan Africa. Where the population is illiterate, physical mnemonics can improve learning. GAIA Vaccine Foundation therefore developed the Hêré Bolo HIV Peer education program that uses a physical mnemonic based on the five fingers of the hand: Hope (thumb; Identity (index finger); Transmission (middle finger); Fidelity and Family (ring finger); and Community (fifth finger completing whole hand) to teach illiterate residents of a peri-urban slum in Mali about HIV disease, treatment and prevention.

The Hêré Bolo door-to-door HIV peer education campaign was initiated in the neighborhood of Sikoro, near Bamako, Mali, in July 2006. A pilot project was initiated in July/August 2006. Community members were trained by the Malian national peer education program (Groupe Pivot) and taught the Hêré Bolo teaching method in Nov-Dec 2007. Answers on the posttest HIV information survey improved following the training program. Formal training was provided to the Peer educators in November 2007 (Groupe Pivot). The program was formally initiated in February 2007. More than 6,443 contacts with community members were initiated by the 11 peer educators over the six-month period 2/2007 to 5/2007. During this period, 4,184 condoms were distributed. HIV testing requests at the Sikoro CSCOM have increased by 20%.

Founder and Scientific Coordinator Dr. Annie De Groot poses for a picture

with the peer educators at the January 2007 Hope Center Clinic grounbreaking

ceremony.

Testimony from a peer educator: I will put all of my energy into the fight against HIV and peer education so that all can benefit from the good news (about treatment) and know that HIV has been ravaging our neighborhood, Sikoro, and we pray to the good god so that one day we will have medicine that will cure everyone of this disease.

The next phase of the program will determine whether the physical mnemonic is “viral” by measuring transmission of the teaching to homes adjacent to the sites where the Hêré Bolo intervention took place. Thus, the Hêré Bolo five-finger simple physical mnemonic improves HIV learning in a pilot intervention. This intervention may be easily adaptable to other settings in West Africa.

Prior work by GAIA VF in Mali

Establishment of GAIA Mission 2002 and “Rendez vous des Specialistes VIH/SIDA”

GAIA Vaccine Foundation has been working in Mali since 2002, when Dr. Annie De Groot first established collaborations with Malian HIV researchers. She soon recognized the lack of coordinated networking between HIV/AIDS NGOs, GOs and HIV care providers and misinformation about HIV/AIDS treatment among practitioners that might impair the ethical conduct of HIV vaccine trials in Mali. GAIA VF’s mission arose from the need to coordinate these HIV/AIDS endeavors. Therefore, GAIA VF developed plans for an annual HIV/AIDS conference and to set up clinical centers in the city where good HIV care would be modeled.

Mother to Child HIV Transmission Prevention, 2004

In 2004, GAIA VF established a clinic-based peer discussion group for women and a Mother-to-child HIV transmission prevention program (MTCP) in Sikoro, a resource-limited village within Bamako. More than 100 women per month are tested. This clinic is named Chez Rosalie after the Providence philanthropist Rosalie Fain who donated the seed funds for the clinic and committed to supporting the clinic for three years.

As of December 2005, the clinic had tested 990 women and identified more than 40 women who needed HIV treatment to prevent transmission to their babies. In Fall 2007, the numbers are higher: 2,700 women have been tested, and 80 HIV-seropositive women have been provided with HIV medications when delivering. These HIV-infected mothers (and their partners) now form the core of the HIV-infected clinic population at the Centre D’Espoir.

Knowledge, Attitudes, Practices, 2005

What does GAIA know about HIV prevention in Mali? GAIA VF has performed surveys about HIV knowledge at the FMPOS medical school (2004) and the markets (2005). To summarize, knowledge about the existence of HIV/AIDS is widespread (87% of 279 persons interviewed in the Bamako market places knew about HIV/AIDS) but the rate of condom use remains extremely low (14 % for females and 15% for males) and only a few respondents had been tested (less than 2.5%).

Very few individuals were aware of ARVs and their life-saving effects. Many knew about condoms but few had access to them. Even fewer had been HIV tested, despite having participated in high-risk behaviors. Misconceptions about HIV infection and PLWH/A were very common. Much remains to be done to improve the average Malian’s ability to reduce HIV risk.

Plans for the Next Two Years

The next year will be a critical phase in the development of the Centre D’Espoir. Not only will construction begin, but also we will be inspected by the national AIDS organization (CSLS) and the regional Department of Health (DRS) in December 2007. Our records and protocols will be audited, in preparation for approval as a “prescriptive center”. Following this evaluation, a decision will be made as to whether we can provide free, government supplied HIV medications and HIV tests at the Centre D’Espoir. We would be the first CSCOM-based clinic to have that right to provide direct care at the neighborhood level, in all of Mali.

In preparation for our government audit, we are hiring a consultant to evaluate our clinic charts and protocols in October, 2007. We expect the construction of the new clinic to be complete in November 2007. With a full-out effort by every member of the GAIA Mali staff, we expect to pass our evaluation and become a prescribing center in January 2008.

Additional Programs will be developed for Sikoro this year, including: (1) A pediatric program (for HIV seropositive children that will be run by the GAIA Mali Director, Karamoko Tounkara, who is a formally trained pediatrician; (2) A microfinance project for HIV seropositive women modeled on a successful program lead by Brown University graduate Jessica Beckerman; (3) A TB case finding program based on a successful program initiated in Kenya by Brown Professor Jane Carter.

We will also perform two evaluations: (1) an evaluation of the effectiveness of the Here Bolo peer education program, and (2) an evaluation of the clinical care – specifically, a survey of patients who are engaged in the clinic. Both surveys will be performed by medical students who are not clinic or GAIA Mali staff so as to have the most objective measures of our interventions.

Additional Programs will be developed for Sikoro this year, including: (1) A pediatric program (for HIV seropositive children that will be run by the GAIA Mali Director, Karamoko Tounkara, who is a formally trained pediatrician; (2) A microfinance project for HIV seropositive women modeled on a successful program lead by Brown University graduate Jessica Beckerman; (3) A TB case finding program based on a successful program initiated in Kenya by Brown Professor Jane Carter.

How Will We Measure Success?

The final criteria for success of the Centre D’Espoir (in the long term) will be the recognition of the Centre D’Espoir clinic as a “model” for other clinics in Mali – for example, the establishment of a second “Hope Center” in another neighborhood in Mali, which would be modeled on the Hope Center in Sikoro.