The World Health Organization has issued new HIV testing recommendations to help countries expand treatment coverage and reach the estimated 8.1 million people living with HIV who have not yet been diagnosed. The WHO guidelines were released on Wednesday ahead of World AIDS Day on December 1 and the International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA2019), which will take place in Kigali, Rwanda on December 2-7.

“The face of the HIV epidemic has changed dramatically over the past decade,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus in a press release. “More people are receiving treatment than ever before, but too many are still not getting the help they need because they have not been diagnosed.”

A woman prepares for an HIV test in Uganda.

The launch of the WHO guidelines comes right on the heels of a UNAIDS report published Wednesday that highlighted mixed success in tackling the HIV/AIDS epidemic. Access to HIV treatment has expanded and new HIV infections have declined by 28% from 2010 to 2018 in eastern and southern Africa, the region most affected by HIV, but women and girls are still disproportionately affected. Four out of five new HIV infections among adolescents in the Sub-Saharan Africa region occur in girls. Additionally, new HIV infections are increasing in eastern Europe, central Asia, northern Africa, and parts of Latin America.

WHO estimates that at the end of 2018, there were 36.7 million people with HIV worldwide. Of these, 21% have not yet been diagnosed. Expanding testing for HIV helps ensure that people are diagnosed early and can start treatment. Testing also helps identify people who are HIV-negative but may be at high risk for contracting the infection and link them to appropriate and effect prevention services.

Both publications highlight that key populations such as injecting drug users, sex workers, transgender people and prison populations are at higher risk of testing positive for HIV, but may be less engaged in HIV decision-making and have less access to healthcare services. Additionally, in countries where high proportions of people have already been tested and treated, it can be difficult to reach the remaining proportion of people living with HIV who have not yet been tested, according to WHO.

The new “WHO consolidated guidelines on HIV testing services” recommends strategies for expanding a package of HIV-related services to those hardest to reach including:

  • Adoption of a standard HIV testing strategy which uses three consecutive reactive tests to provide an HIV positive diagnosis. Previously, most high burden countries were using two consecutive tests. The new approach can help countries achieve maximum accuracy, particularly in high-prevalence settings.
  • Use of HIV self-testing as a gateway to diagnosis based on new evidence that finds people who are at higher HIV risk and not tested in clinical settings are more likely to be tested if they can access HIV self-tests.
  • Implement social network-based HIV testing to reach key populations who are at high risk but have less access to services, and use peer-led, innovative digital communications such as short messages and videos to build demand and increase uptake of HIV testing.
  • Focus on community-based delivery of rapid testing through lay providers for relevant countries in the European, South-East Asian, Western Pacific and Eastern Mediterranean regions. Rapid testing methods cost less and can provide results up to 2-3 weeks earlier than traditional laboratory-based diagnostic tests.
  • Use HIV/syphilis dual rapid tests in antenatal care as the first HIV test to help eliminate mother-to-child transmission of both infections.
Power to Choose, Power to Know, Power to Thrive, Power to Demand

The UNAIDS report, Power to the People, found that significant progress has been made in expanding access to treatment, with an estimated 24.5 million people with HIV accessing anti-retroviral drugs and other therapies. However, progress to slow HIV transmission has stalled, and an estimated 1.7 million people were newly infected with the virus in 2018.

In Eastern and Southern Africa, the hot spots of the global HIV/AIDS epidemic, new infections declined by 28% between 2010 and 2018. However, outside of eastern and southern Africa, new HIV infections have declined by only 4% since 2010. Of concern is the rise of new HIV infections in certain regions. The annual number of new HIV infections rose by 29% in eastern Europe and central Asia, by 10% in the Middle East and North Africa and by 7% in Latin America. the report notes.

“In many parts of the world, significant progress has been made in reducing new HIV infections, reducing AIDS-related deaths and reducing discrimination, especially in eastern and southern Africa, but gender inequality and denial of human rights are leaving many people behind,” said Winnie Byanyima, executive director of UNAIDS in a press release.

The report aims to highlight the importance of including people and communities affected by HIV in HIV service delivery and policy-making. Specifically, stigma and discrimination can still prevent people from seeking knowledge on how to prevent HIV transmission, or accessing diagnosis and treatment.  But when people living with HIV are empowered, these barriers are more frequently overcome. Specifically, the report notes four areas of empowerment for programmes to target:

  • Power to Choose – The report finds almost 40% of adult women and 60% of adolescent girls (aged 15–19 years) in sub-Saharan Africa have unmet needs for modern contraception. Family planning services are closely tied to HIV treatment and prevention services. In sub-Saharan Africa, young women’s uptake of medicine to prevent HIV—pre-exposure prophylaxis (PrEP)—is high in projects that integrate PrEP into youth-friendly health services and family planning clinics and when provision of PrEP is separated from treatment services.
  • Power to Know – Knowledge of HIV among young people is alarmingly low in many regions. In countries with recently available survey data, just 23% of young women (aged 15–24 years) and 29% of young men (aged 15–24 years) have comprehensive and correct knowledge of HIV. This can lead to people finding out their HIV status too late, sometimes years after they became infected, facilitating transmission and leading to a delay in starting treatment.
  • Power to Thrive – Certain populations are being left behind. In 2018, 160 000 children (aged 0–14 years) became newly infected with HIV, and 100 000 children died from an AIDS-related illness. In Eswatini, a recent study showed that adolescent girls and young women who experienced gender-based violence were 1.6 times more likely to acquire HIV than those who did not. The same study also showed that economic empowerment of girls and women helped reduce new HIV infections among women by more than 25% and increased the probability of young women and girls going back to school and finishing their education.
  • Power to Demand – There have been reports of crackdowns, restrictions and even attacks on groups and campaigns supporting key populations most affected by HIV. Some governments refuse to recognize, support or engage community organizations in their national responses to HIV and are subsequently missing out on their enormous potential to reach the people most affected by HIV.

Image Credits: 2011, Sokomoto Photography for International AIDS Vaccine Initiative (IAVI).

The lower house of the French parliament has approved a milestone requirement that pharmaceutical companies must disclose the amount of public funding that was used in the research and development of new medicines entering the national market, as well as allowing those contributions to be factored into negotiations over final drug pricing.

After being initially rejected by the government, the new provision was adopted as an amendment to the French Social Security Budget Bill for 2020 in a nearly unanimous vote by the National Assembly, with 40 Members of Parliament voting in favor and only one opposed. The bill must still pass the French Senate in order to become law, but observers said the upper house was unlikely to drop the amendment after being approved in the National Assembly.

“Of course the adopted amendment is not perfect, but it’s still a historical first step toward the implementation of transparency at the French Parliament, and another proof that mobilization works,” said Pauline Londiex, co-founder of  l’Observatoire Transparence Médicaments (OTM), a French civil society watchdog that had lobbied heavily to see the provision passed by parliament.

The new requirement, enshrined in amendments n°474, n°505 and n°520 of the budget bill, stipulates that pharma companies must disclose the amount of public funding that was received for R&D of a new drug when applying for approval to market the product in France. Moreover, the government body in charge of negotiating drug prices, CEPS, will be able to take into account such public investments when negotiating the final drug price to be paid.

A series of other proposed requirements to disclosing the manufacturing costs of drugs, including costs of active ingredients, as well as profits such as the margins of intermediaries, were dropped from the final approved version of the amendment. A last minute sub-amendment was added to National Assembly approved-bill to further clarify that CEPS’ consideration of public R&D funding in drug price negotiations was optional.

Véran presenting the transparency amendment at the National Assembly on November 25.

Still, the parliamentary move is an important win for civil society groups advocating greater price transparency for health products after months of mobilization, following the approval in May of a landmark World Health Assembly (WHA) resolution on transparency in medicines markets.

The French National Assembly amendments appear to take the WHA resolution a step further – unlike the watered down WHA-approved language to only recommend voluntary disclosure by industry of public contributions to R&D costs, the National Assembly amendments appear to require companies report public funding.

The parliamentary proposal to require disclosure of public funds used for R&D costs had initially been shot down by French Minister of Health Agnéz Buzyn and the general rapporteur Olivier Véran at the first reading of the Social Security Budget Bill on October 24.

A month of political tensions followed, including the French Senate’s rejection of the original budget bill on November 14 in the wake of Prime Minister Emmanuel Macron’s announcement of an Emergency Funding Plan for Hospitals. Civil society groups continued to pressure the government to adopt the transparency amendment, publishing an open letter signed by over 80 notable French personalities that urged the government to support the amendment.

In a turn-around show of support, Véran presented the R&D cost amendment alongside presentations by La France Insoumise, and MP Caroline Janvier at a second meeting of the National Assembly on Monday where it was finally approved.

The final Social Security Budget Bill for 2020 must still be sent to the Senate for a first reading of the bill on Saturday, where the transparency amendment could then still be dropped  – or further expanded. But observers predict that the amendment may remain unchanged due to the wide consensus reached by the National Assembly, although there might be more attempts to weaken rather than strengthen the amendments in the Senate.

Image Credits: http://www.assemblee-nationale.fr.

Unitaid will expand its work in malaria to include chemoprevention for infants in the first year of life and pilot a new “agility” mechanism to support global health innovation in 2020, following approval granted by Unitaid’s Executive Board on November 20 to 21.

(left-right) ED Lelio Marmora, Board Vice-Chair Maria Luisa Escoral de Moraes, Board Chair Marisol Touraine, Deputy ED Philippe Duneton

The Board’s approval will allow Unitaid to launch a call for proposals for projects on malaria chemoprevention for infants.

“Chemoprevention is a key piece of the puzzle in the fight against malaria,” said Unitaid Executive Director Lelio Marmora in a press release.

“Adding infant malaria chemoprevention to Unitaid’s expanding malaria portfolio will not only protect millions of babies from this deadly disease but also help reignite the stalled progress in the global malaria response.” 

Infants and children are highly vulnerable to malaria because they have not yet developed protective immunity, according to Unitaid. Of the 435,000 malaria deaths in 2017, more than 60 percent occurred in children under 5.

Currently, malaria chemoprevention, or the strategy of providing medication to prevent malaria, is used by Global Fund financed programmes protect children 3 to 59 months old during the four-month rainy season in 12 countries in the Sahel, based on evidence from a Unitaid/Malaria Consortium project (ACCESS-SMC). Unitaid also invests in projects to expand and monitor malaria chemoprevention in pregnant women.

In a separate decision, the Board approved up to US$20 million in 2020 to fund a new framework to respond quickly to global health innovation, delegating the authority to enter into legal agreements under the pilot to the Executive Director. Current ED Lelio Marmora also announced to the Board that he will be stepping down by March 2020, and Deputy Executive Director Philippe Duneton has been identified as acting ED in the interim.

Image Credits: Unitaid.

A global campaign focusing on the issue of rape as a form of violence against women is being launched Monday on International Day for the Elimination of Violence against Women. The annual sixteen-day campaign, which is set to end on 10 December, Human Rights Day, will bring together activism against gender-based violence under this year’s theme “Orange the World: Generation Equality Stands against Rape.”

“We must show greater solidarity with survivors, advocates and women’s rights defenders. And we must promote women’s rights and equal opportunities,” said UN Secretary-General Antonio Guterres in a video message. “Together, we can – and must — end rape and sexual assault of all kinds.”

WHO has called violence against women a “public-health problem,” estimating that one in three women globally have experienced some form of sexual or physical violence in their lifetime. Most violence is perpetrated by intimate partners or other people the women know; almost one third of women who have been in a relationship report that they have experienced some form of physical or sexual violence, including rape, by an intimate partner in their lifetime according to the WHO.

The statistics around the prevalence of rape can be unclear, but UN Women’s Executive Director Phumzile Mlambo-Ngcuka notes in an official statement that “almost universally, most perpetrators of rape go unreported or unpunished.”

Mlambo-Ngcuka further adds that women require a great deal of “resilience to re-live the attack, a certain amount of knowledge of where to go, and a degree of confidence in the responsiveness of the services sought – if indeed there are services available to go to” in order to decide to report sexual violence. For those who do report, especially adolescent girls, less than 10% go to the police, Ngcuka says.

Health-care providers are often the first point of professional contact for a woman experiencing violence, according to the WHO. Women who are abused are more likely to seek health services even if they do not explicitly seek care for violence, making providers important first responders for survivors of sexual violence.

WHO launched global guidelines for healthcare providers to respond to sexual violence in 2013 and began working with partners to implement trainings for healthcare workers in India, Namibia, Pakistan, Uganda and Zambia. A pilot of the trainings was completed in two tertiary hospitals in the State of Maharashtra India, and a recent assessment of the impact of the trainings done by the Center for Enquiry into Health and Allied Theme (CEHAT) will be used to inform a potential national-roll out of the trainings.

See here for more information about the WHO Guidelines for Healthcare Providers and WHO and CEHAT’s work in Maharashtra.

See here for more information about the “16 Days of Activism Against Gender-based Violence.”

 

Image Credits: UNICEF/Nesbitt.

Oslo – Norway has launched a milestone “Better Health, Better Life” strategy to combat deadly non-communicable (NCDs) diseases as part of its international development assistance. This makes Norway the first to develop a strategy for combating this large and growing global health threat, which currently receives only about 1% of international health assistance.

NCDs are the cause of some 70% of deaths worldwide – and are now a major, growing cause of illness and premature death in low- and middle-income countries.

‘Worldwide, 41 million people die each year as a result of respiratory disease, cancer, cardiovascular disease, diabetes, mental disorders and other non-communicable diseases. This cannot continue,” said Norwegian Minister of International Development Dag-Inge Ulstein.

“Therefore, Norway will triple its assistance to fight NCDs, allocating over 200 million NOK to these agendas for 2020. This is just the start, we will step up the funding towards 2024,” said Ulstein.

Norwegian Minister of International Development, Dag Inge Ulstein

Speaking at a launch of the strategy in the Norwegian capital at a “Gathering for The Future of Global Health,” the minister noted the “strong upward trend” in the number of deaths from non-communicable diseases in countries at the lowest income levels.

“Tobacco, air pollution, alcohol, unhealthy food, lack of physical activity…These silent killers cause 70 percent of all premature and unnecessary deaths worldwide – yet the fight against them receives only 1 percent of the international development funding that goes to health. 70 percent – One percent,” said Ulstein.

“That has to change – and that is why we are here today. In Africa, the deaths from non communicable diseases are projected to increase from around 35%  to over 50% of total deaths by 2030. We are going the wrong way.”

NCDs often develop into chronic conditions, and when they are not treated or managed early enough, the result can be catastrophically high costs for individuals as well as health systems, he observed.

“If you cannot go to work – or plow your fields – there will be one less bread-winner in the house – and one less co-fighter in our collective quest to win the 2030 race to meet the SDGs,” he said.

Norway Asks Other Donors To Step Forward on NCDS
Norwegian Minister of Health, Bent Høie. (Photo: Stine Jenssen).

In launching the strategy, Norwegian officials were clear that they hope other high income countries which provide billions of dollars in international development assistance will also step forward and follow their example.

“No country until today has presented a programme on how to use development aid as a tool … to address the NCD epidemic. This is what makes this day so special,” said Norway’s Minister of Health, Bent Høie who co-hosted the strategy launch.

Referring to Norway’s longtime record of promoting health in development aid, he said that “this strategy will take it a step further, I urge other countries to follow up and develop their own NCD strategies for development assistance.”

Historically donor aid from high income countries has been used almost exclusively on communicable diseases, he noted, referring to the billions of dollars spent every year on global health programmes to fight AIDs, TB, malaria, other neglected infectious diseases, as well as to promote immunization.

Historically those programmes “corresponded to the disease burden and the biggest challenges in global health,” he noted, but, “today, this has changed.

“The NCDs are claiming far more lives than communicable diseases with many people dying prematurely. With this change in the disease burden, we need to change our priorities accordingly.”

WHO’s Bente Mikkelsen talks about the need for collaboration between health, finance, urban development, agriculture, food and pharma sectors to reduce NCDs, at the launch of the Norway’s NCD Strategy.

While some NCD treatments can be extremely expensive, others are “relatively cheap, like getting medication to lower blood pressure. But in many low income countries, this is out of reach,” he added.

“The [Norwegian] strategy recognizes these challenges and underlines the need to provide treatment based on universal health coverage. Primary health care is the basis.”

He noted that the strategy builds upon the 16 WHO-recommended Best Buys for preventing and controlling NCDs, which include comparably simple and inexpensive measures such as reduced salt and sugar intake and increasing physical exercise. The Best Buys were agreed upon by UN Member States at last year’s Third High Level UN Meeting on NCDs.

“If these were implemented, over 8 million lives could be saved annually by 2030,” Høie said, adding that according to WHO estimates, that would also lead to a savings of $US 7 trillion in low- and middle-income countries over the next 15 years.

Three-Pronged Strategy 

The new strategy has three main points of focus: Strengthening primary health care services: Prevention of leading NCD risk factors like air pollution, tobacco and alcohol consumption and unhealthy diets; Better data management and health information systems.

Strengthening Primary Healthcare Services as part of Universal Health Coverage.

Many NCD interventions, can be delivered effectively and affordably at primary health care level, with greater benefits to patients and savings for health systems.   Examples are checks for hypertension, diabetes, prevention of cervical cancer with HPV vaccination, as well as capacity for prevention and early diagnosis and treatment of mental health disorders in primary health services.  Norway will support the strengthening health services so that primary health care services are well-equipped to support NCD prevention, early diagnosis and treatment, as well as ensuring everyone has access to health services, subsidized in part, by the public authorities.

A woman gets her blood pressure measured to test for hypertension.
Preventing and reducing risks through intersectoral action, including regulation, taxation and other measures.

Norway will help to prevent non-communicable disease through development cooperation that contributes to healthy and sustainably produced food, a healthy environment with clean air and the consumption of clean energy, opportunities for physical activity, access to high-quality education and stronger tobacco and alcohol regulations. Emphasis shall be given to social sustainability and reducing health differences from childhood to old age.

In this context, Norway will also support countries requesting assistance to improve taxation and regulation of products that are harmful to health,  through its Tax for Development Programme (Skatt for utvikling). Such measures can be used to effectively discourage consumption of health-harmful products such as tobacco, alcohol, sugary drinks, saturated and trans fats, and encourage healthier alternatives.  Similarly, pollution taxes and regulations can encourage shifts to clean energy and transport, reducing health-harmful air pollution. These are all among the key risk factors contributing to NCDs, including cancer, hypertension and heart disease as well as obesity-related disease such as diabetes.

Unhealthy, unregulated street foods are commonly sold in low- and middle- income countries.
Strengthening data management, digitalization and other health information needs.  

The strategy also calls for assisting countries in developing better health information systems, to  improve access to health data critical to facilitating early stage NCD diagnosis, treatment; supporting NCD-related health norms and standards, as well as efforts to improve access to medical equipment and medication, particularly  in areas hit by crises and conflict.

Norway’s officials say that the strategy will support the SDG 3 goals of Universal Health Coverage (SDG 3.8) and reducing premature deaths from NCDs by one-third by 2030 (SDG 3.4), as well as the commitments reached at the Third UN High Level Meeting on NCDs  in 2018 as well as the recent UN High Level Meeting on Universal Health Coverage,” Høie added.

The strategy also supports other SDG 3 targets for reducing deaths and illness from hazardous chemicals and air pollution, as well as preventing and treating harmful use of alcohol.

Strategy Launched At Oslo “Gathering for Global Health” Event

Norway has become “the first in the world to launch a strategy to include non-communicable diseases in its international development policy,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in a videotaped message broadcast at the strategy “Gathering for Global Health” launch in Oslo on Friday.

Tore Godal

“Non-communicable diseases are the leading killers of our time. As is so often the case, the world’s poorest bear the heaviest burden,” the WHO Director-General added. “The risks of dying between the ages of 30 and 70 from a heart attack, stroke, diabetes, cancer or asthma are 4 times higher in most countries of Africa than in Norway.”

“You have anchored this strategy in the political declaration on NCDs and Universal Health Coverage, which were adopted this year and last year at the UN General Assembly.”

“And you have built it on the WHO Global Action Plans on NCDs and Mental Health and the WHO Best Buys. I appreciate the central role in the strategy of primary health care, both in preventing and managing NCDs.”

“Thank you for your leadership in this important area.  WHO is delighted to accept your invitation to be a co-sponsor of this strategy. Together we can ensure more people get the health services that they need for NCDs and for all their health needs.”

The launch event included Dr Tore Godal, as a guest of honor, celebrating Godal’s lifelong service to global health on behalf of the Norwegian government and the global community.

Godal, a special advisory on global health at the Norwegian Ministry of Foreign Affairs, compared today’s NCDs challenge to the battle against tobacco, which mobilized the global health community several decades ago and is still ongoing today. Like the fight against tobacco, we need a multi-pronged strategy including legal action, awareness and taxation to achieve meaningful progress,” he said.

 

A video describing the challenge of NCDs in low income countries here:

Image Credits: Twitter: @NorwayMFA, Stine Loe Jenssen, E Fletcher/HP-Watch, Twitter: @NorwayMFA.

Lelio Marmora is stepping down as Executive Director of Unitaid in March 2020, sources told Health Policy Watch. Marmora, who has led the organization since 2014, told staff on Monday that he would be leaving to seek “new challenges.”

His departure is not likely to bring “unexpected or drastic changes” to Unitaid’s funding priorities over the next few months, Unitaid Board Member for NGOs Fifa Rahman told Health Policy Watch. The organization has already set its strategy for the next two years, and has identified an acting ED committed to the same goals.

Rahman confirmed that Philippe Duneton, current deputy executive director of Unitaid, will step in as interim Executive Director. Duneton has been with the organization since its founding in 2006, and has taken on this role at least once before.

Lelio Marmora

Still, it will be important for Unitaid to find a new ED who understands the “unique role [of the organization] in funding change in how medicines are developed and made accessible for people,” Ellen ‘t Hoen, director of Medicines Law & Policy, told Health Policy Watch.

The director of Medicine Law & Policy, which provides legal and policy analysis on issues related to access to medicines and international law, further added that Unitaid is the only funder that explicitly focuses on thorny issues such as intellectual property.

Additionally, according to observers, Marmora did exert a strong influence over the organizational culture. While Marmora doubled the staff during his tenure, sources close to the organization told HPW that there was dissatisfaction among staff about the management style, and hopes that there would be some improvements.

Rahman told Health Policy Watch that the Board will be “monitoring risks” to ensure that any organizational change moves in a “positive direction.” She further added that the Board will be making a final decision on a new ED in 6-8 months.

The announcement was first made to Unitaid’s staff on Monday, and a second announcement was made by Marmora to the Board of Unitaid at the annual Board meeting on November 20-21. The announcement comes less than a month after Unitaid’s success in helping to negotiate a new deal with rifapentine drug manufacturer Sanofi to slash prices for the essential tuberculosis drug by up to 70% in 100 low- and middle-income countries. The volume-based deal between Unitaid, the Global Fund, and Sanofi was announced at the Union World Conference for Lung Health on October 31.

UNITAID’s Role in Global Health Financing

In its 13-year history, Unitaid has emerged as a major donor of upstream health product innovation and downstream access to medicines work in the “big 3” – HIV/AIDs, tuberculosis, and malaria. Among other projects, the organization funds access to medicines work around intellectual property and pharmaceutical innovation.

Notably, Unitaid does not have a United States representative on its board, which may be why the organization can fund work on controversial issues such as intellectual property and pharmaceutical development. Experts in access to medicines work further added that unlike the other, larger “big 3”-focused organization, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Unitaid is a much smaller and more nimble organization.

It has historically helped negotiate major deals to reduce antiretroviral drug prices and is currently the largest multilateral funder of tuberculosis research and development. Some of its major grantees include The South Centre, the Medicines for Malaria Venture (MMV), the Drugs for Neglected Diseases Initiative, the Stop TB Partnership, and the Foundation for Innovative Diagnostics (FIND). Unitaid also funds a significant portion of WHO’s Prequalification Programme, which provides international regulatory guidance on the safety and efficacy of new health products.

Initially formed by France, Brazil, Chile, the UK, and Norway at the height of the global HIV/AIDs crisis in 2006, Unitaid uses so-called “innovative financing” mechanisms to raise money for the “big three” – HIV/AIDs, tuberculosis, and malaria. As of 2019, the organization reports it has received some US$3 billion from donors, with 70% of its funding coming directly from a “solidarity levy” on airline tickets – a funding mechanism first piloted by France and since adopted by nine additional countries. Other member states earmark a portion of specific tax revenues for the organization, such as Norway, which contributes part of its carbon emissions tax revenue to Unitaid.

This article has been amended on November 23 to update Ellen ‘t Hoen’s name and title.

Image Credits: UN Photo/Rick Bajornas.

Over 80% of school-going adolescents worldwide get less than one hour of physical activity per day – leaving children at risk of poorer cardiorespiratory and muscular fitness, bone and metabolic health, and slower cognitive development than their more active peers. The new study published Friday in the Lancet Child & Adolescent Health journal also found that girls are more likely to be insufficiently active than boys, and the gender gap is only widening in most countries.

“Urgent policy action to increase physical activity is needed now, particularly to promote and retain girls’ participation in physical activity,” says study author Dr Regina Guthold of the WHO in a press release.

The first-ever such study to analyze global trends for adolescent physical activity, Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants, was a massive undertaking funded by the World Health Organization and conducted by researchers from WHO, Imperial College London, and the University of Western Australia. The extensive study evaluated data collected annually between 2001 to 2016 on some 1.6 million 11 to 17-year-old students across 146 countries.

In 2016, Bangladesh had the lowest levels of insufficient activity in both boys and girls at 63% and 69% respectively, which the authors attribute to a strong focus on national sports like cricket, or societal factors like traditional gender roles. In contrast, the Philippines had the highest level of insufficient activity in boys at 93%, and South Korea had the highest levels of insufficient activity in girls at 97%.

In a third of the countries surveyed, the fraction of girls meeting the one-hour guideline for daily physical activity was more than ten percentage points lower than the percentage of boys meeting the recommendations, with the United States and Ireland seeing the biggest gaps. Between 2001 – 2016, the gender gap widened in almost three-quarters of the countries surveyed.

Global Gender Gap In Physical Activity Widening

The study found some 15% of girls and 22% of boys maintain the minimum WHO-recommended level of daily activity, and in all but four countries, girls were less active in boys.

And the gap is widening. Globally, the proportion of boys being sufficiently active actually slightly increased from 20% to 22% between 2001 and 2016, but there was no global change in the proportion of girls getting the minimum amount of daily physical activity. The global trend is largely reflected at the country level as well, with some countries experiencing a huge increase in the proportion of boys getting enough physical activity, but little change in the proportion of girls getting enough daily exercise. Interestingly, the study found that the gender gap is growing more in high-income countries.

“The trend of girls being less active than boys is concerning,” said study co-author Leanne Riley, WHO. “More opportunities to meet the needs and interests of girls are needed to attract and sustain their participation in physical activity through adolescence and into adulthood.”

As a case study, the country with the starkest gender difference in physical activity levels is the United States, where approximately 36% of all boys but less than 20% of girls were sufficiently active in 2016. The authors posit that good physical education in schools, pervasive media coverage of sports and availability of sports clubs may have contributed to the increase in the proportion of boys exercising, but girls were not getting the same benefits.

To increase physical activity for young people, governments need to identify and address the many causes and inequities – social, economic, cultural, technological, and environmental – that can perpetuate the differences between boys and girls, the authors said.

Countering Insufficient Activity Among Adolescents

WHO recommends that adolescents do moderate or vigorous physical activity for at least an hour every day. However, the sobering results from the study show that few adolescents actually meet the daily minimum for all types of physical activity – including time spent in active play, recreation and sports, active domestic chores, walking and cycling, or other types of active transportation, physical education or planned exercise.

At current rates of change, the global target of a 15% relative reduction in insufficient physical activity by 2030 – a  goal set by all Member States at the 71st World Health Assembly – will not be achieved.

To improve levels of physical activity among adolescents, the study recommends that:

  • Known effective policies and programmes to increase physical activity in adolescents be scaled up, rather than scaled back.
  • Multisectoral action to create new opportunities for young people to be active, involving education, urban planning, road safety and others.

“Countries must develop or update their policies and allocate the necessary resources to increase physical activity,” said Dr Bull. She added that policy-makers should aim to increase all forms of physical activity through “physical education that develops physical literacy, more sports, active play and recreation opportunities,” as well as invest in providing “safe environments so young people can walk and cycle independently.”

But ultimately, she noted, comprehensive action requires engagement with multiple sectors and stakeholders, including schools, families, sport and recreation providers, urban planners, and city and community leaders.

Image Credits: WHO, Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants.

Incarcerated people suffer from poorer health outcomes and limited access to health care, which can impact them and their communities even after release. However, prisoners’ health is not being monitored well, and there is a lack of evidence to inform policy making to improve the health of prison populations.

These are the main findings of a new study, “Status report on prison health in the WHO European Region,” released Thursday by the World Health Organization European Regional Office. The study collated data from the 53 countries of the WHO European Region collected between 2016-2017 that was reported in WHO’s Health in Prisons European Database (HIPED), launched in January 2018. It notes that a variety of the 90 health indicators in HIPED, such as infectious disease prevalence in prisons, were underreported, and little or no data on the prison population was available for about a fourth of the countries in the Region.

“We only have data from 39 countries, but the data that we have indicate an enormous difference in the general health of people in prison compared to those in the outside world,” said Dr Carina Ferreira-Borges, programme manager for Alcohol and Illicit Drugs at WHO EURO, in a press release.

In the countries that did report, the study found that the overall mortality rate in prisons is 45 per 10,000 individuals, substantially higher than the general mortality rate in the population of 27 per 10,000 individuals, although the reasons for the contrast are unclear.

The report notes that over 1.5 million people are incarcerated in the region each year, and rates of recidivism can be high, causing individuals to shuttle back and forth between disjointed community and prison health systems. Additionally, for those who suffer from addiction or mental health disorders, the risk of suicide, self-harm and drug overdose is high in the early days of a person’s release.

“A prison sentence takes away a person’s liberty; it should not also take away their health and their right to health,” said Dr Bente Mikkelsen, director of the Division of Noncommunicable Diseases and Promoting Health through the Life-course at WHO EURO.

Outside of individual considerations, poor health access in prisons can impact the wider community once an incarcerated person is released; some prisons experience overcrowding, and infectious diseases can spread quickly in such settings, the report notes. The report found that resources for the prevention of infectious diseases are “not universally available” across European prison health systems, with some countries reporting such resources are entirely unavailable. A full vaccination course for hepatitis B is available in only 31% of the Member States in the study.

“A large proportion of people in prison return to the community every year, so viewing prison as a setting for public health opens an opportunity for public health actions and for improving health literacy to support and protect vulnerable populations,” said Mikkelsen.

According to the report, prisons can be seen as settings in which health interventions can address existing health conditions and contribute to positive lifestyles and behaviour changes. Time in prison can also be used to improve people’s skills to help them find a job after release and reintegrate into society.

“The prison population, with its disproportionate disease burden, is one that cannot be forgotten in WHO’s pursuit of the United Nations Sustainable Development Goals. To achieve universal health coverage and better health and well-being for all, as in WHO’s vision, it is vital that prisons are seen as a window of opportunity to change lifestyles and ensure that no one is left behind,” said Mikkelsen.

Limited Availability of Health Care, Health Promotion, and Health Data

The report notes that access to key health care or health-promoting services can be limited in prison settings:

  • Of the 37 countries with national data available, 97% reported that meal production of meals in prisons occurs in centralized kitchens, and 38% reported self-cook kitchens are available. Some 50% of countries reported fresh food is available in prison.
  • Of the member states reporting, 14% do not screen for severe mental health disorders on or close to reception, and 41% do not screen for harmful use of alcohol on reception.
  • Of the 36 countries that provided data on treatment for mental health and substance use disorders, 97% reported specialist mental health support is available. In 35 countries that reported on these indicators, opioid substitute therapy is available in 81% of 35 countries, and only 51% have guidelines on preventing post-release drug-related deaths.

However, the authors note that the limited availability of data makes it difficult to draw more specific conclusions about the health of prison populations. The report found that monitoring and surveillance systems for health in prisons are generally poor, and this affects the development of evidence-based policies that effectively target the needs of the prison population.

“Collecting this data is essential to enable the integration of prison health policies into the broader public health agenda benefiting the entire society,” said Ferreira-Borges.

Image Credits: Council of Europe.

Global leaders pledged US$2.6 billion to the global fight to eradicate polio at the Reaching the Last Mile (RLM) forum in Abu Dhabi on Tuesday, just one day ahead of World Children’s Day. The commitment fulfills part of the first phase of funding requested by the Global Polio Eradication Initiative to finance their 2019 – 2023 Polio Endgame Strategy – leaving a gap of some US$670 million.

The pledging event comes on the heels of a major announcement last month that the world has eradicated two of the three wild poliovirus strains, leaving only wild poliovirus type 1 (WPV1) still in circulation. Additionally, Nigeria – the last country in Africa to have cases of wild polio – has not seen wild polio since 2016 and the entire WHO African region could be certified wild polio-free in 2020, leaving Pakistan and Afghanistan as the last two countries where wild polio still circulates.

A child receives an oral polio vaccine in India.

“From supporting one of the world’s largest health workforces, to reaching every last child with vaccines, the Global Polio Eradication Initiative is not only moving us closer to a polio-free world, it’s also building essential health infrastructure to address a range of other health needs,” said World Health Organization Director-General and Chair of the Polio Oversight Board Dr Tedros Adhanom Ghebreyesus in a press release.

The commitments are critical to continue the momentum of the decades-long polio eradication effort. Barriers to reaching every child – including inconsistent campaign quality, insecurity, conflict, massive mobile populations, and, in some instances, parental refusal to the vaccine – have led to ongoing transmission of the last wild poliovirus strain in Pakistan and Afghanistan. Furthermore, gaps in vaccination coverage in parts of Africa and Asia have resulted in unimmunized children have sparked outbreaks of a rare, vaccine-derived form of the virus.

Pledges came from a variety of donors, such as the host of the pledging moment, His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi, who pledged US$160 million. Commitments also came from classic bilateral donors and the last key countries of the polio campaign, including US $215.92 million from the United States, US$160 million from the Islamic Republic of Pakistan, US$105.05 million from Germany, US$84.17 million from the Federal Government of Nigeria, and US$10.83 million from Norway.

Other pledges came from philanthropic organizations and the private sector, such as a $US 1.08 billion commitment from the Bill and Melinda Gates Foundation, US$150 million from Rotary International, and US$50 million from Bloomberg Philanthropies.

The pledges will not just go towards fighting polio, they will also help fund resources and infrastructure built by the GPEI that can support other health needs. In addition to delivering polio vaccines, polio workers deliver Vitamin A supplements, provide other vaccines like those for measles and yellow fever, counsel new mothers on breastfeeding, and help strengthen disease surveillance systems to anticipate and respond to outbreaks.

Image Credits: Jean-Marc Giboux/Rotary International.

Efforts to eliminate river blindness, a debilitating parasitic disease that causes vision loss in 1.15 million people, may be threatened by another infection known as African eye worm, according to a modelling study published in Clinical Infectious Diseases. While the World Health Organization has set a target to eliminate river blindness in most African countries in the next five years, the study predicts that 4 million people living in areas with African eye worm will still be at risk of the blinding disease in 2025, threatening almost four decades of elimination efforts.

The study, co-authored by researchers from Erasmus MC, University Medical Center Rotterdam in the Netherlands, and the Drugs for Neglected Diseases Initiative, also predicts that 90% of these people will live in areas currently not covered by treatment programmes for river blindness.

A villager’s eyes are being examined for African eye worm by Dr Philippe Urwotho, a medical doctor and Provincial Coordinator of the DRC’s Neglected Tropical Disease National Programme.

Elimination of river blindness, also known as onchocerciasis, is mainly reliant on a strategy of “mass drug administration,” whereby entire communities living in endemic areas are given a safe and effective drug called ivermectin regularly in order to prevent the parasitic disease from progressing or spreading. Ivermectin only targets the juvenile worms that can cause blindness or severe chronic skin itching, so mass drug administration needs to be repeated for the full life span of the adult parasite – 10 to 12 years – to fully eliminate the parasite from a community.

The problem arises when communities live in areas with both the river blindness parasite and the African eye worm, or Loa loa – people who have a high number of Loa loa larvae in their blood are at risk of life-threatening complications if they receive ivermectin. As a result, ivermectin cannot be safely used in mass drug administration campaigns in areas co-endemic for both diseases, and river blindness treatment programmes in these areas have not started.

“The current approach to preventing river blindness based on mass drug administration of ivermectin has been extraordinarily successful,’ says Sabine Specht, Head of Filarial Clinical Programme at DNDi, in a press release. “But alternative treatment strategies will be needed if we want to eliminate the disease, including the development of entirely new tools that offer a rapid and safe cure for river blindness.”

The authors predict that in 2025, there will still be at least 31,000 individuals infected with onchocerciasis and unable to use ivermectin, due to the high load of  Loa loa worms in their bloodstream – as the current treatment regimens for co-infected people are not well adapted for use in the field. According to the study, there are also currently no safe medications that can be used to kill adult forms of the worms that cause river blindness. The authors highlight that the lack of existing field-friendly treatments and diagnostics for both diseases merit further R&D for both diseases.

River blindness is transmitted by the bite of infected blackflies, which live near fast-moving rivers. The disease can progress to severe itching, skin lesions, and eventual blindness. Before large-scale control campaigns began in the mid-1970s, whole villages would eventually go blind from the disease. In 2017, it was estimated that 14.6 million people infected with onchocerciasis had severe chronic itching and skin disease, and 1.15 million had vision loss.

African eye worm, or Loa loa, gets its name from its most infamous tell-tale sign: the visible passing of the Loa loa worm through the eye. While previously thought to be rather mild, recent studies show that Loa loa infection can cause severe illness such as cardiac fibrosis, encephalopathy, and neurological or psychiatric disorders.

Image Credits: DNDi.