Tropical Health Matters

The Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria has made its 2008 awards to some of the world’s largest corporations. “The HIV/AIDS winners include Viacom (leadership); Standard Bank (workplace); Telkom, (testing and counseling); Intesa Sanpaolo (community philanthropy); BBC World Service Trust (core competence); Xstrata Coal South Africa (community initiative); Johnson & Johnson (women & girls). BD (Becton, Dickinson and Company) receives the tuberculosis award and Exxon Mobil Corporation receives the malaria award.” DHL and Novartis have also received commendations for their malaria work. According to the Kaiser Network, “The coalition is a group of 220 companies worldwide that aim to address HIV, TB and malaria in the workplace.”

In its press release GBC President and CEO emphasized that, “‘The prospects for winning the fight against global epidemics are stronger now than ever before, and these nine companies have shown the world what is possible for business to achieve. Business action is making a critical difference. If we get it right – and our partners are depending on us to do just that – business has the power to reach millions of people in a way that no other organization can. It possesses the skills, resources and influence to achieve otherwise inconceivable outcomes. We need many, many more to make their own contribution.” Contributions range from worker health promotion, to community programs to advocacy efforts to stimulate policy and funding of disease control programs.

Ironically, at about the same time, the biggest coordinated source of finance for the three diseases has decried funding gaps on the horizon. Reuters reported that, “The Global Fund to Fight AIDS, Tuberculosis and Malaria requires another $7 billion to $8 billion to reach its funding goals for 2008, the fund’s executive director, Michel Kazatchkine, said on Monday. ‘The estimated gap, again, this year is around $7 to $8 billion. It is going to increase to $10 to $12 billion in the next two to three years,’ Kazatchkine told reporters at a briefing.”

Governments remain the largest contributors to international efforts like the Global Fund. The business world, as evidenced by the GBC awards, offers hope through innovation and example, but the question remains, can the business community offer more with its “skills, resources and influence” to help close these huge funding gaps?

Two new articles stress the role of community volunteers, local alternative providers and household members in controlling malaria.

Ajayi and colleagues trained volunteer community medicine distributors (CMDs) to provide arthmether-lumefantrine (AL) in selected villages near Ibadan, Nigeria. They elarned that, “the use of AL at home and community level is feasible with adequate training of community medicine distributors and caregivers. Community members perceived AL to be effective thus fostering acceptability. The negative attitudes of the health workers and issue of incentives to CMDs need to be addressed for successful scaling-up of ACT use at community level.” Parents in these villages had not heard of AL before, but after one year of intervention they were happy with the results of using AL and with the performance of the CMDs. Challenges learned from this field experience included uncertainties of regula medicine supplies, continued supervision of the CMDs, CMD desires for incentives and negative attitudes of formal health workers.

Mbonye et al. have produced another in their series of articles concerning community distribution of intermittent preventive treatment for pregnant women (IPTp) in Uganda. This time they looked at cost and cost effectiveness of community distributors comparent to health facility based provision of IPTp. They had drawn on a variety of existing people to serve as distributors including traditional birth attendants, drug-shop vendors, community health workers and peer mobilizers. Although it cost slightly more to deliver IPTp in the community (due in part to one time training costs), the cost-effectiveness was greater because of reductions in severe anemia and fewer low birth weight babies. The challenges here are common with pilot or experimental programs – that of linking with the formal health system to guarantee ongoing supervision and support, but this can be built into future efforts.

More effort is needed to test the generalizability of these interventions, but the key message is that the community needs to be actively involved in malaria control efforts. Another key factor is that the health system (whether public, private or NGO) needs to ensure that malaria commodity procurement and supply systems reach the community in a sustained way.

McRobert and colleagues have published promising findings in PLoS Biology on enzymes needed for malaria parasites to produce gametocytes. They explain that, “Our data predict that in addition to targeting asexual erythrocytic stages, a drug inhibiting Plasmodium PKG could also block parasite transmission to the mosquito, a highly desirable property that would help limit the spread of any drug-resistant parasites. Transmission-blocking drugs would be a powerful tool for reducing the malaria burden in areas endemic for P. falciparum.”

David Baker, a co-author, noted in a press release from the London School of Hygiene and Tropical Medicine that, “The enzyme we have discovered, a protein kinasea, is essential for the development of malaria parasite gametes. Working with genetically modified parasites, in combination with inhibitors of this enzyme, we have demonstrated that it is feasible to block the sexual stage of the life cycle of the malaria parasite. This has exciting implications in terms of improving how we go about tackling malaria. If a drug can be developed that targets this stage of the life cycle, and combined with a curative drug, it would be an important new approach for controlling malaria transmission and the spread of drug resistance.

A 2-in-1 drug that not only treats the disease but prevents transmission would be a most valuable addition to the malaria arsenal. And while the time from drug discovery to a drug on the market may take years, it is important to keep the research pipeline flowing in order to keep ahead of drug resistance. For example, researchers are looking far and wide, and Prudhomme et al. suggest that a “source of marine natural products (may be) marine microorganisms.” Simultaneously it is also important to evaluate continually possible resistance of malaria parasites to existing drugs.

We cannot afford to rest on the laurels of ACTs or sit back in hopes of the perfect vaccine. Research funding for all aspects of malaria control must be boosted.

Tanzania has three main ITN distribution mechanisms, the commercial market, a voucher system for subsidized net purchases and free nets distributed during campaigns. Khatib and colleagues found that, “All three delivery strategies enabled a poor rural community to achieve net coverage high enough to yield both personal and community level protection for the entire population. Each of them reached their relevant target group and free nets only temporarily suppressed the net market, illustrating that in this setting that these are complementary rather than mutually exclusive approaches.”

Different distribution strategies reached different groups: vouchers and free nets were more likely to be obtained for young children, while nets purchased at market price were more likely to be obtained for adults. In the study district, “Net use was 62.7% overall, 87.2% amongst infants (0 to1 year), 81.8% amongst young children (>1 to 5 years).” This process appears to have enabled achievement of RBM 2010 targets as early as 2006. Technically since LLINs were not introduced until after the study and some of the ITNs had not been treated in more than six months, the coverage results are not a perfect match for the RBM target, but they do indicate that products can actually be put in place for a large portion of the population.

Another important aspect of the complementarity of the strategies was, “Provision of nets at no cost through the public sector did not compromise the viability of either the voucher scheme or the commercial market.”

While the authors explain that a number of strategies are available to the National Malaria Control Program, it does not appear that the NMCP actually sat down with partners to plan how to achieve coverage using a multi-strategy approach. The results in a way appear to be that of a ‘natural experiment,’ i.e. that it just so happens that three different approaches were in place at the same time in the same district.

We discussed the involvement of the private sector yesterday, and this Tanzanian example reinforces the points made. The challenge is getting partners to sit down together and ensure that coordination happens – that one district does not get only free net distribution while another depends solely on vouchers. Planning is needed to ensure that each strategy reaches its appropriate audience depending in part on service utilization patterns and ability to pay.

RBM has interviewed the UN Special Envoy for malaria, Raymond Chambers and asked, “What needs to happen now so that Roll Back Malaria targets can be reached by 2010?” He responded, “That gives us a thousand days. We have to get all of our people working in the fields in cooperation with the local ministries of health; we’ve got to work with the manufacturers of the commodities for things like bed nets and medication and get them to have a schedule of delivery; we’ve got to accelerate some of the funding so that we can meet the requirements of the manufacturers of the commodities; and we’ve got to get everybody to buy into one plan. We’ve also got to ensure that plan is most effectively implemented and executed.”

As we have reported, countries like Ghana, Mali and Nigeria have a ways to go to achieve the 2005 targets of 60% coverage with ITNs, IPTp and appropriate case management with ACTs, let alone reach 80% or more. While all three countries have received Global Fund Grants, they have concentrated in large part on the public sector for service provision, and although they thereby reach their GFATM targets, they have problems achieving overall coverage goals.

Mr. Chambers is right, every partner – public, private and non-governmental, as well as the community – must come on board if 2010 targets are to be achieved. Often there is a reluctance on the part of the public sector, who often monopolize GFATM and other donor support, to ignore or look down on the private sector, especially the informal private sector such as medicine sellers. In rescuing its GFATM Round 4 grant, Nigeria came to the realization that the private sector is crucial and for Phase 2 selected an additional Principal Recipient to focus on this neglected component of malaria control.

Scale up to reach 2010 will be a challenge when we have yet to reach 2005 goals. We might have a chance if all sectors are involved in the partnership.