Systems-Based Healthcare in Lwala

By Chinonso Opara

Being a Nigerian-born American, I have grown to understand that the benefit of living and working in a first world country is not necessarily lifestyle and “Western amenities”. Nor is it the people or culture. I have come to see that the benefit of living in the United States or any other developed country is the relatively available access to healthcare. You can almost bet that when a medical emergency knocks at your door, there will be services to help meet your newly acquired needs. Through a partnership between Vanderbilt and Lwala Community Alliance (Lwala), I was immersed in the Kenyan healthcare system and was able to draw comparisons between Kenyan healthcare and that in the US. I was placed at Lwala’s hospital and observed care provided in this semi-private facility as well as the care provided through government hospitals in the area. I realized more and more that Kenya, and Africa in general, are relatively young countries – only being about half-a-century old. I realized that while Kenya still has a long way to go, it has come far and has potential to grow even more in terms of improving access to adequate healthcare. I had the opportunity to be exposed to the National Health Insurance Fund. I also had the privilege of contributing to the improvement of the KenyaEMR (electronic medical record) system at Lwala, which was originally designed for the care of HIV patients.

One dismaying thing I saw about healthcare in Kenya is that it is based too much on one’s ability to pay. If you come to the emergency room with a medical emergency, such as acute appendicitis, some hospitals will require you to pay first before they touch you, even though your life is in grave danger. While Lwala provides subsidized and free care, patients that are referred to other facilities for acute conditions face cost barriers. At least in the United States, the ER will see you, even though they’ll hand you a hefty bill later.

One particular patient I remember was a young adult with a past medical history of Hepatitis B, undergoing treatment with tenofovir and lamivudine, and who developed cirrhosis of unspecified etiology complicated by a large hepatic mass seen on ultrasound. He had no other known risk factors: no hepatitis C, no smoking, no drinking, one sexual encounter 5 months prior with a condom, no known family history of abdominal disease. The next step in the workup was to refer the patient to another facility for a CT scan, which will cost his family 7 to 9 thousand shillings ($70-$90). This is a hefty price! Especially considering the median income in Kenya is a little above KSh6000/month ($60), and in village life, it is likely much less than this. They will need help from family and good friends in order to come up with the money.

On another day, we had a patient come in with bowel obstruction. She had initially been diagnosed with bowel obstruction secondary to colon cancer in one of the main government referral hospitals. However, her family could not come up with the necessary funds for further workup and therefore took her home. At home her cancer metastasized systemically and she deteriorated. She was brought by her family to Lwala. However, because she required specified diagnostic tests that Lwala’s hospital does not have, we had to tell the family that we could not do much for her. This is another example of how a family’s limited immediate financial resources hinders even the workup of a life-altering disease.

However, we had another patient during rounds who was HIV-positive with nevirapine-induced dermatitis and hepatitis, requiring further workup, including LFTs, and kidney function tests. The difference here is she had health insurance through the National Hospital Insurance Fund in Kenya, and she could therefore afford the further workup of her condition.

The National Hospital Insurance Fund, established in Kenya in 1966, was designed to make access to adequate healthcare more feasible for families, similar to health insurance companies in the US. It is the oldest such insurance scheme in Africa and the pride of the Ministry of Health. It requires a minimum income of KSh1000/month just to enroll and the individual contribution is based on one’s monthly salary. For instance, the following income brackets of KSh1000 – KSh5999 and KSh6000 – KSh7900 must contribute KSh150/month and KSh300/month, respectively. And anyone who is self-employed must contribute KSh500/month. Considering the median Kenyan income of around KSh6000 this is expensive for the most vulnerable Kenyans.

Because of the very vulnerable population Lwala serves, very few patients are enrolled in NHIF.

In fact, in my whole time in Lwala, I only saw one person who had NHIF and that was the patient described above. Even one of the clinical officers, in his whole time in Lwala has only seen three patients with NHIF in Lwala

Lwala provides free services to pregnant mothers, children under 5 and people living with HIV as well as subsidized services to the general population. However, patients needing specialized care above the services provided at Lwala, must navigate the public system.

Lwala is in the process of registering for NHIF and aims to be a full participant in the program in 2017. Once registered, Lwala will begin an ambitious campaign to enroll its population into the insurance scheme. This will mean increased sustainability of the hospital as it receives reimbursement for the free care it provides as well as fuller coverage for patients when they are referred for higher levels of care.

My hope is that the NHIF expands in Kenya to increase coverage for and access to healthcare, but that it does so in a way that retains quality, as is the hope for any health insurance program.

Highlighting VUMC Research on TB/HIV Co-infection

Tuberculosis (TB) is the leading cause of death among people living with HIV. In 2015, there were 1.2 million people living with HIV estimated to have fallen ill with TB, and 390,000 people who died from HIV-associated TB. To control TB in high HIV-prevalence settings, it is imperative to coordinate efforts for TB and HIV control. Vanderbilt collaborates with international organizations and performs studies in population-based cohorts to identify ways to reduce the burden of TB among persons living with HIV.


William Wester, M.D., M.P.H. leads a large CDC-PEPFAR-funded initiative in Mozambique entitled, “Avante Zambézia” (“Go forward” Zambézia province) where the Vanderbilt University Medical Center (VUMC)/Friends in Global Health (FGH) team provides technical assistance supporting the scale-up of comprehensive HIV and TB services, including the provision of antiretroviral therapy (ART). Currently beginning year 5 of their initial 5-year cooperative agreement plus beginning year 1 of 5 of a new grant award, the VUMC/FGH team is making great strides in the area of service expansion, as they now support ART services in 112 health facilities across 14 out of 23 districts within Zambézia province; with plans to expand into a 15th district, namely the province’s most populous district (Quelimane) beginning in January 2017.  During the recently completed year 4 of the initial grant award (9/30/15-9/20/16), 5,224 new TB patients registered in the program and 92% of eligible HIV/TB co-infected persons initiated ART. During this current funding year, the VU/FGH team plans to specifically focus on improving the timeliness of TB diagnosis via the wide-scale implementation of the Gene Xpert diagnostic test, as well as improve TB infection control via site refurbishment to improve patient flow and air flow/ventilation.



April Pettit, M.D., M.P.H. studies the epidemiology and outcomes of those co-infected with TB and HIV via datasets from large HIV cohort collaborations. Results of an International Epidemiologic Databases to Evaluate AIDS (IeDEA) study examining mortality due to non-AIDS defining events in HIV patients on ART were presented at the International Workshop on HIV Observational Databases (IWHOD) in March 2015. Another IeDEA study led by Pediatric Infectious Diseases Fellow James Carlucci, M.D., looked at TB treatment outcomes in HIV/TB co-infected children in resource limited settings, results were presented at CROI in February 2016. Additionally, Dr. Pettit is involved in clinical studies of TB infection and disease via the Tuberculosis Epidemiologic Studies Consortium and the Tuberculosis Trials Consortium, funded by the Centers for Disease Control and Prevention.


The Caribbean, Central, and South America Network (CCASAnet) for HIV epidemiology, a network of IeDEA and led by Catherine McGowan, M.D., collects and synthesizes data through the Vanderbilt Data Coordinating Center (VDCC). CCASAnet has created a shared repository of HIV patient data that has been merged from 10 sites throughout Latin America. This dataset has allowed high-quality analyses of HIV and TB. The most recent project is evaluating TB treatment intermittency in the continuation phase and associated mortality; preliminary results will be presented at CROI in February 2017.


A newly funded NIH R01 project led by Timothy Sterling, M.D. aims to optimize the treatment of HIV-related TB in a large, genetically diverse cohort in Brazil. Treatment of TB/HIV is complicated by drug-drug interactions and increased drug toxicity risk. The current guidelines recommend a standard 6-month based regimen regardless of HIV status, but recent studies suggest that TB failure and relapse is increased in HIV-infected persons. Pharmacogenomic predictors of TB failure and relapse could help optimize treatment. This project builds on the previously established Regional Prospective Observational Research on TB (RePORT)-Brazil cohort which is enrolling patients from 5 sites in Rio de Janeiro, Salvador and Manaus.


The Vanderbilt Tuberculosis Center (VTC) is a focal point for collaborative efforts in TB research that contribute to a reduction in the burden of TB/HIV globally, including Tennessee and Nashville. The VTC also provides technical assistance to local and global service programs engaged in TB control including the Metro Nashville Public Health Department and the Tennessee Department of Health.

Costa Rica: Renewable Energy’s Success Story

By Derek Brody

Costa Rica is a Central American nation known primarily for its lush rainforests and booming tourism industry, but this year it is attempting to make another claim to notoriety as the first country to last an entire year running on only green energy.

The country has become a pioneer in renewable energy, and has spent the last 5 months subsisting solely on green energy sources, rather than fossil fuel. Twenty fifteen was a landmark year in the push for green energy in Costa Rica, as the country spent 285 days powered entirely by renewable energy sources according to the Costa Rican Electricity Institute, also referred to as ICE. The country has not been powered by fossil fuels since June 17 of this year, meaning they are almost halfway to their goal of an entire 12-month cycle. In fact, ICE announced in April that they “now consider fossil fuels a backup energy generation source.”

In the place of fossil fuels, Costa Rica uses a mixture of hydro, wind, geothermal, and solar energy. Hydropower provides the majority of their energy, greater than 80%, with geothermal plants providing 12.6%, wind turbines providing 7.1%, and solar energy providing 0.01%. The country has been able to utilize its climate and terrain, using its large river system and heavy tropical rainfalls to create large amounts of hydropower. The nation has been lucky in 2016 because of the heavy rainfalls near the country’s four hydroelectric power facilities. Carlos Manuel Obregon, the executive president of ICE, noted that Costa Rica will soon turn on its Reventazon hydroelectric project, which is massive in size and scope. According to the Tico Times, the dam’s five turbines will have a generating capacity of 305.5 megawatts, or enough power for an estimated 525,000 homes.

Costa Rica is also not alone in its quest to reduce dependence on fossil fuels, and a number of European countries have been reasonably successful in their attempts to make greater use of green energy sources. Sweden, for example, draws approximately half of its power from renewable sources, as Prime Minister Stefan Lofven announced that the country will work toward becoming the “first fossil fuel-free” nation in the world in a speech to the UN General Assembly earlier this year. In September, his government announced it would allocate 4.5 billion kronor (approximately $521 million) to green infrastructure, funding projects like the production of more solar panels, wind turbines, and a cleaner public transport and energy grid.

Denmark has also made major steps toward reducing dependence on fossil fuels, and currently ranks as the world leader in energy sourced from wind. In fact, nearly 40 percent of the nation’s electricity came from its wind turbines in 2014. Even Portugal, a nation not well-known for its commitment to renewable energy, ran for 107 straight days without using any fossil fuel-based sources earlier this year.

That is not to say, however, that Costa Rica’s success comes without challenges and obstacles. In fact, it can be argued that their overwhelming reliance on hydropower is actually harmful to the environment, according to Gary Wockner of “Save the Colorado.” In August, Wockner warned against the dangers of hydropower when he said, “Hydropower has been called a ‘methane factory’ and ‘methane bomb’ that is just beginning to rear its ugly head as a major source of greenhouse gas emissions that have so-far been unaccounted for in climate change discussions and analysis.” Additionally, rainfall can be fickle at times and long periods of drought result in countries having to resort back to the use of fossil fuels.

It is also incorrect to assume that Costa Rica’s success is easily transferrable to other countries. The country has only 4.9 million inhabitants, and the Economic Commission for Latin America and the Caribbean estimated they used about 10,713 gigawatt-hours of electricity in 2015. In contrast, the United States generated about 373 times more electricity in 2015, with roughly 4 million gigawatt-hours of total generation.

Recent actions taken by the United States, however, suggest that the U.S. is not as committed to green energy as it could be. In mid-August, the state of Wyoming declared that the state itself owns the wind. This measure, passed by the state legislature, allows the state to increase taxes on energy produced by wind turbines from $1 per megawatt hour to $12 per megawatt hour. This legislation has been criticized for its deleterious effects. Matt Agorist of the Free Thought Process noted that, “This move by the state is not in the interest of the people, nor it is even in the interest of raising funds for the government. In the four years that it’s been law, the state has only raised $15 million from taxing the wind. This move is purely retaliatory and meant to stifle new businesses who threaten the dinosaur coal and fossil fuel industry’s grip on energy production.”

Nevada also passed legislation designed to suppress green energy production, hiking its tax on solar power by 40 percent in January of this year. To make matters worse, the tax increase was applied retroactively, effectively squashing investments in the growing solar industry. Former SolarCity CEO Lyndon Rive expressed his displeasure at the increase, saying, “It will destroy the rooftop solar industry in one of the states with the most sunshine. There is so much wrong with the decision. The one beneficiary of this decision would be NV Energy, whose monopoly will have been protected.”

Despite the challenges put forth by certain state legislatures, the planet as a whole has made large strides away from dependence on fossil fuels and toward a more sustainable future. Leading the charge, perhaps unexpectedly, is a tiny Central American country who may just make history this year.

Castro’s Complicated Legacy

By Victoria Herring

On November 25th, two cities just 90 miles away from each other experienced a radically different array of emotions. In Havana, the streets were silent; some people wept and others retreated into their dark houses. In Miami, shouts erupted from the Cuban community and people paraded through the streets with banners and music, waving both Cuba and American flags in jubilation. Cuba had just announced the death of Fidel Castro, aged 90. The country established a nine-day period of mourning for the deceased leader and shut down concerts, nightclubs, and public performances. University students at the school where Fidel himself had studied law seventy years earlier laid flowers and photos at his monument. His death has brought up many different sentiments, as 51 year old Graciela Martinez, whose father fought in the revolution and whose relatives escaped to the US, said: “For those who loved him, he was the greatest…for those who hated him, there was no one worse.”

Many in the “free world,” as capitalist and democratic countries call themselves, have trouble understanding why those in Cuba are saddened by Castro’s death. However, those Cubans were raised under Castro’s leadership and grew to respect and revere him. He inspired the zeal of the revolution and created important health care and education reforms on the island. As a young Cuban woman stated, “The Cuban people are feeling sad because of the loss of our commander in chief Fidel Castro Ruz, and we wish him, wherever he is, that he is blessed, and us Cubans love him.” As a people, Cubans are proud of their country, for they are a vibrant and adaptable people with an uncanny openness and a strong sense of community. Undoubtedly, all Cubans are in the process of reconciling many feelings, as Castro was the catalyst for many who escaped the country, the communist structure of Cuba, and the indefinite split among many families, many who never saw their loved ones again after leaving Cuba. A quote from another Cuban living in Miami expresses yet another powerful emotion, one of hope and of the disillusionment Castro later incited, “It’s a moment that we’ve been waiting for 55 years. We’re free at last. The man that caused so much suffering, so much people to be sad in my country … has passed away.”

It will be difficult to assess if there are similar sentiments on the island, as social media and wireless access is significantly restricted and all of the news available to outsiders comes from Cuban government sources, as the country has the most restrictive laws on freedom of the press in the Americas. According to citizens of the country who escaped to the U.S., Castro’s death means the end of an era. Raul Castro, Fidel’s brother who has governed Cuba for the past eight years, is 85 years old. There is no other individual officially lined up to take over power, leading many to believe that the time has come for a new Cuban generation. While it is uncertain as to whether the world will see a democratic uprising or another Castro hardliner, the future of Cuba will be the subject of many political debates in the coming months.

Castro was much more than the chief commander of the Cuban revolution; he was and will continue to be a legendary figure, romantic inspiration, and even remarkable survivor – authorities report there were six hundred attempts on his life. He lived to see a historical reestablishment of diplomacy between Cuba and the United States under the Obama administration; many Americans who remember the failed Bay of Pigs invasion and the Cuban Missile Crisis – where Russia, Cuba, and the United States narrowly avoided nuclear war – regarded the island nation as a threat to democracy. Geopolitics required that the U.S. exercise great caution with its close neighbor, and Castro fiercely defied the United States and its embargo on his small and financially struggling country as relations frayed in the 1960s. Over the decades, the embargo proved to be counterproductive: Cubans began blaming the United States for their economic hardships and Latin American countries criticized the U.S. for isolating the island. At the memorial for Nelson Mandela’s death in 2013, Obama and Raul shook hands. The international community pondered whether this symbolic greeting had any meaning for the two nations, it was heralded as “the second handshake between leaders of the two countries in the past half-century.” The action proved to be indicative of change, for Obama became the first U.S. president in 88 years to touch down on the island and meet with leaders. Soon thereafter, relations began to normalize, and certain travel and financial restrictions were weakened; just last week, Southwest and United Airlines announced regular commercial flights to Havana. Congress continues to disagree with the president, however, and debate concerning the lifting of the embargo continues.

In order to gain an idea of what the future of Cuba looks like, one must understand how Fidel has influenced Raul’s leadership in the country for the past eight years. Political analysts speculate as to whether the younger brother held back social and economic reforms for fear of opposition by Fidel; the original commander of the revolution had reportedly kept the Communist Party from carrying out major reforms at the party’s conference just last year. Yet, as he retreated from the public eye due to serious illness, Raul countered the three principles of “Fidelism” – paternalism, idealism, and egalitarianism – with new reforms. He replaced his brother’s established military leaders with his own trusted ones, opened a minuscule space for small businesses, introduced performance-based salary increments and reduced state welfare distribution. After these small measures, Enrique López Oliva, a retired church historian in Cuba, expects an accelerated rate of change with the death of Fidel.

In the timeline of U.S.-Cuban relations, a wild card emerges: the election of Donald Trump to the presidency. He has spoken of reinstating economic sanctions on Cuba if he does not obtain more concessions from its government, calling Castro a “brutal dictator.” and thus opposing Obama’s words of reconciliation after the death of Fidel: “(we pursue) a future in which the relationship between our two countries is defined not by our differences but by the many things that we share as neighbors and friends.” The collapse of Cuba’s longtime ally, the Soviet Union, along with the removal of financial assistance from ailing Venezuela, has created an uncertain stage with a speculating audience. As the next few months unfold, the world will watch with tremendous interest.

Health counselors: A key element in the fight against HIV

By Friends in Global Health

Under the intense sun in the district of Mocubela, in Zambézia Province, Ilda Pedro receives Bethe Gabriel into her home. They kiss each other’s cheeks and smile at each other. Ilda is an HIV positive patient, and Bethe is her health counselor. Over time, their relationship has grown substantially, moving from one between provider and patient to a deep and enduring friendship. At the time of the visit, Ilda was at home with her youngest son, still an infant. Two other children were at school, and her third was at her grandmother’s house.

Ilda sorted and cleaned the beans she would prepare for dinner. “I grew these beans myself. We are great farmers.” said Ilda, proud of her work.

She confessed that her husband was battling for his survival in a remote village. When it was time to talk about her children, Ilda became more hopeful. “My sons are healthy. It was the first one who went through a lot of complications. But he’s fine now. I don’t know yet what they want to be (when they grow up), but I would like for them all to study so that one day they can take care of me,” said the mother of four children.

This climate of health and hope has not always been present in this family. “My eldest son was always sick. I would take him to the traditional healers, but he would always have relapses. When I got pregnant with my third daughter back in 2014, I was advised to take an HIV test. My result came back positive. It was at that time I was advised to have my eldest son tested for HIV. His result was also positive,” Ilda told us.

From that day onwards she started to look out for the family’s health. Today they all know their HIV status. Only Ilda, her husband, and her eldest son have HIV. They are all on combination antiretroviral treatment. The youngest has already had his first child-at-risk (CCR) clinic consultation and his HIV test result was negative.

According to Beto Omar, the FGH clinician at Mocubela, “HIV treatment markedly reduces the probability that pregnant mom’s will transmit HIV to their newborn children.”

Ilda is grateful for the “miracle” performed by the local health unit supported by FGH. “I did not think my son would be alive today. Even his hair color had changed; it used to be brownish. Today he plays and goes to school. He’s the one that asks for his medication when the time comes to take it.”

According to Bethe, Ilda’s health counselor, Ilda was reluctant to initiate antiretroviral treatment early on. She tells us “Just like the majority of people, she (Ilda) did not accept the (HIV test) results. She had to go through a couple of counseling sessions before she could accept the reality. To be successful, we the counselors need to show that we are interested in seeing the patient get healthy.”

Ilda Pedro and Bethe Gabriel, health counselor, at a counseling session.
Ilda Pedro and Bethe Gabriel, health counselor, at a counseling session.

Mauro Timana, Chefe Médico at Mocubela, emphasizes the role of health counselors in the fight against HIV. “The health counselor is the key member of the team. They are the true pillar. It is with the health counselor that patients have their first contact, on which everything else depends.” He adds that “If the health counselor’s work is not done well, all the rest is jeopardized.” Timana says Ilda and her family are monitored by their health counselor and thanks to this follow-up, the entire family is healthy and is thriving.

Ilda finishes our conversation by expressing her angst for those women that are reluctant to be treated (for HIV). “I feel (sad) for them. Before ARVs, a lot of people would lose their children. Even adults would lose their life. But this treatment is very good.”

Health counselors are stationed in key sectors within the health facilities: antenatal care, child-at-risk clinics, HIV counseling and testing, healthy child services, provider-initiated counseling and testing areas, and psychosocial support services unit, in order to receive and welcome patients and to facilitate the health facility’s workflow.

During the antenatal consultation, aside from HIV counseling and testing, the health counselors screen for STIs, TB, hypertension and diabetes. There, they also invite male partners to benefit from the same health counseling, and to receive key positive prevention messages covering sexual behavior, correct and consistent use of condoms, treatment for STIs, prevention of mother-to-child-transmission (PMTCT) of HIV, family planning, disclosing HIV+ status to a partner, adherence to treatment, risk reduction counseling (focused on the dangers of alcohol and drug use), as well as referrals to community support groups.

Ilda is one of many mothers that has benefited significantly from the services provided by the health counselors in the 14 FGH-supported districts within the Zambézia Province as of September 2016. The health counselors support is part of the U.S. government’s President’s Emergency Plan for AIDS Relief (PEPFAR) funded Avante Zambézia project through the Centers for Disease Control and Prevention (CDC). FGH is affiliated with Vanderbilt University Medical Center and provides support to Zambézia’s Provincial Health Directorate for the implementation of HIV health related services. This partnership has made it possible for FGH to have trained health counselors working in all 14 FGH-supported districts; an essential cadre of health professionals in the fight against HIV.


Friends in Global Health (FGH) is an affiliate organization of Vanderbilt University Medical Center currently operating in rural Mozambique. Working in partnership with local government and civil sector organizations, FGH aims to implement health development programs using sustainable strategies with the long-term goal of improving community well-being.)

Dr. Sten Vermund Letter for World AIDS Day

To acknowledge World AIDS Day, December 1, 2016, the Vanderbilt Institute for Global Health wishes to acknowledge the 78 million [UNAIDS estimated range of 69.5 million–87.6 million] people who have become infected with HIV through the end of 2015, reminiscing as to 35 million [29.6 million–40.8 million] people who have died from AIDS-related illnesses in this same time span. Personally, I have lost many patients, school and work colleagues, and close friends to this infection, and I remember them on this day with sadness, but with hope for the future.

Perhaps only pandemic influenza has come close in history to the devastating global impact of HIV/AIDS. HIV infection is mediated by human behavior; persons infected with HIV suffer considerable stigma and discrimination in most venues, and are in need of huge health resources to stay healthy and to reduce infectiousness to others. Happily, the global community, particularly the United States, has made major strides in funding a substantive programmatic response to the HIV pandemic. AIDS-related deaths have fallen by 45% since the peak in 2005, a direct result of these investments through PEPFAR, the Global Fund, and other activist initiatives. For example, in 2015, 1.1 million [UNAIDS estimated range 940 000–1.3 million] people died from AIDS-related causes worldwide, compared to 2 million [1.7 million–2.3 million] in 2005.

In the UNAIDS 2016 fact sheet, 2015 estimates suggest that US$19 billion were invested in the HIV response in low- and middle- income countries (LMICs) with 57% of this total coming from domestic budgets. Even as incidence has declined, prevalence has risen with more persons living with HIV. Hence, UNAIDS projects that US$26.2 billion will be required in 2020 and US$23.9 billion required in 2030. It seems improbable that the current funding climate in the US, UK, and other donor nations will commit to higher sums, but the need will exist nonetheless.

Hence, we need prevention NOW to turn off the flow of new cases into the overflowing clinical settings offering antiretroviral therapy. We also need efficiencies, respectful clinical care, and quality improvements in our clinical care settings. Discovery in the vaccine, cure, and diagnostic arenas can offer more tools for the future. Implementation science is essential for interventions that work, but are not adequately deployed, from male circumcision to the “continuum of HIV care.” We must not succumb to “AIDS fatigue” any more than experts in disease control and prevention of malaria, tuberculosis, cancer, or a myriad of historical or emerging infectious threats can afford to declare premature victory.

This World AIDS Day 2016, let us think how we can merge synergistic agendas, getting away from “siloed,” single disease responses. Can our HIV infrastructures in rural Africa be deployed more effectively to meet community needs in control of TB, parasitic diseases, or other chronic diseases? Might such deployment bring stronger government and local community support? Can the drumbeat announcing the ascendancy of non-communicable diseases in LMICs be combined with reality-based awareness that existing infectious disease threats remain? The temptation to continue business-as-usual in our vertical disease control campaigns invites inefficiencies and competition between legitimate health needs; we can integrate for efficiency to make a maximum footprint on health of LMICs. New political leadership around the globe may not have the historical perspective on the HIV pandemic; we must remind them.



Sten H. Vermund, MD, PhD
Vice President for Global Health
Director, Vanderbilt Institute for Global Health
Amos Christie Chair of Global Health
Professor of Pediatrics, Medicine, Preventive Medicine, Obstetrics and Gynecology