By Kelly Curran. Dr. Moyo at Litsemba Letfu Men's Clinic, Swaziland.

Three clinical trials have shown that male circumcision (MC) reduces female to male HIV transmission by approximately 60%. Modeling suggests that scaling up MC to 80% coverage of men 15 to 49 over the next five years would avert over 4 million new HIV infections in 14 countries in southern and eastern Africa. That would require 29 million circumcisions. The shortage of skilled health professionals in high prevalence countries has posed a major challenge to achieving that goal.

The health professional shortage is both absolute and related to utilization.  WHO estimates that sub-Saharan Africa has 25% of the world’s disease burden, but only 3% of the world’s health workforce.  In addition, many health care workers in the region are unemployed and others are recently retired.

Jhpiego takes a multi-pronged approach to address this shortage, from improved clinical technique and better logistics to task sharing and task shifting.  In Kenya and Swaziland, Jhpiego-supported task shifting has had a great impact.  Jhpiego has helped train and empower nurses to perform MC procedures in an effort to intensify HIV prevention programs. With the involvement of nurses, Kenya was able to circumcise 268,000 men in just 2.5 years.  In Swaziland, a short term MC campaign supplemented the small nursing workforce with volunteer physicians from other countries.  Every volunteer takes an assessment and undergoes training to ensure standardization of critical skills.

By expanding the health workforce through task shifting, Jhpiego is improving locally-sustainable prevention efforts and strengthening the skills of nurses in Southern and East Africa.

There is an age old story about a man walking along a river who sees someone being pulled along by the current and calling for help.  As he reaches for a vine to toss to the person, he sees more people coming downstream.  As he continues to try to rescue those struggling in the river, he asks a friend to go upstream and see what he can do to prevent people from falling in.

Since voluntary medical male circumcision (MC) has been proven to reduce female to male HIV transmission by approximately 60% or more, the world of HIV prevention is driving major national level campaigns to deliver MC to adolescents and adults.  Studies show that this short term ‘downstream’ approach is essential to avert many future infections and reduce the overall prevalence of the disease.

However, in the long term, the attention will shift ‘up stream’ with programs in early infant male circumcision.  Jhpiego is preparing for that future now.  Dr. Tigistu Adamu, HIV/AIDS Technical Advisor for Jhpiego, helped produce the global learning resources package for early infant male circumcision with the World Health Organization (WHO).  The package includes dynamic audio-visual materials, inexpensive anatomic models, and training manuals for the trainer and participant.

Early infant male circumcision is cheaper, easier, and less risky than adolescent and adult MC.  Infant patients heal faster, have even lower rate of complications than the already low rate in adults, and avoid the adult risks associated with sexual activity before healing.  Programs for early infant male circumcision cost less because there is little need for post-procedure counseling, devices are more affordable and accessible, and programs can be integrated with existing maternal health services.

Tonight, Dr. Adamu will share more about this intervention as he joins four other impressive speakers from UNAIDS, WHO and the Kenyan Ministry of Health at a satellite session during the IAS conference in Rome.  (More at http://www.jhpiego.org/en/content/events.)

The Cutting Edge: What’s New in Male Circumcision?

Sunday 17 July 2011; 17:00-19:00; Mini Room 1

For more than 35 years, Jhpiego has pioneered innovative, low-cost, lifesaving solutions for today’s global health concerns, including the prevention of HIV/AIDS.  One of the most effective tools that exists today is voluntary medical male circumcision (VMMC).

Compelling evidence indicates that VMMC can reduce the risk of female-to-male transmission of HIV by approximately 60%.  VMMC provides a greater protective benefit than any potential vaccine studied to date. Modeling suggests that rapid scale up of VMMC to 80% of adult males in East and Southern Africa would avert more than 3 million new infections and save 416.5 billion in care and treatment costs by 2025. Further, there is evidence that female partners of circumcised men have lower rates of cervical cancer and certain sexually transmitted infections.

Join Jhpiego and its partners from WHO, UNAIDS and the Kenya Ministry of Health for conversation and refreshments. 

Speakers include:

Cate Hankins, UNAIDS; 2007-2011: State of the VMMC Scale-up

Tigistu Adamu, Jhpiego; Start at the Beginning: Early Infant Male Circumcision

Tim Farley, World Health Organization; Adult MC Device Update and WHO Approval Process for Medical Devices

Peter Cherutich, National AIDS and Sexually Transmitted Infections Control Programme (Kenya); 250,000 Circumcisions in 2.5 Years

Hally Mahler, Jhpiego; Matching Supply with Demand for VMMC

Maputo, Mozambique – The community health workers grab their signature blue backpacks, hoist them over their shoulders and head down the dirt roads of Mumemo. The things they carry will make a difference in the health of families in this southern African country that has one of the highest HIV prevalence rates on the continent.

Walking six to 10 miles a day, Rosalina Antonio Tamela carries 15 pounds of supplies and forms in her back pack, everything she needs to share information about prevalent health issues and to test a villager for HIV, provide counseling and a referral for treatment. She consults a color-coded map to find the day’s clients—green indicates homes of families where all members have been tested, yellow pinpoints homes where a few have been tested and red signals a refusal to test. But Tamela is not deterred by the number of red houses on her map. She lost her parents and all of her siblings to HIV/AIDS, and she doesn’t want anyone else to suffer. Volunteers like Tamela say, “We must test all—we must make sure that ALL who need services receive them.”

With help from Jhpiego, Mozambique has expanded community-based HIV counseling and testing services throughout the country, reaching provinces where people have limited access to essential health services and facilities. In a country of 20 million, less than 25 percent of adults are aware of their HIV status. Jhpiego worked with the Ministry of Health to develop a national HIV prevention and treatment plan with the goal of providing HIV counseling and testing services to all citizens and helping link them to health facilities. In 2007, Jhpiego developed a pilot program to use community volunteers to counsel and test Mozambicans in their homes and villages.

The pilot was so successful—its testing rate is less expensive and accurate—that it is being replicated through a collaboration with nonprofit organizations and other partners. Since the program began and expanded to 10 provinces, 441,134 Mozambicans have been counseled and tested for HIV, with 192,500 from October 2010 to March 2011, a considerable increase. That’s impressive progress in a country where 11.5 percent of adults and 13.5 percent of pregnant women are living with HIV.

In Mumemo, a Franciscan nun, Sr. Susana Custodio, has been a big supporter of the Home and Community Counseling and Testing for Health initiative (CCT). She knows firsthand the need for such a program—the orphanage she runs is populated by children whose parents have died from HIV/AIDS. The first act of prevention is to get tested, and the community volunteer program brings testing to a family’s doorstep.

The volunteers learned the essentials of health counseling including HIV testing from Jhpiego health professionals who helped design the program. Communities were studied and mapped to identify families who need services. Volunteers—who routinely work long hours and in all weather—carry backpacks that contain HIV rapid testing equipment, supplies, forms, condoms, other HIV-prevention materials and rain gear. Some carry the packs on their head, if their children accompany them on their route.

On any given day, a volunteer will visit five to 15 houses and test about 15 people. On Thursdays in Mumemo, the 10 volunteers, who receive a small monthly stipend, focus on houses with yellow and red codes and check on HIV-positive clients to ensure they are taking their medicines. In conjunction with the Ministry of Health’s emphasis on an integrated health systems approach, the volunteers assess clients for a variety of health concerns—for example, tuberculosis, malaria and hypertension—and make referrals, if necessary.

When a household refuses testing, community workers focus on counseling and testing neighbors. Once surrounding neighbors have been tested, a worker will return to the “red house” and approach the family again about following the good example of nearby residents. Program staff report that, in most cases, members of that family will reconsider participating in testing.

This mission “has put something in our hearts,” says Judite Cardoso, a Jhpiego CCT program coordinator.

Adds Tamela: “We put ourselves in their place. If we can’t help, our hearts are not free.”

On one recent Saturday, counselor tester Alfredo is sitting under a leafy green tree, his equipment and supplies laid out on a tray. A young mother named Sabina arrives with her 12-year-old son Frederico and her new baby. The mother tells Alfredo that her son is old enough to decide if he wants to be tested. He says he does. The boy is curious and nervous. With a prick of the 12-year-old’s finger, the volunteer begins the test. The mother sits nearby, quietly nursing her baby.

The boy’s test is negative and everyone is relieved. Frederico is asked to leave so his mother can receive her test results in private. The news is heartening—Sabina also is negative. Alfredo counsels her on ways to prevent contracting HIV and advises her to seek care for her high blood pressure. As the two are talking, a neighbor wanders by. The man asks the health worker to please visit his family so they can be tested, a request befitting the program’s motto: “Never leave anyone behind.”

A Jhpiego-supported program helps private health provider, midwife Flora Abalot Azondekon, improve services.

By Lopa Basu

Cotonou, Benin — At the Mon Etoile maternity clinic, owner and midwife Flora Abalot Azondekon has learned that quality assurance is good for business. After adapting lessons learned in a Jhpiego-supported program, Madame Flora saw an increase in new clients at her private clinic.

“To make us competitive, Jhpiego taught us approaches in performance improvement to provide quality care to our clients,” explains Madame Flora, who opened the private maternity clinic in 1980 in Benin’s capital of 760,000.

Madame Flora first began working with Jhpiego in 2008 as part of the IMPACT program, an initiative in Benin funded by the U.S. Agency for International Development and designed to strengthen maternal health care services in HIV/AIDS counseling and testing, prevention of mother-to-child transmission of HIV, family planning and reproductive health and to increase demand for these services. Starting with two pilot sites in Glazoue and Kalale, the Benin IMPACT program has expanded to 12 public health centers and more than 50 private clinics affiliated with the ProFam network run by partner Population Service International.

As part of the IMPACT program, Jhpiego, which started its first project in Benin in 1998, worked with health providers to adopt an integrated health services approach to delivering care and to apply the Jhpiego-developed Standards-Based Management and Recognition (SBM-R) process to strengthen health systems and improve services. Through her collaboration with Jhpiego, Madame Flora and her staff were able to set premium health care standards at her facility and build capacity among employees to reinforce and strengthen the quality of care for mothers.

Olivia Tunde, pregnant with her first child, visits Mon Etoile maternity clinic.

Pregnant with her first child, Olivia Tunde, 25, visited Mon Etoile after seeing a local television program highlighting the quality of care and well-trained staff. “I chose the services at this hospital for my first pregnancy and am very happy here because I am treated well. The medical interview and physical examination were well done,” said Mrs. Tunde.

Through the IMPACT program, more than 360 physicians, midwives and nurses in public health centers have received training in an integrated approach to reproductive health. As a result, more than 9,000 clients were counseled and tested for sexually transmitted infections, 7,483 women participated in focused antenatal care (with a majority receiving services for prevention of mother-to-child transmission of HIV) and 1,600 accessed family planning services.

In addition, 137 private health providers received training in integrating HIV-related services with reproductive health care.

For the past five years, Jhpiego’s Benin technical advisor, Dr. Mathurin Lougbegnon, has successfully integrated reproductive health services and HIV prevention programs using Jhpiego’s SBM-R approach with the goal of  strengthening health systems. “The reproductive health (RH) and HIV/AIDS services are strongly integrated in Benin and Jhpiego is working on that approach,” he said. “Now we’re doing an extension of that integrated approach. We are working in 12 public health facilities and 7 of them are offering the integrated services of RH and HIV/AIDS . . . I can ensure you that all Benin residents get the HIV care and services that they need.”

By giving health care providers like Madame Flora a means to develop and implement their own self-improvement program, SBM-R strengthens current local best practices in maternal health care. This accountability-based strategy provides incentives for employees to maintain compliance with performance measures and allows for a more standardized approach to health care delivery.

Midiwfe Flora Abalot Azondekon says improved services means quality care for clients.

A graduate from the National Medical-Social Institute of Benin, which trains midwives, nurses and social workers, Madame Flora decided that instead of taking the traditional route in her profession by working in the public sector, she would open a private maternity hospital. This entrepreneur’s experience with Jhpiego’s pioneering quality assurance program shows how private sector clinics and hospitals can gain a competitive edge by improving their health care services.

Benin is among eight countries—including India, Kenya, Philippines and Tunisia—in which Jhpiego has helped private hospitals, clinics and providers expand and improve health care services. In Benin, private businesses account for about 35 percent of the West African nation’s medical services.

Laura Yekame, 34, is another satisfied customer of Madame Flora’s Mon Etoile clinic. She chose to deliver at Mon Etoile after suffering three previous miscarriages. Diagnosed with malaria, she was placed on an intravenous drip in order to protect her baby and felt reassured that she was in good hands. “My friends advised me to come here for better care,” said Mrs. Yekame. “Indeed, as soon as I entered the clinic, I noticed that the reception is better than in other clinics I’ve attended.”

Operators of Mon Etoile maternity clinic say Jhpiego's quality improvement approach gave them a competitive edge.

Jhpiego’s malaria expert, Dr. Bill Brieger, shows a new flip chart on malaria prevention to a group of a women in Akwa Ibom State in Nigeria.

By Bright Orji and Enobong Ndekhedehe

When word went out for volunteers to help prevent malaria in her home state of Akwa Ibom in Nigeria, Uduak Imo Bob responded to the call. How could she not? For years, she worked as a traditional birth attendant for a church group, delivering babies in the community of Atiamkpat in southeasternNigeria. She had witnessed firsthand the devastating effects of malaria on pregnant women. Death was not uncommon in the women she knew who had acquired the mosquito-borne disease. She, too, had become ill with the fevers and headaches—but survived.

The malaria in pregnancy program introduced by Jhpiego and funded by ExxonMobil offered Uduak a chance to keep others safe. She signed up with 38 other women to serve as a CDD (community-directed distributor) in the villages surrounding the Atiamkpat Clinic, providing malaria prevention services and treatment.

Her neighbors knew they could count on her. “Uduak has been resourceful in the past and always committed in whatever assignment given to her,” one community leader commented about the 47-year-old mother of six.

With Jhpiego’s support, Uduak learned the skills and protocols to deliver malaria in pregnancy services to women, including distributing insecticide-treated bed nets and administering intermittent preventive treatment of malaria in pregnancy (IPTp). She is part of a frontline network of volunteers and health care providers who deliver services from home to health facility in the Onna local government area and help direct community malaria-fighting projects. Uduak and her CDD colleagues have provided malaria prevention and treatment services to 12,106 pregnant women.

Uduak showed such exceptional skills and promise during her training that colleagues chose her to be the chief volunteer coordinator. “Uduak is responsible and one who respects other people’s opinion,” said one co-worker.

In this role, she supervises and coordinates the other women volunteers and ensures their antimalarial drug stocks are adequate and their community registers are updated for accurate service provision.

Uduak understands the threat that malaria poses to Nigerian women and families—malaria causes the deaths of 4,500 pregnant women a year and accounts for one in four cases of anemia in pregnancy. Malaria also causes low birth weight in one in 10 Nigerian infants. On her own initiative, Uduak decided to organize and mobilize traditional birth attendants in her community, persuading them to send their clients for prenatal or antenatal care (ANC), where pregnant women receive malaria prevention services. The nursing officer at the Atiamkpat Clinic and the traditional ruler in the community supported her in this life-sustaining effort.

Without any financial reward or personal gain, Uduak carries out her duties responsibly and enthusiastically. As she explains: “The life and survival of pregnant women is my concern and much more important than money. There is an inner joy in providing quality community service, and this motivates me.”

As part of her work, Uduak delivers health talks to women in her church and offers group counseling sessions on malaria to pregnant women in her community. And she is not shy in her efforts to convince women to protect themselves from malaria. Consider her outreach to one woman who received an insecticide-treated bed net:

“Without Uduak I would not have started using the net,” said the woman who participated in the ExxonMobil-funded program. “Her consistency and persistence in reminding me to use the net prompted and encouraged me to do so.”

The work of Uduak and her fellow community volunteers is improving health services in other important ways. Before the ExxonMobil-funded program began, pregnant women were not patronizing the Atiamkpat health facility and its clinics. Women complained that they couldn’t count on staff being on duty when they visited a facility—there are about six clinics in the district. Uduak and her colleagues met with the health providers and got their commitment to staff the facilities. This coincided with Jhpiego’s training of health staff to improve the quality of ANC and malaria control services they provided.

Now women are coming to the facility to receive ANC. The number of clients has increased from just two pregnant women in the three months preceding the discussions with health staff, to 50 pregnant women in the first three months of staff reporting to the facility. And now women also give birth at the health center. As a result of efforts made by Uduak and her group of CDDs, on average 43% more pregnant women in the Atiamkpat Clinic catchment area are receiving the required two doses of IPTp as compared to pregnant women in three other local government clinics/catchment areas.

Uduak has been a role model to her fellow volunteers and a source of support.

“We would have stopped this work since we are not paid, but Uduak has continued to encourage and motivate us,” said one colleague.

The pregnant women Uduak serves also recognize her contributions. “Uduak is selfless and committed to helping people. Her life is a testimony and a challenge to us,” said one program beneficiary.

Dr. Jean Lankoande and Jhpiego's Dr. Tsigue Pleah discuss cryotherapy treatment that is offered with the visual inspection method of cervical cancer screening.

Ouagadougou, Burkina Faso – As a physician, Jean Lankoande has a hard time telling a patient that she has cervical cancer. At that stage, he says, he can offer a woman little hope. He knows that early detection is the key to treating this preventable disease. But rather than be overcome by his sense of frustration, Dr. Lankoande has channeled his energy into championing cervical cancer prevention programs for women across the West African nation of Burkina Faso.

Dr. Lankoande, 58, has been collaborating with Jhpiego as a trainer and consultant and working toward greater access to cervical cancer screening since 2008, when he attended a training course in Malawi on Jhpiego’s pioneering, single visit approach to screening and treatment. This screening method uses visual inspection of the cervix after it has been swabbed with vinegar to detect precancerous cells. If precancerous cells are identified, the provider offers treatment with cryotherapy—a freezing technique that destroys potentially lethal cells—in the same visit. The single visit approach ensures that women receive their screening results and treatment on the same day, thus reducing loss to follow-up.

According to a World Health Organization survey of cancer in Burkina Faso, an estimated 921 women are diagnosed with cervical cancer every year and 724 women die from the disease. Of all the deaths from cancer among women in Burkina Faso aged 15–44, cervical cancer is the highest, at 13.7 deaths per 100,000.

More than 700 women die from cervical cancer annually in Burkina Faso.

Jhpiego, in partnership with the Ministry of Health, has been working to strengthen health systems and build capacity in maternal and newborn health in Burkina Faso since 1995. A demonstration project on improving basic and comprehensive emergency obstetric and newborn care in health centers and hospitals was so successful that it led to the founding of a regional, comprehensive emergency obstetric and neonatal care center at Bobo-Dioulasso, which serves to build the capacity of midwives and doctors.

Jhpiego’s work in Burkina has since expanded to include projects for the prevention of mother-to-child transmission of HIV, prevention and treatment of malaria in pregnancy, and a cervical cancer prevention initiative funded by the Izumi Foundation. The two-year cervical cancer prevention project, in partnership with the Midwifery Association of Burkina, seeks to expand access to cervical cancer screening by strengthening the skills of midwives and nurses to successfully perform the single visit approach and reach many more women. The project is under way at two university teaching hospitals in Burkina where 512 women have been screened between September and February of this year.

Most women in countries like Burkina Faso don’t have access to Pap tests, the routine way women are screened for cervical cancer in the developed world. With 80 percent of deaths from cervical cancer occurring in the developing world, Dr. Lankoande says he can’t emphasize enough the relevance and importance of the single visit approach in Burkina.

Dr. Jean Lankoande (center) shares his knowledge about cervical cancer prevention and screening at a training for health workers in Burkina Faso.

“This is the best method to boost our activity around managing precancerous cervical lesions,’’ said Dr. Lankoande, who has served as master trainer and consultant for Jhpiego in Guinea and Haiti. “There are

Jhpiego staff receive a warm welcome in a Philippine village where a new cervical cancer prevention initiative is underway.

The program, operating in the Philippines and Thailand, uses cervical cancer prevention screenings to educate women on the benefits of vaccinating their daughters against a virus that causes cervical cancer.

A unique cervical cancer prevention program is underway in Thailand and the Philippines that relies on the special bond between mothers and daughters. The goal of the Jhpiego-supported demonstration project and study is to educate women about a leading cause of cervical cancer, the human papillomavirus (HPV), and protect the next generation by vaccinating young girls, ages 9-13, against HPV. Cervical cancer is the primary cancer killer of women in the developing world.

Results from the program will help guide development and expansion of a vaccination program that is based in facilities where cervical cancer screening and treatment occurs.

Capitalizing on the strong networks of government-supported community health and cervical cancer prevention services in Thailand and the Philippines, the program — a joint effort with Merck and Co., the Cancer Institute Foundation of the Philippines, and Chulalongkorn University in Thailand — hopes to vaccinate 4,000 girls in each country over 18-months.

Health providers at local clinics and facilities are reaching out to women who are screened for cervical cancer and educating them on the benefits of the HPV vaccine, using key messages such as “Protect Your Daughter! Protect Yourself.”

So far, 989 girls in the Philippines and 736 in Thailand have received the first dose of the vaccine.

Community health workers discuss the vaccine program with mothers and daughters.

The goal of the project is to vaccinate 8,000 girls, ages 9-13, in Thailand and the Philippines.

Results from the project will help guide development of national vaccination programs, which could help reduce cervical cancer deaths in Thailand and the Philippines.

Community health volunteers in Mozambique promote infection prevention and control measures.

By Luciana Brondi

Maputo, Mozambique—Health care workers like Eleutéria Jaime face a dual challenge in the fight against tuberculosis. Their clients are often suffering from HIV, the virus that causes AIDS; of all TB patients in Mozambique, 61 percent test positive for HIV. And for HIV-positive patients, TB is a leading cause of death.

That means Jaime and her colleagues at the Rural Hospital of Chicumbane—located in an area of the country with the highest prevalence of HIV (25.1 percent)—must be ever-vigilant in making sure their patients take their medicines and stick to their treatment regimen, which takes at least six months. She also cares for patients who are difficult to treat because they have multidrug-resistant TB (MDR-TB), a particularly stubborn form of TB that is resistant to standard antibiotics.

Despite these challenges, the Government of Mozambique, with support from Jhpiego and the President’s Emergency Plan for AIDS Relief (PEPFAR), has embarked on a five-year national plan for TB infection control. As part of this initiative, Jhpiego helped lay the groundwork for the national program by reviewing standards of care and local infection control policies at 30 health care facilities in three provinces. Jhpiego’s assessment found that few facilities had TB infection control policies, and even where policies existed, health workers knew little about how to prevent or control TB. These findings helped inform guidelines and practices for the TB Infection Control National Policy, which was signed by the Minister of Health earlier this year.

Following that seminal work, Jhpiego and partners set out to help Mozambique implement its campaign to stop TB. Jhpiego has led efforts to prepare workers and facilities across the health system to carry out the national plan, improve detection of TB, address challenges associated with treating patients with MDR-TB and promote proper “cough etiquette” and other TB prevention behavior in clinics and health centers.

To build and strengthen a TB-competent work force, Jhpiego has helped educate more than 200 health care workers in infection control and prevention strategies. Jaime was among them, and, she says, she is now better able to serve her clients and to reinforce the often simple measures that help prevent the spread of TB—for example, covering one’s mouth when coughing and keeping windows open in patient areas to circulate the air.

“I did not have much idea about the issues relating to TB-MDR and TB transmission and infection control,” said Jaime. “I was really pleased to be able to learn more about these issues and how I could motivate my patients to keep fighting TB, how I could protect myself and the patients and their families from TB transmission. It helped me to provide better care and instructions to the patient on cough etiquette and infection control both while in the hospital and at home.”

Every year, more than 7,000 Mozambicans die as a result of TB. Residents who are HIV-positive are more vulnerable to the threat of TB, and in a country with an HIV prevalence rate of 11.5 percent among adults, the challenge of containing that threat is great. The Ministry of Health (MOH) is focused on strengthening health services to avert the spread of TB and provide improved care to its people. One of the key strategies to fight TB is the implementation of collaborative HIV/TB activities.

“The National [TBIC] Plan is crucial to guide the activities to be implemented to control TB transmission in Health Care Units and group settings,’’ said Dr. Alexandre Manguele, Mozambique’s Minister of Health. “We hope therefore to be able to guarantee safer and healthier health care facilities and services for all Mozambicans.”

Health care facilities in Mozambique post reminders on cough etiquette.

From promoting cough etiquette in small rural health facilities to establishing strong TB and general infection control policies in hospitals, Jhpiego is partnering with Mozambican organizations to share evidence-based practices and strategies to strengthen health care and protect health care providers where they work.

Red Cross Mozambique is one of the front-line organizations working to prevent and control TB in the community, especially in remote areas where access to health facilities is more difficult. Red Cross volunteers play an active role in supporting the MOH with its community TB-DOTS (Directly Observed Therapy Short-Course) strategy, which includes a focus on having a friend or relative watch and support a TB patient in taking his or her medicine properly. But many volunteers did not know how to protect themselves and the community against TB infection. Nor were they fully confident about dealing with MDR-TB clients.

Last fall, at the request of the MOH and the World Health Organization, Jhpiego supported TB infection control training for 22 Red Cross medical officers. This training covered twin challenges—treating persons with HIV, or those with MDR-TB. A majority of these medical officers manage 139 field supervisors, who in turn train and oversee 1,404 volunteers working in the 11 provinces of Mozambique. Last year, these Red Cross volunteers reached 62,227 families with updated information on TB prevention and control.

Two Red Cross medical officers learn the proper way to put on a respirator.

“After the training, I was confident to teach the volunteers about TB/HIV issues, adherence to treatment importance and how to motivate clients, the risks of multidrug-resistant TB and how to protect themselves and their clients against TB transmission,” said Celeste Langa, a supervisor with the Red Cross. “I feel privileged and I am happy to hear that people in Jhpiego are concerned with the TB and TB-MDR challenge we face in our country, especially in my province Maputo.”

Melinda Gates (in teal shirt) meets with a new mothers' group in Nairobi's Korogocho community; she is accompagnied by Jhpiego's Jane Otai (in beige suit).

By Ann LoLordo

Nairobi, Kenya—During a visit to Jhpiego-supported programs in a slum outside Nairobi, Melinda Gates heard the same message from dozens of residents—women want to plan their families so they can provide for their children and give them opportunities they never had.

“I talked to more than 50 women about family planning when I was in Kenya, and all but one told me how desperately they wanted to plan their families and space their children…,” said Gates, whose family foundation recently chose Jhpiego, the Baltimore-based international health non-profit and Johns Hopkins affiliate, to lead its $23 million urban reproductive health program in Kenya called Tupange.

“The women I met talked a lot about how important it was to make sure their daughters learned about family planning. One woman said she had six children before she knew anything about family planning, and she told me she must not let the same thing happen to her daughter. Her direct quote: ‘My daughter will be more informed about family planning than I was. I will teach her everything.’”

Whether speaking through a Swahili translator or finding their voice in English, the women who met Gates recognized that spacing their children in a healthy manner would enable them to better care for their families so all would thrive.

“I asked a group of women why they wanted to practice family planning. One woman summed it all up when she said, ‘I want to bring every good thing to one before I have another,’” said Gates. “It just reinforced what I always come away from these conversations realizing—that mothers everywhere want the same things for their children, that we all want to set our children up for a successful future.”

Jhpiego, whose urban health program has been recognized for its innovative strategies to increase access to quality health care and services for Kenyans, hosted Gates during a day-long visit that included meeting with women from a Nairobi area slum. The organization’s work in Korogocho and Viwandani slums led to a significant increase in family planning use by women.

As Gates walked through the communities and talked with Kenyan wives and mothers, women shared the challenges they faced in getting adequate family planning services that include disapproving husbands, physical infirmities and inadequately supplied health clinics.

“One woman had been trying to plan her family for years, but her husband wouldn’t hear of it. Then, because she had so many children in the same room where she was cooking their food, there was an accident and her child got burned. They had to go to Kenyatta Hospital, and the dad finally understood the importance of child spacing. The woman was at the clinic to finally start the process of planning her family.”

But Gates also learned about new family planning methods that were being offered to Kenyan women living in these crowded, impoverished areas of the city.

“I visited a health clinic in Kariobangi, and I happened to be there on the day they set aside for long-term family planning, including tubal ligation, IUCDs and implants,” recalled Gates. “The women I talked to were really excited about the implants. They called them batteries, because they work for four years. I got to see a woman having the procedure done, and it was just amazing to me how easy, quick and relatively painless the procedure is.

“It’s such a cost-effective and effective way to give women the ability to plan. I thought to myself, that little procedure can make such a huge difference in the lives of women, their families and their communities. That’s why there was a line out the door and a four-hour wait to have the procedure done.”

Throughout her visit, Gates was heartened by women’s concerns for one another and the network of support that had developed among many to access family planning services.

“The sad truth is they don’t get much support from the men, but they make sacrifices for one another. At the health clinic, two women told me they’d already gotten implants, but they had come because they wanted to encourage other women who were scared or uncertain,” said Gates. “Seeing that there were women who had come to give advice and another who had come seeking advice made me realize that tools and technology are only part of the equation.”

Gates recalled her meeting with a courageous, determined volunteer health worker named Maureen.

“She was an HIV-positive mother, and one of her five children also had HIV,” said Gates. “Now, she is running a program where HIV-positive mothers counsel pregnant women with HIV about preventing mother-to-child transmission. The most important thing, she said, was helping the women realize that others just like them had overcome the same obstacles. In her words this was ‘Living Positively.’ Maureen told me that in her program, they haven’t had a baby born with HIV since August—and that’s more than 30 healthy children!”

Access to family planning services can have a profound impact on the lives of women and their families. A woman named Mary told Gates about a savings club—called a “merry-go-round”—in which members contribute to a pool from which they can get loans to start a small, home business.

Melinda Gates visits with Mary, a young mother who became a tailor through a Jhpiego-supported program.

“Mary took a loan to buy a sewing machine, and she had a thriving business selling backpacks out of denim. She sold them at the local market for 50 shillings apiece, and she was supporting her family and paying back her loan,” said Gates. “When I visited Mary’s workshop, she was caring for her youngest child while the other two were off at school. I just kept thinking that the futures of those children were so much brighter because their mother had been able to plan her family and band together with other women in the community to grow a business.”