The University of Washington (UW) Center for Stewardship in Medicine, or CSiM (“see-sim”), is a collaborative of over 80 rural hospitals working together on stewardship challenges through education, quality and process improvement, and mentoring. CSiM provides education, technical assistance, and personalized support to facilities and health care professionals to meet their stewardship needs.
In 2023, CSiM moved to the UW Department of Global Health and joined the International Training and Education Center for Health (I-TECH) as a partner.
CSiM works in antimicrobial stewardship and infection prevention, building sustainable quality improvement programs, and providing customized, long-term technical assistance to rural health facilities. The center’s main activities include leading the UW Tele-Antimicrobial Stewardship (TASP ECHO®) project, a telementoring program; coordinating intensive quality improvement cohorts; and providing resources and tools to support facilities in reaching their goals and improving the quality of healthcare.
Currently, CSiM has projects in Arizona, Idaho, Illinois, Louisiana, Maine, Montana, Oregon, Utah, and Washington and is exploring opportunities to extend its model globally.
The World Health Organization recommends countries routinely implement nationally representative HIV drug resistance (HIVDR) surveys among people infected with HIV to measure the level of drug resistance. The results of HIVDR surveys are a critical component of HIV programs and can guide changes to pediatric and adult antiretroviral therapy (ART) treatment regimens, including first- and second-line regimen decisions. I-TECH has been implementing HIVDR surveys in Malawi since 2016.
HIV DR Surveys Conducted Since 2016:
Infant HIVDR Survey: An HIVDR survey was conducted among infants aged 18 months and younger to determine the level of pediatric resistance to nonnucleoside reverse transcriptase inhibitors (NNRTI), nucleoside reverse transcriptase inhibitors (NRTI), and protease inhibitors (PI) ART drugs through exposure during pregnancy and breastfeeding. A total of 232 eligible remnant dried blood spot (DBS) samples from nine early infant diagnosis (EID)-approved laboratories were used for the diagnosis of HIV in infants between June 2016 and December 2017.
Antenatal Care (ANC)/Pregnant Women HIVDR Survey: An HIVDR survey was conducted to measure resistance to NNRTI, NRTI and PI drugs among ANC clients who were found to have a recent HIV infection. A total of 45 DBS samples from women with recent HIV infection were collected as part of the 2016 HIV sentinel surveillance survey and were successfully amplified and sequenced.
The next step in HIV surveillance activity is monitoring HIVDR among pregnant women initiating dolutegravir (DTG)-based regimens, as well as the potential emergence of DTG resistance in infants via mother-to-child transmission. A study of DTG resistance is currently underway in Malawi and will determine the level of DTG resistance in adults who are unable to achieve viral load suppression and DTG resistance in children < 15 years old who are unable to achieve viral load suppression.
The 2023 IAS Conference on HIV Science logo. Read the full background and inspiration behind the 2023 IAS Logo. Image credit: IAS
The International AIDS Society (IAS) hosted the 12th IAS Conference on HIV Science on 23 – 26 July 2023 in Brisbane, Australia, and virtually. This biennial conference brings together top HIV researchers, experts, and scientists for presentations and discussions on the latest advances in HIV research and practice.
This year, representatives from the International Training and Education Center for Health (I-TECH), I-TECH’s partner network organizations, and the Centers for Disease Control and Prevention (CDC) shared findings from I-TECH-supported programs in India, Malawi, and Zimbabwe. Read the ePoster abstracts below.
Voluntary medical male circumcision (VMMC) decreases the risk of female-to-male HIV transmission by about 60%.[1] I-TECH Network partner the Zimbabwe Technical Assistance, Training, and Education Center for Health (Zim-TTECH) supports innovative VMMC engagement solutions that are tailored to the populations they serve.
Caravans Allow for Mobile Services and Door-to-Door Outreach
VMMC Mobilizers engage with men at a farm compound in Goromonzi District. Photo credit: Zim-TTECH
Makumbe Hospital in Goromonzi District, Zimbabwe, serves a population of more than 100,000 people, including the rapidly expanding population of surrounding townships. Zim-TTECH-led consortium ZAZIC has run the Makumbe Hospital site since October 2018 and supports the VMMC team there.
This population within the hospital’s catchment area primarily comprises informal traders selling necessities such as groceries, garden produce, or second-hand clothes, while others run at-home small businesses that manufacture furniture, iron and steel products, and other wares.
“It’s difficult for economically active young men to leave their businesses and attend to VMMC at a venue away from their premises or market,” said Lewis Masimba, VMMC Program Manager at Zim-TTECH.
In light of this challenge, the team implemented a mobile caravan, which could increase the number of men receiving circumcisions by taking services out of the medical facility and bringing them closer to the concentrated settlements of Domboshava Showground, Mungate, and Mverechena townships and nearby farm compounds.
The caravan has been in use in the district since January 2023, and it has vastly shortening the period between client engagement and service delivery. In most cases, two mobilizers at a time will engage with potential clients within the townships, while another three will conduct intensive door-to-door visits in residential areas.
Mobilization efforts include one-on-one and small group discussions at market stalls, small businesses, and drinking spots, where mobilizers will answer questions and distribute information about VMMC. Sometimes the caravan is supported by a roadshow van and dancers who disseminate VMMC information through edutainment.
“The caravans have so many advantages,” said Mr. Masimba. “Men are able to access the VMMC services near their workplaces, minimizing disruptions to their daily routines. The caravan has also brought convenience and privacy to those who did not feel comfortable being ferried in program vehicles to and from the hospital.”
Fig 1: Outputs three months before receiving the caravan and three months after receiving the caravan
Since the site started utilizing the caravan, the number of men who have received VMMC each month has increased from 159 to 233 (Fig. 1).
On the heels of this success, the ZAZIC teams will continue exploring other combination approaches involving engagement activities such as pool/snooker, soccer, and music roadshows to reach hard-to-convince men in their localities.
Peer-to-Peer Learning Takes Center Stage in Performing Arts Program for Adolescents
Eight secondary schools enrolled in the drama competition. Photo credit: Zim-TTECH
The performing arts have been used since time immemorial as motivators to rally communities toward common goals, to relieve stress, and as an effective teaching tool across diverse cultures and religious settings. They are a particularly effective method for engaging adolescents both in and out of schools. As teens seek independence from their parents, the influence of peers becomes increasingly important, and performing arts are a fantastic way to employ peer-to-peer learning strategies.
Harnessing these strategies, ZAZIC uses drama in several districts to complement efforts already made by VMMC teams and teachers who have previously used sporting events and lectures to communicate with students.
In a particularly successful case, Hurungwe District chose to use a drama competition to communicate VMMC and other health messages to adolescents. The goals of the competition included effective peer-to-peer learning, outreach to a large audience, and the demystification of VMMC.
Roadshows to promote the competition were held at major townships to create awareness of the event and invite members of the public to attend. Eight secondary schools enrolled in the competition, and teams of adolescents led the process of writing and directing short, 30-minute performances incorporating messages in a provided guide.
The guide emphasized use of appropriate language, the need to double-check facts; and encouragement of uptake of VMMC and related services, such as HIV testing and counseling and cervical cancer screening.
More than 1,000 people attended, including students, parents, and staff from all competing schools.
“Matawu Secondary School ultimately won the drama competition, but all of the schools did a wonderful job explaining VMMC and its benefits,” said Mr. Masimba. “Messaging also emphasized abstinence for adolescents, the importance of the HPV vaccine for girls, and details about the VMMC procedure. The level of accuracy of information was extremely high.”
Importantly, two of the performances highlighted communities that reject medical interventions and stressed the need for participation by all.
A total of 182 VMMCs were attained by adolescents aged 15 to 19 years old immediately after the competition. Those who were not ready were booked for the procedure and will be followed up with by school health masters and community mobilizers.
The Integrated Next-generation Surveillance in Global Health: Translation to Action (INSIGHT to Action) project is a five-year cooperative agreement with the US Centers for Disease Control and Prevention to assess and strengthen global public health surveillance systems using a One Health approach. The INSIGHT project leverages the capacity building strengths of I-TECH and the One Health disease surveillance expertise of the Center for One Health Research, with a model of engaging local institutions and experts in countries where it will be working in a shared partnership model.
In its first year, the INSIGHT project focused on an in depth assessment of the public health surveillance systems in Peru, in partnership with experts from University of Peru Cayetano Heredia. The completed assessment has now catalyzed the formation of a technical working group with representation across multiple government agencies that will work with other stakeholders including the World Bank at implementing measures to strengthen regional and country capacity to detect, respond to, control, and prevent emerging disease threats to health security.
The INSIGHT surveillance work in Latin America is also now expanding to involve Paraguay, Brazil, Argentina, and Colombia.
IDASH TRAINING PROGRAM
In 2023, the INSIGHT program launched the Informatics and Data Science for Health (IDASH) training program in Eastern Europe and Central Asia. The goals of IDASH are to enhance capacity to create and use public health information systems that enable the capture, management, analysis, dissemination, and use of reliable, timely information to improve population-level health outcomes, as well as strengthen regional capacity to effectively respond to future global health challenges.
UKRAINE RECOVERY
Building on lessons learned from the Peru assessment work, the INSIGHT team is now working with the Ukraine Public Health Center on expanding sentinel and event based surveillance systems in Ukraine and strengthening the capacity of the public health system for emergency management of chemical biological, radiological, and nuclear threats. The INSIGHT team has organized a workshop in Poland bringing together key principals from the Ukraine ministry of health and local health departments to accelerate the pace of activities in support of public health in the country. INSIGHT is coordinating technical working groups on Early Warning and Response, Public Health Emergency Management, and Surveillance strengthening.
Thanks to new generators, the Rehabilitation Shelter had electricity, heat, and Internet connection during massive shelling in Ukraine in fall and winter 2022-2023.
In February 2022, at the advent of the war in Ukraine, the International Training and Education Center for Health (I-TECH) launched the I-TECH Humanitarian Fund to support the work of our team in Ukraine. Many team members remain displaced, away from their homes, and isolated from their families and friends. However, their tireless work continues provide uninterrupted access and services to Ukrainians living with HIV, who are more in need of care and refuge than ever.
Supported by generous donations to the I-TECH Humanitarian Fund, I-TECH Ukraine has been able to advance the work of Eleos-Ukraine, a network of like-minded people and organizations that develop social services through 13 regional offices throughout Ukraine. The common goal of Eleos-Ukraine partners is to feed, clothe, and protect 1 million people in need.
“The compassion and solidarity of our American colleagues and friends with Ukraine and Ukrainians, including those expressed through generous donations to the I-TECH’s Humanitarian Fund just in the first few weeks of the full-scale war, are overwhelmingly moving,” said Anna Shapoval, I-TECH’s Country Representative in Ukraine. “We are eternally grateful.”
To date, the I-TECH Humanitarian Fund has been directed to Eleos’ critical work on behalf of Ukrainian women and girls subjected to sexual violence and other trauma (e.g., incarceration and torture) by the Russian army, notably the development and establishment of the Rehabilitation Shelter in August 2022.
Money from the fund has gone directly to outfitting the shelter with video surveillance, fire alarms, and powerful generators. Thanks to the generators, the shelter had electricity, heat, and internet connection during massive shelling by the Russian Federation in fall and winter 2022-2023.
“We appreciate your cooperation and thank you for helping the citizens of Ukraine during the war,” wrote Eleos-Ukraine Board Chair Serhii Dmytriyev, in a thank you letter to I-TECH Humanitarian Fund donors. “Our joint humanitarian project will help women not just today, at this time of crisis; it will also be important in reducing the consequences of war – which makes it an important contribution to the future of Ukraine!”
Since the shelter opened, more than 150 women from Kyiv, Donetsk, Kherson, Mykolaiv, and Luhansk Oblasts have received help remotely and within the shelter. The duration of a stay in the shelter for one client varies from one to six months and can be extended. The shelter houses 15-20 women and girls as well as their families, with accommodation for up to 30 people.
“Eleos-Ukraine is a truly passionate and efficient organization. They have been at the forefront of response to this war since 2014, the actual start of the Russian invasion,” said Ms. Shapoval. “Eleos put their minds and souls into supporting Ukrainian women and girls, and other civilians, who have suffered from horrifying violence and deprivation daily. They will continue helping people of Ukraine, no matter what – and so, I hope, we as I-TECH will continue supporting groups like Eleos on the ground.”
I-TECH Executive Director Pamela Collins lauded both the Ukraine team’s work with Eleos and those who have contributed generously to the I-TECH Humanitarian Fund. “I am very proud of I-TECH Ukraine’s activities with Eleos to respond to the humanitarian emergency in Ukraine,” said Dr. Collins. “Thanks to our donors, we had the resources to do what I-TECH does well: identify and collaborate with strong partners in the countries where we work to meet urgent needs in a times of crisis.”
Participants gather for group discussion during the first IDASH in-person workshop in Tbilisi, Georgia. Photo credit: CDC/EECA
On April 3, the International Training and Education Center for Health (I-TECH) launched the Informatics and Data Science for Health (IDASH) fellowship training program with an in-person workshop in Tbilisi, Georgia. The program launched in partnership with the United States Centers for Disease Control and Prevention’s Eastern Europe and Central Asia (CDC/EECA) Regional Office, the World Health Organization (WHO) Europe, and country governments.
The first IDASH cohort includes 20 fellows from Georgia, Kazakhstan, Kyrgyzstan, Ukraine, and Uzbekistan. Participants include mid- to senior-level technical, analytical, and public health staff working at the national level in public health informatics or data science.
“After several whirlwind months of collaboration and engagement with stakeholders from the five countries, it’s amazing to welcome the first cohort of IDASH to Tbilisi for the first of three in-person workshops,” said Stacey Lissit, MPH, MS, Senior Technical Advisor for the IDASH program.
Fellows will participate in a 12-month in-service training program, in which each country team of four fellows will identify and develop a collaborative project. Fellows will receive sustained mentorship, and regional communities of practice will be established to ensure regional collaboration, share lessons learned and best practices, and establish linkages for future programming needs that span multiple countries.
“IDASH provides the opportunity to link learning to experience, and enables the application of new public health skills, knowledge, and techniques acquired from the training in a real-life context,” said Peter Rabinowitz, MD, MPH, Principal Investigator for the IDASH project. “It also extends benefits beyond the trainees to partner agencies and organizations, helping strengthen public health capacity in the region.”
Proposed fellowship projects include automating data analysis and visualization for diseases, expanding digital immunization registries beyond COVID-19, and developing spatial analysis modules for multi-disease surveillance and response.
“Today, the afternoon of the 4th day, the room is buzzing as the five country teams are hard at work: two engrossed in consultation with our facilitation team of public health informatics and data science experts about their country team projects; the others working on a data science methods exercise, practicing interpretation of descriptive and inferential statistics plots to assess trends in Hepatitis C,” said Ms. Lissit. “The energy and engagement have been high, and we’re looking forward to the next six days and the rest of the year-long fellowship.”
IDASH goals are to enhance capacity to create and use public health information systems that enable the capture, management, analysis, dissemination, and use of reliable, timely information to improve population-level health outcomes, as well as strengthen regional capacity to effectively respond to future global health challenges and pandemics.
“The COVID-19 pandemic made clear the importance of public health data systems that provide real time, accurate data on disease threats to allow for timely intervention and combatting of mis- and disinformation,” said Dr. Rabinowitz. “Programs like IDASH will help ensure there is a workforce prepared to detect, prevent, and respond to future global health threats.”
Honorees from well-performing sites in the QISSEC project
In late February, the International Training and Education Center for Health (I-TECH) hosted an awards ceremony for the 10 best-performing health facility-based quality improvement teams focused on improving HIV prevention, care, and treatment services in Côte d’Ivoire. I-TECH currently operates in 80 HIV care and treatment (C&T) health facilities throughout Côte d’Ivoire.
Out of a total of 20 points, and using strict criteria, 10 sites received scores greater than or equal to 18 and were honored at the ceremony. Awards included computer equipment, printers, video projectors, blood pressure monitors, and other vital office equipment.
The ceremony was part of the U.S. Health Resources and Services Administration (HRSA)-funded Quality Improvement Solutions for Sustained Epidemic Control (QISSEC) project, which seeks to improve interventions such as the provision of pre-exposure prophylaxis (PrEP), decreasing treatment interruption, and improving viral load testing coverage and suppression.
“This ceremony was a way to applaud the enthusiasm from the teams, demonstrate an understanding of the methodology, and share the projects that have so far been implemented,” said Dr. Nathalie Krou Danho, QISSEC Project Director.
PEPFAR Coordinator Bibola Ngalamulume
In addition to Dr. Danho, ceremony attendees included the National AIDS Control Program (PNLS) Director, PEPFAR Coordinator Bibola Ngalamulume, HRSA representatives, QISSEC Principal Investigator Ellen MacLachlan, CDC and USAID Country Directors, and representatives from the regions, districts, and sites.
“It is important that we put an accent on service quality,” said Ms. Ngalamulume. “The CQI project that is being implemented by I-TECH is an initiative that is extremely important because not only does it ensure that we improve access to care for all the HIV population–those who are infected and affected–but also it gives us the opportunity to create some kind of a mentorship network between health facilities that are performing well and facilities that need support. [This ceremony] is going to drive even more innovation moving forward.”
Within the QISSEC project, I-TECH has been working closely with the Ministry of Health and Public Hygiene (MSHP) and implementing partners to strengthen provider and community counselor capacity in quality improvement to ensure HIV epidemic control.
I-TECH’s methodology is to build a culture of quality improvement from central, to regional, to site levels. Importantly, I-TECH supports sites to work with the community to center their needs, and patient needs, in providing quality care.
One of the sites honored, an urban health center in Libreville, had set a goal to increase individuals on PrEP from 23 in December 2021 to 78 in June 2022. Their root cause analysis revealed that training in PrEP was insufficient. After orienting prescribers and clinical advisors to PrEP, and organizing community awareness sessions where eligible individuals were identified, the site surpassed their goal by 200%, initiating 230 individuals on PrEP by June 2022. The site continued to increase that pace, reaching 353 by August of that year.
“It’s been a lot for the teams to do this work on top of their day-to-day jobs: to form a quality improvement team, brainstorm, and think of ideas on how to implement the changes,” said Dr. MacLachlan, “but they have taken great care in this work. The quality of HIV care in Côte d’Ivoire will be better for it.”
THIS PROJECT IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER U91HA06801, THE INTERNATIONAL AIDS EDUCATION AND TRAINING CENTER (IAETC). THE CONTENT OF THIS POST IS THE AUTHOR’S AND SHOULD NOT BE CONSTRUED AS THE OFFICIAL POSITION OR POLICY OF, NOR SHOULD ANY ENDORSEMENTS BE INFERRED BY HRSA, HHS OR THE U.S. GOVERNMENT.
Representatives from I-TECH Malawi attend ICBD 2023 in Santiago, Chile from 1-4 March 2023 to present findings from the Malawi Birth Defects Surveillance Program. L-R: Luke Chiwala, Simkonda Yamikani Malanga, George Bello. Photo Credit: I-TECH Malawi
The conference brought together maternal and child health practitioners and researchers from around the world who presented their latest research, tools, and approaches in surveillance, diagnosis, and care for babies born with birth defects. This year’s theme was “Accelerating Action for Birth Defects and Disabilities: Surveillance, Prevention, Diagnosis, Management and Family-Centered Care.”
The following presentations were given during the conference:
“Prevalence of Adverse Birth Outcomes and External Birth Defects Among Women Living with HIV in Malawi” Authors: Bello G, Smith-Sreen J, Williamson D, Taulo F, Kabaghe A, Kerry Thomson K, Kagoli M, Chipeta S, Namakhoma I, Nyirenda R, Babaye Y, Auld A, Kim E, Matatiyo B, Zenengeya E, Muula AS, Nyasulu I, Gomes MF, Chiwala L, Kamzati M, Mkungudza J, Valencia D, Moore C, O’Malley G, Wadonda-Kabondo AN
“Correct Diagnosis of Birth Defects by Health Facility Staff in Four Facilities in Malawi” Authors: Malanga SY, Luke Chiwala L, Kamzati M, Valencia D, Mkungudza J, Bello G, Williamson D, Moore C, Thomson K, Ireen Namakhoma I, Gondwe E, Banda F, Sangaya N, Chirwa M, Kagoli M, Chipeta S, Nyirenda R, Zenengeya E, Babaye Y, O’Malley G, Wadonda-Kabondo N, Kabaghe AN
“Use of Electronic Data Collection and Web-Based Portal to Ensure the Completeness, Timeliness, and Accuracy of Final External Birth Defects Diagnosis in Malawi” Authors: Chiwala L, Kamzati M, Valencia D, Mkungudza J, Bello G, Williamson D, Moore C, Thomson K, Namakhoma I, Gondwe E, Banda F, Sangaya N, Chirwa M, Kagoli M, Chipeta S, Nyirenda R, Zenengeya E, Babaye Y, O’Malley G, Wadonda-Kabondo N, Kabaghe AN
On March 21, the Ugandan parliament passed a hardline bill criminalizing LGBTQ+ identity, giving the government wide latitude to prosecute gay Ugandans, punishable by life imprisonment. This represents a clear violation of human rights and dignity for Ugandans who identify as LGBTQ+, putting them at further risk of violence and discrimination in a country where same-sex relations were already illegal.
Global condemnation of the new legislation has been swift, within and outside of Uganda. Richard Lusimbo, a Ugandan LGBTQ+ activist, told NPR, “The LGBTQI community has basically been told, you can’t raise your head, you can’t be seen, you can’t be heard.” The UN’s High Commissioner for Human Rights is urging Ugandan President Yoweri Museveni not to sign the bill. “The bill would have negative repercussions on society as a whole and violates the nation’s constitution. The passing of this discriminatory bill – probably among the worst of its kind in the world – is a deeply troubling development.”
Such violations of human rights, regardless of where they occur, are antithetical to I-TECH’s values and our vision of health and flourishing for all. We strongly object to these actions by the Ugandan government and stand against the criminalization of and discrimination against LGBTQ+ individuals and communities in Uganda.
The University of Washington (UW) Center for Stewardship in Medicine, or CSiM (“see-sim”), is a collaborative of over 80 rural hospitals working together on stewardship challenges through education, quality and process improvement, and mentoring. CSiM provides education, technical assistance, and personalized support to facilities and health care professionals to meet their stewardship needs.
