EDITION 38 NEPHAK Weekly Bulletin 22nd September 2019

Focus on current grants Performance as CSOs issue Letter to the President on the GFATM 2019 Replenishment.

President Kenyatta and Dr. Sands with other top MoH officials in a past photo.

Civil society organizations, comprising NGOs and networks of people living with, at risk of and affected with HIV, TB and Malaria last week sent a letter to President Uhuru Kenyatta (in photo above) urging him to join the other nations in supporting the 2019 replenishment for the Global Fund to fight AIDS, TB and Malaria (GFATM). The Letter to the President and which was copied to relevant agencies, institutions, and individuals, including the leadership of the Parliamentary Committee of Health had twin requests: Kenya to contribute at least $10,000,000 for the 6th replenishment of the Global Fund and; the President to attend the Global Fund replenishment conference in Lyons, France in October.

Under the banner of the Global Fund Advocates Network (GFAN), the CSOs' decision to send a letter to the President was motivated by the fact that Kenya in the past joined other nations in supporting the Global Fund. The letter: https://nephak.or.ke/wp-content/uploads/2019/09/Kenya-Letter.pdf sent last week to the President Office starts by acknowledging this fact and congratulating the President and the Government for this bold and noble move. In the letter, CSOs and communities note with gratitude, that during the 5th replenishment in 2016, Kenya contributed $5,000,000 towards the global goal to end the epidemics of HIV, TB, and Malaria.

Joining the Global Fund Replenishment and contributing to the kitty is really a great venture from a country that is also a beneficiary of the Global Fund. Since 2003, the Fund has disbursed over $1.4 billion to defeat the three diseases and for health and community systems strengthening. The Global Fund is also the only other funding mechanism that takes cognizance of the non-biomedical aspects of the HIV epidemic, including gender inequality, stigma and discrimination, disregard for human rights and harmful social and cultural norms.

The letter to the President coincided with the release of the Global Fund’s Results Report: https://reliefweb.int/sites/reliefweb.int/files/resources/corporate_2019resultsreport_report_en.pdf which among other things showed great progress against some of the biggest challenges in the fight against the three diseases while highlighting new threats. In the report, the Fund’s Executive Director, Dr. Peter Sands stated that “Despite our great progress, the challenges ahead require us to collaborate and coordinate even more if we are to reach the SDG 3 target of ending the epidemics by 2030,” adding that: “None of this can be achieved by the Global Fund alone, but by working together we can succeed.”. The partnership also needs nations that benefit from the Fund such as Kenya.

For Kenya, the letter to the President also served the purpose of focusing the attention of those concerned and communities affected with the diseases on the current Global Fund grants in Kenya. This is because the performance of the grants has been lagging behind and hurting the health resource mobilization efforts. The dismal performance of the Global Fund grants in Kenya is a subject that has been in the lips of PLHIV and communities for some time now. The challenge is in the slow, intermittent release of funding and which results in dismal performance. This is not just with the current grants but has been a historical imperative. Grants are released very late thereby undermining both value for money and quality of services. While in the past this was a preserve of the state Principle Recipient, it is now a big issue even among the non-state PRs.

Therefore, as communities join other stakeholders in drumming up support for the Global Fund Replenishment, it would be better for those concerned to move quickly and make sure the Global Fund grants are effectively and efficiently utilized to do what it was meant for: Prevent diseases and provide treatment, care, and support to those in need. Otherwise, it is pointless looking for more resources if the little that is available is not performing as required.

We can Leverage the Best out of this High-Level Meeting on UHC

A section of Kenya CSOs Leadership at a past forum.

History will be made this week. Leaders of the world’s nations will gather for the UN High-Level Meeting on Universal Health Coverage. After months of tough negotiations, consensus was reached on a political declaration – which you can read here – that will be adopted this week. A lot has been said by many stakeholders and constituencies. Of key concern is the weakened or murky language in the declaration that will make it easier to loosely interpret the fundamental principles of UHC: equity, social justice and the right of every single person to get the quality health services they need without financial hardship. The other worries have to do with the concerns of people and communities living with diseases such as the networks of people living with HIV.

Nonetheless, one thing is certain and this has been underscored by the global UHC Coalition Secretariat: “this is probably the largest global spotlight on universal health coverage to date, and another unanimous pledge that leaders will be on the hook for.” We at NEPHAK strongly agree with the UHC Secretariat that “we cannot afford not to speak up for what we believe and demand the urgent actions we need to see”. We, therefore, believe that the high-level meeting on UHC brings an opportunity to reflect on the aspirations and hopes that come with Health for All. We can actually leverage the best out of this high-level meeting.

For the Kenyan CSOs and communities, the most important development arising out of the global meeting on the UHC is the fact that Kenya is a significant player in the UHC movement. The country will be represented at the meeting by a high-level delegation under the leadership of President Uhuru Kenyatta. Since the President himself has included universal health coverage as one of his four priority agenda, the global forum gives him and the country leadership and opportunity to reflect on the progress made with this agenda. On the world stage, the President will be reminded of what he said during his inauguration for the 2nd term: “My government commits to deliver 100% UHC to all Kenyans by 2022”. The high-level meeting on UHC provides an opportunity to ask the question: Where is the country with regard to the President’s pledge on UHC?

The global forum on UHC also comes with an opportunity for the Kenya CSOs to revisit their earlier calls for meaningful engagement in the planning and delivery of interventions aimed at achieving universal health coverage. Indeed, the call is part of CSOs' position on UHC shared with the government and partners. In the position paper, CSOs asked for the need to invest in social accountability/empowering of communities to ensure that citizens can demand for UHC and hold the government to account on the implementation and achievement of UHC. CSOs also wanted partners, including those at the global level to put in place an all-inclusive governance structure (representatives from CSOs and affected communities) that would oversee the implementation of UHC at all levels and to engage CSOs as equal partners; ensure that the various groups are meaningfully involved and to ensure that their health needs are met.

Specifically, the CSOs leadership wants the Essential Benefits Package for UHC to be inclusive to enable citizens to live a healthy life expanding it to include preventive and promotive health. According to CSOs and communities, this can only be guaranteed through investing in a holistic health systems approach and leveraging existing technological advancement/innovations/existing programs and initiatives in the health sector to support the implementation of UHC. More importantly and as stated above, CSOs consider UHC to be beyond the health sector and the Ministry of Health and want legislators at the county assemblies to be sensitized on the need to implement the budget to ensure there are resources for health. There is also a need for policy guidelines or frameworks to anchor the implementation of UHC in the country’s legal framework.

However, according to the CSOs leadership, the above ideas and contributions remain only on paper if their leadership is not invited by the government to join the structures and platforms where UHC issues are being debated. It is against this background that the CSOs also proposed a national forum on UHC spearheaded by non-state actors and which the state representatives are invited to engage.

For NEPHAK, this statement by the UNAIDS contains all the aspirations and hopes desired by the Kenya PLHIV community when it comes to UHC: The target of achieving universal health coverage is ambitious, but if met could be an important step towards ensuring that all people have good health and that HIV services are available for everyone who needs them. It is essential that efforts to achieve universal health coverage include a fully funded AIDS response and strong community engagement and that they build on the gains in human rights and gender equality made by networks of people living with HIV and key populations. For details, see: https://www.unaids.org/sites/default/files/media_asset/hiv-uhc-guide-civil-society_en.pdf

Combining statins and physical exercise has big benefits for people with HIV and high lipids

Statin treatment and physical exercise – including resistance training and cardiovascular workouts – has a range of benefits for HIV-positive people with high blood lipids, according to Brazilian research published in Medicine & Science in Sports & Exercise. Statins and exercise were individually beneficial, but the very best results were seen in individuals who combined the two. Lipids were reduced, as were markers of inflammation associated with an increased risk of cardiovascular disease, while body composition, cardiovascular fitness and muscle strength improved.

“This is the first study to evaluate the association of statins and exercise training in people living with HIV with dyslipidemia,” wrote the authors. “Although the results suggest an isolated intervention with statins or exercise training showed positive results, the combination of both was more effective.” Cardiovascular disease is a major cause of serious illness and death among people with HIV. Reasons include the aging of the HIV-positive population, the inflammatory effects of untreated HIV infection, lifestyle factors such as smoking, and also the side-effects of some antiretroviral drugs.

Treatment with statins can lead to improvements in lipids and also reduces systemic inflammation – both implicated in cardiovascular disease risk. Statins have shown to be safe and effective in people living with HIV. Previous research has also shown the benefits of physical exercise for individuals with HIV. These include reductions in lipids, improvements in inflammatory markers and also increases in lean body mass, muscle strength, and cardiovascular fitness.

Studies involving HIV-negative people have shown that combining statin therapy with an exercise regimen improves lipid and inflammatory profiles, while simultaneously improving physical fitness. Investigators led by Dr. Hugo Ribeiro Zanetti wanted to see if combining statins with physical exercise had similar benefits for HIV-positive adults with high blood lipids. All the participants had been taking antiretroviral therapy for at least a year and had an undetectable viral load. They also had confirmed dyslipidaemia (triglycerides of at least 150 mg/dL; total cholesterol of at least 190 mg/dL; LDL cholesterol of at least 130 mg/dL; and HDL cholesterol below 40 mg/dL).

At baseline and at the conclusion of the research the participants underwent a range of tests. These included assessment of body composition, blood lipids, cardiovascular and inflammatory markers, carotid artery ultrasound, muscle strength, and cardiorespiratory fitness. The average age of participants was 42 years. Most (51%) were male and white (72%). Hypertension was present in 22%, a quarter were diabetic and 31% were smokers.
BMI remained comparable between all four groups at the end of the study. However, improvements in lean body mass and body fat percentage were seen in the groups randomised to undertake physical exercise. Similar improvements were not observed in the placebo and statins-only groups. (These improvements and all those reported below were statistically significant.)

Improvements in all lipid parameters were observed in the statins, exercise/placebo, and exercise/statins arms. Moreover, improvements in total cholesterol and triglycerides among the exercise/statins group exceeded those observed in the statins and exercise/placebo study arms.

When compared to the placebo arm, major reductions in inflammatory markers were recorded in the statins, exercise/placebo, and exercise/statins groups. The exercise/statins group showed decreases relative to the exercise/placebo and statins arms. There were reductions in markers of cardiovascular risk in the statins, exercise/placebo, and exercise/statins groups compared to the placebo arm. “The present study…confirms that intervention with statins, exercise training, and the combination of both have a positive effect on lipid levels confirmed by comparison with the placebo group,” commented the authors. “The present results also demonstrate that exercise training is an effective non-pharmacological intervention for improving the lipid profile of people living with HIV independently of statin use; the mechanisms responsible for this improvement are related to enhanced lipid metabolism.”

The study investigators, therefore, concluded: “The present findings show that the combination of exercise and statins is useful to control the lipid and inflammatory profiles, reduce cardiovascular disease markers, and improve ultrasound findings, muscle strength and cardiorespiratory fitness in people living with HIV with dyslipidemia.”