The 2019 Annual General Meeting of NEPHAK shall now be held on the 24th August 2019 in Mombasa County. The new date was set by the board of the network after a full-fledged meeting. Members are therefore advised to plan for the AGM. This, as we stated earlier through this Bulletin, is in compliance with the NEPHAK constitution and the regulations of the NGOs Coordination Board. This year, NEPHAK will be deliberating on a number of issues included the populations left behind, HIV financing and PLHIV stigma Index 2.0. In particular, members of the network shall be exploring why some populations and especially men are being left behind in the delivery of the 90.90.90 HIV treatment targets. The team attending the AGM shall also sign on a communique on the need for increased HIV and health financing.
According to the NEPHAK constitution Article XII; Section 1, the network shall hold a General Meeting of all the registered members once every year to be known as Annual General Meeting (AGM). The agenda at the AGM shall be:
a) Confirmation of minutes of the previous AGM
b) The Chairperson’s report
c) The Treasurer’s report which must include the audited annual financial statements
d) Appointment of Auditors
e) The remuneration of Auditors
f) Approving major policy decisions that affect all the members and rules provided for under this constitution.
g) Such other matters as the Board may decide on, and for which, seven (7) days’ notice has been given in writing by any member, to the Secretary.
It should be noted that there shall be no elections of the board at the Mombasa AGM in August as this is slated for next year. The current board is still eligible to serve the network up to 2020. However, there shall be ratification and approval of the constitution to enable the network to comply with the new strategy and accommodate latest developments such as the nomination of the representative of adolescents and young people and key affected populations in the NEPHAK board. At the moment, there is such representation but not explicitly stated in the constitution. Members may also need to re-look at the clause on retention of out-going board members.
Another important aspect of the NEPHAK constitution is found in Section 2 which provides for Ordinary Meetings of the Board stating as below:
a) The Board shall hold at least four meetings every year, one meeting held each calendar quarter (at least every 3 months) and the Standing Committees of the Board shall hold meetings as specified in the Board policy manual.
b) Notice of ordinary meetings of the Board shall be in writing specifying the date, time, place and business to be conducted at the meeting and shall be given not less than fourteen (14) days before the date of the meeting.
c) A meeting of the Board shall not be invalidated by an inadvertent omission to give a member notice or non-receipt of a notice of the meeting. Subject to the approval of the Board, the Secretary may invite senior staff or consultants or any other persons to take part in its deliberations, but such persons shall not be entitled to vote. Subject to this clause, the Board may regulate the manner in which its meetings may be conducted.
d) In case of urgent matters, which require the approval of the Board, the Secretary shall consult the Chairperson on what action to take. The decision thus reached, shall be subject to ratification at the next Board meeting.
It should also be pointed out that Section 3: of the same article provides for a Special Meetings of the Board when:
a) The Chairperson, when so instructed in writing by more than 50% of the members of the Board, shall cause a special meeting of the board to be convened, which meeting shall be convened not sooner than seven (7) days and not later than thirty (30) days after receipt of the instruction.
b) Notice of special meetings of the Board shall be in writing specifying the date, time, place and business to be conducted at the meeting and shall be given not less than fourteen (14) days before the date of the meeting.
The coverage in this Bulletin is provided for under Section 4 on Notice of Meetings and which require that Notice of AGM shall be in writing and shall be sent to all members of NEPHAK not less than 28 days exclusive of the day on which the notice is served and/or posted, specifying the place, day, hour and agenda of the meeting; provided that if without an agenda or if called for a shorter notice, than that specified in this Constitution, it will nevertheless be deemed duly called if it is agreed by all members entitled to attend and vote, provided an agenda is approved. The accidental omission to give notice to or the non-receipt of notice of a meeting by any person entitled to receive such notice shall not invalidate the proceedings of that meeting. A separate communication shall be sent out to all members as stated above.
As we plan for the 2019 AGM in August, members shall be paying attention to Section 5 on Proceedings at Meetings and which outlines the below provisions.
a) The quorum for AGM shall be at least 50% of eligible members and the quorum for the Board shall be at least six (6) members present. No business shall be transacted at any Annual General Meeting, Special General Meeting or Board of Directors meeting unless a quorum of members is present at the time when the meeting proceeds to business. In the Annual General Meeting and Special General Meeting, members present in person or by proxy shall constitute a quorum.
b) If within an hour from the time appointed for the meeting a quorum is not achieved, the meeting if convened upon the requisition of members shall be dissolved, and in any other case it shall stand adjourned to the same day in the next month at the same time and place, and if at such adjourned meeting a quorum is not achieved, the members present shall constitute the quorum, provided that they are at least one third of the members entitled to attend and vote in that meeting.
c) The Chairperson or in his/her absence the Vice-Chairperson of the Board, if present, shall preside at every Annual General Meeting or Special General Meeting. In the absence of both and where their absence is communicated in writing and under their signatures, a member selected by the meeting shall take chair as ad-hoc Chairperson. If the Chairperson or his/her vice arrives when the meeting is in session, the active chairperson shall vacate the seat after completing the issue under discussion. Decisions made under an acting chairperson shall be valid.
d) The Chairperson may at his/her discretion limit the number of persons permitted to speak in favor of and against any motion. The chairperson of any meeting at which a quorum is present may, with the consent of the meeting, adjourn the meeting from time to time and from place to place but no business shall be transacted at any adjourned meeting other than the business left unfinished. When such adjournment extends to more than 30 days since the originally scheduled date of the meeting, a notice of the adjournment meeting shall be given as in the case of an original meeting.
Starting ART at a high CD4 cell count has clear benefits for people with a low viral load
Starting antiretroviral therapy (ART) has significant benefits and entails few risks for individuals with a low pre-treatment viral load, according to an analysis of results from a large treatment initiation study published in the Journal of Acquired Immune Deficiency Syndromes and which we have accessed through the Aidsmap (http://www.aidsmap.com/) online newsletter. (http://www.aidsmap.com/page/3540402/). This study adds on to the earlier studies that emphasized the importance of early initiation of ART.
According to the study, prompt initiation of ART was associated with robust increases in CD4 cell count, sustained viral suppression and favorable changes in inflammatory biomarkers. The investigators also calculated that treatment would have public health benefits by almost eliminating the risk of onward HIV transmission. The study involved patients with a baseline viral load below 3000 copies/ml recruited to the START (Strategic Timing of Antiretroviral Treatment) study. This unequivocally established the benefits of ART for patients with higher CD4 cell counts (above 500 cells/mm3). Treatment guidelines around the world, including in Kenya now recommend ART for all individuals, regardless of CD4 cell count.
However, a small number of individuals with HIV have a persistently low viral load even without the use of ART, leading some to question whether ART is necessary. Investigators from the START study examined their data to see if these patients benefit from therapy. From this study, a serious clinical outcome was observed in 64 patients in the immediate and 61 patients in the deferred group, a non-significant difference. Clearly, immediate therapy had clear benefits in terms of viral suppression. After twelve months of follow-up, 93% of patients in the immediate compared to 22% of those in the deferred group had a viral load below 200 copies/ml. There was evidence that viral load suppression below 50 copies/ml would not be maintained without ART.
CD4 cell counts increased among the patients who started immediate ART but declined among the patients deferring treatment. After twelve months of follow-up, mean CD4 cell count was 125 cells/mm3 higher in the immediate ART group and by month 36 this had increased to a mean difference was 235 cells/mm3. Nonetheless, regardless of study arm, CD4 cell count remained stable in the sub-group of patients with a baseline viral load below 50 copies/ml.
There was little difference over three years of follow-up between the immediate and deferred groups in the proportion experiencing serious changes in hemoglobin, platelet count, creatinine, ALT and kidney function. However, there were beneficial changes in several biomarkers indicating systemic inflammation in the immediate study arm, but not among patients who deferred treatment. In the sub-group with a baseline viral load below 50 copies/ml, these differences were not significant.
Finally, immediate treatment was calculated to have significant public health benefits. The investigators estimated that over twelve months the rate of onward HIV transmission would be 0.2 per 100 patients in the immediate group but 3.2 per 100 patients in the deferred group.
Even with just 93 individuals with a pre-treatment viral load below 50 copies/ml included, Dr. Irini Sereti and colleagues say that this is the largest randomized study of such individuals to date. For this group, a clear clinical benefit to starting ART was not observed, but neither was there evidence of harm. As clinical trials do not provide clear guidance on how to treat individuals with such rare disease phenotypes, they recommend that clinical decision making should be individualized and based on a partnership with the patient.
“In conclusion,” write the authors, “for most HIV-positive people with HIV RNA below 3000 copies/ml, although there are low numbers of clinical events, our analyses show that immediate ART results in suppressed HIV RNA, CD4 cell count increases, little evidence of increased serious clinical outcomes, and an estimated modest decrease in onward HIV transmission.”
Major TB reduction impossible without expansion of ART coverage
Tuberculosis incidence in sub-Saharan Africa is falling too slowly to meet global targets of an 80% reduction by 2030, and where incidence is falling, the decline is strongly associated with the extent of antiretroviral coverage in people living with HIV, a study by former World Health Organization modeling experts has found. The findings of this study bolster the critical role ART plays in the prevention of active TB disease.
The findings, published in the Bulletin of the World Health Organization in June 2019, and which we have gotten through the aidsmap (http://www.aidsmap.com/) online newsletter come from a modeling study carried out by Christopher Dye and Brian Williams. They looked at the relationship between TB incidence, diagnosis, treatment, HIV burden and antiretroviral coverage in 12 countries in sub-Saharan Africa with a high standard of TB and HIV surveillance data. See: http://www.aidsmap.com/page/3540044/
TB disproportionately affects people living with HIV, with immune suppression leading to the reactivation of latent TB infection. Countries with the highest prevalence of HIV also have amongst the highest TB incidence. Antiretroviral therapy reduces the risk of developing TB, as does isoniazid preventive therapy. With little evidence that TB diagnosis and treatment are leading to an acceleration in TB reduction, increasing the coverage of ART is important.
TB incidence and prevalence rose in all countries from 1990 as a consequence of the rise in HIV prevalence but began to decline as case detection and treatment outcomes improved. Antiretroviral therapy began to be introduced from 2003, although the rate of increase in coverage varied between countries. Overall, modelling found an inverse correlation between ART coverage and TB incidence, and regression analysis found that ART coverage was associated with a higher proportion of TB cases prevented in people living with HIV (r2=0.68, p< 0.001).
In contrast, isoniazid preventive therapy had a negligible effect on TB incidence despite strong evidence of effectiveness and guidance from the World Health Organization on the need to implement IPT. The researchers failed to find any correlation between the estimated level of case detection and TB incidence across the 12 countries. If case detection is higher, more TB cases should be diagnosed and treated, preventing onward transmission.
In conclusion, the authors say that TB incidence is declining too slowly to meet international targets. To meet the 2030 WHO End TB strategy’s target of an 80% reduction in TB incidence, the incidence of TB needs to fall by 10% a year. With little evidence that TB diagnosis and treatment are leading to acceleration in TB reduction, increasing the coverage of ART will make an important contribution to reducing TB incidence where the prevalence of HIV is high.
NEPHAK Weekly Bulletin is published by the Advocacy and Communications Office at the NEPHAK National Secretariat. Articles can be reproduced freely as long as NEPHAK is acknowledged. Further details can be obtained from The Editor Tel: 0720209694, Email:info@nephak.or.ke, Website: www.nephak.or.ke, Tweet us: @NEPHAKKENYA
