Mary also opened the RCSI 29th annual international conference entitled, Integrating Care More Effectively: Unlocking the Potential of Nurses and Midwives, which examined the challenges currently facing the nursing and midwifery professions.  The conference was attended by more than 250 nurses and midwives.

The programme is being implemented by Lighthouse, an AIDS centre built by The Rose Project in 2006 and funded since then.

For many of these people, this is the first ever healthcare visit.

The individuals who are HIV negative, receive counselling and education about remaining  negative.

Those who test HIV positive, receive counselling and are treated on site, or referred to a centre for treatment.

5887 tested positive and are receiving treatment

1628 expectant women have tested positive and are now receiving treatment to prevent HIV transmission to their babies.

575 were referred for TB treatment.

(Seats are €100 including mulled wine reception and wine with lunch.  Reception at 12.30 for Lunch at 1 p.m.)

We would be delighted to see both new and familiar faces there. So if you would like to support the work of The Rose Project by attending, please contact Deirdre in The Rose Project Offices on 01-4969131 or email deirdre.naughton@roseproject.org

WHO now recommends earlier initiation of antiretroviral therapy (ART) for adults and adolescents, the delivery of more patient-friendly antiretroviral drugs (ARVs), and prolonged use of ARVs to reduce the risk of mother-to-child transmission of HIV. For the first time, WHO recommends that HIV-positive mothers or their infants take ARVs while breastfeeding to prevent HIV transmission.

“These new recommendations are based on the most up to date, available data,” said Dr Hiroki Nakatani, Assistant Director General for HIV/AIDS, TB, Malaria and Neglected Tropical Diseases at the World Health Organization.  “Their widespread adoption will enable many more people in high-burden areas to live longer and healthier lives.”

An estimated 33.4 million people are living with HIV, and there are some 2.7 million new infections each year. Globally, AIDS is the leading cause of mortality among women of reproductive age.

New treatment recommendations

In 2006, WHO recommended that all patients start ART when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of symptoms.

WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long-term, irreversible side-effects. Stavudine is still widely used in first-line therapy in developing countries due to its low cost and widespread availability. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives.

The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.

Preventing mother-to-child transmission and improving child survival

In 2006, WHO recommended that ARVs be provided to HIV-positive pregnant women in the third trimester (beginning at 28 weeks) to prevent mother-to-child transmission of HIV. At the time, there was insufficient evidence on the protective effect of ARVs during breastfeeding. Since then, several clinical trials have shown the efficacy of ARVs in preventing transmission to the infant while breastfeeding. The 2009 recommendations promote the use of ARVs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period.

WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARVs during that period.  This will reduce the risk of HIV transmission and improve the infant’s chance of survival.

“In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers, when they have access to ARVs,” said Daisy Mafubelu, WHO’s Assistant Director General for Family and Community Health.

National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care.

Benefits and challenges

An earlier start to antiretroviral treatment boosts the immune system and reduces the risks of HIV-related death and disease. It also lowers the risk of HIV and TB transmission.

The new prevention of mother to child transmission (PMTCT) recommendations have the potential to reduce mother-to-child HIV transmission risk to 5% or lower. Combined with improved infant feeding practices, the recommendations can help to improve child survival.

The main challenge lies in increasing the availability of treatment in resource-limited countries. The expansion of ART and PMTCT services is currently hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV-specific interventions within broader maternal and child health services.

The recommendations, if adopted, will result in a greater number of people needing treatment. The associated costs of earlier treatment may be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections.

Another challenge lies in encouraging more people to receive voluntary HIV testing and counselling before they have symptoms. Currently, many HIV-positive people are waiting too long to seek treatment, usually when their CD4 count falls below 200 cells/mm3. However, the benefits of earlier treatment may also encourage more people to undergo HIV testing and counselling and learn their HIV status.

WHO, in collaboration with key partners, will provide technical support to countries to adapt, adopt and implement the revised guidelines. Implemented at a wide scale, WHO’s new recommendations will improve the health of people living with HIV, reduce the number of new HIV infections and save lives.

Mary Donohoe warns that when we recruit healthcare providers to Ireland from developing countries where shortages exist, we cause deaths

The Rose Project is an Irish non-governmental organisation, founded in 2003 by former nurse Mary Donohoe. The organisation has raised significant sums of money and supports locally led healthcare programmes in Malawi.

Malawi is a landlocked country in southern Africa and ranks among the most densely populated and least developed countries in the world. With the majority of people living on less than $2 a day, life is a challenge.

Travelling around the capital city of Lilongwe and its rural surroundings, one is struck by the sinister poverty, with lack of healthcare being a major contributing factor.

HIV positive
According to official figures, 15 per cent of the population is HIV positive; however speaking with hospital staff and healthcare professionals generally, it is estimated to be considerably higher in urban areas.

Prior to the advent of HIV, the healthcare system in Malawi was severely challenged; with its arrival, it has been brought to its knees. Efforts to increase access to healthcare and to maintain and improve the quality of care are being severely hampered, due to the acute shortage of health workers and appalling conditions in the hospitals and health centres.

In relation to healthcare workers, the situation is at crisis level, with only one doctor per 100,000 people and 56 nurses. Nowhere is this more evident than in the area of maternal and infant mortality.

Malawi has the highest rate of maternal mortality for a non-conflict country, with one in 14 women losing their life in childbirth. The country also has one of the highest levels of vertical HIV transmission in Africa, resulting in 30,000 babies being born HIV positive each year. Few of these infants reach their second birthday.

To exacerbate the above, Malawi has one of lowest ratios of healthcare professional per patient in east Africa. The Rose Project is addressing all three problems.

Last month, Dr Mary Robinson and the Vice President of Malawi, Ms Joyce Banda, opened a new maternity hospital in Lilongwe on behalf of the Rose Project. This hospital replaces a shed-like building which was constructed in 1939 to facilitate 4,000 annual deliveries.

There are now 12,000 annual deliveries. Many of the women at the old hospital delivered their infants onto stone floors due to overcrowding and unassisted due to lack of staff. In addition, 25 per cent of the expectant women are HIV positive, many with AIDS. This places enormous pressures on existing services.

State-of-the-art facility
While the new hospital is a state-of-the-art facility and the first of its kind in Africa to afford each couple a private room for the birth of their baby, it still has only has only one resident obstetrician and three qualified midwives for 12,000 annual births. To place this in context, the National Maternity Hospital in Dublin has 9,000 annual deliveries with 18 obstetricians and 138 midwives. The challenge is enormous.

Thirty thousand infants are born HIV positive in Malawi each year. This is preventable, however the greatest challenge is the shortage of healthcare workers to implement the necessary initiatives.

In 2006, the Rose Project funded the Lighthouse AIDS Clinic in the centre of Lilongwe. Prevention of HIV transmission from mother to child has been central to the care provided at this facility.

Co-funded by Irish Aid
In 2008, in an effort to bring PMTCT (preventing-mother-to-child transmission) to the rural areas The Rose Project awarded a three-year grant to Lighthouse Clinic. To date, the clinic has successfully implemented PMTCT at 30 of the 40 healthcare centres. This programme, which is being co-funded by Irish Aid, is working well but has serious challenges due to the shortage of healthcare workers at the centres.

Finally, many healthcare workers are themselves unwell having been infected in the workplace with TB/HIV or succumbed to the virus themselves. These individuals need to be cared for in a confidential and safe environment.

Wellness centres for healthcare workers are an initiative of the International Council of Nurses in Geneva and have been proven most successful in halting the attrition rate of healthcare workers in Lesotho and Swaziland, where they have been in operation for some time.

Critical shortage
Last month the Rose Project funded a new Wellness Centre in Lilongwe, which was opened by the Vice President of Malawi. Undoubtedly, the principal challenge to safe motherhood in Malawi is the critical shortage of healthcare professionals.

Africa has 25 per cent of the global disease burden with only 2 per cent of the global workforce. No one denies that developing countries, including Malawi, need to take the lead in providing solutions to this acute shortage of healthcare workers.

Despite limited resources, the Malawian government is attempting to do this; however given the huge level of illness created by the AIDS pandemic, they are keen for international support.

Ireland has one of the most highly skilled medical and nursing workforces in the world. According to UNICEF’s latest figures, Ireland is the safest place in the world to have a baby. Given this remarkable achievement, surely there is a great opportunity and an urgent need for individuals, medical and nursing institutions to become involved in what is now acknowledged to be one of the greatest tragedies of our time — the level of maternal and infant mortality in the developing world.

As a country we have benefited and continue to benefit from foreign healthcare workers, in some cases to the detriment of local healthcare systems. How much of this recruitment is ethical is questionable.

Everyone has a right to access the global labour market; however it is important to remember that few of these workers wish to leave their families and countries. They do so out of need. This need often fills gaps in healthcare systems in rich countries where investment in training has been insufficient.

We need to understand that the recruitment of healthcare workers from developing countries, where critical shortages already exist, is causing deaths. If recruitment must continue, it should be carried out in a fair and equitable manner in consultation with local governments; after all, for the most part they are funding the undergraduate training.

The Rose Project
Over the past 6 years the Rose Project has funded 28 HIV-related programmes in six east African countries, reaching approximately 200,000 people with treatment and care, including five new healthcare centres, medical/nursing training and salaries, large scale prevention programmes, nutrition, drugs and transport.

Mary Donohoe trained as a nurse in Saint Vincent’s University Hospital Dublin and is a governor of the National Maternity Hospital Dublin

For further information please visit: www.roseproject.org

UNAIDS and the World Health Organization released its annual AIDS Epidemic Update on 24th November, indicating that 33.4 million people were living with HIV in 2008, up slightly from 2007. The higher figure is credited to increased availability to treatment allowing more people to live longer. Overall, the data indicates that new infections have dropped 17 percent over the past eight years.

Despite areas of progress, worrying gaps exist. The report indicates that children still account for 2.1 million of people living with HIV. This is a human rights issue. It’s a human right that a child can grow up to become an adult and yet half of children with HIV die before their second birthday. The reason:  they live in poor countries where access to adequate care is limited.

400,000, children each year are still being newly infected, as a result of mother to child HIV transmission in pregnancy. This is preventable. If you place a HIV positive expectant woman on treatment during her pregnancy, the risk of the virus being transmitted to her infant is almost eliminated. However, the majority of pregnant women to not know their HIV status - they need to have access to testing and where HIV positive – the treatment

The Rose Project is funding major project in Lilongwe the capital of Malawi to prevent mother to child HIV transmission in pregnancy. The project entails the provision of HIV testing at the forty antenatal clinics surrounding the capital city and where necessary, treatment for the women. To date 4,000 HIV positive expectant women have been placed on treatment.

This annually released report demonstrates that AIDS remains a global health priority that needs concerted effort. It’s complexity also means we have to address the root causes of vulnerability, encourage responsible behavior, and promote universal access to health care and treatment for all in need. Universal access is not about geography, it’s about humanity.

‘UNAIDS is fully committed to stop violence against women and girls. The response to HIV provides an opportunity to reduce intimate partner and sexual violence and develop comprehensive responses to gender-based violence and HIV prevention within and beyond the health sector.

There is strong evidence of the links between gender-based violence and HIV. According to a 2006 report by United Nations Secretary-General, one out of every three women around the world has been beaten, coerced into sex, or otherwise abused in her lifetime, usually by someone known to her.

“We need to scale up effective programmes which promote gender equality at country level and invest more in building-up the evidence base,” said Michel Sidibé, Executive Director of UNAIDS. “Policies and programmes addressing gender inequality and gender-based violence will help achieve our universal targets for prevention, treatment and care. Investment in responses is an essential part of HIV programming.”

Mary

5th October
I arrived in Lilongwe, with board member Father Enda Mc Donagh who I had met up with in Johannesburg. Fr Mc Donagh has been an advisor to The Rose Project from the beginning and brings a wealth of experience and knowledge, given his time as advisor with Caritas International HIV section.

6th October
We began the morning with a visit to the old hospital. For anyone not familiar with this facility, it is difficult to take on board the appalling conditions, with many women lying on the floor and giving birth also on the stone floor. From here we went straight to the new hospital-what a contrast. Then we met with the clinical staff at the Lighthouse clinic which is next door. This HIV and AIDS clinic which was funded by The Rose Project, opened its doors December 1st World AIDS Day 2006. Since its opening, it has placed 8,000 patients on treatment, many of them expectant mothers.
We then headed to the new Wellness Centre, a healthcare facility funded by The Rose Project for healthcare workers, many of whom themselves are sick and need support and treatment. Holistic care will also be available to their families. Wellness Centres are the brainchild of the Swaziland Nurses Association and are now in operation in Zambia, Lesotho, Malawi and Uganda. They have been successful in supporting healthcare workers and in turn reducing the attrition rate from these countries. We met Dorothy Ngoma the Director of the Wellness Centre in Malawi and discussed the plans for the official opening.
We then headed to the rural HIV and AIDS programme in Likuni, this programmes which The Rose Project and CAFOD (sister agency of Trocaire) co-fund is experiencing difficulties due to cuts in funding. Whilst the patients receiving treatment are doing well and Home Based Care is not as much in demand, other critical issues are coming to the foreground, such as child abuse and domestic violence. These are areas which The Rose Project and CAFOD will seek to address in the coming months
In the afternoon, three members of the board arrived and joined me at the Irish Embassy for a reception at 7pm. The Irish ambassador, Mary Robinson and the vice President attended the reception. It was a good opportunity to meet other individuals and organisations working in the area of healthcare in Lilongwe.
Following the reception Mary Robinson joined me and the other board members for dinner.

7th October
Opening of the new 146 bed Bewail maternity hospital.

5am
This was a stressful morning, as my computer crashed and I lost part of my speech, however thankfully Julie my daughter managed successfully against a ticking clock, to sort out the problem out.  In addition, The Rose Project members had not anticipated was that all traffic would be stopped to allow the President’s car to move freely as the opening was a state occasion with full honours!
This produced complete chaos, with road blockages within miles of the hospital. As a result we had we considerable difficulty in reaching the hospital on time.
Thankfully, Billy our taxi driver put on his hazard lights and overtook all the cars until we were stopped by the police, at the round about before the hospital. Billy assured the police that we were VIP’s attending the opening and we got through. However the car behind had a little more difficulty in persuading the policeman and it was not until Julie produced my speech to him, which began by addressing the Honourable Vice President Joyce Banda ,that he allowed them through!

The event was absolutely wonderful and it was clear great effort had gone into the organisation. There was singing, dancing and theatre all carrying themes with an emphasis on the human rights aspect of maternal mortality. Malawi has one of the highest rates of maternal mortality in the world and this is for the most part due to the lack of healthcare available to women in pregnancy. Shortage of healthcare workers and infrastructure are the principal obstacles.
There were a large number of humanitarian organisations at the event, many interested in building on the work of The Rose Project in Lilongwe-both at a rural and district level.
After a wonderful morning we headed to a restaurant for lunch and entertained Rachel our representative in Lilongwe, who has worked around the clock to get the hospital ready on time for the opening. Dr Ndovie the district Health Officer also joined us.

8th October
The Vice President joined Dorothy Ngoma and other members of the Malawian Association of Nurses and Midwives to open the new Rose Project funded Wellness Centre. Dorothy is the Director.
This centre will focus on holistic care for healthcare professionals and their families. Due to the level of illness created by the HIV pandemic, healthcare workers in many African countries suffer from stress. In addition many are themselves unwell and require medical care in a confidential environment. Wellness Centres is an initiative of the Swaziland Nurses Association and are operational in Lesotho Zambia and Uganda where they have been successful in addressing poor healthcare amongst workers. In addition these centres have been successful in addressing the attrition rate. There will be a satellite Wellness Centre at the new maternity hospital.
The medical sub committee of The Rose Project met with the clinical staff of Lighthouse, to examine the results of the first year of the HIV counselling and testing in the rural health centres, this programme has a strong emphasis on Prevention of Mother to Chi8ld HIV Transmission. Possibilities were discussed on how the programme could be further enhanced. With 90,000 people having been tested in the first year of the three year programme and 4,000 referred for treatment, it was agreed that the first year has been a success.
The Lighthouse staff explained that each test carried out is of huge importance whether positive or negative. In a country where HIV prevalence is so high, each person who tests negative is given a pack with all the important information on how to remain negative. Of course those who test positive receive extensive counselling for both themselves and their families.

9th October
The Rose Project group headed started out early to visit one of the district health care centres in Lilongwe. Here we saw at first hand the HIV counselling and testing in Rural Areas programme which The Rose Project is funding with Irish Aid. This programme presently runs from 28 centres and is in its second year. We hope to expand to the remaining 13 centre this year. We have provided Lighthouse who is running the programme with extra motor bikes and this will make things easier to organise.
To date 90,000people have been tested, those who have tested negative are counselled on how to remain negative- in a country with had a HIV infection rate of 15% and in some areas higher, this is very important. Additionally this is the first entry into the medical system for many people who are in need to medical care.
For those who test positive a counselling treatment and care programme is commenced. 4,000 have tested positive many of whom are young expectant mothers. If these mothers are placed on treatment at 26 weeks firstly they will be cared for, in addition the chance of transmitting the virus to their infant is almost eliminated.

10th October
I had a meeting with Dr Address Malatta, Principal of Nursing at the University of Malawi, about the plans for The Rose Project and Haukeland University Hospital to fund the training of additional midwives through the University. This programme will start in December 2010 and when the training is complete these midwives will work at the new maternity hospital for a minimum of two years.

11th October

Trip to the rural clinic
This morning, Julie my daughter and Fr Enda accompanied me once again to the rural HIV and Aids programme in Likuni district. Massiye and Margaret the programme co-ordinators introduced us to a support group and we spoke with many of the members. Years ago all these people would have been in very poor health as there were no AIDS drugs available to economically poor people.  However with the advent of drugs to Malawi in 2004, the situation has dramatically improved.
The principal issue for the female members was domestic abuse and it was very difficult to hear their individual accounts of this violence. There were also men attending the group with their equally pressing issues.
However there was certain hesitancy among some of the women to speak in front of men for fear of further difficulties.  Malawi is remarkable patriarchal, in terms of governance and social organisation.
Some of the women in the group were expecting a child and are on The Rose Project funded prevention of mother to child HIV transmission programme.

This afternoon we visited the Wildlife Sanctuary and saw many beautiful animals that have been injured in some way. The area of captivity is huge and a beautiful sylvan setting. It was coming up to sundown and light in the sanctuary was spectacular.

A fitting end to a successful trip

Mary

Please check in later on to see photographs of the first newborns!!!

Deirdre