[Evaluation of France's contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria: Ten years later]. / Évaluation des contributions françaises au Fonds mondial de lutte contre le sida, la tuberculose et le paludisme : dix ans après.

For 30 years, France has been very committed politically in the international combat against AIDS. The discovery of the AIDS virus at the Pasteur Institute in 1983, the AIDS summit meeting convened by Simone Veil in 1994, the excellence of research by French institutions on its virologic and other aspects as well as the socioeconomic and anthropological issues, and the strong commitment to international technical cooperation against this disease - all these have made (and continue to make) France a major political, technical, and financial participant in this battle against the combined pandemic of AIDS and tuberculosis. More than 10 years after the creation of the Global Fund, 5 years after the first evaluation of this Fund, and 2 years before the schedule for meeting the Millennium Development Goals, an assessment commissioned in 2013 from a French consulting firm of the French contributions is timely. The study was expected. Its results are disappointing. Why? Because the team chosen to conduct the assessment has a limited knowledge of the history of the interventions already funded by France and of the results of earlier assessments. The point was not to repeat the same observations but to move forward to see where they lead. In addition, the current and coming challenges are not considered. The countries to which France is providing cooperation are on the continent that after 30 years remains the most heavily affected by the pandemic. Several transitions are occurring there simultaneously: epidemiologic, demographic and urban. These metamorphoses influencing social values quite substantially, as well as risk factors for transmission of the AIDS virus; at the same time, they facilitate overcrowding and the propagation of tuberculosis. Nor do the authors consider the resistance of these infectious agents to the most commonly used drugs. The effects of the propagation of AIDS, of the expansion of armed conflicts in French-speaking Africa and of the sexual violence alongside them are not mentioned, while France is intervening militarily in Mali! I use the observations of this assessment to discuss all these questions.

[The Global Fund to fight HIV/AIDS, TB and Malaria 5-y: evaluation policy issues]. / Enjeux politiques de l'évaluation à cinq ans du Fonds Mondial de lutte contre le Sida, la tuberculose et le paludisme.

The Global Fund to fight HIV/AIDS, Tuberculosis and Malaria (GFATM) was founded in 2002 in the context of increased political and financial commitments towards health and development, in the aftermath of the Millennium Declaration, and on track to implement the Millennium Development Goals (MDGs). As of today, the institution has mobilized over 16 billion US dollars through its partnership, and spent over 8 billion dollars through 620 contracts in 140 countries for these three diseases. Principles at inception were to accelerate and expand HIV, TB, and Malaria prevention and awareness, care, and treatment related activities, in the poorest and the most affected countries worldwide, with a special emphasis on Africa, being the continent with the highest disease burden, especially with respect to HIV/AIDS and its dreadful social and economic consequences. In 2006, a Technical and Evaluation Reference Group was set up. This group responding to the GFATM Board in relation to the 5-year evaluation, defined the Terms of reference for the 5-year evaluation. Macro International, a firm based in Washington DC, was given the contract to conduct three studies over the period 2006-2009, looking at: (i) GFATM organizational effectiveness, (ii) partnerships at international and global levels, as well as systems effects, (iii) collective impact of the GFATM, the World Bank and (PEPFAR) funds on HIV, TB, and Malaria control. Twenty-five countries participated all together in the evaluation, out of which 18 in study area 3. Total budget for the evaluation amounted almost 17 million US dollars. This paper outlines: (i) the results of study areas 2 and 3 as well as the 5-year Evaluation Synthesis report, contents, and (ii) comments on the results and potential policy implications of the GFATM 5-year evaluation findings, as well as first responses prepared by the GF Secretariat shared at the GFATM Board meeting held in Ethiopia in November 2009. The evaluators raised the weaknesses of national health information systems, which limit the availability of reliable data and indicators that could be useful in assessing disease control impact as well as in monitoring the progress through management for result initiatives. Nevertheless, it can be shown that increased funding is linked to expansion of preventive interventions (including Voluntary Counseling and Testing (VCT) and preventing mother-to-child transmission (PMTCT)) as well as treatment (ARV) activities, the quality of which could be improved and better monitored. Especially in Eastern Africa, malaria control has improved significantly, benefiting from additional funding. Health systems' weaknesses at district level, such as human resources, laboratory commodities, and medicine shortages, are major constraints to further expansion of services and impact of funds. Issues at stake are the following: (i) soundness of the GFATM assumptions at inception with respect to national disease control strategies, especially in relation to HIV prevention, (ii) whether it belongs to the GFATM to finance health systems strengthening to start with, (iii) GFATM systems effects, (iv) misfinancing in relation to disease burden, marginalized and vulnerable groups, (v) technical expertise identification, mobilization and financing, (vi) equity of access of funding, expertise and guidance, to francophone countries in Africa. Recommendations are made to bring the attention of the GFATM Board members prior to the Replenishment Conference to be prepared in March 2010 and held in October 2010.

[The Global Fund to fight HIV/AIDS, TB and malaria policy issues]. / Enjeux politiques de l'evaluation du Fonds mondial de lutte contre le sida, la tuberculose et le paludisme.

The five-year evaluation of the Global Fund to fight HIV/AIDS, TB and malaria (GFATM) was carried out by a Consortium of several Universities and institutions, led by a consulting firm based in Washington DC. Evaluation focused on three study areas: (i) organizational efficiency and effectiveness of the Global Fund, (ii) effectiveness of the Global Fund partner environment, (iii) system effects of the Global Fund and impact of increased funding on the level of response to the three diseases. Findings can be summed up as follows: the Global Fund has been successful in mobilizing additional funding and in attracting new players. However, the demand-driven model used for allocation of funding is poorly adapted to epidemiological profiles with regard to population, persons at highest risk, and number of persons affected by the disease. The partner environment of the Global Fund, involving UN technical partners and institutions cooperating in development has failed to produce planned results due to weak institutional capacity of recipients and health systems overall, as well as little synergy and coordination work between international partners. Increased financial resources have allowed rapid expansion of prevention and care services for the three diseases. Spectacular results have been achieved against malaria in Eastern African countries, but little progress has been made in the collective effort to slow down the spread of HIV/AIDS. In preparation for the upcoming Replenishment Conference of the Global Fund and prior to any further decisions to expand the use of innovative financing instruments for development, the author of this article calls the attention of policy-makers on the need to ensure the development of accompanying strategies to increase the effectiveness and impact of these instruments.

[1986-2006: 20 years of failed international policy to control AIDS in Africa]. / 1986-2006: 20 ans d'échec des stratégies internationales de lutte contre le sida en Afrique.

Agencies of the United Nations and other international organizations involved in fighting AIDS in Africa have been wrong for 20 years. Despite this failure that was publicly avowed for the first time by a high UNAIDS official in Brazzaville in March 2006, the international community continues to propose a strategy based exclusively on organizational and financial solutions for a highly complex human tragedy that requires a much more comprehensive, coordinated public health approach. Organization of the fight against AIDS has taken many forms over the period between 1986 and 2006. The WHO Global Programme against AIDS program initiated only five years after the beginning of the epidemic in the United States was followed ten years later by the joint United Nations program named UNAIDS. The period between 2000 and 2006 saw a growing number of worldwide initiatives outside the framework of the United Nations. With programs based on cooperation of bilateral agencies, the European Commission, and the World Bank with expert technical agencies and civilian representatives, the whole international community felt that they were "in the driver's seat ". However analysis of the strategy deployed against AIDS during this period shows a shift from "total emphasis on prevention" (1986-1996) to "total emphasis on ARV treatment" (1996-2006). This shift occurred with no assessment of the benefits of the previous strategy for the main users, i.e., the populations of Africa and health care officials. Financial pledges have considerably increased in the context of global public partnerships such as the Global Fund against HIV/AIDS, TB and Malaria, with no change in the overall strategic vision to control the pandemic. There has been a total lack of planning and leadership in controlling the pandemic. Even though we failed to treat 3 million people before the end of 2005 within the framework of the "3x5" initiative despite the availability of ARV in Africa since 1998, WHO called for "universal access" in Toronto in 2006. But how can we achieve this? The time has come to assess the results of the last 20 years, to share the lessons drawn from this experience, and to develop effective research to control a scourge that annually produces 5 million HIV-positive persons including mainly women and children in Africa. We must implement measures to reach Objective 8 of the Millenary Declaration on which relies the achievement of the other objectives.

[Issues on user participation in health care management in Africa]. / Questions autour de la démocratie sanitaire en Afrique.

The 1990s witnessed great progress in increasing community participation in the management of health care services as an objective for reform of healthcare systems especially in urban areas benefiting from funding from the international community. Community participation has taken various forms from one country to another in terms of sources of healthcare training (public, private, or both), organization of management committees (inclusion or not of healthcare personnel), and scope of public service assigned to district health care units (preventive and/or curative care, management of proceeds from provision of health care procedures and/or medication, etc.). These strategies have had variable results and, although some urban programs have been evaluated, no attempt has been made to use this experience as a basis for analyzing the political implications of issues involving citizenship and public health. This report presents some ideas on these issues from the point of view of both governments and citizens and restates the purpose of user participation in healthcare services in Africa. That intent involves the need not only to increase household contributions to the cost of healthcare especially within the uncertain economic environment of urban areas but also to improve access to as well as quality of healthcare services.

Questions autour de la democratie sanitaire en Afrique

The 1990s witnessed great progress in increasing community participation in the management of health care services as an objective for reform of healthcare systems especially in urban areas benefiting from funding from the international community. Community participation has taken various forms from one country to another in terms of sources of healthcare training (public; private; or both); organization of management committees (inclusion or not of healthcare personnel); and scope of public service assigned to district health care units (preve n t ive and/or curative care; management of proceeds from provision of health care procedures and/or medication; etc.). These strategies have had variable results and; although some urban programs have been evaluated; no attempt has been made to use this experience as a basis for analyzing the political implications of issues involving citizenship and public health. This report presents some ideas on these issues from the point of view of both governments and citizens and restates the purpose of user participation in healthcare services in Africa. That intent involves the need not only to increase household contributions to the cost of healthcare especially within the uncertain economic environment of urban areas but also to improve access to as well as quality of healthcare services

[The campaign against AIDS in west Africa: what perspectives at the end of the century? From the situation of the Cote d'Ivoire as observed from the period 1987-1997]. / Lutter contre le SIDA en Afrique d l'Ouest: quelles perspectives en cette fin de siècle? A partir du cas de la Côte-d'Ivoire observé sur la période 1987-1997.

WHO is commissioned to create the World AIDS Program and to elaborate the strategy for the fight against the AIDS pandemic. The standardised strategy for African countries developed in Geneva in 1987 favours the prevention of sexual transmission of HIV without communicating the methods for such. The external and exclusive nature of the technical intervention of WHO and the lack of its adaptation to the dynamics of the epidemic in the 90s, (increase in seroprevalence among pregnant women, increase in the number of sick and HIV infected children, and economical and social consequences of the disease) explain in part the fact that the objectives haven't been reached on the continent a decade later. It seems important to us that the national authorities take responsibility concerning the development of an integrated strategy for AIDS prevention-care that takes into account the determinants of the propagation of the virus in Africa, advocates widespread access to testing-counselling for the general population and pregnant women, provides training for all health personnel concerning care for infected people, and promotes the implementation of social mechanisms for the future and financing for care, including symptomatic treatment for opportunistic infections.

Mother-to-child transmission of human T-cell lymphotropic virus types I and II (HTLV-I/II) in Gabon: a prospective follow-up of 4 years.

SUMMARY: For 4 years. we determined the mode and risk of mother-to-child transmission of HTLV-I in a prospective cohort of 34 children born to seropositive mothers in Franceville, Gabon. We also determined the prevalence of antibodies to HTLV-I/II in siblings born to seropositive mothers. Antibodies to HTLV-I/II were detected by Western blot, and the proviral DNA was detected by the polymerase chain reaction (PCR). The risk of seroconversion to anti-HTLV-I for the 4 years of follow-up was 17.5 percent. Anti-HTLV-I/II and proviral DNA were only detected after age 18 months. We observed a seroprevalence rate of 15 percent among the siblings born to HTLV-I/II seropositive mothers. Furthermore, we report a case of mother-to-child transmission of HTLV-II infection in a population of HTLV-II-infected pregnant women that is emerging in Gabon. The lack of detection of HTLV-I/II proviral DNA in cord blood and amniotic fluid and, furthermore, the late seroconversion observed in the children indirectly indicate that mother-to-child transmission occurred postnatally, probably through breast milk.

[Blood transfusions in Africa during the AIDS epidemic. Condition of localities and perspectives in the Ivory Coast]. / Réflexions sur la transfusion sanguine en Afrique au temps de l'epidemie de SIDA. Etat des lieux et perspectives en Côte-d'lvoire.

HIV is transmitted essentially by the heterosexual route in Africa. As part of an international mobilization against the Aids epidemic, information, education and communication strategies should continue to reduce the frequency of the infection. In this paper, we underline the high risk of HIV infection from blood transfusion in Africa. Although few epidemiological data are available, we feel that this problem should be made a priority, and that blood transfusion in Africa can be made reasonably safe by rational use of limited resources. We first report how the Ivory Coast health ministry, with funding from the European Community, has organized blood transfusion services in the main urban areas. Despite routine screening tests, the risk of HIV transmission through blood products remains high because of the large number of infected donors who are antibody-negative. The accent must thus be placed on alternatives to blood transfusions, while the use of transfusions must be minimized, especially in pediatric and general medical wards. As malaria, undernutrition and obstetric surgery are leading causes of anemia, health programs should be aimed at controlling these factors with the ultimate goal of limiting the spread of HIV.

Genetic variability affects the detection of HIV by polymerase chain reaction.

Nine isolates of HIV-1 obtained from Congolese AIDS patients were amplified by the polymerase chain reaction (PCR) using primer pairs and oligomer probes derived from the HIV-1 LAV-BRU (BRU) sequence. When compared to BRU, two isolates exhibited a significant decrease of PCR efficiency with a given primer pair. Moreover, the DNA amplified from two other isolates did not hybridize with the corresponding probe despite efficient PCR. Base substitutions were detected in the regions of proviral genomes involved in oligonucleotide annealing and were assumed to be responsible for the failure of both amplification and probing. Our data confirm that the genetic variability of HIV-1 may reduce the efficiency of PCR as a diagnostic procedure, especially in the case of African isolates.

Interpretation of antibodies reacting solely with human retroviral core proteins in western equatorial Africa.

Out of 4176 sera from asymptomatic adults originating from Chad, equatorial Guinea and Gabon tested for HIV-1 antibodies, 146 (3.5%) were positive by an enzyme immunoassay (EIA). By Western blot (WB), 20 (0.5%) were positive, i.e. with antibodies to the core and the envelope proteins, 96 (2.3%) were indeterminate, i.e. with antibodies to the viral core proteins only and 30 (0.7%) were negative. On testing for HIV-2 by WB, two of the 96 indeterminate sera had antibodies to the HIV-2 envelope glycoproteins. Two complementary tests were used: a radioimmunoprecipitation assay (RIPA) and a HIV EIA recombinant assay (ENVACOR) to check 53 of these indeterminate sera. Forty-one were positive for the p25 protein in RIPA, of which 34 were negative in ENVACOR; six were positive for core proteins only and one was positive for envelope and core proteins using this assay. Twelve of the 53 indeterminate sera were negative in RIPA, of which 11 were negative and one positive for core proteins in ENVACOR. Thus, 42 of these sera remained indeterminate even after the two additional tests which did not allow a distinction between retroviral infection or non-specific reactions. We were able to isolate an unusual HIV-1 virus from lymphocyte cultures of two subjects presenting antibodies directed only against the core proteins.