AA&D Executive Director Visits Russia for Project to Address Hepatitis C

Consultation with hospital head doctors in Vladimir, Russian Federation shed light on challenges and advantages of programs in the city

Consultation with hospital head doctors in Vladimir, Russian Federation shed light on challenges and advantages of programs in the city

On November 10, AA&D Executive Director Tom Nicholson visited the cities of Moscow and Vladimir in the Russian Federation as part of AA&D’s work to understand and address barriers to care for people with Hepatitis C (HCV).

In fall of this year, AA&D received funding to support a scoping project to understand the epidemiology of HCV in the Russian Federation and develop an actionable plan to address barriers to treatment for this disease. A core component of this work is to identify potential future paths for importation and delivery of direct-acting antivirals (DAAs), which are life-saving drugs that can cure what was once a chronic disease.

Nicholson visited Vladimir, a city of about half a million outside of Moscow, to meet with doctors, patients and former patients, policymakers, and leadership from local NGOs. The goal of this visit was to understand the scope of the HCV epidemic in Russia, as well as the challenges and opportunities related to logistical and financial barriers to patients benefiting from these new drugs.

An estimated 6 million people in Russia suffer from HCV, and the disease coincides with social and medical co-morbidities that can challenge access to effective care. Less than 2% of people receive care. And if treatment is received through the public sector, it is typically with older, less effective medicines. The reasons for limited access to treatment are complex, but include a limited selection of treatments that are registered in-country, as well as stigma related to social factors (e.g. drug use). The cost of treatment for HCV in Russia and in much of the rest of the world is often prohibitively expensive, forcing people to resort to other treatment options with questionable efficacy and safety. Compared to only a few years ago, the advent of DAAs has opened the opportunity to reverse the epidemic of HCV if comprehensive, cost-effective methods for care delivery can be identified and implemented.

Nicholson’s visit was focused on addressing barriers to effective treatment, with the goal of securing funding for ambitious projects that deliver high-quality care for patients. This work is an important step towards developing solutions for this pressing global health challenge in the near future.


Kenan Biddle Refugee Initiative team holds workshop with Center for New North Carolinians in Greensboro, NC


On Monday, November 12th, team members from the Kenan Biddle Refugee Initiative held a workshop at the Center for New North Carolinians (CNNC) in Greensboro, NC.

Over the past year, Kenan Biddle Refugee Initiative team members have worked with service providers, community health workers, volunteers, and refugee community members to develop a training handbook for people working to serve the refugee community and improve access to much-needed services. The purpose of the workshop was introduce a draft of the handbook to people who interface between service providers and community members, understand the strengths and shortcomings of the handbook, and find opportunities to improve based on the experiences of workshop participants.

The handbook development and workshop are funded by the Kenan Biddle Partnership, a joint funding opportunity between the University of North Carolina at Chapel Hill and Duke University to support collaboration between students from both schools to engage and support the Triangle Area community. Over the past year, AA&D and its partners at Refugee Community Partnership (RCP), CNNC, and other North Carolina-based service providers have collaborated to understand the landscape of services that are available and accessible to refugee communities. The handbook is expected to be finalized in December 2018 and shared with partners in response to expressed need for comprehensive training for community health workers, resource navigators, volunteers, and other people working to support the communities in North Carolina.

The workshop was hosted by the CNNC, a University of North Carolina at Greensboro center to promote access and integration for refugees and immigrants in North Carolina. CNNC aims to improve the delivery of services for newcomers to North Carolina while conducting trainings and research to further support North Carolinian communities.

More information on the Kenan Biddle Partnership, CNNC, and RCP and their programs are available on their sites.

Nobel Peace Prize Laureate Speaks at Duke

AA&D Executive Director and research partners met with Nobel Laureate Nadia Murad and fellow activist Abid Shamdeen on October 29.

AA&D Executive Director and research partners met with Nobel Laureate Nadia Murad and fellow activist Abid Shamdeen on October 29.

On October 29, Nobel Peace Prize Laureate Nadia Murad spoke as a part of the Crown Lecture Series in Ethics at Duke University.

Nobel Laureate Murad spoke about her work to end sexual violence as a weapon of war. As a member of the ethno-religious Yazidi community from Northern Iraq, she knows of the lasting trauma to individuals and the community that such crimes can cause. In the face of intensified persecution in recent years, she has founded a nonprofit, Nadia’s Initiative, as a platform to advocate for women’s and minorities’ rights, especially in emergency and crisis settings.

AA&D, in its partnership with Duke, initiated the work to bring Nobel Laureate Murad to the Triangle. The Crown Lecture event was a successful push to shed light on the urgent humanitarian crisis in Iraq. Already, AA&D and its partners at UNC Chapel Hill and Garmian University have established a research project to understand mental health needs and challenges in maternal and child service delivery among the Yazidi. This research began in mid-2018 among mothers and children in internal displacement camps. Looking ahead, this consortium hopes that momentum will continue to build attention and action to address the crisis facing thousands of Yazidis.

More information about the event can be found at the Sanford School of Public Policy’s feature here.

Nobel Peace Prize Laureate Nadia Murad to Speak at Duke

Nadia Murad Event.jpg

Nobel Peace Prize Laureate Nadia Murad is set to speak as a Crown Lecturer at Duke University on October 29.

As a member of the ethno-religious Yazidi community from Northern Iraq, she has been lauded for her work to end genocide and sexual violence, especially as a means of war. The Yazidi community has faced historic persecution and violence that has intensified in recent years. Her own experience of violence at the hands of ISIS has fueled her work to start a nonprofit, Nadia’s Initiative, as a platform to advocate for women’s and minorities’ rights, especially in emergency and crisis settings.

This event coincides with Advance Access & Delivery’s newly established project with researchers at UNC and Garmian University to  understand mental health needs and maternal and child health challenges among the Yazidi in Iraq. This consortium hopes that this event will foster growing attention and action to address this urgent humanitarian crisis. AA&D, in its partnership with Duke, started the push to bring Nobel Laureate Murad to the Triangle.

She will give the 2018 Crown Lecture in Ethics at Penn Pavilion from 5:30-7:00pm on Monday, October 29, followed by a reception and book signing. More event details can be found here.

AA&D partners with interdisciplinary team to support displaced families in Iraq

AA&D is among a team of researchers and global health practitioners who have partnered across North Carolina and Iraq to improve the delivery of critical health services for internally displaced persons (IDP) in Iraq.

This research project, “Closing the Delivery Gap for Internally Displaced Mothers and Children in Fragile Contexts: Perinatal Mental Health, Infant Feeding Practices and Malnutrition in Iraq,” seeks to understand and improve mental health services for Yazidi mothers and children who have been displaced by conflict in the country. Yazidis are an ethno-religious minority who have suffered extensively in past and ongoing conflicts in Iraq. Currently, most of the population is in displacement camps in Iraqi Kurdistan, and they lack access to basic services including medical care. The immediate and lasting effects of trauma are well-documented among the Yazidis, especially among women and mothers, yet there is little work being done to address this urgent need.

Alongside AA&D and included in this team are Dr. Aunchalee Palmquist, a UNC Chapel Hill assistant professor of maternal and child health and member of the Carolina Breastfeeding Institute, and Dr. Dilshad Jaff, adjunct assistant professor of maternal and child health and program coordinator for solutions to complex emergencies in the UNC Gillings School’s Research Innovation and Global Solutions Office. In Iraq, Dr. Pegah Seidi and Nazdar Qudrat Abas, both of the University of Garmian College of Education’s Department of Psychology, will collaborate in this project’s research and in-country implementation among IDP camps.

The goal of this project is to gather evidence of the ongoing trauma and mental health concerns among this population while prioritizing maternal and infant health in a complex emergency setting. This research will translate to more inclusive health delivery pathways that integrate maternal and child health with important, but overlooked, mental health support for severely traumatized mothers and infants.

“We are honored to take part in this work with UNC and Garmian University, to understand how to support these communities that have been through so much suffering and strife in recent years. This is a modest first step to identify how to assist in the provision of health care and social services to these Iraqi communities, in a spirit of solidarity and respect,” says Tom Nicholson, AA&D executive director.

A news announcement for this project from UNC Gillings School of Public Health can be found here, and an announcement from the Duke Center for International Development here.

Zero TB Initiative featured by New York Times Editorial Board

The Zero TB Initiative has “pushed beyond cynicism to forge a new consensus” towards comprehensive strategies to eliminate tuberculosis (TB), according to the New York Times editorial board.

The Zero TB Initiative, a global coalition of non-profits, research institutions, public and private entities, and patient advocacy groups, seeks to eliminate TB globally through its comprehensive approach. This “Search-Treat-Prevent” strategy emphasizes the need to search actively for people with TB, extend treatment all people who need it, and prevent further transmission and progression of the disease.

The Times article highlights the urgent need for action to eliminate this disease, which kills more than 1.8 million people annually, as well as recent successes in the fight to end TB accomplished by ZTBI partners. In light of the recent United Nations General Assembly meeting on September 26, which is one of only a handful of General Assembly meetings devoted to a single disease, there is new pressure on policymakers to direct much-needed resources towards researching and implementing effective strategies to combat TB.

An NYT Editorial Commentary is an important spotlight on not only the seriousness of the problem that TB presents, but also the clear way forward that has been successful when implemented in the past. The full article can be viewed here.

AA&D launches new project in South Africa linking TB services with NCD care

Durban, South Africa -- On July 9th, over 350 individuals from government, civil society, and the international community joined the Kwamakutha community in the South-Central sub-district of eThekwini to launch a 5-year linkage to care project for tuberculosis (TB) and noncommunicable diseases (NCDs). The event highlighted the importance of integrating screening and treatment for NCDs within the existing TB and HIV services in eThekwini. The event was attended by several high level officials from the National, Provincial, District Departments of Health as well as from the Municipal Health Office, including a keynote speech from Sibongiseni Dholo, MEC KwaZulu Natal.

This 5-year project, called NCD-LINK, is supported by Lilly Global Health and will be implemented in 10 public facilities across Umlazi, a sub-district of Durban. The project will be carried out by Advance Access & Delivery (AA&D) and its partners at Interactive Research & Development-South Africa (IRD-SA) and the South African Medical Research Council will lead the project’s monitoring and evaluation arm. NCD-LINK will build on TB and HIV infrastructure in KwaZulu Natal as a platform for screening and treating NCDs. The goal of the project is to expand access to these important medical services and hasten the delivery of care that people need.

Participants of this event were offered screening for TB, HIV, diabetes, and hypertension. Screening was provided by local teams from IRD-SA, the District Department of Health, and the Municipal Health Office. Project activities will begin later this year and will support the National Service Integration agenda as well as the National Wellness Campaign in which eThekwini is one of the high-burden sub-districts identified.

AA&D reports: Protests in Durban following needle exchange closure

Durban, South Africa

On Tuesday, a group of over 50 people marched in solidarity along Durbans south-central neighborhoods, raising awareness of the citys recent decision to suspend the only legal needle syringe program (NSP) in Durban.

Led by a local branch of South Africas Network of People Who Use Drugs, this peaceful demonstration brought together members from civil society, the local university, drug users, media, and members of law enforcement to show their support for a critical public health program serving the entire community’s interest to be a healthy, resilient city.

As participants danced, raised their voices, and sang traditional isiZulu songs of struggle, several onlookers said that they too knew someone who has become sick or even died because of sharing needles.

The city stated that a trade permit must be issued before the program resumes activity. The concern suggested was that needles and other materials provided by NSP programs pose a health risk to the community and that a proper disposal plan must be outlined before the program is reinstated.

The NSP, started by Monique Marks, a professor and human rights advocate who heads the Urban Futures Center at the Durban University of Technology, has served as a critical resource for over a thousand drug users seeking clean needles, counseling, and peer support.

Following the march, members of the TB/HIV care network and the Urban Futures Center delivered a public statement and petition to the Mayor’s office requesting that the NSP be reinstated as a critical program to support drug users, their families, and the communities where they live and work.

Note on the passing of our dear friend and AA&D colleague Aaron Plourde

A note from AA&D:

It is with great sadness that we at AA&D note the passing of our friend Aaron Plourde, who worked as our media officer from 2016-2018, from cancer. He was a generous, conscientious, and devoted friend who had a drive to help others in his work, from carpentry to communications, the wellbeing and happiness of others was at the front of his mind. In his spirit, we hope to continue to spread a message of hope and optimism in our work. Aaron leaves behind a wonderful family--  his wife Julia and two children.

Please consider donating in his memory to his youcaring site -- given the family’s long and costly battle against his cancer.


We will miss Aaron deeply.

The AA&D team in Durham and around the world

AA&D launches new tool to map global TB drug supply efforts

In March of 2018, Advance Access & Delivery (AA&D) and the Lilly MDR-TB Partnership launched the first of its kind, web-based platform, the TB Drug Access Atlas. This tool highlights over 40 global projects addressing challenges related to the supply and access of quality-assured, second-line drugs for MDR-TB. This interactive platform gives users a first hand look at the burden of MDR-TB at the global and country levels and showcases projects that are working to address one or more of the following seven market indicators: affordability, delivery challenges, forecasting, market incentives, procurement, regimen complexity and regulatory complexity.

One of the intended outcomes of this tool is provide a snapshot of where opportunities exists to leverage resources in a direction that will improve access to medicines for those most in need.

Projects captured on the TB Drug Access Atlas represent activities ongoing or planned between 2014-2020. The database is organized by market indicator and geography and will be updated at regular intervals throughout the year. Please send any questions or comments to tbatlas@advanceaccessanddelivery.org.


Kenan-Biddle Partnership team holds group discussion with community health workers in North Carolina

Members from the Kenan Biddle Partnership team met with a group of community health workers that are supported by the Center for New North Carolinians (CNNC) as part of ongoing discussions to better understand the challenges faced by refugees and immigrant communities when accessing healthcare and social services across the state of North Carolina.

This project is supported by The Refugee Community Partnership, a community-driven organization based in Carrboro, NC focused on intentional support for relocated families in North Carolina and Advance Access & Delivery, a non-profit based in Durham, NC committed to fighting double standards in healthcare policies and access to medicines.

The project aims to create a robust set of training materials that can be used by community organizations working to accompany individuals and families that are new to North Carolina. Through a series of interviews and focus groups, team members have met with volunteers, community health workers, and the leaders of refugee support programs to hear first-hand how they are addressing service barriers within their communities. The team will use this information collected to create a training package to be shared widely with community partners.

The team’s meeting in Greensboro explored the complexities that are often faced when working with refugee and immigrant communities to access even the most basic healthcare services. Several of the community health workers underscored the importance of resourcefulness, flexibility, and compassion in their roles.

Kenan-Biddle Partnership grant to help improve health and wellness among refugee communities


AA&D, in partnership with students and researchers at Duke University and the University of North Carolina - Chapel Hill, are working on an initiative addressing health and wellness among refugee communities in the Triangle area thanks to a Kenan-Biddle Partnership grant. While many state-supported services are available upon arrival, few are sustained beyond the first six months. Long-term, community-based support for refugee communities is often patchwork at best, leading to significant gaps in access to critical health and social services. This collaborative initiative aims to address these issues to improve overall refugee services.

Read more from Duke Center for International Development
Read more from UNC Gillings School of Global Public Health

AA&D and the Lilly MDR-TB Partnership to launch TB Drug Access Atlas


The TB Drug Access Atlas is an interactive, web-based tool for mapping the supply and access of quality-assured, second-line drugs for MDR-TB. This tool presents the burden of MDR-TB at the global and country levels, and highlights work currently being done or planned around the following seven market indicators: affordability, delivery challenges, forecasting, market incentives, procurement, regimen complexity and regulatory complexity.

Read more

Bangladesh Health Minister signs declaration officially launching Zero TB Initiative in Dhaka

Zero-TB Dhaka.jpg

On October 28, the capital of Bangladesh became the latest city to sign onto the Zero TB Cities Initiative. Advance Access and Delivery, is the current secretariat for the initiative, alongside other founding partners at Interactive Research and Development, Harvard Medical School, and the Stop TB Partnership at the UN.

Read more

AA&D report highlights pioneering efforts, imagines path toward comprehensive global care delivery for tuberculosis and diabetes


With the enormous burden across the world of both infectious diseases and non-communicable diseases (NCDs), health delivery programs need to be flexible but purposeful to address the multiple health challenges faced by individuals and communities. Despite much rhetoric about health systems strengthening and integration of health care services from national, international, and local health delivery programs, the detailed considerations in terms of policy and practice for even one area of this inquiry are many and complex.

A newly published report titled “Toward comprehensive global health care delivery: Addressing the double threat of tuberculosis and diabetes” offers examples and supporting data of settings where comprehensive programs are providing, or could provide, successful solutions to combatting multiple diseases in a way that is focused on patient care, efficiency, and strategic harmonization. This report focuses on diabetes, probably the largest public health challenge of the next several decades, and how it intersects with tuberculosis, the leading infectious killer of adults in the world.

With support from the Lilly Foundation, AA&D led a team of health delivery experts, academic faculty, and graduate researchers from Duke University Sanford School of Public Policy, University of North Carolina Eshelman School of Pharmacy, Partners In Health Russia, Harvard T.H. Chan School of Public Health, and Harvard Medical School Department of Global Health & Social Medicine in the writing and preparation of this report.

The authors focused on TB and diabetes, two disease areas in the top ten killers globally, to illustrate how even in a single overlapping and crucial area of global health care, the need for service integration, community-based solutions, inter-departmental and interdisciplinary cooperation, and quality improvement are pervasive and interconnected. They argue that a comprehensive platform is urgently needed to address global health challenges in coordinated fashion, rather than in administrative, academic, and institutional isolation.

“This deadly synergy manifests in programs, health systems, and patients’ bodies in many dangerous and challenging ways,” noted Tom Nicholson, lead author of the analysis.  “This report considers how a coordinated, patient-centered approach might function practically in several high burden countries in the immediate future. Tuberculosis and diabetes in these settings are often considered either too difficult or too expensive to deal with on a population level by health care authorities, but a glance at the near-term implications of inaction in institutional, financial, and mostly importantly human terms, shows that inaction is simply not an option.”

The hope is that reports such as this help strengthen responses in each of the countries profiled with high burdens of both diseases—specifically Peru, Russia, South Africa, and India. For example, contributing authors to the report attended the first national tuberculosis-diabetes conference “International Symposium on TB-DM comorbidity: challenges and opportunities” in Lima, Peru, in May. The event was organized by the Instituto de Medicina Tropical Alexander von Humboldt & CRONICAS from Universidad Peruana Cayetano Heredia, TANDEM,  and the London School of Hygiene and Tropical Medicine, with the support from the World Diabetes Foundation. AA&D Specialist and Contributing author Dr. Kei Alegria-Flores noted that “the Symposium highlighted academic and practical presentations on how TB and DM intersect across institutional lines; it was a long-awaited platform to start moving the needle on meaningful health systems strengthening across diseases in Peru.”

NPR Reports: Public Restrooms Become Ground Zero in the Opioid Epidemic


Opioid Crisis - In the News
With opioid users turning to public bathrooms for a secluded space to use, Many business owners and staff at public buildings don't know what to do. Some doctors, nurses and public health workers who help addiction patients argue any solution to the opioid crisis will need to include safe injection sites, where drug users can get high with medical supervision.

Read more at NPR


Cuban health leaders discuss care delivery strategy


Over a two-day workshop held April 26-27 at Duke Univeristy, senior level health officials from Cuba met with Duke Center for International Development (DCID) faculty, staff and students, along with representatives from Advance Access & Delivery (AA&D) – a nonprofit public health NGO headquartered in Durham, the Indiana Recovery Alliance – a harm reduction organization based in southern Indiana, UNC-Chapel Hill and Harvard University to discuss potential future work and collaboration related to health delivery and service provision in different settings.

The discussions focused on strengthening health care delivery for vulnerable and marginalized populations through the lens of the tuberculosis (TB), opioid epidemics, and social services for immigrant communities. Guests and speakers included Dr. Lourdes Suarez-Alvarez, head of the Cuban National TB Program; Dr. Raul Diaz-Rodriguez, head of Cuba’s National Reference Laboratory of TB; Dr. Jorge Pérez, adviser to the Cuban Ministry of Health and former head of Pedro Kourí Tropical Medicine Institute (IPK); Tom Nicholson MIDP'14, AA&D executive director and associate in research at DCID; Dr. Salmaan Keshavjee, director of the Harvard Medical School Center for Global Health Delivery-Dubai and vice president and senior clinical lead at AA&D; Phyllis Pomerantz, professor of the practice in the Sanford School of Public Policy; Jon Abels, DCID executive director; and Christopher Abert, founder of the Indiana Recovery Alliance.

“This is an opportunity to learn from the global south, where most innovations are coming from,” said Pomerantz, who kicked off the discussions. “There are countries where proposed solutions have been tried but were not successful. In Cuba, we see there has been success and other countries can learn from their solutions.”

Urgent public health challenges
This event highlighted two touchstone issues that underline the difficult work of social and health services reaching marginalized and vulnerable people. Every day, roughly 4,900 people die from tuberculosis (TB), or a total of 1.8 million deaths each year. In 2015, there were an estimated 10.4 million new TB cases (incidence). Though the disease has been nearly eliminated in the United States and other western countries, TB is now the leading infectious killer of adults worldwide.

Meanwhile, in the United States, opioid use and overdose is fueling the worst drug epidemic in the country’s history. Opioid overdose is now the leading cause of accidental deaths in the U.S., with more than 33,000 people losing their lives in 2015 alone.

These drivers of early death and disease disproportionately affect vulnerable and marginalized people across the world. Both issues are fraught with stigma and often make it more difficult for patients to seek appropriate care, and both face public policy headwinds that can undercut elimination efforts.

Cuba’s success in driving down TB
Cuba has some of the lowest TB rates — both for incidence and mortality — among any country in the world. According to Cuba’s Ministry of Health, the country had a TB incidence rate of 6 per 100,000 people, and a mortality rate of .4 per 100,000 people in 2016. As a comparison, the World Health Organization (WHO) reported that U.S. rates in 2015 were 3.2 and .18 respectively, and global rates were 142 and 19 respectively. 

Members of the Cuban delegation attributed its success to the country’s comprehensive epidemiological control strategy for diagnosing, treating and preventing TB. Additionally, they pointed to Cuba’s commitment to providing holistic, community-based care where doctors and nurses are closely involved in the lives of patients as a key driver for improving TB and general health outcomes. These practices make it a strong example that others could follow in the fight against this deadly infectious disease, attendees agreed. The case to emulate Cuba’s strategies is made stronger by the fact that the small island nation has achieved this despite periods of intense resource scarcity, particularly during the 1990s when Soviet aid was discontinued and TB rates tripled.

“The Cuban case shows that a community based health system that focuses on prevention and social support is particularly well positioned to end TB as a public health menace, even in challenging conditions,” said Nicholson. “Certainly, more money will need to be spent around the world to achieve this, but by using this approach the benefits will clearly extend far beyond any single disease.”

Eliminating TB through a comprehensive strategy
Many participants from both Harvard, UNC, AA&D, and DCID are affiliated with the  Zero TB Initiative and Zero TB Cities Project, which were founded to help create ‘islands of elimination’ of TB through a comprehensive epidemic control strategy known as the Search, Treat, Prevent Approach. Through the initiative, cities, regions, or even islands fight TB by actively searching for people with the disease, providing preventive therapy to people infected with TB and those belonging to high-risk groups, controlling TB transmission by routinely using the right tools for early and accurate diagnosis, providing immediate and appropriate therapy, and ensuring supportive programs are in place to help keep patients on therapy.

"For a long time, we in the public health community have ignored tried and tested epidemic control strategies, largely because of cost,” said Keshavjee. “Cuba is proving what can be achieved when there is real commitment and follow through in using a comprehensive strategy for controlling and eliminating TB.”

The initiative works to help communities move toward elimination in their own way and support is provided as needed through founding partner organizations, including AA&D, Harvard Medical School Center for Global Health Delivery-Dubai, Interactive Research & Developments and The Stop TB Partnership. It works to assist programs and encourage exchange between cities like Karachi, Pakistan; Chennai, India; Lima, Peru; Kisumu, Kenya; and others.

Delivering high-quality care
Throughout the two days, participants discussed strategies for improving access to high quality health care and medicines, particularly for economically and socially marginalized groups. Both the Cuban delegation and U.S.-based members agreed that future collaboration on TB and other diseases would be mutually beneficial and committed to further engagement.

“Events like this help to strengthen new platforms for south-south collaboration, while also informing wealthier health systems facing huge challenges of their own,” said Nicholson. “This is a very exciting first step."