January, 2003
Richard Marlink, MD
Harvard AIDS Institute

From The Art of War:
-Sun-tzu, Chapter 1 - Making Plans
The Art of War

-Sun-tzu, Chapter 1 - Making Plans
The Art of War

HIV virion structure
The Art of War

HIV Progression over time: viral load & CD4+ cell count
The Art of War

-Sun-tzu, Chapter 3 - Strategic Offensive
The Art of War

-Sun-tzu, Chapter 2 - Waging War
The Art of War

-Sun-tzu, Chapter 3
The Art of War

We must know our enemy.
Research is not a forbidden word.
The Art of War

The Enhancing Care Initiative: AIDS Care Teams
Brazil, Puerto Rico, Senegal, South Africa, Thailand
South African Enhancing Care initiative Team: KwaZulu-Natal:
• The Team worked with local government offices to develop the
Kwa-Zulu Natal HIV/AIDS Training Program deliver specialized
HIV/AIDS training to health care workers.
• Most importantly, the Team utilized their two years of team building and research of local needs to create a successful proposal to the
Global Fund to Fight AIDS,
Tuberculosis, and Malaria.
Members of the KwaZulu-Natal ECI Team
The Art of War

We must know our enemy: Research is not a bad word
African Comprehensive HIV/AIDS Partnerships:
Preliminary needs assessment in Botswana
Goal: To identify collaborative targets that will shift silence and stigma into action, relationship-building, and mutual commitment.
Result: District Multi-Sectoral AIDS Committees examine and redefine their roles to increase effectiveness through better training and closer collaboration with senior government staff.
Result: Health institutions seek specialized training for HIV/AIDS caregivers, plan counseling program to support medical staff, and improve referral system and communications between hospitals and clinics.
Result: NGOs expand services through project management training, share experience with other organizations, and work closely with government HIV/AIDS committees.
The Art of War

We must know our enemy: Both Biomedical and
Operational Research are Important Analysis
Adult Antiretroviral Treatment and Resistance Study:
The “Tshepo” study (“Tshepo” means “hope” in Setswana)
- Patients will be randomized to receive one of six ARV regimens
- To look at the issue of directly observed therapy, patients’ clinical follow-up will be either:
• Standard Of Care (SOC) with close followup and patient education
• Or SOC with an added community or family-based Directly Observed Therapy
(Com-DOT) component
The Art of War

We should know our enemy, that is –
We should not underestimate our enemy
The Art of War

We should not underestimate our enemy
The Art of War

We must train many more troops, not only to avoid a siege, but to avoid a defeat.
The Art of War

We must train more troops
KITSO AIDS Training Program
• KITSO is an educational program that trains
Botswana’s health care providers to care for those affected by the HIV and AIDS epidemic.
• Training courses address issues such as Anti-retroviral
Therapy, HIV- and AIDS-Related Disease Gender-
Specific HIV Issues, Supportive and Palliative Care, and Psycho-Social Issues.
The Art of War

Comprehensive campaigns are possible: a multi-pronged attack considers and coordinates both care and prevention
The Art of War

An Example of a Comprehensive Approach to HIV and AIDS Care
Basic Health Infrastructure Intermediate Health Infrastructure Advanced Health Infrastructure
Care Interventions:
Voluntary HIV counseling and testing
• Pre and Post test counseling
• Testing using rapid/simple tests
• Confidential result notification
• Follow-up and referral systems
• Distribution system for commodities
• Mobile sites / existing health facilities
• Training and support for caregivers
Psychosocial support
• Ongoing counseling
• Mobile sites / Outpatient health facilities
• Training and support for caregivers
Palliative Care
• Symptom control, terminal care
• Essential Drug distribution system
• Mobile sites / Outpatient health facilities
• Training and support for caregivers
Prevention
Interventions:
HIV Prevention Education
• Counseling and education
• Mobile sites / other channels
• Training for caregivers
Voluntary HIV counseling and testing
• As above
STD Syndromic Management
• Syndrome treatment
• Counseling and condom provision
• Contact tracing
• Surveillance system
• Essential drug distribution system
• Mobile sites / Outpatient health facilities
• Training and support for caregivers
Richard Marlink, MD
Harvard AIDS Institute
Care Interventions:
Home Based Care
• For basic medical care, and HIV clinical management
• Referral systems with health care facilities, welfare, community
• Distribution systems for essential drugs and commodities
• Transportation for workers
• Collaboration with VCT and TB programs
• Training and support for caregivers
Opportunistic Infection Prophylaxis
• Outpatient health facilities / home based care
• Drug distribution system
• Collaboration with VCT and TB programs
• Support systems for adherence
• Microscopy, radiology and PPD-testing facilities for TB
• Hematology and CD4+ cell count for Cotrimoxazole
• Resistance monitoring systems
• Training and support for caregivers
Opportunistic Infection Treatment and Basic Cancer Care
• Inpatient / outpatient facilities / home based care
• Drug distribution system
• Collaboration with VCT and TB programs
• Support systems for adherence
• Laboratory, radiology facilities
• Training and support for caregivers
Prevention Interventions:
Prevention of Mother-to -Infant Transmission
• Chemoprophylaxis with antiretrovirals
• Delivery centers / inpatient facilities
• Drug distribution systems
• Collaboration with traditional birth attendants
• Collaboration with VCT programs
• Counseling regarding breast feeding and affordable substitutes
• Link into network of care for mother and family
• Training and support for caregivers
Post-exposure Prophylaxis
• Outpatient health facilities
• Drug distribution systems
• Universal precaution methods implemented
• Incident reporting systems
• Collaboration with VCT programs
• Training and support for caregivers
• Support and follow-up systems
Care Interventions:
Antiretroviral Therapy
• Inpatient and Outpatient facilities
• Adequate drug distribution systems
• Collaboration with VCT programs
• Support systems for adherence
• Advanced laboratory monitoring including viral load and CD4+ cell count
• Collaboration for monitoring drug resistance
• Specialized training and support for caregivers
• Continuing caregiver education
Opportunistic infections and
Cancers- advanced care
• Inpatient facilities
• Adequate drug distribution system
• Collaboration with VCT programs
• Advanced laboratory and diagnostic facilities
• Specialized training and support for caregivers
Prevention
Interventions:
Focused Prevention Education
• Long-term follow-up counseling for secondary prevention
• Skills-building for prevention techniques
• Peer-to-peer counseling programs
• Family-based intervention
Large Prevention Outreach
Programs
• Schools, prisons, armed forces, companies, door-to-door
The Art of War

The general is the prop of the nation.
When the prop is solid,
The nation is strong.
When the prop is flawed,
The nation is weak.
-Sun-tzu, Chapter 3
The Art of War

Leaders in this struggle do not necessarily choose the easy path.
That is part of leadership.
The Art of War

Leaders in this struggle do not choose the easy path
“We must all take responsibility for the urgent and joint action to combat the [HIV] epidemic. We have fought a hard struggle against this epidemic, and we will continue to fight together to preserve this vibrant and prosperous nation for our children.”
The Art of War

Primary principle in the Harvard AIDS Institute’s
Principles of Collaboration:
The Art of War

We are guests, waging war in someone else’s backyard
HIV-2 Prevalence in Africa
The Art of War

We are guests, waging war in someone else’s backyard
We should not be in charge of this “military alliance,” even if we bring weapons, people, or money.
The Art of War

Botswana National Antiretroviral Program
Since program initiation in 2002, about 3,000 patients have begun HAART
58.7% are women, 41.3% are men
• 39.9% are taking Combivir/NVP
• 48.8% are taking Combivir/ EFV
• 4.6% are taking DDI/ D4T/ EFV
• 4.9% of patients have experienced ARV-related toxicities
• Including: NVP rash, ZDV anemia, hepatitis
• Mortality has been 7.2% among National ARV Program participants
• Causes of death include: TB, disseminated Kaposi’s Sarcoma, advanced AIDS
• Approximately 4% of patients have been lost to follow-up
The Art of War

Ground where mere survival requires a desperate struggle, where without a desperate struggle we perish that is death ground.
-Sun-tzu, Chapter 11
The Art of War