Notes from the Field - Africa

By Lindsey Pollaczek, Program Officer for Africa

Soweto
November 4, 2009
I woke up this morning to thunder rattling the window panes. Unlike yesterday’s brief and powerful storm, the rain has not stopped falling for the past two hours. I keep thinking about Gloria’s family in their small tin shell of a home. I hope it’s not raining in Snake Park.

Conditions in many townships of Soweto have improved markedly in the last few years—in the vast, sprawling area of 3 million some are living rather comfortably. Homes have TVs, running water, a gas stove. But you don’t travel far before you meet abject urban poverty. Our visit yesterday in the Soweto township known locally as Snake Park illustrated how dire the situation is for many, particularly those who are sick and poor.
 
The dark sky has been threatening rain for an hour, but the deluge starts just as we enter the final home of the day. I watch Sr. Freda and Wilhelmina, Soweto Hospice’s nurse and community health worker, offer words of support to their patient Gloria when  the downpour on the tin roof becomes deafening. The conversation fades as the sound of the rain overtakes the small space. Gloria’s daughters hurry to place small containers around the one-room home to catch the rain falling through the holes in the roof. The small puddles outside quickly turn to muddy rivers that begin to rush through the settlement. Twenty minutes pass and the rain stops as quickly as it has begun.  Sr. Freda and Wilhelmina say their parting words to Gloria and we pick our way through the mud back to our 4x4 vehicle and wave goodbye.  Freda and Wilhelmina are already thinking about when they’ll be able to come back—to bring a lifeline to Gloria and her family, to ensure she has adequate support to live comfortably with HIV in this terribly impoverished neighborhood of Soweto.

We are in Snake Park. The name conjures up a wild, inhospitable place. Nearly a decade ago, informal settlements started appearing in the grassy fields, apparently the original home to a number of resident snakes.  It didn’t take long before the fields were overtaken with tin shacks, the homes of tens of thousands of people who couldn’t afford to live anywhere else. I’m told that the government’s Reconstruction and Development Program is  undertaking infrastructure improvements here to provide better housing, water, and sanitation. Unfortunately, this is not at all apparent from Gloria’s neighborhood. 

Gloria was diagnosed with HIV in 2006. Freda, a specialized nurse with six years of training, received a call from Gloria’s brother in 2007 and was asked to come by for a visit. When they first met, Gloria was very sick and barely able to care for herself. Since then, Freda has provided support all along the way through the many ups and downs in managing Gloria’s illness. This week Gloria is feeling relatively well, but she still has some chest pain and is coughing a fair amount. Last week Freda referred her to get a sputum test for tuberculosis and she is still awaiting her result. There is a good chance Gloria has TB, as co-infection among HIV patients is very high.

Gloria adheres closely to the antiretroviral regimen therapy she receives for free from the government. However, without a consistent supply of food, she struggles to remain healthy. The family has no source of income aside from the small government grant that her eldest daughter receives for her child. This is less than $28 a month to feed a family of five--not remotely enough.  Her HIV drugs will not have the maximum benefit if she is not able to keep herself well nourished. Food scarcity also affects her family. Her eldest daughter has epilepsy and had a seizure last time Freda visited. When asked if she took her medicine, she admitted she had not because it made her ill to take it on an empty stomach, and there was no food with which she could take it.

During their near-weekly visits, Freda and Wilhelmina often bring food if the hospice has it available. It is not always possible, because the hospice itself is very strapped for resources as it attempts to care for over 1,250 patients at home and many more in their pediatric and adult in-patient units for those requiring around-the-clock care. Gloria is just one of Freda’s 250 patients to which she provides home- based palliative care. But in Soweto, a township of 3 million, there are undoubtedly many people that cannot be reached.

Soweto Hospice is a member of the Hospice Palliative Care Association of South Africa (HPCA), an umbrella organization that provides financial and technical support to develop the capacity of its more than 150 member hospices. The hospice and palliative care approach is to improve the quality of life of patients and their families facing a life-threatening illness through prevention and relief of suffering. In sub-Saharan Africa, over 90 percent of patients have HIV/AIDS. Fortunately, with the support of nurses and community health workers like Freda and Wilhelmina, many HIV patients in hospice care are becoming healthier and learning to manage their illness as a chronic condition that can be kept under control. Direct Relief has supported the efforts of HPCA and its member hospices by providing donations of medical supplies which are needed in home-based settings and in-patient units. Wound care dressings, through support of Johnson and Johnson, are currently being distributed throughout the HPCA network. 

The amount of compassion and commitment shown by the hospice and palliative care staff is admirable. With very limited resources they are managing to uplift many to good health and provide relief from suffering and pain for those that are nearing the end of their lives. They are just touching the surface of caring for people living with HIV, but they are wholly dedicated to providing the best care they possibly can.

By Lindsey Pollaczek, Program Officer for Africa

October 28, 2009
It’s Saturday night on one of the main streets of Kisumu town. Against the backdrop of a busy night scene—music blaring from a nearby shop, people of all ages milling about in the street—are six Coleman camping tents which have been set up on the side of the road. Three bare lightbulbs strung across the row cast a pale light over the tents, which tonight are serving as private consultation rooms for voluntary testing and counseling of HIV. People congregate outside the tents, waiting their turn for the free service, asking questions and raising concerns about HIV and its mode of transmission, treatment options, and what it will means to know their status. Inside the tents, which are all occupied, HIV counselors provide information on these very issues for people who would otherwise not make it to a health center.

Several days later, many miles north of Kisumu in Wenyila village of Bungoma East District, Florence and Matutu, two skilled counselors, go door-to-door in an HIV counseling and testing program designed to leave no one behind. This is their second week canvassing the village to reach all 140 households, which were alerted prior to their visit by a respected member of the community. Florence and Matutu carry their green Home Counseling and Testing bags over their shoulders, stocked full with HIV testing accessories, and the electronic handheld device on which they gather detailed information about the household and the individual’s HIV status. If someone in the household is HIV positive, the counselors will set up an appointment for them at the nearest health center, will even offer to accompany them to the facility, and will return to do a follow-up if the person does not make their appointment. High priority is given to pregnant women that are HIV-positive to ensure they will be able to access treatment to prevent the transmission of the virus to their child. 

Innovative approaches such as the Twilight Voluntary Counseling and Testing and the Health at Home Initiative are important for making HIV testing and counseling accessible to more people. HIV testing and counseling is often referred to as the gateway to prevention, treatment, and care, because it is essential for people to know their status in order to stop the spread of the virus and to be referred to treatment without delay. While the number of health facilities providing HIV counseling and testing in sub-Saharan Africa has grown rapidly in recent years as governments work toward universal access to HIV prevention, treatment and care, a very large part of the population remains unaware of their HIV status.

Community-based approaches have great potential to reach the segment of the population that is not able to invest the time, effort, and resources to get to a health facility for testing. During the night I visited the Twilight VCT, supported by Ringroad Clinic in the Nyalenda slum and Marie Stopes Kenya, I talked to men and female sex workers who thought it very convenient that these services were being offered at a time (6 to 10 pm) and in a place where they could be easily reached. Men in general and commercial sex workers are two groups that often do not come for testing in a facility setting.  Florence and Matatu, the counselors with AMPATH (Academic Model for the Prevention and Treatment of HIV) were essentially reaching all community members, many of which did not have access to testing prior to the visit.  More than half of the people I met that day in their homes had never had an HIV test and knew very little about the virus.

The 2009 United Nations report on universal access to HIV prevention, treatment, and care discusses where the global health community stands on this internationally endorsed goal. Although many indicators are moving in the right direction, many countries are still far from reaching the goal of universal access. While the number of people in 2008 who received HIV testing and counseling increased over the previous year, recent surveys indicate that more than half of all people living with HIV are unaware of their status.

Direct Relief is helping to address this issue by providing donations of Determine rapid HIV tests in partnership with Abbott, so that more people are able to know their status, primarily pregnant women to work to prevent the transmission to their child. The rapid test is an important tool in diagnosing HIV, but universal access to testing and counseling—and to the essential treatment and care which must accompany it—is only going to be accomplished if a variety of strategies are used. Innovative approaches like the Home Counseling and Testing and Twilight VCT are bringing us one small step closer.

While traveling in Kenya, Africa Program Officer Lindsey Pollaczek delivered this moving dispatch about a woman's journey to healing through obstetric fistula repair.

Jamaa Mission Hospital
Nairobi
October 21, 2009

Today is a typical Wednesday at the Fistula Ward at Jamaa Mission Hospital in the Eastlands area of Nairobi. Thirteen women, ranging in age from 15 to 34, wait patiently for their turn to be wheeled down to operating theater. They have come from just outside Nairobi and as far as the islands of Lake Victoria, some 350 miles to the west. Most all have obstetric fistula due to prolonged and obstructed labor—too many days in the village without proper care. Physical, financial, and social barriers all contribute to the women's inability to get a hospital in good time where a C-section is available.
 
In the ward today there is also a medical fistula case, Ebby, age 34, caused by the slip of the knife during a surgical procedure performed at another hospital. From her hospital bed, Ebby assures me that the staff at Jamaa are “angels of compassion” and have treated her with great respect since she arrived. Due to her incontinence caused by the fistula, it has been a long time since she has been treated with such dignity. Ebby will receive the repair and post-operative care—and the money to take her back to her village—all completely free of charge.
 
Ebby has identified a key component in the equation for a successful fistula repair: compassionate and competent medical staff to oversee her care. Dr. Julius Kiiru, the fistula surgeon at Jamaa, is an essential part of this success, and under his guidance the hospital has become one of the leading institutions in Kenya providing fistula repair. Dr. Kiiru is a young 46, with an abundance of energy that helps propel him through the 40 to 50 repairs he does every month. His dedication to this cause took root when completing his studies in the 1990s when he witnessed many women suffering from fistula and very few surgeons that were able or willing to do the repair.
 
It was his commitment to helping these women that lead him to self-finance his certification in fistula repair surgery in Nigeria in 2001, becoming the first Kenyan to complete the course there. Back in Kenya, he began to provide fistula repair surgery at Jamaa Mission Hospital in 2003. Due to resource constraints, the hospital was only able to provide six to eight repairs a month, although the demand far surpassed this. In 2009, with additional support since committed, Dr. Kiiru himself will provide fistula repair for over 1,000 women. This is an incredible figure for one surgeon at one relatively small mission hospital.  The consequences of the repair extend far beyond improving the physical, mental and social health of the woman to her family and community that will benefit from her reintegration into society.
 
I meet Ebby again in the operating theater—she was Dr. Kiiru’s fourth patient of eight for the day—and says she is relieved to be there and grateful that there was no pain (her previous surgical experience at the other hospital had not been so pleasant). Dr. Kiiru is gracious enough to walk me through the delicate procedure and deftly completes the repair in less than 55 minutes. I feel lucky to be able to see a procedure for a condition that many in the developed world do not even know exists.
 
When I ask Dr. Kiiru about his goals for the future during our lunch break of chicken and rice, he speaks enthusiastically to the importance of incorporating fistula prevention into the program. Preventing fistula by ensuring safe motherhood and delivery is critical. To address this, Dr. Kiiru has designed a plan which would establish maternal waiting homes in five high-risk districts in the Eastern Province, from which a majority of the fistula patients come. Getting women closer to a hospital before labor so they can deliver in the presence of a skilled birth attendant will eventually mean fewer fistulas. Dr. Kiiru also envisions a program in which the women that have received repair—some of the hospital’s strongest advocates—become peer educators in these high-risk areas to emphasize the importance of safe motherhood practices and to explain firsthand the consequences of doing without. 
 
Before heading back to theater for his fifth patient of the day, Dr. Kiiru expresses his appreciation to Direct Relief for providing many of the medical consumables that are used during fistula repair and post-operative care. The first consignment of supplies will arrive at the hospital in December. He hopes that these ongoing contributions will help to lower the cost of each fistula surgery and therefore enable the hospital to provide perhaps even more repairs.  As long as Dr. Kiiru can stay on his feet, I hope this will be the case.  He and the Jamaa Mission Hospital staff are doing an exceptional job providing this critically needed service so a thousand women like Ebby, and their families, can be the deserving beneficiaries.

Malawi 2009

On a two-week visit in April and May to seven partners in Malawi, Kristi Bullock, program officer for Africa, and Dr. Mike Marks, Africa medical adviser, met dedicated people caring for their communities with what little resources they have. Direct Relief’s support allows them to provide that care. Kristi reflects on two especially memorable days during her visit.

Day Two: As we drove for hours off the main road through the Rift Valley, the dirt road connected heavily populated village after village. After all, Malawi is about the size of Pennsylvania but is home to 14 million people. Along the road I saw women dressed in brightly colored clothing cutting and carrying wood, collecting water, washing clothes, and bathing in the rivers flowing down the escarpment. Children were playing, swimming, and walking home from school. The men walked along the street, worked in the fields, and were transporting items--including goats--on bicycles. After the rainy season the Rift Valley is green and beautiful; the land is rich with maize and cotton.   

Unfortunately the joy of rain is often punctuated with sorrow. With the rain comes malaria, and alternating floods and drought often destroy crops. The largest malnutrition ward in Africa is located here in the city of Blantyre at Queen Elizabeth Hospital. The pediatric department serves 100,000 children a year for various illnesses, including malnutrition, malaria, and gastritis. Of the 24,000 admitted, 60 percent are found to be HIV positive. HIV is rampant here.

In southern Malawi, Direct Relief provides support to Queen Elizabeth Hospital’s pediatric department and to three rural hospitals south of Blantyre: Mulanje Mission Hospital, Trinity Hospital, and Montfort Hospital. These facilities are well run but only receive limited drug support from Malawi’s Ministry of Health (MOH) and salaries from Christian Health Association of Malawi (CHAM) and thus are heavily dependent on donations to operate.

Direct Relief’s support helps fill the gaps when pharmaceuticals and supplies are out of stock or not available from the MOH. When I visited with Sister Elizabeth Namuthuwa, who works in the pharmacy at Trinity Hospital, she repeatedly said, “We are very, very grateful for all the things you’ve sent.” 

Thankfully, more is on the way. A 20-foot container for Queen Elizabeth Hospital and a 40-foot container for Montfort Hospital are currently in transit to Malawi and a 20-foot container is being prepared for both Mulanje Mission and Trinity Hospital.

Day Four: Dr. Mike Marks and I made our way to Montfort Hospital in the south of Malawi, near the border with Mozambique. The paved road crossed the Shire River, where crocodiles waited in anticipation for careless fisherman. The day before, while at Trinity Hospital, we viewed the crocodile-scrubbing bath where patients suffering from bites have their wounds scoured out. I am told that the mouth of a croc is filthy--I can only imagine. The hospital administrator told us a recent story of a fisherman calling his daughter to help him pull in his nets when a croc flashed up out of the water and grabbed the girl’s arm. The fisherman saved his daughter by beating the croc and poking at its eyes, then grabbing his daughter and running away. There are a minimum of seven croc bites treated each rainy season at Trinity Hospital; many more that end in death and are never recorded.

In sharp contrast to the to the dirt road along the escarpment to Trinity, the road to Montfort is paved and cuts through fields of sugar cane, which stretches in all directions as far as the eye can see. Operating since 1970, Montfort Mission Hospital is a rural 120- bed hospital located in Nchalo, a town in Malawi’s southern Chikwawa district. It serves a local population of about 100,000, the majority of whom are subsistence farmers. The others are migrant laborers working on the sugar estate. Medical care across the border in Mozambique leaves much to be desired, so it’s not surprising that many make the journey to receive the higher standard of care here.

When we arrived at the hospital, I counted nine pregnant women sitting outside in the shade chatting as they waited to deliver. While we were visiting the delivery room, outfitted with only flat beds to deliver on, a very pregnant woman lumbered in. She didn’t say anything and didn’t look concerned, and just waited for us to leave the room. Less than 10 minutes later we heard a newborn’s first cries. In a room nearby, an intern medical assistant sat with six new mothers teaching them about breast feeding, infant care, post-delivery care for themselves, and local practices and herbal remedies to avoid. With the next closest hospital 25 miles away, Montfort is lucky to be able to provide emergency obstetric care. 

Despite a lack of support for its maternity care, Montfort admits approximately 500 patients a month, delivers more than 150 babies, and supports nearly 2,000 patients on ARVs. Direct Relief International is the only donor providing in-kind support. Ilova, a nearby sugar estate, provides food for all patients and a monthly contribution of 500,000K (about $3,333) to provide in-patient support for its laborers. This consistent monthly contribution and Direct Relief’s support are the primary reason that Montfort can continue to offer their services. Of all the visits conducted thus far in Malawi, Montfort was the most appreciative and in need of Direct Relief’s support.

Refugees fleeing fighting between Tutsi rebels and government troops in the Democratic Republic of Congo have streamed into neighboring countries, including Uganda. Cholera has broken out in D.R. Congo, and an outbreak is feared among the displaced, who are living in crowded camps and scattering into other countries. In communication with local partners to determine the situation on the ground, Direct Relief received this report from Muhindo Hosea B., director of administration at the Rugendabara Foundation for Health in Kasese, Uganda, about 130 miles from Goma, Congo's capital. For more background on the situation, see Reuters AlertNet.

November 5
Many greetings. I have been trying to send information on DRC Congo and that of the big rain with a strong storm that caused us losses last week, but the network was poor.
 
Otherwise, the Congo issue is a big problem for the Congo community and neighbouring countries like Uganda. By the time you communicated, about 80,000 refugees had entered Uganda just in the extreme south, close to districts of Kanungu, Kisoro, Rukungiri, and parts of Kabale.
 
Those who entered through there are said to have rented houses; others living with their relatives there; others living in churches and schools; and about 2,000 are in a refugee camp called Nalukale in Kanungu district.
 
About 350 entered through Kasinde; some have some relatives they are living with, some renting, and about 210 camped at the border DRC Congo and Uganda, in Kasese. We have had some time to support medically, and give some health education. This is after sending there our field officer in charge of disaster and  social welfare.
 
On top of that we had a strong wind and rain that caused many houses and properties to be lost and destroyed. This is in the heart of Kasese Municipality. We are giving [the displaced] medical care and health education on how to live without contracting any communicable diseases like cholera, dysentery, and other water- and airborne illnesses.
 
We only found one major problem of  lacking tents, blankets, mattresses, clothes, mosquito nets to avoid malaria, etc. This is for those who have lacked, to give to at least 150 out of 250 families.
 
We are trying hard to relieve them medically and provide health education with your support  of the drugs and equipment, which the community have liked and appreciated. [Direct Relief provided equipment including hospital beds and wheelchairs in August 2008]. We have also radio education programs on two stations in Kasese, which is attracting many people in the region.
 
Thanks once again. We shall keep updating you on the situation. We stay alert for civil fighters based in the Congo. Any advice, directive, and guidance would be welcomed by this office.

Lindsey Pollaczek, program officer for Africa, has been visiting partners in Tanzania that Direct Relief supports. After an especially moving experience at Bugando Medical Centre in Mwanza, she submitted this report.

Today I met Celestina, Nkwimba, Speciosa, and many other incredibly brave women who have found their way to the fistula ward at Bugando Medical Centre in Tanzania. Their stories are different but revolve around the same themes: prolonged and obstructed labor, often in the village in absence of a trained birth attendant. When no baby is delivered after many long hours—or more likely days—there is no money for bus fare to take them to the nearest health center or hospital where a cesarean section is available. These women have endured what we women in the developed world will never have to endure; many of us outside the public health circle do not know this condition exists. Why should these women have things any differently? Here are their stories—certainly sad but also hopeful, as they are some of the lucky few that have made it to a surgical center and have great potential to leave Bugando with their dignity restored.

Meet Celestina
Celestina is from Kigoma region along Lake Tanganika, many hundreds of kilometers (about 300 miles) from Bugando. She was in labor for three days at home with her eighth child. She did not have the bus fare to make it to the district hospital in time. When she finally arrived, her baby was stillborn and she had developed a fistula. During a routine outreach visit that the Bugando Medical Centre surgeons do in hospitals around the country, Celestina learned of the fistula repair services available at Bugando. (There were too many people on the waiting list in Kigoma for Celestina to be treated there). She had her fistula surgery two weeks ago and is healing nicely. When she is discharged from the hospital, she will be given  bus fare for her trip home. Only when she arrived at Bugando did she realize that she was not alone in suffering from this condition. She will spread the good news that treatment is available at Bugando to others in her village who may have fistulas.

 
Meet Nkwimba
In March, Nkwimba went into labor with her eighth child in her village in Shinyanga District. She was also at home and had no bus fare to the hospital, which was too far on bad roads. Nkwimba suffered significant injury in childbirth, including paralysis of her right leg due to prolonged obstructed labor, severe back pain, and two fistulas, vesico-vaginal (VVF) and rectal-vaginal (RVF). She has been at the hospital since May when her husband was able to afford to bring her to the VVF ward. Her leg feels much better now, and the RVF has been repaired. She is still waiting for her VVF surgery, which could be several more weeks, given the ever-expanding waiting list. It is amazing that she can still smile given what she has been through.

 
Meet Speciosa
Speciosa is from a small island in Lake Victoria. She is one of the older ladies in the VVF ward at 39 years old. Speciosa developed a fistula 10 years ago when giving birth to her first child, which was stillborn. Since developing a fistula, she has been divorced from her husband and has no children. She is waiting for her third surgery; the first two, performed over the last five years, have not been successful. For many women, one surgery repairs the fistula; Speciosa remains hopeful. She has taken on a maternal role among the  pre- and post-surgery patients in the VVF ward.

I was very much affected by these women’s stories and I wanted to record them while they are still fresh in my mind. Over two million women suffer from fistula and have similar stories to Celestina, Nkwimba, and Speciosa; 80 percent of these women are in Africa. I think we can do a significant amount for them and for the incredible surgeons who have dedicated their life to helping these women who are the poorest of the poor. There are not many doctors who want to do VVF repair as it is a time-consuming procedure and more urgent cases take precedence (i.e. cesarean sections, which, of course, are critical to preventing the fistulas in the first place). Fistula repair is clearly part of maternal and child health that is at the core of what we do. Fistula does not directly cause maternal mortality—very often prolonged and obstructed labor results in the death of the child—but it is the worst kind of injury and morbidity in childbirth I can think of.
 
I realize what I've written sounds rather sad, but really it was a hopeful day as these women have access to treatment that will truly change their lives. The women were happy to tell me their stories and were laughing and smiling, and particularly enjoyed looking at their digital portraits.

Women must have access to cesarean section and good emergency obstetric care if the incidence of maternal and infant mortality and morbidity, including fistula, is to be reduced. Small steps are being taken by our partner facilities in Tanzania and throughout Africa to make this a reality. In select regions Direct Relief is helping to facilitate the installation of operating theater suites that have enabled more women to get the care they need.

Until fistulas are eradicated in Tanzania—as they have been in the developing world—with the advancement of good emergency obstetric care, Bugando Medical Center's VVF program and its outreach treatment services give women a reason to smile.

Direct Relief Africa Program Officer Kristi Bullock attended the 17th annual International AIDS Conference Aug. 3 through 8 in Mexico City. Convened by the International AIDS Society (IAS), the conference is a forum to present scientific research and practical observations on the challenges in the global response to AIDS. Here are her impressions from the conference:

August 6
The vibrancy and passion about HIV is evident in diverse and powerful imagery at the International AIDS Conference, where 22,000 delegates are in attendance. For example, a throng of wailing, mourning skeleton-clad people paraded the conference corridors while hauling a casket as they protested the high cost of pharmaceuticals and their inability to afford life-saving drugs. This issue strikes at the core of why Direct Relief International provides its services to partners across the world. 

The need for access to free medicine and medical supplies has been a dominant theme throughout the conference. A powerful photography exhibit, “Access to Life,” graphically documents the positive impact that free antiretroviral drug treatment is having on the lives of millions of people living with AIDS internationally. The AIDS pandemic has had a devastating impact worldwide, especially in countries with limited healthcare access. An estimated 33 million people are now living with HIV. Of these, 72 percent live in sub-Saharan Africa. Without access to life-saving drugs, millions will die unnecessarily. Families will be destroyed, children will be orphaned, and countries will suffer as their work force rapidly dies off.

The deadly co-infection of HIV and malaria is an issue that’s shouting to be heard. Together, HIV and malaria cause more than 4 million deaths per year—more than 80 percent in Africa. HIV-infected people are more likely to contract malaria, as their immune system is suppressed. Co-infection can transiently increase HIV viral load, which can impact the progression and transmission of HIV. Circulating the conference is a petition seeking action in HIV/AIDS and malaria-endemic countries that demands access to insecticide-treated nets, other preventive interventions, and effective malaria treatment as a vital part of healthcare. Nearly a quarter of conference attendees have signed the petition thus far.

Other hot discussion topics include circumcision as a clinical means to decrease risk of HIV transmission (found to protect 51 to 67 percent of the time); pediatric HIV care and treatment; and decentralizing HIV testing from the health facilities to communities through outreach and home-based care services. Despite the fact that HIV was identified a full two decades ago, much remains to be learned about the care and treatment of those infected and affected by the disease. The International AIDS Conference creates a forum in which all interested parties can learn from each other and continue to combat the devastating HIV pandemic.