Identifying and Costing HIV treatment delivery best practices in Eastern & Southern Africa

AIDS is not one uniform global epidemic, but a series of individual epidemics driven by local circumstances. The need for effective HIV treatment programs that reflect particular contexts has never been greater.

A major new program of Pangaea is to develop and cost a series of single descriptive case studies documenting effective approaches to HIV service delivery in East and Southern Africa. The goal of this project is to document ARV treatment and support programs that are improving the uptake of and retention of clients in care. Pangaea is collaborating with the Clinton Health Access Initiative (CHAI) who will be performing the cost estimates for each of the case studies. The selection of programs for the case study development will seek to present information about a diverse set of programs, looking at both community- and facility-based services and at programs addressing urban and rural populations, key affected populations, and programs that are well integrated with other areas of health services including primary care, sexual, reproductive, and maternal health, and TB services.

We are particularly interested in identifying effective HIV treatment initiatives that combine the clinical expertise found in the health facilities and the leadership of the local communities to help as many HIV positive people stay in care and on treatment. The ultimate goal of the project is to produce clear, policy-relevant cost and effectiveness data around best practices in the HIV space. In addition, dissemination of the methodology used to create the case studies and cost estimates can serve as a template for replication of the process at country levels in order to better understand what program models are working. Through this process, Pangaea seeks to improve uptake and scale of HIV services and fill the gaps in the HIV treatment cascade.

The project is funded by the Bill and Melinda Gates Foundation.

As each case study is finalized, it will be posted on this website.

Completed case studies include:

  • AMPATH Case Study Summary & Full Text document
  • LVCT Health Case Study Summary & Full Text document
  • Mauritius Case Study Summary & Full Text Document
  • Zvandiri Case Study Summary & Full Text Document

Global HIV Treatment Optimization

Since 2010, Pangaea has been at the forefront of global efforts to improve the quality of HIV treatment – including drugs, delivery systems, and diagnostics – globally for people with HIV, regardless of where they are from. Pangaea’s Treatment Optimization initiative is a partnership of global researchers, health care providers, drug manufacturers, policy makers, funders, and community members from heavily affected regions.
What is HIV treatment optimization?
There are three priorities:

1. Better drug regimens

Taking stock of the current research and development agenda to answer questions, such as can we make drugs that are easier to take and adhere to? Do we know if they work for pregnant women and children? Who should be doing what, who is going to pay for it and who is going to make sure it happens? When can generic manufacturers plan for scale up? And talk to patients—before spending millions on testing and manufacturing – to make sure the regimens will work for them.

Vancouver July 17-18, 2015

As part of our commitment to working towards global HIV treatment optimization, Pangaea facilitated an expert meeting with AIGHD, CHAI and IAS in Vancouver on July 17-18. The aims of the meeting were to identify gaps in current research and the medium-term agenda on drug development for both first- and second-line therapies appropriate for resource limited countries. The report of the meeting was launched on 22 July at the Vancouver IAS conference and is available here.


Chaired by Dr Tsi Tsi Apollo (Zimbabwe) and Dr Andrew Kambugu (Uganda) Pangaea, AIGHD, Clinton Health Access (CHAI) and the International AIDS Society (IAS) convened an expert meeting to review the progress, gaps and future plans for HIV drug optimization since the second Conference on Antiretroviral Drug Optimization held in 2013. In particular, the perspectives of country implementers, researchers from the North and the South, innovator and generic pharmaceutical companies, community and global normative guideline agencies.

The meeting prioritized key actions that participants considered essential to bringing further to people living with HIV in resource limited settings, effective, tolerable new drugs, formulations and timelines, and how to operationalize these as rapidly as possible. Participants also prioritized recommendations to optimize service delivery as part of the whole treatment optimization package.

The recommendations of this meeting were presented at a formal conference session on treatment optimization during the 2015 IAS conference in Vancouver.

As a key outcome of the meeting, Pangaea reiterated its ongoing commitment to continue monitoring and disseminating progress on all aspects of the treatment optimization agenda, including convening relevant experts where appropriate. In the light of the START and TEMPRANO results, growing global advocacy for treatment for all, the need for significantly increased global and national resources to fund treatment will be needed. In this context, treatment optimization is an even more critical contributor to expanding the scope and quality of long-term HIV treatment.

After over a decade of being at the forefront of the Bay Area’s response to the global AIDS epidemic, Pangaea will be holding its first Global Health Leadership Dinner on May 12th 2015 in downtown Oakland’s Rotunda building, with excellent road and BART links.

We will be honoring the following local and global heroes who have made a significant difference, saving lives and preventing new HIV infections around the world:

  • Dr Peter Piot, Director, London School of Hygiene and Tropical Medicine, and Founding Executive Director of UNAIDS
  • Dr Huma Abbasi, General Manager of Global Health and Medical, Global Health Champion, Chevron
  • Dr Tsi Tsi Appollo, Deputy Director, HIV and TB Program, Ministry of Health and Child Welfare, Zimbabwe
  • Miss Gloria Lockett, Executive Director, California Prostitutes Education Project (CALPEP)

Since 2011, with funding from the Bill & Melinda Gates Foundation, the Pangaea Global AIDS Foundation has supported the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) to make effective and efficient use of the best available HIV treatment tools; drugs, diagnostic tests and health care delivery systems. A final consultation in the series, held in Washington, DC from May 20-21, 2014, reaffirms the centrality of leadership by the affected communities—in this case men who have sex with men (MSM) who are living with HIV—in responding effectively to AIDS. The meeting was held in close partnership with the Global Forum on MSM & HIV (MSMGF).

Meeting participants included 30 global MSM leaders, predominantly from lower- and middle- income countries, many of them living with HIV and all of them longstanding experts in HIV among MSM the field. They gathered to inform the programmatic and research agenda on increasing engagement in the HIV treatment cascade for gay men and other MSM in lower- and middle-income countries. This included optimizing provision and mitigating barriers to services, with an emphasis on legally and socially constrained environments and providing evidence of good practice.

A study led by Dr. Barrot Lambdin of Pangaea has been published in PLoS One. Read below for the abstract and click the link below to access the full text.

Introduction : Current estimates suggest an HIV prevalence of 42% among people who inject drugs (PWIDs) in Dar es Salaam, while HIV prevalence is estimated to be 8.8% among the general population in the city. To address the HIV epidemic in this population, the government of Tanzania began establishing HIV prevention, treatment and care services including outreach and medication assisted treatment (MAT) for PWIDs in 2010. We assessed gender inequities in utilization of outreach and MAT services and evaluated differences in HIV risk behaviors between female and male PWIDs.

HIV and drug abuse are serious inter-related health problems around the world. Recent estimates indicate that there are 16 million people who inject drugs (PWID) throughout 148 counties, among which three million (range 0·8—6·6 million) are living with HIV. In most countries, the prevalence of HIV among PWID is higher compared to the general population due injection-related and sexual risk behaviors associated with drug use. Despite increased HIV risk among PWID, harm reduction and HIV prevention programs among this group are limited, especially in resource-constrained countries.

Supported by the Bill and Melinda Gates Foundation, the consultative meeting on “Optimal Models of Care for People who Inject Drugs” was organized to identify best practices and models of care that provide comprehensive, evidence-based interventions, promote successful linkage to HIV testing, care and treatment, and integrate collaborative TB and HIV services for people who inject drugs. Recommendations from this meeting are intended to inform the World Health Organization’s (WHO) 2014 consolidated treatment guidelines for key populations (KP).

Our Work in Tanzania

In the mid-1980s and the early 1990s, East Africa became an important stop along international drug trafficking routes, thereby introducing heroin in the region. In 2009, 40-45 tons of opiates were trafficked into Africa, most entering through the eastern countries by air and sea, and 34 of those tons were consumed in the region, highlighting it only as a transiting hub, but also a place for consumption. Currently, an estimated 533,000 opiate users live in eastern Africa.

Pangaea is relieved to learn that Dr Paul Semugoma has been released by the South African Ministry of Home Affairs at Oliver Tambo International Airport Johannesburg, and has removed the threat to deport him to his native Uganda where he is at risk of persecution under the country's anti-LGBT legislation. We are enormously grateful to the South African AIDS Council Civil Society Sector, Treatment Access Campaign, Health4Men and other South African, Pan African and international groups for leading the campaign for his release.

Pangaea is launching a new program to identify and document effective HIV treatment programs across East- ern and Southern Africa emphasizing programs that link the best in medical services with community-based organizations.

In the November issue of Current Opinion, Charles Flexner (John Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA), Ben Plumley (Pangaea, Oakland, CA. USA) and David Ripin (Clinton Health Access Initiative, Boston, MA, USA) provide a comprehensive overview of current activities aimed at optimizing global HIV treatment. HIV treatment optimization is a process intended to enhance the long-term efficacy, adherence, tolerability, safety, convenience, and affordability of combination ART. The ultimate goal of this process is to expand access to well tolerated and effective lifetime treatment to all those in need.

Budgets for global HIV treatment and prevention in resource-limited settings will continue to be pressured, and, because the need for treatment scale-up is urgent, the emphasis on value for money has become an increasing priority.

The first CADO in 2010 focused on developing a research agenda to optimize the doses and combinations of existing approved drugs, including through role of process chemistry, and recommended a research development agenda for HIV drug optimization. The conference identified a portfolio of projects with the potential to significantly optimize treatment while achieving major cost reductions. Projects included improvements in process and formulation chemistry and dose reductions as intermediate technologies with an imperative to focus future resources on developing better regimens and formulations.

The goals and objectives of CADO2 were to identify and facilitate the development of novel, affordable, optimized drug regimens in resource-limited settings, within a public-health approach. CADO2 participants looked further into the future, to review drugs in the development pipeline, and to highlight gaps in drug development programs.  Underpinning the meeting was the commitment to a single global standard for the equitable treatment of everyone, in both resource-rich and resource-poor settings. Potent, durable and affordable drug regimens are needed to sustain the contribution of universal access to HIV treatment to reversing the global AIDS epidemic. 

The full report is available for download at or by clicking here 


On Thursday November 29, Secretary of State Hillary Rodham Clinton commemorated World AIDS Day 2012 and unveiled the PEPFAR Blueprint: Creating an AIDS-free Generation that provides a roadmap for how the U.S. government will work to help achieve an AIDS-free generation. Secretary Clinton will be joined by Ambassador Eric P. Goosby, U.S. Global AIDS Coordinator.

Secretary Clinton was joined by:
Ambassador Eric P. Goosby, U.S. Global AIDS Coordinator
Michel Sidibe, UNAIDS Executive Director
Dr. Nkosazana Dlamini-Zuma, Chairperson of the African Union Commission
Florence Ngobeni-Allen, Ambassador for the Elizabeth Glaser Pediatric AIDS Foundation

The PEPFAR Blueprint is available here:

This month, Pangaea published a paper in a preeminent journal of women’s health, Reproductive Health Matters. This paper summarizes data from Pangaea’s SHAZ! Project, a study working to increase access to HIV services and improve health outcomes for adolescent women living with HIV in Zimbabwe. Findings highlight the complex and critical nature of disclosure of HIV status among this age group to achieve good HIV and reproductive health outcomes. Programs and services must do more to help young women living with HIV negotiate the complexities of disclosure in the context of achieving desired fertility.

Abstract: In the Shona culture of Zimbabwe, a high regard for childbearing contributes to strong pressures on women to have children. For young women living with HIV, consequently, disclosure of HIV status can be a central strategy to garner support for controlling fertility. This paper reports findings from qualitative interviews with 28 young women aged 16–20 living with HIV in urban Zimbabwe and discusses how these findings can contribute to better policies and programs for this population. Regardless of their current relationship status, interview participants described disclosure as a turning point in romantic partnerships, recounting stressful experiences with major ramifications such as abuse and abandonment on the one hand, and support and love on the other. All but one participant had been in a committed relationship, and most had disclosed to a previous or current partner, with about half of disclosure experiences resulting in adverse reactions. Findings suggest that sexual and reproductive health services must do more to help young women living with HIV negotiate the complexities of disclosure in the context of achieving desired fertility. © 2012 Reproductive Health Matters

Full article available at:

Pangaea is launching a new report, “The Leadership of Affected Communities in Delivering HIV Prevention, Testing and Treatment”, with recommendations from two consultations held in Zimbabwe and Thailand organized with the World Health Organization (WHO), UNAIDS, the Zimbabwe Ministry of Health and Child Welfare, and the Asian Network of People Living with HIV (APN+). These recommendations have been presented to WHO for consideration as it develops new consolidated HIV treatment guidelines for release in 2013. The report distills lessons learned from HIV treatment community organizations from over 30 countries.

What is a Shadow City?

"A city, municipality or other jurisdictional area that is overshadowed, and thus overpowered by a larger city that is global in nature and possesses more resources such as expertise, enterprise, money, and national government investment."

— Marsha Martin (2011), Get Screened Oakland, an initiative of the Office of the Mayor of Oakland

Dr. Barrot Lambdin, Pangaea's Director of Implementation Science, was lead author of  "Local Residents Trained As 'Influence Agents' Most Effective In Persuading African Couples On HIV Counseling And Testing," published in Health Affairs in August of 2011.

Dr. Barrot Lambdin, Pangaea's Director of Implementation Science, was lead author of  Patient Volume, Human Resource Levels, and Attrition From HIV Treatment Programs in Central Mozambique published in JAIDS in July 2011.

Lambdin, Barrot H PhD, MPH; Micek, Mark A MD, MPH; Koepsell, Thomas D MD, MPH; Hughes, James P PhD, MS; Sherr, Kenneth PhD, MPH; Pfeiffer, James PhD, MPH; Karagianis, Marina MBChB; Lara, Joseph MPH; Gloyd, Stephen S MD, MPH; Stergachis, Andy PhD, MS

JAIDS Journal of Acquired Immune Deficiency Syndromes:

1 July 2011 - Volume 57 - Issue 3 - pp e33-e39

doi: 10.1097/QAI.0b013e3182167e90

Implementation and Operational Research: Epidemiology and Prevention

Full text of article available here.

Pangaea researchers have led the development of SHAZ! (Shaping the Health of Adolescents in Zimbabwe) – an HIV prevention intervention and research study in Zimbabwe that empowers adolescent female orphans to avoid sexual risk behaviors by improving economic opportunities and linking them to life skills-based HIV education and clinical care. As a resource for others in the field, Pangaea is pleased to be able to make available the SHAZ! Facilitator's Guide.

Pangaea convened an expert consultation in July 2009 in Cape Town, South Africa on behalf of the Office of AIDS Research (OAR) at the National Institutes of Health (NIH), aimed at addressing the growing imperative for analyses to inform and improve uptake of proven interventions and to scale up HIV/AIDS programs.

HIV Prevention Among Injection Drug Users: Strengthening U.S. Support for Core Interventions, CSIS Global Health Policy Center, April 2010 

This report examines data on the burden of HIV among IDUs and access to and receipt of MAT, needle and syringe programs (NSP), and ART services in 14 countries.

37 million People worldwide are living with HIV (amfAR Statistics 2014: Worldwide)

16 million Women living with HIV (United Nations Statistics 2014)

15 million People living with HIV having access to antiretroviral therapy (amfAR Statistics 2014: Worldwide)

5,600 People Contract HIV every day - more than 230 every hour (amfAR Statistics 2014: Worldwide)