ABSTRACT
Title: Load Zero Foundation - Saving people with HIV one test at a time Sub-title: Improving access to HIV treatment through Viral Load Testing
Author: Ana Leonor Andrade
The present dissertation, written in the form of a case study, aims to present the Load Zero Foundation (LZF), an American non-for-profit organization dedicated to funding HIV viral load testing in the developing world. The organization was founded in 2013 and is now in the process of gathering the funds to implement its first full low cost laboratory entirely dedicated to viral load testing. We will examine LZF’s fundraising efforts so far and suggest some future strategies for gathering the rest of the funds needed.
In the following pages we will introduce the dissertation outline and then provide the reader with an overview of the main literature collected about HIV, viral load testing, Haiti and its history in AIDS relief and finally, funding options for NGOs. Afterwards, the case study presents the LZF as a social enterprise, providing an overview of its strategies and operations - while referring to the importance of viral load testing in the fight against HIV. Lately, the case study examines the evolution of funding for organizations, and how far the LZF is gathering the funds for its first laboratory. Finally we provide teaching notes for in-class discussion about the case study, and conclude with final remarks and possible recommendations for the LZF on future fundraising strategies.
RESUMO
Título: Load Zero Foundation - Saving people with HIV one test at a time Sub-título: Improving access to HIV treatment through Viral Load Testing
Autor: Ana Leonor Andrade
A presente dissertação, escrita sob a forma de um caso-estudo, tem como principal objectivo apresentar a Load Zero Foundation, uma organização americana sem fins lucrativos dedicada ao financiamento de testes de carga viral de HIV em países em desenvolvimento. A organização, fundada em 2013, está em processo de angariação de fundos para implementar o seu primeiro laboratório completo de baixo custo inteiramente dedicado a testes de carga viral. Vamos analisar os esforços desenvolvidos até ao momento pela LZF para angariar fundos, e sugerir algumas estratégias para reunir os fundos que faltam.
Nas próximas páginas vamos apresentar o esquema dissertação e fornecer ao leitor uma visão geral da literatura analisada sobre HIV, testes de carga viral, o Haiti e sua história no combate à SIDA e, finalmente, as opções de financiamento para as ONGs. Depois disso, o caso-estudo apresenta a LZF como uma empresa social, apresentando uma visão geral das estratégias e operações - referindo a importância dos testes de carga viral na luta contra o HIV. Posteriormente, o caso-estudo analisa a evolução do financiamento para ONGs, apresentando a situação LZF em reunir os fundos necessários para estabelecer o seu primeiro laboratório. Finalmente, fornecemos algumas notas explicativas para aplicação do caso em sala de aula, e concluímos com considerações finais e recomendações para
TABLE OF CONTENTS
ABSTRACT ... I Resumo ... II PREFACE ... I LIST OF ACRONYMS ... II LIST OF ANNEXES AND EXHIBITS ... IV
Chapter 1: Introduction ... 1
Chapter 2: Literature Review ... 2
2.1 HIV/AIDS: a global snapshot ... 2
2.2 Viral Load Testing ... 3
2.2.1 Concept and advantages ... 3
2.2.2 Testing disparities between countries – is there room for improvement? ... 4
2.2.3 How can we move forward? ... 5
2.3 Haiti ... 6
2.3.1 Country in context ... 6
2.3.2 Multidimensional Poverty Index (MPI) ... 8
2.3.3 Education ... 9
2.3.4 Access to clean water and sanitation ... 9
2.3.5 Politics ... 10
2.4 AIDS relief and general health care in Haiti ... 11
2.4.1 History of the epidemiology of HIV in Haiti ... 11
2.4.2 The Expansion of ART -‐ and the importance of International Help ... 12
2.4.3 AIDS release in numbers ... 13
2.4.4 Addressing Challenges ... 13
2.5 Funding for NGOs ... 14
2.5.1 NGO Definition ... 14
2.5.2 The Need for Funding ... 15
2.5.3 business models ... 15
2.5.4 Funding options ... 16
2.6 Annexes ... 22
Chapter 3: Case study ... 29
3.1 Introduction ... 29
3.2 Load Zero Foundation: The Social Enterprise ... 30
3.2.1 History of the LZF ... 31
3.2.2 Mission and Vision ... 32
3.2.3 LZF as intermediaries in health care provision ... 32
3.2.5. Mission in Haiti ... 34
3.3 The Importance of fighting HIV ... 35
3.3.1 The role of VL testing ... 36
3.4. Demand-‐supply gap of funding for organizations – the effects of the economic crisis ... 37
3.5 HIV funding evolution ... 39
3.6 The big fundraising challenge ... 40
3.7 Exhibits ... 42
Chapter 4: TEACHING NOTES ... 52
4.1. Case Summary ... 52
4.2 Learning Objectives ... 53
4.3 Teaching Questions (TQ’s) ... 54
4.4 Suggested Teaching Method ... 54
4.5 Analysis and Discussion ... 54
4.6 Exhibits ... 60
Chapter 5: Conclusion, study limitations AND Future Research ... 62
BIBLIOGRAPHY ... 64
PREFACE
For the purpose of this dissertation I would like to share my gratitude to the Load Zero Foundation, particularly to its CEO Antony Kuhn, for all the interest, time and collaboration provided, without which I would have been unable to write this dissertation. Moreover I would also like to thank my advisor, Ms. Susana Frazão Pinheiro, for putting me in touch with the LZF and for all the advice and patience that has much enriched this dissertation.
Finally, I would like to thank my family, friends and boyfriend for all the love and support throughout this period.
LIST OF ACRONYMS AI - Amnesty International
AIDS - Acquired Immunodeficiency Syndrome ART - Antiretroviral Therapy
BMGF - Bill & Melinda Gates Foundation
CDC - Centers for Disease Control and Prevention CHAI - Clinton Health Access Initiative
CPI - Corruption Perceptions Index
ECOSOC - United Nations Economic and Social Council EGPAF - The Elizabeth Glaser Pediatric AIDS Foundation FCAA - Funders Concerned About AIDS
GCC – Gulf Cooperation Council GDP – Gross Domestic Product
GHESKIO - Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic
Infections
HDI – Human Development Index HIV - Human Immunodeficiency Virus
HIV-TRePS - HIV Treatment Prediction System IFC – International Finance Corporation
KCA - Keep a Child Alive KFF - Kaiser Family Foundation
LMIC - Low and middle-income countries MoH – Ministry of Health
MPI – Multinational Poverty Index MSF - Médecins Sans Frontières
PEPFAR - US President’s Emergency Plan for Aids Relief PIH – Partners in Health
PIH/ZL - Zanmi Lasante Project RDI – Response Database Initiative WHO - World Health Organization
STI – Sexually Transmitted Infections TB – Tuberculosis
UN – United Nations
UNDP – United Nations Development Programme UNROL - United Nations Rule of Law
LIST OF ANNEXES AND EXHIBITS
Annexes
Page
Annex 1 Adult HIV prevalence rate, 2013 22
Annex 2 HIV Prevalence & Incidence by Region, 2013 22222
Annex 3 Breakdown of Average Cost per Viral Load Test 2223
Annex 4 Effect of Throughput on Viral Load Cost per test 23
Annex 5 Estimated Manufacturing Costs of Exemplar Viral Load Tests 24
Annex 6 MPI Indicators and Dimensions 24
Annex 7 Deprivations in each Indicator (Haiti) 25
Annex 8 Multidimensional Poverty across sub-national regions in Haiti 25
Annex 9 Contribution of Indicators to the MPI (Haiti) 26
Annex 10 CPI 2014 - Americas 26
Annex 11 Changing HIV transmission patterns in Haiti 27
Annex 12 Number of HIV testing and ART sites, and number of patients receiving services by year in Haiti
27
Exhibits
Page Exhibit 1 Anthony Kuhn, Executive Director, CEO and Co-Founder of the
Load Zero Foundation
42
Exhibit 2 Viral Load Test Locations 43
Exhibit 3 LZF Board of Directors and Advisors 44
Exhibit 4 Test Equipment 45
Exhibit 5 LZF Partners 46
Exhibit 6 VL Tests comparison 47
Exhibit 7 ExaVir Load specifications 47
Exhibit 8 Resources available for HIV in low- and middle-income countries in billions of US dollars
48
Exhibit 9 HIV/AIDS Philanthropic Disbursements 2007-2013 48
Exhibit 10 Top 20 Philanthropic HIV/AIDS Funders in 2013 49
Exhibit 11 Top 5 Intended Use Categories of 2013 HIV/AIDS Philanthropic
Giving
49
Exhibit 12 Organizations Contacted by the ZLF 50
Exhibit 13 Necessary Resources to set up Operations in Haiti 51
Exhibit 14 Environmental analysis 60
Exhibit 15 SWOT analysis 60
Exhibit 16 Contact Chart 61
Exhibit 17 Fit Between Organizations 61
CHAPTER 1: INTRODUCTION
The present dissertation was developed in the scope of the “Health care Management” seminar and its main purpose is to raise awareness about the potential benefits in the fight against HIV infection of disseminating viral load testing in developing countries. To address this topic we followed a straightforward structure so that the reader can find and follow all expected elements to support the case study.
In Chapter 2 - Literature Review - we access an extensive number of articles and other publications related to our thematic. We start by looking at HIV around the world as to contextualize the reader on the problem the LZF is fighting against. In the second sub-chapter we introduce the reader to VL testing, showing its limitations and potentialities. Then we characterize Haiti following the several dimensions of the MPI index, and refer to its history in the fight against HIV. In the last sub-chapter we present the several funding options for NGOs.
In Chapter 3 - Case Study - we start by presenting the LZF, referring to its history, operations, and current challenges in continuing their activities. Afterwards, we evaluate how the economic crisis has affected funding for organisations, remarking to the evolution of funding for HIV. Finally, we close the chapter reflecting of ZLF’s opportunities for future funding.
Chapter 4 - Teaching Notes - is intended to help professors for the preparation of in-class discussion about the case. We start by laying out a summary of the case study followed by the Learning Objectives, Teaching Questions and suggested Teaching method. Finally, we provide a comprehensive Analysis and Discussion of the referred questions
Lastly, we present our Conclusion and Future Research suggestions, as well as the Bibliography with list of all sources of information used to write this dissertation.
CHAPTER 2: LITERATURE REVIEW 2.1 HIV/AIDS: A GLOBAL SNAPSHOT
The emergence and widespread of the HIV/AIDS epidemic has been originating poverty, widespread orphaning, widespread of infectious diseases, food insecurity and general discrimination for decades. The first cases were reported in 1981 and since then tens of
millions have died. 1
Nowadays, there are about 35 million people living with HIV all over the world and still, most of them do not get access to prevention, care or treatment. Albeit testing capacity has
been increasing, still about half of all infected people are unaware they carry the virus 1
(Annex 1).
There are many risk factors associated with the virus, however heterosexual relations seem
to be the main cause of transmission1 (Annex 2).
HIV is currently the leading cause for death among women both because they are biologically more susceptible to it but also because women generally face situations that increase their vulnerability - like differential access to service and sexual violence.
“Globally, there were 3.2 million children living with HIV in 2013, 240,000 new infections among children, and 190,000 AIDS deaths”.1 (KFF, 2014)
Sub-Saharan Africa is by far the hardest hit region – home to 71% of HIV-infected people and 91% of HIV-infected children. Moreover, South Africa is the country with the highest number of HIV-infected in the world (6.2 million) and Swaziland has the highest
prevalence rate at 27,4%. 1
Combining Latin America and The Caribbean, there are about 1.9 million people living with HIV. The Caribbean itself is the second hardest hit region in the world, with an adult
prevalence rate of 1,1%.1
In Eastern Europe and Central Asia, the number of people living with HIV falls to 1.1 million – with Ukraine and Russia accounting for 85% of this number.
Finally, in Asia and the Pacific, there are around 4.8 million people infected. 1 Although
these numbers are high, the region encompasses two of the world’s most populous nations – China and India –, meaning prevalence rates are actually surprisingly low.
Despite all challenges, amazing global efforts have been put into place to fight this
epidemic, particularly in the last decade. As a result, the number of newly-infected and the number of deaths related to HIV have declined. This is greatly due to the fact that the number of people receiving treatment has increased from 5.6 million in 2010, to 12.9
million in 2013. 1
2.2 VIRAL LOAD TESTING
2.2.1 CONCEPT AND ADVANTAGES
VL quantification refers to a series of methods that allow counting the amount of virus in a body fluid sample. This has become the gold standard in HIV treatment monitoring, as recommended by the WHO, and enables healthcare providers to address disease progression far earlier than immunological monitoring of CD4 cell counts.
By rapidly measuring the level of HIV genome copies, VL monitoring is also successfully used to identify patients with poor adherence to treatment or those where a switch to different drugs may be need.
The criteria of VLs that trigger treatment switches can differ between countries, however “Evidence from the PLATO Collaboration and other studies suggests that, as long as the VL remains 10,000 copies/mL, CD4 cell counts remain stable and the risk of clinical progression is low” (Alexandra Calmy et al., 2007).
Finally, another advantage relates to small infant’s HIV infection. There are over 800,000 infants infected with HIV each year and only with VL test can the infection be readily
detected. (Alexandra Calmy et al., 2007)
Paired with patient care advantages, VL monitoring can also increase the effectiveness of the use of funds. This happens though adherence interventions that help patients stick to first-line regimens longer, thus preventing unnecessary switching costs of treatment.
Moreover, in settings with high patient workload, viral tests allow to differentiate between patients who need regular monitoring and patients eligible for self-administered ART.
2.2.2 TESTING DISPARITIES BETWEEN COUNTRIES – IS THERE ROOM FOR IMPROVEMENT?
In high-income countries, VL tests are performed routinely to guide physicians on the best combination of drugs. There are over 120 antiretrovirals available, providing several alternatives for second, third and even fourth-line regimens.
For LMIC, innovations in VL monitoring have proven to simplify testing and reduce costs. For instance, the use of pooled samples – whereby blood samples from multiple people are mixed and tested together – has shown evidence of significant cost reduction
Nonetheless accessibility in these countries is still far from ideal: “Viral Load tests have been unaffordable in many low-income countries so doctors have had to wait until the patient showed clinical or immunological signs of disease progression before switching: a strategy that has been shown to lead to poorer outcomes.“2 (RDI & LZF, 2014)
The unavailability of VL testing in developing countries results in a lower adherence to treatment when compared to high-income countries. Furthermore, because costs increase with treatment switches, many countries are limited to second-line regimens.
The use of ‘dried blood spots’ in VL testing could allow for a more feasible transportation of samples, helping people living with accessibility issues.
According to an MSF study across six different countries Kenya, Lesotho, Malawi, Swaziland, Thailand and Zimbabwe) there are great cost disparities in VL testng, with its
comprehensive cost per test ranging from $24,00 to $44,07.3
Evidence shows that the largest contributor to these prices are the costs of reagents and consumables – accounting up to 84% of overall costs (Annex 3). Costs associated with intellectual property are also quite significant, with royalty payments ranging from 19% to 63% of overall costs.
Negotiating power plays a big influence on the prices that countries can obtain for reagents and consumables. While Asia manufactures its own machines and reagents and is able to
provide VL tests for about $11, Africa has to import everything. (EGPAF, May 2014)3
Finally, evidence suggests that price per test is also dependent on the volume of tests run on each instrument (Annex 4 and 5). Consequently, if instruments were used to maximal capacity these costs could be significantly reduced.
2.2.3 HOW CAN WE MOVE FORWARD?
“Implementing a high-quality national viral load testing programme requires coordination among all stakeholders (donors and implementing partners) providing support for HIV service delivery. In most cases, some existing capacity in the country may already be contributing to a viral load testing programme.” (WHO, July 2014)
In order to further reduce costs and increase accessibility to VL tests in LMIC, action needs to take place from several fronts.
First, competition should be encouraged, allowing countries to hold more negotiate power in both prices and services quality. Also, by exploring other selling options like leasing or reagent rental, countries can access updated technology without incurring in increased costs.
Second, pricing transparency should be increased. As only few contracts are publicly available countries have no benchmark for comparison and thus hold little negotiating capacity.
Third, countries should adopt measures to increase cost-efficiency by rapidly scaling economies, using capacity to the fullest and treating information – such as cost of manufacture.
And fourth, countries should improve referral network efficiencies and processes to ensure the right mix between point-of-care and lab-based technologies. By doing this, costs will decrease and service delivery will provide faster results. For instance, mobile health allows patients to access results in a faster and cheaper way, while information is automatically saved into patient databases.
2.3 HAITI
2.3.1 COUNTRY IN CONTEXT
With a mass of about 27.700km2, Haiti is located in the island of Hispaniola, in the
Caribbean. It houses a population of about 10 million people and its official languages are French and Haitian Creole, being the latter the most commonly spoken.
“Haiti is the poorest country in the Western Hemisphere, and one of the poorest in the world, ranking 161 out of 186 on the 2012 Human Development Index.” (UNDP, 2013)4 The country’s history has been marked by political instability, environmental degradation and widespread poverty – with more than half of the population living with less than $1 a day. In January 2010, Haiti was hit by an earthquake with catastrophic magnitude of 7.0, affecting an estimated 3 million people. Almost 5 years later, Haiti continues to rebuild its infrastructure, institutions and general systems. (Vanessa Rouzier et al., 2014).
In response to the earthquake, the World Bank allocated $500 million to Haiti in the form of grants, for the government to apply in recovering projects. From then on, the Haitian economy has been slowly recovering, with low growth rates but maintained macroeconomic stability and inflation. (Vanessa Rouzier et al., 2014)
However, investment in Haiti is hampered by a number of challenges from land availability and ownership rights to access to basic infrastructure, skills, logistics and financial services. As such, a long-term development plan is required to guarantee all basic services to the Haitian population. Ergo the World Bank engages in Haiti’s private sector through two-fold joint strategy with the IFC: on one hand, to create immediate jobs, access to infrastructure and income opportunities; on the other hand, to support the sustainable development of the economy by providing advisory programs that help to attract investors and the creation of enterprises.
Economic growth is estimated at 4.3% in 2013 (as compared to 2.8% in 2012). This is mainly due to the construction and industrial sectors (particularly textile and garment
industries) as well as to the pick-up in agricultural production.5
Nonetheless, with a GDP per capita of $820 in 2013, Haiti is still among the world’s poorest countries. With remarkable needs in basic service provision, 6 out of the 10.4
million Haitians still live under the poverty live on $2 a day.5
According to the World Bank, unemployment rates are high especially in the metropolitan area of Port-au-Prince.
Furthermore, emigration is a significant phenomenon, mainly due to the lack of educational and social opportunities – as a result, Haiti is the world’s most remittance-dependent countries.
2.3.2 MULTIDIMENSIONAL POVERTY INDEX (MPI)
‘The MPI reflects both the incidence or headcount ratio (H) of poverty – the proportion of the population that is multidimensionally poor – and the average intensity (A) of their poverty – the average proportion of indicators in which poor people are deprived.’ (University of Oxford, OPHI, 2014)
The MPI is composed of 3 dimensions – Education, Health and Standard of Living -, all equally weighted, and 10 indicators (Annex 6).
For the case of Haiti, when analyzing all indicators and standards for poverty, the absence of appropriate living standards is the one that yields the greater proportion of poor population – especially when considering access to sanitation, cooking fuel and electricity (Annex 7).
Moreover, in a country with limited accessibility, disparities in poverty patterns occur between urban and rural villages – the proportions of poverty in rural villages are higher for all indicators (Annex 8).
In Haiti, we can observe that people in poverty are falling short in about 33% of indicators. Particularly, we can observe that the indicators that most contribute to the overall result are ‘Years of Schooling’ (18%) and ‘Child Mortality’ (15%) - (Annex 9).
Moreover, on a regional level, the MPI is higher for the Center region (0.499) since this is both the region with the highest incidence of poverty (84,1%) and the highest average intensity across the poor (59,4%). In here, 61% of the population is living in severe poverty. In opposition, the Metropolitan Area holds the lowest MDI (0.177) – Annex 8 (University of Oxford, OPHI, 2014).
2.3.3 EDUCATION
Broad access to proper education remains a big challenge for Haiti’s social and economic development. The January 2010 earthquake posed a major setback for Haiti’s education reform as all resources were directed towards survival.
“Surveys conducted by the UNDP indicate that Haitians who are 25 years and older received on average only 4.9 years of education and only 29 percent attended secondary school.” 6 (USAID, 2014)
Most schools have minimal government support and are quite expensive. Moreover there is the problem of the lack of qualifications of the public sector teachers who many times receive no training whatsoever.
Moreover educational expenses often become an unbearable financial burden for Haitian families, leading children to drop out of school from an early age as to start contributing to the household.
2.3.4 ACCESS TO CLEAN WATER AND SANITATION
“Haiti has built safe drinking water systems serving more than 50,000 people and school latrines for more than 5,000 students and teachers in rural Haiti. The government also helped establish professional operators and water and sanitation committees in nine communes (...)” 7(World Bank, 2014)
Despite the advancements achieved in the last decade, disparities between rural and urban villages remain evident.
6 http://www.usaid.gov/haiti/education
7
Local communities often had their rural water systems managed by water committees consisted of unpaid volunteers – as a result, most of them could not assure sufficient funds for operation and routine maintenance.
Moreover, these problems of lack of general access to water supply and sanitation coverage carry significant associated health risks for the community – e.g.: cholera epidemic in October 2010.
2.3.5 POLITICS
The Corruption Perceptions Index (CPI), measures the perceived levels of corruption of public sectors within 175 countries around the world – being the 1st on the list the least corrupt and the last one the most corrupt.
According to the CPI 2014 Haiti is amongst the most corrupt countries, ranking 161º, together with Venezuela – both being the most corrupt of the Americas (Annex 10).
“From time to time, Haiti’s chronic political dysfunction erupts in crisis and violence, compelling the international community to re-engage with an impoverished country it might prefer to disregard” 8 (The Washington Post, 2014)
A current political crisis has been occurring in Haiti, as a result of a three-year-old impasse between President Michel Martelly and legislators. Parliamentary and municipal elections have been frozen, triggering protests and street violence amongst Haitians and the police force.
As a result of this stalemate between lawmakers and the president and the innumerous manifestations on the streets, the Prime Minister Laurent Lamothe resigned in December 2014 and in January 2015 the Parliament was dissolved - leaving President Michel Martelly ruling by decree under the constitution.
2.4 AIDS RELIEF AND GENERAL HEALTH CARE IN HAITI
2.4.1 HISTORY OF THE EPIDEMIOLOGY OF HIV IN HAITI
In 1982, GHESKIO opened the first clinic in the world dedicated to fighting HIV/AIDS in Port-au-prince, Haiti. In that same year, the CDC had listed Haiti as a stage country for HIV, homosexuality, heroin use and haemophilia.
‘AIDS victims have been fired from their jobs, driven from their homes, and deserted by their loved ones. Any homosexual or Haitian has become an object of dread’9 (New York Magazine, June 1983).
Tourism, which had been a strong fuel of the Haitian economy during the 1970s and 1980s, fell down drastically overnight. And in 1990, the FDA issued a policy recommending that all Haitians should be forbidden to donate blood.
This association between Haitians and AIDS led to unprecedented discrimination and prejudice. However, Haitians didn’t settle and decided to mobilize both locally and internationally, fighting against the discrimination of an entire nation. Shortly after, the FDA revoked its policy.
Concerning risk factors, GHESKIO reported that HIV in Haiti had evolved mainly from the homosexual and bisexual population. However, as years passed, this trend shifted and, in 1985, heterosexual intercourse was Haiti’s dominant path for HIV transmission (Annex 11).
Another common risk factor had to do with blood transfusion. At the time, there was little safety control and commercial suppliers were buying blood from impoverished patients – as a result, in 1985, 4% of all blood donors in Haiti were found to be infected with HIV. As a response, the MoH closed all commercial blood suppliers, and established the Haitian Red Cross as only organization authorized to collect blood and provide transfusions.
9 http://nymag.com/news/features/47175/
2.4.2 THE EXPANSION OF ART - AND THE IMPORTANCE OF INTERNATIONAL HELP
“The early collaboration of the Haitian public and private sectors and the priority given to fighting the HIV epidemic were instrumental in setting the stage for the rapid scale-up of HIV services once funding became available.” (Vanessa Rouzier et al., 2014)
In 2002, Haiti was awarded a grant by the Global Fund, which paid for the initial development of a nationwide program directed towards the HIV-infected population. This program was developed by two main implementing organisations – PIH and GHESKIO. On one hand, PIH acted in Haiti’s Central Medical Department providing full medical and surgical service as well as ART for infected patients. On the other hand, GHESKIO expanded its operations on voluntary counseling and testing while providing ART and expanding its network of integrated primary care services.
But only with the financial assistance of PEPFAR (2003) has the dissemination of care reached national levels. In addition to the general provision of ART, this funding enabled to develop clinic and laboratory infrastructures, counseling and testing services, mother-to-child care, general treatment for TB and other STIs, etc.
One of the major accomplishments of PEPFAR in Haiti relates to the introduction of supply chain management systems. By partnering with MoH and local NGOs, PEPFAR has ensured that ART drug stock-outs were rarely a problem for Haitians.
Furthermore, in association with CHAI, PEPFAR has also successfully introduced generic medications and broke down established drug distribution agreements as a means to reduce the costs of ART.
Haiti had built a strong comprehensive response to HIV, which became evident even in the most catastrophic settings. Within just a few months after the 2010 earthquake, ART coverage was over 90% of the pre-earthquake level and HIV prevalence was kept constant.
2.4.3 AIDS RELEASE IN NUMBERS
“As of July 2013, Haiti had reached universal ART coverage for patients with CD4+ T-cell counts ≤350 cells/mm3.” (Vanessa Rouzier et. al, 2014)
Between 2005 and 2012, the number of HIV testing sites nearly doubled while the number of patients tested for HIV increased by 4 times (Annex 12).
First-line ART regimen drugs are available in Haiti for a yearly cost of $138. If a patient develops resistance and needs to switch to second-line therapy, this value would go up to $235. Finally, drugs for third-line therapy have recently been introduced in Haiti. However, generic formulations aren’t available so best case scenario is at $2.006 per year. (Vanessa Rouzier et. al, 2014)
Through all its strategic interventions Haiti has managed to decrease its HIV prevalence from 6.2% in 1993 to 2.2% in 2013.
2.4.4 ADDRESSING CHALLENGES
Although it is undeniable how much has been accomplished in Haiti, the fight against HIV/AIDS still presents significant challenges.
“The cascade from HIV diagnosis to linkage and retention into care is complex and involves many steps.” (Vanessa Rouzier et. al, 2014) (Annex 13)
Due to the complexity and longitude of this process, patients often get retained and fail to complete the treatment. In Haiti, about 30% of diagnosed patients are still lost to care prior to returning for results.
The problem accentuates as treatment adherence is interrupted by food insecurity or extreme poverty. In these settings, economic and social support must be provided to minimize these barriers and maintain patients in treatment.
Another problem relates to personnel training as an essential condition for the dissemination of HIV services.
“From 1992 to June 2013, GHESKIO trained 3.478 physicians, 4.893 nurses, 1.746 laboratory technicians and 1.375 social workers, as well as 3.11787 community and religious leaders.” (Vanessa Rouzier et. al, 2014)
Despite all efforts made, the increased training originated a perverse effect: as Haiti is still a set for political turmoil, insecurity, violence and limited economic opportunities, ‘brain drain’ remains a major challenge, as 80% of Haiti’s university graduates leave the country. Retention strategies like the development of additional academic and professional opportunities are urgently needed to reverse this trend.
Furthermore, the coordination of funds and technical support has proven a problem in Haitian settings, with different organisations sometimes spending funds with similar purposes instead of scaling on each other operations. To maximize future efficiency it is essential to determine funding priorities - ideally, having the local government act as the principal recipient for support programs, coordinating funds where they are most needed.
2.5 FUNDING FOR NGOS
2.5.1 NGO DEFINITION
The meaning of NGO has always has always been subjective and easy to interpretation. To the purpose of this dissertation we decided to use that of the UN:
“A non-governmental organization (NGO, also often referred to as "civil society organization" or CSO) is a not-for-profit group, principally independent from government, which is organized on a local, national or international level to address issues in support of the public good. Task-oriented and made up of people with a10 common interest, NGOs
perform a variety of services and humanitarian functions, bring public concerns to governments, monitor policy and programme implementation, and encourage participation of civil society stakeholders at the community level. Some are organized around specific issues, such as human rights.” (UNROL, 2014)
2.5.2 THE NEED FOR FUNDING
“From its own definition (not-for-profit) we understand that, in order to sustain their activities ― nonprofits need a fundraising strategy carefully crafted” (Dolby and Gregory Dees, 1996).
Especially after the economic crisis, two different effects have arise: (i) philanthropists and donors are becoming increasingly strategic, wishing to see a clear impact on performance derived from their donations; (ii) the number of NGOs increases by the year and with it, so does the competition for funding.
Together, these effects lead to a greater need for NGOs to define a clear structure for their funding. In order to succeed, NGOs need to be credible, professional and efficient in the way they manage their funds and activities.
2.5.3 BUSINESS MODELS
Of course, having a sustainable business model is essential for NGOs to survive. According to Elkington and Hartigan (2008), there are three business models, namely “leveraged nonprofit”, “hybrid nonprofit” and the “social business”.
The first case “leveraged nonprofit” is very common when market failure occurs, that is, when companies are unable to provide their service/good. In this case, the NGOs will resource to third parties for financial support- whether they are external partners, the government or financial institutions.
The “hybrid nonprofit” model is a combination of the nonprofit and the for-profit world. The ideal describes a company with a strong social mission (like nonprofits) but with the commercial logic of a for-profit business. These associations can sell products or provide services and turn their profits to whatever they want - whereas NGOs need to allocate profits for future social projects; nonetheless, they are still eligible for the tax benefits of non-profits.
Finally, the “social business” model refers to “for-profit entities focused on social missions” (Elkington and Hartigan, 2008). While they generate profits like a regular commercial venture, they affect their profits to future social activities instead of returning them to shareholders.
2.5.4 FUNDING OPTIONS
The need to define a clear fundraising strategy sticks with the need to properly position our organization within the nonprofit world. Ahead we will discuss several funding sources NGOs can resource to when looking for funding - focusing on our dissertation’s problematic of HIV.
(i) Public and Private entities
In here we include all entities that perform specific activities within their communities. For-profit companies usually grant funds to NGOs following one out of two philosophies: The first one is the traditional ‘pure corporate philanthropy’ ― “Philanthropy as a form of public relations or advertising, promoting a company‘s image or brand through cause-related marketing or other high-profile sponsorships. (...)” (Kramer & Porter, 2002). The second one arose as competition for funding increased and companies started looking at philanthropic activities not just as a means of enhancing social responsibility but also as a means to support their own business - ‘strategic philanthropy’. Of course, the more a
company’s business relates to social improvement the higher will be the gains and the probability for the company to continue funding.
NGOs following this last approach need to be very committed to the corporation and prove that their funds will both contribute to the development of the society and the company’s competitive context because ― “the impact achieved by a donor, then, is largely determined by the effectiveness of the recipient” (Porter & Kramer, 2002).
Furthermore, another very common way for NGOs to get funding is to resource to other philanthropic organisations. By joining forces, organisations acting in similar fields become stronger and deliver more comprehensive and extensive programs aimed towards a specific cause.
Finally, NGOs can use bank loans and other financial instruments - however this is not a very common option due to impositions like - “limited liquidity, ownership restrictions, lack of performance data, and no developed stock exchange marketplace” (Nicholls & Pharoah, 2008).
(ii) Government
As means to complement their social activities and interests, Governments have been long joining forces with NGOs, by providing them with funding from a variety of sources - the national budget, grants, joint programs, etc.
In the case of the US Government, several initiatives and programs have been created, each to focus on fighting a specific issue. For the purpose of this dissertation we will only focus on two of these programs - USAID and PEPFAR.
USAID is the lead U.S. Government agency that works to end extreme global poverty. It carries the U.S. foreign policy by adopting as its mission statement "to partner to end extreme poverty and to promote resilient, democratic societies while advancing the security and prosperity of the United States."
Thanks to USAID, more than 3 million are saved every year through immunization programs, 850.000 have been reached by HIV prevention programs, and 40.000 were trained to support these programs.
USAID has also contributed to Haiti’s general healthcare provision by spending a total of $56.5 million in health programs 2012 - from which 56,6% were allocated to HIV/AIDS programs.
PEPFAR is a US Government initiative dedicated to provide healthcare to HIV/AIDS victims around the world. It the largest commitment ever made by a nation to fight a single disease internationally and it represents the largest component of the US President’s Global Health Initiative.
On July 30, 2008, the US Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008 (H.R. 5501) was signed into law, authorizing up to $48 billion over the next 5 years to combat global HIV/AIDS, tuberculosis, and malaria.
Finally, NGOs in the US can apply for recognition by the IRS of exempt status under section 501(c)(3). According to the IRS - “The exempt purposes set forth in section 501(c)(3) are charitable, religious, educational, scientific, literary, testing for public safety, fostering national or international amateur sports competition, and preventing cruelty to children or animals. The term charitable is used in its generally accepted legal sense and includes relief of the poor, the distressed, or the underprivileged; advancement of religion; advancement of education or science; erecting or maintaining public buildings, monuments, or works; lessening the burdens of government; lessening neighborhood tensions; eliminating prejudice and discrimination; defending human and civil rights secured by law; and combating community deterioration and juvenile delinquency.”
(iii) International Organisms
Similar to PEPFAR and USAID, there are several organisations working to resolve conflicts worldwide.
One of the oldest and most important is the UN - an intergovernmental organization, established in the 24th October 1945, to promote international co-operation. According to Article 71 of the UN charter: “The Economic and Social Council may make suitable arrangements for consultation with non-governmental organisations which are concerned with matters within its competence.
NGOs have been partners of the UN since 1947, they can have consultative status with the ECOSOC, and their relationship with UN entities varies depending on their location and mandate.
The UN created the Joint United Nations Programme on HIV and AIDS (UNAIDS) - which goal is to be the main advocate for accelerated, coordinated and comprehensive global action against HIV.
“UNAIDS recently announced a set of unprecedented HIV testing and treatment targets for the global health community to reach by the year 2020. Called the 90:90:90 targets, the goals of the initiative are to ensure that 90 percent of HIV-infected patients know their HIV status; that 90 percent of positively diagnosed patients are on life-saving ART treatment; and that 90 percent of patients on treatment are responding successfully to their drugs.”11 (Clinton Foundation, 2014)
Furthermore, there is the WHO - a specialized agency of the UN dedicated to providing leadership on global health matters by shaping the health research agenda, setting norms and standards and providing technical support to countries.
The WHO is working to build a strong and logical VL testing network amongst developing countries. In July 2014, they published a report providing guidance on implementing and expanding VL testing programs for health ministries and implementing partners, using a 3 stage approach: planning, scale-up and sustainability.
11 https://www.clintonfoundation.org/blog/2014/12/01/improving-access-viral-load-testing-hiv-patients-developing-countries
Finally, we refer to UNITAID – the world’s first solidarity contribution for innovative purchasing, founded with the objective of gathering funds to fight HIV, tuberculosis and malaria. Approximately half of its resources come from a small levy on airline tickets in several countries, while the rest is provided primarily by contributions from governments and foundations.
Together with MSF, UNITAID is also developing ways to expand affordable VL testing in resource-limited countries.
(iv) General Public
People who donate money to organisations can be motivated by a variety of reasons; a sense of gratitude or personal passion, the desire to help others, the need to improve social standing, etc. What they all have in common, working as an extra motivation, are fiscal benefits when donating to non-profits.
Although these are usually small donations, when a big number of people comes together they can make a big impact.
Furthermore, organisations can try to identify “Angel Investors” - wealthy people that invest in entrepreneurial companies to accelerate their development. However, in exchange for their funds these investors usually take convertible debt or ownership equity.
(v) Own Business Activities
In here we include service or products delivery by the organization as an independent means to raise funds, as long as they reflect the image of the organization, creating a relationship with the buyer.
A very common example is the membership fees - whereby the organization receives a regular donation from all who want to collaborate with it. This is a recurrent practice especially among organisations that offer some kind of socially responsible certification.
Another usual way of raising funds is through the organization of events. These can be directly related to the nature of activities developed by the organization (e.g.: conferences) or not be related at all - having the unique purpose to raise funds, entertain people and engage them in the companies’ activities. Furthermore, according to Ilona Bray (2008), events ― ”are occasions outside your nonprofit’s usual activities, where your membership and/or the public is invited to attend and support your work, usually by paying an admission fee or buying things once they get there.”
2.6 ANNEXES
Annex 1: Adult HIV prevalence rate, 2013
Source: "The Global HIV/AIDS Epidemic." The Global HIV/AIDS Epidemic. Kaiser Family Foundation, n.d.
Annex 2: HIV Prevalence & Incidence by Region, 2013 Region
Total nº (% Living with HIV)
Newly Infected
Adult Prevalence Rate
Global Total 35.0 million (100% 2.1 million 0.8%
Sub-Saharan Africa 24.7 million (71%) 1.5 million 4.7%
Asia and the Pacific 4.8 million (14%) 350.000 0.2%
Wstern and Central Europe and North
America 2.3 million (7%) 88.000 0.3%
Latin America 1.6 million (5%) 94.000 0.4%
Eastern Europe and Central Asia 1.1 million (3%) 110.000 0.6%
Caribbean 250.000 (<1%) 12.000 1.1%
Middle East and North Africa 230.000 (<1%) 25.000 0.1%
Source: "The Global HIV/AIDS Epidemic." The Global HIV/AIDS Epidemic. Kaiser Family Foundation, n.d.
Annex 3: Breakdown of Average Cost per Viral Load Test
Source: "How Low Can We Go? Pricing for HIV Viral Load Testing in Low- and Middle-Income Countries." Médecins Sans Frontières ACCESS CAMPAIGN: n. pag. 19 Sept. 2014.
Annex 4: Effect of Throughput on Viral Load Cost per test
Source: I"How Low Can We Go? Pricing for HIV Viral Load Testing in Low- and Middle-Income Countries." Médecins Sans Frontières ACCESS CAMPAIGN: n. pag. 19 Sept. 2014.
Annex 5: Estimated Manufacturing Costs of Exemplar Viral Load Tests Reagent costs Moulding costs Reagent container costs Final assembly costs
IP costs Total IP cost as % of total Laboratory-based tests
Abbot Real Time HIV-1
assay $ 2.38 $ 0.02 $ 0.07 $ 0.06 $ 4.25 $ 6.77 63%
Roche CAP/CTM HIV-a
assay $ 4.37 $ 0.07 $ 0.03 $ 0.04 $ 1.80 $ 6.31 29%
BioMerieux NucliSens
EasyQ HIV-1assay $ 1.23 $ 0.00 $ 0.35 $ 0.04 $ 0.00 $ 1.61 0% Cavidi ExaVir Load
assay $ 2.49 $ 0.00 $ 0.22 $ 0.05 $ 0.00 $2.76 0%
Point-of-care tests
Altere Q HIV test $ 1.56 $ 4.01 $ 0.00 $ 1.50 $ 2.26 $ 9.33 24% Diagnosis for the Real
World SAMPA test $ 1.62 $ 3.29 $ 0.00 $ 1.50 $ 2.26 $8.67 26% WAVE 80 Biosciences
EOSCAPE-HIV test $ 1.56 $ 3.50 $ 0.00 $ 0.00 $ 1.20 $ 6.26 19% Lumora 'BART' test $ 1.62 $ 0.00 $ 1.27 $ 0.95 $ 1.00 $ 4.84 21%
Source: "How Low Can We Go? Pricing for HIV Viral Load Testing in Low- and Middle-Income Countries." Médecins Sans Frontières ACCESS CAMPAIGN: n. pag. 19 Sept. 2014.
Annex 6: MPI Indicators and Dimensions
Source: Oxford Poverty and Human Development Initiative (2014). “Haiti Country Briefing”, Multidimensional Poverty Index Data Bank. OPHI, University of Oxford
Annex 7: Deprivations in each Indicator (Haiti)
Source: Oxford Poverty and Human Development Initiative (2014). “Haiti Country Briefing”, Multidimensional Poverty Index Data Bank. OPHI, University of Oxford
Annex 8: Multidimensional Poverty across sub-national regions in Haiti
Source: Oxford Poverty and Human Development Initiative (2014). “Haiti Country Briefing”, Multidimensional Poverty Index Data Bank. OPHI, University of Oxford
Annex 9: Contribution of Indicators to the MPI (Haiti)
Source: Oxford Poverty and Human Development Initiative (2014). “Haiti Country Briefing”, Multidimensional Poverty Index Data Bank. OPHI, University of Oxford
Annex 10: CPI 2014 - Americas
Annex 11: Changing HIV transmission patterns in Haiti
Source: Rouzier, Vanessa, Paul E. Farmer, Jean W. Pape, Jean-Gregory Jerome, Joelle Deas Van Onacker, Willy Morose, Patrice Joseph, Fernet Leandre, Patrice Severe, Donna Barry, Marie-Marcelle Deschamps, and Serena P. Koenig. "Factors Impacting the Provision of Antiretroviral Therapy to People Living with HIV: The View from Haiti." Antiviral Therapy (2014): n. pag. Web
Annex 12: Number of HIV testing and ART sites, and number of patients receiving services by year in Haiti
Year VCT sites, n Patients tested for HIV, n ART sites n enrolled on ART, Patients newly n 2005 83 196 924 23 2 659 2006 99 290 663 32 4 336 2007 114 450 627 40 6 643 2008 122 603 944 45 7 099 2009 128 620 669 49 8 127 2010 145 381 821 53 6 208 2011 153 693 624 64 9 314 2012 161 854 333 96 13 710
Source: Rouzier, Vanessa, Paul E. Farmer, Jean W. Pape, Jean-Gregory Jerome, Joelle Deas Van Onacker, Willy Morose, Patrice Joseph, Fernet Leandre, Patrice Severe, Donna Barry, Marie-Marcelle Deschamps, and Serena P. Koenig. "Factors Impacting the Provision of Antiretroviral Therapy to People Living with HIV: The View from Haiti." Antiviral Therapy (2014): n. pag. Web
Annex 13: Steps in HIV care from diagnosis to treatment
Source: Vanessa, Paul et al. Factors impacting the provision of antiretroviral therapy to people living with HIV: the view from Haiti, GHESKIO: Antiviral Therapy 2014; 19 Suppl 3: 91-104
CHAPTER 3: CASE STUDY 3.1 INTRODUCTION
“Tony has an outstanding reputation as a business and global brand leader with exceptional marketing experience. Tony has worked on some of the largest and most celebrated brands in the world. Having a multi-lingual and multi-cultural background has allowed Tony to develop highly effective and recognized global marketing campaigns, including several nonprofits and private philanthropies.” (LZF)
Before founding the LZF, Anthony Kuhn (Exhibit 1) was working as a consultant for the life sciences industry, launching several lifesaving medical devices and molecular diagnostic tests in India and the GCC, Africa and The Middle East. Throughout his travels to medical facilities all over the world, one thing that Anthony always liked to ask local doctors was “What keeps you up at night?”.
So once in India, he was at a hospital and asked the local doctors this same question, to which they responded - ‘well, this crazy virus - HIV -, that keeps getting worse and worse - we see the infected population growing, it keeps killing people, and we can’t seem to fix it!’
This answer troubled Anthony as the reality in America was quite different – HIV was a problem but not a frontline issue. He thought, Magic Johnson (a very famous former basketball player) had HIV, everybody knew it, and yet he seemed to live a very normal life. So what is the difference between him and a child living in Africa?
He found out that part of the problem was this very rate-limiting VL testing. In the US and most countries in Europe most hospitals have a roach PCR machine to do this test. It will cost a couple of hundred dollars but the doctor will be able to recommend the exact drugs needed for each patient to fight the virus. But in LMIC, PCR machines aren’t as common and very often they do not have the means to support $200 tests per patient.
So Anthony started looking for alternatives and came across Cavidi, a Sweden organization that had a new technology coming from the university of Uppsala. Cavidi uses a reverse transcriptase
test that can be done in a kitchen sink – requiring only water, electricity, and a couple of pieces from the lab. In doing so, Cavidi is able to perform VL tests for just about $20.
The Cavidi test was already available, had been used in multiple locations and proven to work. Although it requires some expertise from technicians and gives slower results when compared to the standard PCR machines, it seemed the perfect solution for low-income settings!
Finally, Anthony decided to fund the Load Zero Foundation (LZF) - the only charitable organization in the world specifically dedicated to providing VL testing for HIV/AIDS patients in desperate need.
This case study aims to examine LZF’s work, focusing on their accomplishments and future challenges, particularly in Haiti where they aim to set up their first full laboratory exclusively aimed to perform VL tests. In the end we wish to inspire people to join their cause, recognizing VL tests as a means to save millions, but also to understand and help the LZF with their challenges ahead, by discussing the big fundraising issue that is at the base of their operations.
3.2 LOAD ZERO FOUNDATION: THE SOCIAL ENTERPRISE
“The Load Zero Foundation (LZF) is the world's only philanthropic organization specifically dedicated to funding low cost viral load testing for over 28 million HIV patients in Africa, India, and Southeast Asia. The foundation funds viral load tests designed for low technology laboratories to measure all HIV types and subtypes active in these regions through donations.”12 (RDI, 2014)
The LZF is an international NGO that provides VL tests, as well as ensures everything needed to perform them in the most resource-limited settings – laboratory equipment, technical training and infrastructure, etc.
12 http://www.hivrdi.org/our-partners.htm
All funding is guaranteed by the organization through its network of international partners, who themselves work with internationally recognized health and healthcare delivery institutions. The LZF works with an existing network of over 100 VL testing sites in 33 countries worldwide (Exhibit 2). When an organization or an individual provides a donation they can choose to allocate their money to a specific testing center at a given donation.
The primary goal of the organization is to make VL testing widely available to reach the largest number of infected people as possible, while reducing the cost of testing and increasing the effectiveness of ART.
3.2.1 HISTORY OF THE LZF
To succeed in implementing its vision, Antony’s first step was to gather advisors and a Board of Directors, comprising members who are well known and highly respected in the international HIV space (Exhibit 3).
From its longstanding background in the non-profit world, Anthony knew he had a long road ahead since he first founded the LZF in April 16, 2013.
Anthony knew he needed to take its concept out to the international AIDS space. As it was only in that same year that the WHO had declared VL testing as the gold standard for HIV/AIDS treatment and monitoring, several organisations were still unfamiliar with its process and advantages.
In that same year, the LZF applied for a 501(c)(3) tax-exempt status on an expedited basis. Since the 9/11 it’s become really difficult to get this status – it’s a complicated and time-consuming process that can take up to two and a half years. The LZF obtained the status within 12 months, which was an immense proof of success and work validation.
Afterwards, they started contacting really credible partners to join and strengthen their cause. The first one was the ‘The Elizabeth Glaser Pediatric AIDS Foundation’ (the global leader in the fight
to end children AIDS), followed by KCA, PIH, amongst others.
Most of these organisations are formed by doctors without borders, used to working in very limited settings. So when hearing about the LZF’s mission, they were very happy as they didn’t have access to VL testing at any of their clinics.
“Even today, HIV viral load testing is not accessible to 95% of the HIV population in these regions. The result is the unnecessary loss of life; human suffering and greatly increased cost of care to parts of the world that can least afford it.”13 (LZF)
This is the reality that the LZF aims to fight, by providing clinicians in developing countries with low cost VL tests and equipment. They do this as they’ve negotiated deep discounts, thanks to their purchasing power and matching donations from suppliers. The LZF will create fully
equipped labs for VL testing for around $20.000 or less than 10% of the costs of a traditional VL testing lab (Exhibit 4).
3.2.2 MISSION AND VISION
“At the Load Zero Foundation, our vision is to help end the devastation brought on by HIV in developing regions around world.”14(LZF)
The LZF has its headquarters in New York City and now counts with an extensive list of partners to help implement its vision (Exhibit 5). It sees VL testing today as the “bottleneck” for curing HIV and it is their mission to change that.
3.2.3 LZF AS INTERMEDIARIES IN HEALTH CARE PROVISION
As a non-profit organization the LZF develops its activities by establishing strong partnerships with (1) suppliers of medical equipment, necessary to set up VL laboratories (2) other organisations that are at the frontline of healthcare provision.
As we’ve seen, there are innumerous organisations worldwide working to fight HIV, but few of them have access to VL testing. This is where the LZF comes in, by functioning as a link between the suppliers and these organisations - by doing this and granting the necessary support to set up the laboratories, the LZF will much improve HIV treatment in LMIC.
3.2.4 PARTNERSHIPS
The partnerships established by the LZF are essential for the organization to continue its operations but also to gain recognition in the HIV space. One of the most important partnerships for the LZF was accomplished in December 2013:
“The RDI is an independent, not-for-profit research group set-up in 2002 with the mission to improve the clinical management of HIV infection through the application of bioinformatics to HIV drug resistance and treatment outcome data” (RDI, 2014)
The RDI created HIV-TrePS, a free online experimental system that uses computer models filled with treatment information from tens of thousands of patients from around the world. Based on collected data, the system is able to predict how patients will respond to the several HIV drugs combinations.
Another great step for the LZF happened in November 2014 when they partnered with PIH - one of the most respected providers of healthcare to poor and underserved communities around the world.
PIH first began in 1987 when Paul Farmer was in a community-based health project in Cange, Haiti. Since this was a country with an extremely high HIV-prevalence, for many years, the sole goal of the organization was to treat HIV-infected patients.
At the time they launched their flagship project - Zanmi Lasante - which would turnout not to be just the oldest but the greatest and most ambitious project ever initiated by PIH. Today, they are the largest nongovernmental healthcare providers in Haiti, operating in hospitals and clinics at 12 sites and serving an area of 1.3 million people.
