1. Why WASH Matters to People Living With HIV Joe Brown London School of Hygiene & Tropical Medicine Department of Disease Control Faculty of Infectious & Tropical Diseases joe.brown@lshtm.ac.uk 25 July 2012

2. WASH importance to HIV Quality of LIFE OIs related to WASH disproportionately affect People Living With HIV (PLHIV) Stakes are higher for PLHIV: increased morbidity & mortality Co-infections can lead to disease progression and early death as infections result from and increase a weakened immune status Gut infections reduce ART uptake!

3. WHO GBD 2008, LMICs

4. Some common co-infections that may be prevented or reduced with WASH Faecal-oral – Hepatitis A,E; viral diarrheas; Campylobacter; cholera; ETEC; Salmonella; Shigella; typhoid; paratyphoid; Crypto; Giardia; Amoebas; Toxoplasma gondii and other opportunists Water-washed – Trachoma; scabies; conjunctivitis; louse-borne infections Soil helminths and tapeworms – Ascaris; hookworm; Taenia Water-based – Cholera; Legionella; Leptospirosis; Schisto; Insect vectors – Dengue, yllw fever, malaria, trypanosomiasis, filariasis, trachoma Rodent borne – Leptospirosis; hantavirus, Tularemia

5. WASH control measures Improve water quality, water availability, hygiene – Hepatitis A,E; polio; viral diarrhoeas; Campylobacter; cholera; ETEC; Salmonella; Shigella; typoid; paratyphid; Crypto; Giardia; Amoebas; Toxoplasma gondii and other opportunists Improve water availability and hygiene – Trachoma; scabies; conjunctivitis; louse-borne infections Sanitation, hygiene, treatment of excreta before re-use – Ascaris; hookworm; Taenia Reduce contact with contaminated water, sanitation, treatment of excreta before re-use – Cholera; Legionella; Leptospirosis; Schisto; Guinea worm Drainage, reducing breeding sites, insecticides/nets – Dengue, yllw fever, malaria, trypanosomiasis, filariasis, trachoma Rodent control, hygiene measures – Leptospirosis; hantavirus, tularemia

7. Children with HIV Children who are HIV+ are at much greater risk of hospitalization, long-term illness, and death as a result of WASH-related infections Children who are HIV+, as well as those who are HIV- but cared for by mothers that are HIV+, are at greater risk of poor nutritional status and health which can be caused or aggravated by enteric infection (Filteau 2009)

9. ART and diarrhea Diarrheal disease and intestinal infection may cause individuals on antiretroviral therapy (ART) not to absorb therapeutic dosages of the medication (Isaac 2008, Brantley 2003, Bushen 2004). Implications for PMTCT, PREP, PEP, long-term disease progression and survival

10. Prevention of Mother-to-Child Transmission (PMTCT) Healthier moms are less likely to transmit the virus to children through breastfeeding – Healthier moms are less likely to pass other infections to baby, also Gut infections in babies may increase the risk of HIV infection by compromising the integrity of the intestinal wall, making it easier for the HIV virus to pass into the infant’s bloodstream Safe water and hygiene play a major role in the limited circumstances when replacement feeding/early weaning are indicated

11. Retention in care Increased retention in care as a result of VitaMeal and hygiene packages (soap, P&G packets/cloth+ storage container) offered Also reported “99.4% usage” of water treatment at 3 month follow up, versus 12% (disinfectant use among mothers with young children) or 20% (all households in Malawi)

12. Rosen S, Fox MP, Gill CJ (2007) Patient Retention in Antiretroviral Therapy Programs in Sub- Saharan Africa: A Systematic Review. PLoS Med 4(10): e298. doi:10.1371/journal.pmed.0040298 http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0040298

14. Cost effectiveness Low cost of including WASH in treatment and care programs – Pennies on the dollar! – Sustained access to safe water would be <5% of the cost of first-line ARVs (drugs only) Significant net savings with integrated programming (Khan et al 2012) Benefits of hygiene and safe water programs can extend beyond antenatal beneficiaries to include friends and relatives (Russo et al. 2012)

15. What we can do now Add WASH to HIV PMTCT programming because: 1. We know HIV-affected children and adults are highly vulnerable to diarrheal illnesses 2. We know that WASH interventions can reduce diarrhea by 50% or more 3. We know that diarrhea in mothers and children can contribute to lower uptake of life-saving drugs that prevent MTCT 4. We know it can increase retention in treatment and care, at low cost

16. Thank you Creative and Novel Ideas in HIV Research (NIH) P&G London School of Hygiene and Tropical Medicine, Environmental Health Group University of Zambia School of Medicine Charlie Van Der Horst & the UNC CFAR