 We're going to talk a little bit about the impact of global health programs, especially focusing on diagnostics in Peru. So it's been like 10 years now since I've been getting involved in global health programs. As mentioned before, the initial programs were called international health now and they are called global health. So I will focus my talk basically on the accompaniments of global health programs in Peru. So these global health programs just put together different fields of studies of epidemiology, the prevention, the training, so putting more multidisciplinary studies together, multidisciplinary also professions. So we are making our best, I guess, especially with US researchers in Peru, like Brandon. There are a couple of things very important I want to show you later, but there are tons of studies running across the country that are coming with nice accompaniments through the time. So this is Peru. So for those of you that don't know where Peru is in South America, this is becoming an important country because its food is very well known around the world. But we have a lot of attractions and a lot of water, so we have nice beaches in the north. We have the capitals, nice buildings, the Colombian buildings. We have nice canyons in the south, so we have the jungle, and we have much people, which is maybe the most famous business there, and we also have the hikikakale. So this is an amazing country, but as an amazing country, also we have many feds across the country. So if we go to the north, where the nice beaches were, we have a lot of infections, so we have very high prevalence of being gay in Malaria. If we go to Lima, which is a very crowded place, 10 million people, a third part of the Peruvian population lives in Lima. So we have tons of work losses, and the HIV epidemic is very high in some part of the capital. And if we go to the south, we have a serious disease, and if we take a look at the jungle, we have more Malaria, more NG, we have Bartonella in Cusco, and we have a big problem of pneumonia across the country. So we have many feds, and many wonders at the same time. So as a public health practitioner, we have to work different stuff, different things across the country, facing different cultures and different languages, because our official language is Spanish, but here in the jungle, we have almost 100 different languages, native languages, so it's very difficult to work with them. So we have like two different languages in the Netherlands, and maybe most of the people speak Spanish, but we have to face where the real problems are, where the people doesn't even speak Spanish. So for starting with my presentation, I would say that to prevent and control, is one of the main goals of the global health, we need to know where the infection is. So we did a couple of studies basically on STIs and HIV to know where the infection is, because normally the infection is in the hospital. So when we see a sick person, this person comes to the hospital because they have symptoms, or they have some signs of the disease. It's an easy word for us, but the problem is out there, when the people are sick and they don't know they are sick, or they don't know they have an infection. So this is, for example, syphilis. So using this penis with this ulcer here is really notable, so you can see it, but when syphilis happens in the throat, in the mouth, in the genital area, or maybe in the anus, you can see it, it's very difficult. And if it's not painful, you can feel it, it's difficult. So sometimes people are infected with syphilis and they don't know they are. So we need to go out there and look for people that have syphilis, being men or being women. This is bad. It's a very primitive bad. So it's maybe the most primitive bacteria we know that cause disease in humans now. It's a very simple bacteria. It can survive without a human. It needs to be inside of the body to survive. So we know about syphilis that in Peru, this epidemic is very well known that it's concentrated in MSN and also in trans-population. So Patoso is affecting pregnant women. So we know where is the problem. And we know where is the problem because we do a couple of studies. We did a national surveillance between 19th and 19th of 2002, and we found a very high prevalence among MSN. It means that like 16 people from 100 have the disease or have the infection. But we look for symptoms, they don't have symptoms. So those 16 people doesn't know they have syphilis. So that's a huge problem. So we did another study one year ago with Alfonso Silva, which is a partner of our office. So we found a new prevalence. So we've been thinking that the prevalence was decreasing. But we found that, yeah, that actually the prevalence is higher. Twenty-three percent is one in four people. And the trans-population or the MSN population is infected with syphilis in Lima. And also we found that we have high rates of infection. I mean, we found the people infected. We gave them treatment. And after three months they are supposed to be cured. They come back to the hospital and we check for the test for syphilis and they are still infected. So what happened? We don't know. The treatment isn't working. It's one possible question. The other question could be the bug maybe has a mutation. So the medication is not affecting the bug anymore. So maybe they got reinfected or maybe they need an increased dose of the medication. So we don't know yet. But something is happening. So this is a very high rate of reinfection. This is part of the study we got funded this year. They are one that Brandon was mentioned. So we're going to explore what is going on among the population infected with syphilis that is becoming very infected so easily. We also have that MSN has the highest prevalence of HIV in Peru. It's around 14-15%. So from those people infected with syphilis we have like many of them are living also with HIV. So something is happening. So there is some relationship we already know between HIV and syphilis. So it's like the story of the chicken and the egg. We don't know who is first. So in this case we are going to explore which is fair as the syphilis or is HIV. And we are not going to explore only the behaviors. We are only going as we see later to explore what's going on in the organism. I mean it's an immunological problem. Is there a behavior problem? So we need to know that. And we are going to research that. So this is a primary health facility laboratory in Peru. So this is, I always show this picture since that year because this is very close to the most finest neighborhood in Lima. So everyone saw the big hospital close to the main square. But three blocks from the main square this is the primary health center. It just looks like very poor laboratory. So you can see they don't have a computer. So they have a writing machine like, those machines are like 30 years old maybe. But they still have it. So in this kind of lab they can't perform modern tests. It's very difficult. So it's hard to. So that's why I'm going to point my presentation on the use of rapid tests. So because what? Because syphilis has a very ancient test. It's a very ancient disease using a very ancient disease. This test has almost 100 years. So we're still using it. There's no modernization for this test. So we are still using the BDRL which means venereal disease research laboratories and the RPR. So there are the most widely known and used tests for syphilis. You can see the sensitivity of those tests. Both have the same sensitivity. So in primary syphilis is 80%. So I'm knowing that from the infected people only 30% has symptoms. So I mean 70% doesn't know that they have syphilis. And from those 30% that has symptoms only 20% of those 30% has an ulcer, a real ulcer. So it's only a few people we can detect with those tests. So we need a better test for diagnosis syphilis. And besides, it's because this test is very cheap. It's like less than $1 each test. And it's very simple to do. It's still unreachable in many public health facilities because it needs a couple of equipment for performing the test. So we need a rotator. We need electricity. We need an incubator. We need a refrigerator. It's kind of difficult in some places. So we have rapid tests. So we have two kinds of rapid tests that can be used for diagnosis syphilis. The DOD DELISA. So the DELISA is the regular test that we use to perform with machines in the lab. But there is one rapid test called DOD DELISA. And we have the immunochromatography, which is another test I will show you a picture later. So both tests are very good tests. But the problem with those tests is that they don't differentiate recent or related infection. That's very important in syphilis. Because recent infection means you got infected maybe in the last six months. Latent infection maybe means that you got infected several years ago. It makes a huge difference. You got recently infected. So it's easy for you to spread the disease or the infection to your couples. If you get the disease maybe two or three years before, maybe you can spread the infection. But the neurological problems in your body are going to be very, very bad. So you can die from syphilis. So it's important to know the stage of the disease you are and also the treatment depends on the stage of the disease. So you have recent syphilis infection, one shot of penicillin will cure you. But you have latent syphilis, you need three shots of penicillin. So it makes a difference in the treatment. So in this test, those rapid tests can be used, not for everybody, but can be used for antinatal care and also for epidemiology studies. Antinatal care, so there are many studies that has proved that are very useful, actually. Because in many countries of the world, pregnant women don't go to control their pregnancy during the nine months of the pregnancy. They just go the last minute to get birth. So with a rapid test, you can know if they have syphilis and you can give a shot of penicillin and take action for the new baby. But we still don't know the performance of this test in very early syphilis because of the lack of antibodies in the body. So this is a cool study that was done in Peru a few years ago to show the utility of this rapid test. So we went to the jungle, so very far, far away from the main city. So because people normally think that HIV is a very urban disease. It's only big cities. So nothing is happening out there in the jungle. So because those people live isolated, so they don't have HIV. That's what we thought. So there was a case of death related to AIDS in this community very far away from the Peruvian jungle. This community is called Chayauita. This community is like 12 hours by boat from the main city or 24 hours hiking from the nearest hospital. So it's very far away. So it's in the middle of the jungle. So and this death occurs there. So what's going on there? Why someone has died from AIDS in the middle of the jungle? So we explored what happened and we found after an epidemiological study that there were a lot of HIV there. So you can see more than one case of HIV. And we also tested for syphilis. So we found syphilis. So what's going on in the community? So we, the investigators did some interviews and those people were farmers and they were saving their products in the main cities. So they transferred the products to the main cities. Once with the money funds, they were to the brothers to look for some prostitutes, have sex without protection and they got syphilis and they got HIV. So they go back to their towns, to their communities and spread the infection to the other members of the community, especially their wives. So because they don't use condoms. So it's a problem. It was in one community. So the university took the lead and performed another study but not only in that community but also including four communities in the Amazon region. So recruiting almost 300 people, testing HIV and syphilis using rapid tests so the results were delivered in five minutes to the people. So what I found is, what I found was that six cases, six new cases of HIV in the jungle which is rare, I mean, never reported. So now the government has taken advantage of this finding and they have a program for, this is like a public program so there are people going to the communities teaching about HIV prevention, about using condoms and about rapid testing for HIV and syphilis. We also did this project which is an NIH funded project. We call it comunidades positivas or positive communities. There's those communities where we have highest prevalence of HIV like 20, 25% so especially MSM and we have randomized this study in four blocks. We have one block for control, one block for comunidades positivas which was a social intervention where we built a community center and this community center where we give advice to the population about HIV prevention and condom use and we also have this arm called MMC which is improvement management of contacts. It's like EPT that improve it. We also have an arm with a mix of both the comunidades positivas and EPT and we put in the MMC we put mobile things with rapid and some hands for testing for syphilis and HIV and also offer rapid treatment for syphilis in case we found any case. So we put these advertisements in the space in Spanish which means in English without condom you are done. So every time the people on the street see that advertisement they know there were a mobile thing maybe in a bar or maybe in a pool place where someone is doing HIV and syphilis testing and also offering condoms for free. So this is another approach. So we went to the field and we increased the treatment for syphilis in one or two months. So if the nearest health center has like 100 tests done for syphilis in one month the next month after the mobile thing goes to the field we had 300 or 400 tests. So it increases the rates of people tested for syphilis and also increases the rates of people treated for syphilis using rapid tests and using this communication campaign on the streets. We also put these stickers on the glasses they use for drinking beer. So you went to a bar and you have a glass of beer you could see the advertisement of the program. So it was cool. And this is the test. It's very easy. You can put here in this rapid test a drop of blood and after two or three minutes you can get the result of your syphilis or HIV test. So it's very easy, very simple. There is another project I wanted just to talk about it because it's not our project actually it's a project from the Dean of School of Public Health in Peru Dr. Garcia. She's doing this project called CISNA project. I want to highlight that this project is advocated to eliminate the neonatal syphilis in Peru so the idea is to offer free rapid testing for syphilis to all pregnant women that can afford to go to the health center. So we are knocking doors in different neighborhoods asking for pregnant women if there are some pregnant women we offer them free syphilis rapid testing. So as you saw rapid syphilis testing could help with many things with rapid detection so the laboratory diagnosis give appropriate treatment for the people who is infected but this needs to be scaled up in different public services not only in big cities but also in cities that are far away from the main. So we need to put those tests also in antinatal care or during the pregnancy especially in the first and fifth semester we found in another study that many pregnant women are on risk of syphilis because of their husbands so they are pregnant and especially during the fifth semester the husband just go away found another woman or maybe another man so half sex without protection came back home maybe sometimes with a couple of years inside have sex with their wife who is pregnant and give them syphilis especially in some villages so that's why we recommend to use syphilis tests in the first and also in the third semester of the pregnancy we also need to test in contact so this is one thing we it's very difficult to work because especially with MSN when you ask them how many sexual partners do you have from the last two months for example it's very difficult to reach 10 they don't want them to know they have syphilis especially 10 different people it's kind of hard so we're still thinking how to deal with that we also need new diagnostic platform especially for groups of people with high rates of infection especially non-invasive tests like maybe using saliva or using urine or different sorts of samples we are trying to work on that once we know where the infection is what's the population affected we need the right tools we're needed so and this is I'm going to show you another example from Cayetano which is TBC so TV Peru is a very well no issue so during the 90s you can read the papers Peru was the most successful on DOT strategy implementation it was a recommendation on the WHA so we decreased the incidence of TV from more than 200 cases to almost 100 cases per 100,000 people in 9 years it was a very successful program but by the end of the 90s the program covered almost 100% of the people and almost 100% was cured so if they were treated they were cured so it was a success but the problem is resistance to the medication that's the new problem we are dealing with so we are having resistance to the regular drugs and also we are having XDR which is worse so this is the problem we are working in Peru so their partners in health has a huge project in Peru now they are recruiting like 30,000 people to know what is the epidemiology of multi-drug resistance to work losses so TV the diagnosis is very easy so you can do the screening with a very cheap and easy test which is the sputum smear microscopy test and it can be performed in every lab so even in the lab you saw in the picture before so it's very easy but the problem is resistance so we don't have any rapid test resistance so we still need very high tech public health laboratories for the tech resistance on the patient we have so we are still dealing with that too so our university developed a couple of years ago this new test the MOTS which is famous Microscopic Observation Drugs Disability test which is called MOTS this test is for determining resistance to histoneicide and rifampicin in 10 days which is very cool because normally the culture for TV takes like 30 to 60 days that's what the manual said and after the culture you need to do the resistance test which takes like 20 to 30 days so in total it's like 4 to 6 months to get a diagnosis of resistance so it's a very long time but this new test can give you results in 10 days so culture and susceptibility test very very fast so but still expensive because you need a very huge expensive microscope and you need to do culture of TV but works very well and the MOTS was developed in a research laboratory so this idea a few years ago the university comes with this idea that we need to spread the MOTS instead of spreading TV we need to spread the MOTS so from the research lab spread the MOTS where it is needed so the university put together different actors so the university here with a Peruvian nationalist to help the national strategy for preventing the national TV program which is a different program here and all the regional rubber authorities together so they build a new protocol to translate this technology to the regional rubber authorities with the collaboration of the national authority so this was actually a very huge project to transfer technology from the academia to the public health to the public health side this was the beginning so the university need to be sure that when they transfer the technology to the public health rubber authorities they will perform the technique very well as in the university so they a validation so where they train the university train all the staff in the regional labs giving them some positive sputoms and negative sputoms and the national easy to the health is the comparison results so among the regional labs and the reference lab if the regional lab met the criteria so they were able to perform the most and we are in the process of transferring this technology to the regional labs now I will skip this because I'm in a hurry now so once we know where the infection is where the technology is needed we need more people trained like you so we need trained people to do the things in the field so this is just for you to remember that there are no no heroes in the lab it's only people working there are no heroes in public health in general it's people working so people outside in the they would never know who is a public health practitioner so we started different collaboration thinking on that training people so we started like 10 years ago with this collaboration between UPCH and UCLA in 1998 so this initial project was called the CIPOL project was a we respond to an RFA from NIMH to do an HIV and STD prevention trial in different countries it was like an 8 year study that includes different bugs at that time the university didn't have an STI laboratory so we performed all the tests in the US Navy laboratory down there in Peru but at the end of the project we came up with this idea to build a new laboratory so we built a laboratory of sexual health that now is doing another studies in collaboration with different institutions that include it with Brandon so this is the laboratory now it's a very big laboratory with many students and many people working there and we have some faculty visitors that come from another country just to learn what we do in there so we have a lot of almost 20 scientists from all over the world that came in the last 6 years to learn what we're doing in the laboratory this is the new project that Brandon was talking about the syphilis project this is a new collaboration between 5 different institutions so that will start in few weeks so we are trying to understand the relationship between the host the pathogen and the environment for syphilis so we are trying to develop better strategies for rich high risk population so developing new algorithms new diagnostics understanding the immunologic response to the infection and trying to understand also the change in the pathogen maybe the mutations or maybe some variants of the back that are affecting our population so we are putting the triangle of infection also we are putting exploring the Facebook, the email the SMS systems just to understand what's going on the environment that is more vulnerable to syphilis we are exploring what are the mutations and if there is any resistance hanging around or what's going on in the body of the people infected they have some deficiencies in the immune response or they have problems for diagnosis almost done this was the last week meeting we meeting in Brazil in a meeting this is very important because now we are vocated to diagnosis in global health and all the Latin American contracts meeting together last week in Brazil or two weeks ago in Brazil and this idea come up with the support of the London School of Aging and Tropical Medicine to put together all the Latin American countries to build and afford to develop more diagnostic tools for public health especially for infectious diseases so all the group meet together one of the first steps we are taking is a survey that is conducted now in Latin American about the needs, about the challenges and about the regulations regarding rapid diagnostics in the region especially for infectious diseases so finally what are we doing at this moment so this is the things we are doing at this moment in our laboratory so we are developing this with another student who is doing a new syphilis test based on LAMA antibodies for simultaneous detection of IgG and IgM for syphilis which is a very cool study because usually the antibodies are produced in mice or in rabbits you can produce more antibodies in LAMA and smaller antibodies which is maybe cooler than the regular antibodies we are trying to work on new systems with the antibodies in saliva for syphilis diagnostic we performed the first step of the study it went wrong but we are now in the second step doing some modifications so we are also developing an in-house PCR for gonorrhea diagnostics especially for resistance to quite a lot we just finished the validation of different HIV point of test the paper is in press and also we have a student doing a PCR test for detecting and differentiating at the same time HSV1 and 2 in blood so those are the challenges we are facing so we guess we need to develop not only new diagnoses but also new resistant tests which are very important now so we have an emerging resistant different medications so we want people for implementing algorithms for studying outbreaks and epidemiology surveillance which is important we need to improve our local public health programs so transferring the technology from the academia to the public health side so we need to participate with other low income contents in the development and validation of new rapid diagnostic technology because more of the knowledge we are using are validated in developed countries this is different behavior so different epidemiology different different patterns of diseases and we also need to increase the investment in diagnostic within so we have set of opportunities this meeting I guess is a good opportunity to meet and talk about so we have the opportunity to do more operational studies more clinical trials to work more on policy and also to work more on developing new facilities for new diagnostic tools and this is my deal of diagnosis for local health so in the future hopefully we can have this test it's spread all over the world for developed countries it's the same test and a cool machine maybe but for low income countries it's the same test but maybe transported with this car by a horse or a mule but it's the same test for everyone so thank you you have any questions? so we appreciate the history of technology development and its applications the original test for syphilis, VDRL and RPR and antibodies so the ELISA one that you developed suddenly detects antibodies very quickly but what is the impediment that that innovation advance these old methods, what was detected? in syphilis there are two kind of methods one are called terponema methods and the other one are called non-treponema terponema methods detects real antibodies against the bacteria and non-treponema detects not real antibodies but also related antibodies so there are antibodies that are kind of allergen antibodies that are produced in the body against some proteins that are similar in the bacteria so it's like an inflammatory proteins so the final diagnosis should be made with a terponema test so ELISA, rapid test FTA or TPPA are terponema tests so why we are still using RPR and VDRL because they are cheap they can be performed in every hospital and every public health facility but they need electricity they need equipment so they cannot be performed in the field where maybe most of the people with syphilis if what happen in Peru is that people doesn't behave like if they feel sick they don't go to the hospital especially men they never go to the hospital so they are maybe the most affected population and we also are dealing with discrimination and stigma issues because most of them are MSM and when they show up in the health facilities they are discriminated so they feel the stigma and they don't go so they do prefer to be at home sick Part of the reason I asked was I know you got a chance to meet today with Cheryl Krugman she gave a talk on Lyme disease and the controversy was also related to diagnostics and comparing diagnostics with different tests and symptoms which also carries some stigma and it's a huge controversy in the field but I think syphilis is much maybe hopefully much straightforward that if you have a good test that detects the presence of the organism then immediately antibiotic therapy is leaving so you don't have vague symptoms but you have carrier status which may be a problem so the next question is in the remote areas when you actually find somebody who tests positive what kind of follow up because in developing countries that's a bigger challenge to make sure people take their medicine to have medical care in those kinds of remote locations Yeah, this is a very interesting question because it's a very challenging so what we do is to give to choose one dose treatment so when you find a new case of syphilis you treat them as if they were re-sensifilis so you only need one shot of penicillin 2.4 million so that's enough so we came back three months later if the titer is increased or the test is negative we consider it cured if it's the same we need to give them three shots once a week so we have to stay there for three weeks HIV is more complicated HIV is more complicated besides the treatment for HIV is free in the country we still have a lot of people not receiving treatment basically because of the stigma discrimination Thank you