Perspectives on Global Health from Pharmacists Around the World, Part Two

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patients needs are met in countless regions across the earth. In this four-part IH Blog series, the pharmacy role accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. 

This second installment focuses on medication quality in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

The onset of the biomedical and synthetic medication era brought with it a formerly unknown hope for the betterment of humanity’s health. The introduction of antibiotics like the beta-lactam class, vaccinations to completely eradicate diseases like smallpox, medications with unique mechanisms of action to regulate hypertension and diabetes, and more recently, targeted oncology medications to successfully attack cancer cells have all contributed to vastly improving patient care across the globe. However, with this tremendous advancement, novel complications have arisen that have plagued health care professionals in devastating arenas. For the pharmacy profession, specifically, the quality of medications has emerged as an additional concern in the treatment and dispensing process. Although a majority of nation states have regulatory bodies to monitor the quality of medications, low quality medications frequently find themselves in the hands of patients. This often leads to substandard care, furthers health inequalities, creates distrust in healthcare workers, promotes drug resistance, and damages the solemn promise every health care professional strives to follow – to properly care for those afflicted with various ailments. The perspectives and ideas that are shared in the following text explores medication quality throughout various parts of the world and initiatives that aim at addressing this determintental issue. 

Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

Access to high-quality medicines in many countries is largely hindered by the rampant circulation of counterfeit and substandard medicines. The use of counterfeit and substandard medicines represents a worldwide public health concern, and its prevalence is particularly high in developing countries. In Cambodia, the Ministry of Health reported in 2001 that 13% of medicines were spurious/falsely labeled/falsified/counterfeit, with 21% being substandard and 50% unregistered.

This crisis affects commonly used lifesaving medicines such as antibiotics, analgesics and anti-parasitics. The impact of poor-quality medicines is enormous ranging from increased adverse effects to increased morbidity and mortality. Poor-quality antimicrobials in particular has led to multi-drug-resistant malaria and bacterial infections which result in a huge burden for the country’s health sector. The high prevalence of poor-quality medicines has possibly contributed to the loss of confidence in health systems and health workers due to repeated treatment failure.

Among the reasons for the high rate of fake drugs in Cambodia are corruption, weak law enforcement, poverty and high sales taxes with self-medicating being often the driving force behind counterfeit drug markets. Counterfeit drugs mostly enter Cambodia through illegal drug outlets. The counterfeiting of drugs in Cambodia usually appears in the form of finished pharmaceuticals imported from neighboring countries, rather than the counterfeiting of bulk drug ingredients. This is due to the country’s lack of manufacturing capacity. Substandard drugs on the other hand are the result of limited implementation of good pharmacy practice regarding the distribution and the storage of pharmaceuticals which results in the deterioration in medicine quality.

Efforts have been made by the Cambodian government to tackle this problem. In 2015, the Cambodia Counter Counterfeit Committee (CCCC) was established and has been in charge of tracking counterfeit and substandard medicines circulating in the country. In 2018, the CCCC confiscated 138 types of illegal goods and substandard medication in 10465 packages from a pharmaceutical company in the capital city, Phnom Penh. The government is also working with its neighbors to decrease the number of fake drugs smuggled across the borders of Southeast Asia. Non-licensed drug outlets have been gradually disappearing, especially in the capital, either due to closure or accreditation, resulting from a strengthening of regulatory efforts. These initiatives are supported by pharmacists in communities by creating a front line against the distribution of counterfeits in the Kingdom through educating the public about the dangers of fake pharmaceuticals. 

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

Maintaining a healthy environment, reducing the healthcare cost, and using effective treatment options are all linked to medication quality. In any community, city, or region there are countless investments undertaken to improve the quality of healthcare overall. The Institute of Medicine defines health care quality as “ The degree to which healthcare services for individuals and populations increases the likelihood of desired health outcomes and are consistent with current professional knowledge.”

More specifically, medicine quality has two major roles: patient safety and effectiveness of treatment. Consuming a poor quality medicine will not only increase the risk to patient safety, but will hinder the proper treatment of patient. This can cause a patient to suffer more and increase the cost of treatment. Being a pharmacist and dispensing a low quality medication will also result in losing a patient’s trust. Since pharmacists have the role of dispensing medications, it is vital to ensure the medicine is in highest quality.

Quality of pharmaceutical products, mainly medicines, poses a serious challenge to the entire healthcare sector including drug manufacturers, distributors and dispensing pharmacists. According to the World Health Organization (WHO), the influx of fake or counterfeit medicine is a major concern in the market over all the globe.

Medicine in the United Arab Emirates (UAE) is manufactured so that medications go through systematic quality checks which are checked and re-checked several times while maintaining records in order to avoid any health hazard, Quality assurance teams then conduct self inspection or hire a third party to undertake inspections. The health regulations make sure that medicine distributed meet the standards of the listed quality and accepted internationally. On the other hand, imported medicines have similar criteria for safety and quality management. 

In order to further address low quality medications, the UAE Ministry of Health unveiled a new machine to detect imported drugs and inspect fake or counterfeit drugs. This machine is known as the TruScan RM Analyzer. It’s high tech detector is used to identify low quality drugs that pose health threats to the community. The device is helpful for chronic disease medicines such as diabetes, heart problems or even cancer drugs. The TruScan RM Analyzer also helps inspection regulators in the country to make informed and timely decisions for the release of drug shipments which are entering the country. In addition, UAE has been fighting the spread of low quality medicines in the country by taking many measures like high quality control labs and research on medicines and healthcare products.

Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America

In the United States, the quality of medications isn’t commonly considered in the process of treating a patient. This is because of laws and regulations that are in place to ensure the quality of the medication. However, this wasn’t always the case. Up until 1906, there was no law requiring medications to be pure. That changed in 1906 with the passage of the Pure Food and Drug Act. This required medications to be labeled correctly and to meet purity standards put forth by the United States Pharmacopeia. 

This act greatly improved the quality of medications produced in the United States as manufacturers were required to list the ingredients that are used in the creation of medicine, and the ingredients and manufacturing process must meet certain standards. However, there is still a market for counterfeit medications as patients search for ways to reduce the cost of medications. It is estimated that 19 million US citizens purchase medicine outside of the current regulated system (e.g. from unlicensed sources such as foreign online pharmacies).  One recent example is with counterfeit Avastin, an anticancer drug, that was found to have no active ingredient. Another example is the recent opioid epidemic. Street drugs are being laced with fentanyl leading to increased overdoses and mortality. 

Recently, there have been discussions to allow for greater importation of medications into the United States. While this could potentially reduce the cost of medications, it could also increase the risk of counterfeit medications. Medications originating from outside of the United States makes it harder for the Food and Drug Administration (FDA) to regulate the quality and purity of medications. 

Patients in the United States can reduce the risk of receiving counterfeit medications by picking up their medications from their local pharmacy and can feel comfortable knowing those medications are of high quality. If cost is an issue, a patient can discuss their options with the pharmacist. There may be a cheaper alternative or an assistance program that can help offset the cost of the medication.

IH Section Webinar 8/20: Insights from Managing a Health Systems Development Program (HSDP) Grant

Dr. Iyabo Obsanjo, the Co-Director for African Development at the College of William and Mary will discuss her involvement with a World Bank-funded Health System Development Project in Ogun State, Nigeria. She’ll share what worked and what didn’t from her perspective as the Commissioner for Health, in addition to describing areas where Health System development funding is lacking.

Date: Tuesday, August 20, 2019
Time: 11 AM – 12 PM ET

Register to attend here

This webinar is hosted by the APHA IH Section’s Health Systems Strengthening Group. The objective of the working group is to provide a venue for interested global health professionals to learn about systems sciences, collaborate around research and practice activities, and advocate for increased consideration of system sciences in education, practice, policy and evaluation for strengthening health systems. We welcome interested members (APHA membership is not a prerequisite) with expertise and/or interests in applying systems thinking approaches and methods to strengthen health systems, in both developing and developed countries. 

Find out more about the Health Systems Strengthening Group  

“Tejas means friend” and other lies we tell ourselves.

If you hear me speak more than a few sentences, you’ll hear the unmistakable accent. And as soon as I can find a natural way to fit it into the conversation, I’ll tell you flat out: I’m from Texas.

As a Texan, I was required to take one year of Texas history in the seventh grade, a statewide tradition since 1946. In Texas history, you’ll undoubtedly learn a few facts that every one of us 29-million Texans has engraved in our hearts.

1.     You don’t pick bluebonnets. They’re a sacred part of our state’s landscape.

2.     Texas was a sovereign nation once: the Republic of Texas. 

3.     California may have more people, but we’re bigger in size.

4.     “Tejas means friend”.

I’ve always found the root of the state’s name to be fascinating, because it has evolved with the land itself and represents the story of Texas. The word traces back to the Caddo word for “friend”, taysha. That word would be misspelled and mispronounced to be Tejas and eventually, Texas. For those of us whose hearts are deeply intertwined with the “Lone Star State”, the root of the word feels right. It embodies our roots, who we were, and the Southern hospitality on which we grew up. The origin of Texas’ name does NOT embody who we are today.

Texas has become the frontline of continued inhumane policy experimentation by the Trump administration. To deter undocumented entry to the United States and tamp down the number of asylum claims made at ports of entry, Trump and his nominated officials began separating children from their caregivers. 2,654 children were taken from their parents, guardians, and chaperones during the peak of this policy’s enforcement, and most of those children were detained in Texas.

The science around this matter is still developing, but one thing is certainly clear: this is bad news for the cognitive development and mental health outcomes of these children. In fact, the picture is becoming clearer that family separation policies produce rates of toxic stress and trauma that are as detrimental to the child psyche at the violence as the violence and insecurity they are fleeing. Researchers, and even the United Nations, cite evidence that separating children from their caregivers creates the type of emotional disturbance and dysregulation seen in survivors of torture.

We aren’t talking about acute emotional disturbance that will recede after reunification. The child’s brain has evolved to be incredibly respondent to its environment. Continued exposures to “fight, flight, or freeze” (especially in the absence of a trusted attachment figure) train the brain to bypass emotional inhibition and complex, rational thought to depend on more primitive survival mechanisms. This means permanent alteration of the brain, shrinking the prefrontal cortex and hippocampus (the parts of the brain that largely control decision making, working memory, and personality expression).  Their brains, and often their relationships with the parents, may never recover. 

“Here we have taken away what science has said is the most potent protector of children in the face of any adversity—the stability of the parent-child relationship”

– Jack Shonkoff

It’s not just theoretical damage happening in research studies void of a human face. Children inside these Texas detention centers have reported high rates of insomnia, decreased ability to concentrate, diminished literacy (even in their native languages), severe mood swings, and feeling constant states of panic and fear. And when they leave, their medical records (including any psychiatric care they’ve needed or received) are often incomplete. Many of these children will receive asylum in the United States, and we will have to face the mental health epidemic we created with a mental health system that is underfunded and culturally inadequate.

Sweeping separation of families and detainment of children was theoretically stopped, but the Human Rights Watch has found that nearly 200 children have been subject to the continuation of this policy since last year. There is no law on the books in the US that requires the separation of families at the border. This was a policy decision that can be rescinded as quickly as it was haphazardly implemented.

These children have often experienced trauma before they ever arrive at our border. They have left the familiarity and comfort of home. They are often physically vulnerable at the end of their migration journey. And they are welcomed with something that, for most of them, is even more traumatic: facing the hostility of a foreign country all alone.

This isn’t exclusively a Texan issue. ICE detention centers now exist in all 50 states. And it isn’t uniquely American, as 100 other countries have policies that allow children to be detained as part of standing immigration policy. But Texas has become ground zero for what the inhumane treatment of children looks like. Texas is no longer a land of Southern hospitality. It certainly isn’t embodying the state motto of “friendship”. And no one should be angrier about what’s happening in our home state than Texans ourselves. 

This article was written in memory of the children who needlessly died in Texas as a result of inhumane immigration policy. These faces represent the failure of all of us.

From top left to bottom right:

Mariee Juarez, aged 2, died after leaving a detention center in Dilley, TX

Carlos Hernandez Va’squez, age 16, died in US custody in Brownsville, TX

Jakelin Caal Maquin, age 7, died in US custody in El Paso, TX

Juan de Leo’n Gutie’rrez, age 16, died in US custody in Brownsville, TX

Happy World Breastfeeding Week!

Happy World Breastfeeding Week (8/1-8/7)! This year’s theme, “Empower parents, enable breastfeeding” is a particularly poignant reminder of how the U.S. government is doing neither for parents and infants entering at the southern border. It is critical to consider the effects of involuntary separation of breastfeeding mothers and their children.

There are short- and long-term physical, emotional, and economic consequences of abrupt discontinuation of lactation. Lactating individuals need to express milk to relieve the pain and fullness in their breasts to avoid plugged ducts and mastitis, a breast infection requiring medical attention. If there is no provision of time, space, and privacy for regularly expressing milk, those individuals will gradually lose their milk supply. Shortened, suboptimal lactation increases risks for breast and ovarian cancers, and metabolic and other diseases and costs $302 billion globally [1].

Infants who no longer receive human milk need a substitute, which will be inherently nutritionally inferior to human milk and cannot provide them the immunologic protection they received from their mothers’ milk [2]. Those infants will need to learn how to feed from a bottle, which may cause distress, can introduce bacteria, and may teach them to ignore satiety cues [3], increasing their risk for overeating as they get older.

Emotionally, the parent–infant bond is severed with involuntary separation. Breastfeeding is not just a feeding method, but also provides an infant with temperature regulation and comfort. We have witnessed maternal distress from this inhumane practice [4]; it is likely that an infant’s distress would be extreme.

On top of the life changing health effects of abrupt discontinuation of breastfeeding, the most egregious offense may be the negation of these individuals’ rights to breastfeed. They were feeding their children optimally until a poor substitute was imposed upon them for political reasons. Now those children have higher risks of infections and chronic disease, from the moment they were taken from their parents and for the rest of their lives.

There have been many discussions about the traumatic effects of parent-child separation but we have not seen or heard a discussion of effects due to abrupt cessation of lactation and breastfeeding. Those effects provide more compelling reasons to end this inhumane practice immediately.

Guest Blog Written By: Jennifer Yourkavitch, MPH, PhD, IBCLC – International Health Section Breastfeeding Forum Liaison, APHA and Research Scientist, University of North Carolina, Greensboro; Whitney P. Witt, PhD, MPH – Chair, Maternal and Child Health Section, APHA and Inaugural Dean and Professor, College of Health, Lehigh University; Briana Jegier, PhD – Chair, Breastfeeding Forum, APHA and Associate Professor, Health Services Administration, D’Youville College

References

1.      Lancet. (2016). Series on Breastfeeding. http://thelancet.com/series/breastfeeding. Accessed July 31, 2018.

2.      Mannel R., Martens P., & Walker M. (eds.). Core Curriculum for Lactation Consultant Practice. Burlington, MA: Jones & Bartlett Learning, LLC, 2013.

3.      Li R., Fein S.B. & Grummer-Strawn LM. (2010). Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? Pediatrics125(6).

4.      CNN. June 14, 2018, https://www.cnn.com/2018/06/12/us/immigration-separated-children-southern-border/index.html. Accessed July 29, 2018.

Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa

By Samantha Dulak BS and Heather F. McClintock PhD MSPH MSW

This is the second part of a IH Blog series featured this summer, Sexually Transmitted Infections in sub-Saharan Africa: Determinants, Outcomes, and Interventions.

Part II: Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa

Sexually transmitted infections (STIs) are a significant public health burden globally and are a leading cause of mortality in lower middle income countries (LMICs). In 2016, there were 988,000 women infected with syphilis worldwide, resulting in 350,000 deaths and delivery complications (Korenromp, Rowley, Alonso, et al., 2019). Human papillomavirus (HPV), an incurable STI, leads to over half a million new cases of cervical cancer every year (Bray, Ferlay, Soerjomataram, et al., 2018). Cervical cancer can be the result of other factors, however, in 90% of all cervical cancer cases that resulted in death, the cancer was caused by HPV (WHO, 2018). Of the 1.8 million newly diagnosed HIV infections each year, 940,000 individuals died globally from AIDS related factors (UNAIDS, 2019a). Unfortunately, a third of those deaths (302,700) are among females aged 15-49 living in sub-Saharan Africa (UNAIDS, 2019b). Higher rates of complications are found in sub-Saharan Africa because of inadequate clinician training, delayed diagnosis, and limited care seeking behaviors (Mayaud & Mabey, 2004). STI surveillance systems are absent or poorly functioning in Africa causing unreliable data on the prevalence of these infections.

STIs are common in low resource settings and their impact can be catastrophic on the lives of individuals. The list of potential complications is extensive. Untreated gonorrhea and chlamydia are associated with the development of arthritis, hepatitis B with liver cancer, and syphilis with central nervous system disorders (Aral, Over, Manhart, & Holmes, 2006). While all individuals are at risk, women and children are disproportionately affected by a greater burden of disability, as assessed by disability adjusted life years. Women suffering without treatment can experience chronic pelvic and abdominal inflammation leading to infertility, spontaneous abortions, and many adverse pregnancy outcomes (Chesson, Mayaud, & Aral, 2017). 

International attention on STI outcomes is imperative to reducing the incidence of STIs not only in sub-Saharan Africa, but globally. Most attention has focused on HIV due to the public health crisis we are experiencing now. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that Africa has the highest burden of STIs compared to all other continents (Lewis, 2011). The UNAIDS 2018 report on the global AIDS epidemic found that there are 37.9 million people living with AIDS in the world and 20.6 million of them live in eastern and southern Africa (UNAIDS, 2019a). 

Prevention strategies in sub-Saharan Africa place a heavy emphasis on sexual health education. A meta analysis of 51 papers reported that while school-based sexual health education significantly increased condom usage, there was no significant effect on the incidence of STIs (Sani, Abraham, Denford, & Ball, 2016). This information is promising, though. School aged children are experiencing positive behavior changes through the use of physical protection methods. Some studies even report a change of attitude towards persons living with HIV/AIDS (Paul-Ebhohimhen, Poobalan, & van Teijlingen, 2008). However, a focus on at-risk groups is missing. Sex workers, men who have sex with men, and intravenous drug users all have high susceptability to contracting an STI and greater attention needs to be directed towards prevention in these populations to reduce the incidence of STIs. 

To address the vast number of cases of cervical cancer caused by HPV, many sub-Saharan countries now qualify for assistance from the Global Alliance for Vaccines and Immunization. As of 2018, eight countries have HPV vaccine programs for school aged children, with pilot programs implemented in nearly 16 additional countries (Black and Richmond, 2018). Data for all 8 countries is not public as of now, but of the five countries with available data, the success rate for at least one dose of the vaccine is 83% (Black and Richmond, 2018). Rwanda was the only country to successfully complete three doses, covering 98.7% of girls (Black and Richmond, 2018).

From a global perspective, Sustainable Development Goals (SDGs) aim to ensure access to sexual and reproductive care and end the AIDS epidemic by 2030 (UN General Assembly, 2015). Primary prevention strategies have become popular among many countries to promote these goals. In 2018, the WHO reported on global STI surveillance, indicating that 44% of countries have HPV vaccines in their immunization programs (WHO, 2018). To reach those who are not benefiting from immunization initiatives, the 2016 Global STI Strategy, along with strategies for HIV and viral hepatitis, fight to meet the SDG 2030 agenda (WHO, 2018). The Global STI Strategy focuses on creating affordable interventions for at-risk individuals and adolescents in all countries. These plans are financed and delivered by promoting universal health care coverage to keep costs low (WHO, 2018). Additionally, the Gonococcal Antimicrobial Surveillance Programme (GASP) has improved national monitoring of antimicrobial resistance to gonorrhea in order to provide stronger data for new treatment research (Wi et al., 2017).

Samantha Dulak BS

Ms. Dulak was a biology major and global public health minor at Arcadia University. She has a strong interest in nutrition as well as maternal and child health. She now hopes to attend graduate school for public health and pediatrics.

Heather F. McClintock PhD MSPH MSW 

Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.

References

Aral, S.O., Over, M., Manhart, L., Holmes, K.K. (2006). Sexually Transmitted Infections. In Jamison, D.T., Breman, J.G., Measham, A.R, Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., Musgrove, P. (Eds), Disease Control Priorities in Developing Countries, second edition. 311–30. Washington (DC): World Bank and Oxford University Press.

Black, E., Richmond, R. (2018) Prevention of Cervical Cancer in Sub-Saharan Africa: The Advantages and Challenges of HPV Vaccination. Vaccines, 6(3), 61. doi: https://doi.org/10.3390/vaccines6030061

Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R.L., Torre, L.A., Ahmedin, J. (2018). Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 68: 394–424.

Chesson, H.W., Mayaud, P., & Aral, S.O. (2017). Sexually Transmitted Infections: Impact and Cost-Effectiveness of Prevention. In Holmes, K.K., Bertozzi, S., Bloom, B.R., & Jha, P. (Eds.), Major Infectious Diseases, third edition. Washington (DC): The International Bank for Reconstruction and Development and The World Bank.

Mayaud, P., Mabey, D. (2004). Approaches to the Control of Sexually Transmitted Infections in Developing Countries: Old Problems and Modern Challenges. Sexually Transmitted Infections, 80(3), 174–182. doi: 10.1136/sti.2002.004101

Korenromp, E.L., Rowley, J., Alonso, M., Mello, M.B., Wijesooriya, N.S., et al. (2019) Global burden of maternal and congenital syphilis and associated adverse birth outcomes—Estimates for 2016 and progress since 2012. PLOS One, 14(2): e0211720.

Lewis, D.A. (2011). HIV/sexually transmitted infection epidemiology, management and control in the IUSTI Africa region: focus on sub-Saharan Africa Sexually Transmitted Infections. BMJ, 87(2), ii10-ii13. doi: 10.1136/sextrans-2011-050178

Paul-Ebhohimhen, V.A., Poobalan, A., van Teijlingen, E.R. (2008). A systematic review of school-based sexual health interventions to prevent STI/HIV in sub-Saharan Africa. BMC Public Health, 8(4). doi: 10.1186/1471-2458-8-4

Sani, A.S., Abraham, C., Denford, S., & Ball, S. (2016). School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health, 16, 1069. doi: 10.1186/s12889-016-3715-4

UN General Assembly. (2015). Transforming our world : the 2030 Agenda for Sustainable Development. Retrieved 16 July 20219 from https://www.un.org/sustainabledevelopment/health/

UNAIDS. (2019a). Global HIV & AIDS statistics — 2019 fact sheet. Retrieved 16 July 2019 from https://www.unaids.org/en/resources/fact-sheet

UNAIDS. (2019b). In sub-Saharan Africa, three in five new HIV infections among 15–19-year-olds are among girls. Retrieved 15 July 2019 from https://www.unaids.org/en/resources/infographics/women_girls_hiv_sub_saharan_africa

Wi, T., Lahra, M. M., Ndowa, F., Bala, M., Dillon, J. R., Ramon-Pardo, P., . . . Unemo, M. (2017). Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action. PLoS Medicine, 14(7). doi:10.1371/journal.pmed.1002344

The World Health Organization [WHO]. (2018). Report on global sexually transmitted infection surveillance. Retrieved 15 July 2019 from https://apps.who.int/iris/bitstream/handle/10665/277258/9789241565691-eng.pdf?ua=1.