Maternal Mortality, HIV/AIDS and the  New Counter-Geography of Surviving  Pregnancy in Central MozambiqueRachel Chapman, P...
Despite overall MMR decreases:HIV Played a Major Role inIncreasing MMR mostly Sub-Saharan AfricaNO SURPRISE…         UNAID...
Overlapping Shadows?   Global Maternal      Global HIV Infection    Mortality (WHO)      (UNAIDS)
Overlapping Shadows?   Global Maternal      Global HIV Infection    Mortality (WHO)      (UNAIDS)
HIV and Maternal Mortality(UNICEF. 2010. Interagency Estimates of Maternal Mortality Levelsand Trends: 1990-2008)   Direc...
Response: Prevention ofMother to Child Transmission(PMTCT)   pregnant women living with HIV in sub-    Saharan Africa who...
   Around the world to Mozambique!
HAI/MOH HIV                                               Treatment               Tambara     Guro                        ...
Guro      Tambara                         Chemba                HIV Treatment                                             ...
Guro      Tambara                         Chemba                      HIV Treatment                                       ...
Guro      Tambara                                HIV Treatment                         Chemba                             ...
Guro      Tambara                                HIV Treatment                         Chemba                             ...
Guro      Tambara                                HIV Treatment                         Chemba                             ...
2009 Treatment Plan     Guro      Tambara                                Manica and Sofala scale-                         ...
THE PROBLEM: Major loss to follow-up(LTFU) occurs at each stage of the“treatment cascadeMaternal and PMTCT LOSS TO FOLLOW-...
pMTCT strategy in Mozambique Figure 1. PMTCT patient flow                     Pre-natal consult                 Pregnant w...
The Emerging Data from Sub-Saharan                          Africa   less than ten percent of pregnant women in Africa in...
Dueling Hypotheses: Possible reasons for high loss to follow up rates  Health Systems               Structural/Social / Cu...
Depoliticize, Individualize, Medicalizethe High Cost of Austerity EconomicsIgnore failed structural     Overlook free mark...
Costs of Austerity to Women’s     Health   Macro: Erosion of health system budget, facilities,    staff, salaries, basic ...
HIV care and treatment scale up    exposes costs of Austerity    Economics   AIDS-related maternal    mortality   Health...
Ethnography: Effects ofinequalityIdentities of Control and Resistance1.  Spirit Intervention2.  The Power of Words3.  Fema...
Current costs of inequality toMaternal Health?   Women hide pregnancy   Avoid prenatal care   Heightened household tens...
counter-geography of survival(Davis 2004, Planet of Slums)   Home birth outside of biomedical    surveillance,   definin...
Women are not “lost” to follow-up
New Research Question:                  What accounts for                   loss to follow-up?
Findings1.   Stigma and fear2.   Domestic violence and     negotiation of disclosure3.   food and drug insecurity in     s...
Where are all the pregnant HIV+women going after they test positive?                       HIV testing and               ...
♀                                    ♀♀                             ♀g+                      ♀    ♀                     ♀ ...
New collaboration:Option B (2012 WHOGuidelines)1.   Starting triple therapy ART directly after     testing rather than wai...
Option A vs. Option B  Pregnant woman comes to ANC visit                                                    CounselingWoma...
Benefits1.   simplification of     regimen and service     delivery and     harmonization with ART     programs,2.   prote...
Not enough:Trojan Horse of ART Scale-Up   Quality HIV care    and services are    only possible within    context of buil...
action agenda   “The is clear. To get Millennium Development    Goal 5 on track by reducing the contribution of    AIDS t...
Answer to Wendy’s question:How do we balance science andadvocacy?   DO BOTH!   They are inseparable.   They are not mut...
Scientists MUSTChallenge Austerity Politics and           Policiesmeans?1. Challenge NGO-centric model of global  health, ...
Public Health Spending – enough              said            Worldmapper
BASTA!
Thank You!      University of Washington       James Pfeiffer       Wendy Johnson       Beatrice Thome      Mozambican Min...
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Rachel Chapman: New Approaches to Maternal Mortality In Africa

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Rachel Chapman (Associate Professor at the Department of Anthropology, University of Washington):
Maternal Mortality, HIV/AIDS and the New Counter-Geography of Survival in Central Mozambique

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  • James McIntyreMothers infected with HIV: Reducing maternal death and disability during pregnancy Br Med Bull (2003) 67(1): 127-135 doi:10.1093/bmb/ldg012 .HIV and maternal mortalityStrengthening HIV services for pregnant women: an opportunity to reduce maternal mortality rates in Southern Africa/sub-Saharan AfricaMoodley J, Pattinson RC, Baxter C, Sibeko S, AbdoolKarim Q. BJOG. 2011 Jan;118(2):219-25Reliable data from South Africa emanating from WHO recommendations for the Safe Motherhood programme underscore HIV-related illness as the most common cause of maternal deaths. The strengthening of HIV services for pregnant women, especially in countries with a high burden of HIV infection, will reduce HIV-related and un-related maternal mortality rates. High-quality and complete data on maternal deaths is a critical foundation for reliably monitoring temporal trends in maternal deaths, and causes thereof, but needs substantial strengthening in many resource-constrained settings. HIV is an increasing contributor to direct and indirect causes of maternal deaths in sub-Saharan Africa. A review of published data on maternal deaths and its association with HIV shows that reliable data come from the Confidential Enquiries into Maternal Deaths from South Africa, population-based surveys in sentinel populations, and facility-based data. Despite an increase in knowledge of the HIV status of pregnant women and the initiation of antiretroviral treatment,reversals in trends towards increased maternal deaths are not being observed. The strengthening of HIV services provides an opportunity to alter HIV epidemic trajectories and reduce maternal deaths.AbstractEditors’ note: The figures are stark: each year 80 million women have unwanted pregnancies and a third of maternal deaths could be prevented through the promotion and uptake of family planning. Each year there are more than 2 million pregnancies in women living with HIV and, in resource-constrained settings, HIV accounts for an estimated ten-fold increased risk of maternal death. This is not because pregnancy increases HIV disease progression—it does not do so in asymptomatic women—but rather because symptomatic women with HIV infection are at greater risk of dying from infectious diseases. Maternal mortality is defined as a death during pregnancy or within 42 days of the end of pregnancy from any cause related to or aggravated by pregnancy or its management, not including accidental or incidental causes. Maternal deaths are underestimated because not all women use health care facilities during pregnancy, for delivery, or for post-pregnancy care – and facility-based reports are the prime source of maternal mortality data. The action agenda is clear. To get Millennium Development Goal 5 on track by reducing the contribution of AIDS to maternal mortality, we must prevent HIV infection in women and girls, prevent unwanted pregnancies, expand HIV testing and counselling, accelerate initiation of antiretroviral treatment in pregnant women who are HIV-positive, and strengthen service delivery and integration of HIV care and obstetric services, along with data collection to track progress.
  • Literature Cited UNAIDS. 2008. Country profile: Mozambique. UNAIDS 2008 Report on Global AIDS and Epidemic.WHO. 2004. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants. Department of HIV/AIDS. Geneva, Switzerland. De Kock, K.L. et al. 2000. Prevention of Mother-To-Child Transmission in Resource Poor Countries: Translating Research into Policy and Practice.” JAMA. 283(9): 1175-1182.WHO. 2004. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants. Department of HIV/AIDS. Geneva, Switzerland. Pp. 3.Dorenbaum A et al. 2002. Two-dose intrapartum/newborn nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission: a randomized trial. Journal of the American Medical Association. 288(2):189–198.Cooper ER et al. 2002. Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 29(5): 484–494.Thorne C, Newell ML. 2004. Are girls more at risk of intrauterine-acquired HIV infection than boys? AIDS. 18(2): 344–347.Buekens P, Curtis S, Alayon S. 2003. Demographic and health surveys: caesarean section rates in sub-Saharan Africa. British Medical Journal. 326(7381):136.Jackson JB et al. 2003. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomised trial. Lancet. 362(9387): 859-68. Guay LA et al. 1999. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet. 354(9181):795–802.The Petra study team. 2002. Efficacy of three short-course regimens of zidovudine and lamivudine in preventing early and late transmission of HIV-1 from mother to child in Tanzania, South Africa, and Uganda (Petra study): a randomised, double-blind, placebo-controlled trial. Lancet. 359(9313): 1178–1186.Gaillard P et al. 2004. Use of antiretroviral drugs to prevent HIV-1 transmission through breast-feeding: from animal studies to randomized clinical trials. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 35(2): 178-87.Lawn, Joy and Lisa Berber. Eds. 2006. Opportunities for Africa's newborns: Practical data, policy and programmatic support for newborn care in Africa. The Partnership for Maternal, Newborn and Child Health. WHO: Switzerland.UNAIDS. 2006. Report on the global AIDS epidemic. 2006. Geneva, Joint United Nations Programme on HIV/AIDS (UNAIDS).Sherman, G G. S A Jones, AH Coovadia, M F Urban, K D Bolton (2004). PMTCT from research to reality-results from a routine service. SAfr Med J; 94: 289-292.Jones, S. A., Sherman, G. G., & Varga, C. A. (2005). Exploring socio-economic conditions and poor follow-up rates of HIV- exposed infants in Johannesburg, South Africa. AIDS Care, 17, 466-470  M. Manzi, R. Zachariah, R. Teck, L. Buhendw, J. Kazima, E. Bakali, P. Firmenich, P. Humblet (2005). High acceptability of voluntary counselling and HIV-testing but unacceptable loss-to-follow-up in a prevention of mother- to-child HIV transmission programme in rural Malawi: scaling- up requires a different way of acting. Tropical Medicine and International Health. 10(12): Pp. 1242–1250. HAI. 2008. Quarterly Report. Health Alliance International. Maputo, Mozambique, Department of Global Health. University of Washington. Seattle, Washington.ICAP. 2008. Collaborative PMTCT and Pediatric HIV Strategic Planning Workshop. In Partnership with Tygerberg Children’s Hospital, South Africa and S2S. Cape Town, South Africa.Sherman, G G, S AJones, AH Coovadia, M F Urban, K D Bolton (2004). PMTCT from research to reality-results from a routine service. SAfr Med J; 94: 289-292.Pfeiffer, James, et al. 2008. Integration of HIV/AIDS Services into African Primary Health Care: A Health System Strengthening Approach in Mozambique. Unpublished manuscript. Health Alliance International. Department of Global Health. University of Washington. Seattle.Moth, I A. A B C O Ayayo, D O Kaseje. 2005. Assessment of utilisation of PMTCT services at Nyanza Provincial Hospital, Kenya. Journal of Social Aspects of HIV/AIDS. 2(2): Pp. 244-250.Jones, S. A., Sherman, G. G., & Varga, C. A. (2005). Exploring socio-economic conditions and poor follow-up rates of HIV- exposed infants in Johannesburg, South Africa. AIDS Care. 17(4): 466-470.M. Manzi, R. Zachariah, R. Teck, L. Buhendw, J. Kazima, E. Bakali, P. Firmenich, P. Humblet. 2005. High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother- to-child HIV transmission programme in rural Malawi: scaling- up requires a different way of acting. Tropical Medicine and International Health. 10(12): Pp. 1242–1250.Eide, Magnhild et al. 2006. Social consequences of HIV-positive women’s participation in prevention of mother-to-child transmission programmes. Patient Education and Counseling. 60: 146–151Blanco, Ana Judith. 2009. Maternal characteristics and poor follow-up rates of HIV-exposed infants in Central Mozambique. Unpublished Master’s Thesis. International Health. School of Public Health. University of Washington.Chapman, Rachel. 2010. Family Secrets: Risking Reproduction in Central Mozambique.Vanderbilt University Press.2006. Chikotsa: Managing The Social Risks of Reproduction in Central Mozambique. Medical Anthropology Quarterly. 20(4): 487-515.2004. “A nova vida: The commoditization of reproductive health in central Mozambique.” Medical Anthropology. 23(3): 229-261.2003. “Endangering safe motherhood in Mozambique: prenatal care as pregnancy risk.” Social Science and Medicine. 57(2):355-374. 2001. Prenatal Care as Reproductive Threat: When Medical Norms Exclude Screening for Social Risks. In Discovering Normalcy in the Reproductive Body. Working Paper. African Studies Program. Northwestern University.2000. Marlene, Rosa. Rachel Chapman, Julie Cliff. Lovers, Hookers, And Wives: Unbraiding the Social Contradictions of Urban Mozambican Women's Sexual and Economic Lives. In Women and Health in Africa. 2nd edition. Meredith Turshen, ed. Trenton, NJ: Africa World Press. Pp. 50-68.
  • HIV and maternal mortalityStrengthening HIV services for pregnant women: an opportunity to reduce maternal mortality rates in Southern Africa/sub-Saharan AfricaMoodley J, Pattinson RC, Baxter C, Sibeko S, AbdoolKarim Q. BJOG. 2011 Jan;118(2):219-25
  • Rachel Chapman: New Approaches to Maternal Mortality In Africa

    1. 1. Maternal Mortality, HIV/AIDS and the New Counter-Geography of Surviving Pregnancy in Central MozambiqueRachel Chapman, Ph.D.Javelina Aguilar, CDBeatriz Thome, M.D., MPHcWendy Johnson, M.D.James Pfeiffer, Ph.D., M.P.H.
    2. 2. Despite overall MMR decreases:HIV Played a Major Role inIncreasing MMR mostly Sub-Saharan AfricaNO SURPRISE… UNAIDS 2010 Report on the global AIDS epidemic
    3. 3. Overlapping Shadows? Global Maternal  Global HIV Infection Mortality (WHO)  (UNAIDS)
    4. 4. Overlapping Shadows? Global Maternal  Global HIV Infection Mortality (WHO)  (UNAIDS)
    5. 5. HIV and Maternal Mortality(UNICEF. 2010. Interagency Estimates of Maternal Mortality Levelsand Trends: 1990-2008) Direct: associated increase in pregnancy complications such as anaemia, post-partum haemorrhage and  Maternal HIV in puerperal sepsis Sub-Saharan Africa  in resource-constrained settings, HIV accounts for an Indirect: increased estimated 10X increased risk susceptibility to of maternal death opportunistic infections  symptomatic women with such as Pneumocystis HIV infection are at greater carinii pneumonia, risk of dying from infectious tuberculosis and diseases.
    6. 6. Response: Prevention ofMother to Child Transmission(PMTCT) pregnant women living with HIV in sub- Saharan Africa who received antiretroviral drugs to prevent transmission of HIV to their children: 2005: 15% 2009: 54%
    7. 7.  Around the world to Mozambique!
    8. 8. HAI/MOH HIV Treatment Tambara Guro Chemba Expansion Plan through public Macossa Maringue sector collaboration Cheringoma 2003 HF Providing HAART (new) Muanza 1 (1) PLWHA Registered (%) Sussundenga 2,000 (1) Chibabava Eligible in HAART (%) 2003 94 (0) MachangaMachaze
    9. 9. Guro Tambara Chemba HIV Treatment Expansion Plan Maringue Macossa 2004 Cheringoma HF Providing HAART (new) Muanza 2 (1) Sussundenga PLWHA Registered (%) 7,300 (2) Chibabava 2003 Eligible in HAART (%) 2004 600 (1) MachangaMachaze
    10. 10. Guro Tambara Chemba HIV Treatment Expansion Plan Maringue Macossa 2005 Cheringoma HF Providing HAART (new) Muanza 5 (3) Sussundenga PLWHA Registered (%) 18,600 (5) Chibabava 2003 2004 Eligible in HAART (%) 2005 2,500 (4) MachangaMachaze
    11. 11. Guro Tambara HIV Treatment Chemba Expansion Plan Macossa Maringue 2006 HF Providing HAART (new) Cheringoma 17 (13) Muanza PLWHA Registered (%) 36,270 (9) Sussundenga Eligible in HAART (%) Chibabava 5,250 (9) 2003 2004 Children <15 y in HAART 2005 2006 (% of those in HAART) Machanga 420 (8)Machaze
    12. 12. Guro Tambara HIV Treatment Chemba Expansion Plan Macossa Maringue 2007 HF Providing HAART (new) Cheringoma 47 (30) Muanza PLWHA Registered (%) 63,390 (16) Sussundenga Eligible in HAART (%) Chibabava 13,225 (22) 2003 2004 Children <15 y in HAART 2005 2006 (% of those in HAART) Machanga 2007 1,323 (10)Machaze
    13. 13. Guro Tambara HIV Treatment Chemba Expansion Plan Macossa Maringue 2008 HF Providing HAART (new) Cheringoma 53 (7) Muanza PLWHA Registered (%) 100,490 (25) Sussundenga Eligible in HAART (%) Chibabava 23,903 (40) 2003 2004 Children <15 y in HAART 2005 2006 (% of those in HAART) Machanga 2007 2008 3,585 (15)Machaze
    14. 14. 2009 Treatment Plan Guro Tambara Manica and Sofala scale- Chemba up through existing PHCs Maringue • 87 facilities offering HAART Macossa (55 March 2008) • 180,000 PLWHA registered for Cheringoma HIV care (49% of the infected) (92,600 March 2008) Muanza • 45,000 in HAART (64% of eligible) (22,000 Mar. 2008, 31% of eligible) Sussundenga • All HUs with TB treatment in Sofala and Manica testing for HIV Chibabava HCB HPC and strengthening of TB screening HG HR in PLWHA CS Proj. Machanga • 202 CPN with PMTCT (156 March 2008)Machaze
    15. 15. THE PROBLEM: Major loss to follow-up(LTFU) occurs at each stage of the“treatment cascadeMaternal and PMTCT LOSS TO FOLLOW-UP: women and exposed infants drop from programs to treat maternal HIV and prevent maternal to child transmission at any step along the “treatment cascade”
    16. 16. pMTCT strategy in Mozambique Figure 1. PMTCT patient flow Pre-natal consult Pregnant woman counseled and tested for HIV Children followed in pediatric clinic and tested for HIV at 18 months Treatment center (if exists): HIV clinical and laboratory staging Mothers Woman starts Woman does not breastfeed ART need ART through 6 months, followed by “rapid transition” Maternity to regular food Woman / newborn given dose of NVP
    17. 17. The Emerging Data from Sub-Saharan Africa less than ten percent of pregnant women in Africa infected with HIV receive interventions to reduce MTCT, one in twenty mother-infant pairs are successfully initiating ART Malawi (Manzi et al. 2005):  55% lost to follow up at 36th week of pregnancy,  68% at delivery,  70% at 1st post natal visit  81% at the baby’s 6 month post natal visit Kenya (2005): 53.6% ♀ not enrolling at HIV clinic (Moth 2005) South Africa : Joburg -85% by baby’s 12th month visit , Gauteng - 90% of babies have no final HIV diagnosis (Jones 2005; Sherman 2004) Mozambique: PMTCT coverage 45% (Pfeiffer 2009) 8% HIV+ pregnant ♀ started on HAART 11% infants tested at 18 months
    18. 18. Dueling Hypotheses: Possible reasons for high loss to follow up rates Health Systems Structural/Social / Cultural contributing factors contributing factors Inadequate counseling  Stigma, and Authorized and discrimination, unauthorized fees  Gender conflict, violence Poor quality, rude staff  Lack of basic resources, Slow or lost tests food, social support Too many appointments  Distance and transport fees Poor linkages within programs at the health  Religious, cultural healing facility beliefs and practices Cost of transport and inaccessibility of clinics
    19. 19. Depoliticize, Individualize, Medicalizethe High Cost of Austerity EconomicsIgnore failed structural Overlook free marketadjustment programs (SAPS) fundamentalist cost-shifting Cutting public sector  Remove price Privatization subsidies Cutting services  Fees for services Lay-offs, salary cuts  Erodes social safety and freezes nets Selective and  Abolish social vertical interventions security
    20. 20. Costs of Austerity to Women’s Health Macro: Erosion of health system budget, facilities, staff, salaries, basic resources, services, moral Meso: Institution of vertical,selective health programssilo-ing focus and resources fromIntegrated primary care Micro: destroys social fabricas people eek out survival from overburdened household resources, especially social-
    21. 21. HIV care and treatment scale up exposes costs of Austerity Economics AIDS-related maternal mortality Health systems failures AIDS-related stigma= tangible consequences of trickle-down politics which have immiserated African households and public
    22. 22. Ethnography: Effects ofinequalityIdentities of Control and Resistance1. Spirit Intervention2. The Power of Words3. Female Envy4. Strangers and Stress5. Uterine Battles6. Spirit Wives7. Inheriting Infertility8. Witches
    23. 23. Current costs of inequality toMaternal Health? Women hide pregnancy Avoid prenatal care Heightened household tension and domestic violence Men circulate informally among several households to assure survival (and welcome) Women cannot afford to not get pregnant to assure male support Increased sex-work in time of increasing prevalence rates of HIV infection
    24. 24. counter-geography of survival(Davis 2004, Planet of Slums) Home birth outside of biomedical surveillance, defining health from their own experience, balancing beliefs about social threats and spiritual protections with biomedical explanations, participating in lively church communities that
    25. 25. Women are not “lost” to follow-up
    26. 26. New Research Question:  What accounts for loss to follow-up?
    27. 27. Findings1. Stigma and fear2. Domestic violence and negotiation of disclosure3. food and drug insecurity in spurring new hungers, new resistances4. Confusion regarding pregnancy and seropositive status
    28. 28. Where are all the pregnant HIV+women going after they test positive?  HIV testing and treatment complicates women’s interface with clinical care.
    29. 29. ♀ ♀♀ ♀g+ ♀ ♀ ♀ ♀g+ ♀ ♀
    30. 30. New collaboration:Option B (2012 WHOGuidelines)1. Starting triple therapy ART directly after testing rather than waiting (test and treat)
    31. 31. Option A vs. Option B Pregnant woman comes to ANC visit CounselingWoman tested for HIV CD4 visits, clinician Start ART <350 visits HIV chart Draw Woman opened in HIV CD4 Counseling Start HIV+ clinic CD4 visits, clinician AZT+sdN >350 visits VP CD4 <350 Continue ART Start ART Draw CD4 lifelong Stop ART 1 week CD4 >350 after breastfeeding
    32. 32. Benefits1. simplification of regimen and service delivery and harmonization with ART programs,2. protection against mother-to-child transmission in future pregnancies,3. continuing prevention benefit against sexual transmission to serodiscordant
    33. 33. Not enough:Trojan Horse of ART Scale-Up Quality HIV care and services are only possible within context of building strong, sustainable, public sector health systems
    34. 34. action agenda “The is clear. To get Millennium Development Goal 5 on track by reducing the contribution of AIDS to maternal mortality, we must prevent HIV infection in women and girls, prevent unwanted pregnancies, expand HIV testing and counselling, accelerate initiation of antiretroviral treatment in pregnant women who are HIV-positive, and strengthen service delivery and integration of HIV care and obstetric services, along with data collection to track progress.” (Moodley, et al. 2011, editor’s
    35. 35. Answer to Wendy’s question:How do we balance science andadvocacy? DO BOTH! They are inseparable. They are not mutually exclusive. To do one without the other challenges the legitimacy and efficacy of either.
    36. 36. Scientists MUSTChallenge Austerity Politics and Policiesmeans?1. Challenge NGO-centric model of global health, resources go NGO rather than public sector and return to donor through phantom aid channels.2. Challenge representations of African peoples, cultures and institutions as pathological, inferior needing management and programs that make this vision inevitable.3. Remove hiring freezes and hire, train and adequately remunerate health care providers.
    37. 37. Public Health Spending – enough said Worldmapper
    38. 38. BASTA!
    39. 39. Thank You! University of Washington James Pfeiffer Wendy Johnson Beatrice Thome Mozambican Ministry of Health Health Alliance International Javelina Aguiar Lucia Lazaro

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