Chan 1

Melissa Chan
Professor Gloyd, Professor Sparke
Global Health 101 AI
10 March 2015

Global Fund Proposal

Country: Nicaragua
Disease: HIV/AIDS

SECTION 1: Background and introduction to proposal plan and strategy:

Recent in-country analyses by the World Health Organization indicate that Nicaraguas
HIV/AIDS epidemic is currently in a nascent stage (WHO11). With only 0.3 percent of adults infected
with HIV as of 2012, Nicaragua has the lowest HIV/AIDS prevalence rate in Central America
(UNICEF4). However, the number of people living with HIV/AIDS has been increasing every year since
the 1990s, from the end of the countrys civil war. (WHO11). Presently, HIV/AIDS programs are not at
the forefront of government healthcare priorities, and with this lack of attention to the growing HIV/AIDS
problem, the preconditions for a more serious epidemic are present (WHO11).
Nicaragua currently has a relatively stable primary healthcare system in place. The Sandinistas
Party established The National Unified Health System in the 1980s to help distribute public healthcare
across the country (Lawton8). The system still stands today and is run by the MINSA (Ministry of
Health), which aims to provide free and universal primary health care to all Nicaraguan citizens through
national, regional, and municipal level health centers ranging from government hospitals to community-
based casas maternas home clinics (PATH16).
However, despite the ideals of the National Unified Health System, as of 2013, only 35 percent of
people living with HIV/AIDS (PLWHA) received ARV therapy treatment (The World Bank2). Although
the MINSA system aims towards decentralization and equitable distribution of care, most of the countrys
major hospitals and HIV diagnostic centers are still centralized around the capital, Managua. This
presents a problem for the 42 percent of Nicaraguans living in rural countryside who do not have easy
access to HIV screening and treatment (The World Bank15). The high-risk populations for HIV infection
include sex workers and homosexuals, many of who are concentrated in the Managua and Chinandega
states, and the indigenous in the countrys rural autonomous regions (WHO11).
In addition, the Nicaraguan governments ability to provide adequate funding for its health
programs has been severely cut since the 1990s with the implementation of structural adjustment
programs by USAID and the World Bank (Birn5). The SAPs privatized the previously public sector health
system and forced a reduction in government health spending by more than 12 percent from 1992 to 1996
(Birn5). Currently, Nicaraguas healthcare spending is only eight percent of its GDP, meaning its spending
on HIV/AIDS programs is only a fraction of that already small percentage (PATH16). As of 2012,
Nicaragua had a public debt of 58.6 percent of its GDP and a total external debt of 79.7 billion USD
(theodora10). This high debt burden and resulting lack of resources for health spending has forced MINSA
HIV/AIDS programs to prioritize focus on diagnosis and treatment, leaving little attention to prevention
education (The Global Fund12).
Furthermore, there is a strongly negative social stigma in Nicaragua culture against PLWHA, as
well as gender role traditions that facilitate the spread of HIV while making discussion of the disease a
taboo (The World Bank2). This stigma is also manifested in various forms of social discrimination that
discourage PLWHA from coming forward. In 1996, advocacy groups succeeded in passing Law 238 for
the promotion, protection, and defense of human rights of PLWHA, but this law has failed in de facto
implementation (The World Bank2).
My strategy for this proposal, therefore, is to utilize and build upon the strengths of Nicaraguas
already existing healthcare framework and advocacy programs. I plan to use the Global Fund grant to
work towards the MINSA ideal of decentralizing access to HIV/AIDS diagnostic and treatment facilities,
 Chan 2

create prevention education programs for the identified at-risk target populations, and to revamp programs
to reduce social stigmas towards PLWHA. This approach will address the spatial gaps in Nicaraguas care
provision system, while also expanding essential prevention programs.

SECTION 2: Overarching goals, objectives, and activities with impacts expected on targeted
populations and burden of disease

GOAL 1:
Increase accessibility to diagnostic tests and ARV treatment for targeted populations
Nicaraguas populations most affected by HIV/AIDS include sex workers, sexual minorities, pregnant
women and their babies, young adults, indigenous/afrodescendants, and the poor (The Global Fund12).
These patients are often limited in their ability to utilize HIV screening and diagnostic facilities by
transportation barriers, as many live in rural communities. In addition, those already infected are often
barred from receiving regular ARV therapy treatment by low supply and high costs (The Global Fund12).
Therefore, increasing accessibility to diagnostic tests and ARV therapy treatment for these high-risk
populations are vectors through which the burden of HIV/AIDS can be managed.
Impact indicators: Year 1: Year 5:
% of people receiving ARV
35% (The World Bank2) 45.5%
treatment

OBJECTIVE 1:
Achieve a 30% increase in number of people who have access to HIV screening/diagnostic facilities
The transportation barriers preventing rural populations from reaching screening/diagnostic facilities
are mainly long distances to the nearest facility and lack of adequate transportation (The Global Fund12).
According to the World Bank, about 16 in every 100 patients in the poorest quintile do not seek health
care when sick because the nearest health facility is too far (Angel-Urdinola1). In addition, for every
additional kilometer away from a consultation facility, the probability of an individual seeking a
consultation decreases by 0.2 percent (Angel-Urdinola1). This issue affects mostly the poor and those in
rural areas. Therefore, addressing this problem makes an important contribution to HIV preventative
care.
Outcome indicators: Year 1: Year 5:
% of poor/rural citizens with access to 36-40% (Angel-
46.8-52%
screening/diagnostic facilities Urdinola1)

ACTIVITY 1:
Build and staff additional HIV screening/diagnostic facilities in high-risk regions
(US$ 15,000,000 over 5 years)
Nicaragua is one of the fastest growing countries in Central America; however, the number of healthcare
facilities available has not changed to accommodate rapid population growth (Angel-Urdinola1). In the
map below, areas of high-risk are colored in red and orange, most notably the states of Managua and
Chinandega (red), and Leon and R.A.A.S (orange). As shown, the few SILAIS screening facilities (blue
bubbles) are concentrated around Managua and the periphery of Chinandega and Leon. These few
locations greatly limit the accessibility of screening for the at-risk populations in distant high-risk areas.
Therefore, I propose that additional screening centers (orange plus signs) be built to increase density in
areas of high-risk.
 Chan 3

Implementing
Process indicators: Year 1: Year 5:
agency/agencies:
Managua: 0.32
Chinandega: 0
Leon: 0
R.A.A.S.: 0.33
# screening/diagnostic [statistics estimated with
0.5 per 100,000
facilities per 100,000 total population of each MINSA
population
population region from INEC13 and
number of SILAIS per
region # per 100,000
= 100,000*(current
#)/(population size)]

ACTIVITY 2:
Set up public transportation system connecting rural areas to closest facilities
(US$ 8,000,000 over 5 years)
Nicaraguas existing public bus transportation system is comprised of refurbished yellow school buses
called Chicken Buses. However, the Chicken Bus routes are very limited, and often stay only within the
major city boundaries. As evidenced by these two maps from Nicaraguas Chicken Bus trip planner, bus
stops density decreases from the urban center (horariodebuses.com7).
 Chan 4

Taking advantage of this already-existing public transportation system, I propose that special bus routes
be planned and reserved for transportation to and from screening facilities and hospitals. New stops
could be planned along the current major highways (yellow paths), so as to reach both rural and urban
areas.

Implementing
Process indicators: Year 1: Year 5:
agency/agencies:
# bus routes reserved to
transport people from
MINSA and the
rural areas to and from 0 per region 2 per region
Ministry of Transport
screening facilities and
hospitals, per region
 Chan 5

OBJECTIVE 2:
Achieve a 30% increase in number of people with access to ARV treatment
According to the World Bank, lack of medicines and high costs are the main reasons people cannot
access ARV treatment (Angel-Urdinola1).
Over the past decade, Nicaragua has remained under high dependency on external funding for ARV
supplies, meaning 75 to 100 percent of ARV supplies is financed through aid (PAHO3). In addition, in
2010, 19 percent of treatment facilities suffered stock-out episodes where supply of ARVs ran out
(PAHO3). Increasing ARV supplies would allow more patients greater access to treatment.
The adult ARV treatment regimen most commonly used is zidovudine + lamivudine + efavirenz, and
costs between US$ 1000 and US$ 1400 per person per year (WHO11). The average annual income for
a Nicaraguan family is only US$ 1650 (World Vision9). Finding a way to lower or subsidize the cost of
ARVs would allow more patients, especially those in poverty, to access treatment.
Outcome indicators: Year 1: Year 5:
35% (The World
% of people with access to ARV treatment 45.5%
Bank2)

ACTIVITY 1:
Increase homemade ARV treatment supply
(US$ 25,000,000 over 5 years)
Utilizing funds from the Global Fund, Nicaragua can purchase more ARVs. However, this is a temporary
remedy to the supply problem, and a more sustainable plan would be to use part of the funds to also
invest in creating its own ARVs. This would mean investing in the research and manufacturing of ARVs,
and as a large endeavor, would probably require the assistance of an NGO (or multiple NGOs) and an
already-existing manufacturer (maybe the Indian manufacturer, Cipla from the in-class video).
Implementing
Process indicators: Year 1: Year 5:
agency/agencies:
MINSA with the help of
% ARV supplies a supporting NGO
75-100% (PAHO3) 60-80%
financed externally and/or existing
manufacturer

ACTIVITY 2:
5% decrease in cost of ARV treatment
The WHO estimates that generic ARVs would cost about US$ 800 annually in comparison to the current
US$ 1000 to 1400 (World Vision9). With a nascent, homemade ARV supply, over time Nicaragua might be
able to produce enough generic ARVs to lower the annual cost, making treatment more affordable for the
poor.
Implementing
Process indicators: Year 1: Year 5:
agency/agencies:
US$ 1000-1400 1650
Cost of ARV treatment US$ 950-1330 MINSA
(World Vision9)
 Chan 6

GOAL 2:
Effective implementation of HIV prevention education programs that also address discrimination
against PLWHA
According to previous Global Fund proposals, the approach to healthcare in Nicaragua has been
characterized by a focus on cures, with limited development of promotion and prevention, leading to
sparse application of the integrated healthcare approach (The Global Fund12). In 2002, a survey by the
World Bank found that 23 percent of sex workers, one of the high-risk populations, did not know how to
practice safe sex (The World Bank2). These examples illustrate how the lack of preventative education
programs contributes greatly to the current increasing trend in HIV/AIDS prevalence people do not
know when they are at risk and how to protect themselves. Implementing effective prevention education
programs will help reduce the burden of HIV because people will be more aware of how the disease
spreads and how to avoid contracting it.
The lack of education surrounding all aspects of HIV/AIDS is also a cause behind some of the negative
cultural stigmas against PWLHA. In 2003, another World Bank survey found that 40 percent of
Nicaraguans surveyed agreed that people with HIV should not have access to public places, and that
60 percent agreed that sex workers with HIV deserved to have the disease due to their bad behavior
(The World Bank2). Common discriminatory practices against PLWHA often occur in the workplace,
where an applicant can be forced to provide an HIV test and can subsequently be denied employment
because of a positive status (The World Bank2). Many of these discriminations stem from false beliefs that
PLWHA are dangerous or contagious, and are immoral (The World Bank2). Working to combat these
negative stigmas and stereotypes is important because many PLWHA feel pressured to lie about their
condition, for fear of being ostracized and discriminated against, thus adding to the burden of HIV
because silence facilitates its spreading (The World Bank2).
Impact indicators: Year 1: Year 5:
% increase in number of new
11.2% (WHO6) 7.84% = a 30% decrease
HIV/AIDS diagnoses per year
Survey indicates that 28-42% of
people surveyed still believe
Survey indicates that about 40- PLWHA are dangerous and
60% of people surveyed believe should be kept away from
Peoples quantitative perception
PLWHA are dangerous and society; more people understand
of PLWHA
should be kept away from society the structural issues contributing
(The World Bank2) to PLWHA contracting
HIV/AIDS, and that they are not
a danger to society

OBJECTIVE 1:
Improve availability of HIV prevention education programs
Prevention education programs must target populations most at risk for HIV infection so as to curb the
burden of disease. These populations include sex workers, sexual minorities, pregnant women and their
babies, young adults, indigenous/afrodescendants, and the poor (The Global Fund12). It would be ideal to
be able to spread education through multiple vectors of society: kids could receive it in schools, mass
media could air a soap opera with safe sex practices embedded, etc. This would facilitate a non-invasive
and adaptable means of promoting prevention education.
Outcome indicators: Year 1: Year 5:
14
% prevalence of condom usage by adults 19% (UN Data ) 25%
 Chan 7

ACTIVITY 1:
Offer sex education in all public schools
(US$ 7,000,000 over 5 years)
Youth and young adults are a high-risk group for infection (The World Bank2). Teaching about safe sex
and drug use practices would help reduce instances of preventable transmission. These classes should be
targeted towards late middle school and high school students, and should include topics such as
promotion of condom usage.
Implementing
Process indicators: Year 1: Year 5:
agency/agencies:
The International
Planned Parenthood
Foundation has just
Expand IPPF program
recently implemented a
to all primary and
# public schools sexual education
secondary schools; IPPF and other NGOs,
offering sex education program in a number of
maybe place more focus Ministry of Education
classes primary and secondary
on HIV/AIDS
schools. The program
prevention
covers sexual health and
STD protection
(IPPF17).

ACTIVITY 2:
Create prevention education brigades for target populations
(US$ 7,000,000 over 5 years)
I propose to model these education brigades after the door-to-door efforts by USAID to spread ORT
knowledge through villages in Africa. Bringing education door to door, especially in rural areas, would
allow for specialized programs targeted to specific populations and their needs. This approach could also
make the education experience more personalized and emphasize its importance to those receiving it.
These locations of these door-to-door programs should parallel the locations of high-risk populations. As
seen on the map below, the orange houses indicate areas where brigades are needed.

Ideally, there would be two to four brigade teams staffing each location site and spreading outwards
within each region.
 Chan 8

Implementing
Process indicators: Year 1: Year 5:
agency/agencies:
Set goal of 70%
Set goal of 1,ooo
regional population NGOs collaborating
# households visited households per brigade
coverage by end of the with the MINSA
by the end of the year
five years

OBJECTIVE 2:
Increase awareness of and combat discrimination against PLWHA
Social norms often pass down generations unquestioned. Concurrently taking advantage of the new
prevention education programs described above, educators could use the same opportunity to teach
about and debunk the false perceptions surrounding PLWHA that contribute to social stigmatization. In
addition, directed efforts must be made to combat the expression of negative stigmas in the provision of
care for PLWHA.
Outcome indicators: Year 1: Year 5:
Survey indicates
little to no
Survey indicates 20%
awareness; similar
reduction in percentage of
to the 40 and 60%
Peoples qualitative awareness of the fallacy of people holding discriminatory
expressing
stigmas surrounding PLWHA attitudes towards PLWHA;
discriminatory
greater understanding of
attitudes from Goal
intrinsic humanity
2 Impact Indicators
(The World Bank2)

ACTIVITY 1:
Include lesson/discussion about stigmas surrounding PLWHA in prevention programs
(US$ 5,000,000 over 5 years)
Prevention programs can serve as a forum for constructive discussion and debunking of false stereotypes.
Educators should help students realize normalized stereotypes and stigmas against PLWHA, and address
them. Then students should actively discuss these stigmas to further understand them and learn to accept
instead of ostracize PLWHA.
Implementing
Process indicators: Year 1: Year 5:
agency/agencies:
# prevention programs Set goal of 20% actively Set goal of 50% actively
addressing PLWHA addressing by end of addressing by end of NGOs
stigmas year year

ACTIVITY 2:
Humanize care of PLWHA through awareness workshops for treatment staff
(US$ 5,000,000 over 5 years)
Negative stigmas towards PLWHA unfortunately also affect provision of care towards PLWHA (The
Global Fund12). PLWHA have reported feeling stigmatized by healthcare professionals and staff while
receiving ARVs and other treatments for their disease (The Global Fund12). Humanization of PLWHA
care is important because PLWHA should be respected by the people they are trusting to provide them
with care. Education programs should be enacted in hospitals and health posts to educate providers
about the fallacy of PLWHA stigmas, similarly to the prevention program lessons.
 Chan 9

Implementing
Process indicators: Year 1: Year 5:
agency/agencies:
Survey indicates
Survey indicates that
PLWHA feel
healthcare professionals
PLWHAs qualitative stigmatized by
and staff have greater NGOs collaborating
perceptions of their healthcare professionals
appreciation for fallacy with MINSA
quality of life and staff even while
of stigmas against
receiving care (The
PLWHA
Global Fund)

SECTIION 3: How the goals and objectives add to or complement activities already undertaken by
the government, external donors, the private sector or other relevant partners
Nicaraguas current HIV/AIDS strategy operates under the National Strategic Plan alongside the
National Policy on the Prevention and Control of STIs and HIV (The Global Fund12). Both initiatives are
under the direction of MINSA, and aim to further decentralize the current care provision system (The
Global Fund12). This seems to resonate with Goal 1 of this proposal, to increase accessibility to diagnostic
tests and ARV treatment for targeted populations.
MINSA is also partnering with other national organizations and NGOs to promote preventative
education. The National AIDS Control Program operates through the Country Coordinating Mechanism
to promote HIV/AIDS prevention and control education in regional hospitals and health posts of local
health care systems (The World Bank2). There is also a new program called the Behavioral Change
Communication, which utilizes mass media to spread sexual awareness and safe sex practice advice (The
World Bank2). Therefore Goal 2 Objective 1 adds to this existing initiative by further specifying the
targets and vectors for the programs.
Finally, various NGOs and national agencies are also beginning to work on both addressing social
stigmas against PLWHA and legally reducing discrimination power towards PLWHA. The Nicaraguan
AIDS Commission works to protect and defend the rights of people with HIV/AIDS through attempting
to enact legal barriers against different forms of employment and healthcare discrimination (The World
Bank2). In addition, the national agency, The Center for AIDS Education and Prevention, focuses on
empowering homosexuals in Nicaragua while changing societal attitudes towards different sexual
orientations. These efforts go hand in hand with Goal 2 Objective 2s mission to support PLWHA and
help reshape their societal image.

SECTION 6: How the goal(s) address the following issues

a. Involvement of beneficiaries
Goal 2 directly addresses societal stigmas and perceptions of PLWHA. PLWHA are beneficiaries
of this goal because if achieved, the provisions of this goal would help reduce negative stigmas
and perceptions that often result in unfair discrimination and dehumanization of PLWHA. The
indicators of Goal 2 and its subsequent Objectives also involve qualitative feedback from
PLWHA.
b. Community participation
Goal 2s preventative education model ideally involves community participation, both in the
classroom programs and the door-to-door visits. Involving the community would enhance the
effectiveness of these programs by mobilizing a larger group of educators towards the goal.
c. Gender equality issues
Women are one of the vulnerable populations listed with high-risk of HIV infection. In 2005,
women accounted for 29 percent of all new HIV/AIDS diagnoses (Espinoza6). Furthermore,
cultural and economic realities of Central America, and specifically of Nicaragua, make
women more vulnerable to HIV (The World Bank2). Goal 2 addresses the need for targeted
prevention education programs. Provisions for programs directed towards vulnerable women
 Chan 10

should address traditional gender roles and attitudes of men vs. women in attempts to educate
women about self-empowerment and equality.
d. Social equality issues
Goal 2 address the current social inequality of discrimination against PLWHA. The objectives
and activities described outline a strategy through which these discriminations can be addressed
and stopped through a transformation of societal attitudes.
e. Human resources development
Goal 1 aims to expand access to HIV screening facilities and treatment staff. In addition, Goal 2
strives to mobilize trained brigaders to be resources for prevention education, while also working
to educate treatment staff on social discrimination issues regarding PLWHA in order to further
humanize care provision.

SECTION 5: Potential opposition to the plan and how it will be addressed

The majority of the activities in my proposal require the MINSA to be the implementer, meaning
that by extension, most of the Global Fund grant will be given to MINSA. Involved stakeholders may
therefore be worried about possible corruption or misuse of funds. However, this problem can be
satisfactorily addressed by requiring MINSA to submit all records of their use of Global Fund grant
money to the Global Fund, where they will be made public for all concerned stakeholders to view
completely transparently. Failure to submit records or attempts to falsify records will result in immediate
withdrawal of Global Fund money and a ban from apply for grants again.
Another potential source of opposition could come from the Roman Catholic Church against the
promotion of condom usage in the HIV prevention education programs. This conflict will be more
difficult and variable to address, but the best approach seems to be to speak directly with the church
authorities in the country and present a cost-benefit analyses with regards to condom usage and
dramatically decreased risk of HIV infection.
 Chan 11

Works Cited
1
Angel-Urdinola, Diego, et. al. Equity, Access to Health Care Services and Expenditures on Health in

Nicaragua. The World Bank HNP, 2008. Web. 9 Mar. 2015.

http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/28162

7-1095698140167/CortezNicaraguaHealth.pdf
2
Antiretroviral therapy coverage. The World Bank, 2015. Web. 6 Mar. 2015.

http://web.worldbank.org/archive/website01063/WEB/IMAGES/CAAIDSNI.PDF
3
Antiretroviral Treatment In the Spotlight. Pan-American Health Organization, 2012. Web. 9 Mar.

2015.

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCgQFjAA&ur

l=http%3A%2F%2Fwww.paho.org%2Fhq%2Findex.php%3Foption%3Dcom_docman%26task%

3Ddoc_download%26gid%3D17512&ei=36__VM3XGsL2oASd0oCoAQ&usg=AFQjCNF-

D4NI088DYVGj3TGPnR9WLcN3dw&sig2=dTpzH2cmpFOxBk_fD5K9zQ&bvm=bv.87920726

,d.cGU
4
At a glance: Nicaragua. UNICEF, 2013. Web. 7 Mar. 2015.

http://www.unicef.org/infobycountry/nicaragua_statistics.html
5
Birn, Anne-Emanuelle, et. al. To Decentralize or Not to Decentralize, Is That the Question? Nicaraguan

Health Policy Under Structural Adjustment in the 1990s. International Journal of Health

Services, Vol. 30, No. 1. Baywood Publishing Co., Inc., 2000. Sage Journals. Web. 7 Mar. 2015.

http://www.ncbi.nlm.nih.gov/pubmed/10707302
6
Espinoza, Henry, et. al. Management of the HIV epidemic in Nicaragua: the need to improve

information systems and access to affordable diagnostics. Bulletin of the World Health

Organiztation, 2011. Web. 9 Mar 2015. http://www.who.int/bulletin/volumes/89/8/11-086124/en/

7
horariodebuses.com Nicaragua. thebusschedule.com, 2015. Web. 9 Mar. 2015.

http://horariodebuses.com/EN/ni/#.VP-wu0KIT8E
 Chan 12

8
Lawton, Nancy. Health Care in Nicaragua. Health Care Issues, Vol. 13, No. 6, 1988. PubMed. Web. 6

Mar. 2015. http://www.ncbi.nlm.nih.gov/pubmed/3412669

9
Nicaragua Country Profile. World Vision, Inc., 2015. Web. 9 Mar. 2015.

http://www.worldvision.org/our-impact/country-profiles/nicaragua
10
Nicaragua Economy 2015. theodora.com, 2015. Web. 7 Mar. 2015.
11
Nicaragua HIV/AIDS Situation Report. WHO, 2005. Web. 6 Mar. 2015.

http://www.who.int/hiv/HIVCP_NIC.pdf
12
Nicaragua Proposal Form Round 8. The Global Fund, 2008. Web. 9 Mar. 2015.

http://portfolio.theglobalfund.org/en/Country/Index/NIC
13
Nicaraguan 2005 Census. INEC, 2005. Web. 9 Mar. 2015.

http://en.wikipedia.org/wiki/Demographics_of_Nicaragua
14
Prevalence of condom use by adults during higher-risk sex (15-49) (%). UN Data. World Health

Organization, 2014. Web. 10 Mar. 2015. http://data.un.org/Data.aspx?q=Condom+high-

risk+sex&d=WHO&f=MEASURE_CODE%3AMDG_0000000015
15
Rural population. The World Bank, 2015. Web. 7 Mar. 2015.

http://data.worldbank.org/indicator/SP.RUR.TOTL
16
The Nicaraguan Health System. PATH, 2011. Web. 6 Mar. 2015.

http://www.path.org/publications/files/TS-nicaragua-health-system-rpt.pdf
17
Voices from Nicaragua. International Planned Parenthood Foundation, 2011. Web. 9 Mar. 2015.

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&ved=0CFsQFjAI&url=

http%3A%2F%2Fwww.ippf.org%2Fsystem%2Ffiles%2Fchanging_lives_nicaragua.pdf&ei=jc7-

VJrKMIX0oASxr4GIDw&usg=AFQjCNH2bVGK1RTkzorLKmqrpQVJjphKew&sig2=3NmvK

EGEGKW5xCnszdYqdw&bvm=bv.87920726,d.cGU