Patients and Methods. We retrospectively analyzed serum IgG4 concentrations and IgG4/IgG ratio and IgG4+/IgG+ plasma cell ratio in tissues of 132 patients with IgG4-related disease and 48 patients with other disorders. Result. Serum IgG4 >135  mg/dl demonstrated a sensitivity of 97.0% and a specificity of 79.6% in diagnosing IgG4-related disease, and serum IgG4/IgG ratios >8% had a sensitivity and specificity of 95.5% and 87.5%, respectively. IgG4+cell/IgG+ cell ratio in tissues >40% had a sensitivity and specificity of 94.4% and 85.7%, respectively. However, the number of IgG4+ cells was reduced in severely fibrotic parts of tissues. Conclusion. Although a recent unanimous consensus of all relevant researchers in Japan recently established the diagnostic criteria for IgG4-related disease, findings such as ours indicate that further discussion is needed.IgG4-related disease is a new disease classification established in Japan in the 21st century. Patients with IgG4-related disease display hyper-IgG4-gammaglobulinemia, massive infiltration of IgG4+ plasma cells into tissue, and good response to glucocorticoids. Since IgG4 overexpression is also observed in other disorders, it is necessary to diagnose IgG4-related disease carefully and correctly. We therefore sought to determine cutoff values for serum IgG4 and IgG4/IgG and for IgG4+/IgG+ plasma cells in tissue diagnostic of IgG4-related disease.  IgG4-related disease (IgG4-RD), a new disease classification first established in Japan in the 21st century, is characterized by hyper-IgG4-gammaglobulinemia and massive infiltration of IgG4-positive plasma cells into various swollen organs . In geneSome patients with early or limited stage IgG4-RD, however, may show the sufficient pathological characteristics and clinical features of this disease, such as good response to glucocorticoids, despite having serum IgG4 concentrations <135 mg/dL. In addition, an IgG4+/IgG+ ratio >40% in tissue and >10 cells/high-power field (HPF) have been used in the histopathologic diagnosis of IgG4-RD in Japan. Thus, a proper diagnosis of these patients may require the use of other criteria, including IgG4+/IgG plasma cell ratio. Since lower cutoff values may increase sensitivity while decreasing specificity, it is necessary to establish accurate cut off values for this ratio.To better establish the diagnostic criteria for IgG4-RD, we, the members of the IgG4+MOLPS/Mikulicz's disease research group in Japan, sought to determine the cutoff values for serum IgG4 and IgG4/IgG and for IgG4+/IgG+ plasma cells in tissue diagnostic of IgG4-RD using retrospectively collected data.Serum IgG4 concentrations and IgG4/IgG ratio and the ratio of IgG4+/IgG+ plasma cells in tissue were determined in 132 patients with IgG4-RD and 48 patients with other disorders registered retrospectively in the IgG4+MOLPS/Mikulicz's disease research group . The 48 Patients with borderline IgG4-RD were defined carefully as those with (1) >40% IgG4+/IgG+ plasma cells in tissue, (2) strict pathological differential, and (3) a typical clinical course .The numbers of IgG4+ and IgG+ cells in tissue samples from 36 patients with IgG4-RD and from 21 with other disorders were determined by counting cells counts in 5 high-power fields (HPF) under light microscopy. We also recounted cell areas of 17 samples from patients with IgG4-RD that contained both fibrotic and nonfibrotic parts.We also assessed the sensitivity and specificity of IgG4+/IgG+ cell ratios >10%, >20%, >30%, >40%, and >50%, and of >10, >20, >30, >40 and >50 IgG4+cells/HPF, as well as the presence of obliterative phlebitis, storiform fibrosis, eosinophilia, fibrosis, and lymphocyte infiltration as determined by hematoxylin and eosin staining in the diagnosis of IgG4-RD.Tissue samples with borderline IgG4-RD were defined as those with (1) serum IgG4 >135 mg/dL, (2) strict pathological differential, and (3) typical clinical course. Clinical course including response to steroid is not included in the comprehensive diagnostic criteria for IgG4-RD, to avoid the needless treatment with steroid of patients suspected of having IgG4-RD. As this was a retrospective analysis, however, we analyzed the clinical course of these borderline patients, including their response to steroid treatment.A serum IgG4 cutoff value >135 mg/dL had a sensitivity of 97.0% and a specificity of 79.6% for the diagnosis of IgG4-RD. In 4 patients with relatively small and restricted lesions, however, this criterion was not adequate to diagnose IgG4-RD, although all had a histopathology and clinical course compatible with IgG4-RD . All 4 pIn contrast, neither a serum IgG4 cutoff of >135 mg/dL nor a serum IgG4/IgG ratio >8% was adequate for the diagnosis of four patients with MCD and one each with B-cell lymphoma, scleritis, and Sjögren's syndrome, because all of these patients had hyper-IgG4-globulinemia associated with polyclonal gammopathy. We therefore estimated the sensitivity and specificity of various IgG4/IgG ratios . We founWe also assessed the ability of the ratio of IgG4+/IgG+ plasma cell ratios in 5 HPFs of tissue samples to diagnose IgG4-RD. We found that a ratio >40% had a sensitivity of 94.4% and a specificity of 85.7% . AlthougIn tissues containing both fibrotic and nonfibrotic areas, we counting the number cells in each part showed that fibrotic areas contained fewer IgG4+ cells .We also assessed the ability of obliterative phlebitis and storiform fibrosis to diagnose IgG4-RD. Although both had specificities of 100%, their sensitivities were not very high .Serum IgG4 >135 mg/dL has been widely accepted as a cutoff value for diagnosis of IgG4-RD. Although this concentration was determined by comparing patients with IgG4-related sclerosing pancreatitis and those with pancreatic cancer , and, inCareful diagnosis is required in patients with lower IgG4 concentrations, since those patients may have other distinct disorders with different clinical features than IgG4-RD. Patients with untypical clinical courses, including glucocorticoid refractoriness, should be reassessed.IgG4+/IgG+ plasma cell ratios in tissue >40% and >50%, and >10 IgG4+ cells per HPF have been used for the diagnosis of IgG4-RD. We found that an IgG4+/IgG+ cell ratio >40% in tissue had a sensitivity of 94.4% and a specificity of 85.7% in the diagnosis of IgG4-RD. We also found that IgG4+ plasma cell concentrations in tissue were diminished in fibrotic tissue areas, suggesting that a ratio >40% is a better histopathologic cutoff value. The presence of obliterative phlebitis and storiform fibrosis demonstrated specificities of 100%, but their sensitivities were much lower, indicating that these findings would be useful when added to, but not in place of, other results.Since patients with disorders such as MCD and lymphoma may demonstrate hyper-IgG4-gammaglobulinemia and massive IgG4+ plasma cell infiltration in tissue, serum IgG4 concentration and IgG4+ cells in tissue are not specific indicators of IgG4-RD. Rather, a diagnosis of IgG4-RD should be based on the overall balance of clinical features, such as disease distribution throughout the body, clinical course, serum concentrations, and histopathology.The pathologic consensus statement of the first international Symposium on IgG4-RD in Boston did not adopt IgG4+/IgG+ cell ratio in tissue as diagnostic, although it did suggest cutoffs for numbers of IgG4+ cells in HPFs of various organs. This, however, may be confusing for many pathologists and physicians. Although pathologic findings are very important in the diagnosis for IgG4-RD, clinical features and serological findings should be included.Recently, some patients with IgG4-RD were found to have lymphoma , 14 and


The Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) pandemic has caused far-reaching effects in sub-Saharan Africa. The pandemic has effectively diminished the workforce, increased poverty rates, reduced agricultural productivity, and transformed the structure of many rural households. HIV/AIDS further strains the already fragile relationship between livelihood and the natural and social environments of these regions. Therefore, the objective of this review is to characterize the impact of HIV/AIDS on the environment and the social infrastructure of rural sub-Saharan Africa. There are many aspects of rural life that contribute to disease transmission of HIV/AIDS and that pose unique challenges to the population dynamics in sub-Saharan Africa. Widespread AIDS-related mortality has caused a decrease in population growth for many African countries. In turn, these alterations in population dynamics have resulted in a decrease in the percentage of prime-age working adults, as well as a gender disparity, whereby, females carry a growing burden of household responsibilities. There is a rising proportion of older adults, often females, who assume the role of provider and caretaker for other dependent family members. These changing dynamics have caused many to exploit their natural surroundings, adopting less sustainable land use practices and utilizing protected resources as a primary means of generating revenue. The Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) pandemic has caused far-reaching effects in resource-limited settings. The continent of Africa has been particularly hard hit. It is estimated that two-thirds of the 33 million people living with HIV/AIDS worldwide, reside in this region, with a rising majority in rural areas . Based oWhile much attention has focused on the medical aspects of HIV/AIDS, other issues beyond the medical sector have emerged. HIV/AIDS further constrains the already fragile relationship between livelihood and the environment, as thoroughly described by Niehof, Rugalema, and Gillespie . Rural lThe juxtaposition of these factors evokes the question: what is the environmental impact of HIV/AIDS on the rural communities of sub-Saharan Africa? This review discusses the attributes of rural life that influence HIV/AIDS in sub-Saharan Africa, describes the fluctuations in population dynamics as a result of the pandemic, and characterizes the variations in the management and use of the local environment. It also highlights recommendations to lessen and reverse the effects of HIV/AIDS on the natural environment in this region.“HIV”, “Africa”, “rural” and “environment” were used alone and in combination to yield the maximum number of articles within each database. Of the 147 publications identified, 13 were included for meeting all of the following inclusion criteria: pertained to the environment, described original research findings, involved patients with HIV/AIDS, location in sub-Saharan Africa, and focused on issues pertaining to rural community life. Publications failing to meet the above criteria were excluded. The citations of relevant articles were also reviewed to yield an additional 18 articles. The articles are classified by focus area in Searches of the MEDLINE and GreenFILE databases were conducted to identify pertinent articles. The searches were restricted to articles published in peer-reviewed journals in the English language. The terms The various HIV/AIDS epidemics across sub-Saharan Africa are diverse in terms of rate of spread and characteristic variations from region to region . The preThe migratory tendencies of infected individuals in these areas further complicate rural life for people with HIV/AIDS. Previous studies of migration patterns have noted that HIV-infected individuals often return to their home village in order to be closer to relatives that can provide and care for them while they are ill ,15. ThisOne of the most notable consequences of the HIV/AIDS pandemic has been the reduction in population growth as a result of AIDS-related mortality. A report produced by the U.S. Census Bureau in 2004 indicated that many sub-Saharan African countries are projected to experience a decline in life expectancy . This reIncreased mortality due to AIDS, will not only reduce the overall population, but will also distort the age structure of many of these countries . Such deThe deleterious impact of disease on population growth is a mounting challenge for countries with high seroprevalence. First, consider that the estimated seroprevalence in 2001 was 20% in South Africa and 5% in Uganda . BecauseThe age distortion of the population influences the rural family unit. In South Africa, the percentage of the adult population is decreasing, yet the percentage of the elderly population is increasing. This is hypothesized to be a result of decreasing fertility rates among women, low levels of life expectancy among children born with HIV/AIDS, and adult AIDS mortality . Suppreset al. [Elders often resume primary responsibility for the household following the death of their adult children, as demonstrated by an interview of women sampled from South African villages by Schatz et al. . The autet al. . Older fet al. . As the et al. demonstrated that women with violent or controlling male partners were at increased risk for HIV infection [Approximately 60% of individuals living with HIV/AIDS in sub-Saharan Africa are female . In contnfection . The effnfection . These get al. conducted a study of farming households in Uganda to assess the gender influence on the livelihood of homes affected by AIDS and those unaffected by the disease [et al., Aliber et al. did not detect a link between HIV/AIDS mortality and land security for females, yet, the authors still concluded that HIV/AIDS does further complicate the issue of land tenure for females [In addition to the numerous farming responsibilities, women must also face property inheritance issues. Female control of agricultural households typically transpires following the death of a male spouse, often from AIDS. This raises the concern of land tenure and ownership. Land in sub-Saharan Africa is traditionally inherited through a patriarchal lineage; thus, widowed women are vulnerable to losing land rights upon their spouse’s death ,28. Kany disease . The inv disease . In contet al. sought to describe the trend in the abandonment of proper soil fertility management in Kenyan households afflicted by AIDS [Many communities have attempted to cope with the HIV/AIDS pandemic by increasing their dependence on the physical environment as a way to maintain their livelihood. Unfortunately, this is often done in a manner that is unsustainable. The agricultural needs at present may compromise future needs; therefore, environmental health, economic viability, and overall quality of life for farmers and society may decline. The Food and Agriculture Organization of the United Nations (FAO) has recognized and characterized the link between HIV/AIDS and the natural environment. The FAO has cited rural Africa as especially influenced by this link, given the reliance of these communities on agricultural activities . An exam by AIDS . The aut by AIDS . Given t by AIDS . The aut by AIDS .Another growing concern is the unsustainable harvesting of natural resources. Examples of other unsustainable practices that have been previously documented include uncontrolled charcoal mining, fishing, hunting, and the gathering of protected plants by individuals striving to make a living ,44,45. Oet al. conducted a study among Zambian Wildlife Authority officers to assess the influence of AIDS on worker productivity [p < 0.0001) in the amount of days on patrol, during the year of observation, compared to the previous year [The crux of the problem can often be attributed to the loss of human lives, specifically the loss of prime-age adult workers. The World Wildlife Fund, Inc., a non-governmental organization dedicated to environment conservation and restoration efforts, has cited a loss of human capacity due to HIV/AIDS as a major hindrance to preservation efforts . The orguctivity . After aous year . The invous year . The losMany of the problems and unique challenges in preserving the environment and social structure of rural sub-Saharan Africa appear to be closely linked to the loss of life. Unfortunately, reversing these deficiencies is a great feat to overcome. Ultimately, HIV/AIDS prevention is imperative to ending the pandemic and relieving the strain the disease places on the environment. Despite the prevalence of disease in sub-Saharan Africa, many of these countries appear to be underrepresented in terms of study location sites, in the identified articles. Strong governmental legislation is ideal for implementing policies geared towards disease prevention, but this may not be feasible for those nations that lack political stability. Still, through education, collaboration, and the active involvement of the population, many actions initiated at the community-level can be helpful to strengthen human capacity and to decrease the disease’s environmental impacts.i.e., for the workplace, places of worship or communal gathering, or for the home).Increasing HIV/AIDS awareness and overcoming the stigma of disease in all sectors of rural life is imperative to sparking reform and ultimately attaining prevention. Programs should ensure people understand: (1) what HIV/AIDS is; (2) how it is transmitted; (3) how it affects daily living; and (4) how it can change one’s dependency on natural resources. This knowledge can be disseminated by a variety of methods including, but not limited to, hosting educational sessions, training workshops, community meetings, focus groups, and wellness programs by peer educators and community leaders. As the disease affects all aspects of life, any newly adopted initiatives should be tailored accordingly , as the sole land inheritor. They may also benefit from information regarding sustainable alternatives to agricultural livelihood, such as agroforestry and crop species diversification ,47. OldeHIV/AIDS continues to pose an array of concerns for sub-Saharan Africa. The spread of HIV/AIDS further strains the fragile relationship that has long existed between the local environment, social infrastructure, and rural livelihood. Changing population dynamics and a growing dependency on the environment and its resources are at the center of this crisis. Nevertheless, plausible solutions to overcome some of these problems do exist. If implemented, rural communities of sub-Saharan Africa can effectively work toward environmental preservation.


Twenty-one patients with high-grade glioma, previously treated with surgery and radiotherapy with chemotherapy and first radiological suspicion of recurrence were enrolled. The uptake was assessed by the maximum standardized uptake value (SUVmax) and lesion-to-normal tissue count density ratio (L/N ratio). Of the 21 lesions, 15 were diagnosed recurrent gliomas and six were necrotic lesions. The average SUVmax was not significantly different between recurrent gliomas and necrotic lesions on either MET-PET or FLT-PET. The average L/N ratio of recurrent gliomas (3.36 ± 1.06) was significantly higher than that of necrotic lesions (2.18 ± 0.66) on MET-PET (p < 0.01) and the average L/N ratio of recurrent gliomas (7.01 ± 2.26) was also significantly higher than that of necrotic lesions (4.60 ± 1.23) on FLT-PET (p < 0.01). ROC curve analysis showed that the areas under the curves were high but not different between MET- and FLT-PET. PET studies using MET and FLT are useful in the differentiation of recurrent glioma from treatment-induced necrotic lesion. However, there is no complementary information in the differentiation with simultaneous measurements of MET- and FLT-PET.We retrospectively evaluated the usefulness of combined measurement of L-methyl-[ Recurrence in glioma may occur after macroscopic total removal of tumor or stabilization of tumor with treatment. In many cases, recurrence occurs at the initial tumor bed or within 2 cm of the primary site . Radiati11C]methionine (MET) is a well-established imaging tool for brain tumour detection fluorothymidine (FLT), has emerged as a promising PET tracer for evaluating tumor proliferating activity in various malignant brain tumors [Positron emission tomography (PET) can overcome the limitation of conventional MRI and can be used to derive information on tumor metabolism. PET with L-methyl-[etection , tumour etection ,6,7, preetection ,9, evaluetection ,11,12,13etection ,15 in paetection ,17. The deoxy-3'-Ffluorothn tumors ,20. FLT n tumors ,22. As Fdeoxy-3'-Ffluorothn tumors ,20,21,23n tumors ,25. A reOf 21 lesions, 15 were recurrent tumors  and six were necrotic lesions by the final diagnosis. All lesions showed moderate to strong enhancement effect on T1-weighted MR image after gadolinium administration.All 15 recurrent gliomas showed increased uptake on FLT- and MET-PET A. Of thep = 0.063). The average L/N ratio of recurrent gliomas (3.36 ± 1.06) was significantly higher than that of necrotic lesions (2.18 ± 0.66) on MET-PET (p < 0.01) (p = 0.095). The average L/N ratio of recurrent gliomas (7.01 ± 2.26) was significantly higher than that of necrotic lesions (4.60 ± 1.23) on FLT-PET (p < 0.01) (The average SUVmax of 15 recurrent gliomas (4.59 ± 1.64) was higher than that of six necrotic lesions (3.51 ± 0.83) on MET-PET but this was not statistically significant ( < 0.01) A. The av < 0.01) B.r = 0.41, p = 0.064) . Significant correlation was not observed between the individual L/N ratio of MET and FLT (= 0.064) . There wAnalysis of the ROC curve showed that the areas under the curves were high but not different between tumor uptake values of MET and FLT in both L/N ratio (Az: 0.844 for MET and 0.833 for FLT) A and SUVContrast enhancement of brain tumors depends on the BBB breakdown. Treatment-induced necrosis or necrosis occurring spontaneously during tumor progression may also show contrast enhancement and hence cannot be distinguished accurately from tumor recurrence after treatment . In addi11C-MET, can be applied only in centers with an on-site cyclotron because of short half-life of 11C (20 min) and rapid in vivo degradation. MET-PET possesses high specificity in tumor detection [in vitro Ki-67 expression [p < 0.01). MET SUVmax measurement might be uninformative because of large interindividual variability of large neutral amino acids in the plasma competing with MET at the amino acid transporter. In this study, there was a significant overlap of MET uptake between glioma recurrence and radiation necrosis. It has been reported that gliomas with oligodendroglial components show relatively high MET uptake even in low grade gliomas [et al. [Labeled amino acids and their analogs are particularly attractive for imaging brain tumors because of the high uptake in tumor tissue and low uptake in normal brain parenchyma and, as a consequence, higher tumor-to-normal tissue contrast. The most frequently used radiolabeled amino acid, etection , tumor detection , and difetection ,28. Varietection ,6,7. METpression ,30. Incrpression . In an epression . Also, npression . Althoug [et al.  showed t18F-FLT is a PET tracer that allows for noninvasive assessment of tumor proliferation [et al. [feration ,20. In cferation . In our feration . As uptaferation . The nonferation . To incrferation ,35. A prferation . Kinetic [et al.  proposedModern MRI techniques are being increasingly used to improve the sensitivity and specificity of tumor diagnostics; these techniques offer possibilities for the detection of functional information. MR spectroscopy (MRS) can assess tumor metabolism and physiology and perfusion-weighted imaging (PWI) can assess vascular integrity and function. Histopathologically, radiation necrosis is characterized by endothelial damage and fibrinoid necrosis, whereas recurrent tumor is characterized by increased microvasculature. A recent study showed that regional cerebral blood volume (rCBV) measurements to be equivalent to MET-PET in the follow-up of patients with high-grade gliomas . No studp < 0.05) and the average T/N ratio of recurrent gliomas (7.03 ± 2.51) was significantly higher than that of necrotic lesions (4.70 ± 0.72) on FLT-PET (p < 0.05). Again, the number is small and the results are preliminary. Further studies involving a larger number of treatment-induced lesions and kinetic analysis are necessary for accurate evaluation of the specificity of FLT-PET.This study has several limitations. It has a small number of treatment-induced necrotic lesions (n = 6) and the final diagnosis was made by clinical and radiological follow-up in eight of 21 cases. When we evaluate 13 patients (10 recurrent gliomas and three necrotic lesions) whose diagnosis was confirmed with histopathology, the results are similar to those in all patients. The average SUVmax was not significantly different between recurrent gliomas and necrotic lesions on either MET-PET or FLT-PET. The average T/N ratio of recurrent gliomas (3.70 ± 0.96) was significantly higher than that of necrotic lesions (2.54 ± 0.56) on MET-PET  were included in this retrospective study . Inclusiet al. [14N2. The resultant 11CO2 was reduced to 11C-methanol by lithium aluminum hydride and subsequently converted to 11C-CH3I by the addition of hydrogen iodide by a modified method of Ishiwata et al. [MET and FLT were produced using HM-18 cyclotron . FLT was synthesized using the method described by Machulla et al.  and the a et al.  and the 68Ge rod sources rotating around the head, transmission images of the brain were obtained for 3 min for MET-PET and for 5 min for FLT-PET. A dose of 126–318 MBq  of 11C-MET or 91–337 MBq  of 18F-FLT was injected intravenously. Regional emission images of the brain were obtained for 5 min, beginning 10 min after the 11C-MET injection and for 10 min, beginning 40 min after the 18F-FLT injection.No special dietary instructions were given to the patients before PET examination. Images were acquired with patients in the supine position, resting, with their eyes closed. Using MET and FLT uptakes in the brain lesion were semi-quantitatively assessed by evaluating the standardized uptake value (SUV). The region of interest (ROI) was set manually by an observer around the hottest area of each lesion. The maximum value of SUV (SUVmax) was regarded as the representative value of each lesion. To calculate the lesion-to-normal tissue count density (L/N) ratios, ROI was set on the normal brain parenchyma  and the mean value of SUV (SUVmean) was calculated. The L/N ratio was determined by dividing the SUVmax of the lesion with the SUVmean of the normal brain tissue.P < 0.05 was considered statistically significant.All parametric data were expressed as mean ± SD. The Wilcoxon signed rank test was used to evaluate the difference between MET and FLT in brain lesions. The Mann-Whitney U test was used to evaluate the difference between SUVmax and the L/N ratio of recurrent gliomas and of necrotic lesions. Linear regression analysis was performed to evaluate the relationship between MET and FLT uptake in the lesion. Receiver-operating-characteristics (ROC) curve analysis was used to determine the best index of MET-PET and FLT-PET and compare the differentiation capability between tumor uptake of MET and FLT. PET studies using MET and FLT are useful in the differentiation of recurrent high-grade gliomas from treatment-induced necrotic lesions. However, quantitative values do not appear to be absolute indicators and no complimentary information is provided in the differentiation with simultaneous measurements of MET-PET and FLT-PET.


Drugs and chemicals are easily available in Iran. Therefore, drug abuse and addiction are common . Iran isStreet drugs are being adulterated with lead, steroids, thallium and … for economical benefits ,4. This Coal heroin has been in use in Iran for over 50 years. In 2005, we reported crystal heroin for the first time, which is more potent and it is possible to dissolve in water in room temperature . It relaRecently a new type of heroin opiate has been introduced to heavy abusers in north east Iran Mashhad. According to the clinical features of the addicts that have been referred to Medical Toxicology Centre, Imam Reza Hospital, the euphoric effects of this opiate is reported to be more potent than coal heroin, crystal heroin and crack heroin. It is called ‘’Se Doodi” . It costs 2 to 2.5 times more than crystal heroin.The clinical features are the same as heroin use including sedation, euphoria and myosis. In overdose, a decrease in consciousness level, bradypnea and pinpoint myosis is being observed. Withdrawal symptoms included restlessness, anxiety, insomnia, pain, diarrhea and sneezing. Urinary tests are positive for morphine and negative for meth/amphetamines.This is the first report of this more potent heroin in the scientific literature. Further laboratory tests are needed to evaluate this newly introduced heroin.


Background. Many believe antibiotic use results in a tragedy of the commons, since overuse may lead to antibiotic resistance and limiting use would benefit society. In contrast, mass antibiotic treatment programs are thought to result in community-wide benefits. A survey was conducted to learn the views of infectious disease experts on the individual- and societal-level consequences of antibiotic use. Methods. The survey instrument was designed to elicit opinions on antibiotic use and resistance. It was sent via SurveyMonkey to infectious disease professionals identified through literature searches. Descriptive statistics were used to analyze the data. Results. A total of 1,530 responses were received for a response rate of 9.9%. Nearly all participants believed antibiotic use could result in a tragedy of the commons, at least in certain circumstances (96.0%). Most participants did not believe mass antibiotic treatment programs could produce societal benefits in an antibiotic-free society (91.4%) or in the United States (94.2%), though more believed such programs would benefit antibiotic-free societies compared to the United States (P < 0.001). Conclusions. The experts surveyed believe that antibiotic use can result in a tragedy of the commons and do not believe that mass treatment programs benefit individuals or society. A tragedy of the commons occurs when multiple individuals, acting solely out of self-interest, ultimately exhaust a limited shared resource despite the fact that it is not in the community's long-term interests , 2. AntiAt the same time, mass antibiotic treatment programs have been proposed to reduce morbidity and mortality from infectious diseases in certain communities. For example, the World Health Organization endorses repeated nonspecific, mass antibiotic treatment as a key component of trachoma elimination programs , 17. SucSuch programs have thus been shown to benefit both individuals and the larger society. Yet, concerns about antibiotic resistance, including resistance potentially caused by mass treatment, indicate that there may be a point at which individual and public health interests cross. Understanding when and how this point might occur is an important goal, but mathematical models have yet to clearly define this threshold . In lighIn September 2012, a cross-sectional survey was sent to professionals with expertise in infectious diseases and antibiotic resistance. In order to survey a broad cross-section of such experts, PubMed and Web of Science were searched for articles published on antibiotic resistance and infectious diseases from 2008 to 2012. Emails of corresponding authors were extracted, with duplicates removed. Similarly, infectious disease modelers were targeted by extracting emails of authors who published in one of five journals focused solely on mathematical modeling  on infectious diseases during the same time period. The authors who were identified in the searches and who identified themselves as working in infectious diseases were deemed eligible. Those with invalid email addresses and who had previously opted out of receiving emails from SurveyMonkey were ineligible. The eligibility of nonresponders was difficult to determine with the broad, electronic approach to sampling, but the authors received numerous direct email messages from both responders and nonresponders. As some of these messages indicated ineligibility for survey participation, these messages were tracked and categorized to help provide some inference about the eligibility of nonresponders.The 18-item survey consisted of Likert items and multiple choice questions designed to elicit opinions on the individual- and societal-level consequences of antibiotic use and resistance . The email message contained a link to the survey and indicated the nature of the survey, that participation was voluntary and that responses would be anonymous. The survey was sent once to the entire group of potential participants and remained open for one week. Recipient responses and inquiries sent directly to the investigators were tracked and categorized.After the UCSF Institutional Review Board granted the study's exemption of approval, the survey was disseminated by email via SurveyMonkey , or the R program . Multiple statistical comparisons were made, so The literature search identified 16,575 unique email addresses. After removing email addresses that were invalid or that had opted out of receiving email from SurveyMonkey, the survey was sent to 15,508 email addresses. A total of 1,530 responses were received for a response rate of 9.9%. The investigators received 129 direct emails, of which 31 (24.0%) indicated the recipient was out of the office, 22 (17.1%) indicated the recipient was not an infectious disease expert, and 16 (12.4%) indicated the survey could not be completed because the link was already closed. The remaining 60 (46.5%) emails included a variety of comments and questions about the survey itself.P < 0.001). Participants generally believed that either antibiotic-resistant strains spread more easily in a population (39.7%) or that both resistant and susceptible strains spread equally well (43.0%).A summary of responses by area of work is shown in P < 0.001) and believed patient wellbeing to be the most important consideration in deciding whether to prescribe antibiotics (P < 0.001). Though not significant, more modelers believed that antibiotic-susceptible strains spread more easily than antibiotic-resistant strains . Additionally, a greater proportion of those working in clinical care responded that antibiotic-susceptible strains were more virulent than other groups .Overall, most responses did not vary significantly by area of work, though a few differences were noted . CompareP < 0.001) and that limiting the use of antibiotics would benefit society (P < 0.001). These participants also tended to believe that antibiotic resistance is a major public health problem (P = 0.007), that an individual decision to use antibiotics impacts population-level resistance (P = 0.02), and that physicians should weigh benefits to the individual against harm to society before prescribing (P = 0.004). Those who believed antibiotic use would never result in a tragedy of the commons were more likely to believe that physicians should only consider the needs of the patient when prescribing antibiotics (P < 0.001) and that antibiotic-susceptible and antibiotic-resistant strains spread equally well in populations (P < 0.001). This group also tended to respond that these strains are equally virulent (P = 0.003), although the association is not significant.The majority of participants believed that antibiotic use could result in a tragedy of the commons , with 72Many suggest that antibiotic use results in a tragedy of the commons –5. In otIn our survey, most respondents believed such a conflict between individual and societal goals could result from antibiotic use. Multiple questions were used to elicit opinions on this conflict, all of which indicated similar beliefs. Though this survey was not designed to detail the specific requirements for this scenario to occur, it does provide some evidence that infectious disease professionals believe that antibiotic use can lead to a tragedy of the commons. This was seen across disciplines and the majority of respondents appeared to agree with previous models that require specific circumstances for a tragedy of the commons to occur. It is, however, difficult to know whether those who indicated that a tragedy of the commons could occur in “certain circumstances” responded this way because they had specific scenarios in mind or because it was the most neutral response option available. Despite this, 42.2% responded that they believed this could occur “always” or “typically.”Most of those surveyed here indicated a belief in no benefits from mass treatment for either individuals or society. Yet, previous studies have shown that mass treatment can result in both individual- and community-level benefits , 21–26. Some variations were noted among responses by area of work. Those working in clinical care were more likely to think that patient well-being is the most important consideration when prescribing antibiotics also that physicians should consider societal effects of antibiotics when making such decisions. These results agree with previous surveys that indicated a high level of physician awareness of the societal consequences of antibiotic resistance along with the practical nature of the importance of individual patient well-being .Our results largely agreed with those of previous surveys that were conducted to assess knowledge, attitudes, and perceptions of physicians on antibiotic use and resistance in clinical settings. These studies also found that physicians believe antibiotic resistance is a significant public health problem and agree antibiotic overuse contributes to its development , 34–37. Strengths of this study include the large, diverse sample and the consideration of reliability and validity in the survey design. The questions were developed in light of previous surveys and used variations of previous survey questions with similar resulting responses. The tragedy of the commons questions were also asked in multiple ways to provide evidence of validity.This study suffers from several limitations. Though the low response rate was expected from our broad approach, the ability to generalize from these results is necessarily limited. We tracked direct emails from potential participants to provide some inference about those of unknown eligibility and found that a number of recipients were incorrectly contacted or could not respond during the survey period. As we did not collect author names, we were unable to prevent authors from receiving and responding to the survey more than once if they had multiple email addresses. Also, though the majority of publications identified in the literature search were in English, it is possible that language was a barrier to completing the survey for some of the selected authors.The survey questions and format themselves are also potential limitations. We favored a general approach over a focus on specific antibiotics and infections, and this lack of context may have influenced responses. The broad phrasing of the questions pertaining to mass antibiotic treatment should also be considered when interpreting responses. Responses might have differed if specific scenarios, such as mass azithromycin treatment for the prevention of trachoma in sub-Saharan Africa, had been proposed. The phrasing of other questions may have affected the resulting responses as well. For example, if the question, “Do you believe that antibiotic use results in a tragedy of the commons?,” was worded in a more neutral manner, perhaps there would have been a different distribution of responses. We also focused on clinical settings despite the massive use of antibiotics in agricultural settings. The simplicity of the survey format was not conducive to the expression of complex ideas and this lack of complexity should be considered when interpreting results.In conclusion, we found that nearly half of infectious disease experts believed that antibiotic use typically results in a tragedy of the commons. This is somewhat at odds with previous mathematical modeling studies that have only rarely found a tragedy of the commons. Models may not be incorporating the insight of these surveyed experts. On the other hand, a true tragedy of the commons may be more elusive than the experts believe. Future studies could assess the specific circumstances in which antibiotic use could result in a tragedy of the commons, either through transmission models or perhaps even community-randomized studies in the appropriate context.


Perception is fundamental in the fight against stigmatization of people living with HIV/AIDS (PLHIV). Perception generally influences discriminatory attitudes towards PLHIV which exacerbates their problems and quickens the degeneration of the disease from HIV to AIDS. This study examined the Anambra people's perception and knowledge of HIV/AIDS with the goal of creating knowledge on these issues in order to design effective intervention programmes towards the reduction of social stigmatization associated with the pandemic. The study was carried out in Idemmili North and Oyi local government areas of Anambra State. Qualitative and quantitative methodologies were used to elicit information from respondents who were adult males and females of 18 years and above. The research instruments were questionnaires and in-depth interview schedule. Questionnaires were administered on 1000 respondents while 13 people were interviewed in-depth. Analysis of quantitative data were conducted by using the Statistical package for Social Sciences. Univariate analysis in the form of frequencies were conducted which generated the distribution of respondents across the research variables. Furthermore, multivariate analysis were conducted to test the hypotheses and sought for relationships among variables. The qualitative data were reported in themes based on the research objectives and were analysed jointly with the quantitative data. The findings were that majority of the respondents viewed HIV/AIDS as a disease that afflict immoral people and as a punishment from God. Only a handful of them saw the disease as a disease that could afflict anybody. Also, many of the respondents said that AIDS is real but showed a low level of knowledge. It was further indicated that there were significant relationships between educational level, sex, occupation, income influence perception and peoples' reactions to HIV positive status of a relative while there were no significant relationships between these variables and knowledge of HIV/AIDS. It was concluded that these negative perceptions were as a result of the people's low level of knowledge and cultural belief systems, which see a strange illness as punishment from God for disobedience. Furthermore, the fact that most of the socio-economic characteristics of the respondents had significant relationship with perception and reaction to HIV was an indication that most people in the study area had a uniform perception. It was also an indication that government HIV/AIDS awareness programmes were not effective. It was recommended that strategies for effective HIV educational programme should be sought and carried out in the study area. Effective intervention programme have the power to change behaviours and would likely change the people's negative perception and low level of knowledge of HIV/AIDS, thereby reducing stigmatization of people living with HIV/AIDS. The perception of HIV/AIDS has been a big problem owing to the its central place in the discrimination, stigmatization and attitudes towards people living with HIV/AIDS (PLHIV) throughout the world. A 2004 report from UNAIDS projected that more than 80 million Africans could die from AIDS and infections could soar to 90 million or more than 10% of the continents population. Presently, Africa accounts for 90% of infected babies in the world. The more number of women living with HIV/AIDS in Africa is a result of certain cultural practices and the unequal gender relations, which render women and girls vulnerable to STDs including HIV/AIDS. At the onset of the HIV/AIDS pandemic, more males were infected but the trend has been reversed due to these cultural practices .According to Low level of knowledge of the disease has also been indicated as one of the problems associated with HIV perception and misconceptions. In a study of Barbing saloon operators in Sokoto, Nigeria, Owing to the fact that HIV/AIDS is to some extent a behavioural disease, PLHIV have been perceived by many as immoral people  ignoring the link between human action and socio-cultural factors. Under this situation, people's attention could be turned away from critical questions that must be understood only by examining the socio-cultural context of behaviour and this is the gap the present study is addressing. The study is addressing this gap by studying people in their particular society instead of individuals who came to live in towns from different cultural contexts. There is, therefore, need to explore peoples' perception of HIV/AIDS in the socio-cultural context of the Anambra Igbo because it is believed that the socio-cultural context influences perception of HIV/AIDS. Furthermore, knowing their perception as a people would inform the kind of intervention programmes that would be effective in the bid to reduce negative perception and reduce stigma in order to contain the epidemic.The study focused on Anambra because Anambra State was identified  as one oThis study was carried out among the Igbo people of Anambra State, Nigeria. The Igbo people live in the east of the River Niger and they speak the Igbo language. They are known for their industry, doggedness, business acumen, hospitality and a strong belief in their cultural practices and their ancestors. They are traditionally farmers and petty traders but some are now civil servants. They farm at the subsistence level and live communally. The Igbos practice African traditional religion but many are now Christians due to the influence of Christianity and Westernization. Interestingly, this does not stop the people from conducting their traditional festivals and rituals and observing their cultural practices and beliefs and this makes the people to combine Christianity and traditional religion, making it difficult to tell who is a Christian and who is a traditional religious worshipper. The African traditional religion as practised in the area is so pervasive that every activity  is embedded in it. This is why divination is very central to health seeking and healing in the area. Divination is the main means of diagnoses. However, in recent times, divination is combined with hospital care. The welfare system in the study area is mainly the communal life led by community members; supporting one another when they are in need. There is no government structure or policy with relevance to PLHIV in the study area.Politically, Anambra people traditionally do not have a centralized system of government. The power is in the hands of the elders who are also the kingmakers and who take the opinion of the majority into consideration before taking decisions. Kings are chosen by the people and they work for the benefit of the people at community level and their power is moderated by the elders. One can describe their style of government as republican. However, at the state level, there is a state governor who represents the state at the federal level. Many communities in Anambra State are rural with the exception of few towns that can be called urban. The socio-cultural context of Anambra state is akin to what is obtained in many parts of Nigeria, West Africa and other sub-Saharan African countries in the sense that there is hardly any place in sub-Saharan Africa that one cannot find the kind of economic, political and religious arrangement practised by Anambra people. However, Anambra is distinct in the sense that their strong attachment to their cultural and religious beliefs is so pronounced that it influences their every activity, including their perception of HIV/AIDS.In this study, perception of HIV/AIDS was conceived as a product of the traditional belief systems of the people and the definitions of the situation of the people as informed by their cultural and environmental factors and level of knowledge.Perception is the process by which organisms interpret and organize sensation to produce a meaningful experience of the world . PerceptThe theoretical framework for this study was the action frame of reference , which pWeber postulated that cultural values circumscribe and direct social action and as such, another main defining agency is the community. Owing to Weber's overt emphasis on individual meaning, Talcott Parsons Voluntaristic Social Action Theory was employed to strengthen the shared meaning aspect of human action, which is the main force in individual behaviour. Parson's Voluntaristic Action Theory is a variant of the functionalist perspective. This theory emphasizes constraint of individual within particular customs and values. This helps to explain human behaviour with regard to socio-cultural factors and their influence on perceptions and attitudes. Much like Weber's action theory, which asserts the primacy of the society over the individual , it arguThis perspective focuses on the course of action as determined by the conditions of the cultural, physical and social environment; society influences the end which the actor seeks and the means he/she will use in attaining them. Parsons' theory like that of Weber states that action can be explained in the context of the subjective meaning, given to it by the actor and that actions are always directed at the attainment of goals with the choice of the most appropriate method by the actors.Applying action theory to the study of perception of Anambra people to HIV/AIDS and PLHIV, the assumption is that social action  must arise from the definition of the situation, which is to a great extent culturally defined. That is to say that how the people define (perceive) the HIV/AIDS disease and people living with it is determined by the cultural beliefs of the people. This definition of the situation also influences the behaviour of PLHIV. It is this culture's ability to define the situation for the person that is responsible for these uniformities in behaviour of a particular people (in this case Anambra people's perception of HIV/AIDS).Hypothesis 10: There is no significant relationship between socioeco- nomic characteristics of respondents and knowledge of HIV/AIDS.HHypothesis 20: There is no significant relationship between socioeco- nomic characteristics of respondents and perception of HIV/AIDS.HHypothesis 30: There is no significant relationship between socioeco- nomic characteristics of respondents and reaction if a relative tests positive for HIV/AIDS.HThe study employed qualitative and quantitative data collection methods to generate data for the examination of perceptions of HIV/AIDS in the study area. The independent variables are age, sex, educational level and marital status. In order to get a deep insight into the study problem, in-depth interviews were conducted to complement data from the survey. The combined use of these methods strengthened the result of the research because the weakness of one method was strengthened by the strength of the other.In selecting respondents for the administration of questionnaires, Household census was carried out in three purposively selected communities in each local government area . These communities are the three biggest communities in each of the selected local government and as such are the microcosm of the Local Government Areas. All the households in each selected community were listed serially to form the sampling frame. Systematic random technique was used in selecting every fifth household. The systematic random method has the strength of making the sample more representative of the population. In the selected households, questionnaires were administered on adult males and females (18 years and above). In each selected household, there was balloting  and any of the adults in the household that picks yes was given the questionnaire. This means that only one respondent was chosen from each selected household.Four university graduates of the social sciences were recruited and trained as research assistants for the data collection. A total of 1000 questionnaires were administered on 1000 respondents and 914 were completed successfully and analysed. The qualitative methods for the study (in-depth interviews) were conducted on 6 caregivers and 6 opinion leaders (12 people). Participation in the interviews was voluntary.The data collection was carried out between February 2009 and July 2009. Before the commencement of the data collection, a short proposal was written and submitted to the ethical committee of the University of Ibadan/University College Hospital, Ibadan which duly approved the research project. Also efforts at informed consent were made by contacting the community leaders and having a series of meetings with them. During the meetings, the nature and purpose of the research were explained to them. They were also assured that all information gathered during the data collection would be kept confidential and that no one would come to any harm because of it. The community leaders then called a meeting of all the villagers and introduced the research team to them and assured them of confidentiality of their opinions and their safety. The research team then used this opportunity to seek the consent of the villagers and explained every thing about the research to them. The villagers unanimously agreed to participate in the research and this paved the way for a hitch-free research. Before the commencement of the research proper, a pilot qualitative study was carried out in January 2009 administering 40 questionnaires and conducting four interviews to elicit information from respondents based on the objectives of the research. The result of this study helped in designing the questionnaires and the interview guide. The questions in the questionnaires and interview guide fill the gap in the previous research on the subject, in the sense that the previous research on the subject was mainly on the individual level of perception, ignoring the socio-cultural context of individual behaviour.For the in-depth interviews, the members of the communities identified opinion leaders  in their communities. Opinion leaders are men and women of integrity in the villages. The people have great respect for them and anything they say is taken seriously without any argument from the people. Achieving the status of an opinion leader does not happen in one day. Opinion leaders have built their reputation over time through good deeds, honesty, hard work and they handle community projects as if it is their personal project and by rendering help to members of the community. They have, therefore, through these means endeared themselves to the members of the community. They are, therefore, trusted and respected. The cultural significance of opinion leaders is that their opinion represents the opinion of the people. As such, opinion leaders by virtue of their position can conveniently tell the opinion of the people because they have constant and daily contact with the people and they hear and know what the people need or can say on any issue. Also the people trust them and can tell them their inner most feelings. The opinion leaders are, therefore, the mouthpiece of the people. The opinion leaders were reached in their family homes and the participation was voluntary.Qualitative data generated through In-depth interviews were analysed using ethnographic software for qualitative data analysis version 0.5. Responses were arranged thematically based on the objectives. Analyses of quantitative data were both descriptive and inferential, using SPSS software version 11.1 to enter the data in the system. Univariate analysis in the form of frequencies and percentages contributed to understanding of the distribution of each variable across survey respondents. Multivariate analyses were conducted using a one-way analysis of variance (ANOVA) statistics to test for categorical factors and to establish relationship between dependent and independent variables. In the end, both quantitative and qualitative data were analysed jointly by using the qualitative data to support findings from the quantitative data.Systematic sampling method was used because it has the strength of making the sample more representative of the population. By choosing every fifth household, it makes it possible for the sample to spread out so that more areas were covered which helped to include more households instead of choosing only people who live very close to one another. Using the systematic sampling technique made it possible to give every household equal opportunity to be selected in the sampling frame.In order to minimize bias/errors, objective sampling technique was used. Systematic sampling technique is a random sampling technique which minimizes bias/errors in the conduct of research. This made it possible for every household in the study area to have equal chance of being selected and during the final selection of the participants, balloting was carried out within the household which also gave every adult member of the family an equal chance of being selected. Also, before the commencement of the study proper, a pilot qualitative study was carried out in January 2009 in which eight in-depth interviews were conducted to elicit information from respondents based on the objectives of the study. The result of this study helped in designing the questionnaires and the interview guide. The interview questions for the pilot study originated from the literature reviews on HIV/AIDS care in Nigeria/Africa. Furthermore, in the recruitment of the research assistants, it was ensured that the four of them were social science graduates who had previously conducted field study in social sciences and had acquired experience in this regard. Apart from this, the research assistants were trained for the purpose of this study using the research instruments as a training manual. This was to ensure uniformity in the data collected. Also, some of the participants were visited a number of times to retrieve the questionnaires. This was in order to reduce the attrition rate.These age categories were just used to describe the age distribution of the respondents. I am only interested in description and inferential statistics and not the dispersal analysis of the respondents.This table showed the social, economic and demographic features of the respondents, using the following variables: age, marital status, educational level, religion, occupation and sex. The people's knowledge of HIV/AIDS was explored because it was believed that their knowledge of HIV/AIDS influenced their perception of HIV/AIDS.Furthermore, data from the in-depth interviews showed that many people in the study area did not know much about the disease. For instance, a male informant said that the disease is so strange that they feel that someone can contract it through the air. This great fear of contraction of the infection means that many of the people would not want to come near or have anything to do with PLHIV. This low level of knowledge affects perception and inhibits how PLHIV cope with the disease. Also during an interview session, an opinion leader said that he did not believe that AIDS is real. To him, it was the white man's propaganda to curb men's libido. He maintained that he had not seen anybody who said he/she had AIDS. These responses showed lack of knowledge of the disease which were likely to affect the people's perception.According to According to According to a male informant:In most cases, the family of PLHIV kept him/her in one room and would be taking care of the person by providing his/her needs as much as possible. They accompany him to the herbalist or hospital and they tell outsiders that the person travelled or that he/she is suffering from typhoid fever or poison. No family ever mentions that their family member is living with HIV/AIDS because the shame would be on the entire family.A male respondent during one of the interview sessions indicated, ‘If my relation is HIV positive, I can only contribute money for his care but cannot go near him/her because I would not like the sight.’A female opinion leader also indicated that it is difficult to even come near PLHIV, let alone trying to help them. If my family member is living with HIV/AIDS, I would never mention it to anybody outside the family. This is because it is a big shame for all the members of the family. According to her, it is a big shame for the family that one of their own is suffering from a disease of immoral people meaning that the entire family members are likely to be immoral people.Furthermore, a mother of a widow living with HIV/AIDS said that her family kept her daughter in one room and they were catering for her needs. They tried as much as possible to take care of her, provide her needs, counsel her and assure her that her children would be taken care of even if she died.The essence of tests of hypotheses is to validate the hypotheses that are found to be true and reject those that are found to be false. In any social research, Hypothesis provides explanation for certain facts and the relationships between variables.0) if the F-value  is less than the calculated table value and if the p-value is > .05. This will indicate that there is no significant relationship between the variables. On the other hand, null hypothesis (H0) would be rejected if the calculated F-value is greater than the table value; in this case, the alternative hypothesis (H1) would be accepted.The decision rule is to accept the null hypothesis  of respondents and knowledge of HIV/AIDS.’ To test this hypothesis, data collected on socio-economic characteristics of respondents and the knowledge of HIV/AIDS were subjected to One-way Analysis of Variance (ANOVA).p ≤ .05 level of significance. As shown in the table, the result of the analysis for marital status revealed that the Mean Squares between Groups and Within Groups were 4.728 and 0.935, respectively . These yielded the −Fval of 5.055 and F−tab of 19.50 which was significant at p < .05 level of significance . Therefore, from the statistical analysis below, the null hypothesis (H0) was rejected and alternative hypothesis (H1) accepted. This meant that there was a significant relationship between marital status and knowledge of HIV/AIDS.In p ≤ .05 level of significance. The result of the analysis for highest educational attainment indicated that the Mean Squares between Groups and Within Groups were 2.448 and 1.562, respectively, . These yielded the F−val of 1.562 and F−tab of 19.50 which was not significant at p < .05 level of significance . Therefore, from the statistical analysis below, the null hypothesis (H0) was accepted. This meant that there was no significant relationship between the educational level and the knowledge of HIV/AIDS.Also shown is the descriptive analysis of one-way ANOVA on the relationship between educational level of respondents and knowledge of HIV/AIDS in Anambra, Nigeria at p < .05 level of significance is shown F−val of 3.551 and F−tab of 19.50 which was significant at the p < .05 level of significance  in-spite of the fact that the F−tab was greater than F−val, suggesting a weak significant relationship. Therefore, the null hypothesis (H0) was rejected and alternative hypothesis (H1) accepted. This meant that there was a significant relationship between sex and knowledge of HIV/AIDS.A one-way ANOVA on the relationshipbetween sex of the respondents and knowledge of HIV/AIDS in Anambra, Nigeria at F−tab for these variables were greater than their F−val and p > .05, which was an indication of no significant relationship between these variables and knowledge of HIV/AIDS.Furthermore, using ANOVA, 0Test of Hypothesis 2: H‘There is no significant relationship between socio-economic characteristics  of respondents and perception of HIV/AIDS.’ To test this hypothesis, data collected on socio-economic characteristics of respondents and the perception of HIV/AIDS were subjected to One-way Analysis of Variance (ANOVA).p < .05 level of significance. As shown in the table, the result of the analysis for marital status shows that the mean Squares between groups and within groups were 5.596 and 0.926, respectively . These yielded the F−val of 6.044 and F−tab of 5.63 which were significant at p < .05 level of significance . Therefore, from the statistical analysis below, the null hypothesis (H0) was rejected and alternative hypothesis (H1) accepted. This meant that there was a significant relationship between marital status and perception of HIV/AIDS.p < .05 level of significance.In the same vein, the relationship between educational level, sex and occupation and perception of HIV/AIDS were found to be significant at F−tab for this variable was greater than F−val and p > .05 which was an indication of no significant relationship between religious affiliation and perception of HIV/AIDS.However, using ANOVA, 0Test of Hypothesis 3: H‘There is no significant relationship between socio-economic characteristics  of respondents and their reactions if a relative tests positive for HIV/AIDS.' To test this hypothesis, data collected on socio-economic characteristics of respondents and their reaction if a relative tests positive for HIV/AIDS were subjected to One-way Analysis of Variance (ANOVA).p < .05 level of significance. The result of the analysis for marital status showed that the Mean Squares between groups and within groups were 1.364 and 0.942, respectively . These yielded the F−val of 1.447 and F−tab of 8.53 which was not significant at p < .05 level of significance . Therefore, from the statistical analysis below, the null hypothesis (H0) was accepted. This meant that there was no significant relationship between marital status and reaction if a relative tests positive for HIV/AIDS.The descriptive analysis of one-way ANOVA on the relationship between socio-economic characteristics of respondents and their reactions is shown in p < .05 level of significance with the mean squares between groups and within groups of 30.220 and 1.474, respectively . These yielded the F−val of 20.505 and F−tab of 8.53 which was significant at p < .05 level of significance .However, ANOVA on the relationship between educational level and reaction is a relative tests positive for HIV/AIDS was significant at p < .05 level of significance.In the same vein, the relationship between sex, occupation and income and reaction of respondents if a relative tests positive for HIV/AIDS were found to be significant at t-test was conducted. The ANOVA indicated a significant relationship between sex and perception of HIV/AIDS. Therefore, in order to know which sex has more positive perception of HIV/AIDS, The socio-demographic characteristics of the respondents showed that a majority were secondary school graduates meaning that many of them were not highly educated which had serious implications for their perception of HIV/AIDS. The low level of divorce and separation in the area can be attributed to the marriage pattern in the area in which the marriage relationship is between two families and there is no room for divorce even after the death of a spouse.Also, many of the respondents defined HIV/AIDS as a disease that afflict immoral people. This perception could be attributed to the fact that many of the respondents saw sexual intercourse as the only way through which HIV/AIDS could be contracted. This is because promiscuity is frowned at in the study area and as such, there is no pity for a person suffering from any disease that is sexually transmitted in nature. This lack of pity is also part of the negative perception of the disease. This corroborates The study indicated that many of the respondents saw HIV/AIDS as real, but their level of knowledge of the disease was quite shallow considering that many of them do not feel that everybody was at risk and many also indicated that HIV is contracted through shaking of hands and some even indicated that they were using medicine to protect themselves. This signifies a low level of knowledge which influences the perception of the disease. This corroborates Furthermore, the result of the tested hypotheses showed that only marital status was significant for the knowledge of HIV/AIDS. Others socio-demographic variables were not significant which was an indication that a person's socio-demographic status does not influence knowledge of HIV/AIDS in the study area. This corroborated The result of Hypothesis 3 showed that the relationship between marital status and respondents' reaction if a relative tested positive for HIV was not significant. This could be because the blood relationship is very strong in these areas, which implies that no matter a person's marital status, he/she is more likely to care for a sick relative. Apart from marital status, all the other variables  had a significant relationship with respondents’ reactions if a relative tested positive for HIV/AIDS. The reason for the influence of income on people's reaction to a relative's HIV positive status could be because poverty has a way of making people to run away from responsibility because a poor person may not have anything to offer a sick relation. This inability to afford anything may make the person to react negatively to a relative with HIV/AIDS. In the same vein, religion's influence on people's reaction to a relative's HIV positive status could result in the fact that religious affiliation calls for one to be easily sympathetic to the plight of others.Furthermore, females were found to have a more positive perception of HIV/AIDS than males. This could result in the fact that females are usually more sympathetic to people who are suffering. Moreover, in the study area, every female views every child in the community as her child and this is also exhibited during illness.Health workers have to implement a number of community awareness programmes to make PLWHIV and their families more acceptable to their communities and to disabuse the minds of the people of their negative perception of the disease. Therefore, a cultural and family approach is needed in HIV/AIDS prevention and care and in a bid to change the negative perception of the disease in Africa. Behavioural analysis and intervention points of entry into a community should focus on culture rather than on individual behaviours. The first step that should be taken by health workers in the area should be to mount HIV/AIDS educational campaigns and target communities through their community leaders. The health workers should educate the communities on how HIV is contacted so as to disabuse the peoples' mind of their negative perceptions of HIV/AIDS. This knowledge would help families to bring PLWHIV/AIDS to hospitals instead of confining them at home. Also, because it is difficult to reach PLHIV in the study area, health workers should find a way of using village informants to reach PLHIV and their families. Furthermore, the implication for prevention efforts is that families should be educated on the routes of contact and how to avoid being infected. This would help in the change of perception and attitudes generally.In conclusion, the study found a negative perception and a low level of knowledge among the Igbo. The respondents saw HIV/AIDS as a punishment from God and as a disease of immoral people and this was a product of the people's cultural and religious beliefs. These perceptions influenced how PLHIV in the area were treated. It also influenced the behaviour of infected persons. Seeing the disease as a punishment from God and disease of immoral people had the serious implications of making the people not to have any form of pity for PLHIV. This also meant that PLHIV in the area hardly get help. It, therefore, followed that PLHIV in the study area would degenerate quickly from HIV to AIDS as they did not have much support. Furthermore, the fact that marital status and other socio-economic characteristics of the respondents influenced perception and reaction if a relation tests positive for HIV/AIDS was an indication of a uniform perception which meant that the people reacts alike to the issue irrespective of their social status. This was a sign that changing this negative perception and reducing stigma was likely to be a difficult task which would constitute a hindrance towards the containment of the pandemic.It was, therefore, recommended that more awareness campaigns should be done in the study area to enlighten the people on HIV/AIDS and how it could be contracted or transmitted. This would increase their level of knowledge of the disease and would change this negative perception.


We evaluated the patient satisfaction with HIV/AIDS care and treatment and its determinants across levels of health service administration in Vietnam.We interviewed 1016 patients at 7 hospitals and health centers in three epicenters, including Hanoi, Hai Phong, and Ho Chi Minh City. The Satisfaction with HIV/AIDS Treatment Interview Scale (SATIS) was developed, and 3 dimensions were constructed using factor analysis, namely “Quality and Convenience”; “Availability and Responsiveness”; and “Competence of health care workers”.In a band score of , the mean scores of all domains were large; it was the highest in “Competence of health workers” (9.34±0.84), and the lowest in “Quality and Convenience” (9.03±1.04). The percentages of respondents completely satisfied with overall service quality and treatment outcomes were 42.4% and 18.8%, respectively. In multivariate analysis, factors related to higher satisfaction included female sex, older age, and living with spouses or partners. Meanwhile, lower satisfaction was found among patients who were attending provincial and district clinics; in the richest group; had higher CD4 count; and drug users.This study highlights the importance of improving the quality of HIV/AIDS services at the provincial and district clinics. Potential strategies include capacity building for health workers, integrative service delivery, engagements of family members in treatment supports, and additional attention and comprehensive care for drug users with HIV/AIDS. Over the past decade, the rapid expansion of antiretroviral treatment (ART) in Africa and Asia has dramatically reduced HIV-related morbidity and mortality, and transformed HIV into a chronic illness Since 2011, Vietnam has been taking the lead in universal access to comprehensive HIV services as the first country pilots the Treatment 2.0 In developed countries, measuring patient-reported outcomes and satisfaction is central to designing and evaluating modern healthcare services and delivery system Data use was approved by the Authority of HIV/AIDS Control, Ministry of Health of Vietnam. Ethical approval was granted by the University of Alberta's Health Research Ethics Board. Written informed consent was obtained from all participants after clearly introducing the survey. Respondents could refuse to participate or withdraw from the interview at any time, and this did not affect their continuation of health care services. Confidentiality was assured using codes of patient's information, and secured storage was prepared for both paper questionnaires and electronic dataset.The 2012 Vietnam HIV Services Users Survey (HSUS) was conducted in three epicenters of Vietnam, including Ha Noi, Hai Phong, and Ho Chi Minh City We conducted a cross-sectional survey in 1016 patients at 07 ART clinics , including 1 central hospital with 201 patients (20%), 3 provincial hospitals with 406 patients (40%), and 3 district health centers with 409 patients (40%). Eligible subjects included those patients who were diagnosed HIV-positive, registered for HIV/AIDS care or treatment at selected sites, and were present at the clinics during the period of the study. This included both inpatients and outpatients who came for receiving regular check-ups and ARV medications. Selection of patients was basically convenient given the fact that we could not develop a sample frame of HIV/AIDS individuals due to confidentiality. There was only the total number of patients managed at each hospital and province. The proportion of sample by cities was 60% from Hanoi, 20% from Hai Phong, and 20% from Ho Chi Minh City. Well-trained investigators came to each HIV/AIDS out-patient or in-patient department, clearly explained the purposes and study information, and invited patients to participate in the study. To reduce information bias, these interviewers were not from the same hospital where the patients were approached.In face-to-face interviews, we collected information about socioeconomic and HIV-related characteristics of patients and their satisfaction with HIV/AIDS treatment services. The socioeconomic characteristics included age, gender, marital status, religion, education level, employment, and income. Household's monthly income was self-reported by summing up all sources of income from each member in 2011 and then stratified into five quintiles. As for clinical characteristic, HIV/AIDS stages, history of drug use, the duration of knowing their HIV status, and duration of ART were recorded.Development of the Satisfaction with HIV/AIDS Treatment Interview Scale (SATIS): We developed a measure to assess patients' satisfaction, namely the Satisfaction with HIV/AIDS Treatment Interview Scale (SATIS) following a standard procedure. First, a systematic review of the English literature identified from PubMed searches was conducted to explore candidate measure items of patient satisfaction with HIV/AIDS care and treatment services Exploratory factor analysis was applied to examine the construct validity of the SATIS measurement. These factors were extracted by the principle component analysis at an eigenvalue of 1.0, which was the threshold, defined using the scree test, where the eigenvalue curve flattened out. Orthogonal Varimax rotation with Kaisers' normalization was used to reclassify the measure items in order to increase the interpretability of these factors. The cut-off point for factor loadings was set at 0.40. We had a cross-loading in one item and assigned it to the corresponding domain based on the nature of the questions and the overarching dimension. Internal consistency reliability of measurement was estimated using Cronbach's alpha. Chi-square and ANOVA tests were used to examine the differences between proportions or means. Multivariable linear regression was used to determine factors associated with general satisfaction. We applied a stepwise forward model building strategy which selected variables based on the log-likelihood ratio test at a p-value<0.1, and excluded variables at a p-value>0.2 The baseline demographic characteristics of respondents were summarized in The proportion of respondents who were completely satisfied with different criteria of service quality was the lowest in “Convenience in using medical services” (44.2%) and “Convenience in check-up booking, waiting time, and administrative procedure” (44.6%). Meanwhile, it was the highest in “Competence of health care workers” (52.6%) and “Confidentiality” (60.1%). The average domain score was large across three domains; it was the highest in “Competence of health care workers” (9.34±0.84), and the lowest in “Quality and Convenience” (9.03±1.04) . The perWe developed the SATIS - a specific measure to assess patients' satisfaction with HIV/AIDS care and treatment in the Vietnamese context. Using this instrument, we found a high level of patient satisfaction over three SATIS dimensions, including “Quality and Convenience”, “Availability and Responsiveness”, and “Competence of health care workers”. The measure profile showed that the proportion of complete satisfaction was the highest in health care worker's competence and the lowest in the convenience of services. We determined various factors that influenced patient satisfaction with HIV/AIDS care and treatment services, including levels of the health service administration, socioeconomic status , duration of ART, CD4 cell counts and drug use behavior.Our findings are consistent with previous studies, which assessed patient satisfaction with HIV/AIDS care and treatment services. The convenience in service utilization, including waiting time and administrative procedures, was observed to be lower than other service quality dimensions in both developed and developing countries Treatment 2.0 initiative is to engage community in delivering ART service as well as treatment support interventions. Findings of this study highlight the importance of family members in supporting patients during the course of ART. Those patients who are living with their couples or partners are more satisfied with services' availability and responsiveness; probably, due to better communication and easier utilization of HIV/AIDS services, as well as perceived emotional and psychological supports among drug users Up to now, this is the first study assessing patient satisfaction with HIV/AIDS care and treatment services in various patient groups across levels of health service administration in Vietnam. The study results provide helpful evidence for further expansion of ART services as well as the realization and implementation of the newly introduced Treatment 2.0 initiative in the country. Firstly, there should be cautious steps in decentralizing and integrating ART services to other services at the grassroots level. Services and patients' flow should be managed in a convenient manner, in order to reduce waiting time, simplify administrative procedures, and improve service linkages, referrals, and collaborations. Secondly, additional attention should be paid for ART patients who were drug users. Drug users may have severe co-morbidities that requires various types of health care services and more frequent use The strengths of this study include the use of a standard procedure to develop a contextualized and HIV-specific measure of patient satisfaction with HIV/AIDS care and treatment services. Since, there is no gold standard method of measuring patient satisfaction that might be generalizable across settings; this approach could improve the validity and reliability of our measurement In conclusion, the patient satisfaction at HIV clinics in Vietnam was generally high. However, performance of HIV/AIDS services at the grassroots level of the health system should be improved. Potential strategies include capacity building for health workers, integrative and comprehensive service delivery, and engagements of family members in treatment supports. Regular assessment of services quality and patient-reported outcomes and satisfaction should be carried out for ART monitoring and evaluation.Table S1Satisfaction with HIV/AIDS Treatment Interview Scale (SATIS).(DOCX)Click here for additional data file.