Ehrlichia chaffeensis in lemurs is described. DNA of Ehrlichia chaffeensis was identified by polymerase chain reaction in peripheral blood from six of eight clinically ill lemurs. Organisms were cultured from the blood of one lemur exhibiting clinical and hematologic abnormalities similar to those of humans infected with E. chaffeensis.A naturally occurring infection of  Ehrlichia species comprise an obligate intracellular group within the alpha Proteobacteria –6, but, Lemurs were housed at the Duke University Primate Center in two extended family groups of 9 and 10 animals, respectively. During the months of October 2000 through April 2001, lemurs were housed in wire-enclosed cages averaging 22 x 24 x 8 ft with access to indoor, heated rooms. On May 1, 2001, both groups were released into a 22.5-acre, fenced, mixed pine and deciduous hardwood forest in Durham for the summer.Lemur catta) and one red ruffed lemur (Varecia variegata rubra), ranging in age from 14 months to 17 years. Amblyomma americanum, Rhipicephalus sanguineus, and Dermacentor variabilis adult ticks were found on lemurs at the time of illness, but the numbers of ticks were not quantified.From May 16 to June 25, 2001, anorexia, fever, lethargy, and lymphadenopathy developed in seven ring-tailed lemurs  amplification. Two milliliters of EDTA-anticoagulated blood were maintained at room temperature for attempted isolation of E. chaffeensis–infected lemurs. As normal clinical pathology values for red ruffed lemurs vary minimally from that of normal ring-tailed lemurs described here, data from the eight ill animals were analyzed as a single group rather than as separate species  from 200 μL EDTA blood samples that had been frozen at –80°C. PCR was performed in a two-step method as previously described  with E. canis, whereas infection of vervet monkeys (Cercopithecus pygerythrus) did not induce disease (Macaca mulatta) and baboons (Papio anubis) experimentally infected with A. phagocytophila, but behavioral abnormalities were not observed (A. phagocytophila developed pyrexia, lethargy, neutropenia, thrombocytopenia, anemia, and morulae in monocytes and neutrophils (E. canis, A. phagocytophila, or E. chaffeensis.Previous reports of experimental infections of nonhuman primates with  disease . Neutroptrophils . CollectE. chaffeensis, presumably by A. americanum, disease manifestations very similar to those reported in human patients developed in lemurs in a research colony. For diagnosis, morula may be found in monocytes and lymphocytes in lymph node aspirates. E.chaffeensis can be isolated in tissue culture and E. chaffeensis DNA can be amplified from peripheral EDTA anti-coagulated blood samples. Treatment with doxycycline, the drug of choice for treating human and canine ehrlichiosis, elicits a dramatic clinical and hematologic response. The impact of vector-borne diseases should be considered when working with nonhuman primate colonies maintained in natural environments in tick-endemic areas.In summary, after transmission of


Preparing health workers to confront the HIV/AIDS epidemic is an urgent challenge in Haiti, where the HIV prevalence rate is 2.2% and approximately 10 100 people are taking antiretroviral treatment. There is a critical shortage of doctors in Haiti, leaving nurses as the primary care providers for much of the population. Haiti's approximately 1000 nurses play a leading role in HIV/AIDS prevention, care and treatment. However, nurses do not receive sufficient training at the pre-service level to carry out this important work.To address this issue, the Ministry of Health and Population collaborated with the International Training and Education Center on HIV over a period of 12 months to create a competency-based HIV/AIDS curriculum to be integrated into the 4-year baccalaureate programme of the four national schools of nursing.Using a review of the international health and education literature on HIV/AIDS competencies and various models of curriculum development, a Haiti-based curriculum committee developed expected HIV/AIDS competencies for graduating nurses and then drafted related learning objectives. The committee then mapped these learning objectives to current courses in the nursing curriculum and created an 'HIV/AIDS Teaching Guide' for faculty on how to integrate and achieve these objectives within their current courses. The curriculum committee also created an 'HIV/AIDS Reference Manual' that detailed the relevant HIV/AIDS content that should be taught for each course.All nursing students will now need to demonstrate competency in HIV/AIDS-related knowledge, skills and attitudes during periodic assessment with direct observation of the student performing authentic tasks. Faculty will have the responsibility of developing exercises to address the required objectives and creating assessment tools to demonstrate that their graduates have met the objectives. This activity brought different administrators, nurse leaders and faculty from four geographically dispersed nursing schools to collaborate on a shared goal using a process that could be easily replicated to integrate any new topic in a resource-constrained pre-service institution. It is hoped that this experience provided stakeholders with the experience, skills and motivation to strengthen other domains of the pre-service nursing curriculum, improve the synchronization of didactic and practical training and develop standardized, competency-based examinations for nursing licensure in Haiti. In light of severe physician shortages in the developing world, the World Health Organization's strategic framework for the emergency scale up of antiretroviral therapy (ART) involves training a range of health-care staff to support the delivery and monitoring of HIV/AIDS treatment. 'Task shifting' is the name given to a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers .Task shifting has lead nurses to be heavily involved in performing HIV testing and counselling, assessing patients for ART eligibility, assessing toxicity and treatment failure, and providing patient education, psychosocial support and adherence support . Nurses As nurses are becoming increasingly central points of contact for clinical care of people living with HIV and AIDS (PLWHA), they must first be ensured adequate preparatory education. Scattered reports have shown, however, that most nurses in developing countries are not well prepared during their pre-service education in the knowledge, skills and attitudes needed to provide quality HIV/AIDS-related care ,5.Preparing nurses to confront the HIV/AIDS epidemic is a need in Haiti where the HIV prevalence rate is 2.2% , approxiHaiti has four national nursing schools, graduating approximately 120 registered nurses per year. These schools face under-resourced infrastructure , variable quality of teaching with few classroom instructors prepared to educate, and few clinical instructors and sites available for clinical skills practice. Graduates often must do much of their learning on-the-job during their rotations, under limited supervision. Specific to HIV/AIDS education, a recent assessment revealed that related content is very loosely woven throughout the courses, and that inclusion of HIV is arbitrarily dependent on the interest of the faculty member assigned to the course, with key areas, such as HIV/AIDS counseling, prevention of mother-to-child transmission, and ART adherence, being largely overlooked .Since 2004, the International Training and Education Center on HIV (I-TECH) has worked in Haiti to build capacity to respond to the AIDS epidemic. I-TECH is a collaboration between the University of Washington and University of California San Francisco and was established by the Health Resources and Services Administration (HRSA) in collaboration with the Centers for Disease Control and Prevention (CDC).Direction de Formation et de Perfectionnement en Sciences de la Santé (DFPSS), and I-TECH started a process of integrating current HIV/AIDS knowledge, skills and attitudes into the current curriculum using a competency-based approach. This article details the steps undertaken to develop, integrate and implement the new curriculum.In June 2006, the Haitian Ministry of Health and Population (MSPP), specifically the directorate that is in charge of health science education, the In June 2006, DFPSS and I-TECH convened deans of the four public nursing schools, officials from the Haiti ministries of health and education, and selected education and HIV/AIDS experts to reflect on the status of HIV/AIDS-related education at the nursing schools and how to quickly address new content into an already overloaded curriculum in a resource-strained environment.The stakeholders chose to form two committees – a coordinating committee made up of school heads and ministry officials that would ensure broad-based support and integration of the new topic into the existing curriculum and an eight-member curriculum committee made up of Haitian nurse educators, nurse trainers and one nurse HIV/AIDS expert to draft the new curriculum.Upon review of other international projects and the education literature on various models of curriculum development and integration, stakeholders opted to use a competency-based approach for the integration process.A competency is defined as the blend of skills, abilities, and knowledge needed to perform a specific task . In bothRecent reforms support the application of competency-based education – defining, teaching, and assessing competencies and then assessing student performance in relation to these, thus focusing on the outcome of the education, rather than on the process of the education (applying knowledge and skills rather than merely gaining knowledge) . ExperieA competency-based education model starts by asking the question: What will the nurse do on the job? Once this is known, specifications of learning objectives for instruction are derived. If integrating a new theme into an existing curriculum, these learning objectives can then be mapped to existing courses. Then, appropriate teaching and assessment methods are derived that will ensure mastery of the objectives, and faculty are trained in and oriented to the new curriculum. Finally, evaluation is conducted to ensure that students achieve mastery of the competencies. A schematic representation of this model appears in Figure When the curriculum committee began to design the new curriculum, the initial hurdle was to articulate and reach consensus on the HIV/AIDS competencies relevant for nurses. In-depth discussions among the participating experts at the beginning of the project, who had a good overview of the ongoing HIV/AIDS activities in Haiti, helped to identify a draft list of general competencies. Then, the curriculum committee reviewed HIV competencies relevant for developing country settings, which were drafted by the World Health Organization  and the The committee then defined the associated learning objectives for each sub-competency. Over 350 learning objectives were defined, with each sub-competency having multiple knowledge, skill and attitudinal learning objectives. The committee then mapped each of these objectives to existing courses in the overall nursing curriculum. Hours were not taken from existing courses to specifically make room for the new objectives, nor were additional hours added to the curriculum, but rather, the new HIV/AIDS-related learning objectives were integrated into the current courses. For example, in the Counseling and Communication course, when discussing how to use job aids and demonstrate good interpersonal skills, the faculty member is prompted to use an example of ART adherence counseling.The learning objectives build upon each other at different stages in the curriculum. For example, a student nurse in year 1 will describe the relationship between HIV and nutrition, but by the years 3 and 4, she or he is able to define dietary needs of specific sub-groups of PLWHA and how to educate patients on specific meal preparation.To support faculty with up-to-date HIV/AIDS content, the committee drafted an 'HIV/AIDS Reference Manual' that features evidence-based national and international core content, protocols, and guidelines for faculty to access.The committee also drafted a 'HIV/AIDS Teaching Guide' organized by curriculum year and course, which was approved for dissemination to the nursing schools by the MSPP in November, 2007. For each course, the associated competency and sub-competencies, learning objectives, recommended chapters of the 'Reference Manual' or other materials, learning methods and evaluation methods are listed. An excerpt of a plan for a specific course is shown in Table As noted, a key tenet of competency-based education is moving away from rote memorization or knowledge acquisition to the application of knowledge and skills. As such, the 'Teaching Guide' places great emphasis on a mix of interactive teaching methods to stimulate active student participation, such as case-based learning, role plays, and group discussions. The 'Teaching Guide' ensures integration between theory and practice, as many of the course plans specify practice-based experience with nurse monitors in a clinic setting.Typically, the sole form of assessment in Haiti nursing schools is a final written examination, of essay, short answer or multiple-choice type. However, such examinations tend to reward rote recall of facts and don't assess a student's ability to apply knowledge in practice. The 'Teaching Guide' emphasizes structured observation as an alternative assessment method and emphasizes periodic assessment at regular intervals throughout each course. The final exam for nurses to obtain their license to practice will also be modified to reflect the new competencies.It has been noted that faculty development is probably the single most necessary precursor to the successful implementation and maintenance of curricular reform ,19. UnleOver the next four years, as students progress from Year 1 through Year 4 of the degree program, the HIV/AIDS curriculum will be evaluated formally in all four schools. In addition, data on faculty use of and satisfaction with the curriculum will be collected through semi-structured qualitative interviews and observation, the results of which will be used to identify any weaknesses and needed changes to the Teaching Guide or Reference Manual, as related to the level of difficulty, time allocation, content updates, or other areas. A revision schedule has not been set for the teaching material, as another goal of faculty development will be to build their skills in maintaining their currency in their field and to reflect this in lesson planning.The effect of this change has broad implications for the Haiti nursing education community. All nursing students will now need to demonstrate mastery of HIV/AIDS-related competencies during periodic assessment with direct observation of the learner performing authentic tasks. Using what they learned in the faculty development workshops and the instructions and model exercises in the 'HIV/AIDS Teaching Guide', faculty will have the added responsibility of developing exercises to address the required competencies and creating assessment tools to demonstrate that their graduates have met the competencies. The major challenges in the next step will be creating assessment tools that are reliable, valid, and practical in this developing country setting.There were several lessons learned from the process of developing the HIV competencies and integrating them into an already established broader nursing curriculum. The first lesson was the importance in identifying the right stakeholders for both the coordinating committee and the curriculum working groups. For both groups, bringing a multidisciplinary group of officials, faculty, administrators and HIV experts enriched the process, garnered buy-in, and improved the outcome by virtue of the collaborative process. The curriculum working group was made up of dedicated nurse leaders who were passionate about elevating the profile of nursing education in Haiti and graduating students competent to care for the large number of people living with HIV and AIDS.The second lesson was that this activity brought different nursing schools together to collaborate on a shared goal that was manageable and timely using a process that could be repeated for other aspects of curriculum reform. Haiti's nursing schools face numerous challenges: lack of funds, lack of available clinical mentors, poor infrastructure, lack of curriculum developers, etc. Against this backdrop, other aspects of the overall nursing curriculum program need major reform but addressing only one topic through this systematic process gave the schools a manageable victory. It is hoped that this provided stakeholders with the experience, skills and motivation to strengthen other domains of the pre-service nursing curriculum, improve the synchronization of didactic and practical training, and develop standardized competency-based examinations for nursing licensure in Haiti. Each of these goals is part of the Ministry of Health's strategic plan for 2005–10 [The third lesson was that defining competencies and related learning objectives, though absolutely essential to clarifying what students must learn, was conceptually difficult for the curriculum committee. Even experienced educators may find it challenging to clearly state the knowledge, skills, and attitudes underpinning a competency. Writing clear and measurable learning objectives, particularly attitudinal objectives, was challenging for the committee, and required a great deal of debate and revision.It is necessary to develop the evidence base on the impact of pre-service curriculum strengthening initiatives in developing countries like the one described here . There iIn light of the critical role that nurses play in the care of Haiti's population, investing in pre-service nursing education institutions to improve the quality of HIV/AIDS training is a critical part of increasing the overall quality of HIV/AIDS care and treatment in the country. Education in HIV/AIDS is now an integral part of the four national nursing schools in Haiti. This was achieved using a multi-disciplinary, participatory process that can be applied to future curriculum reform efforts.The authors declare that they have no competing interests.EK provided technical assistance to the nursing committee and drafted the manuscript. NP conceived of the intervention, participated in its coordination, and helped to draft the manuscript. AD supported the technical committee. RD and MP participated in the design and implementation of the intervention. All authors read and approved the final manuscript.


The causes of wide variation in the rates of HIV and AIDS epidemics among Japanese and non-Japanese nationals are not well understood. So, this paper examines the associations and assesses the potential roles of mean age at marriage, and migration in the HIV and AIDS epidemics in Japan. For the purpose, bivariate and multivariate regression analysis have been performed using epidemiological panel data to build up the relationships among overall HIV and AIDS prevalence, mean age at marriage, and migration. The same analyses have done for non-Japanese nationals living with HIV and AIDS separately. These indicators were significantly correlated with mean age at marriage, and migration. Multivariate linear regression analysis identified non-Japanese nationals' HIV and AIDS prevalence and mean age at marriage as the two most prominent factors linked with the national HIV and AIDS epidemics. The findings of this study supported the hypotheses that a high average age at marriage in the population leads to long period of premarital sex and the non-Japanese nationals' high prevalence facilitating the spread of the HIV and AIDS epidemics in Japan. Since the identification of the human immunodeficiency virus (HIV) in the early 1980s, much has been learned about how the virus is transmitted and how it attacks the body's immune system and causes the acquired immune deficiency syndrome (AIDS). The AIDS epidemic has grown on an unprecedented scale in three decades since it was first recognized, and is now considered a global crisis. In 2007, the total number of people living with HIV was 33.2 million, newly infected with HIV was 2.5 million, and AIDS deaths was 2.1 million . While tCurrently, more than 100 million persons move voluntarily within or between nations each year and almost 40 million are either internally displaced or refugees outside their own countries. Many studies have revealed evidence of a potential association between human mobility and the epidemic , especiaA dataset was created by compiling data from two different sources. The total number of HIV and AIDS and the number HIV and AIDS of non-Japanese nationals, and mean age at marriage were collected from MHLW  and the Bivariate and multivariate approaches have been applied in the analysis. Roles of time, mean age at marriage, and migration are examined here in turn.r) were derived to examine direction, strength and significance of linear relationships between the variables included in the study (Table Correlation coefficients (dy Table .r = .341) than the overall HIV prevalence (r = .967). Again for the case of AIDS epidemic, the correlation was slightly lower for the size of AIDS epidemic among non-Japanese nationals (r = .880) than the overall AIDS prevalence (r = .976).The significant similar relationships were found between time and the sizes of the HIV and AIDS epidemics for both the cases. The correlation was considerably lower for the size of the HIV epidemic among non-Japanese nationals (r = .964) and the non-Japanese nationals' share of the epidemic (r = .211) is very lower compared to the former. Again for the case of AIDS epidemic, the correlation was slightly lower for size of the AIDS epidemic among non-Japanese nationals (r = .795) than the overall AIDS prevalence (r = .955).As expected, age at marriage is likely associated with the overall HIV prevalence (r = .973 and r = .960 respectively). But its correlation was significant and slightly lower with the proportion of HIV and AIDS prevalence who are non-Japanese nationals (r = .380 and r = .857 respectively).Migration is the most important issue in HIV and AIDS prevalence perspective. Correlation coefficients show that the higher migration, the greater HIV and AIDS epidemics. However, among the four explanatory variables considered, migration score appeared to have a significant, and the strongest, relationship with the overall HIV and AIDS prevalence . In the set 2 of regression models showed that migration and age at marriage were the more significant predictors compared to non-Japanese nationals' share in the total HIV epidemic (Models 4–7). When non-Japanese nationals' prevalence was included in the model, migration was no longer significant (Model 7), although it was significant independently (Model 5). Finally, age at marriage and non-Japanese nationals HIV prevalence are the most significant predictors for the total prevalence of HIV epidemic in Japan.In the fist two sets of regression models, age at marriage and migration were included, and all these variables were significant predictors of HIV prevalence. For the case of non-Japanese nationals' HIV prevalence, the migration was stronger than that of age at marriage and better explained the model as indicated by the higher values of R2 (Models 8–9). But, when mean age at marriage and migration were included in the models, mean age at marriage was no longer significant (Model 10), although this was significant independently (Model 8). Thus, migration is the more significant for the non-Japanese nationals' AIDS prevalence. The set 4 of regression models showed that migration, and mean age at marriage were the two significant predictors compared with non-Japanese nationals share in the total AIDS epidemic (Models 4–7). When non-Japanese nationals' prevalence was included in the model, migration was no longer significant (Model 14), although this was significant independently (Model 12). As a final point, age at marriage and non-Japanese nationals' AIDS prevalence are the most significant predictors for the total prevalence of AIDS epidemic in Japan.Similarly, in the second two sets of regression models, age at marriage and migration were included, and all these variables were significant predictors of AIDS prevalence. For the case of non-Japanese nationals' AIDS prevalence, the migration was stronger than that of age at marriage and better explained the models independently as indicated by higher values of RGood health is an important component of human wellbeing and the improvements in health and life expectancy are likely to contribute to greater economic growth and human resource development. HIV/AIDS affects not only the infected person, but also his or her family, community, and country. At the household level, people have loss of companionship and income. At the community and national levels, they experience loss of productivity because of absenteeism and deaths. The prevalence of HIV and AIDS are still low and little public attention is given to the epidemic as a serious issue confronting Japanese society. Experts point out that the epidemic may be spreading much more quickly than available figures indicate Figures , 2, 3. VComparing other countries, Japan has three particular characteristics in HIV/AIDS situation: (i) a majority of reported HIV cases is infected through male-to-male sexual conducts, (ii) the higher prevalence rate among the non-Japanese nationals, and (iii) very few reported HIV cases is infected through intravenous drug use (IDU). The people considered being high risk and vulnerable to the epidemics are MSM, migrant workers, CSW and their clients. In the recent years, more than half of new HIV reported cases are infected through male-to-male sexual conducts. The main route of infection was sexual contact, in particular, MSM, which accounted for 63.4% of all PLHIV  greatly exceeded the previous year's figure (529 cases), and represented a record high. Also, the number of Japanese female PLHIV increased from 32 cases in 2005 to 49 cases in 2006. In terms of Japanese male PLHIV, the number of cases resulting from MSM 571 cases) had increased from the previous year (514 cases), representing the highest reported to date. Moreover, there were 173 cases of Japanese males infected through sexual contact with individuals of the opposite sex, up from 161 cases in the previous year. The number of Japanese female PLHIV infected through sexual contact with individuals of the opposite sex increased yearly until 1999, after which the numbers appeared to have stabilized. Figures  of foreign national PLHIV and 51 AIDS patients (12.6%) in Japan. These PLHIV were, in order of those nationalities most frequently reported, from Latin America, Southeast Asia, and the East Asia and Pacific Area excluding Japan. Among foreign AIDS patients, those from Southeast Asia were most frequently reported, followed by Sub-Saharan Africa, and the East Asia and Pacific Area excluding Japan. Looking at regional trends, Tokyo and the Kanto Koshinetu area (excluding Tokyo) remained areas with high levels of infection, representing 528 (55.2%) PLHIV and 211 (52.0%) AIDS patients in 2006. The number of PLHIV increased in Hokkaido, the Tohoku region, the Kanto Koshinetu area, Tokyo, and the Tokai and Kinki regions.The average age at marriage has risen in most industrial countries, especially in Japan . Even countries with less development, or who have come lately to industrialization show a rise in the average age at marriage for women. These statistics may reflect a greater feminist stance in most countries, with more women working and completing college. As well they reflect a trend away from marriage. Which results the considerably change the sexual behaviors among the youth and they participate in more sex with causal friends or multiple partners. In Japan, a network of youth having unprotected sex is rapidly expanding, leading to sharp increases in sexually transmitted infections (STI) and terminations of unplanned pregnancies . As a reThere has been a dramatic change in Japan's sex industry since the 1980's, especially in urban areas, where the traditional CSW is being marginalized by new type who offers manual stimulation, cunnilingus, and fellatia, but not vaginal intercourse. All types CSW are vulnerable population at the higher risk of HIV infection as well as transmission to their partners. The actual reported number of HIV/AIDS cases that involve sex workers is unknown. Japanese youth are actively involved in paid sex. Prostitution has been prohibited in Japan since the enforcement of the Anti-Prostitution Law in 1957. However, the sex industry has never disappeared and has continued to diversify since the 1980s as certain adult entertainment businesses were legitimized under a law regulating their establishments and services. More than 20,000 shops are registered throughout the country and it is said that many more operate illegally . Among tJapan is simultaneously facing crises of exclusion and inclusion. By adopting more stringent laws to exclude foreign workers, it faces tremendous difficulties in coming to terms with its demographic future diminishing population and labor force. Yet because these laws invariably become less effective in stemming the entrance of foreign workers as both Japanese enterprises and recruitment networks find new ways to recruit them, it also perpetuates a system of illegal migration. While perhaps convenient to enterprises wishing to pay very low wages, this risks an equally problematic crisis of inclusion of foreign workers into everyday life accompanying the advent to Japan as a multicultural society. The non-Japanese nationals, most are believed to be migrant workers. Although a smaller portion, migrant workers, especially unregistered non-Japanese nationals without legal status, are similarly vulnerable and seriously at risk of HIV infection. A particularly high number of cases were reported in 1992, but since then the number has leveled off, meaning that this group cannot be used to explain the increasing number of HIV cases in Japan. In this period many women from Asian countries come to Japan as CSW and most of them were infected outside Japan . There aIn Japan, social awareness and public perception about HIV/AIDS is extremely low and few people voluntarily attempt to have HIV testing, except for a part of gay communities in the large cities. So, it is reasonably difficult to know the actual number of people with HIV, HIV infection rates, and the trends of HIV/AIDS at the early stages based only on the reported cases of HIV/AIDS. In reality, there is a big difference between actual number of HIV/AIDS and the trend, and the number of HIV/AIDS and the trend, which are represented by the Committee of AIDS Trends (CAT) and MHLW, etc. Thus, HIV/AIDS cases in Japan seem to continue increasing slowly but the increase rates are becoming faster and it seems to be just an iceberg. In Japan, HIV testing system is not strong and totally lacks counseling and the motivation for HIV testing is also weak. It is impossible to know the latest trend in the actual number of HIV/AIDS cases, based on the present surveillance systems, which depends on only reported HIV/AIDS cases. Using the present surveillance system, it is also impossible to know which population groups and communities are at the risk of increasing HIV infections. The government did not recognize the threat posed by the pandemic and only declared HIV/AIDS a national disaster. This is the major limitation to understand the current situation of HIV/AIDS in Japan. If the prevalence rates of HIV and AIDS epidemics rise tremendously, Japan must face the most critical situation, which is not expected.Among most developed countries, the number of newly reported HIV positive and AIDS patients has been decreasing, but it is increasing steadily in Japan. Based on the analyses of the present surveillance data, the HIV infections through sexual conducts tend to increase tremendously in the next few years. The major limitation to understand the current situation of HIV and AIDS is the present surveillance systems, which only depends on the reported HIV and AIDS cases. Added to this is a belief that only a low percentage of people testing to HIV in Japan actually report as required, suggesting that the number of HIV positive people in Japan is much higher than MHLW survey states. The continuous and simultaneous increase in both STD and HIV infection trigger the current situation and lead to a full-blown HIV epidemic, if no immediate action is taken. However, Japan is now in the low level of HIV and AIDS epidemics, it is considered as shifting to "concentrated epidemics". The study results suggest that the urgent need for introducing prevention measure for HIV and STD among youth which are currently appropriate for the target population. The findings support the hypothesis that a high average age at marriage in a population contributes to the spread of HIV because a higher age at marriage is strongly associated with a longer period of premarital exposure to the risk of infection. So, it is burning need to find out why the youth are disheartened to get marriage in proper time. Japan's anti-prostitution law needs to amend in the context of HIV/STD control because strict police security drives the problem underground and discourages street girls, especially those living in the country illegally, from seeking proper health services for HIV/STD. Consequently, HIV infection is rising enormously among non-Japanese females. Group-based interventions, better access to health care and a comprehensive public approach should be applied to the non-Japanese nationals. In fine, an AIDS center for prevention should be established to acquire knowledge and expertise and to demolish the epidemics.The authors declare that they have no competing interests.NIM performed statistical analysis and drafted the manuscript. YO developed the analytical approach and econometric methods. HT contributed to the drafting of the manuscript. All authors read and approved the final manuscript


The reuse of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalized HIV epidemics. The U.S. and the WHO have begun to support large scale injection safety interventions, increased professional education and training programs, and the development and wider dissemination of infection control guidelines. Several African governments have also taken steps to control injecting equipment, including banning syringes that can be reused.However injection drug use (IDU), of heroin and stimulants, is a growing risk factor for acquiring HIV in the region. IDU is increasingly common among young adults in sub-Saharan Africa and is associated with high risk sex, thus linking IDU to the already well established and concentrated generalized HIV epidemics in the region. Demand reduction programs based on effective substance use education and drug treatment services are very limited, and imprisonment is more common than access to drug treatment services.Drug policies are still very punitive and there is widespread misunderstanding of and hostility to harm reduction programs e.g. needle exchange programs are almost non-existent in the region. Among injection drug users and among drug treatment patients in Africa, knowledge that needle sharing and syringe reuse transmit HIV is still very limited, in contrast with the more successfully instilled knowledge that HIV is transmitted sexually. These new injection risks will take on increased epidemiological significance over the coming decade and will require much more attention by African nations to the range of effective harm reduction tools now available in Europe, Asia, and North America. Medical injections performed with used syringes and needles may explain a large part of Africa's intractable AIDS crisis, allowing cyclic transmission within high risk groups treated at sexually transmitted disease clinics, transmitting HIV between closed sexual networks, and infecting individuals who believe they are not at risk . Blood eIn South Africa and Ethiopia many health workers consider injections safe when the needle is changed but the syringe is reused, but syringe reuse is practiced even where 97% of health workers recognize single use guidelines ,6. SouthEvidence of this role for poverty in the AIDS pandemic has been neglected, if not actively suppressed in HIV epidemiology . ReverseThe core public health message that AIDS is transmissible both through sex and through needle reuse has been taught consistently in developed nations because injection drug use (IDU) is common. Many AIDS prevention programs in Africa have set aside injection risks in their communications with the public, perceiving IDU as uncommon. Introducing this information and supporting efficacious infection control in primary health care is vital to protecting patients from HIV as well as other blood borne agents. In addition, a high risk group for blood exposures needs to be acknowledged and targeted for outreach. Africa's growing population of IDU are, in some communities, largely unaware that sharing needles carries a risk of transmitting HIV.Injection drug use is no longer rare in sub-Saharan Africa. Established along opiate and cocaine transshipment routes up and down both coasts in the 1990s, IDU is now prevalent even among refugees from the interior regions of the Democratic Republic of Congo . The mosIDU have been interviewed through treatment centers and the use of snowball sampling  in urban Africa and large towns, but the prevalence of IDU in rural Africa has not been assessed. National IDU prevalence estimates from data on urban areas range up to an astounding 1.4% in Mauritius, and prevalence is highest among secondary students, sex workers, and prisoners in Africa. The living situation of male IDU varies from city to city, but most hold only temporary jobs or rely on crime and begging to support their drug habits, and homelessness is common ,17,18. IHeroin use was introduced in the 1980s in a form called "brown sugar" that is smoked  . InjectiMost IDU in Africa are male, ranging from 66% in northern Nigeria to 93% in Nairobi, Kenya ,22. HoweAlthough men and women often inject under different circumstances, injecting practices are readily transferred between them. Tanzanian sex workers share blood with fellow users who cannot afford heroin, in a particularly dangerous practice called "flashblood," which has recently been reported among men as well. One user draws blood back into the syringe after injecting heroin, and passes the syringe to a companion, who then injects the 3–4 mL of blood . This amPatterns of heroin injecting vary from daily or intermittent use for most Nigerian IDU to frequent binging in Dar es Salaam, Tanzania ,28. HeroIn the town of Malindi in coastal Kenya, heroin use is associated with drug and sex trafficking with European tourists . Here inIDU is increasing among youth in most parts of Africa, and has the potential to accelerate HIV transmission in the very demographic with the highest HIV incidence, as sexually active IDU may bridge concentrated and generalized epidemics among young adults. Injecting behavior in youth is associated with ease of access to heroin and unemployment ,37. In aIn South Africa the average age at onset of heroin use is 20 . One thiDrug criminalization and drug-related crime contribute to high IDU prevalence in African prisons. Injecting has been reported in prisons in Cote d'Ivoire, Mauritius and Ghana. From a human rights perspective, the threat of HIV and hepatitis C transmission in prison warrants harm reduction interventions such as providing needles for IDU, and this would also mitigate the role of prisons as disease reservoirs in the community .Drug treatment and HIV counseling could reach a large fraction of IDU through prisons, as criminalization has driven IDU underground and made them a hard to reach population on the street. In Mauritius 17% of juvenile offenders and 50% of adult offenders are IDU, and an estimated 16% of IDU were imprisoned at some time in 2005 ,19. In GIn Europe, Iran, Australia and Russia, harm reduction programs for prisons address the great HIV transmission risk injecting in prison entails . SimilarKnowledge that a clinically significant amount of viable HIV can survive outside the body on blood-contaminated instruments for several hours is not widespread in Africa ,3,46. TaThe syringes available to drug users in East Africa are large gauge and typically damage small veins early in the injection careers of heroin users . Reuse rThe HIV prevalence among IDU who share needles is high, reaching 28% in Zanzibar (vs. 5% in IDU who do not) . The IDUIn Dar es Salaam the HIV prevalence among IDU varied from 0–90% across neighborhoods in 2006, averaging 57%. This variation was notably unrelated to religion (neighborhoods with fewer or more Islamic families) or socioeconomic status; both highest and lowest prevalence neighborhoods were culturally mixed . Here anIn most African countries resources for harm reduction are still lacking and drug use is marginalized as a crime . Recent Table In Tanzania, drug policing is highly visible, but demand reduction has not received the same attention, and injection drug use has been driven underground . Some 30In coastal Kenya a small service for heroin addicts, the Omari Project, has incorporated injection safety into its counseling sessions . HoweverIn South Africa drug treatment has been accessible mostly to white IDU who can make co-payment for clinical services ,60. PublMauritius' 2006 HIV and AIDS Act established Africa's first needle exchange and methadone maintenance program . This reEstimates of the relative importance of unsafe medical injections in the AIDS pandemic vary across orders of magnitude. This is because the probability an individual unsafe medical injection will transmit HIV is not known, and estimates supported in the peer reviewed literature range from 0.1% to 6.9%. These estimates are drawn from four types of empirical evidence: (1) rates of HIV infection from needle-stick injuries  ; (2) HIVHIV prevalence is stabilizing in much of sub-Saharan Africa, but the AIDS burden on health care is still increasing as more patients progress to advanced HIV disease, unfortunately outpacing the availability of antiretroviral drugs. Updating the WHO's model of the global burden of disease from unsafe injections (describing the epidemic in 2000), to account for the elevated clinical prevalence of HIV, an estimated 12–17% of new HIV infections in 2007 could be attributed to unsafe medical injections alone . HospitaHundreds of recorded cases of HIV positive children with HIV negative mothers indicate that the harm to children has been substantial . Today mThe WHO's model of injection risks in the year 2000 estimates that African adults receive on average 2.1 injections per year, and that almost one in five injections are unsafe . More reMore than a third of the population of sub-Saharan Africa  should be at much lesser risk of unsafe injections, as they are protected by national bans on the use of disposable syringes that can be unsafely reused. Other injection safety interventions have been funded under the President's Emergency Plan for AIDS Relief (PEPFAR) through Making Medical Injections Safer projects. These interventions and those of the WHO's Safe Injection Global Network (SIGN) have reduced the frequency of unnecessary injections, reduced the risks posed by improper disposal of sharp medical waste, and produced and disseminated infection control guidelines to improve clinical practice. However these programs ignore larger problems with infection control capacity in African health care settings, as reported in Table AIDS researchers and health workers under rationing pressures face a conflict of interest in acknowledging and investigating risks to transmit HIV from patient to patient, as this may undermine public confidence in the competence and motivation of researchers and health workers, leading to under-utilization of essential health services and to preventable morbidity and mortality . MinistrWHO assurances that medical injection risks are minimal are not credible, and reflect a pattern of suppressing evidence that heterosexual sex explains less than 90% of HIV transmission in Africa . Where eBlood exposures were of interest to HIV epidemiologists in the 1980s, before a consensus focusing on heterosexual transmission was established for Africa, but even transfusion risks were considered intractable at an early stage. Early Western experts' statements concerning the place of infection control in HIV prevention efforts in Africa were highly pessimistic . The pro78,33 and the prevalence of methamphetamine injecting has risen to 0.3% of adults under 50 [Injection drug use has increased rapidly during the recent past throughout sub-Saharan Africa, with the greatest increase in Mauritius, and the greatest numbers of IDU in West-Central Africa. Projecting a similar rate of increase through the year 2015, IDU prevalence could reach 0.24% in Southern Africa, 0.08% in East Africa, and 0.19% in West-Central Africa. For comparison, in the U.S. the prevalence of heroin use (primarily administered by injecting) has stabilized at around 0.2%,under 50 . AlthougHIV prevalence among IDU can also be expected to increase, as the scant drug treatment and harm reduction activities in sub-Saharan Africa are unlikely to impact upward trends that have been documented in Nigeria and South Africa. Interventions to raise awareness of the HIV transmission risk from sharing needles are needed, particularly in Nigeria. Outreach (1) to out-of-school youth as well as students, (2) to female sex workers' clients as well as at-risk women, and (3) to unemployed adults and the homeless, as well as IDU who can afford residential treatment, will be needed. Support for harm reduction spending may hinge on recognition that concentrated HIV epidemics among IDU are relevant to the spread of HIV among sexually active young adults in Africa's generalized epidemics.For the protection of patients, accurate information that HIV can survive outside the body in blood-contaminated instruments and on sharps must be taught, and suspected iatrogenic HIV cases should be traced through the implicated clinics and investigated to identify and prevent other cases. These efforts will in no way detract from the message that HIV is sexually transmitted, even if it is evident that sexual transmission explains less than 90% of infections in Africa. Public awareness of HIV transmission risk from other prevalent skin-piercing procedures  is also poor in Africa, and should be addressed simultaneously ,80,81. IThe author declares that they have no competing interests.SR carried out the literature search, reviewed the studies identified by search, created the text, and created the illustration. SR is the sole author. All authors read and approved the final manuscript.


The receptor tyrosine kinase Met is involved in the progression and metastasis of numerous human cancers. Although overexpression and autocrine activation of the Met signaling pathway are commonly found in human cancers, mutational activation of Met has been observed in small cell and non-small cell lung cancers, lung adenocarcinomas, renal carcinomas, and mesotheliomas.To investigate the influence of mutationally activated Met in tumorigenesis, we utilized a novel mouse model. Previously, we observed that various Met mutations developed unique mutation-specific tumor spectra on a C57BL/6 background. Here, we assessed the effect of genetic background on the tumorigenic potential of mutationally activated Met. For this purpose, we created congenic knock-in lines of the Met mutations D1226N, M1248T, and Y1228C on the FVB/N background. Consistent with the mutation-specific tumor spectra, several of the mutations were associated with the same tumor types as observed on C57BL/6 background. However, on the FVB/N background most developed a high incidence of mammary carcinomas with diverse histopathologies.This study demonstrates that on two distinct mouse backgrounds, Met is able to initiate tumorigenesis in multiple cell types, including epithelial, hematopoietic, and endothelial. Furthermore, these observations emphasize that even a modest increase in Met activation can initiate tumorigenesis with both the Met mutational spectra and host background having profound influence on the type of tumor generated. Greater insight into the interaction of genetic modifiers and Met signaling will significantly enhance our ability to tailor combination therapies for Met-driven cancers. Aberrant activity of tyrosine kinases through overexpression and/or mutation has been associated with numerous human cancers. The receptor tyrosine kinase ErbB2 (Her2/Neu) is overexpressed in 20% of breast cancers www.vai.org/met) The receptor tyrosine kinase Met is an oncogene involved in the progression and metastasis of numerous human cancers Mutational activation of Met can induce tumor growth. Kinase domain mutations in Met are found in papillary renal carcinomas Met genomic locus Mouse models have been essential for understanding the roles of tyrosine kinases in both normal mammalian development and tumorigenesis. To understand the role of Met in tumor development and progression, we have utilized a unique mouse model that allows us to compare four different mutations knocked into the –/ERBB2– and basal-like breast cancers We first evaluated the effect of the activating Met mutation M1248T/L1193V on the FVB/N (FVB) background met locus. For these studies, heterozygous animals were used due to the embryonic lethality that was observed in homozygous M1248TMet, Y1228CMet, and M1248T/L1193VMet mice. Some homozygous knock-in animals were also aged for the D1226NMet line. Each line carried one mutant allele expressed under the endogenous promoter; therefore phenotypic differences were not due to differences in insertion sites (as found in transgenic models).Previously, we developed a knock-in mouse model of activating mutations in the Met receptor D1226NB6-Met; Y1228CB6-Met; M1248TB6-Met; and M1248T/L1193VB6-Met. Previously, we found with the FVB strain that the M1248T/L1193VFVB-Met line was more permissive for tumor formation and on this background a dramatic shift in tumor type occurred from rare and infrequent carcinomas to highly aggressive mammary carcinomas M1248T/L1193VFVB-Met females developed aggressive mammary carcinomas on average by 11 months. Although other tumor types were identified, mammary carcinomas were the predominant tumor and present in 70% of female M1248T/L1193VFVB-Met mice. Expecting to see similar changes in tumor frequency and type, we created congenic strains on the FVB background for the other three Met alleles . Nulliparous and multiparous females heterozygous for each knock-in mutation were aged until tumor growth required euthanasia. Morbidity was observed in several animals unrelated to tumor growth as detailed below.Four mouse lines were initially generated on a B6 background and are referred to according to the effect the change has on the amino acid sequence of Met: M1248T/L1193VFVB-Met line developed tumors more rapidly than the three other mutant lines  and M1248TFVB-Met (p<3×10−6) were statistically significant). Parity decreased the time of tumor onset in the M1248T/L1193VFVB-Met mice but had a less predictable effect in the other lines  than the M1248TFVB-Met nulliparous females (21.8 months), yet in the Y1228CFVB-Met and D1226NFVB-Met lines, multiparous females survived slightly longer than the nulliparous females. The differences between the lines are likely due to the predominant tumor phenotypes described below.The nt lines . The aveer lines . MultipaM1248T/L1193VFVB-Met mice; however, M1248T/L1193VB6-Met mice did not develop epithelia neoplasias in any tissue aside from a single occurrence of lung adenoma. Mammary tumors were the predominant cause of death in M1248T/L1193VFVB-Met mice; however, several animals also developed sarcomas or lymphomas. Once mammary tumors were identified, subsequent tumor growth was rapid in the M1248T/L1193VFVB-Met mice, especially in the multiparous females. This rapid growth likely resulted in the survival differences observed between the M1248T/L1193VFVB-Met mice and the other mutant lines , which is consistent with the lack of sarcomas observed in M1248TB6-Met mice Y1228CFVB-Met mice, 24% developed mammary adenocarcinomas, but only one sarcoma and two lymphomas were observed  mice and in 72% of D1226NB6-Met (mu/mu) mice D1226NMet mice were identified in the mammary pad  whereas multifocal tumors were identified in 6 M1248T/L1193VFVB-Met females  characterized. Although multifocal mammary tumors are not unique in mouse models, the fact that the multifocal M1248T/L1193VFVB-Met tumors had distinct morphologic patterns is uncommon. The most remarkable case was a M1248T/L1193VFVB-Met mouse that developed two contiguous tumors with distinctive morphologic characteristics in the mammary pad , will activating Met mutations induce the same tumor type specificity? And what role, if any, does the host background play?Previously we have shown that activating knock-in mutations in the Met kinase domain unexpectedly gave rise to mutation-specific tumor profiles on the B6 background. For example, When knock-in activating alleles were placed on the FVB background, tumor latency significantly decreased and a more highly penetrant carcinoma phenotype was generated. Since this is a knock-in mouse model, each mutation is expressed under the endogenous promoter, and therefore phenotypic differences were not due to differences in insertion sites or differential expression levels. The variation in tumor profiles observed on both the B6 and FVB backgrounds is markedly comparable to the diverse allele-specific spectra observed in p53-deficient mouse models of Li-Fraumeni syndrome D1226NMet mice developed hemangiosarcomas at a high frequency on both backgrounds, whereas the M1248TMet mice rarely developed sarcomas on either. On the other hand, we also observed distinct tumor-specific phenotypes between the two backgrounds. Mammary adenocarcinomas were the most common neoplasia in all FVB lines, whereas mammary tumors were not observed on the B6 background. This may be in part due to the development of parity-associated hyperplasia in FVB females M1248T/L1193VFVB-Met line, which is not unexpected considering that the M1248T/L1193VMet double mutant is more tumorigenic in in vitro and in vivo assays Several of the tumor-specific phenotypes were consistent between the B6 and FVB backgrounds. For instance, the M1248T/L1193VFVB-Met and Y1228CFVB-Met mice developed similar mammary tumors with diverse features such as squamous metaplasia and solid and tubular patterns. On the other hand, M1248TFVB-Met mammary tumors only displayed acinar and tubular features, but squamous metaplasia was not observed. These results indicate that activation of Met is able to initiate neoplasia in multiple mammary cell types and that Met mutations may uniquely influence cellular differentiation in the mammary gland during tumorigenic growth.MET overexpression is observed in 20–30% of human breast cancers and is a strong, independent predictor of decreased survival Met allele (expressed under the endogenous promoter) is able to initiate such diverse tumor phenotypes. This underscores the affect that even a modest increase in Met activity may have on cell transformation. Amplification of the MET allele has been observed in gastric and lung cancers MET locus) is sufficient for papillary renal carcinomas MET allele may have significant consequences in various cell types. Therefore, future cytogenetic analysis should evaluate cancers for both high and low levels of MET amplification.It is noteworthy that only one copy of a mutated www.vai.org/metandcancer). More recently, MET amplification and activation via HGF/SF has also been implicated in resistance to EGFR inhibition in lung cancer We show that Met is able to initiate tumorigenesis in multiple cell types—including epithelial, hematopoietic, and endothelial—on two distinct mouse backgrounds. The mutation-specific spectra observed on the FVB strain validate our unique mutation-specific findings on the B6 background. These results indicate that each mutation has distinct effects on downstream signaling that may be influenced by the cellular environment and/or modifying genes. Furthermore, these results support the numerous studies in human cell lines and tissues that demonstrate aberrant MET activity is involved in the initiation, progression, and metastasis of diverse cancers . Animals were housed in the VAI Vivarium. Housing and care of the animals were in strict accordance with the guidelines established by the VAI Institutional Animal Care and Use Committee. All research involving animals was approved by the VAI Institutional Animal Care and Use Committee (Permit Numbers: 05-08-023 and 08-10-029).Germline knock-in lines were derived on a mixed C57BL/6 background as previously described 3. Tumor samples along with selected organs were surgically isolated and fixed in 4% paraformaldehyde/phosphate-buffered saline for 24 h. Fixed tissues were dehydrated, paraffin-embedded, cut into 5-µm sections, and stained with hematoxylin and eosin (H&E).Mice were examined biweekly for tumor development and were euthanized when tumors were between 1–2 cmTissue was homogenized in SBN lysis buffer , 1 mM sodium orthovanadate, and Complete Proteinase Inhibitor Mixture Tablets (Roche Applied Science). For immunoprecipitation, 0.5 mg of protein was incubated overnight with anti-Met antibody  at 4°C. Immune complexes were collected with protein A-Sepharose beads (RepliGen) and washed three times in HNTG buffer . Immunoprecipitated lysates were separated on a 4–20% Tris-glycine gel (Invitrogen), transferred to a nitrocellulose membrane (Invitrogen), and examined by Western analysis using a phospho-Met (Tyr1234/1235) antibody  and an anti-Met antibody (B-2).p-value <0.05.Survival was determined using the Kaplan and Meier survival function. Pairwise comparisons of survival curves were done using a log-rank test. To compare differences in the proportion of tumor types in each background, a two proportion z test for equal proportions was used. Proportions were considered significantly different if the


The epidemic of HIV/AIDS linked to injecting drug usage is one of the most explosive in recent years. After a historical epicentre in Europe, South and North America, at present it is clearly the main cause of dissemination of the epidemic in Eastern Europe and some key Asian countries. Recently, 10 African countries reported the spread of HIV through people who inject drugs (PWID), breaking one of the final geographical barriers to the globalization of the epidemic of HIV among and from PWID.Several countries of the Asia and Pacific Region have HIV epidemics that are driven by injecting drug usage. Harm reduction interventions have been implemented in many countries and potential barriers to implementation are being overcome. Harm reduction is no longer a marginal approach in the Region; instead, it is the core tool for responding to the HIV/AIDS epidemic among PWID. The development of a comprehensive response in the Region has been remarkable, including scaling up of needle and syringe programmes (NSPs), methadone maintenance treatment (MMT), and care, support and treatment for PWID. This development is being followed up by strong ongoing changes in policies and legislations. The main issue now is to enhance interventions to a level that can impact the epidemic.The World Health Organization (WHO) is one of the leading UN agencies promoting harm reduction. Since the establishment of the Global Programme on AIDS, WHO has been working towards an effective response to the HIV epidemic among PWID. WHO's work is organized into a number of components: establishing an evidence base; advocacy; development of normative standards, tools and guidelines; providing technical support to countries; ensuring access to essential medicines, diagnostics and commodities; and mobilizing resources.In this paper, we trace the course of development of the HIV/AIDS epidemic among and from PWID in the Western Pacific and Asia Region (WPRO) as well as WHO's role in supporting the response in some of the key countries: Cambodia, China, Lao PDR, Malaysia, the Philippines and Viet Nam. MMWR bulletin from the Centers for Disease Control and Prevention (CDC), Atlanta [Worldwide, around 13 million people inject drugs [ Atlanta . As of S Atlanta .By the late 1980s and 1990s, concentrated epidemics of HIV in PWID were restricted to North and South America and Europe. Since the beginning of this century, explosive epidemics of HIV have occurred among PWID in Eastern Europe and in many countries of South, Central and South-East Asia. Cases of HIV infection within the community of PWID were recently reported from 10 African countries, disrupting the geographical barrier for a globalized phenomenon .Harm reduction is a new name for an old concept. One of the first harm reduction activities was described in Great Britain in 1926, when Sir Humphrey Rolleston, President of the Royal College of Physicians, proposed the use of morphine or heroin for the treatment of opium addiction. This decision was the beginning of a pragmatic and humanitarian approach to the treatment of drug addiction .In 1984, to control an outbreak of hepatitis B in the Netherlands and pressured by the Association of Drug Addicts (Junkies' Union), the health authorities of the City of Amsterdam implemented one of the first known needle exchange programme with a very successful outcome . When thThe offer of treatment for drug dependence has proven to be a very effective tool in controlling the HIV/AIDS epidemic arising from injecting drug use. From abstinence-based treatment, to detoxification or self-support treatment (such as Narcotics Anonymous), all these measures have some impact on the epidemic . HoweverThere is no published information on when methadone was first used to treat heroin dependence. Apart from reducing or eliminating illicit heroin and other drug use as well as other benefits, methadone maintenance treatment (MMT) reduces the level of involvement with crime associated with opioid use ,11. BesiAnother important strategy to control the HIV/AIDS epidemic among PWID is the offer of antiretroviral therapy (ART) for those in need -15. A coSince the establishment of the Global Programme on AIDS, WHO has been working in a strategic and systematic way in the field of HIV/AIDS and drug use. WHO is one of the leading UN agencies promoting harm reduction and the main interlocutor with the health system involvement in harm reduction. Its work is organized into a number of components: establishing an evidence base; advocating for effective policies and programmes; developing normative standards, tools and guidelines; supporting countries in implementing programmes; ensuring access to essential medicines (such as methadone and buprenorphine), diagnostics and commodities; and mobilizing resources . The OrgAlthough national HIV prevalence levels are still very low in the Asia-Pacific region, the huge population sizes of many Asian countries mean that very large absolute numbers of people are being infected each year with HIV . Urgent Many countries in the Asia-Pacific region face difficult public policy and legislative problems with regard to sex work, homosexuality and drug use. In addition, widespread poverty, and a general lack of access to effective health-care services by the poor and disadvantaged in both rural and urban areas means that the challenges of developing targeted intervention programmes, and ensuring coverage of vulnerable groups, are particularly acute .The WHO Western Pacific Region comprises 37 countries from the Mekong River Valley in Asia to countries in the Pacific. Many of the epidemics in the Region are currently driven by needle-sharing among PWID. The epidemic of HIV is clearly driven by injecting drug use in three of the countries . China accounts for 75% of the total population of the Region. Three other countries in the Region are beginning to build a comprehensive response to limit the burden of the HIV epidemic related to injecting drug use . The other 31 countries are considered very Low Prevalence countries . In the present paper we concentrate the information in the 6 key countries for the subject.The first case of HIV infection was notified in Cambodia in 1991. By 2003, approximately 123,000 people were living with HIV including 57,000 women and 9,000 children out of a total population of 14,071,000 . An estiNational prevalence of HIV among those aged 15–49 years has declined from 1.2% in 2003 to 0.9% in 2006  with HIVIn 2004, about 20,000 people were using amphetamine-type stimulants (ATS) and 2,500 were heroin users, of whom 1,750 might have been PWID . Local nCambodia developed a policy for mounting a strategic response to harm reduction in 2003. The HIV/AIDS National Strategic Plan of the National AIDS Authority (NAA) explicitly promotes harm reduction as an evidence-based intervention . The druA memorandum of understanding (MoU) was signed between the NACD and NAA in 2004 to collaborate in preventing drug-related HIV/AIDS. An illicit drug-related HIV and AIDS working group (DHAWG) was then established to integrate HIV/AIDS into the full range of illicit drug-related activities nationwide and now meets quarterly.Capacity building for harm reduction has been undertaken of several provincial NGOs and Government social service agencies. Two local NGOs in Phnom Penh have been operating comprehensive harm reduction community outreach and drop-in centre activities – including NSPs – under NACD authorization since 2005. Cambodia now has at least 11 centres for the treatment and rehabilitation of drug users located around the country . HoweverIn 2008, the Government announced its intention to establish a methadone maintenance programme in Phnom Penh (document N° DG-DHS). Planned for September 2008, referrals will be established to services for voluntary counselling and testing (VCT), sexually transmitted infections (STIs) and tuberculosis (TB), prophylaxis and treatment of opportunistic infections (OIs)/ART as well as emergency medical assistance. NCHADS is also developing detailed plans to establish several VCT demonstration sites in the capital to attract drug users; this approach will then be scaled up nationwide. In 2008, NCHADS also plans to commence referral for prisoners to VCT, and drug treatment and rehabilitation centres nationwide.Since its support to a qualitative assessment of drug use in 2004 in collaboration with the US CDC, WHO in Cambodia has become the co-lead agency with the United Nations Office on Drugs and Crime (UNODC) for drug use in the Joint UN Theme Group on HIV/AIDS . WHO's wIn collaboration with a range of partners, WHO (i) provides support for the operationalization of the DHAWG and associated costed National Strategic Plan for Drug Use and HIV/AIDS; (ii) provides technical assistance for the NSP policy, guidelines, standard operating procedures (SOPs) and implementation plan (with related training in 2006); (iii) provides technical support to establish an MMT programme; (iv) gives technical advice for the development of policies, guidelines and SOPs related to drug dependency detoxification and treatment, and related resource mobilization for both community and closed settings; (v) supports linkages between the NACD, NCHADS, National Programme for Mental Health (NPMH) and NGOs working with drug-using communities for an effective response to the epidemic; (vi) supports communication initiatives including the development of guidelines in the Khmer language targeting health, social and education service providers, law enforcement personnel and parents, as well as four harm reduction video educational interventions for PWID, entertainment workers, ATS users and inhalant/solvent users; (vii) provides technical assistance to the Government and its NGO partners for resource mobilization, such as the Global Fund and the Swedish International Development Agency (SIDA).China sits between the "Golden Triangle" and "Golden Crescent" – two of the three biggest opiate suppliers in the world – and has seen a significant surge in the number of illicit drug users since the 1980s. Heroin is the main illicit drug used in China, with amphetamine and polydrug use on the rise.China's first case of HIV was reported in 1985 and first case due to injecting drug use in 1989 . By DecePWID continue to engage in high-risk behaviours. Recently published national surveillance data show that 40% of participating PWID reported needle-sharing . EstimatThe unique pattern of the HIV/AIDS epidemic in China – high HIV infection rate among PWID and former plasma donors (FPDs), but a relatively low overall infection rate in the country – provides a window period for taking action . China hIn February 2003, the Ministry of Health (MOH), MPS and the State Food and Drug Administration (SFDA) issued an interim "Opium abusers community-based drug maintenance treatment protocol" to start piloting MMT . In JulyA 2007 evaluation survey conducted in the first phase of eight MMT clinics found a positive change in the self-reported rate of injecting drug use, drug-related illegal offences, employment opportunities and family relations . The aveBy December 2007, China had 503 functional MMT clinics. Cumulatively, over 97,554 drug users had entered the programme. In addition, 45,121 PWID had regularly attended NSPs . These cThe Chinese government has taken bold steps to scale up HIV testing and counselling, offer free ART to AIDS patients, and expand primary prevention measures such as MMT and NSPs for drug users, and condom promotion for sex workers and men who have sex with men (MSM). The remarkable achievements in such a short period of time indicate that China is strongly committed to limiting the epidemic and maintaining a low HIV prevalence in the future .Although the current policy environment is favourable for harm reduction activities, China faces several difficult challenges in establishing a comprehensive HIV/AIDS response among PWID. These include (i) difficulty in coordination among different bodies; (ii) inadequate implementation of prevention strategies; (iii) increasing the demand for care, support and treatment for PWID to reach all those in need; and (iv) need for effective control of HIV/AIDS transmission inside closed settings.In China, eligible HIV-positive PWID in the community have access to free ART since 2003 through referral linkages between MMT clinics, hospitals and CDC in China. Over 31 000 adult and paediatric patients have been treated . China iWHO assists China to confront the challenges it faces, by providing timely information about new approaches and technologies that are later adapted and adopted according to China's needs. WHO works with several key partners on various issues through the UN Theme Group on HIV/AIDS and Drug Use.Specifically, WHO supports China in the following areas: (i) policy development and advocacy (e.g. supporting pilot NSP and MMT projects); (ii) providing HIV prevention education; (iii) training staff in drug detoxification and drug dependence treatment in closed settings; (iv) providing technical support for the provision of drug dependence treatment from pilot projects to scaling up; (v) advocacy for testing and counselling; (vi) care, support and treatment for PWID; and (vii) monitoring and evaluation of harm reduction projects.WHO is also working with the Government to change the common perception that drug users are criminals instead of people who are ill and in need of care, support and treatment.Lao PDR is experiencing an impressive development in the recent years. According to UNAIDS Report of 2008, Lao PDR is currently losing the status of a considered land-locked country and being fast transformed in a land linked country . A high Lao PDR is a low HIV-prevalence country. To date, the HIV epidemic has been driven by multipartner client-sex worker behaviours, with some data showing that HIV infection may spread as well among MSM . It is eLao PDR has Myanmar, China (Yunnan), Viet Nam, Thailand and Cambodia as its neighbours and injecting drug use has been reported in all these countries. Lao PDR is in the border of the Golden Triangle which is one of the important sources of opium globally speaking. Lao PDR is also a neighbor of countries that are producing methamphetamines and is therefore being considered as a transit country for methamphetamine and its precursors . The trath National Socio-Economic Development Plan, elevating the fight against the epidemic for a higher level of development concerns of the country [The response to the HIV/AIDS epidemic in Lao PDR started early and has a high level of public commitment. Lao PDR developed a National Strategy and Action Plan 2006–2010, with clear priority targets. A costed action plan forms the basis for the resource mobilization of the country. According to UNAIDS 99.52% of the funds comes from external resources . Global  country .Recently, with the support of the UN system, the Lao PDR Government set up a Task Force on HIV and Drug Use with the objectives of developing a policy, proposing concrete activities to address the vulnerability of drug users to HIV, and developing guidelines for harm reduction and treatment of drug abuse . This TaHarm reduction for PWID is embedded in the National HIV/AIDS/STI Strategy 2006–2010 . This inAn access to ART project was started in 2003, which at the moment covers around 700 patients in two centres of the country. Even if a larger number of people are in need of ART according to estimates, there are no known people in need of ART who are not receiving it. According to the Universal Access Report launched by WHO, UNAIDS and UNICEF in June of 2008, Lao PDR is one of the few countries in the world where the coverage for people in need of ARV bounds 100% .WHO supports the Task Force technically (with UNODC and UNAIDS) and financially by strengthening coordination, carrying out a rapid assessment of the injecting drug use situation, organizing study tours, developing and adapting guidelines for the treatment of addiction, organizing advocacy workshops and supporting the secretariat of the Task Force.The main partnership of WHO in the country is with the Sweden Cooperation for a 2 years project (2008/2009) specifically dedicated to the implementation of Harm Reduction as a key strategy to avoid or mitigate the epidemic in Lao PDR.As Lao PDR does not yet have an HIV epidemic caused by injecting drug use, this gives the country the opportunity to start a meaningful harm reduction programme and thereafter try to prevent an epidemic.The first case of HIV was diagnosed in Malaysia in 1986 . By DeceAs a consequence of the large proportion of PWID in the population with HIV/AIDS, the epidemic in Malaysia is clearly a concentrated epidemic, since HIV prevalence has been less than 1% among the general population but consistently higher than 5% (between 3% and 20%) in PWID . The firFrom a highly punitive approach of sending drug users to forced treatment centers as the only strategy by the beginning, the response to the HIV/AIDS epidemic in Malaysia has been stepped up in the past 18 months . ResponsMMT has been scaled up continuously since it was introduced in October 2005. The country now has 74 MMT services serving more than 4000 PWID. As of 31 December 2007, a total of 4,135 drug addicts had been registered and enrolled into the Government MMT programme, which is totally free for patients. Furthermore, the expansion of methadone availability in Malaysia is being also amplified by the inclusion of General Practitioners. In April 2008, the MMT programme was extended into the prison system starting with a pilot project in Pengkalan Chepa prison in one of the eastern states. Methadone availability is being enhanced and monitored by the Ministry of Health. The cost has been reduced several fold, but qualified counsellors are scarce .At present, 40% of those who fulfill the criteria for initiating ART are under treatment . This is a great development in comparison with 10% 18 months ago . However, Malaysia still needs to develop the sexual component of its response to the HIV/AIDS epidemic due to the rapid spread among the female population.WHO has been constantly and consistently providing technical support for capacity building. The first contribution to the Government of Malaysia in this field was in 2004 when an Injecting Drug User Behaviour Survey Study was conducted with technical and financial support from WHO. This study was a baseline for a series of decisions that the Government took to better develop its strategy to confront the epidemic.In September 2004, a workshop on the development of the National Strategic Plan on HIV/AIDS was conducted, again with WHO support. The Plan was developed in the workshop itself and the first draft was designed by a WHO consultant to support the Government of Malaysia. This strategy was later reviewed in 2005, also with WHO support, when the Government of Malaysia presented their evaluation of the Millennium Development Goals (MDGs) and regretted that the only goal that Malaysia did not achieve at that point in time was MDG 6 – failure to control HIV/AIDS.Again in 2005, in conjunction with the Asian Parliamentarian Forum, WHO supported a dialogue in the Malaysian Parliament advocating for their support to harm reduction. This activity brought about strong political support for harm reduction.In 2006, WHO conducted a Bi-Regional Workshop (WPRO and SEARO) in Malaysia and an Informal Consultation to develop guidance for care, support and treatment for PWID. This was crucial for developing the next step of engaging PWID in treatment with ARVs.Technical support was also provided for the monitoring and evaluation exercises associated with the pilot NSP and MMT programmes. WHO Malaysia hired highly respected international consultants to help conduct an in-depth analysis of the MMT as well as NSP programmes. There was no seminar or event in that field where WHO was not clearly involved.WHO also supported a Rapid Assessment Study among PWID; and their initial findings were presented during the Symposium on Drug use and HIV in Kula Lumpur, Malaysia, held on 3 December 2007. The study concluded that the majority of subjects initiated drug use before the age of 18 years and shift to injecting very fast. Heroin is the main drug of injection; however, an increasing number of people use ATS as their main drug of choice. Rates of sharing of injection equipment are very high and condom use is less than 20% with all kinds of partners. The data will be released in 2008 by WHO and the University of Sains, Malaysia.The country's response to the HIV/AIDS epidemic among PWID was analysed in depth at a national AIDS conference and a national symposium on Drug use and HIV promoted by WHO and partners in December 2007. The achievements were acknowledged both within and outside Malaysia. Malaysia's understanding of its epidemic pattern is increasing based on evidence, and the country is stepping up its response by scaling up methadone clinics, NSPs, as well as care, support and treatment for PWID.At present, besides ongoing technical assistance, WHO is providing support for policy development in the area of Government and public acceptance of harm reduction programmes.The HIV epidemic in the country has been described as low prevalence . There wHowever, drivers of the epidemic in PWID have been documented. In 2007, an integrated HIV behavioural and serological surveillance (IHBSS) showed that 52% of PWID had shared needles and syringes the last time they injected; condom use was only 24%; and prevalence of hepatitis C among PWID was 88% in Cebu City and 6% in Zamboanga City . At presThe National HIV and AIDS Registry, a passive form of surveillance, recorded a total of 3,061 reported cases of HIV from January 1984 to December 2007, of whom 7 were PWID .The Department of Health (DOH), as chair of the Philippine National AIDS Council, a multisectoral policy-making body on HIV prevention, is the lead government agency mounting a national response to the HIV epidemic. The country's responses are geared towards universal access to prevention, treatment, care and support, including protecting the rights of PLHA and their families .The following prevention strategies are being implemented: community outreach and education, scaling-up counselling and testing, early diagnosis and management of STIs, 100% condom use programme (15 sites), prevention of mother-to-child transmission , provision of post-exposure prophylaxis, and a harm reduction programme for PWID (3 sites) .Implementing a harm reduction programme in the Philippines is challenging because of the illegal nature of drug use. Despite a law on the prevention and control of AIDS (Republic Act 8504), a more recent law, the Dangerous Drugs Act (Republic Act 9165) emphasizes the supply and demand reduction approach to control drugs. Recognizing these conflicting mandates, the National AIDS STI Prevention and Control Programme and the Philippine National AIDS Council (PNAC) Secretariat initiated discussions with the Dangerous Drugs Board, the Philippine Drug Enforcement Agency, and other relevant partners, to come up with more appropriate and acceptable approaches that would treat the PWID situation in the country as a public health concern to be addressed rather than as a criminalized, legal issue.While central government agencies tried to work at the policy level, NGOs, in coordination with the local health departments and local stakeholders, started providing harm reduction services among PWID including community outreach, peer education, referral networking to counselling, provision of clean needles and syringes, psychosocial support, and referral and treatment for STIs and other health-related concerns. Outreach work was initiated in 1995 by the Program for Appropriate Technology in Health (PATH) in partnership with the University of Southern Philippines Foundation, through the AIDS Surveillance and Education Project of USAID. Other NGOs such as Remedios AIDS Foundation, KABALIKAT, USAID-Local Enhancement and Development (LEAD) for Health Project were also involved in outreach education work among PWID. Currently, the Philippine NGO Council for Population, Health and Welfare, Inc. and the Tropical Disease Foundation continue to implement PWID harm reduction programmes through the Global Fund AIDS projects.In 2007, the Asian Development Bank's Regional Technical Assistance Project complemented the country's initiatives by supporting the conduct of a situation and response analysis of PWID-related work in the country and of IHBSS among PWID in the cities of Zamboanga and General Santos .Currently, 800 PWID are reached by prevention services through three major outreach service delivery points, which includes provision of clean needles/syringes ,66,67.In the area of care and support, there are 11 treatment hubs with trained HIV AIDS Core Teams that provide clinical and psychosocial care and support to PLHA. ART is provided free since 2005. The baseline CD4 count is also done free at the STI AIDS Cooperative Central Laboratory . As of December 2007, there are 390 PLHA enrolled for free ART and are receiving extended care and support services .WHO remains the major provider of assistance to the DOH in advocating for sustained efforts to support the harm reduction programme among PWID and to dispel the perception that this is not effective and not needed in the Philippines. WHO is the lead agency on matters pertaining to health, and in preventing the transmission of HIV through injecting drug use (since there is no UNODC office in the Philippines). In conjunction with other UN agencies, WHO supports the evidence-based development of harm reduction strategies and ensures that only scientifically effective harm reduction strategies are introduced, adapted and continuously implemented in the Philippines in order to address the public health concerns of people who inject drugs.WHO supported a study on behaviour patterns among PWID admitted to rehabilitation centres; the results were initially disseminated in January 2008. WHO also conducted the first orientation on PWID harm reduction programme (2007) among DOH and UN staff, and among high-level officials of the DOH, Department of Interior and Local Government, and the PNAC Secretariat. WHO is a key member of the Harm Reduction Working Group which will draft appropriate national guidelines on the harm reduction programme in the Philippines.After the first HIV case was diagnosed in 1990, transmission and reporting of cases accelerated such that it was estimated that there were 293,000 PLHA in Viet Nam at the end of 2007 . CumulatSince 1990, the majority of reported HIV infections and AIDS cases have been in PWID (50–60%), though heterosexual transmission, particularly through commercial sex, appears to be increasing . With a The Ministry of Health (MoH) is the lead agency for harm reduction activities. HIV prevention measures were initiated in 1993 and predominantly involved mass education and small-scale needle/syringe distribution. In 2003, the first of the large donor-funded prevention projects started with financial support from the UK Department for International Development (DFID) and Norwegian Directorate for Development Cooperation (Norad) in 19 provinces and two cities . In 2005, the response was expanded by the addition of the World Bank-funded MoH Viet Nam HIV/AIDS Prevention Project in 18 provinces and two cities (six provinces and the two cities overlap) .An impressive government HIV/AIDS response over the past five years has seen an expanding public health response and the National Assembly pass the Law on HIV/AIDS Prevention and Control in 2006 and associated Decree 108/2007 ND-CP in 2007 ,74. ProtUnder the Law, the MoH is specifically mandated to lead harm reduction activities for HIV prevention among risk groups and to work with the Ministry of Public Security (MoPS) and Ministry of Labour, Invalids and Social Affairs (MoLISA) to ensure the implementation of needle and syringe, condom distribution and OST programmes.The MoH Viet Nam Administration of HIV/AIDS Control (VAAC)-led projects for prevention have expanded since the HIV/AIDS Law, in particular, coverage with NSPs increased from 21 provinces in 2005 to 42 provinces in 2007. During 2007, expansion of all projects led to the distribution by government health services of more than 11 million needles and syringes (sufficient to provide around one quarter of the registered PWID with one per day), and more than 100 million condoms – predominantly through the activities of more than one thousand peer outreach workers ,76.In 2007, VAAC, in collaboration with other MoH departments and international partners, developed national guidelines and a proposal for pilot MMT programmes for 1500 patients. Treatment commenced at three sites each in Hai Phong and Ho Chi Minh City during the first half of 2008 with support from the US Government President's Emergency Plan for AIDS Relief (PEPFAR), WHO, DFID and World Bank .By the end of September 2007, a total of 14,180 adults were receiving ART in 64 provinces – a 5.7-fold increase from the end of 2005 (or 28.4% of those needing ART) . Though The national network has more than 80 Treatment and Education Centres, which are institutions for drug users (and sex workers) who are required to go through drug detoxification, education and occupational training for one to two years (except in Ho Chi Minh City which has a five-year requirement). Implementation of small-scale provision of ART commenced this network in 2007 with PEPFAR support. Substantial expansion is planned under the Global Fund Programme in 2008 and beyond. Many of these closed settings, housing over 60,000 drug users, have a high prevalence of HIV (30–60%) and burden of AIDS-related illnesses, but until now have been without adequate resources to provide HIV prevention, treatment or care .In response to requests from the MoH, WHO has been a principal provider of technical assistance for harm reduction activities, which are largely conducted by the health sector. WHO efforts to increase the coverage and quality of harm reduction interventions for the MoH-DFID/Norad-funded HIV prevention project in 21 provinces has been through the development of guidance documents, tools, identification of good practices for the needle-syringe and condom programmes for entertainment establishments, street-based sex workers and other groups at risk through non-pharmacy outlets, and capacity building, including participatory training for managers and peer outreach workers.Building on these experiences, WHO has been taking a lead role in supporting VAAC, with support from DFID and SIDA, to develop the national technical guidelines on the needle-syringe and condom programmes, in collaboration with PEPFAR, UNAIDS, UNODC and others. Furthermore, development of strategic and operational collaboration between MOH, MOLISA, MOPS and their local entities are being promoted and supported by Joint UN Team on HIV in which WHO plays an active role.Through 2007, WHO and international partners supported the complex collaborative development process for the MMT guidelines, implementation proposal, training curriculum and methadone procurement.WHO provided key support to OST/NSP study tours for the MoH in 2007 to sites in Hong Kong, Malaysia, Indonesia and Australia, including participation to provide translation into a familiar language and organizational context. WHO continues to collaborate with UNODC and UNAIDS to ensure that partnerships between the MoH and MoPS/MoLISA remain supportive of harm reduction.WHO has continued to support expansion of HIV treatment and care including ART for active PWID and development of the National HIV Monitoring and Evaluation Framework including refinement of indicators related to PWID and Sex Work.Challenges remain for WHO, working with advocacy partners, to expand the supportive political environment for harm reduction in Viet Nam and in the development of effective HIV prevention and care linkages between closed settings ('Treatment and Education' centres/prisons) and communities.In 2003, the WHO Region for the Western Pacific and Asia developed a workplan in support of harm reduction that embraced HIV/AIDS prevention, care, support and treatment for PWID. It was based on assessment missions to countries with varied situations with regard to HIV and the use of drugs including China, Cambodia, Lao PDR, Malaysia and Viet Nam. Consultations were also held also with key partners in this area, including UNAIDS, UNODC, CDC-Global AIDS Program, Family Health International (FHI) and Burnet Center for Harm Reduction. The framework used reflects WHO's overall management plan and expected results: to develop tools and guidelines; to strengthen country capacity; and to provide regional support for country programme development.One of the expected results was the development of tools and guidelines:Drug dependence detoxification and treatment guidelines for low-resource, high HIV-risk settings. These protocols and associated training packages have been developed as a joint initiative with the Australian National Drug and Alcohol Research Centre, one of the WHO Collaborating Centres. The package is being field-tested in Cambodia in the second semester of 2008. A final version will be published by the end of 2008.(1) A publication entitled HIV/AIDS care and treatment for people who inject drugs was published in March 2008.(2) A manual on HIV testing and counselling in settings attended by people who inject drugs is scheduled for publication in 2008.(3) These tools and guidelines will be extremely helpful for Members States and civil society to further develop harm reduction strategies in the Region.(4) A revised framework to address TB-HIV Co-Infection in the Western Pacific Region, was launched in July of 2008 and dedicated one chapter for TB-HIV in Closed Settings and among people who inject drugs.A second main task from the workplan is to give support to Member States. It is important to state that HIV Programmes in WHO country offices in the region count with a focal person for Harm Reduction in the six mentioned countries. Their contribution is being crucial. Consistency and technical back-up for the work of WHO country offices in the Region is provided by WPRO. The HIV/STI Focus Unit of WPRO had an important role to play in the achievements made by the six countries discussed in this paper.th International Harm Reduction Conference in Bangkok, in 2009, of all the relevant community-based organizations in the field of drug use. WPRO is also collaborating with the Australian National Council on Drugs and the Burnet Institute to better develop a network on drug research in the Pacific Area, almost unexplored in terms of the health consequences of the misuse of illegal drugs.The third main task is to provide regional support. A standing participation in the UN Regional Task Force has been an important contribution from WHO to a collective effort. WPRO is also working hard to develop regional alliances with crucial partners  for better development of harm reduction strategies to tackle the epidemics in the Region. Together with UNODC, WPRO will organize a meeting during the 20At present, the main objectives of the WPRO HIV/AIDS and STI Unit in the field of harm reduction are to harmonize (as much as possible) the response to the HIV/AIDS epidemics among PWID in different countries of the Region; help countries to develop better policies, legislations and practices to facilitate their response; increase the availability of advocacy tools; reinforce the main package of interventions comprising NSP, Drug Dependence Treatment (mostly but not only OST) and care, support and treatment (including ARV). Co-infections of TB and Hepatitis C are also being addressed. WHO is in a privileged position among the UN agencies to be the interlocutor with the health sector, supported by science, evidence-based results and political will. WHO also has the technical expertise to take the lead in helping to promote the changes needed to adequately face the epidemic among and from people who inject drugs.Injecting drug use is driving HIV epidemics in many countries and accounts for almost a third of new infections outside sub-Saharan Africa . Across In conjunction with many other partners, WHO pioneers the promotion and development of evidence-based strategies for harm reduction in the Region. Because of the efforts made, harm reduction is no longer a marginal strategy in the Region. While the progress made has been impressive, it is important to consolidate the advances and scale up interventions to better confront the epidemics driven by injecting drug use.The authors declare that they have no competing interests.DJ and MF were responsible for the Vietnam piece of the paper. DR developed the Lao PDR piece of the manuscript. GS was the main contributor for the Cambodian piece of the paper. HT and NS contributed to the piece of the paper on Malaysia. HY and KP were the main responsible for the piece of the paper about China. MS was in charge of the piece of Philippines in the manuscript. FM as the main author overviewed the paper and was responsible for the overall manuscript. All authors read and approved the final manuscript.