New and explosive HIV epidemics are being witnessed in certain countries of Eastern Europe, including Ukraine, as well as a rapid and dramatic increase in the supply, use, and negative public health consequences of illicit drugs. A majority of registered HIV cases in Ukraine occur among injection drug users (IDUs), large numbers of whom report HIV risk behaviors such as needle sharing. The purpose of this study was to apply the World Health Organization's Rapid Assessment and Response on Injection Drug Use (IDU-RAR) guide to create a situational picture in the Vinnitsya Oblast, Ukraine, a region with very scarce information about the HIV/AIDS and injection drug use (IDU) epidemics.The IDU-RAR uses a combination of qualitative data collection techniques commonly employed in social science and evaluation research to quickly depict the extent and nature of the given health problem and propose locally relevant recommendations for improvement. The investigators focused their assessment on the contextual factors, drug use, and intervention and policy components of the IDU-RAR. A combination of network and block sampling techniques was used. Data collection methods included direct observation, review of existing data, structured and unstructured interviews, and focus group discussions. Key informants and locations were visited until no new information was being generated.The number of registered HIV cases in Vinnitsya has increased from 3 (1987–1995) to 860 (1999–10/2004), 57 of whom have already died. Ten percent of annual admissions to the area's Regional Narcological Dispensary were for opiate disorders, and the number of registered IDUs rose by 20% from 1999 to 2000. The level of HIV/AIDS awareness is generally poor among the general population but high among high-risk populations. Both HIV/AIDS and injection drug use carry a strong stigma in the community, even among medical professionals. There was very little evidence of primary HIV/AIDS prevention efforts, and IDU prevention efforts focused on promotion of anti-drug messages in the schools.Given that Ukraine has sparse resources to be devoted to this problem, action recommendations should be prioritized, realistic, and initially targeted to persons in greatest need. The following action recommendations are prioritized by the following categories: First priority: Voluntary Counseling and Testing; Second Priority: Prevention and Education; and Third Priority: Harm Reduction and Treatment. They are provided in this sequence based on what response can realistically be implemented first with limited additional resources and can make the greatest immediate impact. The persons at greatest risk, HIV positive persons and IDUs, should be attended to first. New and explosive HIV epidemics are being witnessed in certain countries of Eastern Europe: Russia, Moldova, Belarus, and Ukraine -6. AccorPolitical independence in Ukraine and surrounding Eastern European countries in the 1990s has been associated with a rapid and dramatic increase in the supply, use, and negative public health consequences of illicit drugs -10,16. WThe majority of reported HIV infections in Ukraine were diagnosed in IDUs from 1987 to 2004 ,15. A toThe proportion of total cases acquiring HIV through opiate IDU in certain areas of Ukraine dropped from 72.7% in 1997 to 56.7% in 2004, suggesting expansion of the epidemic to the general population . Data inAt the time of this study, information about the HIV epidemic came mainly from the most heavily affected Ukrainian cities, such as Odessa, Kharkiv, and Mykolaiv . The attThis project builds on a successful three-year joint collaboration between public health, HIV/AIDS, and drug addiction researchers and clinicians from the University of Alabama at Birmingham (UAB), The Regional Narcological Dispensary (RND) in Vinnitsya, Ukraine , and the Vinnitsya National Pirogov Medical University (PMU). This collaboration was initiated by the UAB John J. Sparkman Center for International Public Health Education and an International Clinical, Operational and Health Services Research and Training Award (ICOHRTA) awarded by the National Institutes of Health Fogarty International Center to UAB in 2001.The fieldwork phase of this study was completed from May through July of 2001.This study utilized rapid assessment and response (RAR) methodology developed by the World Health Organization (WHO) in 1998. The RAR method uses a combination of qualitative data collection techniques commonly employed in social science and evaluation research to quickly depict the extent and nature of the given health problem and propose locally relevant recommendations for improvement. One of the key principles of RAR is that data are collected from different sources, which allows continuous examination of the reliability and consistency of the data and enables investigators to make better informed decisions about what evidence should be sought in the next stage of the assessment. RAR is designed to rapidly assess a current problem situation (e.g. IDU) in a community. This information is then used to make informed decisions about the development of interventions needed to reduce the adverse health and social consequences of the targeted condition. The WHO Rapid Assessment and Response guide on injection drug use (IDU-RAR) , includiDue to limited financial resources and a short time frame, we directed our focus to three areas of the IDU-RAR when assessing the IDU situation: Contextual Assessment, Drug Use Assessment, and Intervention and Policy Assessment. The Contextual Assessment identifies factors that influence the current and potential situations regarding drug injection and its adverse health consequences, as well as opportunities for the development of interventions. Key areas for assessment include factors for spread of IDU, exacerbation versus amelioration of adverse health consequences of injecting, and factors that are likely to hinder or enable the development of interventions. The Drug Use Assessment focuses on the nature and extent of drug use – who is injecting drugs and where this occurs, as well as trends in injection drug use over time. Finally, the Intervention and Policy Assessment is designed to assess existing interventions and policy responses aimed at reducing drug use and its consequences while allowing the assessment team to examine their effectiveness and develop recommendations. Our study also included an assessment of the HIV/AIDS situation, which incorporated the nature and extent of the epidemic, HIV/AIDS awareness, attitudes toward individuals living with HIV/AIDS, and existing prevention/control measures.As a first step of the rapid assessment, the principal investigator met with key collaborators in Vinnitsya to assemble an assessment team and identify key informants. Immediately following the initial consultation, a conceptual map of the Vinnitsya community was developed. The map captured key locations for the needs assessment including major gathering points for IDUs, areas where drugs are sold, needle exchange sites, treatment facilities, transportation routes, and other key locations. The investigator traveled to all key locations to develop a physical map, noting activities that would help to provide some insight into the nature of IDU.network and block sampling techniques was used. The network sampling method involved a chain of referrals initiated by the key informants. All key informants were asked to provide a list of individuals who would be able to offer additional information on a given area of the needs assessment. These individuals were then contacted for further information and asked to provide another list of informants. This approach was used until no new information was being generated. The block sampling technique was similar to the networking sampling, but instead of using key informants as the starting point, the needs assessment team traveled to key locations (identified by the mapping exercise) to identify new informants. As an example, the leading investigator frequently traveled to a local market in the Vishinka district (identified as a gathering point for IDUs) to develop rapport with IDUs and gain access to new informants who would be willing to provide information on the IDU situation in Vinnitsya.In order to create a representative sample of informants, a combination of Data were collected using a combination of rapid assessment methods, including direct observation, review of existing data , structured and unstructured interviews, and focus group discussions. An important component of the needs assessment was the triangulation of information, or cross-checking of collected data through the multiple sources. This allowed for collection of more representative data with higher confidence in its accuracy.The first occurrences of HIV infection in the Vinnitsya region were officially registered with the Sanitation and Epidemiological Service between 1987 and 1995. At this point, only 3 HIV infections were registered. By 1996, the number of new HIV infections rose to 46 , including the first officially registered AIDS case. Between 1999 and 2001, there was a sharp increase in the number of new HIV infections in the region (at approximately 130%) that brought the total number of HIV infections to 431. At the end of 2001, a total of 112 new HIV infections, 26 AIDS cases, and 17 AIDS-related deaths were recorded for the Vinnitsya region. The regional Sanitation and Epidemiological Service statistics for the year 2001 revealed that the largest proportion of HIV infections occurred through injection drug use , followed by sexual transmission . Individuals in the 20–29 age group accounted for the largest proportion of HIV infections (69.6 %). Within this age group, the male to female ratio was 3 to 1. The most heavily affected areas within the Vinnitsya Oblast were Gaisyn, Ladyzhyn, and the city of Vinnitsya with 29.5%, 20.5%, 15.1% of the total number of new HIV infections in 2001 respectively. By October 2004, there were 783 cases of HIV infection and 57 AIDS deaths registered in Vinnitsya Oblast. In 2004 for the first time heterosexual route of transmission has prevailed with 54.1% of newly registered cases .Information gathered from NGOs and local researchers suggests similar trends. However, accurate prevalence rates at the present time are difficult to assess due to lack of testing resources and fear and mistrust among those who may be at risk of having HIV/AIDS.Data collected through personal interviews with key informants and focus group discussions suggest that residents of Vinnitsya have heard of HIV/AIDS, but the level of knowledge and perception of risk vary among different groups. A focus group discussion with students from local universities in Vinnitsya revealed that young people in the community were likely to perceive HIV/AIDS as something that is found exclusively in the West and thus is not a real threat to their community. Many of the students were surprised to learn that HIV cases were reported in Vinnitsya and admitted that they were not as well informed about the disease as they needed to be. Discussions with IDU at a needle exchange program in the Vishenka District, on the other hand, revealed a much different outlook on the HIV/AIDS situation. These individuals were well aware of the presence of HIV in the community, and some even knew someone who had already contracted the virus. They felt that they were well informed about HIV/AIDS and how to protect themselves against the virus. Interviews with Vinnitsya city service providers and representatives from local NGOs confirmed that the level of HIV/AIDS awareness among high-risk populations was high. The same level of HIV/AIDS awareness, however, did not appear to extend to the rural communities. According to information from rural health providers working with IDUs, many of their patients lacked information about HIV/AIDS and did not perceive themselves as being at risk. A director of a government program focusing on the social welfare of youth in the Vinnitsya region also attested to low HIV/AIDS awareness among young adults in the rural communities.Vinnitsya residents living with HIV face a great deal of stigma and lack a widespread support system within their community. According to infectious disease treatment providers at a local hospital in Vinnitsya, HIV positive patients tend to stay secluded and often are very concerned that other people not learn about their infection. It is not unlikely for someone diagnosed with HIV infection to seek treatment and consultation with a physician during evening hours or at other times when they would be less likely to be seen by other people at the medical facility. Though many physicians seemed compassionate toward HIV positive patients , direct observations and interviews with medical staff revealed that HIV positive individuals were stigmatized within treatment facilities. Test results that were to be kept confidential were openly shared in patient charts, and HIV patients were placed in isolation blocks. Interviews with nurses and other clinical staff revealed that some of the staff were reluctant to treat HIV infected patients. HIV positive patients at a local narcological dispensary stayed in an isolation block consisting of a small single-bed patient room, a nurse's cabinet, and a small waiting area. Anyone in the facility could easily determine who was staying in the isolation block and why he or she was there (as the restricted area was clearly labeled). It was not until recently (at the time of writing this paper) that the isolation block was discontinued and persons diagnosed with HIV/AIDS mainstreamed into the hospital.Aside from counseling provided by some physicians who work with HIV-positive patients, there was very little evidence of routine counseling and follow-up for individuals who are tested for HIV. An important concern expressed by a physician at a hospital-based HIV/AIDS center was the lack of a support system that would allow patients diagnosed with HIV to speak openly about their condition and gain more information on living with the virus.Prevention activities found in the area were classified according to the three categories: primary (prevention of occurrence), secondary (diagnostics and treatment), and tertiary (minimization of adverse consequences). With the exception of a school-based educational program and some media efforts, there was very little evidence of primary HIV/AIDS prevention. The school-based program, organized by a local NGO, was implemented at only one of the 40 local elementary schools. The program (modeled after the American Project Hope) utilized innovative educational methods, through which children took part in skill building exercises (including self-efficacy building) and learned through peer-education. This program, however, did not have a built-in evaluation or measures to ensure sustainability. The local media were known to disseminate HIV/AIDS information through newspaper articles, but none of the information concentrated on the prevention of HIV/AIDS. At the time of the study, Peace Corps volunteers based in Vinnitsya were planning to develop and implement an HIV/AIDS education program through UNAIDS-Kyiv, which would serve as a great opportunity to create more educational programs at local schools in Vinnitsya and surrounding rural areas.Primary prevention efforts carried out by a local NGOs reached out to high-risk populations, including commercial sex workers and IDUs, in the city of Vinnitsya and surrounding smaller cities. Outreach workers at needle/syringe exchange sites distributed condoms and information about HIV/AIDS and other sexually transmitted diseases. Educational booklets included information on safer sex practices and where to go for treatment. IDUs participating in the needle-exchange program were referred to a local hospital that had a special hepatitis and HIV/AIDS center within its facility. Some referrals to substance abuse treatment also were made. The program provided opportunities for HIV, HBV, and HCV testing free of charge. This effort, however, was fully funded through a time-bound grant, and it was not clear whether it would be sustained.The AIDS Center at the local hospital provided HIV infected individuals with necessary medical attention and some counseling services and linked them with other sources of information. There were limited resources, however, for secondary prevention activities, such as screening, analysis, and HIV/AIDS disease monitoring. Availability of antiretroviral therapy was limited due to high cost. Patients had to make arrangements to buy their own medications. This situation was likely to change with the Ukrainian government's intention to provide subsidized antiretroviral therapy in the near future, supported by the grant from the Global Fund. The AIDS Center also worked closely with local NGOs to recruit individuals from high-risk populations for testing and treatment.During the Soviet era, IDU was largely hidden and mostly limited to individuals from wealthy families. The drugs that were consumed during that time usually included "clean" drugs such as morphine and heroin. Substance abuse treatment providers who treated patients during the Soviet era indicated that the nature of drug use in Vinnitsya has changed dramatically over the past decade. In the years following Ukraine's independence, drug use has increased rapidly and shifted from purer, more expensive drugs to drugs that can be made at home. According to recovering IDUs from a local church, raw materials became easily accessible, and preparation procedures were passed around like cooking recipes. One especially potent amphetamine-like injectible drug, commonly referred to as "vint," was prepared using readily available chemicals that could be purchased at drug stores and local pharmacies. Though this particular recipe came at a price, IDUs could easily learn how to prepare a homemade opiate solution ("hanka" or "shirka") from their peers.Individuals who were new to IDU could purchase ready-filled syringes or small medicine containers with the opiate solution at a local market. According to informants at a market in the Vishinka District of Vinnitsya city, drug dealers (often IDUs themselves) were able to do their business there without getting much attention from law enforcement while having good access to new customers. An inexperienced person might be invited to the dealer's apartment or a nearby garage, as attested by social workers at a local needle exchange program, where the dealer would help him or her to inject the drug.There were no reliable epidemiological studies available to estimate the prevalence rates of opiate IDU in Vinnitsya and surrounding areas. Ten percent of the annual admissions to the area's only RND for drug and alcohol treatment were diagnosed with opiate disorders, but the actual prevalence rate in Vinnitsya was estimated to be more than ten times that figure or 2,000 persons with opiate disorders . Dr. Slobodyenyuk also reported that the number of registered IDUs from rural areas during the year 2000 rose by 20% from the previous year. According to reports from the regional Sanitation and Epidemiology Service, rural areas were the most heavily affected in terms of opiate IDU and reportedly include the regions of Koziatyn, Zhmerynka, Trostyanets, Ladyzhyn and Illinitsi, as well as various small towns such as Hnivan and Vapniarka.hanka quickly became a prosperous business. The drug production was not difficult, the raw material was grown in the area, and the demand for opiates was increasing. The cultivation of poppies has been part of the Ukrainian culture for many generations. Consequently, there was fairly easy access to poppies in the Vinnitsya region, especially in the rural areas. IDUs were able to gather poppy straws directly from the fields or purchase them from babushkas (grannies) at the local market. A 1-ml dose of hanka sold for about 5.00 grivnas (about $0.95 US) during the poppy season and for about 8.00 grivnas (about $1.50 US) out of season according to local IDUs. Selling a liter of hanka in a day allowed one to make more than ten times the income an average person makes in a month.Results from this study indicated a combination of numerous factors that encouraged the spread of opiate IDU, including Ukraine's economic situation, social changes following the country's independence, easy access to poppy plants, and lack of knowledge. As Ukraine transitioned from the old (i.e. Soviet) system, many people were left without jobs or ones that pay on average US $30–50 a month as revealed by community informants. The sale of There did not appear to be a single driving force behind the increase in drug use among young adults. Discussions with IDUs at local treatment facilities and needle exchange programs revealed that people turn to drugs for different reasons. Some people sold drugs to make money while others were drawn to use IDU out of boredom, curiosity, or an attempt to be part of a social circle. As graduates from universities and technical colleges, young adults often had to travel to larger cities to find employment. When they first arrived they would try to find a social circle and a place to belong. This was how many people were introduced to people who inject drugs, according to IDUs and substance abuse treatment providers. They would then introduce their friends to IDU upon returning home and consequently form small IDU communities. Furthermore, the consumption of alcohol is a very important part of the Ukrainian culture. With the economic situation under strain, people turned to alcohol to escape the harsh realities of everyday life. IDU is slowly becoming the mechanism of abuse among young people who wished to do the same. Though information collected through different sources did not contradict this observation, more research is needed to confirm that there is indeed an association between alcohol use and illicit drug use.Another important factor that was indicated as a possible facilitator of drug use, and one that should also be explored through further research, is the changing social environment among school-aged children. As the economy began to crumble, many parents were forced to take on additional jobs to compensate for low income. Their children were under less supervision, and some community representatives speculate that they became more vulnerable to exploring drugs. Extracurricular activities such as sports and various special interest clubs were free-of-charge during the Soviet era. Following the fall of the Soviet Union, however, local schools no longer had the necessary financial resources to sponsor extracurricular activities, and thus children were left with more free time and less to do. These are factors that may play a role in the increasing IDU epidemic. However, more research is needed in this area.While young people from the Vinnitsya community were exposed to various forms of pro-drug messages  on practically a daily basis, the effort to counteract the influence of these messages by informing the public about the dangerous consequences of substance abuse was minimal. Aside from the recent implementation of school-based anti-drug programs and a special radio program that reaches out to the Vinnitsya city residents, there was very little evidence of anti-drug propaganda . Furthermore, not much was said about the association between alcohol abuse and HIV/AIDS. This was especially true in the rural areas, where the information was needed the most.The promotion of anti-drug messages in schools tended to be the most favored primary prevention approach toward controlling the spread of IDU in this area. The RND has been active in launching several school-based anti-drug prevention programs in all 40 local schools in Vinnitsya, as well as schools in the surrounding areas. Most schools and teachers were surprisingly open to this type of intervention. Students were also quite open and interested in the topics presented and actively asked and answered questions. These programs, however, did not appear to be carried out to their fullest potential. They were not theory-based or standardized in their delivery. The focus of the sessions was primarily on IDU and excluded more common substances such as tobacco and alcohol. The programs were mostly didactic with no experiential components. Teaching materials and information were not always age appropriate, and there were no hand-out materials or resources to obtain help or further information about drug abuse. Furthermore, the programs did not have a built-in evaluation system.st–4th grades self-efficacy skills  through fairy tales, games, and various fun activities. Teachers also were provided with guides on how to conduct interactive sessions and ideas on how to get parents involved. Older children were encouraged to participate in a voluntary Children's Club, in which children taught each other about the negative consequences of drug, alcohol and tobacco use and sexual activity, as well as sexually transmitted diseases. This program, however, was being implemented at only one school in the Vinnitsya area, and no information on its efficacy has been presented.Another school-based primary prevention program implemented by a local NGO, titled Project Hope, was modeled after a project that started in the United States and has been implemented in many areas around the world – including Moscow and three Ukrainian cities . The goal of the program was to teach children in 1The local media also were involved in primary prevention. The public radio aired a special program on drugs, during which various substance-abuse specialists talked about the consequences of drug abuse and how to deal with addiction. The program also included individuals who had personal experience with substance abuse and were willing to share their story with others. The goal of the program was to provide people with the necessary information to encourage young people not to take drugs or encourage individuals who use drugs to seek treatment. The local newspaper also has created a special section with information about drug use . Most of this information, however, was limited to individuals who live in Vinnitsya and did not reach the rural areas, where the information also was needed.In the area of tertiary IDU prevention, a local NGO has been carrying out a needle/syringe exchange program (NEP/SEP) at various sites in the Vinnitsya area over the past three years. There were two NEP/SEP sites in Vinnitsya, as well as sites in Kalynovka, Ladyzhyn, Zhmerynka, and Haysin, with one being planned for Kaziatin. IDUs in the area were able to exchange used needles and syringes for new, sterile needles and syringes at no cost. The goal of the program was to reduce the potential harm of IDU by reaching out to individuals who put themselves at risk for physical injuries, nerve damage, and infection with sexually transmitted diseases and various blood-borne viruses including HIV, Hepatitis B and Hepatitis C. Educational booklets distributed included information on safer injection practices (to avoid serious injuries such as nerve damage), safer sex practices, and information on where to go for treatment.Though the authorities have supported harm reduction programs such as this, needle exchange was not yet fully accepted within the community. There was still some doubt as to the effectiveness of such a program, and there was even some suspicion that NEP/SEP served as a place to purchase drugs. According to the social workers from the Vyshenka District NEP, the local police had been suspicious that the social workers were involved in the drug trade. The police had been known to send in undercover agents, for instance, to see whether they could purchase drugs or poppy straws from the social workers. The program was advertised through "word of mouth" due to the stigma placed on IDUs. There tended to be a lack of coordination between the NGO and other organizations in the community, all of which would help to make the program more effective. No empirical information on the effectiveness of this program has been presented to the research or local community over the three years of program operation.The RND  is the only facility for the diagnostics and medical treatment of alcohol and drug related disorders in Vinnitsya. Located in the south Leninsky district, it is staffed by medical doctors, psychologists, social workers, and nurses. It also carries out the expert assessment of substance use disorders for local road police and the criminal justice system and provides educational lectures to local and rural elementary schools. There were more 24 thousand persons "registered" as patients of the RND. The patient population was primarily male and approximately 60 percent from the city of Vinnitsya and 40 percent from rural areas. Most patients were being treated for alcohol-related disorders. Only 10 percent were opiate IDUs, despite the increasing demand for treatment of this problem. Treatment was organized into three stages: medical, psychotherapy, and rehabilitation. Primary emphasis was placed on medical treatment.Though the RND is a public health facility, the government covers only a small portion of the total cost of treatment, which barely covers staff salaries. Treatment in public institutions is considered free, which means that patients do not pay any hospital or physician charges. However, since the breakdown of the Soviet system, the state budget does not make provisions for medication. Consequently, patients were responsible for covering the cost of medicines and various medical supplies, which usually added up to about 150 grivnas ($28) for the minimum length of stay – an amount that exceeded some people's monthly salary. The RND provided treatment primarily for the patients' physical dependency  with very little aftercare, and it was plausibly reported that many patients have short remission times and return to alcohol or drug abuse just a few months following the completion of the treatment. Each patient is recommended to follow up with a psychologist or a regional narcologist after discharge; however no monitoring system is in place, which prevents valid outcome assessment. According to the treatment providers' personal experience, very few patients do see their psychologist or narcologist before the next full-blown relapse. Factors that may hinder the effectiveness of the treatment include: high cost and short length of treatment, lack of evidenced-based interventions, lack of outpatient treatment and drug use monitoring, and absence of narcotic substitution medication therapies. There are essentially no eligibility criteria for admission; any resident of Vinnitsya oblast could enter the RND if diagnosed with a substance use disorder. High costs of medication and little faith in the efficacy of available treatment among potential patients further decrease the attractiveness of drug treatment in Vinnitsya.There was a great amount of prejudice toward IDUs both within the community and among medical professionals that presented another barrier to the effective treatment of IDUs. Interviews with medical practitioners revealed discriminatory attitudes toward IDUs. They were perceived to be criminals and/or individuals who lack moral values. Furthermore, IDUs were not the most "liked" patients, even at the RND, where patients with alcohol dependency were said to get preferential treatment. Alcohol dependency may be more acceptable due to the strong cultural role of alcohol in this society. Some medical professionals viewed IDUs as "hopeless cases" or as individuals who are "impossible to treat." It is commonly believed that IDUs generally were not willing to change their lifestyle and came for treatment only in order to lower their tolerance level (as it becomes too expensive for them to inject) or avoid a prison sentence. Furthermore, some health professionals explained that IDUs are so mentally disturbed (due to brain damage) that they are no longer receptive to any treatment. Direct observations at the treatment center revealed that it was not unlikely to see a physician on duty refuse treatment to HIV positive IDUs and send them to another facility . The director and staff of the RND, however, were highly compassionate and motivated to improve the state of treatment services for alcohol and drug related disorders at the RND.A response designed to positively impact mortality and morbidity associated with HIV and IDU in this part of the world must be swift and comprehensive. Given that Ukraine has sparse resources to be devoted to this problem, action recommendations should be prioritized, realistic, and initially targeted to persons in greatest need. The following action recommendations are prioritized by the following categories: First priority: Voluntary Counseling and Testing; Second Priority: Prevention and Education; and Third Priority: Harm Reduction and Treatment. They are provided in this sequence based on what response can realistically be implemented first with limited additional resources and can make the greatest immediate impact. The persons at greatest risk, HIV positive persons and IDUs, should be attended to first.The existing ICOHRTA has a four-year history of training health care providers, medical students, and drug addiction specialists and has a relationship with existing agencies capable of responding to the HIV and IDU epidemic. As such, we recommend using the resources and staff of ICOHRTA for initiating and sustaining the implementation of the following priorities. IROHRTA resources and staff can link in-country stakeholders with educational materials, risk assessments, skill building protocols, and evidence-based prevention and intervention protocols, training. They also can offer assistance with writing grants to procure funds for HIV testing supplies, condoms, bleach kits, educational materials, research, and salary support for prevention staff.Voluntary counseling and testing for HIV (VCT) is often used as the first step in addressing HIV transmission and prevention. Most people who have HIV do not know they have it. Furthermore, many people at risk are afraid to be tested because of the stigma associated with IDU and HIV and fear of testing positive. One way to address the AIDS epidemic is to give people an opportunity to know their HIV status so that they can take precautions to avoid further spread and seek treatment if they are infected ,26. ApprIdentification of those in need of help through effective outreach, motivational enhancement, risk assessment, and VCT must be the first priority to make an immediate impact on those at greatest risk in Vinnitsya. Vinnitsya has various locations appropriate for VCT sites. For example, the RND, the Infectious Disease Hospital, PMU, the STEPS program , and the NEP NGO are existing organizations that could offer VCT services. Training of agency staff is recommended in effective peer outreach strategies, risk assessment, motivational enhancement, and VCT protocols. Immediate diversion of agency funds and applications for small grants are recommended to fund the purchasing of HIV test kits. Successful outreach and VCT will immediately break down the first barrier to assessing the problem through anonymous testing, epidemiological prevalence surveys, and provision of prevention, education, and treatment to those most in need.As a result of effective outreach and VCT, four high risk populations will emerge, in order of severity: HIV positive IDUs, HIV positive non-IDUs, HIV negative IDUs, and HIV negative non-IDUs. The second priority is the prevention of HIV transmission among high risk populations through education, skills development, and distribution of free condoms with support from the ICOHRTA. Secondary prevention or the prevention of the spread of HIV by persons who are HIV positive IDUs or HIV non-IDUs should be given the greatest attention. Since only persons with HIV can spread HIV, reducing risk behaviors among persons who are HIV positive can make the most immediate impact on transmission rates.HIV positive IDUs should be targeted first for secondary prevention by VCT providers via education about their risk of transmitting HIV to others and how to prevent transmission through abstinence or reduce it through condom use. They should first have access to free condoms and be trained in correct condom use and then interpersonal sexual negotiation skills to practice safer sex or abstinence. HIV positive IDUs should then be educated about the HIV transmission risks associated with IDU and the dangers associated with sharing needles, syringes, paraphernalia, or drug solutions. Drug and alcohol use in general reduces the practice of safer sex and drug use behaviors, but IDU is the most risky behavior due to the opportunity to spread the virus by sharing needles, syringes or other contaminated drug use paraphernalia. Therefore, training in needle and syringe cleaning with bleach should be given high priority.Persons who are HIV positive may be suffering from despair and depression and be less motivated than high risk populations to practice safer sex or IDU behaviors. It is recommended that VCT prevention staff be adequately trained in the areas of coping with HIV diagnosis, apathy, depression, and even suicidal ideation. Finally, prevention staff should work on identification and notification of sexual and IDU partners. HIV positive IDUs represent a significant risk to their sex and drug use partners. HIV positive IDUs should be encouraged to inform partners of their HIV status so the partners can have the opportunity to practice HIV prevention themselves.The next two high risk populations in order of severity are HIV negative IDUs and HIV negative non-IDUs. They should be targeted next for prevention and education. Many of the prevention strategies proposed above for HIV positive persons apply to these groups. HIV negative IDUs should be given the first priority because of their risky practice of IDU. They should be provided with the abovementioned programs to prevent drug use prevention, teach sexual negotiation skills and provide condoms. They also should be encouraged to return for re-testing after three months. Finally, HIV negative non-IDUs are the next target population. This group should be assessed for unsafe sex behaviors and non-IDU risky drug and or alcohol use. They should be provided with condoms, HIV prevention education, risk reduction skills, and information about the use of drugs and alcohol and practicing unsafe sex.Once high risk populations are identified and tested for HIV, and prevention and education have been implemented, attention should be given to reducing harm from existing risky behaviors and enhancing opportunities for treatment. The philosophy of harm reduction, as opposed to abstinence, should guide the initial delivery of tertiary prevention. While abstinence from both sex and IDU behaviors is the only safe way to prevent HIV transmission, this advice is often met with resistance, takes a long time to achieve, and is not realistic for many persons. The most commonly practiced harm reduction method to limit the spread of HIV among IDUs is implemention of NEP/SEP. Vinnitsya has had an NEP funded by a NGO for the past several years. This NEP reaches out to the community from two street sites, offering clean needle exchange and alcohol swabs. The concept of NEPs in Vinnitsya is not fully accepted by the police, and the NEP sites are regularly monitored for any illegal practices. It is recommended that the ICOHRTA investigators meet with the leader of this NGO and discuss ideas of offering free condoms and prevention literature, making referrals for treatment, site expansion, and additional funding. Strategies should be discussed about how to link the NEP with treatment providers in the community to refer persons needing and motivated to seek out drug addiction treatment or medical services related to IDU or HIV/AIDS.Treatment for IDU and HIV/AIDS is limited in Vinnitsya. However, since the beginning of the ICOHRTA approximately four years ago, training, research opportunities, and grant funding for treatment of both IDU and HIV/AIDS has increased. Assessment of drug addiction treatment model preferences was assessed among providers and patients of the RND in preparation for the technology transport of behavioral, HIV prevention, motivational enhancement, and relapse prevention interventions . The NatIt has been stated that in order to control the HIV/AIDS epidemic, one must first understand the cultural, political, economic, and religious context in which populations, individuals, and their behaviors are situated . An incrThough the Vinnitsya Oblast is not the most severely affected region in terms of HIV infection, the assessment of the current state of the HIV/AIDS in this area of the country does shed some light on what is going on there. First, we have learned that there is a great shortage of resources for testing of HIV/AIDS  and low HIV/AIDS awareness in the general population. It is therefore possible that the statistics from these areas may be inadequate due to underreporting. Thus, there may not be such a large difference between the heavily affected regions  and other regions of the country. The most heavily infected regions may simply have better reporting systems and resources for HIV testing.Second, while the statistics for Ukraine as a whole seem to indicate that there is a shift toward heterosexual transmission of HIV, a great majority of the HIV infections reported prior to 2004 in the Vinnitsya region were among IDUs. It seemed plausible, that the HIV/AIDS epidemic in the Vinnitsya region was a few years behind. In fact, there were no officially registered HIV infections in this region until the year 1996, and the current distribution of HIV infections by risk group actually resembles the national statistics for that same year. Unexpectedly, the majority of newly registered HIV cases in Vinnitsya in 2004 were attributed to heterosexual transmission (54.1%). It can be explained either by a true shift in the epidemic dynamics or by improved surveillance after the establishment of the Regional AIDS Centre; however, there are no sufficient data to document either explanation. In any case given that the great bulk of existing HIV cases are among IDUs it is reasonable to conclude that high, significant problems lie ahead without enhanced prevention and treatment efforts.There also is a shift in the nature of drug use and the demographics of individuals who abuse drugs in this part of the country. Currently, individuals who abuse drugs tend to be younger, and the drugs tend to be more potent and riskier than they were when Ukraine was a part of the Soviet Union. Drug abuse appears to start with the use of alcohol and smoking of cannabis among children as young as 10 years of age, which may help to explain the earlier onset of IDU. Konoplya, a strong cannabis-based substance that was not as common among teenagers during the Soviet era (perhaps due to a stricter regulation at the borders), may serve as a gateway drug, leading the way to experimentation with more risky drugs (i.e. homemade stimulants and opiates). Because many IDUs make the opiate solution themselves in non-sterile home-laboratories, they have control over its strength; face a greater chance of contaminating the solution (i.e. by using unclean works and solvents); and present great risks of HIV transmission through needle and drug sharing. Prevention and treatment efforts have been attempted with limited success due to inadequate resources, training, and the burgeoning IDU problem in the area. Avenues for change in the drug addiction prevention and treatment fields are open due to caring and motivated health care providers and public health officials. In order to control the HIV/AIDS and IDU epidemics, one needs to consider a great deal of factors that fuel these epidemics. Changes may have to be made at the levels of individuals, services, communities, environments, and policies. Consequently, it will take a collective effort to make significant progress.ICOHRTA – International Clinical, Operational and Health Services Research and Training AwardIDU – Injection Drug UseIDUs – Injection Drug UsersIDU-RAR – Rapid Assessment and Response in Injection Drug UseNEP/SEP – Needle/Syringe Exchange ProgramNGO – Non-governmental OrganizationPMU – Vinnitsya National Pirogov Medical UniversityRND – Regional Narcological DispensaryUAB – University of Alabama at BirminghamWHO – World Health OrganizationThe author(s) declare that they have no competing interests.Katerina Barcal, MPH conceived of the study and its design, the collection of data, organizing the data for qualitative analysis, drafting the article and making final edits, and giving final approval for publication.Joseph E. Schumacher, PhD mentored Ms. Barcal in the study conceptualization, design, data analysis, manuscript preparation, giving final approval for publication.Kostyantyn Dumchev, MD, MPH participated in the design and methodology of the study, collection of the data, organization of the data, editing the manuscript, and giving final approval for publication.Larisa Vasiliyevna Moroz, MD, PhD participated in the acquisition and interpretation of the data, editing the manuscript, and giving final approval for publication.


At a two-day private meeting in Tokyo in June 2005, some of Japan's most senior politicians and powerbrokers met to consider the steadily expanding HIV/AIDS epidemic. AIDS has recently become a matter of increasing concern in Japan following an HIV epidemic in several major Japanese cities among Japanese men having sex with men at sex-on-premises venues. The Japanese elites at the Tokyo meeting were shocked to learn that the United States has by far the highest annual AIDS incidence among OECD countries at 15/100,000  on M on M8] oIn response, 35 individuals from United States' War on Drugs organizations wrote to Ambassador Randall Tobias on May 25, 2005 see  9]. Thi. Thi9]. Fixing 'the intelligence and facts on the policy' has trapped the United States of America into a military quagmire in Iraq and contributed to looming economic problems resulting from the twin current account and Federal budget deficits. Fixing 'the intelligence and facts on the policy' for illicit drugs, ensured tragic health, social and economic consequences for the United States of America . ExtendiAmbassador Randall Tobias-Zero Tolerance file.doc A response from 35 individuals and organisations urging Ambassador Tobias to continue to promote and defend the United States' position in a document expressing UNAIDS HIV prevention policy.Click here for fileAmbassador Randall Tobias HR.doc Letter to Ambassador Randall Tobias expressing concern about recent reports that US officials have questioned the efficacy of needle exchange programs and sought to block support for needle exchange in a document expressing UNAIDS HIV prevention policy.Click here for file


The Internet has served as a fertile and un-refereed medium to spread HIV denialist beliefs, argue the authors. It may seem remarkable that, 23 years after the identification of the human immunodeficiency virus (HIV), there is still denial that the virus is the cause of acquired immune deficiency syndrome (AIDS). This denial was highlighted on an international level in 2000, when South African president Thabo Mbeki convened a group of panelists to discuss the cause of AIDS, acknowledging that he remained unconvinced that HIV was the cause . His idehttp://www.actupsf.com/aids/index.htm). In 2000 the chapter wrote letters to every member of Congress asking them to stop funding research into HIV  diseases called AIDS. Many biochemical scientists now question this hypothesis. We propose that a thorough reappraisal of the existing evidence for and against this hypothesis be conducted by a suitable independent group. We further propose that critical epidemiological studies be devised and undertaken” .These signatories do not, however, suggest who the “suitable independent” group should be, since, presumably, many scientists have already been “indoctrinated” into believing that HIV causes AIDS.  They also ignore thousands of epidemiological studies that have already been published in the scientific literature. And the signatories fail to provide a convincing case that there is widespread acceptance in the scientific community for their marginal position.Nevertheless, Farber wrote in a 1992 article that “more and more scientists are beginning to question the hypothesis that HIV single-handedly creates the chaos in the immune system that leads to AIDS” . SimilarFurther, deniers exploit the sense of fair play present in most scientists, and also in the general public, especially in open and democratic societies. Calling for a fair discussion of dissenting views, independent analysis of evidence, and openness to alternatives is likely to garner support, regardless of the context. But it is misleading for the HIV denial movement to suggest that there is any real doubt about the cause of AIDS.Of all the characteristics of deniers, repeatedly nudging back the goalpost—or the threshold of evidence required for acceptance of a theory—is often the most telling. The strategy behind goalpost-moving is simple: always demand more evidence than can currently be provided. If the evidence is then provided at a later date, simply change the demand to require even more evidence, or refuse to accept the kind of evidence that is being offered.In the 1980s, HIV deniers argued that drug therapy for AIDS was ineffective, did not significantly prolong survival, and in fact was toxic and damaged the immune system . HoweverHIV deniers also arbitrarily reject categories of evidence, even though they are generally accepted across scientific disciplines. For example, they deny inferential evidence that HIV causes AIDS, including data examining the closely related simian immunodeficiency virus (SIV) in genomic and animal studies . LikewisAfter so much criticism levied upon the prevailing theories by deniers, one might think they would have something to offer to replace HIV as the cause of AIDS. However, the alternatives they offer are much more speculative than the mainstream theories they decry as lacking evidence. Further, their arguments amount to little more than another logical fallacy, the false dichotomy: they assume that overturning the prevailing theory will prove their theory correct, by default.http://www.aliveandwell.org/) .Interestingly, alternative hypotheses for AIDS causation depend on where the patient lives. In Africa, HIV deniers attribute AIDS to a combination of malnutrition and poor sanitation, i.e., they believe that AIDS is simply a relabeling of old diseases. In America and other wealthy countries, they claim AIDS is caused by drug use and promiscuity. Duesberg has long been an advocate of the idea that the use of “poppers,” or amyl nitrate, is a cause of AIDS in the gay community . With thNature Medicine [Because these denialist assertions are made in books and on the Internet rather than in the scientific literature, many scientists are either unaware of the existence of organized denial groups, or believe they can safely ignore them as the discredited fringe. And indeed, most of the HIV deniers' arguments were answered long ago by scientists. However, many members of the general public do not have the scientific background to critique the assertions put forth by these groups, and not only accept them but continue to propagate them. A recent editorial in Medicine  stressesWhile the descriptions of HIV denialism above refer to relatively organized campaigns, there are other less orchestrated examples of such denialism. A recent study, for example, showed that a large percentage of African Americans are suspicious of mainstream AIDS theories due to a general distrust of government authorities . ArgumenHow much of this lingering denial is the fault of scientists and the media for originally proclaiming AIDS a universal “death sentence”? Even though this idea may no longer appear in the scientific literature, it remains a public perception of the disease. It is difficult to strike the correct balance between providing information conveying on one hand the severity of the disease, and on the other optimism about treatment and advances in understanding HIV pathogenesis . Oversimplifying AIDS science to the public lends itself to exploitation by AIDS deniers who remain “alive and well” years after diagnosis with HIV. Yet these concerns must be balanced with the desire to convey the proper gravity of the situation and motivate those who are known to be HIV positive to seek treatment: a difficult line to walk.This balancing act, in fact, deserves increasing attention from medical scientists in the age of the Internet and a broadening gap between the practice of science and public understanding of science. Successful public health education requires the presentation of a clear and simple message supported by a solid consensus of the medical community. Yet the reality behind the scenes is often quite different. Every medical field has its legitimate controversies and complexities, and the process of science is often messy. Denial groups exploit the gap between public education and scientific reality.Further, countering the misinformation of HIV deniers needs to be conducted in the broader societal context of countering anti-science and pseudoscience. The strategies of HIV deniers, like many other denialist movements, seek to undermine the very philosophy of science itself, to distort public understanding of the scientific process, and to sow distrust of scientific institutions. Unscientific alternative medical modalities have made significant inroads into the institutions of health care through political means, despite a continued lack of scientific legitimacy: vaccines are characterized as dangerous instead of life-saving; psychiatry is mocked by celebrities and others in the public eye. Meanwhile, many leaders in science and business are concerned that the United States is losing its edge as a scientific powerhouse.There remains a deep problem of overall scientific illiteracy in this country and others, creating fertile soil for those who wish to spread scientific misinformation . The sci


In 2004, bioethicist Michael J. Selgelid decried:Given the magnitude of the AIDS catastrophe in Africa – and given that the causes and consequences of this crisis directly involve issues of justice – it is surprising that, to date, no major books addressing AIDS in Africa have been produced by (those who primarily consider themselves to be) bioethicists. As this is one of the most important issues of our time, the lack of bioethics literature is unfortunate and reflects poorly on the discipline of bioethics .Ethics and AIDS in Africa: The Challenge to Our Thinking  happen to die of an ailment whose remedy or part thereof is locked up in one's cupboard (p. 189)."In chapter 12, the third discussion of HIV vaccine trials takes a different slant, examining the issue of enrolling children in trials. Melissa Stobie, Ann Strode and Cathy Slack present a coherent and timely analysis of the ethical and legal dimensions of the 'best interest standard' for children in South Africa vis-à-vis HIV vaccine trial participation. By drawing on legal frameworks  and ethical guidelines , they illustrate the disjuncture that exists between the paternalistic protection of specific children versus the anticipated generic protection of children as a vulnerable population who deserve special safeguards. This dilemma mirrors the tension between individual and collective good, and between deontological and consequentialist approaches that have been woven throughout the book.et al recommend that the best interest standard should apply to both individual children and children as a class, and should be used to balance paternalism with empowerment. To further guide practice, they present a range of criteria  that should inform this balancing act.Ultimately, Stobie In the final chapter of the anthology, co-editor Loretta M. Kopelman presents yet another approach to the issue of ethics and AIDS in Africa by drawing on historical and biblical ideas embedded in the punishment theory of disease. She critiques this theory which understands people as being culpable for acquiring HIV because of sins (in the religious form) or dubious lifestyles (in the secular form). Ultimately, and not surprisingly, she discredits this approach in both its religious and secular forms and argues that emphasis on this approach to HIV is counterproductive and undermines the compassionate care for those in need.A recurring theme throughout the anthology (to the point of redundancy) is critique of the mismanagement of HIV/AIDS by the South Africa political leadership, and President Thabo Mbeki and Minister of Health Manto Tshabalala-Msimang in particular. This repetition can be explained by at least two factors: first, that the issue itself is so dire, and second, that 9 of the 13 chapters are authored by South Africans. However, there are important insights presented to broaden the opinion of readers who may only have heard of Mbeki as a morally-questionable president who queries whether HIV causes AIDS. Rather, we see Mbeki painted as an outstanding leader helping South Africa through the difficult post-Apartheid transition, and for whom AIDS policy has been a bizarre anomaly in an otherwise impressive political record. Various authors provide insight into his baffling stance, drawing most compellingly on explanations that are located within historical contexts of Western domination and imperialism as opposed to explaining away the phenomenon as due to a corrupt or uncaring president. Of course, such explanations do not excuse this behaviour or the profound suffering that it has caused.To deepen this analysis, we would have appreciated further exploration of the by-products of these (in)actions. For instance, one of us (NN) has found that a central reason for the apathetic response to HIV/AIDS from South Africa youth leaders  is that statutory youth organizations adopt the policy platforms of their parent organizations. Thus, the ANC's abandonment of HIV/AIDS at the highest level has been mirrored among their youth leaders. However, South Africa is currently experiencing what appears to be a sea-change whereby the morally dubious approaches of President Mbeki and his Minister of Health may be reversing and a new dawn is (possibly) being ushered in for HIV/AIDS policy.A glaring omission in this book is a sophisticated treatment of the ethical dimensions of gender vis-à-vis AIDS in Africa. This is not to say that gender is not taken up as an issue by several authors, but the analyses are narrow at best . Furthermore, in keeping with earlier comments about the limited engagement with ethics theory, there is an absence of feminist ethics perspectives informing our thinking on these issues.One final note is that only 3 of the 13 chapters were authored by women. Tallying gender ratios is not always a useful exercise, but in the case of AIDS in Africa where the voices of women have historically been underrepresented, this sort of reflection is essential.The fact that this book has been written largely by African academics is an important contribution for a field that is dominated by commentators from the West. However, it is noteworthy that all of the African authors, with one important exception, are from South Africa and that the focus of many chapters is the South African experience. Indeed, there are enough ethical issues complicating AIDS efforts in South Africa to fill several books, but the stated aim of this anthology is Africa, which leaves room for further reflection.In a related concern, any discussion of AIDS in Africa risks homogenizing Africa as if it is one culture experiencing one HIV epidemic. This is, of course, fully inaccurate. However, comments such as, "Too little is known about the culture of African sexual practices and the curbs on sexual behaviour that would be conducive to the prevention of AIDS" (p. 63), remind us of the need to explicitly recognize when issues are relevant to Africa broadly (e.g. destructive effects of odious debt) and when not they are not .A peculiar omission is discussion bridging the contribution of human rights with ethics in our thinking about AIDS in Africa. Human rights and ethics share terrain, but can also offer unique and complementary perspectives in analyses of HIV/AIDS. The one time that human rights was invoked in this anthology involved a critique of the "almost inordinate emphasis" on the right to privacy in the management of HIV and how this focus may have inadvertently contributed to further stigmatization of HIV (p. 64). The author then warns about the danger of "rights-talk". This perspective is consistent with other criticisms of human rights-based approaches to HIV of late, especially in the context of testing; that is, whether the voluntary counselling and testing that dominates current thinking and that emerged in the West amidst heightened concern for protection of human rights is an appropriate model for generalized epidemics in Sub-Saharan Africa.What is important in both of these cases is to avoid throwing the baby out with the bathwater. While there may be shortcomings of overemphasis on the right to privacy, this should not translate into a full-scale discounting of human rights-based approaches to HIV in general. There is a universe of other rights that can contribute to the way that, for instance, opt-out routine testing is implemented, or that can promote a response to HIV that is not individualistic or secretive in nature . In otheIt is because the co-editors have provided such a useful range of insights on the ethics of AIDS in Africa that we are in the position to reflect on this effort to inform future work. The topics presented in this anthology have been diverse at times, overlapping at others, and have indeed "challenged our thinking" about responses to AIDS in Africa. A useful next step would be the development of a coherent framework that unites these oft-disparate dimensions of the problem; a framework that provides a mechanism for systematically laying out the range of ethical issues facing AIDS in Africa in a way that is accessible yet thorough.By no means are we trying to be reductionist in our approach to the problem. On the contrary, we are advocating a framework that enables broader reflection on the topics that are receiving attention as well as those that are not. Not only could such an ethics framework provide the basis for identifying a more comprehensive range of issues, but the framework itself would be open to externalist critique for the kinds of perspectives that it excludes, thus expanding our universe of concern even further.et al, to macro-level concerns with the impact of globalization on vulnerability to HIV/AIDS, as discussed by Benatar. This architecture serves to reveal not only areas that have been addressed but, importantly, those that have been neglected.What might such a framework look like? We propose that Benatar's micro/meso/macro framework provides an excellent starting point for mapping out the range of issues from, for instance, micro-level issues with informed consent, as discussed by Moodley and Tangwa, to meso-level concerns regarding the participation of children in HIV vaccine trials, as discussed by Strode At the micro-level, for instance, we are better able to see that concerns related to the research process have been explored here, but that ethical dimensions of the clinical encounter, especially in this era of treatment scale-up, have been overlooked. Vaccines have been given due attention, but other prevention technologies, such as microbicides and circumcision are equally deserving of ethical scrutiny. Also at the micro-level is an absence of the voice of people living with HIV regarding the ethical dilemmas that they face in their lives. One further omission is an ethical analysis of 'ABC' prevention programming and its usefulness and limits in different settings.Meso-level concerns with community value systems have been discussed, but topics such as the rationing of scarce ART have not. This is also where we might see ethical analyses of the impact of HIV on health systems and the dilemmas they face in mounting responses, including issues around health care worker migration. The meso-level also serves to shine a light on the dicey concern of cultural practices and their links to HIV.At the macro-level, global disparities in wealth and health have been highlighted, but rich countries have largely escaped moral scrutiny for their role in both helping and exacerbating the pandemic in Africa through their trade, economic and development policies. The proliferation of HIV/AIDS donors is also a topic for ethical analysis with focus on major players that have emerged in recent years including the Bill and Melinda Gates Foundation and PEPFAR. A final suggestion is to focus on the macro-level issue of global health governance, including the role of UN agencies.Beyond the gaps illuminated by this particular ethics framework, a welcome contribution to conceptualizing the ethical dimensions of AIDS in Africa would be a critique of this theoretical approach for the kinds of issues it privileges and excludes. One such critique could come from feminist scholars, drawing in particular upon ethics-in-care approaches to thinking about the pandemic and responses to date. The point of these various conceptual framings is not only to give rise to theoretical analysis of issues, but to a programme of empirical research that examines how issues are being played out (and could or should be played out) on the ground.Ethics and AIDS in Africa, van Niekerk and Kopelman provide us with an excellent springboard for moving toward that goal.As noted by Selgelid, the ethics of AIDS in Africa is an area in dire need of study. With Both authors are researchers at the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal where Alan Whiteside (lead author on chapters 1 and 2) is the Director. Solomon Benatar (author of chapter 5) was a PhD co-supervisor for Stephanie Nixon.SN and NN analyzed the book. SN wrote the first draft of the manuscript. Both authors read and approved the final manuscript.


The Free by 5 declaration, launched in November 2004, aims to achieve free access for all individuals with HIV to a comprehensive medical package including antiretroviral treatment. User fees pose a significant barrier to achievement of the “3 by 5” strategy The declaration was developed in response to the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) “3 by 5” strategy, which aims to scale up access to ART to ensure that 3 million people have access to ART by the end of 2005 [The Free by 5 declaration  at a Commission on HIV/AIDS and Governance in Africa meeting in Maputo from Veronique Collard, an academic and activist, who asked, “What do economists believe?” This challenge led to the idea that a declaration, giving the economists' position, could be adopted by the International AIDS Economics Network meeting in Bangkok. A first draft was prepared and presented at this meeting, but the reception from the assembled economists was underwhelming.Despite this, we decided to press ahead. Veronique gave freely of her time in developing the initiative and was guided by many people, particularly Bernard Taverne of Institut de Recherche pour le Développement, Senegal; Alice Desclaux of University of Paul Cezanne, France; Gorik Ooms of Médecins Sans Frontières (MSF) in Belgium; and Alan Whiteside. We at HEARD contributed to the costs involved and provided a secretariat. Countless others in the field gave their support and enthusiasm, without which the initiative could not have happened.The overall goal of the initiative was to gather support from professionals and organisations to promote universal free access to a minimum health-care package, including ART, for people with HIV. It aimed to lobby international institutions, including UNAIDS, WHO, and donors— such as the Global Fund, the World Bank, and the US President's Emergency Plan for AIDS Relief—to adopt guidelines and actively promote the principle and implementation of free treatment. Donors were urged to pledge additional resources to ART through long-term commitments. Finally, the initiative sought to provide economic and public health evidence to inform the decisions of policy makers and governments and assist activists in their advocacy efforts.The Free by 5 declaration makes the point that the 3 by 5 strategy is unrealistic. Although the WHO seeks increased access to ART for all people living with HIV/AIDS, it does not address the costs at the patient level. The Free by 5 campaign believes that free treatment is an absolute prerequisite to the scale-up of treatment programmes and universal access to treatment.User fees inhibit patient adherence.Despite clear indications that patient fees inhibit access to treatment programmes, as outlined in the following section, the WHO strategy documents do not address this issue. Instead, the WHO treatment guidelines make frequent references to “affordability.” The WHO strategy published in 2003 recommended making antiretrovirals affordable and providing them free of charge to the poor . A revisWhat affordability means and who is poor is not defined in these WHO guidelines. Defining the poor by income level is problematic in countries where the informal economy  dominates and income records are poor.The process of implementing exemptions based on income is a waste of scarce financial and human resources as systems are costly to put in place and administer. Exemptions or waivers rarely reach those who are eligible to receive them . While tCountries set their own criteria for access, and these vary. In addition, perceptions of equity vary among and between governments, donors, and activists. These variations are difficult to manage from a clinical perspective and prevent equity from being attained at a national and international level . ExistinThe Free by 5 declaration details a number of arguments that have been made against free treatment and gives evidence that counter these views.There are claims that patients should pay in order to give value to treatment and remain adherent to the drugs. Studies in Senegal have shown that user fees inhibit patient adherence and cause frequent interruptions in therapy , and in A major argument against free treatment is that of AIDS exceptionalism. In other words, why should AIDS be treated for free when others diseases are not? There are three simple arguments countering this view.First, AIDS is the worst epidemic humanity has ever faced, which has devastating long-term social, economic, and personal impacts and is a major obstacle to development. The exceptionalism of the disease requires exceptionalism in the response. At the UN General Assembly meeting on HIV/AIDS in New York, on 22 September 2003, WHO Director General Jong-Wook Lee described the lack of ART as a global health emergency. Second, other diseases are treated free where there is a public health reason to do so. Third, it is feasible to implement free HIV/AIDS treatment in resource-poor settings. Given the nature of the AIDS epidemic, providing free treatment should be an imperative even if it can not be applied to all diseases or all in need.It is argued that patient fees are necessary to ensure the sustainability of treatment programmes. However, in Senegal fees amount to little more than 10% of the cost of drugs . PatientAIDS is the worst epidemic humanity has ever faced.The Free by 5 declaration, which is available in French, English, and Spanish, was disseminated worldwide through global MSF offices, universities, schools of public health, and NGO networks. It was signed by more than 600 people, many of whom are respected public health professionals, economists, policy makers, and key activists. Some of the influential signatories are shown in Stephen Lewis, UN Special Envoy on HIV/AIDSHelene Rossier-Blavier, Director General of AIDES France and Vice-President of the Global FundHoosen Coovadia, Victor Daitz Chair in HIV/AIDS Research, University of KwaZulu-NatalPhilippe Douste Blazy, French Minister of HealthBernard Kouchner, Founder of Médecins Sans Frontières, former French Health MinisterOmar Kabbaj, President of the African Development Bank, TunisMax Essex, Chair, Harvard School Public Health AIDS InitiativeNorwegian Council for AfricaInternational HIV/AIDS AllianceTreatment Action CampaignNational Agency for AIDS Research (ANRS) FranceRéseau Accès aux Médicaments Essentiels (RAME), Burkina FasoFondation Femme Plus, DRCThe initiative sparked extensive debate among Internet-based development and public health fora. It culminated in a media release, which was disseminated widely among the global press. The initiative was picked up by British, French, South African, and Kenyan national newspapers as well as the UN IRIN Plus News. It was also featured on a number of Web sites.It is difficult to asses the impact of the declaration over such a short time frame. After the media launch, the declaration and list of signatures were sent to UNAIDS, WHO, and the World Bank. We urged these organisations to give unambiguous support to the implementation of free treatment and take a lead in raising awareness about the issue. We encouraged all governmental and nongovernmental actors to adopt universal free treatment and actively promote its implementation. We asked that the issue be included on the agenda of technical meetings and political forums planned in the framework of the 3 by 5 initiative, and reflected clearly in all WHO/UNAIDS guidelines.At the very least, the Free by 5 declaration publicised the issue and the importance of universal free access to treatment and created a debate surrounding free treatment in public health, health economics, and human rights circles throughout the world. It is an issue that has been placed on the international agenda for discussion.For instance, the Free by 5 campaign played a role in inspiring the recent WHO/UNAIDS/World Bank meeting entitled “Ensuring universal access: User fees and free care polices in the context of HIV treatment” (21–23 March 2005). The meeting acknowledged that “for many individuals in poor countries, affordability poses an insurmountable obstacle” that depresses uptake of AIDS treatment programmes and decreases adherence of those enrolled. The meeting also noted that user fees contribute very little to overall sustainability and that if AIDS care and treatment programmes are to be scaled up, a broad shift to other financing models is required .There are many lessons from this initiative, but two are particularly important. The first is that a good idea can, with the right support, be turned into something concrete. The second is that goodwill and good sense are as important as money in shaping the policy environment. It was a small initiative with a big impact. We hope that eventually we will see the fruits of our efforts: universal free access to ART to all who need them. We feel privileged to have been part of this important campaign.


People living with HIV/AIDS (PLWA) face many forms of stigma and discrimination. This is the case in whichever country they may live, as has been shown in a number of previous research studies. In addition to experiencing unfair treatment in their families, communities, and places of work, PLWA may encounter discrimination from health-care professionals. This can interfere with effective prevention and treatment. Discriminatory practices in the health-care sector may also appear to legitimize other forms of discrimination against PLWA.Vincent Iacopino and colleagues from the organization Physicians for Human Rights, in collaboration with researchers from Policy Project–Nigeria and the Center for the Right to Health  investigated the problem in Nigeria. With a population of roughly 130 million, Nigeria is home to one in 11 of the 40 million PLWA worldwide. Around 6% of adult Nigerians are thought to be HIV-positive, and there will be an estimated 310,000 AIDS deaths this year. The indications are that infection rates will increase. Until now, little has been known about the nature and extent of discrimination against patients with HIV/AIDS in Nigeria.Trained interviewers conducted a cross-sectional questionnaire survey of 1,021 Nigerian health-care professionals in 111 health-care facilities in four of Nigeria's 36 states. Those sampled were 324 physicians, 541 nurses, and 133 midwives, and 23 health-care workers of unknown profession. Fifty-four percent of them worked in public tertiary care facilities. Many of the survey's results are worrying. Nine percent of professionals reported refusing to care for a patient with HIV/AIDS, and 9% said they had refused a patient with HIV/AIDS admission to a hospital. Fifty-nine percent agreed that PLWA should be on a separate ward, and 40% believed a person's HIV status could be determined by their appearance. Ninety-one percent agreed that staff should be informed when a patient was HIV-positive in order to protect themselves. Forty percent believed health-care professionals with HIV/AIDS should not be allowed to work in any area of health-care requiring patient contact. Twenty percent agreed that many with HIV/AIDS had behaved immorally and deserved their infection. Eight percent felt that treating someone with HIV/AIDS was a waste of resources.Providers who reported working in facilities that did not always practice universal precautions against HIV transmission were more likely to favor restrictive policies towards PLWA. In general, basic materials needed for treatment and prevention of HIV infection were not sufficiently available. Providers who reported less adequate training in HIV/AIDS treatment and in ethics were more likely to report negative attitudes towards patients with HIV/AIDS. There was no consistent pattern of differences in negative attitudes and practices across the different professions surveyed.The researchers concluded that, while most health-care professionals surveyed reported being in compliance with their ethical obligations, discriminatory behavior and attitudes towards patients with HIV/AIDS existed among a significant proportion. Inadequate education about HIV/AIDS and a lack of protective and treatment materials appear to favor these practices and attitudes. The findings of the study, in just four states, cannot be generalized to Nigeria as a whole and, although sampled systematically, it is possible that sampled facilities and health-care professionals may differ significantly from those that were not sampled in the study states. Concerns over a perceived lack of privacy in the interviews or about job status may have resulted in an underreporting of discriminatory behavior and/or an overreporting of “correct” practices or attitudes. The authors note that the health-care system in Nigeria is underfunded and suffers from fundamental problems, including material scarcity and inadequacies in infrastructure, both of which may contribute to discriminatory behavior. They call for targeted education of health-care professionals and provision of adequate resources to health-care facilities, and for the introduction and enforcement of anti-discrimination policies.