The field of heroin use disorder intervention has been in transition in South Africa since the outbreak of the heroin epidemic. Yet despite growing evidence of an association between heroin users' use of supplementary intervention services and intervention outcomes, heroin use disorder intervention programmes in South Africa generally fail to meet international research-based intervention standards.Semi-structured interviews with ten heroin use disorder specialists were conducted and the interviews were subjected to content analysis.In terms of theory and practice, findings of the study suggest that the field of heroin use disorder intervention in South Africa remains fragmented and transitional. Specifically, limited strategic public health care polices that address the syndromes' complexities have been implemented within the South Africa context.Although many interventions and procedures have begun to be integrated routinely into heroin use disorder clinical practice within the South African context, comorbidity factors, such as psychiatric illness and HIV/AIDS, need to be more cogently addressed. Pragmatic and evidence-based public health care policies designed to reduce the harmful consequences associated with heroin use still needs to be implemented in the South African context. Minimum Norms and Standards for Inpatient Centres, which explicate the criteria for the registration of residential substance use disorder rehabilitation centres in South Africa, was issued by the DoSD [In the not too distant past, almost anyone in South Africa could open a drug rehabilitation centre, offer rehabilitation services and charge a fee for these services - regardless of his or her professional training and background. These facilities were able to fall outside the ambit of the Mental Health Act Act 17 of 2002) and the Prevention and Treatment of Drug Dependency Act (Act 20 of 2002) by calling themselves 'care centres'. Such facilities were thus not regulated by the Department of Health (DoH) or the Department of Social Development (DoSD). Numerous unregistered examples of such centres still exist in South Africa, and various human rights violations have been reported [7 of 2002the DoSD .According to Weich, Perkel, Van Zyl, Rataemane and Naidoo (2008), medical practitioners in South Africa are increasingly confronted with requests to treat patients with heroin use disorders, but many do not possess the required skills to deal with these patients effectively . The colThe study explored heroin use disorder intervention strategies as imparted by a group of South African heroin use disorder specialists. The following goals were formulated for the study:* To obtain expert opinion from South African heroin use disorder specialists with regard to intervention strategies that best facilitate heroin use disorder recovery.* To furnish a description of the effective and ineffective aspects of heroin use disorder intervention from the perspective of South African heroin use disorder specialists.* To formulate context appropriate recommendations, based on established evidence-based best practice research and the outcomes of the study, for the advancement of heroin use disorder intervention programmes within the South African context.Purposive sampling was undertaken and semi-structured individual interviews with 10 heroin use disorder specialists were conducted from April 2007 to November 2009, ranging from 24 to 42 minutes. Potential participants were recruited based on their reputation for being heroin use disorder specialists within the South African context; as all the authors have practised in the field for between 10-25 years, identifying prominent specialists was greatly facilitated. All specialist participants gave their consent to participate voluntarily in the study. The small sample size was deemed adequate due to the in-depth nature of the study ['What interventions, both psychosocial and pharmacological/medical, are in your opinion the most effective in treating heroin use disorders?'A standardised plan of the interview was read out to each specialist participant, and they were assured of confidentiality and anonymity. Two professionals that were approached for participation in the study, a psychiatrist and clinical psychologist, were unable to participate in the study due to professional and personal pressures. Ethical approval for this study was granted by the Ethics Committee of the Psychology Department, University of South Africa, in February 2007.A qualitative descriptive approach guided the theoretical framework of this study. Content analysis was employed to analyse the interview information, such methods have been shown to be particularly valuable in the development of public health care interventions. This technique of analysis was also considered to be especially relevant considering the scarcity of research within the heroin use disorder intervention field in South Africa. Axial and sub-axial coding was adopted in the analysis for the disaggregation of core themes. Transcribed interviews were read, subjected to content analysis by the first author, and discussed by all the authors in order to determine the usability of the material. The interview comprised separate meaning units. These units were determined by phrases or paragraphs that were able to stand on their own and generate meaning. The translation of interviews into such units involved using the participants' own language in order to best generate a true meaning of their language. Categories were established by removing the meaning units from the rest of the interview and applying phrases that would encompass several of these units at once in their totality. These categories were coded in order to identify the regularities. Categories that were clustered together became themes. The inductive categorising of themes within the interviews increased the inter-rater reliability of the study.To authenticate interpretations, interview conclusions were taken back to all the specialist participants for possible enrichment and verification of interpretations ,12.Table All the specialist participants regarded the availability of heroin, and consequent heroin use disorder syndromes, to be a relatively new and concerning phenomenon in South Africa. The need to intervene on a national level with regard to drug dealers was highlighted as an imperative, especially taking into account the relatively early onset of the heroin problem in South Africa. The lack of manpower due to the dismantling of specialised police units such as the South African Narcotics Bureau (SANAB) was cited as a severe constraint in dealing with the heroin availability problem in South Africa. Corruption within law enforcement departments and amongst mental health and health professionals was also mentioned by the specialist participants. Due to the relatively new emergence of heroin use disorders in South Africa, a lack of specialised knowledge amongst professional people working within heroin use disorder field came to the fore; however, the specialist participants felt that this backlog of knowledge has improved markedly in recent years. Problems with regard to the monitoring of substance use disorder rehabilitation programmes were also cited as a barrier in the effective implementation of the National Drug Master Plan. One participant spoke of the stigmatisation of heroin use disorders in the traditional white Afrikaner Calvinistic community, which may, for example, have contributed to delays in the development of appropriate medical interventions.South Africa has not kept up to speed with the rest of the world... it was seen as a non-white issue, and because of the Calvinistic culture of this country, it was seen as a moral issue.''Intervention was regarded by all the specialist participants to be a central aspect in recovery and deemed of high importance. The themes of intervention and recovery were regarded to be interchangeable. The need to initiate intervention as early as possible  was cited as vital. Also, the need to thoroughly assess clients was thought to be pivotal in terms of planning the most appropriate intervention, such as psychotherapeutic, outpatient and residential, pharmacological, legal and statutory input. All specialist participants were of the opinion that the length of residential intervention depended on the chronicity of the individuals' dependence on heroin. However, some specialist participants were of the opinion that all heroin use disorders should be regarded as severe regardless of length of use.The necessity for information and education within intervention, both in terms of facilitating cognitive restructuring and enhancing professional staffs' therapeutic skills, was thought to be of significance in the study. The enhancement and improvement of therapeutic skills, professional qualifications, maintenance of professional boundaries as well as the incorporation of indigenous healers within the therapeutic intervention was noted. The specialist participants also emphasised that heroin use disorders need to be seen as primary health conditions . The need for education and accreditation within the substance use disorder treatment field in South Africa was also viewed as an imperative. Therapeutic competencies such as Motivational Interviewing, as opposed to confrontation, were deemed as effective means of intervention. High level early intervention and long-term care were highlighted as important strategies in treating chronic heroin use disorders. The need for adequate resources, such as skilled medical staff, as well as equipment and medication in residential facilities, was cited as key in treating clients holistically. The monitoring of those presenting with heroin use disorders on an aftercare and outpatient basis was deemed important in securing long-term abstinence and eventual recovery. Lack of accommodation and facilities such as halfway houses was cited as a vast obstacle relating to the long-term treatment and care of heroin users. A number of specialist participants felt that few resources could be found to assist the extremely progressed cases of persons presenting with heroin use disorder syndromes. The need for an adequate time period to detoxify those in recovery was regarded as vital especially prior to continuing on an outpatient basis with therapeutic intervention. The use of alternative therapies in treatment intervention, such as relaxation and exercise, was also supported within the scope of this study. A further treatment intervention component that was reported to be influential in producing positive effects was the adoption of a holistic approach, in addressing the heroin use disorder syndrome, underlying problems, and problems caused by the using of heroin. The range of targets include behaviours, coping methods, physical and psychological problems, co-morbidity, practical problems, social and relationship difficulties, self-awareness, problematic behaviours, lifestyle, circles etc., rather than just the heroin use disorder syndrome. The specialist participants emphasised the need for protected specialised drug units away from temptations, especially for youth, during early recovery.Some specialist participants held the sentiment that most rehabilitation centres in South Africa are not sufficiently successful in the treatment of heroin use disorders, and that the need for more therapeutic specialisation is necessary. Problems with regard to residential treatment accessibility were also mentioned, especially for people with average or low-incomes. One of the factors considered to be of most value was the continued use of post-treatment aftercare and counselling, and the importance of having a safe environment to return to if required. Residential detoxifications were also regarded to be medically safer compared to detoxifying on an outpatient basis. The need for counselling alongside pharmacological and medical intervention was regarded as an important component to intervention.The cost benefits of outpatient programmes were highlighted by several specialist participants. The financial viability and accessibility of such programmes especially for advanced individuals presenting with heroin use disorders that have little recourse to financial resources, was regarded as a major advantage to such intervention. The opinion was held by a number of specialist participants that outpatient treatment, as opposed to residential care, is more realistic in that it facilitates recovering heroin users to deal with demands and triggers within their environment without succumbing to heroin.Inpatient treatment is expensive, and doesn't test if the person can be out in the community without suddenly using the stuff; that is, can you control the craving within a community where there are a lot of triggers, knowing that there is support available.''The use of outpatient facilities that supply supervised pharmacotherapeutic interventions, such as the outpatient methadone maintenance programmes in the United Kingdom, despite the association with accidental death, was cited as being beneficial in assisting recovering heroin users adapt to their new life-styles while still being supported and monitored. One of the drawbacks of residential treatment, especially long-term residential treatment, was the possibility of inadvertently institutionalising individuals presenting with heroin use disorders and not facilitating their ability to cope in the outside world. The need to offer regular structured outpatient programmes, which enhance self-efficacy skills, was regarded to be of fundamental importance in the rendering of efficient services. Formulating a contract with clients, such as regular random urine testing, and the stipulation of possible consequences, was also highlighted as key in the rending of such services. Compliance to such programmes was found to be better with heroin users that had an active support system, employment etc. as opposed to those with minimal resources.Substitute pharmacological intervention was generally supported by the specialist participants, especially those with a medical background. However, some specialist participants reflected that a significant number of persons in recovery maintain their abstinence with supportive therapeutic input only.Two alternative modes of intervention were discussed by the specialist participants, namely no use of substitute pharmacology, implying the use of only symptomatic pharmacotherapy, the alternative being substitute pharmacotherapy such as methadone and buprenorphine. A number of the specialists felt that the pharmacotherapy intervention should not be of a long duration. The aspect of sleeping difficulties was noted as another important aspect that needed to be addressed pharmacologically in recovery as sleep deprivation is often regarded as a high risk factor for relapse.Criticism against the use of pharmacotherapy was voiced mainly from specialist participants without medical training. The sentiments were shared by these specialist participants that long-term voluntarily abstinent heroin users who were not on any form of substitute maintenance programme, were more likely to remain completely abstinent from all forms of psychoactive substances. The use of opiate maintenance programmes was generally seen as a form of substitution, without addressing the underlying psychological and physiological factors. The negativity of prolonging the dependence syndrome was cited as a prominent criticism against pharmacological maintenance programmes. However, based on the outcome of this study, pharmacological intervention appears to continue to play an important role in heroin use disorder recovery as the phenomenon involves some degree of physical dependence.The lack of sufficient medical and rehabilitative initiative within prisons, especially those awaiting trial, was highlighted as a serious problem within the Correctional Services structure within South Africa. Heroin users who struggle with withdrawal symptoms seldom obtain necessary medical and pharmacological assistance. Furthermore, individuals with a heroin use disorder serving long-term sentences rarely obtain any form of specialised care for their syndrome. The incarceration of persons with heroin use disorders presenting with no co-morbidity or anti-social type personality traits was generally held in disdain by the specialist participants. There was general consensus amongst the specialist participants with regard to the establishment of community programmes, diversion programmes and rehabilitation instead of incarceration. The need to lobby government to be more proactive in their stance toward heroin use disorder rehabilitative initiatives was seen as a necessity.Harm reduction interventions such as needle exchange programmes, though contentious, were discussed at length by all the specialist participants. Two medical specialist participants, who are both internationally acclaimed substance use disorder intervention experts, stated that since the implementation of needle exchange programmes overseas (such as in Holland), a significant decrease in health-related consequences has failed to actualise. One specialist participant reiterated the fact that under international law , heroin remains an illicit substance, this factor adversely impacts on and makes the implementation of needle exchange programmes complex.Harm reduction is a debatable issue. Unfortunately I have to quote the existing international law within the legislation, which is clearly regulated by the International Narcotics Control Board, and implemented by the UNODC - United Nations Office for Drugs and Crime. Heroin is an illicit substance, and it is listed as such.''All specialist participants were in agreement that needle exchange programmes are generally implemented with the intention of reducing harm associated with intravenous heroin use, such as the contraction of HIV/AIDS and hepatitis B, C and G. A number of specialist participants felt that needle exchange programmes might also maintain individuals presenting with heroin use disorders at a user level, extenuating their syndrome. The sentiment was held by some specialist participants that as mental health and health-care professionals, the goal of intervention should be to heal - and not to maintain heroin users' at the level of dependence. Another concern voiced by some of the specialist participants was that needle exchange programmes may further discourage heroin users from seeking rehabilitation intervention. Such programmes may also be promoting the use of heroin, sending mixed messages to impressionable individuals. A number of specialist participants also held the view that programmes such as needle exchange are too extremist. A few other specialist participants were of the opinion that it is immoral to condone and implement such programmes. One of the specialist participants mentioned that another problematic aspect with regard to needle exchange programmes, and so-called responsible use, arises with regard to progressively increasing tolerance levels and that inability to maintain dosages. The opinion of some specialist participants was that abstinence is not encouraged in such programmes, and that the heroin use disorder syndrome is perpetuated.You're actually encouraging the addiction and you're not going to stop it like that because I don't think that one guy who's really severely addicted... you will not be able to maintain a dosage of that, that's my experience with addiction. I mean he will always want more.''Concern was also verbalised by some specialist participants that an intravenous users' family, and in particular children, might also be drawn into the heroin subculture due to exposure and by experiencing dualistic messages from their parents and other family members. Comparisons were made between that of intravenous heroin use and STDs in terms of advocating abstinence and implementing harm reduction approaches such as condom use. The comment was made by one specialist participant that once an individual is sexually active or dependent on heroin, for example, the likelihood of abstinence and behaviour change is not prevalent or always realistic. In such instances, harm reduction approaches may be the only manner in which risks may be reduced; be it through needle exchange programmes (regarding intravenous drug use) or condom use . Another specialist participant verbalised that South Africa (as well as SADC and the African Union) is not at present in a position to support needle exchange programmes due to a lack of monitoring infrastructure and resources. Due to this factor, the specialist participant was of the opinion that stipulations of the United Narcotics Convention should still be adhered to within the South African context.For substances that are as destructive as what heroin is, I think needle exchange provision of clean syringes and so on, is not something you can recommend in a country such as South Africa, in the SADC region, in the African Union countries, because we don't have the infrastructure to monitor, and we don't have the resources to provide these things.''Another factor mentioned by numerous specialist participants was that at present intravenous use in South Africa is still fairly low compared to that of other countries where needle exchange programmes have been implemented. However, these specialist participants commented that should the intravenous drug use level rise (which it is likely to), then needle exchange programmes in South Africa are likely to become necessary as part of strategic public health care interventions.The general measures of heroin use disorder intervention that emerged from the study are mostly long-term measures, aimed at bringing about long-term and fundamental changes. They are often collectively described as 'rehabilitation'. The following intervention principles emerged from the study:Clarity of purpose - Are the goals of the treatment clear and are both provider and recipient in tune regarding these goals? Are there specific outcomes  being sought?* Appropriateness to the presenting condition - Is there a fit between the person's current condition and what is proposed by them?* Assessment and care planning - Has there been a thorough assessment to inform the care plan? Is this assessment based upon sound practice and knowledge and conducted skilfully? Is the care plan clear and well thought out?* Motivation for change - Can the intervention cope with and respond intelligently to ambivalence, fluctuating motivation and varying degrees of realism? Does it meet the client where he or she is at? Is the client's choice understood and taken into account?* Preparation - Is the client thoroughly prepared for the intervention to which he or she is referred? This applies to initial treatment or aftercare.* Supportive evidence and best practice - Is evidence available to justify using the intervention and to indicate that it offers a better chance of success for the presenting condition than others? Has it been properly applied in practice? If there is a shortage of evidence, what is the rationale for employing the intervention? Does this make sense and is it testable? Qualitative and quantitative research may be able to make an important contribution here.* The whole person - Are physical, psychological, social, cultural and spiritual factors taken fully into account?* * Families - Where appropriate and depending on circumstances, engaging with families and significant others at the earliest opportunity.Responsiveness - Is there an ability to adapt to changing circumstances?* Workforce - Do its members possess the right knowledge and skill to be of real help and can they apply them effectively? Do they have adequate self-knowledge? Can they combine professionalism and vocationalism? Are they expertly led, supervised and managed? Is there a commitment to continuing professional development by both the employee and employer?* Harm reduction - Are pragmatic and evidence-based public health care policies designed to reduce the harmful consequences associated with heroin use and HIV/AIDS implemented?* HIV testing - Are HIV testing and treatment services made available in places accessed by vulnerable people? Fear of stigma and discrimination often keep injecting heroin users away from public health facilities.* Environment and culture - Is it conducive to helping people to effect change? Is it attractive and does it encourage engagement? Does it signal care and invite confidence and trust? Is it structured, containing and safe? Is it positive and optimistic? Does it situate the client's welfare at the centre of its business? Does it help promote a recovery culture as opposed to a using one?* Scaffolding and recovery resources - Individual interventions function better and last longer if the client is scaffolded by a support system to sustain motivation and is helped to develop personal resources so as to sustain treatment gains.* Organisation - Is the organisation or service well run? Is it able to cope with the powerful projections associated with a distressed client group and avoid the associated pitfalls? Does it state a very clear ethical code which ensures that professional boundaries are maintained?* Quality control - Are there active systems for auditing and monitoring processes and gaining client feedback?* The system - Is the system for arranging and funding treatment, and in which treatment operates, coherent and therefore one that promotes effectiveness or undermines it? Are the pathways clearly defined and free from obstacles?* Findings of the study suggest that interventions should include a mix of approaches, both modern and indigenous, including assessment and diagnosis, pharmacological intervention, self-help intervention, outpatient, diversion and restorative justice approaches, residential care, and harm reduction tactics. However, as corroborated in the study of Odjide (2006), poor funding, insufficient skilled health personnel, poor laboratory facilities, inadequate treatment facilities, and lack of political will are some of the impediments to controlling heroin use in South Africa, as well as on the African continent in general .The outcomes of the study suggest the importance of matching persons presenting with heroin use disorders to intervention. Assessment may identify the nature and severity of the heroin-related problem, to understand why it arose, to assess its consequences and to establish the strengths and weakness of the client and his or her situation; this finding is also mirrored in the studies of Dos Santos and Van Staden (2008), Terry (2003) and McIntosh and Mckeganey (2002) -16.Once assessment is completed, the crucial question of how to help a heroin user with their problem has to be answered. The study findings suggest that the immediate response often needs to be pharmacological, although this is sometimes only a short-term measure and can only be regarded as one component of the total intervention response. A variety of counselling therapeutic intervention options were identified by the specialist participants: some are directed at the underlying causes which may have initiated heroin taking and/or contributing to its continued use, while others help to resolve the problems associated with or the consequences of heroin taking. Others dealt more with the heroin-taking behaviour itself; these are aimed at reducing or stopping heroin taking regardless of other problems or circumstances. This mix of approaches is further supported in the studies of Coombs (2004) and Rotgers, Morgenstern and Walters (2003) ,18. FindStudy findings highlight that different treatment settings may be appropriate for different individuals in recovery. Residential hospital care may be appropriate for those with coexisting acute medical or severe psychiatric problems. Long-term residential care in a non-medical setting  may be most appropriate for those in recovery who are socially unstable, but who do not suffer from co-existing acute medical or severe psychiatric problems. Outpatient care, apart from its cost efficiency, may be indicated for socially stable individuals without coexisting acute medical or severe psychiatric problems. The differences in problems and in the individuals with these problems must be taken into account before one can make an informed decision about what type of treatment intervention is likely to be most appropriate, findings of which are supported by the studies of Dos Santos and Van Staden 2008), Gossop (2003) and Gruber, Chutuape and Stitzer (2000) ,20,21.08, GossoWithin the South Africa context, the collaboration between mental health practitioners and indigenous healers should perhaps also be promoted. The motivation for corroboration by the specialist participants is put forward as indigenous healers have been serving African communities since time immemorial, understand the belief system of their people, and enjoy a respected place in their society. By understanding and entering African religious and therapeutic expressions through its own language, important underlying, and possibly historic, commonalities and connections can be identified. The basis for variants and transformations can also be established more intelligibly and is supported in the studies by Mpofu (2003) and Janzen (1998) who explored indigenous healing practices in central and southern Africa ,23. UltiThe mixed study outcomes suggest that when illicit substance use can be prevented, every effort should be made to stop the problem before it starts. Where it cannot, creative means of dealing with the risks may have to be sought. The problem is that heroin use disorders are a kind of mental illness that do not manifest itself until it is too late. It sometimes makes sense to intervene at a political level. This is particularly true in cases where demand is not yet widespread - it may be in the best interest of society to make a collective decision not to allow certain substances to become popularised. As Leggett (2001) reiterates in his multiple studies undertaken within the South Africa context regarding the phenomenon; the question of any given society must be: is this strategy workable in the present circumstances ?The specialist participants that favoured more regulated drug markets advocate a variety of harm-reduction techniques, such as allowing users to obtain their heroin or methadone from a government clinic or sponsoring needle-exchange programmes The state could participate in the market by providing the substance or the equipment under controlled conditions, thereby undercutting the illicit market, although international findings such as that of Adelekan and Stimson 1997) suggest mixed results  suggest . The revThe results of this study indicate that heroin treatment programmes and early intervention are recognised as important responses that can indirectly have a great value in rehabilitation and HIV prevention programmes among those who use heroin. Existing interventions, however, lack the scale necessary to meet the growing needs of heroin users; likewise, the high cost of adequately scaled programmes for inpatient treatment may be a problematic. Outpatient treatment, support groups, diversion programmes as opposed to incarceration and community-based treatment and support could have a significant additional impact at a lower cost. Similarly to the findings of Affinnih (2002), the present study highlights the need for risk and harm reduction strategies to be translated and adapted to the specific conditions in the South African setting . LearninRepresentative limitations may be evident in this study as different professional disciplines were interviewed across the spectrum of health and mental health, self-help and policy makers. However, the most easily identifiable persons were approached based on the authors' therapeutic, policy development and academic experiences within the substance use disorder intervention field, which ranged from 10-25 years, as well as on the objectives of the study. The sample size limitations also need to be noted. Ultimately however, the aim of this study was not to provide a basis for substantial generalisation, but rather to provide an explorative and descriptive account of heroin use disorder intervention from the view of a group of South African specialists. It is also important to note that the number of heroin use disorder specialists in South Africa was limited at the time that the study was conducted. Collecting data and information on the individual and programme levels needs to be further encouraged, as well as of the adoption of representative multilevel methods in future studies to examine the effects of various heroin use disorder interventions.Diagnosing, assessing and the management of interventions for those presenting with heroin use disorders can be quite complicated. The established HIV/AIDS epidemic in South Africa also compounds the situation. As confirmed in the South African studies of Myers (2005) and Myers and Parry (2002) treatment services, much of what is currently delivered as intervention within the South African context is based upon current best guesses of how to combine some science-based  and self-help (12-step programmes) approaches into optimal intervention protocols ,26. It iThe authors declare that they have no competing interests.MMLDS drafted the original manuscript and undertook the data collection and analysis. The other authors advised and assisted in the interpretation of the data, technical quality of the paper and the development of policy recommendations based on the outcomes of the study. All authors; MMLDS, STR, DF and BT, have read and approved the final manuscript.


There has been a renewed debate over whether AIDS deserves an exceptional response. We argue that as AIDS is having differentiated impacts depending on the scale of the epidemic, and population groups impacted, and so responses must be tailored accordingly. AIDS is exceptional, but not everywhere. Exceptionalism developed as a Western reaction to a once poorly understood epidemic, but remains relevant in the current multi-dimensional global response. The attack on AIDS exceptionalism has arisen because of the amount of funding targeted to the disease and the belief that AIDS activists prioritize it above other health issues. The strongest detractors of exceptionalism claim that the AIDS response has undermined health systems in developing countries.We agree that in countries with low prevalence, AIDS should be normalised and treated as a public health issue--but responses must forcefully address human rights and tackle the stigma and discrimination faced by marginalized groups. Similarly, AIDS should be normalized in countries with mid-level prevalence, except when life-long treatment is dependent on outside resources--as is the case with most African countries--because treatment dependency creates unique sustainability challenges. AIDS always requires an exceptional response in countries with high prevalence (over 10 percent). In these settings there is substantial morbidity, filling hospitals and increasing care burdens; and increased mortality, which most visibly reduces life expectancy. The idea that exceptionalism is somehow wrong is an oversimplification. The AIDS response can not be mounted in isolation; it is part of the development agenda. It must be based on human rights principles, and it must aim to improve health and well-being of societies as a whole. Countries are struggling to deliver on their pledges for universal access to a comprehensive set of interventions for HIV prevention, treatment, care and support, while the global economy is in crisis. At the same time there has been a renewed debate over whether AIDS deserves an exceptional response. This dispute has divided scientists, civil society, researchers and policy-makers. While deliberation is important, we must maintain focus on the 7000 people who are newly infected with HIV every day, and on those who continue to die from a treatable and preventable disease.The many AIDS epidemics affect countries and specific groups in various ways and to differing degrees. In Swaziland, 26 percent of the adult population is infected, in Kenya 7.1 percent is infected, while in Canada, only 0.4 percent is infected. South Africa, has the highest number of people living with HIV and AIDS in the world - an estimated at 5.7 million men, women and children [In wealthy countries, localized epidemics occur in specific contexts. On Vancouver's Downtown Eastside, the infection rate amongst commercial sex workers is 26 percent . In the In the early 1980s, AIDS was a new disease from an unknown retrovirus; its mode of transmission was mysterious, initially affecting mostly the gay population in the West. Its exceptional status was promoted through an alignment of interests of the medical community and gay advocates . There wThe Global Infectious Disease Threat and Its Implications for the United States' [th International AIDS Conference, in Durban in 2000, the inequity of treatment was highlighted. AIDS had become a chronic disease in the West, and a death sentence elsewhere. Activists demanded that the drugs, which were beyond the reach of most people in the developing world, should be made universally available.Internationally, AIDS became increasingly 'globalised.' In 2000, the United States National Intelligence Council (NIC) produced the ' States' . Six mon States' . At the Manufacture and sale of generic drugs, plummeting prices and growing international initiatives, resulted in an astonishing treatment roll-out, making the response once again exceptional. The costs of ART fell from about $10,000 per patient per year to $350 in the early 2000s . In 2002In our view, AIDS exceptionalism is under attack from two sources. The first were characterized by Stephen Lewis, speaking at the International AIDS Society Conference on Pathogenesis, Treatment and Prevention in Cape Town in July 2009, as: "the pinched bureaucrats and publicity-seeking academics who advocate exchanging the health of some for the health of others - who propose robbing Peter to pay Paul rather than arguing, in principled fashion, that money must be found for every imperative, including maternal and child health, and sexual and reproductive health, and environmental health as well as all the resources required to turn the tide of the AIDS pandemic" . The secA series of books and articles set out the exceptionalism debate. Chin argued UNAIDS and AIDS activists perpetuate certain myths about the epidemiology of HIV so as to keep the disease on the political agenda and, by implication, ensure funding and jobs . Pisani The strongest  arguments were advanced by England, who claimed that AIDS financing has undermined health systems in developing countries ,18. He aThe realization that AIDS programs have sometimes, in their single-minded zeal for results in less than optimum contexts, been misinformed and poorly planned should be taken as constructive criticism, instead of eliciting defensive responses. We know funding has not always been applied where it is most required. For example, in West Africa sex trade workers are a core transmitter group, but most prevention funding is applied to the general population. The Commission on AIDS in Asia found that almost 90 percent of all investment in prevention went to areas with insufficient returns . PlanninThere is also the issue of what Peter Piot, former UNAIDS Executive Director, describes as "The health system's myth. The myth that if we just, if we only strengthen health systems this will solve everything, including AIDS" . The impIn October 2008, the Lancet wrote "A view beyond HIV/AIDS will reinforce plurality and justice, protecting minorities and thus wider majorities" . In counAddressing AIDS as a 'normal' public health issue counters the stigma that is directed towards at risk groups by labeling them as 'different;' instead of getting 'special treatment' they get the treatment they deserve. This could offset the tendency of some governments to shirk responsibility for providing for these groups by labeling them as 'special interest groups' or those who make specific 'life style choices.'A 'normal' public health response is also necessarily adaptable; most at risk population groups are not static. For example, in Russia, young male injection drug users were recognized as the most at risk group until recently. However, the proportion of infections amongst women rose from 13.0 percent in 1995 to 44.0 percent in 2006 , indicatSimilarly, AIDS should be normalized in countries with mid-level prevalence, except when life-long treatment is dependent on outside resources - as is the case with most African countries - because treatment dependency creates unique sustainability challenges. Once treatment begins, medications must be taken for life. The drugs are expensive and patients will, after a period of time, need to move from first-line (costing about $92 per patient per year) to second-line treatment (at about $1214 per patient per year) . The reqBetween 2005 and 2008, 60 percent of funding for AIDS responses in sub-Sahara Africa came from multilateral, bilateral and philanthropic organizations, and more than half of AIDS funding came from the United States . In MozaPlanning for HIV and AIDS funding also demands urgency: the current economic crisis, which has hit the United States particularly hard, threatens the sustainability of AIDS funding. It is unlikely the required US $25.1 billion for low- and middle-income countries for treatment and prevention programs in 2010 will be forthcoming . The chaEven where treatment is available, AIDS requires an exceptional response in countries with high prevalence (over 10 percent) due to the need to provide treatment or face increased morbidity and mortality, and the continued challenges of implementing effective prevention programs. High incidence of AIDS related illness and death has demographic and social impacts that will be felt for generations. Life expectancy declines, the size and the structure of the populations changes, and numbers of orphans increase. For example, in Botswana life expectancy fell from 56 years during the period 1970 to 1975; to 46.6 years in 2000 to 2005 . In SoutIn high prevalence countries the epidemic has a particularly unique and troubling characteristic, often referred to as 'the feminisation of AIDS' . In SoutIn the context of high levels illness and mortality, the HIV and AIDS response also must recognize the increased care burden placed on women. UNAIDS estimates that 90 percent of HIV and AIDS related caregiving in sub-Sahara Africa is done in the home , and theIn high prevalence contexts AIDS must be mainstreamed across a nation. For example, in education there will be issues of teacher deaths, children living with HIV and the need to prevention programmes; in agriculture HIV/AIDS may be implicated in lower production . The heaWe have argued that AIDS is exceptional but that that response should not be mounted in isolation. The Maximizing Positive Synergies report identifies a range of opportunities for building on the results-based programmes established to address HIV and AIDS to strengthen health sectors and systems . For exaThe idea that exceptionalism is somehow wrong is an oversimplification. While normalizing the response where AIDS is located largely in specific population groups can ensure equitable services and treatment by addressing stigma and discrimination. AIDS must be seen as exceptional in those places where it is having long term development impacts due to high incidences of illness and death. Critics of AIDS exceptionalism do not take into account the unique situation where international aid is literally keeping people alive. In high prevalence countries, prevention programs have yet to slow the rate of infection, and finding ways to do so will require creativity and an unprecedented political commitment. The AIDS response can not be mounted in isolation; it is part of the development agenda. It must be based on human rights principles, and it must aim to improve health and well-being of societies as a whole.The authors declare that they have no competing interests.These authors contributed equally to this work.


To assess the functional status of patients with Acquired immunodeficiency syndrome (AIDS) registered in the Anti-Retroviral Treatment (ART) center.Design: Descriptive study. Study setting: ART center in Calicut Medical College, Kerala, India. Subjects: Cohorts of AIDS patients attending the ART center during the year 2007. Data collection: Done prospectively from the secondary data available from the center. Outcome measures: The demographic, morbidity, functional status and laboratory parameters were collected. Data processing was done using Excel datasheet and analysis were done using Epi info 2003.P = < 0-0001), and CD4 count and hemoglobin levels negatively correlated with staging (P = <0.001). 62% are having any of the opportunistic infections.One hundred and ninety-five patients received care during this period; 69% were males. The mean age was 38±9 years; 80% of them were married and in 50% of their spouses also tested positive for HIV. The mean CD4 count was 127 cells/microliter. The majority (90%) were categorized as WHO Stage 3 or 4 of HIV. Only 52% of them were able to perform their usual work in or outside their house; the rest were not able to lead an economically productive life. Thirty-six per cent were only able to perform activities of daily living; 12% were bedridden. The functional status of the patients positively correlated with WHO disease stage (Fifty per cent of the AIDS patients are disabled and need support and care. As AIDS is a growing problem, community-based palliative care for AIDS patients should be strengthened in India. According to UNAIDS and the World Health Organization (WHO) there are 33 million people living with HIV/AIDS around the world, of which 90% are in developing countries. During the year 2007, 2.7 million (95% CI 2.2 – 3.2 M) people were newly infected and 2.0 million (95% CI 1.8 – 2.3 M) died due to AIDS.[AIDS is a disease with a prolonged course finally leading to death in which effective cure is not yet available. Now the anti-retroviral treatment (ART) which was started in India as a government program during 2004 is prolonging the life of AIDS patients. Since more young persons were affected with HIV they live with various functional disabilities which need lifelong continuous care.th Plan period, 16.9% were earmarked for support and treatment services . According to national guidelines National Aids Control Organisation (NACO) will provide funds to NGOs for setting up community care centers for AIDS patients.[The stated Goal of the National AIDS Control Program III (NACP) of the Government of India is to halt and reverse the epidemic of HIV within five years. The strategies for achieving the goals are scaling up of interventions by providing ART to three lakh patients through establishing 250 ART centers throughout the country by 2012, thus incOut of the 172 ART centers in the country six were functioning in Kerala catering centralized services in five Government medical colleges and one at the district hospital of Palakkad. The state has 101 Integrated Counseling Testing Centers (ICTC) functioning at District / Block level and six community care centers.6 The CalUnder NACP III all ART centers will be linked to community care centers with outreach workers trained in home care. In a couThe descriptive study was conducted at the ART center (Ushus) attached to the Kozhikode Medical College Hospital in Kerala, India (Clarification given at the end). The center cater ART services to five northern districts covering a population of about 125 million, hence the data can be representative of the state and the result can be generalized. The community care center for HIV/AIDS patients for this area was functioning in the Institute of Palliative Medicine run by the Pain and Palliative Care Society, Calicut (A WHO demonstration project), which has been functioning attached to this medical college. This center has got community based organization (CBO)-based network of palliative care services and volunteers spread out in all northern districts.The subjects selected were cohorts of AIDS patients attending the ART center during the year 2007. The data collection was done prospectively from the secondary data available from the ART register (JMC-second author), after obtaining approval from the institutional ethical committee. From the registration point onwards each patient's data was collected periodically by subsequent follow-up visits for a one-year period from January 2007 till the end of December 2008. Demographic details like age, gender, literacy, marital status, and morbidity details like stages of HIV including opportunistic infections, HIV status of spouse and laboratory parameters like CD4 count, hemoglobin level were collected using a standardized form. The HIV staging was done as per WHO Classification of clinical staging. Stage I: Asymptomatic. Stage II: Unexplained weight loss <10%.Stage III: Unexplained severe weight loss >10%+symptoms. Stage IV: HIV wasting syndrome.78 The gradP value of <0.5.The data processing was done using Excel data sheet and analysis were done using Epi info 2003 (TTJ-first author).The discrete variables were expressed as proportions and quantitative variables were expressed as means +SD and the significance was fixed at a One hundred and ninety-five patients received care from this center during this period (January 2007 to December 2008). The baseline demographic data was as follows:The majority (69%) were males, which was the same as for the Y R Gaitonde Center for AIDS Research and Education YRG cohort data from south India. In the IThe CD4 count is a proxy indicator of severity of disease which corresponds to the functional status and reflects the immunocompromised state of the patients. The mean CD4 count was 127 cells micro liter  which wa8The blood hemoglobin level is another determinant of functional status. According to the hemoglobin status the majority were anemic (mean HB −10.8 gm %) which reflect the poor nutritional status of the AIDS patients attending here . AccordiP = 0.0001) and body weight The severity and progress of the HIV/AIDS disease status was assessed by WHO clinical staging. Stage I: Asymptomatic. Stage II: Unexplained weight loss <10%. Stage III: Unexplained severe weight loss >10% + symptoms. Stage IV: HIV wasting syndrome. The distP = 0.0001) and negative correlation with CD4 count .The functional status worsened during follow-up visits after six months and at this point only 39% were able to work [4According to the grades of disability, the functional status of the HIV patients was categorized into three grades by WHO, which was internationally validated. It is followed by NACO and used in all ART centers in India. The grad to work . Since Ato work 4Due to stigma and discrimination towards people living with HIV (PLHIV) existing in our society even family members are reluctant to take care of the AIDS patients.45 Someti4P = <0.05). In the future multiple disease burden and recurrent infections would make their life crippled making supportive care from others a necessity.AIDS patients are prone to various opportunistic infections. Sixty-two per cent of the studied cohort had many of the opportunistic infections associated with AIDS which worsen their disability and quality of life. At the entry level itself 33.3% were suffering from Tuberculosis (TB), 36% were affected with Candidiasis and 8.7% had pneumocystis carnie pneumonia . Among tForty-eight per cent of the AIDS patients had disabilities , were noAs AIDS is a growing problem in India and Kerala and ART has prolonged the life expectancy of PLHIV, we have to expect more PLHIV with functional disability in our society. Studies around the world have shown that the mortality decreased rapidly after the initiation of ART. Since hoData was collected from a tertiary care hospital from those who were attending ART center and hence got reporting bias. Large proportions of AIDS patients in the community were not able to report to the center due to some/any sort of functional disability and accessibility problems hence the chance of under-reporting was high.The data was collected from the ART treatment register at the center and not directly from the patients.


Gay, bisexual, and other men who have sex with men (MSM) have been among the most affected populations by HIV since the AIDS pandemic was first identified in the 1980s. Evidence from a wide range of studies show that these men remain at the highest risk for HIV acquisition in both developed and developing countries, and that despite three decades of evidence of their vulnerability to HIV, they remain under-served and under-studied. Prevention strategies targeted to MSM are markedly under-funded in most countries, leading to limited access to health services including prevention, treatment, and care. We explore the global epidemic among MSM in 2008, the limited funding available globally to respond to these epidemics, and the human rights contexts and factors which drive HIV spread and limit HIV responses for these men.What do we mean by the term MSM? MSM is a construct from the 1990s that tries to capture behavior and not identity. It was crafted to avoid stigmatizing and culturally laden terms such as gay or bisexual, which do not capture the wide diversity of orientations, sexual practices, cultures, and contextual settings in which male same-sex behaviors occur, and where HIV transmission and acquisition risks are centered. MSM includes both gay and non-gay identified men, bisexual men, and MSM who identify themselves as heterosexuals. It also includes men engaging in "situational" sex between men, such as can occur in prisons, schools, militaries or other environments; and it includes male sex workers who may be of any orientation but are often at very high risk for HIV. MSM may include some biologically male transgender persons, though some do not identify as male. And MSM includes a wide array of traditional and local terms worldwide–with enormous cultural diversity in Asia, Africa, Latin America and elsewhere. We use the term MSM here at its most inclusive. While cultural and human rights contexts, as well as prejudice, misconceptions and ignorance, are clearly important for understanding HIV/AIDS among MSM, risks for acquisition and transmission are grounded in individual behavior. At the individual level there are a number of known risk factors for HIV infection among MSM. These include unprotected anal intercourse (UAI), with the greatest risk being for receptive UAI; a high frequency of male partners (>3 per week); high numbers of lifetime male partners (>10); and a history of injection drug use (IDU)–these are individuals with dual MSM and IDU risk, and we see these where IDU and MSM epidemics overlap. There also is emerging evidence of the role of non injection drugs, especially methamphetamines, which likely increase sexual risks for MSM. In the United States, Black/African American race is associated with much higher odds of being HIV infected even when controlling for such factors as socio-economic status and educational level .Country-level population estimates for HIV among MSM reveal a number of trends. Figure To further explore this global trend, Baral, et al, conducted a systematic review of the global literature from 2000–2006 and calculated adjusted odds ratios for MSM compared to reproductive age adults by region and by prevalence , which receives substantial government funding, has been strongly supportive of MSM prevention activities In fact, NACO has filed a court challenge to India's sodomy laws on the basis that they are a barrier to HIV prevention. . Head of NACO .Another recent example of state-sanctioned homophobia impacting HIV programs for MSM comes from Uganda. At the recent PEPFAR Implementers meeting in Kampala, Uganda, three LGBT activists were arrested and charged while peacefully demonstrating for access to HIV services for MSM. On 25 July, 2008, the Ugandan police arrested and tortured one of the three (the only man) for his continued call for access to health services .These are not isolated incidents, unfortunately, but examples of the continued limitation on the rights to freedom of expression, privacy, and the rights of consenting adults to choose their sex and life partners. The international lesbian and gay association, ILGA, maintains a website with the status of rights and protections worldwide . Eighty-For example, in Senegal the law states that: "Without prejudice to the more serious penalties provided for in the preceding paragraphs or by articles 320 and 321 of this Code, whoever will have committed an improper or unnatural act with a person of the same sex will be punished by imprisonment of between one and five years and by a fine of 100,000 to 1,500,000 francs. If the act was committed with a person below the age of 21, the maximum penalty will always be applied."From Senegal, is the following personal communication to one of the authors (JS): " I am HIV positive man. Here, in my country, to be gay is against the law. The ones who are, like myself, we cannot say it openly. In order to socialize or meet other gay people, or to dance and be with our boyfriends, we need to go to clandestine places, these places are frequently closed by the police or city authorities, therefore every three months we need to look for the new one. When we go out of the clandestine gay bar, most of us will separate and take different roads to our own homes, in order to return to "normal" life, with our wives and kids. The only possible way to have a socially acceptable life, here in Senegal is to marry and have children" Personal communication with Jorge Saavedra by JOPH, person living with HIV in Dakar .How do these laws compare to international human rights standards? The International Convention on the Eradication of All Forms of Discrimination Against Women (CEDAW) states that: "Nobody should be forced to marry against their will and people should have the right to choose who they marry." Surely this basic right to choose one's spouse, which was gained by the women's movement, should apply equally to men, including when their choice is a same sex spouse.The XVII International AIDS Conference began with the world's first international march against homophobia. In advance of the march one of the authors (JS) alerted LGBT activists and the government of Panama that the march would highlight Panama as the only Latin American country still criminalizing homosexuality. That law was changed by executive order two days before the march, making Latin America the first region of the once called the third world, to be completely free of these discriminatory laws. "sex" including "sexual orientation." This ruling has made clear that discrimination based on sexual orientation is a fundamental human rights violation. Realizing this right, and ending discrimination, will likely be essential to achieving universal access to HIV prevention, treatment, and care for MSM. This is a key part of the response, particularly in those settings where social stigma and isolation for MSM remain the most marked.As part of honoring Dr. Jonathan Mann, who pioneered work on the interface of HIV and human rights, the HIV/AIDS community needs to address the human rights protections for MSM and other sexual minorities. The International Covenant on Civil and Political Rights (ICCPR) guarantees human rights "without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status" . In 1994There is evidence of the marginalization of MSM in the global response from the United Nations Joint Program on AIDS (UNAIDS) annual survey conducted among the UNAIDS country coordinators in low- and middle-income countries . Indeed,The reports cited above would seem to warrant some optimism given that a reported 72% of national AIDS action frameworks included prevention programs for MSM. However, this finding seems to be at odds with other results from the same survey. For example, only 31% of national reports on the epidemic produced globally in 2007 included government publication of "a surveillance report that includes MSM". There was only one country in sub-Saharan Africa that included such a report, and one country in the Middle East and North Africa region that did so. While half of the countries in the Asia Pacific region reported that they had a government surveillance report disaggregating HIV or AIDS data for MSM in 2007, only 38% of Latin American countries and 25% of Caribbean countries had such a report.This lack of participation has been matched by very limited funding for MSM-specific programs. United Nations (UN) Member States are required to submit country progress reports to the UNAIDS Secretariat every two years to monitor progress towards the goals established in the UN General Assembly's (UNGASS) 2001 Declaration of Commitment on HIV/AIDS (DoC). In adopting the 2001 Declaration of Commitment on HIV/AIDS, UN Member States obligated themselves to regularly report on their progress to the General Assembly. The Secretary-General charged the UNAIDS Secretariat with the responsibility for developing the reporting process, accepting reports from member States on his behalf, and preparing a regular report for the General Assembly. These progress reports include data on HIV spending (by activity and source) as the first indicator of national commitment. This indicator measures total HIV expenditures, as well as separate expenditures for HIV prevention (and other seven other groups of services and programs). The specific expenditure targeting MSM is to be disaggregated from of the sub-total for prevention .Unfortunately, not all countries have been able to report with precision their disaggregated expenditures. A total of 109 country reports included HIV expenditure information for 2006 . HoweverHow do the expenditures relate to the needs? A preliminary analysis of country reports on MSM expenditures, as reported for the monitoring of the Declaration of Commitment (DoC) signed during the Special Session of the United Nations General Assembly in 2001 (UNGASS 2001), could be compared with the 2006 country resource need estimates that UNAIDS previously developed for its report on Global Resource Needs 2006–2008  using thFigure Based on country reports to monitor progress in the implementation of the DoC, the percentage of MSM in 27 countries who report knowing where they could receive an HIV test, and who received condoms between 2005 and 2007 was 40%. Although this was an improvement, since only 9% of MSM responded similarly just two years earlier. Nevertheless, this very basic and limited measure of access to services still is extremely low.Countries where non-discrimination laws and regulations exist show higher coverage rates of prevention services among MSM. The median percentage of MSM who reported receiving condoms and knowing where they could be tested was almost 60% in countries with protective laws or regulations, compared with countries that do not have such policies (38%) .When countries are classified according to the ILGA classification of the policy environment with respect to MSM , there iBoth individual and structural level actions are called for. A minimum package of services would include: education, behavioral interventions, peer outreach, condom promotion and social marketing, lubricants, HIV voluntary counseling and testing, sexually transmitted infections diagnosis and treatment, antiretroviral treatment, and access to care and support. Addressing homophobia and providing MSM-friendly services in health services would also be required, along with efforts to reduce the social-structural determinants of HIV risk and vulnerability for these men including decriminalization, addressing stigma, discrimination and homophobia, and making concrete advances in human rights. This requires funding commensurate with need.In the National AIDS Program of Mexico, expenditures for HIV have increased overall from 2001 to 2005. They have also expanded for MSM specific programs Figure . This isHIV continues to disproportionately affect MSM worldwide. The exclusion of MSM from surveillance, targeted prevention, and treatment and care still limits the global response to HIV/AIDS. To improve the human rights and health of MSM comprehensive advocacy efforts are needed. In the third decade of AIDS it is time to realize the equal rights of MSM to access health and other services in environments that are friendly to their sexual orientation, and to recognize that meeting these needs is both a global public health priority, and a compelling human rights issue. To achieve the latter, there is a clear need to significantly increase the proportion of HIV resources targeted towards MSM.This paper derives from the plenary speech of the same name, presented during the XVII International AIDS Conference (AIDS 2008). AIDS 2008 was perhaps the most comprehensive and intensive International AIDS Conference focusing on the realities of MSM and HIV globally. The events began with the first International March Against Homophobia. In the Opening Session of the Conference UN Secretary-General Ban Ki-moon stated: "I urge nations to pass laws against homophobia". Immediately afterwards, both the President and Minister of Health of Mexico addressed directly and openly the need to eradicate homophobia. The aftermath has been far reaching: before the finalization of this paper, one of the authors (CB) was notified that, because of the denouncement of the violation of the rights of MSM activists in Uganda during this plenary, the charges against the detained activists were dropped by the authorities .The XVII International AIDS Conference was a milestone, where the MSM community, along with policy- and decision-makers, said: Enough! Evidence must inform policies. The epidemiological evidence is striking; it has existed for a long time; and we cannot continue failing to respond. Despite the occasional mention in national plans, the inadequate response to MSM has been demonstrated by low coverage rates of basic preventive services for these men, and by the scarcity of targeted spending, –still reaching only one tenth of the estimated resource needs. Such data underscore the urgent need to act now to stop homophobia, stigma and discrimination in order to deliver quality and effective services to MSM. When countries, international agencies and donors begin to target their efforts and resources based on the epidemiological evidence, and adjust funding levels to be commensurate with the HIV burden among MSM, we will see dramatic changes in the response to HIV in multiple settings. Funding efficiency can only increase when flows are directed towards populations with the greatest unmet HIV prevention needs.The authors declare that they have no competing interests.Jose Antonio Izazola-Licea was an employee of the Joint United Nations Programme on HIV/AIDS (UNAIDS) as chief of the AIDS Financing and Economics Division at the time of the writing of this paper. His co-authorship does not necessarily represent the institutional view of UNAIDS.JS conceived the plenary presentation and manuscript. CB led the epidemiology component, and JAIL led the unmet needs analsis. All reviewed the literature and contributed to the writing of the manuscript. All authors read and approved the final manuscript.


School children of today are exposed to the risk of being victims of HIV/AIDS - which was quite unknown to their predecessors a few decades ago. The epidemic of HIV/AIDS is now progressing at a rapid pace among young people. Studies have reported that young people form a significant segment of those attending sexually transmitted infection (STI) clinics and those infected by HIV. Programmst August 2005 to 31st October 2005. The students were administered a pre-designed proforma, which included multiple choice questions. Written consent was obtained from the school principals after explaining the purpose of the study to them. Data were entered and analyzed using SPSS version 13.0 by means of simple comparison of proportions.The present study was undertaken by the Department of Community Medicine, Maulana Azad Medical College and Harbans Kaur Memorial Trust (HKMC), a non-governmental organization (NGO) and a partner of programme implementation by Delhi State AIDS Control Society (DSACS). Out of 1689 senior secondary schools in South Delhi area, 60 schools (3.5%) had been allotted to HKMC Trust by DSACS for carrying out school AIDS education programmes, in which there were 48 government schools  and 12 private co-educational schools. A total of 2592 students belonging to Classes IX to XI in these schools participated in the study. The response rate of students was 100%. The study was conducted over a period of 3 months from 1In the present study, majority of the students 74.9%) belonged to the age group of 15-17 years. The mean age was 15.8 ± 0.8 years see . Most of3.9% belonOnly 48.2% of the students could name sexual route while 44.4% named sharing of syringes and needles as a mode of transmission . Similar7In the present study, only 72% of students were aware about HIV/AIDS as being preventable. Moreover, awareness about the different methods of prevention was rather low. Only 14.9% had knowledge about condoms as a means of protection, which awareness was significantly higher amongst boys. Higher levels of awareness have been observed amongst school children of Haryana.–12 Only 13With regard to the sources of information about HIV/AIDS, 79.6% of the students mentioned that television and radio were the main sources of information to them. Likewise, a majority (62.7%) of senior secondary students belonging to a government school in Chandigarh reported that they derived most of the information from TV and radio.In our study, a majority (77.8%) of students had a favorable attitude towards People Living with HIV/AIDS (PLWHA), stating that such patients should be allowed to pursue/continue studies or allowed to work in common work places. However, this favorable attitude towards HIV positive patients was not observed among college students in Nashik. About 51The findings in the present study reiterate the need for re-enforcing school AIDS education. Significant changes have been observed between pre-test and post-test knowledge and awareness levels through school HIV/AIDS education programmes in different regions.–19 While


Harmonic decoding of byline information resolves the conundrum of authorship credit allocation by providing a simple recipe for source-level correction of inflationary and equalizing bias. Harmonic counting could also offer unrivalled accuracy in automated assessments of scientific productivity, impact and achievement.Authorship credit for multi-authored scientific publications is routinely allocated either by issuing full publication credit repeatedly to all coauthors, or by dividing one credit equally among all coauthors. The ensuing inflationary and equalizing biases distort derived bibliometric measures of merit by systematically benefiting secondary authors at the expense of primary authors. Here I show how harmonic counting, which allocates credit according to authorship rank and the number of coauthors, provides simultaneous source-level correction for both biases as well as accommodating further decoding of byline information. I also demonstrate large and erratic effects of counting bias on the original  Modern science is dominated by multi-authored publications Correcting for the equalizing bias inherent in both allocation schemes requires either a total reliance on explicit contribution statements h-index Here, I identify equalizing and inflationary counting bias as the two main varieties of bibliometric bias and show how a popular bibliometric measure, the inflationary bias generated by the multiple counting of multi-authored publications th author, andthe first author gets the most credit, and in general the the greater the number of authors, the less credit per author.In contrast, biased counting systematically benefits secondary authors at the expense of the primary authors who, in the absence of byline information to the contrary, presumably earned their authorship rank by contributing more. Primary authors are located in the lower half of h-index—a heuristic metric of merit that combines inflated counts of publication and citation data for an individual author into a single integer h, equal to the number of publications with at least h citations Bibliometric counting bias affects all derived measures of per capita scientific production, impact and achievement, including publication metrics, citation metrics, and the h-index, I compared h-index scores calculated from harmonic, fractional, and inflated non-self citation counts To illustrate the erratic effects of counting bias on the h-index scores of 80% of the FBA staff were altered by the combined effect of unidirectional inflationary bias and bidirectional equalizing bias, i.e. by the difference between harmonic and inflated h-index scores , and distorted mid level scores erratically, e.g. a fractional h-index score of 4 corresponded to inflated scores ranging from 4 to 9. Two recent publications evaluating the effect of fractional counting on the h-index similarly found that fractional index scores were reduced to 58–86% of their original values Unidirectional inflationary bias, i.e. the difference between fractional and inflated scores, increased the  members , Table 1h-index scores between associate professors and full professors shows that the harmonic h-index minimized the range of overlap to a level where it would have been eliminated entirely by promoting the two highest ranking associate professors and demoting the two lowest ranking full professors , Bodø Regional University. The collective publication output of the FBA staff consists of 364 publications in 124 journals, with a total of 3685 citations, a range of 0–152 citations per paper, and a median of 5 citations per paper (mean 10.35). Only 9 publications had more than 1 coauthor among the present staff members.h-index scores, and judged it to be inconsequential.Publication and citation data were obtained from the ISI and SCOPUS databases in December 2007. Self-citations were excluded manually by checking the citation records for all publications recorded in either database. Some publications not recorded in either database were located by using the Cited Author Search feature of ISI. It was impractical to check the citation records of these publications manually, but I assessed the potential effect of self-citation in these records on individual The publication and citation coverage of ISI and SCOPUS varied. SCOPUS listed 2315 citations from 237 publications, whereas ISI listed 3030 citations from 310 publications. I compared citation counts for the 219 publications listed in both databases , and consistently used the maximum value when citation counts differed .


Sir,P>0.05), this is not of much importance. A comparison of the risk factors of the 2 years showed that during 2006, all the 22 seropositive cases had multiple sex partners and in two cases there was history of IVDU (Intravenous Drug Use) as well. No personnel were infected through contaminated blood or syringes/needles. This is in contrast to the findings in 2005 where positivity through the sexual route was 82.7% (6/7) and through blood transfusion was 17.3% (1/7). This shows an awareness about HIV/AIDS but very low use of safe sex practices 2.8% (20/712). A study conducted by experts under the National AIDS Control Organisation (NACO) reported that the Central police and Para military forces were not properly equipped to handle the serious problem of HIV/AIDS and interventions were ad hoc and uncoordinated. They also observed that the attitude towards HIV-positive personnel whose numbers were increasing every day was quite discriminating.(Acquired Immune Deficiency Syndrome (AIDS) is the most disastrous disease of its time for every segment of society. It is all the more dangerous for the forces . Ever since the first HIV case in our armed forces was discovered in a soldier returning from a UN mission in 1992, the number of HIV-positive personnel in the armed forces has grown to 6,180 in a force of 12 lakhs.(