Acquired Immunodeficiency Syndrome (AIDS) has become an important public health hazard in Iran. It is believed that AIDS-related knowledge does not necessarily translate into behavior modification. Hence, it has been suggested that culturally appropriate educational campaigns should be implemented to obtain satisfactory outcomes. Here, we evaluated the female high school students' attitude towards HIV/AIDS in Tabriz, Iran to assess the cultural needs for the related educational programs and to discover sources of information about AIDS.Anonymous, self-administered questionnaires were filled by the young female students. Among 300 students, 91% agreed that being an HIV carrier should not be an obstacle to obtaining education and employment. Moreover, 72.5% of the students declared that the community should be informed of HIV-positive people. In addition, one-tenth declared that they would feel extremely uncomfortable towards their HIV infected classmate. In addition, only 16% of the students stated that they would continue to shop at HIV infected grocer's store. The mass media and the experts were the major source and the most reliable source of information about AIDS, respectively.Tabrizian female students have overall negative attitudes towards HIV/AIDS. HIV/AIDS related educational campaigns should target the students, society and the families with emphasizing the leading roles of health staff. This fi century . Neverth century . Hence,  century .Health education and prevention remain the main health care priorities in AIDS prevention . It mighThree hundred female high school students from the fourth grade participated in the present study. The mean age of the respondents was 17.9 +/- 0.16 years (range 17–22). Two hundred and seventy three students (91%) agreed that being an HIV carrier should not be an obstacle to obtaining education and employment. The majority of the respondents (93%) believed that the community in which they were living was not protected from AIDS. Two hundred and sixty respondents (86.3%) recommended that special hospitals should be built for AIDS patients. Interestingly, 217 of the students (72.5%) declared that the community should be informed of HIV-positive people in order to strengthen the social awareness of potential source of the infection. Seventy seven students (25.5%) stated that they were not interested in having a friend who was an HIV carrier, whereas 83 respondents (27.5%) expressed that it would make no difference to have such a friend. Furthermore, only six students (2%) dissented from abortion of the HIV infected fetuses. Nearly one-tenth of the respondents disagreed with sending the HIV-positive children to special classes. A list of questions with the percentage of each response is provided in Table The mean attitude score was 59.9 out of 100 . Considering a score of 75 as the cut-off point for a positive attitude, only 6% (n = 18) of the students had a positive attitude towards HIV/AIDS. Among the demographic items, educational level of father had a negative correlation with the attitude score . We found no significant correlation between the other demographic items  and the attitude score (p > 0.05).In addition, the students were asked to suppose they found out that one of their classmates was suffering from AIDS. Only thirty respondents (10%) declared that they would feel extreme discomfort for such a situation. Interestingly, almost all the respondents (97.9%) stated that they would stay at the same school where the HIV-positive student was studying. Of these, one-fourth indicated that they would discontinue having any contact with their HIV-positive classmate, while more than half (52.1%) declared that they would treat their classmate in a usual manner. Two hundred and four students (68%) stated that they would feel discomfort to know that the neighborhood grocer had AIDS. Only 48 respondents (16%) stated that they would continue to shop at that grocery store.The majority of the respondents (80%) indicated that the mass media  was the major source of their information about AIDS, followed by school educational materials  (10%), and family and friends (10%). Furthermore, more than 75% of the students mentioned that they would rely on an expert's information on HIV/AIDS. In contrast, families and school teachers constituted the least reliable sources of AIDS-related information, respectively (3% and 2%).In the present study, we surveyed a group of Iranian female high school students' attitude towards HIV-positive and AIDS patients. The overall findings from this study indicated a relatively negative attitude towards HIV/AIDS among Tabrizian female high school students. Similarly, a previous survey by Tavoosi and colleagues on a group of Iranian high school students in 2004 revealed an intolerant attitude towards AIDS and HIV positive patients . More thIn this study, the respondents also expressed affirmative attitudes towards some of the given items. In the current survey, only a few students thought that being a carrier of the HIV should be an obstacle to receiving education and employment. This is comparable to the study of Pita-Fernández and colleagues on a group of nurses in Spain . ContrarThe reports of rapid spread of HIV infection in different populations have no doubt increased the level of anxiety in the communities . This maThis study demonstrated that educational level of father was inversely associated with the level of attitude towards HIV/AIDS. The potential indications of this finding is unclear to us, however, the paternal factors affecting the attitudes of female students may demand further investigation. No significant correlation was found between age and the attitude score, well compared to the study by Montazeri . HoweverThe present study revealed that one-forth of the students would discontinue having any contact with their infected friend. In the study of Tavoosi et al., nearly one-third of students declared that they would avoid sitting near an infected student . SurprisThe mass media  were the most common means of obtaining information about HIV/AIDS. This finding is consistent with those of Brook , TavoosiThe overall findings from this study revealed an overall negative attitude about HIV/AIDS among Tabrizian female high school students. Based on the present study, one may recommend that the currently implemented HIV/AIDS related educational campaigns for the Iranian students should be extended beyond the schools to the society and families due to unsatisfactory role of families in AIDS education and prevention. Furthermore, the leading roles of health staff including physicians should be highlighted not only in HIV/AIDS educational programs at schools, but also in the media, which at present is the most frequent but not necessarily reliable source of information.This cross-sectional study was conducted in May 2005 in Tabriz, a city located in Northwest of Iran. The study population consisted of female high school students from the fourth grade who attended the educational institutes throughout Tabriz before entering the universities. Ten out of approximately 40 educational institutes in Tabriz were randomly selected. The data was collected by self-administered anonymous questionnaires. The questionnaire Table  was deveThe authors declare that they have no competing interests.KG participated in the design of study, acquisition of data, analysis and interpretation of data, drafting the article, and final approval of this version. MMS participated in the design of study, acquisition of data, interpretation of data, and drafting the article. PK participated in acquisition of data, analysis and interpretation of data, and drafting the article. All authors read and approved the final manuscript.


Policies, Physical Structure, Work/School, Attitudes/Support, and Service/Assistance were evaluated in patients selected from a STD/HIV clinic in Jackson, MS. They were chosen based on previously diagnosed HIV/AIDS status and age (16–95). Written consents, demographics sheets and self-administered questionnaires were obtained. Data were analyzed using Excel and SPSS software. Interviews started in July 2007 and ended in August, 2007. One hundred and thirteen patients responded. Participants were 72.6% (82) male, 26.5% (30) female and 0.9% (1) transgender. The median age of participants was 38.8 (18–63). Over 50% (65) had some college or higher education, and 35.4% reported annual incomes less than $10,000. Multivariate analysis showed marginal significance between disease diagnosis and gender (p < 0.10), and statistical significance between disease diagnosis and income (p = 0.03). Also, age (p = 0.01) and education (p = 0.03) were significant predictors in one of the subscales. The CHIEF subscales that showed the greatest significance among AIDS respondents were Attitudes and Support, and Government Policies with mean sensitivity scores of 1.39 and 1.42, respectively. The element with the least effect on AIDS patients was the Work/School subscale, with a mean score of 0.74. In general AIDS patients were disproportionately affected in all but one of the five subscales observed. Conversely those with HIV were more affected in the Work/School subscale with a mean score of 1.70. This proved to be the only subscale responsible for causing the greatest degree of perceived barriers for the HIV population. With a mean score of 0.75, Physical/Structural subscale showed the least negative impact on those infected HIV without AIDS. It is therefore recommended that the environmental barriers identified in this study be addressed in order to eliminate/minimize their negative effect and improve the quality of life of HIV/AIDS patients.In recent years, environmental awareness has received a great deal of public attention. However, little emphasis has been put on the influence of environmental factors  on the quality of life of persons infected with HIV/AIDS. The goal of this study was to assess the effect of selected environmental factors on the quality of life of persons affected by HIV/AIDS. To achieve this goal, the Craig Hospital Inventory of Environmental Factors (CHIEF) subscales including  Since then, scientists have developed an effective arsenal of drugs that help manage the Human Immunodeficiency Virus (HIV), so that persons infected with the virus can live longer and healthier lives. Although there is currently no vaccine or cure for HIV or AIDS, the development of Highly Active Antiretroviral Treatment (HAART) as effective therapy for HIV infection and AIDS has substantially reduced the death rate from this disease. As the life expectancy of persons with AIDS has increased in countries where HAART is widely used, the number of persons living with AIDS has increased substantially . An alarWhile the federal government’s investment in treatment and research is helping people with HIV/AIDS live longer and more productive lives, HIV continues to spread at staggering rates. In a study named the HIV Aware/Not in Care Project several environmental/structural barriers to productive living were identified. The environmental barriers identified included; hassle of getting care, negative provider patient relationships, societal attitudes, and funding for care. Structural barriers to successful HIV treatment were transportation and poverty. The social barriers identified included; care-giving responsibilities (putting others first), fear of stigma and discrimination, and disclosure concerns ,9. This Previous research based on the Craig Hospital Inventory of Environmental Factors has demonstrated that various environmental factors including transportation issues, weather, finances and societal attitudes serve as barriers to the productive living of persons with disabilities such as traumatic brain injury, spinal chord injury, amputations and others. However, very little research has been done on environmental barriers related to HIV/AIDS. In the present study, we hypothesize that specific environmental factors/conditions have a negative impact on the quality of life of persons suffering from HIV infection and/or AIDS. Hence, our main objective was to assess and identify environmental factors that are perceived by HIV/AIDS patients as impediments to productive living.With the advent of HAART, HIV infected persons can focus not only on the treatment’s ability to extend their life span but also their quality of life. For the purpose of this article quality of life has been defined as the personal satisfaction (or dissatisfaction) with the cultural or intellectual conditions under which you live .2.2.1.et al. identified five characteristics of the environment that corresponded with or helped facilitate participation by persons with disabilities. The five characteristics of the environment purposed in the CHIEF manual were listed as: accessibility, accommodation, resource availability, social support and equality. Each is spelled out and defined in the manual as follows: Accessibility answers the question “Can you get where you want to go?” Accommodation addresses the question “Can you do what you want to do?” Resource availability addresses the question of, “Are your special needs met?” Social support addresses the question “Are you accepted and supported by those around you?” Finally, equality addresses the question “Are you treated equally with others?” These five characteristics have been found to be useful tools in evaluating environmental influences. Despite this they must be observed on an individual basis and applied to each individual’s own situation. What could potentially restrict one person may have the opposite effect and assist or not affect another. In each case, these five environmental characteristics can be assessed ranging from restrictive barriers to inclusive facilitators .The Craig Hospital Inventory of Environmental Factors (CHIEF) model was chosen for this study largely based on the fact that it had been pre-validated and contained questions that are instrumental in acquiring the data necessary to evaluate the effect of environmental factors on persons living with HIV/AIDS. In addition to questions related to environmental barriers, care was taken to add questions to collect demographic information including age, sex, and race. Hence, the CHIEF protocol was administered to HIV/AIDS patients to collect relevant environmental information including barriers related to: (a) school and work barriers, (b) physical and structural settings, (c) attitudes and support, (d) government policy barriers, and (e) services and assistance. These items individually encompass all of the areas specifically identified as barriers and as such have been found to be contained within the framework of the CHIEF questionnaire. Therefore, the CHIEF model asks questions designed to track the frequency (how often are they encountered?) and magnitude (how severe are they?) of each potential environmental barrier. From the study participants responses, the frequency at which barriers are encountered are calculated based on a scale of 0–4 , the magnitude of the problem related to a specific barrier is rated on a scale of 0–2 , and the overall score representing the product of frequency times magnitude is presented on a scale of 0–8 indicating the overall impact of the barrier. Questions were prefaced by the words, ‘In the past 12 months how often has…, where respondents could shade in one of the five answers given. As it relates to work or school they could choose a sixth response of “Not Applicable”. Once the answer was chosen as to how often they were then guided to a second part of the same question stating, “When this problem occurs has it been a big problem or a little problem”. Respondents could then shade in one of the two (questionnaire attached). Detailed information on questionnaire administration and scoring is outlined in the CHIEF manual .Although the CHIEF was designed to measure factors that keep people from getting things done, it is well known that the type and severity of a disability can affect what an individual is able to accomplish. Also, both intrinsic  and extrinsic  factors may have a significant impact on the lives of people with disabilities. In conclusion, the information collected in our CHIEF-based surveys provided a basis to understand how HIV/AIDS patients are affected by their environment, and how the specific characteristics of this environment impact their quality of life. Ultimately, this information is instrumental in helping policy makers implement the changes needed to minimize the public health impact.The findings outlined by the study done on those with traumatic brain injuries showed similar findings to this study, although done on persons with HIV/AIDS. In this study, it was also found that transportation, the surroundings, government policies, attitudes and the natural environment were considered by this group of people, particularly those with AIDS, to be the items that showed the greatest perceived barriers.Whiteneck’s evaluation of the CHIEF as a valuable tool when used to evaluate the effects of specified environmental factors is substantiated by this study. Despite this truth further studies designed to address specific factors of the environment need to be done where a larger sample size is chosen and follow-up questionnaires can be administered over a longer period of time. These findings prove instrumental in showing that the environment plays a significant role in the lives of those infected with HIV/AIDS.4.1.Almost 90% of the participants were African Americans which reduces the possibility of generalizability. Future studies should consider a more representative racially diverse population conducted in diverse settings. Further, the majority of the sample was male, thereby not accounting for gender differences. Also, Participants were recruited from one community center. Findings may be varied for persons living with HIV and/or AIDS who have private physicians or other health care providers.At certain stages, AIDS is known to be a very debilitating disease; therefore those with AIDS have to sometimes rely on others to carry out simple daily responsibilities. At one point in the study it was noted that the number of new AIDS participants started to decline, indicating that the pool of AIDS candidates had been virtually exhausted. Knowing this, future studies should involve multiple study sites, in an attempt to acquire a larger number of AIDS participants. Further, health takers who provide services to persons living with HIV and/or AIDS should be provided education on the types of environmental factors identified as barriers to productive living.Based on self-reported data, it was also found that questionnaire understanding plays an important role. Some participants did not fully understand the instructions, as indicated by missing data. Most incidences of missing data came from the design and formulation of questions. Each question had two parts and respondents with the missing data failed to fill out one of the two parts thus implying that more time should be allocated to explaining the questionnaire before hand and evaluating it afterwards.Income level was also a limiting factor because the Crossroads Clinics HIV/AIDS programs are specifically designed for those individuals who fall within a specific income range. Those with higher incomes were underrepresented creating a bias towards the lower income population. Moreover, the sample size included in the multivariate linear regression analysis may have been too small to detect or ascertain important factors that determine or predict the total CHIEF and respective sub-scales.


Evidence in the literature suggests that hyperthermia (HT) or inhibitors of calmodulin can increase the sensitivity of rodent cells to bleomycin (BLM) by interfering with DNA repair functions. In an attempt to explore methods of improving the efficacy of thermochemotherapy we have investigated the individual and combined effects of HT (44 degrees C) and the calmodulin inhibitor trifluoperazine  on early plateau phase monolayer cultures of mouse EMT6 tumour cells for simultaneous exposures to BLM. Early plateau phase cultures are relatively resistant both to HT and to BLM. The selected HT and TFP regimens  were non-toxic. Comparing the sensitizing effect (given by the ratio: Do BLM/Do BLM + modifier) of the various regimens on BLM-treated cells, we found that: TFP alone had a marginal effect (ratio 1.3), HT alone showed significant potentiation (ratio 19) and the combination of HT and TFP strongly sensitized (ratio greater than 110) cells to BLM cytotoxicity. We propose that the use of calmodulin inhibitors in thermochemotherapy is worthy of further evaluation.


Despite the centrality of family in Indian society, relatively little is known about family-based communication concerning sexual behaviour and HIV/AIDS in rural Indian families. To date, very few family-based adolescent HIV-prevention interventions have been developed for rural Indian youth. This study conducted formative research with youth aged 14 to18 years and their parents in order to assess the feasibility of conducting a family-based HIV-prevention intervention for rural Indian adolescents.Eight focus groups were conducted (n = 46) with mothers, fathers, adolescent females and adolescent males (two focus groups were held for each of the four groups). All focus groups consisted of same-gender participants. Adolescents aged 14 to18 years old and their parents were recruited from a tribal community in rural Maharashtra, India. Focus group transcripts were content analyzed to identify themes related to family perceptions about HIV/AIDS and participation in a family-based intervention to reduce adolescent vulnerability to HIV infection.Six primary thematic areas were identified: (1) family knowledge about HIV/AIDS; (2) family perceptions about adolescent vulnerability to HIV infection; (3) feasibility of a family-based programme to prevent adolescent HIV infection; (4) barriers to participation; (5) recruitment and retention strategies; and (6) preferred content for an adolescent HIV prevention intervention.Despite suggestions that family-based approaches to preventing adolescent HIV infection may be culturally inappropriate, our results suggest that a family-based intervention to prevent adolescent HIV infection is feasible if it: (1) provides families with comprehensive HIV prevention strategies and knowledge; (2) addresses barriers to participation; (3) is adolescent friendly, flexible and convenient; and (4) is developmentally and culturally appropriate for rural Indian families. Preventing the transmission of HIV in India remains a significant goal for global public health. In 2007, an estimated 2.4 million Indians were living with HIV . Among tRecognizing that the successful prevention and treatment of HIV/AIDS requires international cooperation across multiple disciplines, the Indian Minister of Health and Family Welfare and the US Secretary of Health and Human Services signed a bilateral agreement in 2006 to collaborate on the prevention of sexually transmitted infections (STIs) and HIV/AIDS in India ,5. The oOur study is a collaboration between social scientists in India and the United States that was conducted as part of the Indo-US bilateral agreement. The overall goal of the collaboration is to conduct formative research that will inform the development of a family-based intervention to prevent HIV infection among Indian youth living in a rural community in Maharashtra. The family-based intervention will integrate the principles of "highly-active HIV prevention" by incorporating both biomedical  and behavioural prevention strategies that have been deemed efficacious for preventing HIV transmission .A secondary goal is to scale up the knowledge base and research capacities of both Indian and American social scientists to develop and implement innovative, culturally appropriate, effective and sustainable HIV/AIDS prevention and treatment programmes. The results of this study represent the first of several formative research projects in support of these two goals.The overall objective was to gain insight into diverse family perspectives on the feasibility and acceptability of a family-based adolescent HIV prevention programme for rural Indian families. The proposed intervention is distinct from previous prevention approaches in that parents will be targeted as agents of change who can provide their adolescents with the guidance, information and strategies necessary to reduce their risk of HIV infection.To date, we know of no family-based adolescent HIV-prevention programmes for rural Indian youth. The majority of adolescent prevention programmes have tended to target adolescents via peer models or school-based programmes -9, or haThis study focused on adolescents aged 14 to 18 years old and their families who reside in a rural community near Mumbai and Pune in Maharashtra. Rural adolescents in Maharashtra were targeted for several reasons. First, Maharashtra continues to bear a disproportionately high burden of HIV cases in India . In addiSexual behaviour remains the leading cause of HIV infection in India , and comAlthough male adolescents report higher rates of sexual activity than females, female adolescents are also vulnerable to HIV. A complex combination of factors related to increased biological susceptibility, low levels of education, poverty and gender inequality heighten vulnerability for many females . Many yoA growing body of research conducted with young people in developing contexts indicates that parents can influence the sexual decision making of their adolescent children -17. ThesDespite widespread support for the influence of parents on adolescent sexual behaviour, parent-based approaches to preventing adolescent HIV infection in India are rare. Indian culture is often characterized as having strong norms against open discussions of sexual behaviour , and IndResearch also indicates that Indian adolescents are influenced by their parents. For example, a study in Uttaranchal observed that many young men attributed premarital sex to low levels of parental control and supervision . In addiOur study is distinct from previous research in several ways. First, it focused on families and parent-adolescent communication about HIV/AIDS as a means of preventing sexual risk behaviour and reducing adolescent vulnerability to HIV. Although the family has been the focus of interventions to help Indian persons living with HIV/AIDS, less research has focused on the family as a way to reduce adolescent vulnerability to HIV/AIDS. Open discussions about sexual behaviour are perceived as taboo in Indian culture ,24,29. AWe conducted exploratory research with families to generate insight into an understudied topic in the HIV/AIDS prevention literature. Previous research has tended to interview individual family members, i.e., adolescents ,10. In cFinally, a strength of the study is the collaboration and integration of Indian and US perspectives into the development of study protocols and a family-based intervention to prevent adolescent HIV infection.Focus group methodology was selected for several reasons. First, focus groups are ideal for understanding the norms and values of culturally diverse populations ,31. In Ipadas, or hamlets. The objectives of the IRHDP are to promote health and education and to effectively utilize and generate local resources for villagers in collaboration with the local primary health centre.The study was conducted in Aghai, a village in the Thane district of Maharashtra. Thane, which is north-east of Mumbai and adjacent to Pune, has a population of 8.1 million, of which 30% is rural. In 1986, the School of Social Work at the Tata Institute of Social Sciences established an Integrated Rural Health and Development Project (IRHDP) in Aghai and its 20 surrounding padas. As part of its work, the IRHDP also creates a map of each village and keeps records on the nature of health work conducted in each village. Using the IRHDP village social map and the most recent community census, we selected a pada with which local health workers had a strong existing relationship, but no special history of HIV/AIDS-related work. In total, there were 41 households in the selected pada. Of the 41 households, 25 included at least one unmarried adolescent aged 14 to18 years.The IRHDP has developed strong community relationships with the local After the sampling frame was finalized, recruitment was conducted via face-to-face outreach by trained, indigenous recruiters who visited homes with eligible adolescents and invited them and their eligible family members to participate. One target adolescent and one target parent from each family were asked to participate. In cases of two or more eligible adolescents, recruiters invited the youngest to participate.The target parent and adolescent were asked to join a focus group study that sought to understand family members' perspectives about participating in a family-based programme to help adolescents avoid HIV. As part of the consenting process, families were given basic information related to HIV. Recruiters explained the purpose of the study, the nature of the focus group process, and the right to refuse with no penalty.A total of 48 individuals were approached to participate in the study and 46 (96%) consented to participate in the study and completed the focus groups. Adolescents received 100 Indian rupees for participating and each parent received 250 Indian rupees . Institutional Review Board Approval was obtained from both the Tata Institute of Social Sciences (IEC/IRB No: 03/2009) and Columbia University (IRB-AAAC8244); all research protocols complied with the Helsinki Declaration.Separate groups with mothers, fathers, adolescent females and adolescent males were conducted for several reasons. First, Vissandjée, Abdool, and Dupéré  suggest padas meant that two groups each with adolescent boys, adolescent girls, mothers and fathers were sufficient to cover the research questions. On average, each group lasted for 1.5 hours.The standard protocol is to conduct at least three focus groups with each type of participant ,39. Howepada lacked a common space, the girls and the mothers groups met in the house of the pada worker, and the boys and fathers groups met in the house of the anganwadi (primary school) teacher. The venues were carefully selected spaces that were well known and respected by community members as this was deemed important to engendering participant trust and comfort in the focus group process by the indigenous research staff. Utmost care was taken to ensure privacy during the focus groups. The presence of onlookers and other distractions were minimized by holding the meetings indoors  can happen to anyone. From small children to anybody. It can happen to anybody who gets pricked by an infected needle. When in mother's womb ... it can happen then too. If she comes to know about it, then she can take medicines and save her child from the disease. Only she can't breast feed. This much I know.This same level of detail was evidenced in the father focus groups, where one father explained how he arrived at his knowledge about HIV transmission:Yes I know [about AIDS], the doctor gives information. Or the information is on the board . I know how to read so I was able to read. It is written that "Don't go to outside women, because if she has AIDS then it can happen to us." When we go to the doctor and get an injection, if it is not sterilized then we can get it. We go to the barber and if an old blade is used and if there is blood on it and if we get wounded from that blade then we too can get AIDS.Of the parents who were aware of HIV, parents discussed sexual behaviour between men and women, sexual behaviour with female sex workers , infected syringes, "contaminated blood", and mother to child transmission as possible routes of HIV transmission. In addition, this group of parents was also aware that HIV/AIDS could be treated with medication.In contrast, other parents indicated that they knew very little about HIV/AIDS. In both the mother and father focus groups, a small number of parents admitted to knowing "nothing" about HIV/AIDS, how the virus was transmitted, or such methods as condoms for reducing one's risk. For example, one mother stated, "No [I] didn't know [about AIDS] before [the focus group], now that you are telling, that we are hearing."This was echoed in the father focus groups, where one father stated that HIV could be transmitted by sharing drinking water with an HIV-positive person. Still other parents were unaware that HIV could be prevented within the family, as evidenced by a father's statement that, "If one woman gets it [AIDS], one man gets it, and then everyone in the family gets it." When asked to identify their primary sources of information about HIV/AIDS, the majority of mothers discussed learning about HIV/AIDS from the television while fathers indicated that they had received information via the radio, television, doctors, the health centre and written materials.Largely missing from the focus group discussions was mention of the role of correct and consistent condom use as a means of protecting oneself from HIV. Neither parents nor adolescents discussed condoms as an optimal strategy for protecting oneself from HIV. Families reported low levels of knowledge related to correct and consistent condom use. In general, focus group participants provided less clear feedback in relation to the use of condoms.Most of the families were uncomfortable with their adolescent children being sexually active outside of marriage. However, in those instances where parents knew that adolescent sexual behavior was occurring, parents reported having great concern in keeping their children safe from potential health consequences associated with risky sexual activity. For instance, one father stated that he observed his adolescent son and some of his son's friends going into a brothel in a city located in close proximity to the target community. The brothel is a known establishment for sex work. The participating father expressed disapproval of his son's seeking out sex workers. However, he also reported wanting his adolescent son to protect himself from sexually transmitted diseases by using condoms if he was to continue frequenting this establishment.The second theme that emerged from the focus groups focused on the extent to which families perceived that adolescents were vulnerable to HIV/AIDS. In general, adolescents did not believe that HIV/AIDS was something that directly affected them. Although a small number of boys indicated that HIV/AIDS could occur outside of urban areas, the majority believed that HIV/AIDS occurred mostly in cities.One boy explained how there are "bad" boys in the city and "good" boys in the village. This feeling was summarized by one male adolescent who said that he felt there was limited possibility of HIV spreading in the local community. In both the male and female focus groups, youth reported that they did not know anyone who was living with HIV/AIDS.Like their adolescent children, mothers did not readily identify knowing anyone with HIV/AIDS. Although several mothers stated that HIV/AIDS could affect "anyone", another stated, "Where it [HIV/AIDS] is where it is not, we do not have any idea." In addition, mothers echoed the sentiments of their adolescent children about who became infected with HIV/AIDS. One mother said, "One who goes 'wrong' will get the disease."In contrast to the mother and adolescent focus groups, a number of fathers spoke about their personal experiences knowing people affected by HIV/AIDS. One father shared the story of a friend who had contracted HIV via a sexual relationship with a woman:There was someone I knew who visited another women and he started getting fever regularly. Later on we came to know that he has AIDS and he died. I know this because this happened in front of us.Still another shared the story of a friend who had travelled from the village to Mumbai:There was a friend of mine, he used to roam around, used to go to Mumbai. He must have been doing such things there so he got AIDS. Later, doctor told that he had got AIDS. After that, for some time he tried, but later he passed away.Finally, another father shared his familiarity with HIV/AIDS via his work as a truck driver, "I am a driver and these things [AIDS] happen earlier to us."Unlike their adolescent children, both mothers and fathers believed that their children were at risk for HIV. Perceptions of adolescent vulnerability were most often discussed in the context of economic constraints that forced children to seek work in neighbouring villages or cities.Mothers recognized that they could not effectively monitor their children's whereabouts when they left home for work and believed this opened the door for sexual behaviour that could expose their children to HIV. Fathers, who had also discussed their own experiences migrating for work or knowing other adults who had migrated for work, believed that travelling to other villages and cities for economic opportunities placed their children at risk for HIV, "They are outside and they feel it is a need so they have sexual relationships." one father said.All four groups of stakeholders indicated that a family-based intervention was a feasible and culturally acceptable way to prevent HIV transmission among adolescents. For example, both adolescent males and females indicated that they were interested in participating in a family-based intervention that would provide them with comprehensive skills and information to reduce their risk of acquiring HIV. When asked to elaborate, adolescent males indicated that they listened to their parents and respected their beliefs and opinions more than they would an "outsider".Related to this, adolescent males also recognized that a comprehensive family-based approach could be easily integrated into their daily life. As one adolescent male stated, "It is beneficial if information and skill are given by families because someone who comes from outside will only be there for one day but if you err then family is there every day to tell."Similarly, adolescent girls believed it would be beneficial to have their parents talk to them about HIV/AIDS and that their parents could be a good source of knowledge and skills. Family-based approaches were praised by girls for their inclusiveness. As one girl said, "We don't feel that anybody should be excluded like girls, boys, mothers, fathers. All should come together for the programme."In addition, adolescent girls believed that their parents could be effective teachers, especially if given correct information and skills about HIV/AIDS.Mothers and fathers were open to participating in a family-based programme and believed that a comprehensive family-based programme was feasible. All of the parents were concerned about their child's health and wellbeing, and many were aware that HIV/AIDS posed a serious health risk. Like their adolescent children, parents recognized that a family-based approach might be more successful than other types of programmes. As one father stated:Parents will say and children will listen, but when an outsider comes and talks then there are many things that children will feel shy to speak to you as an outsider, they will not talk the way we are talking to you ... they will feel shy. That's why it is important for parents to explain to them.Without exception, parents wanted to talk with their children about HIV/AIDS. As one mother stated, "It is the duty of parents to speak to their daughters and sons about these issues. We should only make them understand and if we don't tell them how will they know?"At the same time, only a small number of parents said that they had actually talked with their children about topics like HIV/AIDS and sexual behaviour. Overall, both mothers and fathers felt that they lacked the necessary information and skills to communicate effectively with their children. In particular, parents felt they lacked adequate information related to correct and consistent condom use, and would need additional help if they were to instruct their teens on this topic. For their part, mothers wanted factual information and believed that their children would listen to them if given proper information. One mother said, "You should teach us. What all we don't know, you must tell us. You should give information to parents as well as children. Then even we will be able to speak."Similarly, fathers believed that they should speak with their children about sexual behaviour and HIV/AIDS, but needed additional support to have effective conversations. Fathers believed that a family-based HIV prevention programme would be especially useful as it could "give us advice which we can give our children".Adolescents and parents identified a number of barriers to participating in a programme. Identified barriers focused on three primary areas: (1) embarrassment and fear of discussing sensitive topics like sexual behavior, correct and consistent condom use and HIV/AIDS, especially when considering gender dynamics in Indian families; (2) stigma surrounding HIV/AIDS; and (3) economic and environmental constraints.Both adolescents and parents discussed the need to address potential feelings of embarrassment. For adolescents, feelings of discomfort emerged around the idea of having a mixed-gender programme. Although some adolescent boys and girls felt comfortable with a mixed-gender HIV/AIDS intervention, the majority wanted separate groups and felt that family communication might be more effective between mothers and daughters and between fathers and sons. The discussion of same-gender communication in the family system was more often discussed by girls than by boys. If a programme was going to use a mixed-gender approach, adolescent girls recommended involving the entire community, e.g., individuals, households, families, schools and villages, as this would lessen their embarrassment.For their part, parents discussed how fear of negative consequences could deter their participation in a family-based programme. In the mother focus groups, some women indicated that although they wanted to talk about HIV/AIDS with their children, they were worried that their adolescents would react negatively to such conversations. However, mothers were unable to provide specific examples of how youth might respond in a negative way. Unlike their children, mothers did not identify gender in the family system as a potential barrier to participation.In contrast, fathers indicated that they might be embarrassed discussing a sensitive topic like sexual behaviour or HIV/AIDS with their adolescent daughters. As one father stated:When our daughters have come to age (meaning has become a teenager), it becomes awkward to speak with her by a father. So one can ask the mother of the girl to speak to her. Mother-daughter communication happens.This sentiment was echoed by other fathers, who suggested that embarrassment could be overcome by supporting "mother-daughter" and "father-son" communication. At the same time, other fathers felt that a family-based programme was not embarrassing. "It sometimes gets a little awkward for the parents to speak to their children, but we don't feel that," one father said.In addition to potential feelings of embarrassment, another barrier to participation addressed the role of stigma related to HIV/AIDS. Adolescents, mothers and fathers all described stigma related to HIV/AIDS. In the adolescent male focus groups, some boys indicated they would feel shy or scared about discussing the topic of HIV. For example, one boy stated, "This is a bad disease, and it feels weird so even I don't speak."Moreover, boys discussed the fear and stigma towards people living with AIDS and how people in the village responded. One boy said, "If someone amongst us has AIDS then people will try to stay away from him. People might criticize or make fun of him or might tell him something." Another boy said, "Anything can happen to such a person so he is kept outside the house in the village."Girls expressed similar fears about people living with HIV/AIDS, as evidence by the statements, "Nobody will even speak to him [person living with HIV/AIDS]" and "People will stay away from him [person living with HIV/AIDS] ... because we will get the disease."Similarly, mothers also indicated that individuals who were known to be HIV positive were shunned by the rest of the community. One mother stated, "If someone comes to know [about having AIDS] then who will go to his house, nobody will eat from his house not even drink water." Fathers also discussed the role of stigma towards people living with HIV/AIDS and believed that it could deter some people from participating, as is clear from this statement, "This programme is on AIDS so people will not come ..."At the same time, fathers also believed that stigma surrounding HIV/AIDS could be overcome by discussing the importance of prevention with community members and by highlighting the benefits for adolescents and future generations.The final barrier to participation focused on the role of economic and environmental constraints experienced by families. Adolescents and their parents all discussed the role of work and the importance of earning money to meet basic needs, such as shelter and food. Adolescents in the focus groups often worked to help support their family and stated that they would not attend a programme that interfered with work or with school, for those youth attending school. Adolescents also stated that monsoon season could pose a serious challenge, as the weather could make it too difficult to attend a programme that required them to travel.Parents were similarly focused on the constraints posed by work and having to meet basic needs associated with daily living. All of the parents had limited economic resources. As one mother stated, "Without work we won't be able to sustain our life." Fathers also noted that their work could necessitate that they travel to other villages or cities and as such, they would not be able to attend a programme that required them to attend multiple sessions. Both mothers and fathers indicated that a programme had to be flexible for their schedules and not interfere with their ability to support their families.Adolescent boys and girls provided specific suggestions about how best to recruit and retain them into a family-based programme. Overall, adolescents recommended a face-to-face outreach, conducted by a recruiter who would visit the adolescents' houses to invite them to participate. In addition, adolescents suggested that they would be receptive to hearing from youth already enrolled in a programme, and recommended using village friendship networks as a mechanism to reach large numbers of youth.For adolescents, successful recruitment efforts would highlight the health benefits of the programme for both youth and the broader community. Both adolescent males and females believed that a family-based programme could have a larger community impact and that this was an important point to publicize.Mothers and fathers also recommended face-to-face recruitment methods. Overall, parents endorsed a personalized approach, with recruiters going from house to house to provide information on the project. Both mothers and fathers mentioned the importance of drawing upon existing social networks to recruit families and emphasizing how a family-based programme would benefit the future of their children.Parents also recommended that male recruiters should recruit fathers and sons, and female recruiters should recruit mothers and daughters. For example, one mother stated:pada should tell people in the same pada that a meeting on health is organized and they should come. This information is in the context of the future of our children. If we only don't listen then who will think about the future of our children. All this we can tell in our hamlet.Women from a Similarly, a father recommended an approach where a recruiter could:.... personally go and speak to them. What do they feel, one must personally try to make them understand and speak. You must tell him that come to the programme if you understand what is being said then make use of it, if not then you can leave the programme.In addition, fathers felt it was important for recruiters to clearly state the goal of the programme so that families could easily understand its purpose and relevance for their lives.Both adolescent boys and girls wanted accurate, relevant and developmentally appropriate information. Many of the youth in the focus groups stressed the importance of giving "proper advice" about HIV/AIDS. In general, adolescents felt it important to have a proposed family-based intervention that is "comprehensive and includes content both related to abstinence and safer sex". Adolescents expressed interest in knowing both about ways they could avoid becoming sexually active and ways they could protect themselves if they did in fact become sexually active.Both adolescent boys and girls were clear that a programme had to be flexible, convenient and adolescent friendly. Youth identified a number of characteristics that would make a youth programme friendly, including the use of diverse types of materials and programme activities. Adolescents felt that programme information could be shared through a variety of methods, including skits or plays, songs, and posters, pamphlets and other print materials. Regardless of the medium, adolescents emphasized the importance of addressing illiteracy and suggested that information about a family-based programme needed to be provided orally and in writing, as many of their parents could not read.Parents wanted current and factual information on HIV/AIDS, strategies for protecting oneself from HIV/AIDS, including correct and consistent condom use, and sexual behaviour. Parents were open to receiving information about HIV/AIDS in a variety of ways, including via written materials and visual images. For written materials, parents stressed the importance of addressing illiteracy in the village and of making materials available in multiple languages, e.g., Hindi and Marathi. As one mother stated, "Now we get paper but we can't even read it ... what you will tell us face to face we will understand from there only." Regardless of the format, both mothers and fathers stressed the importance of making programme materials adolescent friendly.To date, very few family-based HIV prevention interventions have been developed for rural Indian youth. The majority of interventions have targeted adolescents in schools or health clinics. As a result, a number of questions regarding the feasibility and acceptability of a family-based intervention remain.To the best of our knowledge, this study is one of the first to conduct focus groups with rural adolescents, mothers and fathers on the feasibility of a comprehensive family-based adolescent HIV prevention intervention. Our findings suggest that a family-based intervention is feasible provided that it: (1) provides families with comprehensive knowledge and strategies about preventing HIV/AIDS; (2) addresses potential barriers to participation; (3) is adolescent friendly, flexible and convenient; and (4) is developmentally and culturally appropriate for rural Indian families.Overall, both parents and adolescents believed that a family-based programme was feasible and culturally acceptable. Although India is often characterized as having strong cultural barriers to open communication about sex , our finFor their part, adolescents respected their parents' opinions, were open to learning about HIV/AIDS from their parents, and identified their parents as important and influential sources of information. At the same time, it is notable that none of the adolescents named their parents as a current source of information or knowledge about HIV/AIDS. This suggests that family communication about HIV/AIDS is low, a finding that has been observed in previous research .In turn, both mothers and fathers believed it was their responsibility to counsel their adolescents on matters related to HIV prevention. Although previous literature has described cultural taboos surrounding the discussion of sexual behaviour in India ,9, the pThese findings are important, as they indicate cultural norms and taboos are not immutable, and can be addressed with straightforward intervention activities designed to promote open communication about sensitive topics like HIV/AIDS and sexual behaviour .In addition, programmes will also have to address some parents' fears that talking about HIV/AIDS could have negative consequences for their adolescents. Because the mothers in our study were unable to identify specific negative consequences, additional research is needed to better understand how negative expectancies and other factors influence both parent-adolescent communication about HIV/AIDS and family participation in a family-based HIV prevention programme.It may be that parents feel they do not have the knowledge to have effective conversations with their children. Indeed, research with families in the US on parent-adolescent communication about sex has identified lack of knowledge as a barrier to communication . ResearcTheory-based research is necessary to identify the determinants of parent-adolescent communication about sex that can be targeted in the context of a family-based intervention. Such information is necessary if we are to support Indian parents to effectively communicate with their adolescent children about how to reduce their risk of HIV infection.In addition, research is needed to elucidate the contextual factors associated with increased vulnerability to HIV infection among rural Indian adolescents. One contextual factor that emerged as potentially important was the role of poverty, especially as it relates to youth migration to cities and nearby villages in search of work. A number of researchers have highlighted the complex relationship between poverty and HIV/AIDS ,54, and In our study, poverty appeared to break down the protective role of families when young males were forced to leave home in search of economic opportunities. Mothers believed that this minimized their ability to monitor their children's whereabouts and fathers were concerned about their children's exposure to risk factors, such as commercial sex work. Although none of the parents in our study discussed the relationship between poverty and commercial sex work, other research in India has underscored the role of poverty and economic inequality in young women's entry into sex work . While pOn a practical level, families provided concrete advice about how best to recruit and retain them in a family-based programme. Parents and adolescents endorsed face-to-face recruitment methods as the most successful way to recruit and retain them in a family-based prevention programme. In addition, parents and adolescents recommended using social networks to outreach to families. This is consistent with previous research, which has identified social networks as an important mechanism to promote communication about sexual health and to inform the design of health prevention programmes in India ,56.Parents and adolescents in our study were clear that literacy needs to be addressed. Nationwide, approximately 61% of Indian adults are illiterate . This poFinally, gender emerged as an important consideration, with daughters and fathers voicing support for programmes that fostered same-gender communication in the family system. Numerous studies have observed gender differences in family communication about sex, with mothers communicating more with daughters than with sons ,59. GlobHowever, recent research with fathers in the US suggests that fathers can be engaged in intervention research focused on adolescent HIV prevention and can be supported to communicate with their sons about topics like sexual behaviour, condoms and HIV . ResearcThe findings of the study should be interpreted in the context of the study limitations. First, the study focused on Indian adolescents and their families living in a rural hamlet of Aghai. We did not interview urban families, and the community from which we sampled families was relatively poor. India is a diverse country and our sample may not be representative of other geographical communities. Our study was qualitative in nature; consequently, no causal inferences can be made.Although demand characteristics  could have influenced participant responses, these potential biases were addressed in several ways.First, we selected a homogenous sample from a small number of hamlets and separated the groups by gender and generation. Familiarity can impede openness, but it can also promote trust and self-disclosure, as well as enhance participants' comfort in challenging one another. Second, informed consent was obtained from all participants, and the focus groups were conducted in ways to protect participant comfort and confidentiality. Third, focus group moderators were carefully selected and trained. All facilitators received extensive training on how to moderate focus groups, manage group dynamics, and facilitate discussions about sensitive topics like sexual behaviour and HIV/AIDS.Because of the focus group setting, we did not ask in-depth questions about parent-adolescent communication about sex. As a result, we cannot make definitive statements about the nature of family communication. Future research should explore this topic in both individual in-depth interviews and in survey research with adolescents, mothers and fathers. Here, multiple perspectives will be especially important as they can be used to explore congruency in family reports of parent-adolescent communication about HIV/AIDS and to identify behavioural targets at both the parent and adolescent levels.Despite these limitations, a strength of this research was the integration of perspectives from adolescent females, adolescent males, mothers and fathers. HIV/AIDS is a disease that affects all members of the family, and research focused on helping Indian adolescents avoid HIV needs to reflect the perspectives of all members of the family system.In addition, the scope and impact of HIV/AIDS in India necessitates international collaborations that can address the diversity of the epidemic. This study was a collaboration between social scientists in India that was funded by the Indo-US bilateral agreement. It is the first of several formative studies focused on developing an empirical body of literature on how to develop efficacious family-based HIV-prevention programmes for rural Indian youth, and the findings have important implications for researchers interested in developing family-based HIV prevention interventions for Indian adolescents.The authors declare that they have no competing interests.Drs Soletti and Guilamo-Ramos, as principal investigators, had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The study was designed by Drs Guilamo-Ramos, Soletti, Burnette and Bouris. Drs Soletti, Guilamo-Ramos and Burnette and Ms Sharma were responsible for acquiring the data. All authors are responsible for data analysis, interpretation of data, writing of the manuscript, and for the decision to submit the manuscript for publication.


In 1992 Liomba et al used HIV-AIDS prevalence data from 1980 to 1990 and projected the adult HIV prevalence and the impact of AIDS for the years 1991 to 2000, under high and low HIV incidence scenarios, using EpiModel, DemProj and the AIDS Impact Model. This report compares the actual outcomes of the HIV-AIDS epidemic in Malawi from 1991 to 2000 with projections made by Liomba et al.Due to the lack of data on rural HIV prevalence in 1992, the prevalence estimates for the years 1980 to 1990 used by Liomba et al were higher than the now published prevalence. We re-estimated the projections for 1991 to 2000 based on more recent estimates of 1980 to 1990 HIV-AIDS prevalence using the Spectrum modeling software, and compared the old and new projections with the actual epidemic figures reported by NAC. The original projections made by Liomba et al and the adjusted projections made in this report are both very similar to the observed course of the AIDS epidemic reported by National AIDS Commission. Unfortunately for Malawi the epidemic seems to have followed the high scenario of HIV incidence.The course of the epidemic in Malawi and the social and economic devastation caused by it, despite the presence of reasonably good projections and prevention recommendations by Liomba et al, highlights the need for better co-ordination between research and practice. It also emphasizes the need to examine the difficulties faced by countries like Malawi to act more rapidly and implement effective prevention measures in the face of an epidemic. Malawi is one of the most AIDS-affected nations of the Sub-Saharan region, and ranks among the top 10 AIDS-afflicted countries of the world In 1992, Liomba et al, including one of us  used an epidemiologic modeling approach to project the course of the AIDS epidemic in Malawi, including projections of adult HIV prevalence, annual adult AIDS deaths, number of AIDS orphans, number of tuberculosis patients, and total population size for the years 1991 to 2000 . These pLiomba et al used EpiModel Liomba et al used EpiModel to estimate incidence levels in Malawi, based on the prevalence data available from 1980 to 1990. They estimated that the HIV incidence in Malawi was negligible between 1980 and 1984 but rapidly increased to an average of about 2% per year between 1985 and 1990. Based on this incidence estimation, they made various AIDS impact projections for high and low scenarios from 1991 to 2000 using Demproj and AIM . In the When we compared the prevalence estimates from the monograph to those reported by the NAC To better evaluate the accuracy of the projection methods we re-estimated the predictions in the monograph using the NAC reported prevalence from 1980 to 1990. We first linearly adjusted the predicted prevalence in the monograph, to account for the lower actual prevalence from 1980 to 1990. After this we re-computed the projections listed in Since the NAC reported HIV prevalence for people between the years 15–49, and the monograph projected prevalence for adults 15 years and above, we adjusted the NAC values for all adults above the age 15 by using population weights, in order to make it comparable with the monograph's projected prevalence. Our re-estimated projections are hereafter referred to as “adjusted projections” and the monograph's projections are referred to as “original projections.” A copy of the original monograph is available upon request.The original projections, the adjusted projections and the NAC reported figures for the year 2000 are presented in The original HIV prevalence projection was 18.75% under the high scenario, and 10.1% under the low scenario , for allRegarding impacts of the epidemic in the year 2000 on: (a) annual AIDS deaths, (b) numbers of AIDS orphans, (c) number of TB patients, both the original and adjusted high incidence projections for the year 2000 are very close to recent estimates by the NAC Behavioral and biologic surveillance data and HIV-AIDS projections should help guide policymakers and public health officials to identify geographic areas or populations with higher incidence or prevalence; and help target, design and implement effective interventions. While model-based projections of AIDS cases were sometimes criticized as being alarmist or as exaggerating the dangers from HIV, the 1992 monograph on Malawi was accurate in its projections, despite the limited prevalence data available . AlthougAs mentioned above, the Liomba et al monograph also included results from a generic simulation model, illustrating a reduction in HIV-AIDS incidence and prevalence due to preventive measures, like partner reduction, condom use, and improved STD control. Did this monograph have a policy impact, for instance speeding up the implementation of preventive measures? It is not possible to answer this question definitively, as there are many other influences on government actions.In 1988, the Malawi government prepared its first medium term plan for AIDS control and various donor agencies and researchers became involved in AIDS prevention activities As seen from this study's comparison of the adjusted 1992 HIV prevalence projections with the 2003 NAC official estimates , there iPolitical sensitivity and openness to epidemiological projections can translate research to practice as demonstrated by success stories of countries like Thailand, Uganda, Kenya and Zimbabwe The course of the HIV-AIDS epidemic in Malawi and the social and economic devastation caused by it, despite the presence of reasonably good projections, highlights the need for better co-ordination between epidemiologists, modelers and policy makers. Further research may be useful to examine the difficulties of countries to act more rapidly to implement effective prevention measures, despite the existence of information regarding the possible consequences.In 1992, a monograph by Liomba et al, used an epidemiologic modeling approach to project the course of the AIDS epidemic in Malawi. The monograph also suggested some preventive measures to avert a possible catastrophe due to the spread of the epidemic. The actual course of the epidemic in Malawi during the projected years was very close to the high incidence scenario of these projections. The course of the HIV-AIDS epidemic in Malawi and the social and economic devastation caused by it, despite the presence of reasonably good projections and prevention recommendations, highlights the need for better co-ordination between epidemiologists, modelers and policy makers. While warnings from epidemiologists and modelers are not always heeded, this retrospective examination of a simple modeling approach shows that the projections were accurate, and should encourage modelers and epidemiologists to continue their efforts.


Mortality data are used to conduct disease surveillance, describe health status and inform planning processes for health service provision and resource allocation. In many countries, HIV- and AIDS-related deaths are believed to be under-reported in government statistics.To estimate the extent of under-reporting of HIV- and AIDS-related deaths in Botswana, we conducted a retrospective study of a sample of deaths reported in the government vital registration database from eight hospitals, where more than 40% of deaths in the country in 2005 occurred. We used the consensus of three physicians conducting independent reviews of medical records as the gold standard comparison. We examined the sensitivity, specificity and other validity statistics.Of the 5276 deaths registered in the eight hospitals, 29% were HIV- and AIDS-related. The percentage of HIV- and AIDS-related deaths confirmed by physician consensus  was 95.4%; however, the percentage of non-HIV- and non-AIDS-related deaths confirmed  was only 69.1%. The sensitivity and specificity of the vital registration system was 55.7% and 97.3%, respectively. After correcting for misclassification, the percentage of HIV- and AIDS--related deaths was estimated to be in the range of 48.8% to 54.4%, depending on the definition.Improvements in hospitals and within government offices are necessary to strengthen the vital registration system. These should include such strategies as training physicians and coders in accurate reporting and recording of death statistics, implementing continuous quality assurance methods, and working with the government to underscore the importance of using mortality statistics in future evidence-based planning. Accurate and standardized systems for the reporting of causes of death are essential in order to monitor the impact of public health interventions and analyze mortality trends over time ,2. AlthoDeaths specifically due to HIV and AIDS are under-reported in low- and middle-income countries . As a reEven when HIV and AIDS is listed as a cause of death on a death certificate, inaccurate coding of the death may occur . In SoutBotswana is believed to have one of the better vital registration systems in Africa. In 2004, 91% of all deaths occurred in a hospital , and thiBotswana is the first African country to provide free antiretroviral (ARV) treatment for its citizens, starting in 2002. By the end of 2007, more than 80% of those eligible had received treatment. Much reduction in the impact of HIV and AIDS deaths is anticipated, but it is not known whether the current vital registration system will be able to accurately capture this reduction. To evaluate the vital registration system for this purpose, we focus on three major objectives: (1) assessing the validity of HIV and AIDS deaths reported from hospitals; (2) characterizing the extent to which deaths related to HIV and AIDS fail to be recorded as such; and (3) providing statistics on HIV- and AIDS-related deaths adjusted for under-reporting.We conducted a retrospective study to validate cause-of-death reporting among a sample of deaths occurring in selected hospitals in 2005. We restricted our analysis to deaths occurring in hospitals because almost all deaths in Botswana occur and are verified there . We usedUsing the vital registration database, deaths were stratified into HIV- and AIDS-related or non-HIV and AIDS-related. Systematic samples of 10% of HIV- and AIDS-related deaths and 50% of non-HIV- and AIDS-related deaths were planned for study. We chose 50% as the sampling percentage for non-HIV- and AIDS-related deaths because we were primarily interested in under-reporting of these deaths and wanted to ensure adequate power to provide precise validity estimates.th record was selected from among HIV- and AIDS-related deaths. The cause of death as recorded in the government database (see the process described below) was then compared to cause of death as reported by physician consensus after detailed chart reviews.Over-reporting among HIV- and AIDS-related deaths was a secondary research question and we believed that the degree of misclassification would be less; thus, we chose the smaller sampling percentage of 10%. These sampling percentages were not determined using formal power calculations. Sampling was achieved after sorting all deaths by the two disease categories and by hospital record number. Every other record was selected from among non-HIV- and AIDS-related deaths and every 10For each death in the hospital, an MH 017 form . It also varied by hospital, ranging from 19.1% to 55.7%. The hospital that had 55.7% under-reporting was clearly an outlier, being significantly statistically different from all other hospitals.Overall, using Method A (physician consensus), we found under-reporting of HIV- and AIDS-related deaths to be 30.9% . The most common non-infectious causes of death listed among those coded as non-HIV- and AIDS-related deaths prior to the medical record review were hypertension, stroke, congestive cardiac failure, renal failure, trauma, hepatic failure, diabetes and cancer of the esophagus. It is important to note that as several causes of death were listed for each patient, this does not represent a mutually exclusive, ranked list of the most common cause of death.In 2005, mortality statistics in Botswana indicate that approximately 29% of deaths were related to HIV and AIDS. In our validation study, we found that approximately half of all deaths we studied were HIV- and AIDS-related. This was true using a variety of validation methods.We found the vital registration system to be 56% sensitive in reporting HIV- and AIDS-related deaths and 97% specific in ruling out HIV and AIDS deaths. Given that we found under-reporting of HIV- and AIDS-related deaths in eight of 32 public, missionary and mine hospitals, we caution the use of government mortality statistics to estimate the burden of HIV and AIDS in Botswana without the use of corrections for under-reporting.Errors in government mortality statistics have been studied throughout the world  and in sEven with similar validation methods, different patterns of cause-specific mortality have been shown to influence sensitivity and specificity rates . It has In the United States, death certificates listing diabetes anywhere on the certificate have been found to be 34.7% sensitive and 98.1% specific . ClearlyThere are a variety of factors that are likely to have contributed to the under-reporting of HIV- and AIDS-related deaths in Botswana. First, it is important to note that hospital facilities in our study differed substantially in the degree of under-reporting. This implies that it is possible to improve statistics by examining the best practices in the hospitals with the lowest under-reporting and implementing them in the other hospitals. Other factors include HIV-associated stigma, which continues to be highly prevalent .The need for death reports for burial may cause families to request that HIV not be listed as a cause of death, or physicians may assume that this is what families would wish. Physicians whose primary aim is to care for patients and their families may not fully appreciate the value in accurate and timely death statistics. Also, the limited number of government nosologists may have made it difficult for them to follow up with physicians to ensure that MH 017 forms are fully and accurately completed. There appears to be no current method for ensuring quality of reporting and, in the past, there has been little systematic training for physicians on completing the MH 017 and using the most recent versions of ICD coding.Our study has a number of important strengths. First, we examined multiple geographic locations and samples from all deaths that occurred in eight hospitals. This allows us to generalize to those settings where almost half of all deaths occurred. Second, our method of validating mortality statistics employed additional information beyond re-review of death reports. Finally, we used various definitions of HIV- and AIDS-related deaths, which allowed us to estimate the degree of misclassification due to the definition itself. Our different methods yielded comparable results.Despite these strengths, our study also has limitations. Information in the medical records may not have been complete, making it sometimes difficult for the study physicians to reach consensus on the causes of death. In addition, the physicians did not have the benefit of being present in the hospital before or at the time of death, which would have strengthened their ability to make the most accurate diagnosis. It is also possible that the study physicians overestimated the number of HIV- and AIDS-related deaths due to their awareness of the study objectives.In the smaller hospitals, our sampling fraction of 10% for HIV- and AIDS-related deaths, even with contingency sampling, resulted in small sample sizes restricting our ability to study the performance of individual doctors. Finally, our best estimate for out-of-hospital deaths is 8.7% in 2004 [Our results are only generalizable to the decedents from the areas served by the eight hospitals to the degree to which out-of-hospital deaths are proportionately few. To confirm these percentages, more research is needed on the number of deaths that occur outside the hospitals among families who do not need death certificates and are without insurance, and are unlikely to report a death to local officials.With the broad use of antiretroviral therapy in Botswana, people with HIV and AIDS are likely to be living longer, as has been found in Brazil . Given tHow then should one determine the sequential order of the causes of death in a decedent who had been treated with ARVs and who also died with diabetes? As shown above, diabetes is clearly under-reported, even in a vital registration system that is generally considered to be complete and accurate . So it iTo improve cause-of-death reporting in the future, we recommend the following:1. Continue to use the recently implemented two-part report  to reduce the tendency for physicians to omit an AIDS diagnosis to alleviate families' fear of exposure .2. Provide physician-focused trainings at hospitals and medical schools, emphasizing the importance of accurate vital statistics for the country and providing detailed instructions on proper completion of death registration forms.3. Institute quality assurance, such as employing an on-site person responsible for ensuring completion of the form within 24 hours of death.4. Implement incentives for accurate and complete reporting of death registration forms and possibly implement consequences for inaccurate reporting.5. Simplify the death reporting process by working closely with the physicians who complete the forms, creating standards, and possibly mandating these standards.6. Identify staff at the Ministry of Health who, with proper training, are charged with the responsibility of ensuring quality of death registration forms on a quarterly or semi-annual basis.7. Encourage the practice of data utilization for decision making.8. Continue to expand HIV and AIDS testing so that the condition does not remain hidden.In the short term, improvements in vital registration systems may cause some difficulty in interpreting mortality trends and attributing declines to programme successes. However, in the long term, accurate mortality statistics will provide the country with many benefits, including: the ability to monitor the impact of programmes that have been scaled up to the population level; the ability to compare mortality across districts, allowing studies of best prevention and treatment practices; and the opportunity to track the impact of emerging diseases, such as diabetes and obesity.In conclusion, this study shows that HIV- and AIDS-related deaths are substantially under-reported in Botswana. However, it is clear that the government is committed to improving its vital registration system as part of its national strategy to significantly impact the HIV and AIDS epidemic by 2016 . Periodic studies, such as the one reported here, will allow the country to monitor improvements in its vital registration system. The goal of a complete and effective system is expected to be accomplished in the near future.The authors declare that they have no competing interests.NT conceived the study, and participated in its design and coordination and helped draft the manuscript. JW provided a comprehensive analysis of the data, interpreted the results, and took a lead role in writing the manuscript. SB participated in its design and coordination, and helped draft the manuscript. LP participated in the analysis and interpretation of the data, and took a lead role in writing the methods and results of the study. DM participated in the study and coordinated study activities including access to the vital registration data. ES helped with interpretation of the data, and provided advice on the design of the study. TR helped to conceive the study, and participated in its design and coordination. GK provided administrative support during study implementation and helped in data analysis. E-H S participated in the design and coordination of the study.We varied the definition of HIV- and AIDS-related deaths by asking independent clinicians, who are employed by the Centers for Disease Control and Prevention (CDC) and the University of California, San Francisco, as HIV and AIDS experts, to review the -consensus causes of deaths, to examine the individual items on the abstract forms, and to use their clinical judgment to render an expert opinion on whether the death was truly HIV- and AIDS-related. In doing so, the experts used three different algorithms that resulted in classifications of "definitively HIV- and AIDS-related", "probably HIV- and AIDS-related", or "possibly HIV- and AIDS-related"."Definitively HIV- and AIDS-related" deaths were determined in the following manner. Experts classified records in which the consensus cause of death was "HIV", "AIDS", "AIDS-related complex", or any HIV-related opportunistic illnesses as definitely HIV- and AIDS-related deaths. If all of the consensus causes of death were missing , a death was coded as HIV- and AIDS-related if one or more of the individual physician reviews indicated the conditions listed above.pneumoncystis jiorvecii pneumonia (PCP), had a viral load test result available, or receiving cotrimoxazole for PCP prophylaxis. The causes of death from these records were reviewed again and classified as probably HIV- and AIDS-related deaths if the causes contained conditions listed in Section A."Probably HIV- and AIDS-related" deaths were determined by the experts examining records, in which the individual physicians' abstract forms noted that the decedent was diagnosed with any WHO Stage IV condition during hospitalization prior to death, had a positive HIV test result, was noted to be receiving HIV-specific care, on ART, treated for Kaposi's sarcoma or "Possibly HIV- and AIDS-related" deaths were determined as above, except that causes also included the conditions listed in Section B.When experts used the "definitive" definition, we labelled this as Method B. When experts used the definitive or probably definition, we labelled this as Method C. Finally, we defined Method D as experts using the definite, probable or possible definition. These three methods provided us with a range of estimates, from a conservative definition of HIV- and AIDS-related death (Method B) to a very liberal definition of an HIV- and AIDS-related death (Method D).Section A: Probable HIV- and AIDS-related deaths if the cause of death was:• Abscess, brain or lung• Acute encephalopathy• Cervical cancer• Lymphoma (including non-Hodgkin's)• Cardiomyopathy• Dehydration• Dementia (if <60 year old)• Diarrhea/gastroenteritis• Disseminated intravascular coagulation• Electrolyte imbalance• Empyema• Encephalitis• Endocarditis• Hepatic failure/hepatitis• Mediastinal mass• Meningitis• Multi-organ failure• Pancreatitis• Pericardial effusion• Peritonitis• Pleural effusion• Pneumonia• Prematurity• Respiratory failure (no other cause)• Sepsis• Tuberculosis (pulmonary and extrapulmonary).Section B: Possible HIV- and AIDS-related deaths if the cause of death was:• Adrenal insufficiency• Ascites• Bronchiectasis, pneumoconiosis, pulmonary fibrosis• Congestive heart failure (if <45 years old)• Pulmonary edema• Renal failure• Stevens Johnson syndrome• Stroke.*Only in the sample of records in which data from the chart abstraction form suggested that the decedent was HIV infectedMorbidity, mortality, and obstetric in-patient form, Botswana, 2003. This form is completed by physicians for all in-patients in health facilities and is used by the Ministry of Health to monitor deaths.Click here for file