Hotez et al. argue that achieving success in the global fight against HIV/AIDS, tuberculosis, and malaria may well require a concurrent attack on the neglected tropical diseases. The age of hypocrisy has been succeeded by that of indifference, which is worse, for indifference corrupts and appeases: it kills the spirit before it kills the body. It has been stated before, it bears repeating: the opposite of love is not hate, but indifference. —Elie WieselTIME Global Health Summit, branded by Bono as the “Woodstock of Global Health” .The last five years have witnessed increased efforts by G8 nations and United Nations agencies to improve the health of the world's 3 billion people living on less than US$2 a day. Most of this attention has focused on efforts to intensify resources for fighting the three most devastating diseases: HIV/AIDS, tuberculosis, and malaria. Together, these “big three” account for a staggering 5.6 million deaths and the loss of 166 million disability-adjusted life years (DALYs) annually , and schistosomiasis . CysticeThe burden of disease resulting from the neglected tropical diseases is huge. As shown inAscaris lumbricoides,Trichuris trichiura, and the hookworms,Necator americanus andAncylostoma duodenale) and the two schistosomes (Schistosoma haematobium andSchistosoma mansoni) are highly endemic to sub-Saharan Africa, where they adversely affect childhood growth and physical fitness ),The President's Emergency Plan for AIDS Relief (http://www.avert.org/pepfar.htm),The Bill and Melinda Gates Foundation (http://www.gatesfoundation.org), supporting the development of new technologies for disease control.


Indonesia has an explosive HIV/AIDS epidemic starting from the beginning of this century, and it is in process to build its response. Reported AIDS cases doubled from 2003 – 2004, and approximately 54% of these cases are in people who inject drugs.th largest country in population in the world, a predominantly Muslim country with strong views on drug users and people living with HIV/AIDS. Globally speaking, Indonesia has one of the most explosive epidemics in recent years.Indonesia is the 4IHPCP (Indonesia HIV/AIDS Prevention and Care Project) is a joint support project (primarily AusAID-based) that works in partnership with the Government of Indonesia. IHPCP has been a key player of in the country's response, particularly pioneering NSP; stimulating and supporting methadone programs, and being key in promoting ARV for people who currently inject drugs. The project works via both the public health system and NGOs.It is still early to measure the impact of current interventions; however, this paper describes the current status of Indonesia's response to the HIV/AIDS crisis among people who inject drugs, and analyses future challenges of the epidemic in Indonesia. According to the last UNAIDS report on the global HIV/AIDS epidemic, the core expansion of the HIV/AIDS epidemic (absolute number of cases reported) is currently based on injecting drug use in Asia and Eastern Europe . India rIndonesia is a country of approximately 17,000 islands, with the fourth largest population in the world. It is a predominantly Muslim country with strong views on drug users, sex (use of condoms) and people living with HIV/AIDS.After 32 years dominated by a military dictatorship, the democratization process is very recent, having started in 1998. As part of this process, decentralization of power and budgets, and consequently decentralization of the responsibilities on public policies and governance, has a clear impact on the public health system. As time passes, cities, districts and provinces are addressing the alignment of responsibilities in public health matters. The decentralization of the response to the HIV/AIDS epidemic is an ongoing process with increasing responsibilities shared among different levels of government.The epidemic of HIV/AIDS in Indonesia reported its first case of AIDS in 1987. The first reported AIDS case among people who inject drugs (IDU) was in 1995. Since then, IDUs have constituted a major component of the country's epidemic . AccordiCurrently, there are many bodies of the Government playing a role in the control of the HIV/AIDS epidemic, primarily the KPA or the National Commission on AIDS, which has been attached to the Presidential Cabinet from July 2006. With a recently empowered strong leadership, KPA is in the process of recruitment to build their internal team with some of the best staff in the field of HIV/AIDS in the country and has a very promising role in response leadership. KPA is not involved in policy implementation, but rather responsible for formulating policies, and works mainly with international sources – centred on DFID, the British Cooperation – via partnership funds, which are administrated by UNDP. UNAIDS is the multilateral organization that provides technical support to KPA.The Ministry of Health is responsible for implementating the response to the HIV/AIDS epidemic, comprised of four departments. The Pharmacy Department is responsible for all medications. The Centre for Diseases Control includes the National AIDS Program which is responsible for program development, building local human resources and for all matters related to epidemiology. The Department of Medical Services runs all the hospitals, the Drug Program (including methadone clinics), and all laboratories. Lastly, the Community Health Department is responsible for the Community Public Health Centres (Puskesmas) programs. It has been somewhat difficult to integrate all departments in one coordinated implementation of the HIV/HIV/AIDS response. WHO is the multilateral organization that works closely with the Ministry of Health to assist the Indonesian national response.At the national level in the harm reduction field is the National Narcotic Board (BNN), which is attached to the National Police. This body is also responsible for narcotic demand and supply reduction, their primary focus. Also related to this effort is the Ministry of Justice and Human Rights, which runs prisons in the country and is responsible for every intervention inside the prison system.In addition to the Indonesian government sectors, the international community is involved in the country's HIV/AIDS response. Indonesia received $64 million US from the fourth round of the Global Fund with a project whose scope contains what is required to confront the epidemic, including a detailed cost study build in the WHO model (Costing Guidelines for HIV/AIDS Intervention Strategies). The Ministry of Health, through the Centre for Disease Control, leads the implementation of the Global Fund project. Unfortunately in Indonesia, administration of the Global Fund sources has led to a "D" classification, with results below expectations . NationaIn addition to the efforts from the Indonesian national government and international partners, there are local responses organized in several provinces and cities, in conjunction with the decentralization process already mentioned. Commitments are different based on the specific local history and importance of the epidemic, as well as the political climate of the various local governments. To complete this complex framework, Non-Governmental Organizations (NGOs) were involved at the onset and are still crucial in the Indonesian response to the HIV/AIDS epidemic."prevention  treatment and rehabilitation activities in both public, NGO, and private facilities, employing various modalities. Supply Reduction Strategies are implemented through more intensive eradication of cannabis cultivation, intensive investigations and raids of clandestine manufacturers and applying strict airport and seaport interdictions" [With permeable borders in its 17,000 islands, geographically close to the Golden Triangle, and as well not greatly distant from Afghanistan, since the late 90s, Indonesia has become a great market for heroin, and currently also a rising market for amphetamines. In its 2005 report, the National Narcotics Board indicated that there are 3.2 million drug users in Indonesia of which 25% are heavily addicted and injecting drugs . Still, ictions" . Under tAt the early stage of the epidemic among drug users in the late 90's, the response was dominated by NGOs supported by international aid agencies such as USAID and AUSAID [st century. All of these organizations are made up of people with previous experience in the drug field (the majority former drug users) to address the AIDS epidemic among IDUs. Yet their connection within the AIDS social movement has been weak. Meanwhile, these organizations had modestly better connections with the international platform, especially more recently. Their primary source of financial support is international donors , with the exception of a few organizations with diversified donors and partners. Interestingly, their activities have not put much emphasize on activism, and have not exhibited much responsibility in fighting for the rights of drug users . Such advocacy is being promoted by IHPCP and more recently by the Open Society Institute as well.Regarding harm reduction, the first recorded NGO organizing harm reduction services was Yayasan Hati-hati  in 1998. Since then, more organizations developed in many parts of the country, the majority founded after the beginning of the 21Thus, despite the growing commitment by all players especially in recent years, all are convinced that the response to the HIV/AIDS epidemic so far is insufficient for the size of the problem. The dominance of NGOs has proved ineffective in scaling up efforts of AIDS services, particularly for IDUs.In response to the problem, IHPCP's latest commitment in harm reduction has been to include the public health system in the service of AIDS to drug users and the empowerment of drug users as Indonesian citizens for universal access to health care.The Indonesian response to the HIV/AIDS crisis among people who inject drugs is still modest. There is a clear consensus among stakeholders of an urgent need to scale up the response to the epidemic. In total, 41 NGOs are working in the field of harm reduction. Among these, 16 are conducting needle and syringe program projects, targeting 4,500 people who inject drugs on a monthly basis, all but one of these 16 NGOs supported by IHPCP. The other 25 organizations started modest syringe distribution after the second semester of 2006 with funding from the Partnership and the Global Fund, and they are partners of Family Health International in Indonesia. Besides NGOs, public health centres (Puskesmas) are also conducting harm reduction activities, including needle and syringe exchange. In July 2005 only one Puskesmas from Jakarta was developing harm reduction activities in Indonesia. By 2006, this had increased to 65. IHPCP and the local AIDS commissions are sharing the cost of these facilities for one year, with the commitment that future costs will be fully borne by the government. In September 2006, the City of Bandung Public Health Department in West Java, with their own funds, opened another 9 NSP in Public Health Centres. IHPCP provided technical support for planning and staff capacity building. So the current total of NSP slots in Indonesia by December of 2006 is actually 115.These public health centres are targeting to reach another 23,000 people who inject drugs. The interaction of public health services and non-governmental organizations is the key element of interventions to scale up the response in the country. The role of the Public Health Centres, especially in the capital region of Jakarta and West Java (two of the main provinces of Indonesia) is to lead the response and use the infrastructure of the health system to scale the response to the level of the epidemic. The expansion was based on a successful experience conducted in the City of Sao Paulo, Brazil, from 2001 to the present . Today tAt the beginning of 2005 , most of the NEPs were still focused on the distribution/exchange of syringes only. Our effort after 2005 was to change the intervention for a comprehensive prevention package which includes, besides the sterile syringes, condoms, alcohol swabs, IEC  material; projects conducted mainly on an outreach basis with a strong connection to the health system for referral in basic health care, drug treatment (highlighting methadone), and support and treatment for drug users at risk for HIV/AIDS.Drug treatment in Indonesia is primarily based on drug free clinics for detoxification and rehabilitation, normally conducted by mental hospitals, NGOs or therapeutic communities. There is no official compulsory treatment in Indonesia. Buprenorphine is still expensive and not widely available. So far, approximately 300 doctors (mostly private doctors) across the country are certified to prescribe Buprenorphine. As well, anecdotal reports from IDUs in several provinces including Bali, West Java and other regions indicate a high rate of injecting Buprenorphine as heroin becomes scarcer in the market. Methadone was established first in Indonesia in 2003 by WHO and the Ministry of Health in two pilot projects, one in Jakarta and one in Bali. These two pilots together existed until the end of 2005, serving a population of approximately 300 drug users. Since 2004, IHPC has supported the main expenses of these two projects. Under the political influence of BNN in June 2005 (during the Anti-Drug World Day), Indonesian President Suscilo Bambang Yudoyono visited one of the clinics and announced a public program to expand methadone use based on its success so far. The expansion of methadone really started in 2006. By the end of 2006 there were 7 clinics serving approximately 1,000 clients. KPA's plan is to increase the number of drug users treated to more than 50,000 by 2010.The work in prison is another front of harm reduction work in Indonesia. In June 2005, the Ministry of Justice and Human Rights launched the National Strategy for Prevention and Control of HIV/AIDS and Drug Abuse in Indonesian Correction and Detention Centres, for the period 2005–2009 . The docThe legal basis for the Indonesian Response to HIV/AIDS among people who inject drugs is for the most part based on policy. Legislation in Indonesia is under debate to allow programs to assist in controlling the epidemic. There is no law against harm reduction in Indonesia, but prejudicial interpretation and misinterpretation of the current laws  have resulted in many constraints, primarily in the realm of prevention. The Sentani Commitment signed in January of 2004 by the Head of the National AIDS Commission and many other authorities in Indonesia – and re-edited clearly delineating needle and syringe programs, as well as methadone programs – in June of 2005 is the main document supporting harm reduction activities in the country . MemoranAdvocacy of the police is the most difficult part of the job. Indonesia has a history of militarization of the street police that is still currently in effect. Police officers are underpaid, under-trained and under-equipped in Indonesia. As in many other countries, the police are susceptible to corruption and the use of unnecessary force. Politicized and influential, positions often change and sometimes all expenditures related to a specific advocate decrease or even disappear as a result of constant changes and are subsequently re-introduced. This can make for noticeable cost inefficiency.The concept of universal access to AIDS treatment is new to Indonesia. The policy of free and universal access for ARV was implemented in 2004. According to the 3 × 5 initiative of WHO, Indonesia was recorded as having 10,000 people with AIDS (in need of ARV) by the end of 2005, of which 4,000, or 40% of the target, had been treated with ARV.In Indonesia, national production of ARV is done by Kimia Farma, an Indonesian Governmental Pharmaceutical Company contracted by the Ministry of Health. First line medications produced in the country are Zidovudine, Nevirapine and Lamivudine. Indonesia has also made available other ARVs by import: Efavirenz; Stavudine and lopinavir + ritonavir - Kaletra  and gradA recent global review estimates that in Indonesia, people who inject drugs are about 31% of the people treated with ARV . Thus, oBy 2006 IHPCP had attempted to stimulate among doctors in Indonesia the potential benefit of WHO and several other organizations to increase the number of current injecting drug users for ARV treatment . From thFormally, Indonesia is the only country in Asia that does not restrict people who inject drugs (including current users) from access to ARV treatment, and it is one of the few countries that produce the first line of ARVs for its own consumption. The KPA strategic plan has the provision to extend care, support and treatment of people who inject drugs to a total of 75 Public Health Centres (Puskesmas) by 2010, doubling the current possibilities for access.Drug user participation is also currently a key element of the growing Indonesian response to the epidemic. Besides many NGOs made up of current and former drug users, two networks highlight the key participation of drug users. Jangkar is network of organizations working in the field of AIDS, and IDUSA is a Drug Users Individual Network. Both are obtaining strong support for their activities from IHPCP and other partners and are gradually being included in all important governmental meetings and decisions. Their agenda includes both the controlling of the HIV/AIDS epidemic and the key issue of the human rights of drug users.currently, all the components for a comprehensive response are in place in Indonesia. The remaining question is how to expand this scenario, simultaneously guaranteeing the quality of interventions.The current scenario seems challenging. But realizing that as recently as two to three years earlier the current infrastructure for HIV/AIDS treatment was not in place, it's fair to say that Indonesia, the third biggest country in Asia, is facing an explosive epidemic driven by people who inject drugs. Even in a very inhospitable political and social environment, Indonesia is building a comprehensive response spearheaded by the commitment of the Indonesian government, province governments, civil society and international agencies. The response among people who inject drugs is being included in the public health system as a key strategy to push for the needed expansion of services. The role of the local governments is crucial, including their political and budget commitments, as a strong step in the sustainability of the response. The clear direction of the key interventions to address the HIV/AIDS epidemic that has affected Indonesia for the last 25 years is another important result. The clear focus on NSP, methadone, and care, support and treatment of people who inject drugs speaks to what needs to be done to address the epidemic. Initiatives from Indonesia such as the program to supply methadone inside prisons, and the promotion of ARV for current injecting drug users, are being perceived as the gold standard for all of Asia, a continent severely impacted by the HIV/AIDS epidemic. There is a long way to go in Indonesia to significantly impact the epidemic and thus celebrate the saving of thousands of lives, but the bases are very well established.As UNAIDS head Peter Piot stated: "...we need to do more of the wonderful things we have been doing so far".


Illicit drug abuse and HIV/AIDS have increased rapidly in the past 10 to 20 years in China. This paper reviews drug abuse in China, the HIV/AIDS epidemic and its association with injection drug use (IDU), and Chinese policies on illicit drug abuse and prevention of HIV/AIDS based on published literature and unpublished official data. As a major drug trans-shipment country with source drugs from the "Golden Triangle" and "Gold Crescent" areas in Asia, China has also become an increasingly important drug consuming market. About half of China's 1.14 million documented drug users inject, and many share needles. IDU has contributed to 42% of cumulatively reported HIV/AIDS cases thus far. Drug trafficking is illegal in China and can lead to the death penalty. The public security departments adopt "zero tolerance" approach to drug use, which conflict with harm reduction policies of the public health departments. Past experience in China suggests that cracking down on drug smuggling and prohibiting drug use alone can not prevent or solve all illicit drug related problems in the era of globalization. In recent years, the central government has outlined a series of pragmatic policies to encourage harm reduction programs; meanwhile, some local governments have not fully mobilized to deal with drug abuse and HIV/AIDS problems seriously. Strengthening government leadership at both central and local levels; scaling up methadone substitution and needle exchange programs; making HIV voluntary counseling and testing available and affordable to both urban and rural drug users; and increasing utilization of outreach and nongovernmental organizations are offered as additional strategies to help cope with China's HIV and drug abuse problem. Illicit drug abuse has become an increasing public health and social concern in the past decades worldwide. Drug abuse causes many problems both to individuals and to societies, including loss of productivity, transmission of infectious diseases, crime, family and social disorder, and excessive health care expenditures . Human iZhonghua Liu Xing Bing Xue Za Zhi); (2) Chinese Journal of STD/AIDS Control and Prevention (Zhongguo Xing Bing Ai Zi Bing Fang Zhi); and (3) National HIV sentinel surveillance data 1995–2004.This paper reviews global illicit drug trafficking, drug abuse and its association with HIV/AIDS epidemic in China, and Chinese policies on illicit drug abuse and prevention of HIV/AIDS, and offers additional strategies to governmental crack down on drug smuggling and drug use prohibition to help cope with China's HIV and drug abuse problem. We searched English and Chinese language literature via Medline and the China National Knowledge Infrastructure and reviewed unpublished official data, including national reports on illicit drug control and HIV/AIDS sentinel surveillance data. More than 100 papers and reports were reviewed. Key databases included: (1) Chinese Journal of Epidemiology (Drug abuse in China can be traced to the late Qing Dynasty (1644–1911 A. D.), when British colonists forcefully brought Indian opium into China for exchange of silk, tea, and cash. Opium was then locally planned. By the founding of new China in 1949, more than 20 million Chinese people were opium addicts, representing 5% of the total population . After aIllicit drugs reemerged in China in the 1980s as China adopted an open-door policy, and the reemergence was mainly connected with global drug trafficking activities. In Asia, there are two major opiate-producing regions: the "Golden Triangle," comprising three Southeast Asian countries of Myanmar (Burma), Laos and Thailand, and the "Golden Crescent" that includes the three Southwest Asian nations of Afghanistan, Iran and Pakistan ,5. The mThe number of drug users documented officially by Chinese public security departments increased from 70,000 in 1990 to 1.14 million by 2004 ,11.The main drug of choice in China is heroin. According to a report of the National Narcotic Control Commission (NNCC), 87.6% of drug users abused heroin in 2002 . The abuExperimentation (90%), peer pressure (44%), and relaxation (42%) are commonly cited reasons for beginning to use drugs. Initially, drugs were taken primarily through sniffing/snorting (55%) or smoking cigarettes mixed with drugs (38%) . InjectiSince the first AIDS case was detected in 1985 , China hIn 1995, only one out of 8 national sentinel sites for IDU detected HIV infections. The detected prevalence was 0.02% . By 1997At least 7 HIV-1 subtypes , and 3 major circulating recombinant forms  have spread in China -31. HoweDrug trafficking and abuse are illegal in China. Offenders may be sentenced to prison if smuggling 10 grams or more of heroin and could receive the death penalty for smuggling more than 50 gram of heroin. In 1990, the "Regulations on Prohibition Against Narcotics" were enacted with three levels of penalty to be applied to drug users. First-time offenders may be fined and/or allowed to go to voluntary detoxification centers, where they receive 10-day methadone treatment managed by the Ministry of Public Health. The cost of treatment is about 2,000 to 5,000 Chinese yuan – a cost considered expensive for many drug users and their families. If drug users who have gone through a voluntary detoxification program are caught again using drugs, they are sent to compulsory rehabilitation centers (CRC) administered by the Ministry of Public Security for 6 to 12 months. Drug users who relapse users after going through CRC are sent to reeducation-through-labor-centers (RELC) administered by the Justice Department for two to three years .In Chinese history, drug abuse and prostitution have been considered "social evils." The Chinese government typically takes "crackdown" measures and tries to eradicate these phenomena. China did achieve a success story in the 1950s. Illicit drug abuse and prostitution were eradicated through national anti-drug and anti-prostitution campaigns ,34. HoweCurrently, the Chinese government adopts more pragmatic policies and takes measures targeting both the root and surface of the drug abuse problem. The measures targeting the root include continuously cracking down on drug smuggling activities and discouraging new users through anti-drug education campaigns. The Chinese government actively seeks to collaborate with neighboring countries to prevent drug smuggling across borders and to help Myanmar, for example, to reduce opium poppy cultivation by replacing with crop plantation. Chinese mass media have increased anti-drug education to the general population. Anti-drug education has been included in the curricula for primary and secondary school students . The meaWhether or not China can shun a generalized epidemic of HIV/AIDS may be largely dependent on how China deals with IDU risk factors and breaks the bridge between IDU and heterosexual transmission. Past experience in China suggests that solely cracking down on drug smuggling and prohibiting drug use can not prevent or solve all illicit drug related problems in the era of globalization. Governmental support, harm reduction programs, voluntary counseling and testing, and utilization of non-governmental organizations are recommended.China has a strong central government. Without government support, it would be not imaginable to achieve success in the campaigns against drug use and the spread of HIV/AIDS. Since the late 1990s, the Chinese central government has stepped up HIV/AIDS control efforts, including setting out national policy framework for responding to HIV/AIDS, increasing funding inputs, expanding collaborations with international organizations. The Chinese National Medium-and-Long-Term Strategic Plan for AIDS Prevention and Control (1998–2010) was formulated in 1998 and set one goal that "by 2002, health education on preventing HIV/AIDS and STDs should be carried out at all detoxification centers and re-education centers as well as in 80% of jails..." . The ActOn the other hand, there is substantial autonomy at provincial level in some areas. Responses to drug use and HIV/AIDS epidemic vary significantly at provincial and lower administrative levels. For example, Yunnan and Guangxi provinces have done far more than other provinces in supporting, implementing, and advocating for harm reduction interventions for IDUs. Some local governments are not fully motivated to confront drug abuse and HIV/AIDS problems. Some government leaders still ignore or even cover up these problems. They are far more interested in economic growth than HIV/AIDS control and wish for their administrative areas to become "economy provinces" or "economy cities" rather than "AIDS provinces" or "AIDS cities," which is believed to be helpful for their career promotion. Advocacy to and support from government leaders at all administrative levels for harm reduction and community-based prevention are needed.Harm reduction includes many strategies, such as methadone maintenance, needle exchange, dispensing other drugs, and outreach services . Harm reIt is easy to access sterile needles and syringes in urban areas of China because they are legally sold and available at pharmacies and medical clinics ,44. HoweIn addition to cost and availability, other factors might also affect acceptability of methadone maintenance therapy, such as concerns about the safety and efficacy of the therapy . GreaterThere are still persistent conflicts in the policy and legal landscape. The central government has given explicit support to harm reduction, for example, as stated in the Medium- and Long-Term Strategic Plan and the Action Plan. Some programs have been implemented successfully ,50,51. HHIV voluntary counseling and testing (VCT) is often considered the first step for initiating prevention and/or therapy. One of the strategies for addressing the AIDS epidemic is to give people an opportunity to know their HIV status so that they can take precautions to avoid further spread and receive early therapy if they are infected ,54. HoweNon-governmental organizations (NGO) can play a critical role in the delivery of HIV prevention services and other assistance to persons living with AIDS. The flexibility of NGOs enables them to respond quickly to fill in gaps in health care and social services. NGOs can do what government agencies cannot do or are not willing to do – for example, reaching out without perceived threat to IDUs and other marginalized sub-groups whose behaviors are often stigmatized and also put them at higher risk of HIV/AIDS. A recent survey of 29 NGOs in Central and Eastern Europe showed that most NGOs targeted injection drug users; provided needle exchange and HIV prevention peer education; and delivered AIDS presentations and distributed educational materials . In AfriChina has large number of government organized NGOs (GONGOs), including Family Planning Associations, Women's Federation, Red Cross, Youth League, trade unions, and diverse academic associations. The members in these GONGOs have formal positions in governmental organizations while they volunteer at GONGOs. The "true" NGO that has no relationship to the government is just emerging in China. More and more of existing Chinese GONGOs are getting involved in sexually transmitted disease/AIDS prevention. Since the 1990s, the Chinese government has encouraged them to participate in HIV/AIDS control. These government-sponsored NGOs support HIV/AIDS education and academic publications and participate in AIDS research and education with foreign governmental and non-governmental partners, and they can serve as a powerful aid to the Chinese government to achieve the goal of stopping further spread of drug use and HIV/AIDS epidemic.In spite of its potential for greatly contributing HIV prevention in China, there is little literature in this area. An exception is a recent study  of a Women Federation's HIV prevention program in south China. The study showed that the Women Federation was able to deliver a culturally oriented, multi-level intervention program targeted at female drug users. The data also indicated that the program was successfully in increasing knowledge about HIV/AIDS, increasing condom use, and decreasing needle and syringe sharing among the female drug users in the project. Studies which systematically evaluate the implementation and effectiveness of NGO based intervention programs are greatly needed in the future.ATS – Amphetamine-type-stimulantsCRC – compulsory rehabilitation centersGONGO – government organized non-governmental organizationHIV – human immunodeficiency virusIDU – injection drug useMDMA – methylenedioxymethamphetamineMMT – methadone maintenance therapyNNCC – National Narcotic Control Commission of China,NGO – non-governmental organizationRELC – reeducation-through-labor-centerVCT – voluntary counseling and testingThe author(s) declare that they have no competing interests.HZQ and JES conceived of the study and wrote the first draft of the manuscript, HZQ, HTC and YHR collected the data, and all authors participated in the data interpretation and manuscript revisions.


Most literature on the medical emergency team (MET) relates to its effects on patient outcome. Less information exists on the most common causes of MET calls or on possible approaches to their management.We reviewed the calling criteria and clinical causes of 400 MET calls in a teaching hospital. We propose a set of minimum standards for managing a MET review and developed an approach for managing common problems encountered during MET calls.A to G': ask and assess; begin basic investigations and resuscitation, call for help if needed, discuss, decide, and document, explain aetiology and management, follow-up, and graciously thank staff. This approach was then adapted to provide a management plan for episodes of tachycardia, hypotension, hypoxia and dyspnoea, reduced urinary output, and altered conscious state.The underlying reasons for initiating MET calls were hypoxia (41%), hypotension (28%), altered conscious state (23%), tachycardia (19%), increased respiratory rate (14%) and oliguria (8%). Infection, pulmonary oedema, and arrhythmias featured as prominent causes of all triggers for MET calls. The proposed minimum requirements for managing a MET review included determining the cause of the deterioration, documenting the events surrounding the MET, establishing a medical plan and ongoing medical follow-up, and discussing the case with the intensivist if certain criteria were fulfilled. A systematic approach to managing episodes of MET review was developed based on the acronym 'A suggested approach permits audit and standardization of the management of MET calls and provides an educational framework for the management of acutely unwell ward patients. Further evaluation and validation of the approach are required. Medical emergency team (MET) systems have been introduced into hospitals to identify, review and treat acutely unwell ward patients. Most of the literature related to METs has concentrated on their effects in reducing cardiac arrests and serious adverse events , primariLimited information exists on the causes and outcomes of episodes of MET reviews. There is even less information on the process of assessment and management undertaken by the MET during an episode of MET review. To our knowledge, no information exists on a systematic approach to managing MET calls.It is likely that a limited number of conditions precipitate MET calls  and thatWe present here a systematic approach for the assessment and management of problems commonly encountered during an episode of MET review.The Northern and Austin Hospitals are both situated in the north of Melbourne and are affiliated with the University of Melbourne. The Northern Hospital provides acute and elective medical services, except cardiac surgery, neurosurgery and organ transplantation. The Austin Hospital provides all acute and elective medical services and is the referral centre for liver transplantation and spinal cord injuries for the state of Victoria. The Northern Hospital has a 10-bed intensive care unit (ICU) that is staffed by an intensive care registrar during the day, and a senior hospital medical officer and anaesthetic registrar overnight. The Austin Hospital has a 21-bed ICU that is staffed by intensive care registrars at all times. In both hospitals the ICU medical staff may have a background in anaesthesia, internal medicine or emergency medicine.Approval for the introduction of the MET and for the collection of data related to it was obtained from the Hospital Research and Ethics Committee of both hospitals.Both hospitals have two levels of emergency response. The traditional 'Code Blue' call is intended for the resuscitation of cardiac arrests and other acute life-threatening emergencies. It consists of an anaesthetic registrar, a coronary care registrar and nurse, an ICU registrar and nurse, and the medical registrar of the receiving unit of the day. The MET is intended to review all medical emergencies other than cardiac arrests; it has been described in detail previously . It can At the Austin hospital the MET consists of an ICU registrar and nurse, as well as the Medical registrar of the receiving unit of the day. Previously, activation of the MET at the Northern Hospital resulted in notification of only the patient's parent unit doctors. As part of an ongoing programme to improve the use of the MET at the Northern Hospital, activation of the MET now results in notification of the medical registrar and the intensive care registrar or hospital medical officer.A detailed log book is maintained by the switchboard operators at both hospitals that records all medical emergency calls. At the Austin Hospital, case report forms are also completed by the ICU registrar at the end of each call. These forms document the parent unit of the patient as well as the indications for the MET call. Since March 2002 the registrar has also recorded a provisional diagnosis of what medical condition is thought to have caused the MET call. Details of 400 calls that occurred between April and October 2004 were manually entered into an Excel spreadsheet to provide details on the trigger and the presumed aetiology of the call. Data are presented as percentages or absolute number of calls. No assumptions are made in cases in which data on presumed diagnosis were missing.A to G' approach to managing a MET call was subsequently developed to achieve these minimal standards. Finally, the 'A to G' approach was adapted to provide a plan for the management of the five most common 'MET syndromes': tachycardia, hypotension, dyspnoea and hypoxia, altered conscious state, and oliguria.The proposed minimum standards were developed after a series of meetings and electronic communications between all the authors of this manuscript. The 'Of the 400 MET calls, 23 had only the 'staff worried' criterion. Of the remainder, 248 had one listed physiological MET criterion, 105 had two, 23 had three and one patient had four criteria. The average number of listed MET criteria for the 400 MET calls was 1.3 .The proportions of MET criteria triggering a call were hypoxia (41%), hypotension (28%), altered conscious state (23%), tachycardia (19%), increased respiratory rate (14%) and oliguria (8%). Of the 531 calling criteria for the 400 MET calls, 61 had no documented provisional diagnosis. Several common causes for these triggers were identified . Infections , cardiogenic shock or pulmonary oedema (104/531 criteria) and arrhythmias (51/531 criteria) were thought to be responsible for 53% (280/531) of all triggers for MET calls .The proposed minimum requirements for managing an episode of a MET review included the following: first, determining the cause of the deterioration; second, documenting the events surrounding the MET; third, establishing a medical plan and ongoing medical follow-up; and fourth, discussing the case with the intensivist if predefined criteria were fulfilled . Requirements specific to the Austin Hospital also included automatic medical referral for surgical patients who remained on the ward after a MET call for a medical reason, and compulsory review of the patient by an intensivist for a patient requiring two MET reviews in a seven-day period.A to G' . The members of the MET are encouraged to ask the nurses the reason for the MET call  and assess the patient for the aetiology of the deterioration before beginning basic resuscitation. They are also encouraged to call for help if needed. After initial resuscitation and assessment, the staff are instructed to discuss the case with appropriate medical staff, decide where the patient should be managed, and document the events surrounding the MET. Issues surrounding the resuscitation status of the patient should also be discussed if appropriate. Once a management plan has been established, the members of the MET are encouraged to explain the cause of the call and subsequent management and follow-up plan to the medical and nursing staff, the patient and/or their next of kin. The subsequent frequency of monitoring of vital signs should also be discussed, as should the criteria for doctor re-notification. Finally, the members of the MET are encouraged to graciously thank staff for their help with the MET call.An approach to the management of a MET call was developed with the acronym 'In addition to these guidelines, emphasis is placed on three principles regarding MET call management: first, always be helpful; second, never criticize the staff for making the call, or for the management of the patient; and third, always remain calm and concentrate on the management of the patient.A to G', a plan was developed for the management of an episode of MET review initiated for a patient who is hypoxic or tachypnoeic . Similar plans were developed for the management of the 'hypotensive MET call', the 'tachycardic MET call', the 'oliguric MET call' and, finally, the 'altered conscious state MET call'.Using the framework of the acronym 'The aetiology and features of the common causes of the call are listed, as well as an approach to the management of each cause. In addition, criteria for seeking assistance or for notifying the intensivist are listed.We conducted a study to determine the most common reasons for initiating 400 MET calls in a teaching hospital. In addition, we proposed minimum standards for the management of a MET call and developed a systematic framework for the assessment, management and referral of the various 'MET syndromes' that resulted in these calls.Most of the literature related to METs has concentrated on their effects in reducing cardiac arrests and serious adverse events , primariLimited information exists on the cause of MET calls, and there is even less information on the process of assessment and management undertaken by the MET during an episode of MET review. To our knowledge, no information exists on a systematic approach to the management of such episodes.Our analysis of 400 recent MET calls at the Austin Hospital revealed initial evidence supporting previous opinion that MET calls are likely to be made for a limited number of conditions  and thatAt least two other studies have assessed the abnormalities leading to the activation of a MET service. In the original description of the MET, Lee and colleagues.  analyzedA to G' approach outlined in this article provides information about the aetiology, management and recommendations for referral and follow-up of patients with these and other syndromes.At least two other approaches exist that teach junior medical staff to manage acutely unwell hospital patients. The ALERT™ course was developed by staff affiliated with the University of Portsmouth ,8. The cA to G' approach outlined in this article is aimed primarily at medical and intensive care registrars and fellows, and incorporates acute deteriorations of both medical and surgical patients. It emphasizes the need to establish a diagnosis of the aetiology of the call and to establish a management and follow-up plan for the patient. In addition, we have included strategies to facilitate communication between members of the MET and the parent unit of the patient. Finally, we have emphasized the importance of not criticizing ward staff for initiating the call. Fear of criticism has been shown to be an obstacle for the activation of MET services [The CCrISP course was developed by the Royal College of Surgeons (England) and is a two-day course aimed at surgical house officers . The 'A services ,11.Our study has several strengths and limitations. Our approach lends itself to education of the members of the MET and auditing of the MET review process. It is tailored for the team approach of the MET that involves an initial assessment and coordination of ongoing care. The other major strength of the approach is the ability to adapt it to the requirements of different hospitals. First, the 'MET syndromes' can be adapted according to the case mix and demographics of the patients at a given hospital to reflect the most common criteria and causes for the initiation of a MET call. Second, the details of the management plans can be altered according to local medical opinion and to reflect the level of experience of members of the MET. Third, it is possible to apply more objective and specific criteria for the notification of senior members of medical staff .The major limitation of the approach is that it has not been validated. We are currently implementing a detailed education programme at the Northern Hospital based on these recommendations that seeks to improve the documentation and outcome of patients who receive a MET review.We reviewed 400 MET calls and found that five syndromes accounted for essentially all MET calls observed; More than 90% of calls were associated with hypoxia, hypotension or altered conscious state. Sepsis, pulmonary oedema and arrhythmias were the most common triggers of MET calls and of the above syndromes. In response to these observations, we propose an approach that permits audit and standardization of the management of MET calls and provides an educational framework for the management of acutely unwell ward patients. Further evaluation and validation of the approach are required.• 	Little information is currently available on what conditions trigger medical emergency team (MET) calls.• 	We reviewed 400 MET calls and found that they could be reduced to five main syndromes.• 	More than 90% of calls were associated with hypoxia, hypotension or altered conscious state.• 	Sepsis, pulmonary oedema and arrhythmias were the most common underlying triggers for MET calls.• 	Given the above observations, we propose minimum standards of response and a structured approach to managing MET calls.ICU = intensive care unit; MET = medical emergency team.The authors declare that they have no competing interests.DJ, GD, JG, JB, AC and RB were responsible for the design of the study. DJ, AC and RB collected the data. DJ, GD and RB performed the data analysis. All authors performed the critical data review and prepared the manuscript. All authors read and approved the final manuscript.A Microsoft Word file containing five tables: 'Calling criteria for Medical Emergency Teams' (Table 1); 'Common reasons for MET calls at the Austin Hospital' (Table 2); 'Proposed minimum criteria for managing a MET call' (Table 3); 'An approach to managing a MET call' (Table 4); 'Management of the 'hypoxic-tachypnoeic MET call" (Table 5).Click here for file


Hospital medical emergency teams (METs) have been implemented to reduce cardiac arrests and hospital mortality. The timing and system factors associated with their activation are poorly understood. We sought to determine the circadian pattern of MET activation and to relate it to nursing and medical activities.We conducted a retrospective observational study of the time of activation for 2568 incidents of MET attendance. Each attendance was allocated to one of 48 half-hour intervals over the 24-hour daily cycle. Activation was related nursing and medical activities.P = 0.001). The greatest level of half-hourly utilization was seen between 20:00 and 20:30 , before the evening nursing handover. Additional peaks were seen following routine nursing observations between 14:00 and 14:30  and after the commencement of the daily medical shift .During the study period there were 120,000 consecutive overnight medical and surgical admissions. The hourly rate of MET calls was greater during the day , but 53% of the 2568 calls occurred between 18:00 and 08:00 hours. MET calls increased in the half-hour after routine nursing observation, and in the half-hour before each nursing handover. MET service utilization was 1.25  times more likely in the three 1-hour periods spanning routine nursing handover (Peak levels of MET service activation occur around the time of routine observations and nursing handover. Our findings raise questions about the appropriate frequency and methods of observation in at-risk hospital patients, reinforce the need for adequately trained medical staff to be available 24 hours per day, and provide useful information for allocation of resources and personnel for a MET service. The medical emergency team (MET) concept is an evolving hospital system change that aims to reduce morbidity and mortality in acutely ill ward patients -3. The MP = 0.12). Lee and coworkers [We recently reported that the implementation of a MET system in our hospital resulted in a 65% relative risk reduction for in-hospital cardiac arrest over a 4-month period [Available evidence suggests that between 69% and 82% of MET calls are initiated by a nurse ,6. The cAustin Health is a university-affiliated teaching hospital with three hospital campuses situated in Melbourne, Australia. The Austin Hospital is the acute care hospital in which the MET service operates. It has 400 beds and receives approximately 60,000 day and overnight admissions per year.The acute care hospital has two levels of medical emergency responses and teams. A traditional cardiac arrest ('code blue') team is comprised of a cardiology fellow and coronary care nurse, as well as an intensive care fellow and nurse, and the receiving medical unit fellow. All wards are equipped with resuscitation trolleys containing resuscitation drugs and defibrillators.In September 2000 a MET system was introduced into the acute campus following an extensive preparation and education process . The teaCalling criteria for our MET service are based on acute changes in heart rate (<40 or >130 beats/min), systolic blood pressure (<90 mmHg), respiratory rate (<8 or >30 breaths/min), conscious state, urine output (<50 ml over 4 hours), and oxygen saturation derived from pulse oximetry . In addition, the calling criteria contain a 'staff member is worried' category to allow staff to summon senior assistance to manage any possible emergency situation.Information on the activation of all MET calls is maintained on a hospital switchboard logbook that includes the date and time of the call, as well as the ward where the MET review occurred. The details of 2568 MET calls were manually entered into an MS Excel™ spreadsheet by two investigators who worked together and cross-checked the entries to minimize errors.Each call was allocated to one of 48 half-hourly intervals over a 24-hour period . A graph was then constructed from the 2568 episodes of MET service review to illustrate the frequency of activation at various times over the 24-hour period.Episodes of activation were related to the periods of routine nursing handover , routine nursing observations , and commencement and completion of the daily medical shift (08:00–18:00).P < 0.05 was considered statistically significant.The frequency of MET service activation during peak periods was compared with the average activation over the 24-hour period. In the case of nursing handover, the 1-hour period spanning handover  was compared with the average activation over the 24-hour period. Statistical significance was determined by analysis with Fisher's exact test using MS Windows Statview . During the study period (August 2000 to September 2004) there were 120,000 consecutive overnight medical and surgical admissions to the Austin Hospital and 2568 activations of the MET service. Activation of the MET service was not uniform over the 24-hour period .Over the study period, 53% of the 2568 calls occurred in the 14 hours between 18:00 and 08:00 (58% of the day). On an hourly basis, MET call utilization was more common during the hours covered by the parent unit doctors . In the 5 years that the MET system has operated, there has been a trend for an increasing proportion of calls to occur after hours .On average there were 106 calls (2568/24) for each hour period, or 53 calls (2568/48) per half-hour period. Increased activity of the MET service was typically seen in the half-hour following routine observations, and in the half-hour before routine nursing handover . Additional peaks of activity were seen between 14:00 and 14:30  and between 09:00 and 09:30 . All other peaks of activity failed to achieve statistical significance.The highest level of MET service activation for any given half-hour period was seen between 20:00 and 20:30, when use of the MET service was 1.8 (95% CI = 1.25–2.48) times greater than average half-hourly utilization , a substantial proportion of MET calls occur after normal working hours , with the peak time of activity occurring between 20:00 and 20:30. These findings have important implications for the frequency and method of patient monitoring, as well as for allocation of critical care resources and MET personnel, and require detailed discussion.In a previous study at our institution  there waIn the present study, 53% of all calls occurred 'out of hours' (18:00–08:00) when wards are not staffed by parent unit doctors. In addition, there was a trend toward increased frequency of activation of the MET service during these hours in the 5 years following the introduction of the MET system. When directly compared with the study conducted by Lee and coworkers [The frequent use of the MET service after 18:00 has important implications for allocation of resources to the MET service out of hours, and further reinforces previously reported opinion  that appUtilization of a MET system has been associated with a reduction in all-cause hospital mortality in our institution ,6. Thus,The present study has a number of limitations. First, it is an observational study and does not demonstrate the effect of MET service utilization on patient outcome. However, we know from previous studies ,6 that tIn our institution, peak levels of MET service utilization occur around the time of routine nursing observations and nursing handover, and the majority of calls occur after hours. Our findings raise questions about the appropriate frequency and technology of observations in hospital ward patients. They also provide useful information to guide appropriate resource allocation for the provision of the MET service.• 	More than half of MET calls occur after hours.• 	The peak time of MET activation is at 20:00, just before nursing handover.• 	Other peak activities occur around nursing handover times or medical ward round times.• 	These findings suggest that critical illness detection in hospital is episodic.• 	More systematic approaches to hospital patient monitoring may be desirable in order to provide more timely intervention.CI = confidence interval; MET = medical emergency team; OR = odds ratio.The author(s) declare that they have no competing interests.DJ conceived the study, constructed the data base, and was the principle author of the manuscript. SB, DG, and SW assisted with construction of the data base. HO, GG, and RB contributed with the study design and authorship of the manuscript. All authors read and approved the final manuscript.


Beyrer and colleagues discuss infectious disease threats in Burma and suggest policy options for responding to them. In 2004 the Global Fund to Fight AIDS, Tuberculosis, and Malaria  awarded program grants to Burma (Myanmar) totaling US$98.4 million over five years—recognizing the severity of Burma’s HIV/AIDS and tuberculosis (TB) epidemics, and noting that malaria was the leading cause of morbidity and mortality, and the leading killer of children under five years old . For thoIn that same year, Burma’s authoritarian military regime—the State Peace and Development Council (SPDC)—was accused of severe and ongoing human rights violations, and United Nations Secretary General Kofi Annan appointed a Special Rapportuer on Human Rights, signaling a high level of concern about the junta’s governance. Given these occurrences, the Global Fund imposed additional safeguards on their Burma grants—including additional monitoring of activities and expenditures—and requested and received written guarantees from the junta to respect the fund’s safeguards and performance-based grant system.On August 18, 2005, the Global Fund announced termination of the grants, stating that “given new restrictions recently imposed by the government which contravene earlier written assurances it has provided the Global Fund, the Global Fund has now concluded that the grants cannot be implemented in a way that ensures effective program implementation” [In the same month, the executive director of the World Food Programme visited Burma and called for a relaxation of government controls on the procurement and distribution of food commodities . The WorIn each case, restrictions on health and/or humanitarian activity have included lengthy delays for approval to travel to project sites, variously reported as taking up to three weeks; the addition of junta approved “minders” on all site visits; and limits on the time allowed at sites. In February 2006, the SPDC Ministry of National Planning and Economic Development put forward guidelines for NGOs, UN agencies, and international organizations working in Burma [http://www.psi.org). The aid dilemma has become more compelling as Burma’s health and humanitarian crises have been increasingly recognized as playing important roles in South and Southeast Asia [The program withdrawals from Burma highlight what has become a contentious and complex dilemma for the international community: how best to respond to the health crises affecting the people of Burma. While some donors have withdrawn from Burma, others including the European Commission have called for increased levels of humanitarian assistance . And a nast Asia .We reviewed the recent medical and policy literature on Burma, with a focus on HIV/AIDS, TB, and malaria. We searched the PubMed database using MeSH terms “Burma” and “Myanmar.” We reviewed all articles from January 1, 2004, to May 1, 2006, relevant to HIV/AIDS, TB, and malaria. We reviewed data available on Burma’s health expenditures and infrastructure and on SPDC policies, and analyzed information from a variety of sources and informants—attempting, wherever possible, to assess the validity of reports. Given the range of limitations on the availability of information from Burma, including restrictions imposed by the SPDC on publications and reports, we acknowledge that there are likely to have been information sources that were unavailable to us. We had the following objectives: attempt to synthesize what is known about HIV/ AIDS, TB, malaria, and other disease threats—including avian influenza (H5N1 virus) in Burma; assess the regional health and security concerns associated with these epidemics; and suggest policy options that would respond to these threats in the context of the tightening restrictions imposed by the junta. Field investigations were conducted by our group and by Burmese colleagues in 2005 and 2006, which included visits to health facilities in Burma and along its borders, as well as discussions with health professionals inside and outside the country.The SPDC has been cited for its markedly low levels of public funding for health and education . Public-http://www.myanmar.com/Ministry/health/g09.htm).Widespread corruption has weakened the health sector . DisinveBurma’s laboratory infrastructure has also weakened, both directly as a result of disinvestment and indirectly from creating a dearth of skilled technical personnel . The US We reported an estimate of the scale of Burma’s HIV/AIDS epidemic in 2003 using data from the national HIV sentinel surveillance and a national household survey to generate conservative estimates of HIV prevalence [Molecular epidemiologic data from several groups working both within the country and in the country’s border regions with India, China, and Thailand suggest that Burma’s epidemic is characterized by marked viral diversity, high rates of recombination and circulating recombinant forms, and high rates of HIV and hepatitis C coinfection among injection drug users (IDUs) . This moSouth and Southeast Asia have the highest burden of TB worldwide: one in three cases of TB diagnosed worldwide is in this region . Burma rThe epidemic of TB in Burma is closely linked to HIV. WHO estimates that approximately 6.8% of patients with TB in Burma have HIV, while 60%–80% of patients living with HIV also have TB—making TB the most common opportunistic infection in people living with HIV/AIDS ,34,35 BuWith the introduction of WHO’s Directly Observed Therapy, Short-Course (DOTS) program in Burma in 1997, the government reports that case detection rates have improved . In 2005There is also microbiologic evidence—i.e., rising antibiotic resistance—that the TB control program in Burma is troubled. In the first report on multidrug-resistant (MDR) TB in Burma, in 2000, 33.3% of isolates from patients newly diagnosed with pulmonary TB were resistant to at least one first-line drug, and 2% of isolates were MDR TB . In a 20Burmese official statistics reported to WHO show that malaria causes proportionately more mortality in Burma than in any other country in Southeast Asia . Burma rAccording to 2003 WHO data, the annualized country-wide incidence rate of malaria is approximately 3.6 cases per 1,000 population, (0.36%) per year . The areP. falciparum, particularly along the frontiers of the country [Burma has also become an epicenter for drug-resistant  country . Chloroq country ,49–51. T country ,50.P. falciparum malaria, defined as malaria that is resistant to three or more drugs, is most problematic on the Thai–Burma border [MDR a border . As a rea border ,52Several factors may hasten the spread of drug-resistant malaria, including incomplete or inappropriate use of antimalarials, program failure, and the sale and use of fake or expired antimalarials. There is little regulatory oversight of the importation and sale of antimalarials in Burma, and the proportion of fake drugs is high . DondorpThe more expensive artemesinin derivatives strain already scarce resources available for treatment of malaria, and many Burmese continue to purchase their medications over the counter and on the black market ,45,52,54Avian flu is a regional and global concern. Given Burma’s poor health and laboratory infrastructure and the limits on access to Burma, the concern over Burma’s potential to aid in the evolution of avian flu is prudent. Burma’s first report of the H5N1 virus describes emergence on March 8, 2006, on a farm in the Mandalay district, about 430 miles north of Rangoon .Some 112 birds died in the outbreak. Veterinary authorities in the country called for international assistance, but the state-run media did not notify the Burmese people of the threat until March 17, 2006, more than a week later . Six dayThe main concern with the failure to inform the public about avian flu is the risk of further unwitting spread . Such spread has subsequently been reported in Burma by the UN Food and Agriculture Organization (FAO), with over 100 bird flu outbreaks reported by FAO at an April 10, 2006, press conference in Bangkok . He ChanHow important are Burma’s ongoing epidemics of HIV/AIDS, TB, and malaria to the country’s neighbors? A driver of regional importance in HIV/AIDS has been the interaction between the spread of HIV and narcotics use and exports from Burma. Burma remains the world’s second-largest opium- and heroin-producing state, and has dramatically increased its production and export of methamphetamine ,59. In BYunnan Province, in China’s southwest, is the area with the highest HIV prevalence in China. Epidemic spread in Yunnan began among IDUs in several districts on the Yunnan–Burma border in the early 1990s . The uptThe National AIDS Control Program of India, in collaboration with the Avahan Program, has mapped the HIV prevalence rates among pregnant women across India’s HIV- surveillance-reporting districts . These dThe population exodus from Burma has made MDR TB an issue of regional concern . IsolateThe large-scale migration of Burmese people across international borders has significant regional malaria-control implications, especially for Thailand, where malaria incidence rates have been steadily declining. This declining trend is not seen in those provinces that share a border with Burma ,68. Of tMDR-malaria parasites are common along the Thai–Burma border . A similGiven the scale and scope of Burma’s health needs, are there policy options for health work in this current climate? Several options for working in Burma may have some utility: (1) cross-border approaches, (2) use of independent media for health education and information, and (3) expanded support through international organizations and NGOs .One of our findings was that much of the available data on HIV/AIDS, TB, and malaria come from border areas. Indeed, one might assume that the health threats themselves were most marked in the Thai–Burma border areas. However, at least some of the emphasis on data from this area is no doubt a result of the paucity of information from areas bordering India, Bangladesh, the Lao People’s Democratic Republic, and China. Cross-border efforts, where feasible, are likely to increase in importance in regard to the health of the Burmese people if SPDC restrictions continue to tighten.Many communities of internally displaced people on the Thai–Burma border rely on a network of mobile indigenous health workers, known collectively as “Backpack Health Worker Teams,” for basic health care. These communities have very poor access to health services and are considered inhabitants of “black zone,” or “conflict” areas, by the SPDC. These health workers are indigenous, highly mobile, and have successfully navigated the ongoing conflict to provide much-needed care and information.A number of other ethnic groups within Burma have health organizations that operate clinics and/ or mobile backpack teams  on all of Burma’s borders, with varying degrees of development. The Karen team, for example, runs more than 30 clinics, servicing a population of over 80,000; the Kachin, more than 60 clinics, servicing a population of 98,000 . With inThe new government guidelines for the provision of humanitarian assistance put forth by the Ministry of National Planning and Economic Development in early 2006, if enforced, is likely to markedly diminish independent capacity to respond to health threats in Burma. Nevertheless, a number of organizations and NGOs will continue their activities in Burma, as well as continue to provide needed services. While a range of donors are engaged in efforts to counter the funding losses incurred by the pullout of the Global Fund, the new restrictions are more explicitly supportive of junta control of activities, staffing, site visits, procurement, and the like. The fundamental dilemma of how best to respond to health threats and provide humanitarian assistance while the SPDC further restricts access to Burma’s neediest has worsened in 2006.Health-related programs such as Population Services International, Médecins Sans Frontières Netherlands, and numerous others that are currently functioning in Burma are likely to continue. But from a public health perspective, much more fundamental and widespread change will be required to actually meet the scale and scope of Burma’s HIV/AIDS, TB, and malaria epidemics, increasing malnutrition, and other health threats. While such reform in Burma has been painfully slow, disease spread can be markedly rapid. Perhaps the concerns over emergent avian flu will have more regional impact than the tragedies of HIV/AIDS, TB, and malaria in Burma have had to date.http://www.jhsph.edu/humanrights/research. The Chinese- and Burmese-language versions of the executive summary are available at http://www.soros.org/initiatives/bpsai/articles_publications/publications/respondingtoaids_20060330.A longer version of this report is available at


In response to the growing HIV epidemic in Nigeria, the U.S. Agency for International Development (USAID) initiated the VISION Project, which aimed to increase use of family planning, child survival, and HIV/AIDS services. The VISION Project used a mass-media campaign that focused on reproductive health and HIV/AIDS prevention. This paper assesses to what extent program exposure translates into increased awareness and prevention of HIV/AIDS.This analysis is based on data from the 2002 and 2004 Nigeria  Family Planning and Reproductive Health Surveys, which were conducted among adults living in the VISION Project areas. To correct for endogeneity, two-stage logistic regression is used to investigate the effect of program exposure on 1) discussion of HIV/AIDS with a partner, 2) awareness that consistent condom use reduces HIV risk, and 3) condom use at last intercourse.Exposure to the VISION mass media campaign was high: 59%, 47%, and 24% were exposed to at least 1 VISION radio, printed advertisement, or TV program about reproductive health, respectively. The differences in outcome variables between 2002 baseline data and the 2004 follow-up data were small. However, those with high program exposure were almost one and a half  times more likely than those with no exposure to have discussed HIV/AIDS with a partner. Those with high program exposure were over twice  as likely as those with low exposure to know that condom use can reduce risk of HIV infection. Program exposure had no effect on condom use at last sex.The VISION Project reached a large portion of the population and exposure to mass media programs about reproductive health and HIV prevention topics can help increase HIV/AIDS awareness. Programs that target rural populations, females, and unmarried individuals, and disseminate information on where to obtain condoms, are needed to reduce barriers to condom use. Improvements in HIV/AIDS prevention behaviour are likely to require that these programmatic efforts be continued, scaled up, done in conjunction with other interventions, and targeted towards individuals with specific socio-demographic characteristics. Like many African countries, Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is a serious concern in Nigeria. By the turn of the century it was estimated that the HIV prevalence in Nigeria had exceeded 5%, which corresponds with approximately four million infected people . In 2003In response to the HIV/AIDS epidemic in Nigeria, the U.S. Agency for International Development (USAID) mission in Nigeria initiated the VISION Project, a three-year project designed to maximize the use of family planning services, HIV/AIDS services, and child survival services in Nigeria -13. The The VISION Project was implemented by EngenderHealth in partnership with IntraHealth, Johns Hopkins University Center for Communication Programs, Population Services International, and local non-governmental organizations (NGO) working in VISION Project target areas. The project targeted 15 local government areas (LGAs) in Bauchi, Enugu and Oyo states, and was active from September 2001 through September 2004 -13. The Sports for Life to promote healthy lifestyles and spread information on family planning and HIV/AIDS prevention during football competitions.The VISION Project worked with local NGOs active in the selected LGAs to develop "informed clients." BCC activities aimed to increase knowledge and to empower individuals and communities to demand quality family planning, STI/HIV/AIDS, and reproductive health information and services. The project developed information and education print materials and radio public service announcements (PSA) for women with an unmet need for family planning, as well as messages aimed at men and youth that focused on male involvement and responsibility in reproductive decision-making. In collaboration with local sports clubs, the VISION Project also developed an outreach strategy primarily aimed at youth called One Thing at a Time, Garin Muna Fata (Town of Hope), Odenjiji, and Abule Oloke Merin. As well, SFH implemented a television to promote safe sex that featured Nigerian soccer superstar Sunday Oliseh. A billboard campaign to increase awareness that someone who is HIV positive may not have symptoms supplemented the radio and television campaign [The VISION Project media campaign also included a set of weekly radio programs in target areas to disseminate family planning, HIV/AIDS, and other reproductive health information to the general public. VISION, with its partner NGOs, organized radio discussion clubs in the VISION Project target areas and provided these clubs with radios. In addition to these activities, the VISION partners conducted several complementary mass media activities . For example, the Society for Family Health (SFH) implemented several radio dramas aimed at increasing awareness of HIV/AIDS, and its causes and consequences. These radio dramas included campaign .The purpose of this paper is twofold: 1) to identify determinants of FP/RH program exposure, and 2) to assess the effect of a FP/RH mass media campaign on HIV/AIDS awareness and condom use in the VISION Project target areas. Specifically, this paper tests whether exposure to VISION-related mass media programs  had an effect on individual level willingness to discuss HIV/AIDS (awareness), whether said programs had an effect on individual level perception about condom use for reducing the risk of HIV infection (awareness), and whether exposure to mass media programs translates into increased condom use (HIV/AIDS prevention).Data were collected from a representative sample of households in the 15 Local Government Areas (LGA) targeted by the VISION Project. These include 5 LGAs in each of 3 states: Bauchi State located in the North-East, which is comprised mainly of Gerawa, Ningawa, Hausa, Fulani, and the Tangale ethnic groups; Eungu State located in the East, which is comprised mainly of the Igbo ethnic group; and Oyo State located in the South-Western part of Nigeria, which is comprised mainly of the Yoruba ethnic group. The selected LGAs in each of the 3 states represent VISION Project areas. LGAs were considered for selection into the VISION Project if: 1) the population was over 100,000, 2) the population contained at least 20,000 women of reproductive age, 3) the LGA contained private and public health facilities at the primary and secondary levels, 4) the LGA has access to media resources such as radio, television and newspapers, and 5) the LGA has support from Nigeria's federal Ministry of Health (MOH) and the relevant state-level Ministry of Health (MOH). VISION partners visited the LGAs and made the selections [This paper analyses data from the 2002 and 2004 household survey waves of the VISION Project evaluation ,13. The Data collection was conducted by trained interviewers. All fieldwork supervisors first participated in a 5-day centralized training. Subsequent to this, supervisors and interviewers jointly participated in 5-day regional trainings. The household questionnaire was field tested prior to the onset of the survey to check for errors, and to evaluate the readiness of the interviewers.Kusaurara, Dunniya J'atau, A New Dawn (Ayedotun), One thing At A Time, Gari Muna Fati, Abule Olokemerin, or Odenjinjin. Respondents were also asked if they had seen the Femi Kuti or Fati Mohammed television campaigns, if they had seen any HIV/AIDS or reproductive health advertisements in the newspaper, or had received any information from clinics or community health workers about HIV/AIDS or reproductive health.The survey questionnaire was based on the Demographic and Health Survey questionnaire. In addition to standard demographic and fertility questions, questions related to family planning, sexual activity and behavior, and exposure to various media campaigns were also asked. Specifically, respondents were asked if they had listened to the following programs on the radio: The outcome measures for this analysis are as follows: 1) Have you ever talked with a partner about ways to prevent getting the virus that causes AIDS (yes/no)? 2) Can people reduce their chances of getting the AIDS virus by using a condom every time they have sex (yes/no)? 3) Did you use a condom during your last sexual encounter (yes/no)?The respondent's age (continuous variable), education , religion , gender, marital status, place of residence , knowledge of a condom source (yes/no), state of residence , and whether or not the respondent has had at least 1 partner in the past 12 months, served as control variables in all regression models (described below). Based on the distribution of the data during preliminary analyses, exposure to media was measured by dichotomizing whether a respondent reads the newspaper at least once a week (yes/no), watches television at least once a week (yes/no), or listens to the radio at least once a week (yes/no). Media exposure variables served as control variables in the first-stage Poisson regression models only (see below).Our indicators of program exposure included a total count of the number of FP/RH radio programs heard, television programs seen, or printed FP/RH advertisements seen over the past 6 months (0 – 10). A separate count of the number of radio programs exposed to (0 – 7), and the number of TV programs exposed to (0 – 2), were also used as indicators of program exposure in separate models. All values, whether part of the cumulative number of programs exposed to or the individual programs exposed to for the respective media types, were then categorized as low (none), medium (one), or high (2 or more). The decision to use the same categories for each program exposure model was based on the distribution of program exposure data for each media type. These analyses showed that the proportion of respondents exposed to each category  of program exposure was similar between total program exposure counts, radio program exposure counts only, and TV program exposure counts only. No model was run for the printed advertisement media, as the questionnaire only asked about exposure to any printed advertisement (yes/no).cluster. Standardized state-level probability weights, based on the relative population size of program LGAs in each State (pweight) were applied to regressions, and to all between state estimates.Data analyses were done using STATA™ 7.0. Comparisons of the outcome variables were made between the baseline 2002 data and the follow-up 2004 data. Chi-square statistics and two-stage logistic regression models were used to analyze the data . Using dSocio-demographic characteristics of the population are presented in Table Figure Table 2 = 3.2, P = 0.07). The percentage of respondents that used a condom at last sex was lowest in Bauchi and greatest in Enugu in both 2002 and 2004. The percentage of respondents that have discussed ways to prevent getting HIV/AIDS with a partner increased from 44.7% in 2002 to 48.1% in 2004  . This decrease largely stems from a reduction in perceived condom efficacy in Enugu.Figures The effect of exposure on the relative odds that respondents were willing to discuss HIV/AIDS with their partner is shown in Table The effect of program exposure on the belief that consistent condom use can reduce the risk of HIV infection is shown in table The effect of exposure on condom use at last sexual intercourse is shown in table Nigeria is one of several sub-Saharan African countries trying to deal with the current HIV/AIDS epidemic. In response to this need, the USAID-funded VISION Project launched a mass media campaign focusing on HIV/AIDS awareness, perception, and behavior modification. The purpose of this paper was to assess the determinants of program exposure, and test whether exposure to FP/RH/HIV/AIDS program information translates into increased knowledge, awareness, and prevention of HIV/AIDS.While the VISION project communication strategy predominantly focused on radio communications and community health workers, some of the VISION partners also used other media. The results from our study show that in combination these media activities had high reach among the target population. Exposure to radio communication was highest, with 59% of the population reporting to have heard at least one advertisement or radio program. Exposure to TV programs was the lowest media source, with 24% of the population reporting having seen at least one VISION program. Exposure to printed advertisements was also lower than radio program exposure, with approximately 47% having seen an advertisement about reproductive health or HIV/AIDS. Community health workers and visits to the clinic were also important information venues, with over 25% of the population having been exposed to one or the other.Despite the relatively high percentage of respondents that believe consistent condom use can reduce the risk of HIV infection, and the high percentage of respondents that have discussed HIV/AIDS with a partner, relatively low numbers of respondents reported using a condom at last sex (<16%). This result is consistent with other surveys done in Nigeria and suggests that different strategies for reaching subgroups within the population may be needed to increase condom use. Programs that specifically target rural populations, females, and unmarried individuals, as well as disseminate information on where to obtain condoms, are needed to increase condom use in the VISION Project areas. The overall differences between the 2002 baseline data and the 2004 follow-up data in the three outcome indicators are small, suggesting that more needs to be done to increase HIV/AIDS awareness and influence behaviour change. However, the differentials by sub-groups of the population suggest that changes are starting to occur among smaller subgroups within the population. This is consistent with theories of behaviour change that posit that some subgroups may have a more advanced stage of readiness for behaviour change. It is therefore important to investigate if exposure to media campaign is facilitating behaviour change.Also of significance is the detected association between education and HIV/AIDS awareness and perceptions about the use of condoms for reducing the risk of HIV transmission, and the lack of detected significance between education and condom use. In all models of this analysis, those knowing where to obtain condoms was positively associated with increased HIV awareness and perception, and the use of condoms. These important outcomes lend insight into how and where future programs should be developed and implemented. Paramount to effecting behaviour change is the development of programs that create educational opportunities to enhance awareness, as well as the development of programs that create awareness about where condoms can be found. Concerted efforts must be made to reach populations that do not readily access media sources, or that are incapable of reading important public health announcements to disseminate information on the importance of using condoms consistently to reduce the risk of HIV transmission. This conclusion is further supported by results that suggest a majority of the community believes it is O.K. to discuss HIV/AIDS on the television and radio. Future efforts should also focus on increasing awareness of, and access to, condoms within the community.As with any data collection and evaluation exercise, there exists limitations in both the data and study design that may distort the true effect of the program on the outcomes investigated. The VISION Project was designed as a full-coverage program; as such, it was not possible to evaluate the effect of the program in relation to an equivalent comparison group. That is, we were unable to find a control group that would not be exposed to the intervention; because many of the partner NGOs were also active outside of the VISION Project target areas, contamination of the control areas was unavoidable. Hence, we decided on the use of a post-test design, and statistical techniques, to control for the potential limiting effects of extraneous variables in the analysis. That being said, in the absence of additional evidence, readers should be cautious when trying to generalize these results to other, and possibly dissimilar, areas.There is evidence to suggest that program exposure is increasing the communities' willingness to discuss HIV/AIDS with partners, as well as increasing the communities' knowledge about the benefits of consistent use of condoms for reducing HIV/AIDS risk. Less clear however, is the effect of the respective programs on condom use, as evidenced by insignificant estimated values, and differences in the magnitude of the effect between models. One possible explanation is that it may take much longer for the radio and TV programs to effect condom use behaviour change within the community. As state above, a second possibility is that our study design failed to capture the true effect, as a quasi-experimental design with a comparison group is better than a post-test design for teasing out the controlled effects of program exposure on behaviour-related outcomes. In either case, this analysis suggests that a necessary next step is to specifically target groups within the population that are not currently aware of the dangers of HIV/AIDS, or not aware of the availability and location of prevention methods, and then scale up the coverage, content, and distribution of media campaigns in these populations to ensure that HIV/AIDS prevention information is readily available and understandable to the majority of the population.The data shows that the FP/RH media campaign by VISION and its partners is reaching a large portion of the target population, and exposure to these mass media programs can help increase HIV/AIDS awareness. Programs that target rural populations, females, and unmarried individuals, as well as disseminate information on where to obtain condoms, are needed to reduce barriers to condom use. Although the overall differences in the outcome variables between 2002 baseline data and 2004 follow-up data were small, differences in the outcome variables observed in the respective project areas for sub-groups of the population suggest that change is starting to occur. Improvements in HIV/AIDS prevention behaviour are likely to require that these programmatic efforts be continued, scaled up, done in conjunction with other interventions, and targeted towards individuals or areas with specific socio-demographic characteristics.The author(s) declare that they have no competing interests.JK analyzed and interpreted the data, and drafted the manuscript. DM designed the study, assisted with the analysis and interpretation of data, and drafted sections of the manuscript. AA led data collection activities, designed the study, and provided substantial content for subsequent revisions to the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here: