Advice from a medical expert on concerns and queries expressed anonymously through the Internet by patients and later posted on the Web, offers a new type of patient–doctor relationship. The aim of the current study was to perform a descriptive analysis of questions about AIDS and hepatitis made to an infectious disease expert and sent through the Internet to a consumer-oriented Web site in the Spanish language.. The highest numbers of questions were submitted just after the weekend (37% of questions were made on Mondays and Tuesdays). Risk factors for contracting HIV infection were the most frequent concern (69%), followed by the window period for detection (12.6%), laboratory results (5.9%), symptoms (4.7%), diagnosis (2.7%), and treatment (2.2%).Questions were e-mailed and the questions and answers were posted anonymously in the “expert-advice” section of a Web site focused on AIDS and hepatitis. We performed a descriptive study and a temporal analysis of the questions received in the first 12 months after the launch of the site. A total of 899 questions were received from December 2003 to November 2004, with a marked linear growth pattern. Questions originated in Spain in 68% of cases and 32% came from Latin America . Eighty percent of the senders were male. Most of the questions concerned HIV infection (79%) with many fewer on hepatitis (17%)Our results confirm a great demand for this type of “ask-the-expert” Internet service, at least for AIDS and hepatitis. Factors such as anonymity, free access, and immediate answers have been key factors in its success. Although substantial progress has been made in the fight against HIV/AIDS, in terms of developing new treatments and understanding factors that cause the disease to worsen, putting this knowledge into practice can be difficult. Two main barriers exist that can prevent individuals seeking information or treatment. The first is the considerable social stigma still associated with HIV; the second is the poverty of the developing countries—such as those in Latin America—where the disease has reached pandemic proportions. In addition, the disease, which used to be spread mainly through the sharing of injecting drug needles or through sex between men, has now entered the general population. When healthcare services are limited, people are often unable to seek information about HIV, and even when services do exist, the cost of accessing them can be too high. The same is true for other diseases such as hepatitis infection, which often co-exists with HIV. The Internet has the potential to go some way to filling this health information gap. And, many patients seek information on the Internet before consulting their doctor.El Mundo launched an HIV and hepatitis information resource situated in the health section of its existing Web site. One aspect of this resource was an “ask-the-expert” section, in which readers could anonymously e-mail questions about HIV and hepatitis that would be answered by an infectious disease expert. These ranged from how the diseases can be transmitted and who is most at risk, to what to do if an individual thinks they might have the disease. There seems to be a clear need for this Spanish-language service; in Latin America, 2.1 million people are infected with HIV, with 230,000 new cases in 2005. In the Caribbean, AIDS is the leading cause of death in people aged 15–44 years. In Spain, 71,000 people were infected with HIV in 2005. Although the Internet contains a vast store of health information, and many aspects of patient–doctor interactions have been made electronic, little is known about what format is ideal. The researchers, who included employees of the newspaper, decided to investigate the effectiveness of the question–answer format used byEl Mundo.In 2003, the Madrid-based newspaperIn the first 12 months after the service was launched, the researchers recorded several details: what day of the week questions were sent, what the questions were about, and whether they were sent by the person needing the information or by a family member or friend. They also noted demographic information, such as the age, sex, and country of origin of the person e-mailing the question.Of 899 questions sent to the Web site between December 2003 and November 2004, most (80%) were sent by males. Most questions came from Spain, followed by Latin America, and most questions were sent on Mondays and Tuesdays. Some e-mails were from people who felt they had been waiting too long for an answer to their first e-mail—despite the mean time for answering a question being fewer than seven days. Messages of support for the Web site rose during the year from 2% to 22%.The messages of support and encouragement sent in by users indicated that the service was well-received and useful. Most of the questions were about HIV rather than about hepatitis, which the researchers say could represent the more prominent media coverage of HIV. However, despite the disease's high profile, the questions about HIV were very basic. It could also mean that people hold a false impression that hepatitis is a less serious illness or that they have more information about it than about HIV.Since most questions were sent in at the start of the week, the researchers believe that many individuals wrote in after engaging in potentially risky sexual behaviour over the weekend.The researchers also found that existing information on the Web site already answered many of the new questions, indicating that people prefer a question-and-answer model over ready-prepared information. The anonymity, free access, and immediacy of the Internet-based service suggest this could be a model for providing other types of health information.The findings also suggest that such a service can highlight the needs and concerns of specific populations and can help health planners and policymakers respond to those needs in their countries.http://dx.doi.org/10.1371/journal.pmed.0030256.Please access these Web sites via the online version of this summary atAIDSinfo Web site from the US Department of Health and Human Services provides information on all aspects of HIV/AIDS treatment and prevention and has sections specially written for patients and the general public• TheHIV in Latin America that includes details of transmission, infection rates, and treatment• AVERT, an international AIDS charity, has a section on Marco and colleagues analyzed questions sent by the public to a Spanish language "ask-the-expert" Internet site, and found that 70% of queries were about risk factors for acquiring HIV. AIDS can be considered the first media disease. Since its discovery in 1981, HIV infection has had a constant presence in the public eye. Its obscure origin and lethality, the fact that celebrities were affected by the disease, and its initial relationship with homosexuality, drug abuse, or racial origin made HIV an immediate public concern and subject in the media. Today things have changed: AIDS is a treatable disease and an example of how an enormous research effort can bring about dramatic results in the knowledge and management of a new medical problem. The AIDS epidemic has changed dramatically since its beginning. In Western Europe and North America it has slowed its progress, while other parts of the world such as Africa and Asia are suffering a devastating pandemic. The latest survey shows a total of 720,000 HIV-infected patients in Western Europe with an estimated 22,000 new cases in 2005 [The number of people living with HIV in Latin America has risen to an estimated 1.8 million. In 2005, approximately 66,000 people died of AIDS, and 200,000 were newly infected. Primarily due to their large populations, the South American countries of Argentina, Brazil, and Colombia are home to the biggest epidemics in this region. Brazil alone accounts for more than one-third of the estimated 1.8 million people living with HIV in Latin America. Viral hepatitis C (VHC) frequently coexists with HIV infection. With the progress made on antiretroviral treatment, hepatic disease has become an important aspect in the management of HIV patients: use of antiretroviral drugs can be limited by liver toxicity, and end-stage hepatic disease is sometimes the main problem of co-infected subjects .The Internet revolution has drastically changed aspects of daily life . FactorsA considerable amount of research has been done on Internet use by HIV-infected patients. The existence of a digital divide has been a major concern in most of these studies. While people with a higher level of education and income have fairly good access to Internet resources and are able to understand the information given, a considerable number of people are still on the blind side of this revolution –16. AccLooking at the wide variety of initiatives now under way, giving expert medical advice about questions and concerns expressed anonymously by patients through the Internet and made public on the Web offers clear advantages. If we place this tool in a channel of general information and make it available 24 hours a day, seven days a week, we end up with a tremendously active and constantly changing interaction. AIDS and hepatitis C have their own unique attributes on a site with these characteristics. Both are diseases with great impact on the media. They also need chronic and complex medical management, and toxic side effects are common. The general population is deeply concerned about them because of their contagiousness rather than because of their widespread existence . With thEl Mundo, through its online edition (http://www.elmundo.es) launched a new Internet site centred on different aspects of HIV infection and viral hepatitis, including an “ask-the-expert” section. According to the official Spanish agency that registers Internet traffic (Oficina de Justificación de la Difusion), in October 2005http://www.elmundo.es was the largest Internet newspaper in the Spanish language with 7,252,353 unique users monthly, andelmundosalud.com  received six million accesses with 830,000 unique users during this same month. An HIV/AIDS and VHC consumer-oriented Internet resource that is directly accessible through a news media outlet and which has great impact on the targeted population offers a unique opportunity for health education and is an excellent tool for identifying patient needs and the information demands of the general public. The present paper analyses an Internet service of “ask the expert” on advice about HIV/AIDS and hepatitis of the aforementioned characteristics in a Spanish-speaking population.In December 2003 the Spanish newspaperThe aim of this study was to perform a descriptive analysis of questions about AIDS and hepatitis made to an infectious disease expert sent through the Internet to a consumer-oriented website in the Spanish language. Answers to the questions had been posted on the Web site along with the questions (which were presented anonymously). We evaluated complementary aspects such as demographic characteristics of our users, type of questions, age of questioner, and the evolution of the service in its first 12 months of life.elmundosalud.com , which is the home page of the more general health site host, and which includes specific pages about tobacco, cancer, and pain. There is an active link on most of the pages that connect to the AIDS and hepatitis pages . The hepatitis and AIDS pages are divided into sections on news, special information, chats, interactive graphics, and “expert advice” .The AIDS/hepatitis Web site is sponsored by the pharmaceutical industry . The company pays a fixed yearly amount to the newspaper for the presence of a publicity banner on the Web site. There is no other contractual obligation between the partners, and by written accord there is no interference with content nor is the Web site subject to any kind of control by the sponsor. The medical expert has no relationship with the sponsoring company. Access to the site is made throughlud.com ,  on which the e-mail was sent, the presence in the text of a request for an urgent or speedy answer, subject of the question , and if the solicited information was for the sender, a friend, or a family member. We also took into account if it was a first or a follow-up question, and if there were present in the text support or encouragement for the Web site. We also registered demographic characteristics of the senders  when it was possible to obtain this information from the text of the e-mail. The evolution in the number and type of queries for the successive months was also analysed. We performed a descriptive study and a temporal analysis of the questions. Bivariate relationships were determined using the chi-square test for categorical variables andp = 0.2). Workdays had the heavier traffic, especially Mondays and Tuesdays (18.5% each). On weekends, this number was cut by half (9.9% on Saturdays and 8.5% on Sundays).A total of 899 questions were received from December 2003 until November 2004 with a marked linear growth pattern . 703 of 131 users (14.6%) sent more than one question, and this was a growing trend over time. Sometimes they wrote to enquire about their previously asked question (53%), other times to include new information (30.5%), and only 2.3% of the time with a new enquiry. Of the 899 questions, 48 (5.3%) considered their enquiry urgent and asked for an immediate reply. In general, the questions concerned the sender (only 7% were in reference to a friend or family member). The number of messages containing some sort of encouragement or support for the service was 204 (22.7%), with clear linear growth over time from 2% in January 2004 to 22% in November 2004 . HIV infOur results confirm a great demand for this type of “ask-the-expert” service through the Internet, at least for HIV and HCV infections. The use of this service shows in our experience a growth pattern typical of demand niches which are not covered by other types of services . The meaFor a Spain-based Web site, the high number of users from Latin America is surprising and reflects the enormous reach of the Internet. The reason is probably multiple: information is more limited and access to social and health services is more restricted in Latin America than in Europe. Also, looking at the few questions originating in other European countries, the sharing of a common language (Spanish in this case) is another reason for the high usage in Latin America. Messages supporting the Web site were attached to questions, reflecting the constant growth of the site. Many of the messages were critical of the absence of similar initiatives or they praised different aspects our Web site, such as its seriousness, free access, quality, or the scientific content of the answers.Most of the questions were directly related to HIV infection, with hepatitis clearly behind in interest. The high media exposure of AIDS compared with hepatitis is probably the main reason for this imbalance. Also, higher levels of information about hepatitis or the wrong impression that it is less serious than HIV could be behind these differences. The gap in the number of questions for the two diseases is more marked in Latin America where AIDS was clearly the main concern. The highest numbers of queries are sent just after the weekend, a fact most probably related with an increase in risky sexual practices during the weekend. The types of questions received suggest a low information level about AIDS among our users. Although one would think that with the high level of media exposure of AIDS/HIV, people using the Internet would have knowledge about the disease, but many of the questions addressed were very basic.A considerable number of graphics and special documents were available on our Web site, illustrating and discussing many aspects present in the written questions. However, it seems that users prefer the question–answer model rather than ready-made information. It could be that a different profile exists for users on the Web who are not asking for direct advice. This latter group would have a higher level of education and be more knowledgeable about the disease and thus more capable of searching for and finding information directly.Concerning hepatitis, in most of the cases it was the patient who was consulting about the risk of infecting household contacts. Most of the questions about hepatitis came from Spain, a fact that can be attributed to a lower level of awareness of this disease in Latin America. Compared with AIDS, we registered a higher percentage of questions about healthy living, treatment efficacy, and toxic effects for the different types of hepatitis. The level of information was higher than for HIV infection, especially in the questions coming from Latin America.A considerable number of repeated questions were follow-ups of previous e-mail by the same sender. The mean time elapsed between question reception and answer posting was generally fewer than seven days, but it seems that this delay was considered excessive by some of our users. The Internet is perceived by users as a speedy, almost instantaneous means of communication, and an effort should be made to shorten these time lapses when interacting with them ,6. AfteBasic data such as age and country of origin was missing in some of the queries. We consciously decided not to use a proper questionnaire, in favour of confidentiality, easy access, and swift communication of standard e-mail. Although improbable, the profile of our users could be somewhat different from the one we describe. Also absent from our study are other important data such as expectations of the users, how the information given was used, and how the community as a whole might be using the information on the Web site. All this data was unfortunately out of our initial scope and should be obtained by specific questionnaires different from the simple circuit of e-mail and posting of answers that we used.Looking at our results, it seems obvious that there is a great demand for this type of consultation service in the general population. In our opinion, factors such as anonymity, no fee charged, and immediacy of the answers are important keys for success. Perhaps one of the most interesting results of our study is that a general media information site, such as a newspaper on the Internet, turns out to be a good vehicle for delivering health information and advice. The media site delivered high Internet traffic, with a mean of four million accesses and 400,000 single users per month.Sponsorship by the pharmaceutical industry can be a good working model if standards for independence are strictly followed. Users are sensitive to conflicts of interest in the healthcare industry. The Internet seems to be a practical source for a second opinion: it reduces cost, there is no waiting list, and the quality of the answer is guaranteed by a certified expert in the field  chosen bAn “ask-the-expert” Internet resource for AIDS and hepatitis can be a good model for giving valid, widely sought information to patients in an anonymous, convenient, and timely way, and apparently it is in great demand. Its placement as a specialised site inside a health section that is part of a general information and news Web site appears to be a good model for this type of service, offering great accessibility to and exposure of the information. In view of its high demand and the increasing number of supportive messages received, our experience has been tremendously satisfactory. After two years, the Web site is well-established and its traffic continues to grow. Future investigations should employ a simple Web-based anonymous questionnaire including some questions about how the information given is used. This data will give a more comprehensive description of users and could be a very useful tool for tailoring content to their needs.Alternative Language Abstract S1(21 KB DOC)Click here for additional data file.Alternative Language Abstract S2(21 KB DOC)Click here for additional data file.


The HIV/AIDS pandemic in sub-Saharan Africa is widely recognised as a development disaster threatening poverty reduction, economic growth and not merely a health issue. Its mitigation includes the societal-wide adoption and implementation of specific health technologies, many of which depend on functional institutions and State.Donor and International Institutions' strategies to mitigate HIV/AIDS in sub-Saharan Africa are premised on a single optimal model of the State, one which focuses on the decentralised delivery of public goods alone  – the service delivery state. The empirical evidence, though sparse, of "successful" and "unsuccessful" sub-Saharan Africa states' performance in mitigating HIV/AIDS does not support this model. Rather, the evidence suggests an alternative model that takes a country context specific approach – encompassing political power, institutional structures and the level of health technology needed. This model draws on the historical experience of East Asian countries' rapid development.For international public health policies to be effective, they must consider a country tailored approach, one that advocates a coordinated strategy designed and led by the State with involvement of wider society specific to each country's particular history, culture, and level of development. The HIV/AIDS epidemic in sub-Saharan Africa (SSA) is a human and development disaster . Now sigDonors are funding the implementation and expansion of anti-HIV/AIDS programmes incorporating treatment for HIV/AIDS . They are generally targeted at low-income SSA countries that have a high HIV/AIDS prevalence and have conditions attached that insist on adopting the current state model – the Service Delivery State (SDS).We begin by outlining the necessary technological elements of an effective anti-HIV/AIDS strategy, then describe the SDS, and review the empirical evidence of SSA State's performance in HIV/AIDS mitigation. Finally we explore a different State model and the consequences of persisting with the international mitigation strategies.Mitigation strategies exist to control, treat, and prevent HIV/AIDS and are a form of technology  that a State needs to adopt in order to achieve mitigation . MitigatThe State plays an important role in the interventions described above that other providers  or private) either cannot or have a limited role. Many of these technologies are dependent on a functioning State and institutional structure that reflects these technological requirements. The State is the legitimate body that can lead societal-wide efforts to prioritise and co-ordinate anti-HIV/AIDS activities. These would include providing leadership, legislation, and enforcement regarding sensitive gender, cultural and sexual practices and roles. The State has responsibility for the health of its citizens and its function also encompasses negotiation of intellectual property rights on say, drug patents, including the use of emergency rights available in the World Trade Organisation rules, important not just for current health technologies, but future innovations too .The model of the State that the mitigation strategies assume is the SDS which views the State's role as providing public goods  with the market delivering all other goods and services . Allied The experience of mitigation in SSA can be divided into those countries that have seen some "success" namely an active and sustained response that has stalled (and possibly reduced) the prevalence of HIV/AIDS and those that have not achieved this. We reviewed the published literature and attempt to compare these responses with the SDS model and have focused on low-income SSA countries as they bear the bulk of the disease burden and are the target of the mitigation strategies.The "successful" countries are generally acknowledged as Uganda and Senegal. The evidence -12 pointIn contrast the "unsuccessful" countries, those that have not mounted a meaningful mitigation response reviewed here are Zambia, Namibia, and Ethiopia. The evidence -15 findsA failure of political will to tackle influential groups that may block mitigation , and, build a committed response to the epidemic. Difficulties with decentralisation include a lack of supervision and control, little interest (and hence funds) in HIV/AIDS by some local decision-makers, inequities in service provision, a need for improved information sharing between national structures and the decentralised entities. The evidence demonstrates the existence of a lack of clarity regarding the powers and functions of decentralised levels of government, poor financial frameworks for fiscal decentralisation, and poor capacity of local officials and councillors at a local level. Further, national mandates were not well clarified to local levels with service delivery assigned to specific government agencies . Building community coordination and integration activities are lengthy and intensive yet were largely unfunded. However, some promising developments of decentralisation were noted – integrated local level planning, and local HIV/AIDS coordination systems linking NGOs with local government to produce a more coherent response.Parkhurst reviews the experiences of several countries in tackling HIV/AIDS and emphasises that to understand a country's response to the epidemic one must look to the context, namely the national culture, political environment and actors involved in implementing policy ,17. ParkVan de Walle in a major survey studied African political economy in the context of donor imposed institutional reforms of the past two decades . He findThese findings are echoed by Szeftel who sees institutional reforms as imposing rules and regulations developed for rich liberal democracies on very different environments like SSA . These rUganda and Senegal achieved more success as they had a clear goal to tackling HIV and had commitment from important societal stakeholders that the State led and encouraged. Both countries recognised the limitations of their capacity and adopted health technologies appropriately (and attempted a sequenced development over time). Both developed a mitigation strategy suitable for their context and were able to some extent to draw donors into this vision. The other countries, in contrast, did not have such a clear and wide political commitment; rather there was a superficial articulation of this, if at all. Ethiopia, for example, suffered from political instability and mitigation at the lowest technological level  was barely delivered.The evidence emphasises the diversity of political arrangements in both the successful and unsuccessful groups, but with success due to a committed pro-mitigation political settlement. Institutional decentralisation (as in Namibia) is to be carefully considered as the findings point to gaps in capacity  undermining mitigation. The experience of Senegal, for example, points to the benefits of centralisation as a way of delivering higher technology interventions in a capacity constrained environment.Importantly the findings emphasise the primacy of political commitment and that it need not be democratically based. There is no clear evidence of the benefit of democracy and decentralisation in delivering mitigation (including ARV use). All this points to the inadequacy of the SDS suggesting that a different model of the State may be necessary to understand the context in a particular country and then develop a successful strategy. This alternative model has to address specific issues in State failure. Unfortunately, there are few studies of country performance in tackling HIV/AIDS particularly from a political economy perspective and the ones that are available (and reviewed here) tend to be reports which may not have been subject to peer-review.However the experience of Uganda and Senegal demonstrates that their approach to HIV mitigation  has similarities with the East Asian States' significant successes in their social and economic development. Political economic studies of this success have highlighted a possible alternative state model – the Developmental State (DevS).The DevS sees the critical area of state failure as the lack of adequate institutional and political capacity to produce a dynamic societal transformation towards greater social and economic development. Such states are described as having two elements- ideological and structural . The ideThe political settlement is key, successful States are a task of "political engineering" as much as "institutional engineering" . The misThe SDS recognises this political importance in a limited way, hence the good governance institutional agenda. But, there is a distinction to be made between power and institutional structures. The distribution of power may not match institutional "paper" structures. The establishment of formal institutions  may be unsuccessful in this context where the informal institution of power is with competing interest groups. Spending on mitigation may be diverted or contested by these groups, and there is also the possibility of the fragmented and unproductive acquisition of health technology rendering it less effective in a few years e.g. through ARV resistance.Different institutional arrangements of a State lead to different consequences for what the State can achieve or not . In makiFinally history has shown that SSA State elites have tended to be strengthened following imposed institutional reforms. Particular groups may gain preferential access to ARV's thus entrenching inequalities perhaps preventing any new social contract arising from the epidemic. Donors insist on decentralisation, and in a capacity-constrained environment this means reliance on NGOs and non-State actors risking a lack of accountability, poor regulation/performance monitoring, a variation in standards, inequities in access and uncertainty over funding timescalesThis is a broad look at the State and mitigation, limited by the evidence-base on SSA State performance. Whilst more research is indicated, little support for the current SDS model is found. Rather the DevS model is preferred as it recognises that a context specific approach is necessary, taking into account the existing political settlement and institutional and technological solutions, along with a long timescale coordinated strategy designed and led by the State with involvement of wider society specific to its particular history and culture. International institutions and donors should reconsider promoting a "one-size-fits-all" approach to mitigation; especially overlooking the crucial role of the State.A rethink considering the political economy of the State would lead to more effective and sustainable HIV/AIDS mitigation strategies in SSA countries. For instance, States can act to introduce a new form of health financing/taxation, acquire trade and debt concessions, invest in human capital and local pharmaceutical industries and so on. The battle against HIV/AIDS in SSA States is no less than a social transformation and as such should be linked to wider development goals to be truly effective.The author(s) declare that they have no competing interests.


In order for an HIV organization to receive funding from the United States, grantees must explicitly oppose prostitution. In January 2003, United States President George W. Bush announced the President's Emergency Plan for AIDS Relief (PEPFAR), the appropriation of $15 billion dollars for programs to combat the global HIV/AIDS epidemic, in his State of the Union address. Congress responded with the legislative authorization for the plan, the United States Leadership Against Global HIV/AIDS, Tuberculosis, and Malaria Act of 2003, and assigned seven primary implementing agencies, including the United States Agency for International Development (USAID) and the United States Department of Health and Human Services (HHS) ” and “counsel[ing]”, “help[ing] them escape,” and “provid[ing] them with condoms” . HoweverThe government also suggests that the Spending Clause of the Constitution allows Congress to “attach conditions on the receipt of federal funds,” and that Congress “has repeatedly employed the power to further broad policy objectives by conditioning receipts of federal moneys upon compliance by the recipient with federal statutory and administrative directives.” The government therefore argues that organizations that apply for federal funds are free to not accept them if they don't agree with the requirements .The Supreme Court has recognized this congressional power, but also its limits. Under the Unconstitutional Conditions Doctrine, Congress cannot ask recipients of their money to surrender vital constitutional rights . BalanciIn May 2006, the US District Court for the Southern District of New York issued a preliminary injunction against application of the policy requirement to AOSI and Pathfinder . The couThe DKT case was appealed as well—to the US Court of Appeals for the D. C. Circuit. Its February 27, 2007 decision in favor of the government overturned the District Court's original ruling and held that the Prostitution Pledge requirement is constitutional . The couReactions to the Global AIDS Act of 2003 and its prevention policies have varied, notably between groups already working on the ground and those applying for new funds. Brazil's National STD and AIDS Program made global headlines in May 2005 by refusing to adopt the Pledge and turning down some 40 million dollars from USAID for HIV prevention activities. Pedro Chequer, then Director of the National STD and AIDS Program, stated that “sex workers are part of implementing our AIDS policy and deciding how to promote it…They are our partners. How could we ask prostitutes to take a position against themselves?” [How has the pledge requirement actually affected programs? While we found few published studies, several cases do suggest possible implications. In our view, the pledge has the potential to restrict programs for those it seeks to protect. Changes in policy have forced some non-US-based projects, such as the Médecins Sans Frontières–run Lotus Project in Svay Pak, Cambodia, to close . InterviThe experience of the Lotus Project contradicts a principal argument used in a friend of the court brief in support of USAID. This argument stated that “Organizations can oppose the prostitution industry without stigmatizing the individuals bought and sold in it…Helping victims while opposing the industry that exploits them is the best way to prevent HIV/AIDS, the best way to advance human rights, and the best way to fulfill the intent of the Act” . We agreIn this polarized debate, neither side has been ready to surrender what it believes to be the best approach to HIV prevention among sex workers. Public health professionals have an obligation to demand that funding be driven by evidence-based strategies for addressing health and social problems, but evidence does not function in a political vacuum. The history of HIV prevention is all too full of programs that have proven to be politically unfeasible in the US despite overwhelming scientific evidence in their favor, such as the efficacy of needle and syringe exchange programs as HIV prevention tools for injecting drug users. The Federal Government continues its ban on federal funding for this intervention, despite endorsements from the Institute of Medicine, the US Surgeon General, and all of the major health professional associations .These political realities have complicated responses to HIV prevention for sex work as well as for injection drug use. While sex work may be seen by some as inherently degrading, it is nevertheless the case that in many settings sex workers choose to continue to work and to demand preventive and other health services. The provision of support, goods, and services to sex workers who want and need them is a compelling ethical and public health priority. Building trust and showing care by providing sex workers with the tools necessary to stay alive, whether they be condoms, counseling, or a safe place to receive medical attention, is our duty as health professionals and as human beings. Whether these goals can be met if we must “oppose prostitution” is actively being argued in the courts, and perhaps more vitally, in the many settings where sex workers provide services societies continue to disdain and demand.


Little information exists on the impact of highly active antiretroviral therapy (HAART) on health-care provision in South Africa despite increasing scale-up of access to HAART and gradual reduction in HAART prices.Use and cost of services for 265 HIV-infected adults without AIDS  and 27 with AIDS (WHO stage 4) receiving HAART between 1995 and 2000 in Cape Town were compared with HIV-infected controls matched for baseline WHO stage, CD4 count, age, and socioeconomic status, who did not receive antiretroviral therapy . Costs of service provision  included local unit costs, and two scenarios for HAART prices for WHO recommended first-line regimens: scenario 1 used current South African public-sector ART drug prices of $730 per patient-year (PPY), whereas scenario 2 was based on the anticipated public-sector price for locally manufactured drug of $181 PPY. All analyses are presented in terms of patients without AIDS and patients with AIDS.For patients without AIDS, the mean number of inpatient days PPY was 1.08  for the HAART group versus 3.73 (95% CI: 3.55–3.97) for the No-ART group, and 8.71 (95% CI: 8.40–9.03) versus 4.35 (95% CI: 4.12–5.61), respectively, for mean number of outpatient visits PPY. Average service provision PPY was $950 for the No-ART group versus $1,342 and $793 PPY for the HAART group for scenario 1 and 2, respectively, whereas the incremental cost per life-year gained (LYG) was $1,622 for scenario 1 and $675 for scenario 2. For patients with AIDS, mean inpatients days PPY was 2.04 (95% CI: 1.63–2.52) for the HAART versus 15.36 (95% CI: 13.97–16.85) for the No-ART group. Mean outpatient visits PPY was 7.62 (95% CI: 6.81–8.49) compared with 6.60 (95% CI: 5.69–7.62) respectively. Average service provision PPY was $3,520 for the No-ART group versus $1,513 and $964 for the HAART group for scenario 1 and 2, respectively, whereas the incremental cost per LYG was cost saving for both scenarios. In a sensitivity analysis based on the lower (25%) and upper (75%) interquartile range survival percentiles, the incremental cost per LYG ranged from $1,557 to $1,772 for the group without AIDS and from cost saving to $111 for patients with AIDS.HAART is a cost-effective intervention in South Africa, and cost saving when HAART prices are further reduced. Our estimates, however, were based on direct costs, and as such the actual cost saving might have been underestimated if indirect costs were also included. Healthcare costs for HIV-infected South African adults on HAART compared with costs for HIV-infected controls not on HAART. Authors conclude HAART is cost effective. South Africa is experiencing an HIV epidemic with enormous social and economic consequences. Recent estimates suggest that between 4.5 and 6.2 million of the 43 million South Africans are infected with HIV-1  in the HAART group versus 32 y [IQR: 28–40 y] in the No-ART group  compared with 4.35 (95% CI: 4.12–5.61); χ2 = 145, OR = 2.00, 95% CI: 1.78–2.25, p < 0.0001 (Patients on HAART had 1.08 (95% CI: 0.97–1.19) mean inpatient days, significantly fewer than the 3.75 d (95% CI: 3.55–3.97) of the No-ART group; χ< 0.0001 . The ave< 0.0001 .Based on the two HAART price scenarios, the average cost of service provision PPY for the HAART group ranged from a minimum of $760 to $1,377 PPY, with scenario 2 having the lowest service provision cost . The incp = 0.27). Gender distribution, with 63% and 70.4% males in the HAART and No-ART groups respectively, was not significantly different in the two groups  , and 40.74% were of low socioeconomic status. Median age did not differ in the two groups; 35 y (IQR: 32–41) in the HAART group versus 37 y (IQR: 33–50) in the No-ART group (median test .56) see . Median 2 = 1,019, OR = 0.13, 95 CI: 0.11–0.15, p < 0.0001). Mean outpatient visits PPY in the two groups did differ significantly; at 7.62 (95% CI: 6.81–8.49) for the HAART group compared with 6.60 (95% CI: 5.69–7.62) for the No-ART group; χ2 = 7.3, OR = 1.15, 95% CI: 1.04–1.28, p = 0.007, though not as substantially as for the non-AIDS group (see Patients on HAART had significantly fewer mean PPY inpatient days at 2.04 d (95% CI: 1.63–2.52) compared with 15.36 d (95% CI: 13.97–16.85) for the No-ART group . Highly active antiretroviral treatment (HAART) is a treatment that uses a combination of three or more antiretroviral drugs that attack different parts of the virus. HAART is expensive, making it difficult for poor countries to provide treatment for all who need it. Prices are falling, however, and South Africa is one country where efforts are now being made to improve access to treatment.The cost-effectiveness of HAART has been studied in developed countries, but developing countries also need to know how much it is going to cost their health services if they introduce HAART, and whether there will be financial savings because of switching to a more effective treatment.During the study period (January 1995 to 31 December 2000), HAART was not available in the publicly funded South African health-care sector. The study, funded by the drug manufacturer Bristol-Myers Squibb, took place in HIV clinics affiliated with the University of Cape Town. The researchers compared the cost of services for 292 patients who were given HAART with the costs for a comparison group (with the same number of patients) who were not given any antiretroviral drugs. Twenty-seven patients in each group had AIDS; the others were HIV-infected but did not have AIDS. The researchers calculated costs per patient year (PPY) and per life-year gained (LYG), i.e., the total cost divided by the number of extra years the treated patients lived. Calculations were done separately for patients with AIDS and those without AIDS. Patients on HAART required fewer hospital admissions. Depending on how long the patient survived and the price of antiretrovirals, it cost less to treat the HAART patients with AIDS. For this group, the cost saving ranged from $219 to $2,116 (in U.S. dollars). For patients without AIDS, the cost of treatment  was, by the South African standard of cost of living, affordable. However, it is expected that South Africa will soon be able to manufacture antiretroviral drugs locally and more cheaply. This would increase the amount saved by introducing HAART.HAART seems to be a more cost-effective way for South African hospitals to treat HIV infection than simply waiting for patients to come to hospital and then dealing with their symptoms. However, it should be noted that when a person is infected with HIV and becomes ill or dies from AIDS, it is not only hospitals that face costs. The patient, their family, and the country suffer financially. Effective treatment might also lower these “indirect” costs, but this was not an issue examined in this research.For a comprehensive source of information on HIV/AIDS:http://www.thebody.comThe site also includes a useful section on HAART:http://www.thebody.com/Forums/AIDS/Infections/Archive/NewMedications/Q12178.htmlFor information about the global AIDS situation and the position in different countries:http://www.unaids.org.


Globalisation affects all facets of human life, including health and well being. The HIV/AIDS epidemic has highlighted the global nature of human health and welfare and globalisation has given rise to a trend toward finding common solutions to global health challenges. Numerous international funds have been set up in recent times to address global health challenges such as HIV.However, despite increasingly large amounts of funding for health initiatives being made available to poorer regions of the world, HIV infection rates and prevalence continue to increase world wide. As a result, the AIDS epidemic is expanding and intensifying globally. Worst affected are undoubtedly the poorer regions of the world as combinations of poverty, disease, famine, political and economic instability and weak health infrastructure exacerbate the severe and far-reaching impacts of the epidemic.One of the major reasons for the apparent ineffectiveness of global interventions is historical weaknesses in the health systems of underdeveloped countries, which contribute to bottlenecks in the distribution and utilisation of funds. Strengthening these health systems, although a vital component in addressing the global epidemic, must however be accompanied by mitigation of other determinants as well. These are intrinsically complex and include social and environmental factors, sexual behaviour, issues of human rights and biological factors, all of which contribute to HIV transmission, progression and mortality. An equally important factor is ensuring an equitable balance between prevention and treatment programmes in order to holistically address the challenges presented by the epidemic. Globalisation, narrowly defined by Joseph Stiglitz as "the removal of barriers to free trade and the closer integration of national economies." , has a mAIDS is a pandemic of unprecedented pervasiveness, spreading to the furthest corners of the world. Globalisation is both midwife to the spread of the disease, as modern travel facilitates rapid dissemination of HIV infection across national borders, and, through concerted global action, triumphant conqueror over its devastating impact and expansion. Despite poorer countries having ever greater access to money, effective and affordable interventions, and technical support, the epidemic continues unabated in many of the resource-constrained regions of the world. A major reason for this continued spread is the numerous constraints within health systems in developing countries, which impact upon government policy, strategic and health policy management and health service delivery.In this paper, we discuss trends in the global AIDS epidemic as well as the numerous global funds that are available to meet the challenges posed by the disease. We also highlight the need for equal prominence to be given to both treatment and prevention programmes in the global fight against HIV/AIDS. Lastly, we examine how bottlenecks in health systems of developing countries reduce the effectiveness of such aid and suggest ways in which these blockages can be eradicated through systematic strengthening of health systems.Despite increased resources being available to address the global AIDS challenge, the infection continues to spread. Table HIV prevalence is intensifying in most regions, with sub-Saharan Africa, Eastern Europe and Central Asia being the worst hit, accounting for approximately 79% of new infections between 1998 and 2003. Although the greatest number of people living with HIV are in sub-Saharan Africa, of equal concern is the growing epidemic in Central Asia [The epidemiology of the disease differs between regions. It has been suggested that, due to dissimilar patterns of sexual behaviour between Africa and Asia, the extent of the spread to the heterosexual population in Asia will be circumscribed. In most of sub-Saharan Africa, HIV spreads through an intricate web of relationships from sex workers to male clients to female spouses/partners. According to Peter Piot of UNAIDS, females in Africa generally report more sexual partners than their Asian counterparts . In most• An increasingly mobile global population exacerbates the risk of HIV transmission. The increasing volume of international travel contributes to the spread of sexually transmitted infections, including HIV . Refugee• Females are more at risk of contracting HIV than males. In 1997, women accounted for 41% of people living with HIV worldwide. This figure had risen to almost 50% by 2002. This gender-bias is especially apparent in sub-Saharan Africa, where the majority of those infected are women and girls. Widespread wars and regional conflicts in Africa escalate, by orders of magnitude, the risk of rape of women and girls. The low social status of women, risky sexual practices, and endemic poverty in Africa contribute to the spread of the disease. The impact on women is less marked in Asia (where 28% of those infected are women), although women's low socio-economic status renders them more susceptible to infection. Women's increased vulnerability to HIV infection is not confined to developing countries. Between 2001 and 2003, the percentage of HIV-infected who are women increased in North America from 20% to 25%, and in Oceania from 17% to 19%, suggesting that gender inequalities underpin the transmission of HIV [• The impact of HIV mortality is greatest on people in their 20's and 30's; this severely distorts the shape of the population pyramid in affected societies. Projections indicate that mortality rates will increase: The UN predicts that, in seven selected countries in sub-Saharan Africa, 14 million AIDS-related deaths will occur between 1995 and 2025 .• In sub-Saharan Africa, it is estimated that 12 million children have lost one or both parents to AIDS, a figure which is expected to increase to 18 million by 2010. Even in countries where HIV infections have plateaued, the number of orphans continues to rise due to the time lapse between infection and death of parents [• Agricultural output, the cornerstone of production in agrarian economies, is decreasing as a result of increased mortality in the workforce, resulting in what has been termed "new-variant famine". Studies predict that in the ten most severely affected African countries, the agricultural workforce will decline by 10–26% by 2020 . Bertolt• The macroeconomic repercussions of the epidemic vary, depending on the industries underpinning the economy and degree of HIV prevalence. UNAIDS postulates that any deceleration in economic growth (as measured by Gross Domestic Product) will be offset by similar reductions in population numbers due to increased mortality and therefore resource consumption . A faste• The major economic impact is microeconomic. Individual households are primarily responsible for coping with the repercussions of AIDS, and as such bear the brunt of the epidemic. This translates into increased healthcare expenses, funeral charges and education costs for households. In areas where stigma prevails, the psychological impacts of the disease increase the burden.• Impact on the workplace is also considerable, translating into productivity losses and increased costs to employers due to staff illnesses and deaths, higher health insurance premiums and low morale . In addiTable Various global initiatives and collaborations are addressing the global HIV/AIDS challenge. For example, the United Nations Millennium Development Declaration, signed in 2000 by 189 nations, encompasses eight Millennium Development Goals (MDGs), three of which are health related: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases, by 2015 . Many inat the current level of need. The MDGs are unlikely to be met at the current rates of progress, with the worst affected countries likely to make the least headway.Despite the large amount of aid being made available in addressing the AIDS epidemic, shortfalls in both money and numbers of people being reached are apparent. Of the estimated 6 million people in developing countries who are in need of ART, only 400,000 currently receive it. Of these, 208,000 are in Brazil alone . Even ifAnother issue of concern is that the focus of many of these programmes is on treatment rather than prevention of HIV. Initiatives geared to increasing the delivery of treatment to developing countries has increased substantially since 2001, when the Declaration of Commitment on HIV/AIDS was signed by 189 member states of the United Nations . For exa• The Global Fund to fight AIDS, Tuberculosis and Malaria has approved funding for the provision of antiretroviral therapy (ART) to 700,000 people .• The World Bank plans to increase financial assistance for ART programmes in eligible countries .• PEPFAR's focus is largely on treatment  and plan• The focus of the WHO's "3 by 5" programme is also exclusively on the treatment of HIV .Current data suggests that approximately 33% of funding for AIDS initiativesbe allocated for treatment and care, with approximately 51% for prevention programmes . SchwartDuring the early stages of the epidemic, programmes designed to prevent HIV had rightly been the prime endeavour of poorer countries; indeed there was little else on offer. Even when the prospects of effective specific antiretroviral treatment improved after 1996, many scientists and health professionals remained committed to a dominant role of prevention over treatment and care. Prevention services, they believed, were not restricted to prophylaxis but included palliative care and the management of opportunistic infections. The latter were inexpensive and cost-effective; the concern was that highly active antiretroviral therapy (HAART), being more costly, would drain money from prevention programmes. But the direct and indirect financial, social, economic, political and security costs of failing to introduce effective prevention measures are undeniably very high. Based on figures from previous studies , MarseilMarseille's evaluation, however, disregards the synergy between prevention and treatment interventions. Prevention, although an important component in addressing the epidemic, is inadequate in isolation. The low rates of uptake of preventive measures in many developing countries, which we discuss later, do not diminish this assertion. In addition to prevention programmes, the provision of HAART is not only financially feasible, but morally imperative. The difficulties associated with introducing ART are well known: there is no eradication of the virus, therefore treatment is lifelong; adherence lapses occur; drug formulations are not optimised; drug toxicities are frequent; drug-drug interactions complicate management and drug resistance requires special attention. In addition, there are aspects of HAART management which are still not settled – optimal start time and regimen sequence, the meaning of regime failure, and the sustainable reduction of resistance. The World Health Organization argues that the provision of ART, through its ability to prolong life and alleviate fears about HIV, can both change attitudes to the disease and, in combination with prevention, greatly reduce HIV transmission. It is suggested that resource-constrained countries such as Senegal, Thailand and Brazil, which introduced HAART early, are also the countries with the greatest success in controlling the epidemic. A 70% decline in AIDS-related deaths in affluent countries, where ART is available to the majority of the population, is cited to support this assertion .It is becoming apparent that the advantages of ART might be offset by factors which may, on balance, fail to prevent or reduce transmission of the virus. These include disinhibition of risky sexual behaviour, the spread of drug-resistant strains, and an increased risk of exposure to HIV due to the improved survival rates of infected persons. In the context of the developing world, these putative negative impacts are likely exacerbated for several reasons:• Early detection of HIV is rare. Patients tend to present in a state of advanced disease when viral load is high and the patient is very ill. This usually follows a period of relative good health during which maximal sexual activity and consequent high transmission of virus has occurred.• Provision of ARVs may reduce condom use • ART efficacy may diminish as successive ARV regimes are used Despite these inherent hazards, given the continued escalation in HIV infections worldwide, it is reasonable and compassionate to attempt to achieve synergies between HAART and prevention services through their simultaneous implementation.UNAIDS has identified a comprehensive list of prevention, treatment and care services which define standard services for HIV/AIDS control Table . Most ofAn over-reliance on donor funds can reduce the long-term sustainability of aid programmes, and the reduced absorptive capacity of recipient countries for such assistance often results in bottlenecks, preventing aid packages from being used where they are most needed. As a result, despite higher levels of acceptance of AIDS by certain governments, a global climate of increased political stability and economic growth, and greater public access to information and advocacy, inequitable access to treatment and prevention persists. While challenges experienced by households and communities in terms of providing resources for home-based care are also significant hindrances to the effective delivery of care, shortcomings inherent in health systems constitute the major blocks in channeling ever-increasing amounts of aid to those most in need. It follows that inequities in the provision of healthcare services may escalate in the coming years unless efficiency is coupled with justice in the construction of national health systems.Constraints relating to supply within health systems, including finance, information systems, human resources, drugs and logistics , as wellThe example of introducing prevention of mother to child transmission (PMTCT) programmes, which are among the simplest and most cost-effective of anti-HIV programmes available, into national health systems, is illustrative of the challenges faced by developing countries. Single dose Nevirapine (a dose each to mother during delivery and to her newborn) is the most widely used regimen for PMTCT, having the advantages of simplicity, affordability, and effectiveness. Most programmes and agencies, including UNICEF, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), and state authorities, have found that in developing countries, of the women who should be given ART, only a minority receive the drugs. Even fewer infants are given their prophylactic dose of Nevirapine. Until recently, experience suggested that, despite wide variations between countries, in general, of the HIV positive women attending antenatal clinics, probably < 20% received ARVs. Neff Walker  has estiCurrent information from some centres, however, suggests that uptake is improving. Data from studies undertaken in Kwazulu Natal, South Africa – a region severely affected by the epidemic – show that, for 150,000 deliveries per annum, PMTCT coverage increased from 10% in 2001 to 78% in 2003/04  states that "The 3 by 5 initiative...cannot be implemented in isolation from a regeneration of health systems." . SeveralUNAIDS  suggestsHowever, constraints may have multiple causes, both within and external to the health system itself, which may themselves be interdependent. Two approaches to overcoming constraints may be identified: dealing with constraints specific to the disease across all aspects of the health system, or addressing specific weaknesses in the health system across all diseases. It has been argued that disease-specific programmes can build skills and develop effective management structures to allow health services to cope with the demands placed on them . The scaIt follows that the health system, rather than the specific disease, should be tackled in order to achieve the effective and holistic delivery of interventions. Such restructuring tends to be effective only in the long term, so immediate interventions may have to be introduced into the health system to deal with the pressing needs of prevention and of HIV/AIDS patients.Robust health systems play a fundamental role in channelling globally recognised prevention and treatment best practice for the mitigation of HIV/AIDS. However, certain social and biological complexities profoundly affect the transmission, progression and mortality of the disease; these lie beyond the scope of health services. Intrinsically difficult to control, these elements constitute significant obstacles to the prevention and management of the HIV/AIDS epidemic. Biological factors, such as exposure to infected individuals , infectivity , and concomitant sexually transmitted infections (STIs) greatly increase susceptibility to infection. Social and environmental determinants, which include socio-economic status  may increase proclivity to risky behaviour (such as unprotected sex or drug use) and heighten the possibility of infection. Another important factor here is gender and age: women's lower status and adolescents' relative youth renders both groups more vulnerable to infection due in part to a consequent lack of power in relationships. -38.It follows therefore that addressing health system constraints alone will not constitute a comprehensive solution to the management of the epidemic. Mitigation of risk factors needs to be an integral part of the response to HIV/AIDS in order for real progress to be made in the propitiation of the disease.The expansion of the AIDS epidemic across the globe has galvanized the global community into demonstrating a willingness to challenge its unabated spread. The increasing mobilisation of resources aimed at mitigating the impact of the disease in developing regions of the world in particular holds numerous potential benefits on the course of the AIDS epidemic. Whether these benefits are realized or not depends on resources dedicated to addressing the global AIDS challenge being received by those in need.The large volumes of aid being made available to developing countries has in many instances resulted in bottlenecks in health systems in these regions, which are historically unable to cope with the demands being place upon them by the accelerating spread of HIV and concomitant influx of resources to meet this challenge. Effective delivery of aid is thus hampered. This problem can be addressed through systemic strengthening of health systems in order to build capacity and sustainability, thereby redressing the inequities in healthcare delivery due to historical differences in health systems between and within rich and poor countries. However, other risk factors such as behaviour, socio-economics and biology also contribute to the spread of the disease. It follows that addressing both health systems and these external factors is necessary in order to manage and contain HIV comprehensively.Another important factor in the management of the epidemic is the balance between prevention and treatment programmes. The present apparent emphasis on treatment to the detriment of prevention needs to be redressed in order to meet the challenges of the disease at all levels.Globalisation brings with it many benefits in addressing the spread of HIV throughout the world. However, these benefits can only be realized if appropriate programmes are available in areas of need. As part of the generous supply of aid aimed at addressing problems specific to HIV/AIDS, attention needs to be paid to building capacity in recipient countries so that such funds may be effectively disseminated and the epidemic effectively curbed.HC and JH contributed equally to the compilation of information and composition of the paper. Both authors read and approved the final manuscript


Sidaction's appeal regarding the sentencing of medical personnels in the Libyan-HIV infection cases. A court in Tripoli, Libya, sentenced five Bulgarian nurses and a Palestinian doctor to death for intentionally infecting 426 Libyan children with HIV at Al Fateh Children's Hospital in Benghazi, Libya.The six medical workers, along with the children and the families concerned, were involved in a political trial and are victims of a severe infringement of the most elementary human rights. Although new genetic evidence published earlier this month in the journal Nature  found thPr. Hakima Himmich, member of Sidaction's Board and President of Moroccan Ngo ALCS, said that "it is an appalling story! These people are definitely victims of a political manipulation." Mr. Pierre Bergé, President of Sidaction, also declared "we're dealing here with a new example of collective cowardice". Sidaction denounces this trial as a parody of justice, which cannot hide the total incapacity of the Libyan Government to promote an appropriate politics of prevention and take care of people who are ill secondary to HIV infection-adults and children-in an appropriate way. It is useful to recall that the majority of Libyan people living with AIDS who are in need of an antiretroviral treatment can still not afford it.Sidaction would like to stress that the fight against AIDS can only be carried on by respecting human rights, which includes the access to prevention, to appropriate care and to antiretroviral treatments. Sidaction appeals to the Libyan authorities to immediately release the six medical workers and commit to the fight against AIDS in an effective manner, by respecting human rights, and in particular the rights of people living with AIDS.


Letamo discusses the implications of a new study suggesting that some health professionals discriminate against people with HIV. PLoS Medicine, Reis and colleagues set out to characterise the nature and extent of discriminatory practices and attitudes in the health sector, and indicate possible contributing factors and intervention strategies [Anecdotal evidence suggests that health-care professionals in Nigeria may discriminate against and stigmatise people living with HIV/AIDS(PLWA). In a study in the August issue of rategies . The stuIn order to answer these questions, a representative sample of 1,103 health-care professionals  working directly with patients with HIV/AIDS were selected from four states in Nigeria and asked to participate in a study. The response rate was 93% . A survey questionnaire was administered to respondents to collect information about their knowledge, attitudes, and behaviour. The study was reviewed and approved by an independent ethics review board of individuals with expertise in clinical medicine, public health, bioethics, and international HIV/AIDS and human rights research.The results suggest that some health-care professionals discriminate against and stigmatise PLWA. For instance, 9% of professionals reported refusing to care for a patient with HIV/AIDS, and 9% reported that they refused a patient with HIV/AIDS admission to hospital. Two-thirds reported observing other health professionals refusing to care for a patient with HIV/AIDS, and 43% observed others refusing a patient with HIV/AIDS admission to hospital.The study suggests that a significant number of health-care professionals engage in discriminatory and unethical behaviour. Some professionals reported giving confidential information to other people  without the patient's consent. Despite these discriminatory attitudes, an optimistic finding is that most health-care professionals expressed an interest in additional information and suggested education and counselling as a way to address discriminatory behaviours by their colleagues.Myths and misconceptions about HIV transmission play a role in promoting discrimination.The study concludes that all clinical staff should be educated about HIV/AIDS, modes of transmission of the virus, universal precautions, and the rights of PLWA. Such education is likely to reduce discriminatory practices towards PLWA and may improve these patients' care and access to health services. The study also asserts that a lack of protective materials and other materials needed to treat and prevent the spread of HIV, documented in several health facilities and reported by professionals themselves, contributes to discriminatory behaviour among health professionals.The study raises the possibility  that patients with HIV/AIDS may not fully utilise health-care services because they are denied access by health-care providers who discriminate against them. The fact that some health workers have discriminated against PLWA in the past suggests that health-care professionals serving PLWA should urgently be educated about HIV/AIDS so that they fully understand how HIV can and cannot be transmitted.It is clear from Reis and colleagues' study and others, including my own research in Botswana , that myIn my own research in Botswana, I found that although the prevalence of discriminatory attitudes towards PLWA may be high, respondents tend to be less discriminating when the HIV-positive person happens to be a family member . People In order to further our understanding of the root causes of discrimination and stigmatisation of PLWA, qualitative research is needed to understand cognitive processes that lead one to discriminate. It would also be interesting to investigate how PLWA feel that they are perceived by people around them. In order to adequately address issues of discrimination, we must involve PLWA and find out what they feel needs to be done to address stigma and discrimination. We also need to investigate the extent to which researchers are able to measure what they purport to measure with the current indicators of discrimination and stigmatisation. It is possible that the prevalence of stigma and discrimination against PLWA is not being adequately measured with the research instruments currently in use.


AIDS Research and Therapy, the Anderson group presents an important research tool to help address some of the critical unanswered questions in this area [In 1983, during the earliest days of AIDS research, Deborah Anderson and her colleagues in Boston, Massachusetts hypothesized that AIDS was transmitted by virally-infected "Trojan horse leukocytes" in semen [his area .A series of salient studies have shaped current concepts on HIV-1 in semen. In 1984, Ho et al. described retroviral particles and infected cells in the semen of a homosexual man with AIDS . ShortlyEpisomal HIV-1 c-DNA, a by-product of HIV-1 infection, is currently used in clinical trials as a marker of residual viral replication and potential evolution of drug resistance mutations in viral reservoir sites in individuals on HAART . Such a


There is an increasing trend toward the use of electronic databases of scientific information, such as the PubMed database of the National Library of Medicine and the various databases of the Institute for Scientific Information (ISI). These databases are frequently used nowadays for various purposes, including the peer-review process of papers submitted for publication in scientific journals. Most of the scientific journals now use a Web-based peer-review system that offers editors, peer reviewers, and publishers the capability to check the previous papers published by authors submitting a manuscript for consideration for publication . In addiHowever, it is widely known that a considerable proportion of authors share the same last name and first initial. This seems to be the case for people of most ethnic heritages. In addition, authors of scientific publications do not frequently use their middle initial, which contributes to the confusion regarding the assignment of publications to the appropriate author. Frequently, it takes considerable effort and time to assign publications to the appropriate authors, particularly if there are authors that share the same last name and first initial . This is usually based on the pattern of research interests, as well as the institutional affiliations of the various authors with the same name. In fact, this task is often impossible.In order to decrease the problems arising from authors with identical names, I suggest the introduction of a unique author identification number (UAIN) in modern electronic databases of scientific information. I further suggest that such an identification number may be hidden in the electronic databases, i.e., it is not necessary for the UAIN to appear when reviewing the record of a publication. This function of the electronic databases could start operating after the providers of the databases are given a reasonable time to prepare. To avoid the resources needed to update the electronic databases with the appropriate assignment of publications to each author, I suggest that the UAIN not be used retrospectively. In this case, the record of publications for a specific author would be divided into two parts. The publications that are prospectively connected to a given author with a specific UAIN would have an indicator denoting this, while older publications (before the introduction of the UAIN) would not have such an indicator.


Heroin use causes considerable harm to individual users including dependence, fatal and nonfatal overdose, mental health problems, and blood borne virus transmission. It also adversely affects the community through drug dealing, property crime and reduced public amenity. During the mid to late 1990s in Australia the prevalence of heroin use increased as reflected in steeply rising overdose deaths. In January 2001, there were reports of an unpredicted and unprecedented reduction in heroin supply with an abrupt onset in all Australian jurisdictions. The shortage was most marked in New South Wales, the State with the largest heroin market, which saw increases in price, dramatic decreases in purity at the street level, and reductions in the ease with which injecting drug users reported being able to obtain the drug. The abrupt onset of the shortage and a subsequent dramatic reduction in overdose deaths prompted national debate about the causes of the shortage and later international debate about the policy significance of what has come to be called the "Australian heroin shortage". In this paper we summarise insights from four years' research into the causes, consequences and policy implications of the "heroin shortage". Heroin use causes considerable harm to individual users through the development of dependence upon the drug, fatal and nonfatal overdose, mental health problems, and blood borne virus transmission. It also adversely affects the community through drug dealing, property crime and reduced public amenity. Recent decades have seen an increase in the prevalence of heroin use in many developed  countries as reflected in rising overdose deaths .Australia had a particularly steep increase in heroin overdose deaths between the mid and late 1990s with the result that in 1999 there were 1116 opioid overdose deaths among those aged 15 to 54 years . Such deIn January 2001, the increase in overdose deaths was reversed by an unpredicted and unprecedented reduction in heroin supply that abruptly affected all Australian jurisdictions. The shortage was most marked in New South Wales, the State with the largest heroin market ,7, whereThe onset of the heroin shortage was followed by substantial reductions in multiple indicators of heroin use in the larger Australian heroin markets in NSW and Victoria  as "normal". In exploring the effects of a reduction in heroin supply the absolute levels pre and post the change are less important than the fact that there was a substantial reduction in supply with an abrupt onset. Availability and purity decreased and price increased ,31 withiincrease in heroin supply during this period . Thihigh-level law enforcement operations that disrupted highly centralised drug importation networks were probably a contributory cause of the shortage [lowest levels of the drug market may have negative consequences for users [Furthermore, our conclusion was that shortage . This door users ,40.outine heroin seizures have little or no effect on heroin prices or heroin use [large scale heroin traffickers. The disruption of these centralised large scale drug distribution networks seems to have produced a return to the methods of importation that were used before the "glut", that is, multiple importations of smaller quantities of heroin using drug couriers and other methods. This has been reflected in the number of recently highly publicised arrests of Australian heroin "mules" in Australia, Indonesia, Hong Kong and Singapore.Nor do our findings contradict other research evidence that rroin use ,42. The roin use  comparedThe heroin shortage has demonstrated that it was possible, in the unique conditions that characterised heroin supply in Australia in the late 1990s, for drug law enforcement to play a role in substantially reducing supplies of a major drug of dependence. However, this outcome occurred in a unique context that may not be easily reproduced in most countries, specifically (i) a small number of highly centralised heroin importation networks, (ii) that were importing large quantities of heroin into Australia, (iii) an isolated island continent, (iv) that had a relatively small heroin market by world standards, and (v) in which IDU had good access to a wide range of treatment and harm reduction options.The heroin shortage has also shown that supply reduction can result in drug market shock, increasing price and decreasing purity and availability. We are now aware that in such situations, dependent heroin users alter their drug consumption patterns – the shortage resulted in a clear reduction in heroin use and increase in the use of other drugs, albeit (in some instances) of a limited duration. This provides some evidence that demand for heroin is price-elastic, i.e. heroin consumption and expenditure is reduced when price increases . The effThese market changes led to clear public health benefits including reduced overdose deaths and a possible reduction in injecting drug use and hepatitis C infections. It is the latter conclusions that have been considered by some the most contentious, but as we have argued previously, the benefits of the heroin shortage need to be interpreted in the context of existing harm and demand reduction initiatives which are ameliorated its impact on heroin users. Deaths attributable to opioid drug overdose have remained at the same level for three years post-shortage, but there has been a small increase in overdose deaths attributable to stimulant drug use .These findings are consistent with what is known about the supply and control of licit drugs. There is good evidence to suggest that when the availability of legal drugs such as alcohol and tobacco are altered , that community level harms also alter as a result ,47. The The Australian heroin shortage provides good evidence that the integration of supply, demand and harm reduction measures can substantially reduce the harmful effects of injecting heroin use. It would have been very difficult to monitor these changes had we not had the benefit of established strategic early warning systems to document the changes we were able to examine.All authors 1) have made substantial contributions to conception; 2) have been involved in drafting the manuscript or revising it critically for important intellectual content; and 3) have given final approval of the version to be published.The author(s) declare that they have no competing interests.


Vital registration and cause of death reporting is incomplete in the countries in which the HIV epidemic is most severe. A reliable tool that is independent of HIV status is needed for measuring the frequency of AIDS deaths and ultimately the impact of antiretroviral therapy on mortality.n = 282) were considered to have died of AIDS in the gold standard. Verbal autopsies were randomly allocated to a training dataset (n = 279) to generate classification criteria or a test dataset (n = 102) to verify criteria. A rule-based algorithm created to minimise false positives had a specificity of 66% and a sensitivity of 76%. Eight predictors  were included in the algorithm. In the test dataset of verbal autopsies, 69% of deaths were correctly classified as AIDS/non-AIDS, and it was not necessary to invoke a differential diagnosis of tuberculosis. Presence of any one of these criteria gave a post-test probability of AIDS death of 0.84.A verbal autopsy questionnaire was administered to caregivers of 381 adults of known HIV status who died between 1998 and 2003 in Manicaland, eastern Zimbabwe. Individuals who were HIV positive and did not die in an accident or during childbirth  with the caregivers of 381 adults who died between 1998 and 2003 in Manicaland, a rural area of eastern Zimbabwe. For all of these people, it was known whether they were HIV positive or HIV negative.  The 282 people who were HIV positive and did not die in an accident or during childbirth were considered by the researchers to have died of AIDS. The questions the caregivers were asked about the condition of the person who died included whether or not they had any of the following signs or symptoms that are common among patients with AIDS: moderate or severe weight loss, jaundice, herpes zoster, presence of abscesses or sores, oral candidiasis, acute respiratory tract infections, and vaginal tumours. Explanations of what these conditions looked like were given to the caregivers. There were also questions on the circumstances surrounding each death. Using the answers to the questions, it was possible in 69% of cases to make a correct decision as to whether the death was the result of AIDS.A verbal autopsy using the signs and symptoms selected by these authors can be used to make reasonable estimates of the number of AIDS deaths. The authors believe that, with the same set of questions, it might also be possible to produce estimates of the number of people living with HIV/AIDS. Validation of the questions used should, however, be carried out separately in each country that adopts this technique.http://dx.doi.org/10.1371/journal.pmed.0030312.Please access these Web sites via the online version of this summary at MedlinePlus has many pages providing information about HIV/AIDS.• Web site of the Joint United Nations Programme on HIV/AIDS (UNAIDS).• Information about the global epidemic of HIV/AIDS and international efforts to fight it can be found on the UNAIDS' country-by-country analysis of the situation in Africa.• Of particular relevance is The World Health Organization's pages on HIV/AIDS. A recent discussion on verbal autopsies has been published by WHO.• The Manicaland HIV/STD Prevention Study.•  UNAIDS estimates that 24.5 million people in sub-Saharan Africa were living with HIV by 2005. The estimated annual 2.0 million AIDS-related deaths in sub-Saharan Africa in 2005 represent a dramatic impact on patterns of adult mortality . HoweverThe demand for accurate data on levels and trends in AIDS mortality is increasing. Mortality statistics are an important advocacy tool and, in the era of antiretroviral therapy (ARV), the documentation of trends in AIDS mortality becomes even more important, as has been shown in the developed countries ,5. AIDS In the absence of vital registration, data on the levels and trends of AIDS mortality in the general population are derived from health facilities, special population-based studies . Mortuary studies ,10 and bDemographic surveillance systems provide valuable information on trends in age- and sex-specific mortality , and mayThe World Health Organisation has recognised the value of the verbal autopsy (VA) in settings lacking vital registration, and has called for validation studies for the VA tool in general, as well as for specific causes . ValidatThe Manicaland HIV/STD Prevention Project eastern Zimbabwe, where the HIV serostatus of individuals is known prior to death, provides a unique opportunity to identify the signs and symptoms differentially associated with AIDS deaths in the pre-ARV era. Verbal autopsy data along with HIV status are used to explore a method of creating a diagnostic algorithm and assessing its performance.n = 180) did not provide more complete interviews than other respondents (n = 201). Data were collected on the signs, symptoms, and circumstances preceding death using a structured, closed, interviewer-led questionnaire  than those of HIV-positive women , as has been observed in other studies [For the purposes of the gold standard, we defined an AIDS death as an individual who was (a) HIV positive at baseline survey based on antibody testing and (b) was not reported to have suffered major injury from motor vehicle accident, injury that was self-inflicted (suicide), or that was accidentally (accident) or deliberately inflicted by another person (homicide) in the two weeks prior to death. For females, direct obstetric deaths—defined as (a) death shortly before delivery, with excessive bleeding and/or severe headaches, or (b) death during childbirth—were classified as being non-HIV-associated. This categorisation scheme is justified because (a) mortality rates in HIV-positive individuals are nine and ten times higher in males and females, respectively, in this population  and (b)  studies . Misclas studies  and the Two datasets were created from all deaths for which full information was available for analysis. The first dataset (train) was used to create the diagnostic algorithm, as described below. The algorithm was then applied to the second dataset (test), in order to evaluate how accurately deaths were classified. Each case had an independent chance (0.75:0.25) of being assigned to the train or test dataset. A random number ranging from 0 to 1.0 was generated for each case; cases with a number 0.75 or lower were assigned to the train dataset2 test on 1 degree of freedom at p < 0.05) or greater was retained for further analysis. The focus of the algorithm was on specificity because (a) we knew a priori that most adult deaths were HIV-associated and (b) we wanted to err conservatively by avoiding false positive results. The classification algorithm was then constructed with signs/symptoms added stepwise in an iterative process. First, the sign/symptom with the highest specificity for AIDS deaths was identified. All deaths with this symptom present were then classified as AIDS-associated. The specificity of all the remaining signs/symptoms were then recalculated using only those cases not classified as AIDS-associated based on a previously included sign/symptom. This procedure was repeated until all criteria were added stepwise.The strength of association of a range of clinically relevant signs and symptoms with the outcome of AIDS death was measured by calculation of the likelihood ratio (LR), where LR = sensitivity / (1 – specificity). Each sign and/or symptom with a LR of 1.92  curves were plotted.  The best cut-off value from the modified ROC curve was selected by choosing the point closest to the upper left hand-corner of the plot.In order to assess the reliability of the classification scheme, we examined associations between characteristics of the verbal autopsy procedure, the respondents, or the deceased, and the proportion correctly classified. Logistic regression models were fitted using “correctly classified” (Y/N) as the dependent variable.+|D)P, that an individual died of AIDS was set at 0.65—the population attributable fraction of 17- to 44-year-old mortality attributable to HIV, where the population attributable fraction represents the proportion of all deaths that would be averted if AIDS mortality was removed completely [In this study, post-test probability (+) was the likelihood that an individual death was due to AIDS (according to the gold standard) after the verbal autopsy algorithm provided a positive result—that is, AIDS death. The post-test probability was calculated with the following formula:A total of 404 deaths were recorded in the study period. Verbal autopsy was not performed on 21 of these deaths and HIV status at baseline was missing from another two deaths, leaving 381 complete records (94%) from the total population that died . Of thisClassifying all HIV-positive non-accident/injury and non-childbirth deaths as “AIDS deaths” and all others as “non-AIDS deaths” gave a gold standard of 282 AIDS deaths (74%) and 99 Non-AIDS deaths (26%).2p = 0.44).Of the 381 deaths studied, 279 (71%) were randomly assigned to the train dataset and 102 (29%) to the test dataset. In the train dataset, 73% of the deaths were AIDS-associated compared with 75% in the test dataset (χp ≤ 0.05).  and specificity of 76% .p = 0.13), time between death, and VA (p = 0.5), sex of the respondent (p = 0.6), side of family of respondent (p = 0.5), relationship of respondent to the deceased (p = 0.5), whether the respondent was the primary caregiver (p = 0.4), or sex of the deceased (p = 0.6). The proportion correctly classified was between 0.65 and 0.81 for all strata . Therefore, we estimate 5.4% (20.6/381) of all deaths or 7.2% (20.6/283) of HIV-positive deaths were misclassified in the gold standard.Given an underlying hazard of death of 7.45 per 1,000 person-years in this population , we woulThe positive predictive value using the eight criteria was 89% on the test dataset . BecauseAnalysis of verbal autopsy data in this rural Zimbabwean population revealed a distinct pattern of signs and symptoms associated with AIDS deaths. Using an algorithm built on specificity that minimised false positives, an overall sensitivity of 66% and a specificity of 76% for identifying AIDS deaths was achieved, and this method gave similar results when tested on a random sample of the data. These eight criteria were selected because they maximised the trade-off between sensitivity and specificity, while being independent of diagnosed TB.Differential diagnosis of AIDS and TB is difficult amongst the living; it is not surprising therefore that classification using verbal autopsy is problematic. TB and other opportunistic infections of HIV infected people share many symptoms such as chronic cough, wasting and prolonged fever. In Zimbabwe, an estimated 67% of all new adult TB cases are HIV-positive and 7.5% of all AIDS deaths are due to TB . One valA classification system with known sensitivity and specificity has practical applications. First, the unbiased (UB) proportion of deaths that are AIDS-associated can be calculated as follows:true positive + Pfalse positive = 0.56), we would calculate a true proportion of AIDS deaths of 0.76  [If we apply the observed proportion (designated P here) from the test dataset (P method) . The reaUB below:positive:Furthermore, if we know the mortality rate ratio of HIV-positive individuals with respect to the HIV-negative population, the HIV prevalence can be “back-calculated” by the formula for proportionpositives = 0.071/y; ratenegatives = 0.0075/y; or rate ratio = 9.4) . The obevalence , is closknown than that they be exceptionally precise and accurate.Both the sensitivity and specificity of this tool may be considered modest. However, as the extrapolations presented above demonstrate, for many purposes it is more important that the characteristics of a diagnostic be Other methods of creating the classification system were investigated; for the sake of brevity these data are not shown. Preliminary analysis showed that these methods  were leUsing different approaches, others have also used the VA to identify AIDS deaths. Using a physician-based, rather than algorithm-based, approach, Kamali et al.  achievedThe WHO definition of AIDS (two or more major signs plus one or more minor signs) was not a very accurate tool, classifying less than half of all deaths as a result of AIDS . HoweverHow predictive would these eight signs and symptoms for AIDS mortality be in other settings? In this cohort, the post-test probability (if a death was associated with one of the eight criteria) was 84%. If none of the criteria were met there was a 19% chance that the death was AIDS-associated. However, these probabilities are affected by HIV prevalence and presence of differential symptoms in non-AIDS deaths. Thus, predictive power will be diminished in populations with higher background levels of these signs/symptoms ; however, we do not expect the signs/symptoms used in this algorithm to be common in populations with low levels of AIDS mortality.n = 109) by Hosegood et al. [Studies of diagnostic validity face the problem of finding a suitable reference standard, and the major verbal autopsy validation studies have used hospital records ,30. In td et al.  did in fIncorrect classification of HIV status at baseline would affect the validity of the gold standard. However, the probability of misclassification due to incorrect testing status is very low, given the 99.6% sensitivity and specificity of the HIV dipstick test . LikewisVerbal autopsy is potentially an important way in which population levels and trends in AIDS-specific mortality can be monitored. The data can be collected as part of developing vital registration systems, sample vital registration systems , and locDataset S1(24 KB XLS)Click here for additional data file.Protocol S1(148 KB PDF)Click here for additional data file.Protocol S2(18 KB DOC)Click here for additional data file.Table S1Abbreviations: D, disease; FN, false negative; FP, false positive; LR+, likelihood ratio when sign/symptom is present; Se, sensitivity; Sp, specificity; T, test; TN, true negative; TP, true positive; uOR, unadjusted odds ratio.(198 KB DOC)Click here for additional data file.


There were an estimated 370,000 AIDS deaths in South Africa in 2003 alone. It is, therefore, not surprising that the apparent reluctance of the South African government to support the provision of antiretroviral treatment to people with HIV/AIDS has been the subject of much controversy internationally. The situation is, however, changing, and South Africa is now seeing a scaling up of access to highly active antiretroviral therapy (HAART) and a gradual reduction in HAART prices.HAART, nevertheless, remains an expensive option, and one that many low-income countries are unable to afford. South Africa is better placed than most sub-Saharan nations to increase access to HAART, but it is clearly essential to establish how much this will cost the country's public health sector and what will be the benefits. It is unfortunate, therefore, that cost-effectiveness studies on HAART have so far been limited to the developed world.PLoS Medicine, Motasim Badri and colleagues publish a study of the use of the cost-effectiveness of HAART conducted in South Africa. During the study period (January 1995 to December 2000), HAART was not available in the publicly funded South African health-care sector.In the January issue ofThe research was funded by Secure the Future—a Bristol-Myers Squibb initiative to provide resources for capacity building and for the search for sustainable interventions to address HIV/AIDS in sub-Saharan Africa— and took place in HIV clinics affiliated to the University of Cape Town. The sponsors had no involvement in the study design, analysis, or decision to publish. The study was based on a prospective cohort study—the Cape Town AIDS Cohort (CTAC).The researchers compared the cost of services for 292 patients who were given HAART with the costs for a matched comparison group (with the same number of patients) who were not given any antiretroviral drugs. Twenty-seven patients in each group had AIDS; the others were HIV-infected but did not have AIDS. The researchers calculated costs per patient year (PPY) and per life-year gained (LYG)—i.e., the total cost divided by the number of extra years the treated patients lived. Calculations were done separately for patients with AIDS and for those without AIDS.Patients on HAART required fewer hospital admissions. Depending on how long the patient survived and the price of antiretrovirals used, HAART reduced treatment costs for those patients with AIDS. For this group, the cost savings ranged from US$219–US$2,116. For patients without AIDS, the yearly cost of treatment  was, in the opinion of the authors, and after taking into account the South African standard of cost of living, considered to be affordable. However, it is expected that South Africa will soon be able to manufacture antiretroviral drugs locally and more cheaply. This would increase the amount saved by introducing HAART.The study had a number of limitations. Because HAART was not used in routine clinical practice, the researchers had to compare a group of patients enrolled in clinical trials with a control group that was not part of the trials. The study was also confined to the use and cost of services; but when a person is infected with HIV and becomes ill or dies from AIDS, it is clearly not only the health services that face costs. The patient, their family, and the country suffer financially. HAART, as a more effective treatment might also lower these “indirect” costs, but this was not an issue examined here. It is to be hoped that further research includes an evaluation of the indirect costs and benefi ts. Nevertheless, the present study should encourage policymakers in low- and middle-income countries to consider introducing HAART into public-sector health care; reductions in the use of hospital services by patients with HIV could free scarce resources, to the benefi t of all who use the health services.