Surface bonded lead zirconate titanate (PZT) transducers have been used for damage detection and parameter identification for various engineering structures over the last two decades. In this work, a reusable PZT transducer setup for monitoring initial hydration of concrete and structural health is developed, where a piece of PZT is bonded to an enclosure with two bolts tightened inside the holes drilled in the enclosure. An impedance analyzer is used to acquire the admittance signatures of the PZT. Root mean square deviation (RMSD) is employed to associate the change in concrete strength with changes in the PZT admittance signatures. The results show that the reusable setup is able to effectively monitor the initial hydration of concrete and the structural health. It can also be detached from the concrete for future re-use.During the construction of a concrete structure, strength monitoring is important to ensure the safety of both personnel and the structure. Furthermore, to increase the efficiency of  In the first few hours after mixing, the fresh concrete gradually achieves solid properties with reasonable compressive strength. Due to different type and amount of cementitious materials, concrete additives  and curing temperature, different rates of hardening are expected. In addition, some other factors like the quality of the cementitious materials further increase the uncertainty in determining the appropriate time for demolding of concrete.The hydration of cement is a complicated physical and chemical process which determines the microstructure of the concrete. Various methods have been developed to monitor and characterize the hydration of cementitious materials . During et al. [The ultrasonic technique, which needs to have access to both sides of the structure, has been employed to monitor the hydration process –6, and aet al. . Howeveret al. ,2. For tet al. ,9.et al. [a is the short circuit mechanical impedance of PZT and Z is the mechanical impedance of structure. Ē = E(1 + ηj) is the complex modulus of elasticity and κ is the wave number, related to angular frequency of excitation ω by Ȳ consists of real and imaginary parts, the conductance  and susceptance (imaginary part). Conductance has been traditionally used for structural health monitoring due to its better indication of changes in the structure. The prominent effects of structural damage or materials characteristic change on the PZT admittance signatures are the lateral and vertical shifting of the baseline or appearance of new peaks in the signatures, which are the main indicators for damage or material change.Based on the electromechanical impedance (EMI) technique, surface bonded PZT transducers have been widely used for damage detection and parameter identification for various engineering structures over the last two decades –19. In tet al.  as follothi measurement point. Generally, larger difference between the baseline signature and the subsequent signatures would result in bigger value of RMSD.Statistical techniques such as root mean square deviation (RMSD)  have beeIn this work, a reusable PZT transducer setup for monitoring hydration of concrete and structural health is developed, where a piece of PZT is bonded to a piece of aluminum or plastic enclosure with two bolts tightened inside the holes drilled in the enclosure. During concrete casting, the bolts and the bottom surface of the enclosure is set to penetrate part of the fresh concrete. At different stages of the first 48 hours after casting, the PZT admittance signatures are acquired. RMSD indices are calculated to associate the change in concrete strength with changes in the PZT admittance signatures. For the three test samples, the reusable PZT setups are not removed from the structure after curing of concrete. The samples are further tested under gradually increasing compressive loading to examine the capability of the reusable setup for structural health monitoring (SHM). The results show that the developed reusable setup is able to effectively monitor the initial hydration of concrete and its structural health. It can also be detached from the concrete for future re-use.2.2.1.The acquired signature of the PZT is sensitive to moisture and will change if the PZT is submerged in water. In addition, the enclosure in which the PZT is bonded on needs to be strong enough such that it can be easily detached from the hardened concrete without any damage to the PZT or the enclosure. For these reasons, commercial aluminum and plastic enclosures with dimensions of 50 × 45 × 30 mm and a thickness of 1.5 mm have been used. Two holes have been drilled at the bottom of the enclosure and two bolts been tightened inside to ensure a solid connection of the reusable setup to the concrete. After concrete hardening, the two bolts will be unscrewed and the PZT and enclosure will be removed for future applications. Cement hydration residues will remain on the surfaces of the aluminum enclosure, so the repeatability will be slightly affected after a few reuses.In the reusable sensor setup, there are two holes at the bottom of the enclosure where water may permeate into the enclosure along the bolts, resulting in circuit shortcut during PZT admittance measurement. To avoid this problem, a water proofing agent called Plastic DIP  has beenPZTs with two different sizes of 20 × 20 × 0.5 mm and 20 × 20 × 2 mm developed by PI Ceramic Co.  have bee2.2.In this work, the same mix proportion has been cast four times  and the same reusable PZT setup called Setup 1a, has been used to evaluate the hydration rate. This process is meant to ensure the reusability of the setup for hydration monitoring. To check the repeatability from one sample to another, in mix Cast 4, a bigger volume has been cast to compare the acquired signatures obtained from different reusable setups. Two more mixes (Casts 5 and 6), one with retarder and the other with faulty retarder which leads to a very weak hydration in the first 48 hours, have also been cast. The results from retarder and faulty retarder specimens are compared to show the ability of the developed setups to distinguish various rates of hydration. The experimental work has been summarized in 2.3.For the three samples in Casts 7 and 8, the reusable PZT setups were not removed from the structure after curing. These three samples were further tested under normal laboratory compressive loading. Surface bonded PZTs were additionally bonded to the two samples in Cast 8 to compare the sensitivity of surface bonded PZTs with the reusable setups for SHM. The tests were performed in two conditions of cyclic and on-hold loading.As shown in i.e., after acquiring the initial signature, the sample was held under 1, 10, 20, 30 kN and till failure and the signatures were obtained without releasing the load. For each sample, one reusable setup and one surface bonded PZT transducer were attached to the structure. Both the reusable setup and the surface bonded PZT were under direct loading area in fairly equivalent distance from the loading point on two opposite sides. The two 100 mm cube samples from Cast 8 were tested under on hold loading, 3.3.1.Repeatability of the results is a key criterion for reliability of any health monitoring technique. The repeatability of results could be affected by PZT transducers quality, human errors during production of reusable setup including the epoxy thickness and modulus of elasticity and finally damage during the initial hydration or health monitoring process. For all the setups, 2-meter thin wires have been soldered to the PZTs and their signatures have been obtained prior to attaching them to the enclosure. The signatures should also be repeatable in the same initial condition for all the reusable setups. The signature obtained at the initial condition should be similar to that obtained after the setup is used and removed from several tested sample. To verify this, Setup 1a has been used four times to check the reusability of the setup. As shown in Furthermore, 3.2.Slump is the measure of the fluidity of concrete. Depending on the amount of water content in the aggregates, the size of aggregates, the temperature during casting and other parameters, the initial slump of concrete can change from one mix to another though the mix proportion is the same. Even the delay time before casting can change the slump of concrete. To eliminate the initial variation of water content and slump from one sample to another, the signatures were obtained from the third hour onwards after casting. After that, the signatures were acquired every three hours. It means that the signatures of the structure at 3, 6, 9,…,48 hours were acquired for comparisons. As shown in The RMSD values based on comparison between the signatures measured at different measurement points and the signature at the third hour have been calculated for each mixes. As shown in However, if the RMSD values are calculated based on the difference between two consecutive signatures, the continuous progress of hydration can be observed, as shown in As mentioned in Section 2.2, two more mixes (Casts 5 and 6), one with retarder and the other with faulty retarder have been cast in order to study the ability of the reusable PZT setup for monitoring different hydration rates. The RMSD changes for these two mixes in comparison to the normal concrete are illustrated in It can be seen from 3.3.As mentioned in Section 2.3, the tests were performed under two conditions of cyclic loading on the sample from Cast 7 and on-hold loading on the two samples from Cast 8. As shown in For the on-hold loading, both reusable setup and surface bonded PZT transducers were under direct loading area in fairly equivalent distance from the loading point at two opposite sides. Two signatures were acquired from each setup before loading and RMSD for repetitive reading were around 1% for both the surface bonded PZT and the reusable setup. As shown in In 4.The reusable PZT setup developed in this work is able to effectively monitor the initial hydration of concrete and can be used for SHM. With a controlled bonding layer, the repeatability of PZT signatures has been confirmed and thus the reliability of the reusable PZT setup. It is also found that thicker PZTs have higher sensitivity as compared to the thinner ones. The device can be easily reused for many times with minor changes in sensitivity and initial signature. Various rates of hydration as a result of using retarders were monitored using this reusable setup. The reusable PZT setup showed good consistency in RMSD values as compared to the surface bonded PZT SHM. It can also be detached from the structure for future application.


Our unit adopted the single administration of cefepime as the initial treatment for febrile episodes in neutropenic patients with hematological malignancies. However, recently, cefepime-resistant gram-negative bacteremia, including those with extended-spectrum β-lactamase (ESBL)-producers, was frequently observed in these patients. Therefore, we instituted a rotation of primary antibiotics for febrile neutropenic patients in an attempt to control antibiotic resistance.This prospective trial was performed from August 2008 through March 2011 at our unit. After a pre-intervention period, in which cefepime was used as the initial agent for febrile neutropenia, 4 primary antibiotics, namely, piperacillin-tazobactam, ciprofloxacin, meropenem, and cefepime, were rotated at 1-month intervals over 20 months. Blood and surveillance cultures were conducted for febrile episodes, in order to assess the etiology, the resistance pattern (particularly to cefepime), and the prognosis.P<0.01). Interestingly, ESBL-related bacteremia was not detected after the initiation of the trial . Infection-related mortality was comparable between the 2 periods.In this trial, 219 patients were registered. A 65.9% reduction in the use of cefepime occurred after the antibiotic rotation. In the surveillance stool cultures, the detection rate of cefepime-resistant gram-negative isolates, of which ESBL-producers were predominant, declined significantly after the intervention (8.5 vs 0.9 episodes per 1000 patient days before and after intervention respectively, We implemented a monthly rotation of primary antibiotics for febrile neutropenic patients. An antibiotic heterogeneity strategy, mainly performed as a cycling regimen, would be useful for controlling antimicrobial resistance among patients treated for febrile neutropenia. Febrile neutropenia is one of the most serious adverse events in patients with hematological malignancies and chemotherapy. A prompt initiation of empirical antibiotic therapy is favorable for patients with febrile neutropenia, regardless of the detection of bacteremia. Based on guidelines Most antibiotic rotation trials, known as cycling therapies, have been conducted in adult intensive-care units (ICUs), where infectious agents are exposed to heavy antimicrobial pressure. Many cycling therapies implemented in clinical settings have been reported to date. Most of these trials were conducted in order to reduce the selective pressure of antibiotic-resistant gram-negative bacteria, which was a major concern for patient prognosis in an ICU setting. The efficacy of antibiotic cycling on the recovery of antimicrobial susceptibility and patient mortality is controversial. Several trials have successfully reported a recovery of susceptibility to specific antibiotics or a reduction in detection rates of multidrug-resistant bacteria Cycling therapies have been instituted as the primary treatment for febrile neutropenic patients in hematological units For the abovementioned reasons, the efficacy of antibiotic cycling in reducing antibiotic resistance among patients with hematological malignancies, as well as those in ICUs, has not been determined. However, patients with febrile neutropenia, which often develops in those with hematological malignancies, are expected to apply for antibiotic rotation strategy in controlling antibiotic resistance. Febrile neutropenia is a unique infectious disease. Broad-spectrum antibiotics are often administered to febrile neutropenic patients for long periods, without the identification of the causative bacteria, until the neutrophil count recovers. A few classes of antimicrobial agents are recommended as the first line of treatment for febrile neutropenic patients. As a result, overuse of some antibiotics in a small population increases the risk of selecting antibiotic-resistant bacteria. Therefore, if cycling therapy reduces the selection of antibiotic-resistant bacteria, this therapeutic regimen may be beneficial in patients with febrile neutropenia following hematological malignancies.We prospectively conducted a systematic cycling program for initial use of antibiotics in febrile neutropenic patients in our unit. After a prospective observational period of cefepime administration, 4 antibiotics were rotated monthly over 20 months without quinolone prophylaxis. We observed a significant decrease in the rates of antibiotic resistance. This is the first study to show a significant reduction in antibiotic resistance in a hematology and febrile neutropenia setting after use of antibiotic cycling. Further discussion on the benefits and difficulties of introduction of antibiotic rotation strategies is warranted in hematological settings.This study was conducted in a single hematological unit with 37-beds at the Hara-Sanshin Hospital. The study was prospectively conducted from August 2008 to March 2011. The protocol was approved, through the ethics review process, by the Institutional Review Board of the Hara-Sanshin Hospital. Written informed consent was obtained from all registered patients before the study protocol was implemented, in order to publish these case details. Infection control measures, including hand-washing promotion and isolation procedures, were maintained at the same intensity before and after the initiation of the study.3 or an ANC that was expected to decrease to <1,000 cells/mm3 during the following 48 h. Exclusion criteria included treatment for allogeneic hematopoietic stem cell transplantation (HSCT), evidence of hepatic and/or renal dysfunctions , and a history of hypersensitivity to β-lactam antimicrobial agents. Patients receiving an allogeneic HSCT were excluded from the trial, because a confirmative diagnosis of febrile neutropenia is often difficult to make due to the presence of other causative factors such as graft-versus-host disease and engraftment syndrome. The routine use of fluoroquinolone prophylaxis for neutropenic patients was discontinued in January 2006 at our unit.The study protocol was applied for patients with febrile neutropenia who had provided informed consent. The febrile neutropenia defined in this study needs to fulfill both of fever and neutropenia as follows: (1) fever was defined as a single axillary temperature >38.0°C or a temperature of >37.5°C sustained over a 1-h period, and (2) neutropenia was defined as an absolute neutrophil count (ANC) of <1,000 cells/mmFrom August 2008 to July 2009, cefepime was used as the initial agent for treating febrile neutropenia in the registered patients. Next, 4 primary antibiotics, namely, piperacillin-tazobactam, ciprofloxacin, meropenem, and cefepime, were rotated at 1-month intervals over 20 months from August 2009 to March 2011. Ciprofloxacin was adopted as a rotated agent in addition to the 3 other antibiotics recommended for febrile neutropenia The Standard dosage of antibiotics rotated in this study was piperacillin-tazobactam 4.5 g intravenous (i.v.) every 8 h, ciprofloxacin 0.3 g i.v. every 12 h, meropenem 0.5–1 g i.v. every 8 h, and cefepime 2 g i.v. every 12 h. Meropenem (2 g/day) was administered in unequally divided doses. A daily dose of ciprofloxacin, meropenem and cefepime was the maximum dosage approved for them in Japan. The administration of antibiotics was continued until recovery of neutrophil counts and/or resolution of infection. When causative bacteria were isolated from a sample of culture, antimicrobial therapy was adjusted according to the antibiotic resistance pattern obtained. The degrees of consumption of rotated antibiotics were compared before and after the intervention, using the defined daily dose (DDD) per 1000 patient days as an index for the evaluation. The DDD of each antibiotic is defined by the World Health Organization.Clostridium difficile toxin A and B were examined in stool samples, using a TOX A/B QUIK CHEK kit .When the registered neutropenic patients had fever defined as above, blood and stool samples were collected. Several samples were obtained from the same patient and treated as independent results. If multiple organisms were detected from a single sample, they were counted and analyzed as independent isolates. An automated blood culture system (BACTEC) was used for each test. Stool samples were cultured, chiefly using 5% Sheep Blood Agar medium (BD) and CHROMagar Candida medium (BD). The species were identified using the Vitek system . Antibiotic susceptibilities were determined by the breakpoints standardized by the Clinical and Laboratory Standards Institute  U test. P<0.05 was considered to be statistically significant. All statistical calculations were performed using the SAS software .In the comparisons between patients receiving pre-intervention and those receiving the antibiotic rotation trial, categorical variables were analyzed using a Fisher's exact test, and continuous variables were compared using the Mann-Whitney In this study, 219 patients were enrolled. Seventy-one patients were registered with 2350 patient days before the antibiotic rotation. After the initiation of cycling therapy, 148 patients were recorded, accounting for 4592 patient days. Some patients were enrolled multiple times for sequential chemotherapies. The basic characteristics of the registered patients were found to be different before and after the rotation, as shown in Staphylococcus aureus (MRSA) was first detected after the intervention. The incidence of Enterococcus species was similar in both periods. Vancomycin-resistant enterococci (VRE) were not isolated in either of the 2 periods.Before the initiation of the cycling therapy, 23 bacterial strains were isolated from the blood cultures of the patients, with a total of 71 episodes of febrile neutropenia . During Escherichia coli isolates significantly decreased after antibiotic rotation. The incidence of gram-positive isolates was similar in both periods. MRSA was recovered from enteric cultures as well as blood cultures after antibiotic rotation. The incidence of a whole of Enterococcus species was comparable in both periods; however, the number of Enterococcus faecium isolated significantly increased after the antibiotic rotation. The colonization of VRE was not seen in either of the 2 periods. Candida species were detected more frequently after the cycling therapy.Acquisition of VRE, as a causative and/or colonized organism, has been reported after antibiotic rotation in both ICUs and hematological units P. aeruginosa  during the pre-cycling period and 4 (2.7%) during the cycling period (P = 1.0). One patient died during the trial due to possible septic shock caused by E. coli. No infection-related death was seen before cycling therapy.The antibiotic agents adopted in this study were well tolerated, regardless of the intervention. Although clinical and laboratory abnormalities, including skin rash, diarrhea, and elevation of serum transaminase level, were observed, these occurred at a frequency of less than 5% and were not severe. In this trial, cefepime administration, as a result, dramatically declined at a unit-wide level after antibiotic rotation . Thus, tKlebsiella infection and colonization within 1 year The primary purpose of this study was to investigate whether antibiotic rotation, when used as the first line of treatment for febrile neutropenia, contributes to controlling the spread of antibiotic resistance; a significant reduction in the incidence of cefepime-resistant and ESBL-producing organisms was observed after antibiotic rotation  and 5. TThere is a concern regarding the quality of this trial. A control group, to be compared to the enrolled group, was not included in our study. To split a single unit into 2 sections was needed in order to set up a definite control group. In this case, the control group included patients that were under continuous antibiotic pressure induced by the dominant use of cefepime. Finally, we abandoned preparing a control group due to concerns about feasibility. Retrospectively, we tried to analyze the detection rates of cefepime-resistant bacteremic organisms throughout our unit, including in registered and non-registered patients. As shown in Enterococcus sp., as an agent of infection and colonization, has been observed E. faecium dramatically increased, in the form of bacteremic isolates, after adoption of antibiotic rotation Enterococcus isolates detected from blood did not increase after antibiotic rotation; however, a stool culture showed a significant increase in E. faecium after antibiotic rotation (E. faecium isolates found here. Thus, if VRE is epidemic in a certain area, colonization pressure on VRE may be higher after a trial of antibiotic rotation. Further studies will be necessary to confirm this hypothesis.Antibiotic rotation may affect the etiology of bacteria detected, for not only gram-negative but also gram-positive organisms. In antibiotic cycling trials conducted for febrile neutropenic patients with hematological malignancies, an increase in the incidence of rotation  and 3. NP. aeruginosa. A guideline issued by the IDSA dose not recommend monotherapy with ciprofloxacin as an initial treatment for febrile neutropenia E. coli isolates resistant only to fluoroquinolones, including ciprofloxacin and levofloxacin, were frequently detected in this study, even though the routine use of quinolone prophylaxis was avoided in febrile neutropenic patients. The epidemic spread of quinolone-resistant E. coli is characteristic as a local factor. Considering these results, it may be difficult, in our institution to use fluoroquinolones as an initial monotherapy for febrile neutropenia, even if the quinolones have anti-pseudomonal activity.In this trial, ciprofloxacin was used as the initial agent for the treatment of febrile neutropenia. This selection was based on ICU-oriented regimens, which focus on the control of multidrug-resistant gram-negative bacteria, such as Whether antibiotic cycling strategies contribute to decreased mortality has not been addressed. However, some studies reported improved prognosis after antibiotic rotation We implemented an antibiotic rotation protocol conducted in our institution, in which 4 antibiotics were rotated at 1-month intervals. Multiple compliance issues with the protocol were appropriately overcome by the presence of properly educated staff, including physicians, nurses, pharmacists, and laboratory technicians. However, due to the limited feasibility of such a protocol, it will be difficult to adopt such a cycling program widely, even if antibiotic resistance could be controlled by this rotation strategy. The most important conclusion of this study is not that this cycling regimen is needed to control antimicrobial resistance, but that the maintenance of “antibiotic heterogeneity” may be effective in reducing the selection pressure on antibiotic resistance. Antibiotic heterogeneity can be achieved by antibiotic mixing, as well as antibiotic cycling Stenotrophomonas maltophilia or metallo-β-lactamase-producing bacteria. Treatment with all the first line antibiotics recommended for febrile neutropenia was well tolerated in our trial. The strategy of “antibiotic heterogeneity” would be useful for the control of antimicrobial resistance, particularly in the treatment of febrile neutropenia, in which long-term administration of broad-spectrum antibiotics is often needed.Some groups have performed antibiotic rotation trials in febrile neutropenic patients with hematological malignancies


Efforts to mitigate stigma and discrimination have been central to the national response to HIV in Brazil, a country historically recognized as a leader in human rights-based HIV prevention, treatment and care –3. BraziIn spite of difficulties in implementing universal ART access among more vulnerable groups, political leaders have implemented diverse strategies aiming at securing universal access to antiretroviral (ARV). The country has produced generic ART since the early 1990s. But the rising costs of second-line treatments prompted the Brazilian government to explore additional strategies. Since 2000, the government made a few public threats to issue a compulsory license for local production of generic versions of patented ARVs, leading several multinational pharmaceutical companies to slash the prices of AIDS medicines. Brazil was also the first country to grant a compulsory license for an AIDS drug – Efavirenz, the ARV drug most used by Brazilian patients. Since this compulsory license was granted, the government has been able to save US$103 million (2007–2011). Today, of the 38 presentations of ARV drugs used for AIDS treatment, 14 are produced domestically .Through the local manufacturing of ART and an emphasis on comprehensive medical care extending beyond HIV-related treatment, the country has reduced mortality rates by 50% and AIDS-related hospitalizations by 80% , 7. Thishttp://oquenostiraosono.tumblr.com/home). The movement was recently presented at the 2nd International HIV Social Sciences and Humanities Conference [http://www.akissforgabriela.com) [Historically, the Brazilian response to HIV has supported the reduction of stigma and discrimination among marginalized groups, including both drug users and sex workers , 13. Hownference , and it ela.com) .In 2012, the Brazilian Ministry of Health censored a campaign targeting young gay men, the group with the highest HIV incidence rates in the country. In March 2013, a series of comics themed on sexuality and education for students was censored before its distribution in Brazilian middle and high public schools. The comic books addressed issues such as adolescence, gender, sexual diversity, sexual and reproductive rights and living with HIV. Those comics were part of the Health and Prevention in Schools project, an initiative of the Ministries of Health and Education in partnership with the Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations Population Fund (UNFPA) and United Nations Children's Fund (UNICEF).And on June 4, Brazilian Minister of Health Alexandre Padilha ordered that a poster reading, “I'm happy being a prostitute,” be removed from the Department of STD/AIDS and Viral Hepatitis' website. The poster was one element of a larger campaign entitled Without Shame to Use Condoms, and it was launched on International Prostitutes Day (June 2). The campaign materials were developed by sex workers during a workshop held in March 2013 that was organized by the Department of STD/AIDS and Viral Hepatitis. After the minister's initial decision to remove the “I'm happy being a prostitute” poster, conservative Evangelical groups in Congress mobilized and questioned the whole campaign, making discriminatory and stigmatizing comments and demanding an explanation from the government. By the end of the day, the head of Brazil's Department of STD/AIDS and Viral Hepatitis, Dirceu Greco, had been removed from his position, which was followed by the resignation of his two deputy directors. Following the firing of Greco, on June 17, all civil society organizations resigned from the National AIDS Commission.According to Nilce Machado, an activist, a sex worker and the president of a sex workers’ NGO who was one of the campaign's faces, “The decision negates the rights of sex workers to be proud of their work, to speak for themselves and to have access to the kind of health information based on citizenship principles that the Brazilian government itself has championed in the past.”During the Dilma administration, despite strong rhetorical commitment to recognizing the link between human rights and HIV vulnerability, funding and support for rights-based interventions that explicitly target stigma and discrimination, human rights violations and structural impediments against more vulnerable groups such as sex workers have been declining in Brazil.This conservative path is also being seen in Brazilian changes to drug policy. The Federal Drug Law Bill is still under evaluation in the Brazilian Senate, but since 2013 local governments have been enforcing a policy of compulsory treatment of all drug users: not only adults but also adolescents and children. The government also allocated a large amount of federal funds to therapeutic communities, the majority of them run by conservative, faith-based groups .This was a highly controversial decision supported by the Dilma administration. In 2011, 68 therapeutic communities from all Brazilian regions were visited by a task force led by the Brazilian National Human Rights Commission and the Federal Psychology Council. The group identified a wide range of human rights abuses, including violence and torture; cruel, inhuman and degrading treatment; forced labour and lack of proper medical treatment (including during abstinence crises), among other severe problems. Almost all institutions received government financial support . In thisCompulsory addiction treatment is condemned by major international institutions . In 2012For 30 years of the HIV epidemic, the Brazilian response has been accompanied by vocal, and sometimes contentious, advocacy from scientists, activists and even government officials. Those diverse social actors have been working together and were able to create a paradigm shift in how HIV policies and programmes were developed, prioritized, funded and implemented in the country. The complexity of the response towards the HIV epidemic in Brazil is far from reaching 100% universal access, as pointed out by several studies , 7, 20, However, during the current administration we are seeing marked retrenchments in Brazil's rights-based response. Since the beginning of the epidemic, guaranteeing human rights has been an essential aspect of successful Brazilian strategies regarding the HIV epidemic. It is time, once again, for human rights activists, affected communities, local leaders and researchers to work together in order to turn this tide. The appointment of Dr Fabio Mesquita as head of Brazil's Department of STD/AIDS and Viral Hepatitis (in July 2013) was received with optimism. Mesquita was a pioneer in implementing harm reduction strategies in Brazil in the late 1980s and has been actively engaged in the implementation of evidence-based policy and interventions in Brazil and elsewhere. The impacts of his leadership remain to be seen in the near future. It is critical that he succeeds.


This paper deals with the study of damage produced during freeze-thaw (F-T) cycles using two non-destructive measurement approaches—the first approach devoted to continuous monitoring using embedded sensors during the cycles, and the second one, performing ultrasonic imaging before and after the cycles. Both methodologies have been tested in two different types of concrete specimens, with and without air-entraining agents. Using the first measurement approach, the size and distribution of pores were estimated using a thermoporometrical model and continuous measurements of temperature and ultrasonic velocity along cycles. These estimates have been compared with the results obtained using mercury porosimetry testing. In the second approach, the damage due to F-T cycles has been evaluated by automated ultrasonic transmission and pulse-echo inspections made before and after the cycles. With these inspections the variations in the dimensions, velocity and attenuation caused by the accelerated F-T cycles were determined. The freezing and melting of water with deicing salt in porous structure causes serious damage and requires large investments in the repair and/or replacement of such structures. This deterioration process has widely been studied and as consequence different theories and standards have been proposed to evaluate the resistance of concrete subjected to F-T cycles using accelerated tests.Among the theories proposed in the literature that describe the effect of water frost in the porous structure of cement-based materials the hydraulic and osmotic pressure theory proposed by Powers and Helmuth , and a mMany standards were developed to evaluate the resistance of concrete subjected to accelerated F-T cycles, such as: UNE 12390-9 , ASTM C6This paper deals with the evaluation of the resistance of concrete to frost action by two non-destructive methodologies. In the first case, continuous measurements of temperature, humidity and ultrasound were performed during all the cycles while in the second one, automated inspections were made only before and after the cycles. This paper represents the first time, to the best of our knowledge, that the damage state has been evaluated monitoring several parameters at short time intervals (2 min) using embedded temperature/humidity sensors and ultrasonic transducers along the F-T cycles, and using ultrasonic imaging.et al. [The first methodology is based on measurements of temperature and ultrasonic velocity during F-T cycles. Estimations of size and distribution of pores are carried out by using a thermoporometrical model . The poret al. . The resIn the second methodology, automated ultrasonic inspections were made before and after the F-T cycles to obtain maps of dimensions, velocity and attenuation in all specimens.The experimental trials were done using two types of concrete specimens with and without air entraining agents that were subjected to accelerated F-T cycles in accordance with the Rilem recommendations . In this2.2.1.cap is capillary pressure, fS is the entropy of fusion per unit of ice crystal volume (fS ≈ 1.2 MPa/K), fC is the heat capacity difference between water and ice per unit of ice crystal volume (fC ≈ 2.1 MPa/K) [0 is the reference temperature (273.15 K for water) and T is the absolute temperature (T (K) = θ (°C) + 273.15). In 0) [r, as:The thermoporometrical model allows the determination of pore diameter as well as the pore-size distribution in concrete. To make a thermoporometric measurement it is necessary to embed a liquid into the porous specimen, cool the specimen until all the liquid is frozen, and then warm it up until all liquid is melted again. This measurement can determine phase changes or the quantity of liquid/ice in the specimen. In the porous medium, water and ice in the pores can coexist, and the water can freeze when the interface liquid/ice is propagated towards the unfrozen zones. The model is based on the fact that the pore water freezes at a temperature determined by the curvature of meniscus at the interface solid/liquid according to the Gibbs-Thomson equation. It means that each pore diameter is related to a determined temperature as:1 MPa/K) , T0 is t). In 0) , while tr is related to the pore radius pr and the layer thickness e, which remains constant and equal to 9Å as [Assuming that the crystal ice is surrounded by a homogeneous layer of unfrozen water, to 9Å as , by the At each temperature, the water contained in pores is frozen or melted, and can be related to a determined pore radius by:ϕ(pr) can be determined as the variation of ice volume fraction cS regarding the pore radius (temperature):The logarithmic pore size distribution The above Equations –5) are  are 5) aversus temperature, respectively. In The variations in the produced capillary pressure and the pore diameters during a freezing and thawing cycle are calculated from Equations  and 2)..2). In tThe maximum possible capillary pressure to achieve in the freeze-thawing cycle is 22 MPa, and the range of pore diameters is between 7 nm and 2.4 μm. These limitations can be avoided if we increase the temperature of freezing and the precision of climatic chamber, e.g., considering a temperature of −100 °C and a precision of 0.001 °C, the range of pore diameter varies between 2 nm and 120 μm.2.2.C, is obtained as:v is the volume fraction, T represents Wu's tensor in global coordinates for each type of inclusion, and the brackets 〈〉 denote the average over all possible orientations. The superscripts m, p and a refer to the constituent phases, namely, matrix, and two types of inclusions, in this case pores and aggregates, respectively.Frozen water modifies the porous structure in several aspects such as geometry, density and elastic properties affecting global properties of the material. This behaviour is studied by a micromechanical model based on the Mori-Tanaka homogenization scheme ,26,27. Tα which is described by an ellipsoid.The tensor T is a function of the geometry, the distribution and the orientation of the inclusions and it can be calculated using the method given in . The geomv = 1–pv–av: When the temperature drops below 0 °C the water in the porous structure does not freeze at the same time, part of the water freezes and the rest can be super-cooled depending on the pores size [wv and iv denote the volume fraction of water and ice, respectively. It is worth noted that these variables have an opposite behaviour, when iv increases; wv decreases.The volume fraction of matrix can be calculated as res size –5. For tC is reduced to two independent elastic constants, C11 and C44 in reduced notation. These constants are related to the longitudinal (lV) and transverse (tV) velocities as:Considering the concrete as an isotropic material, the elastic tensor ρ, is calculated in terms of density and volume fraction of constituent phases as:The concrete density, m), aggregates (a) and pores (p) which are distributed randomly in the matrix. The sand and gravel are modelled as a one phase (aggregates) because they have the same elastic properties and previous studies have shown that the shape of the aggregates has little influence on the ultrasonic velocity [aα = 1). The geometry of pores is modelled as cylinder  representing capillary pores.A theoretical study was made to study the behaviour of the ultrasonic velocity with the increase of ice volume fraction in the pores. Before applying the micromechanical model it is necessary to take into account several assumptions. The concrete is considered as a three phase material composed by a solid matrix  and B, respectively. All specimens were made with Portland cement CEM I 42.5 R. The aggregates used were silica sand and siliceous gravel river with sieve modules of 2.87 and 7.31, respectively. The maximum size of coarse aggregate is 25.4 mm. The proportions of the mixtures are shown in The specimens were manufactured in accordance with the standard UNE-EN 12390-2 . In each3.2.Microstructural testing of mercury intrusion porosimetry and thermogravimetric analyses were performed before and after the F-T cycles to obtain the porosity, pore size distribution and degree of hydration . The ope3.3.The accelerated F-T cycles (F-T) were made according to the standard UNE-CEN/TS 12390-9, CDF Test (Alternative Method) , in a DY3.4.In this paper the concrete resistance to frost was evaluated by monitoring the temperature, relative humidity and ultrasonic parameters along all F-T cycles. Temperature and relative humidity sensors were embedded in the concrete while the ultrasonic transducers were adhered to the outer side surface before the lateral faces were sealed with epoxy paint according to the standard , see FigCommercial sensors, SHT1 from Sensirion Compay, were used to measure temperature and relative humidity. They were placed at different depths  of the concrete specimens through the specimen face in contact with the dissolution of NaCl, The ultrasonic transducers (US) were designed and manufactured by the research group due to the size of the concrete specimens and the conditions of the trial. Piezoelectric ceramic with a central frequency of 500 kHz, emitting in longitudinal mode were used to manufacture the ultrasonic transducers. These ceramics were encapsulated in a ceramic body to be electrically insulated and to improve the signal noise ratio. The measurements were made in transmission mode with the transducers adhered to the outer side surface approximately at 35 mm of the face in contact with the dissolution, see A multi-sensory system of real-time monitoring in Matlab environment was designed allowing the simultaneous acquisition of up to four channels for ultrasonic measurements and 20 channels for T/RH measurements with programmable acquisition intervals. V) was determined by the travelling time of the ultrasonic pulses in the specimen (t), the thickness (d = 150 mm) considered constant along all cycles and the reference travelling time (0t) in order to calibrate the ultrasonic acquisition system using a reference aluminium specimen:The ultrasonic velocity , expressed in dB/m, was computed as the quotient of the maximum amplitude of the received pulse traveling through the specimen, sA, and the pulse travelling just in water, wA, as:The ultrasonic velocity of the concrete specimens was determined as:From the automated inspections, dimensions, velocity and attenuation maps were generated for the concrete specimens, before and after the cycles. It is necessary to point out that all manufactured specimens (10 specimens of each mix) were inspected, although not all were subjected to accelerated cycles in the climatic chamber.4.4.1.The obtained results from the microstructural mercury intrusion porosimetry and thermogravimetric analysis tests performed before and after the F-T cycles for specimens A1.4 (Mix A) and B1.3 (Mix B) are shown in In both concrete types the porosity is increased after the F-T cycles, see 4.2.The temperature and relative humidity behaviour inside the concrete specimens and the ambient conditions in the climatic chamber along all F-T cycles is represented in The temperature behaviour with respect to depth inside the specimens and the maximum and minimal values during all F-T cycles are shown in 4.3.The ultrasonic signal, A-scan, of a specimen of concrete with and without air entrainment, before and after of the F-T cycles is shown in A B-scan image was generated from all recorded A-scan signals throughout the cycles see , this isIn all specimens it can be observed that in the 20th F-T cycle there is a slight discontinuity in the measurements, shown as a mild colour change, due to an electric power failure in the laboratory. In specimen B1.3 a change can be seen in the ultrasonic signal from the 16th and 17th F-T cycles indicating damage in the concrete material. A similar but smoother behaviour was also observed in specimen B1.5.vice versa. The same behaviour was observed in all monitored specimens and the relative velocity was determined to analyse this behaviour.The behaviour of the ultrasonic velocity along the cycles for specimen A1.4 is shown in The relative velocity was calculated as the ratio of the maximum and minimum velocity at the plateau of freezing and thawing cycles, respectively. The relative velocity along the F-T cycles illustrates that the specimens are grouped by the type of mixtures, A or B, see In all specimens the relative velocity increases progressively along the cycles, probably indicating damage in the material. The concrete specimens with air entrainment exhibit the smallest differences among frozen and unfrozen states. However, the difference between the F-T cycles increases more with the cycles for the concrete specimens without air entrainment. The B1.3 specimen has the higher relative velocity indicating that it is the most damaged specimen. This behaviour is consistent with the previous results obtained in The evolution of the ultrasonic velocity with the temperature in the concrete specimens is shown in 4.4.The volume fraction of ice was determined from the micromechanical model and the longitudinal velocity. The variation of ice volume fraction with temperature is shown in 4.5.The pore size distribution of concrete specimens determined by the thermoporometry technique is shown in Also, the difference between the exerted pressure by mercury porosimetry and thermoporometry techniques is approximately of 7.5 in our experiments. Similar behaviours have been pointed out by other authors ,35. Desp4.6.From the ultrasonic automated inspections three parameters were determined: dimensions (width and length), ultrasonic velocity and attenuation for each specimen before and after the F-T cycles. The maps of dimensions, velocity and attenuation before and after the cycles are show in It should be noticed that in all images the second and fourth specimens in the third row, B1.2 and B1.4, are not subjected to the accelerated cycles. The dimension maps before and after the F-T cycles of all specimens and the arrangement of specimens in automated inspections are shown in 2 for specimens of Mix B and 0.10 kg/m2 for specimens of Mix A [In the images after the F-T cycles, see of Mix A .The velocity maps of the concrete specimens before and after the F-T cycles are shown in After the F-T cycles a decrease in velocity is observed in all specimens, The attenuation maps of concrete specimens before and after the cycles are shown in 5.In this paper the damage produced in concrete during F-T cycles was evaluated using two non-destructive approaches, continuous measurements of T/RH and ultrasonic velocity during all the cycles, and automated inspections only before and after the cycles.The continuous monitoring of two types of concrete, with and without air entraining agents, during the freeze-thaw cycles was carried out using temperature, relative humidity and ultrasonic sensors. These embedded sensors and the multisensorial system used for the monitoring were developed by our research group. The monitoring of T/RH was performed at different depths. The behaviour of temperature and humidity were in phase during the cycles and it was observed that it did not vary with depth. It was also verified that the temperature inside the concrete specimens follows the F-T cycle fixed in the climatic chamber. Concrete uniformly freezes from the first cycle.From the ultrasonic wave monitoring, it was observed that the ultrasonic pulse changes and the amplitude decreases strongly after the cycles in both materials. In addition, the relative velocity was calculated at the plateau of F-T cycles, and in all monitored specimens it was observed that this velocity increases progressively along the cycles, allowing the identification of the beginning of damage from the first cycle. The increment of relative velocity is a consequence of the increase in the ice pore volume and the porosity. An increase in velocity regarding the first cycle is observed.A thermoporometrical model was used to estimate the size and distribution of pores using temperature and ultrasonic measurements. The results obtained show that the volume and diameter of pores increase after the cycles in both materials, although is more accentuated in concrete without air entrainment. This behaviour agrees with the results obtained with mercury porosimetry technique, but in different proportions as a consequence of the differences between these methodologies.The automated ultrasonic inspections were made before and after the F-T cycles to decouple the effect of concrete heterogeneity from possible damage caused by the water frost. From these inspections, maps of dimensions, attenuation and velocity were obtained. From the dimension maps, it was noted that the concrete specimens without air entraining agents are more degraded than the specimens with air entraining agents and the edges of the specimens are not defined. These results agree with the surface mass loss results. The decrease of velocity and attenuation after the cycles were more accentuated in concrete without air entrainment and coincides with the results obtained with the monitoring. The attenuation and velocity maps show the microcracking and internal defects in the specimens.The non-destructive methodology proposed in this work, using ultrasonic velocity measurements and a thermoporometrical model can be an alternative method to evaluate the damage in cementitious materials subjected to F-T cycles. The monitoring of ultrasonic velocity along of the F-T cycles allows one to identify the beginning of damage.


HAART has significantly reduced AIDS-related morbidity in children. However, limited evidence is available from developing countries regarding patterns of opportunistic illnesses. We describe these events and their associated factors in children with AIDS in Brazil.This study is based on two representative retrospective multi-center cohorts including a total 1,859 children with AIDS, infected via mother-to-child transmission (MTCT), between 1983-2002. Opportunistic illnesses were described and analyzed over time. The association of demographic, clinical and operational data with the occurrence of opportunistic diseases was assessed.Pneumocystis jirovecii pneumonia , and bacterial meningitis/sepsis .In total, 1,218 (65.5%) had at least one event of an opportunistic disease. Variables significantly associated with occurrence of these events included: region of residence , age < 1 year at diagnosis , and non-performance of MTCT prevention measures . Protective factors included year of HIV diagnosis in the HAART era  and ART use . In both periods bacterial infections represented the most common opportunistic events , followed by Despite the significant reduction in recent years, opportunistic illnesses are still common in Brazilian children with AIDS in the HAART era, especially bacterial diseases. The data reinforce the need for scaling up prevention of MTCT, early diagnosis of infection, and improvement of comprehensive pediatric care. Over the past 15 years, both morbidity and mortality associated with human immunodeficiency virus (HIV) have been systematically reduced in children. Greater knowledge on the clinical course, early diagnosis of HIV infection, adoption of prophylaxis, improved management of opportunistic diseases, and introduction of antiretroviral therapy (ART) contributed to this trend . New patThe adoption of highly active antiretroviral therapy (HAART) also has had an important role in modifying the natural history of HIV infection in children, characterized by a reduction of the progression to AIDS. The limited evidence available in children exposed to HIV via mother to child transmission (MTCT) shows reduced rates of clinical events in category "C" of CDC revised classification system for HIV infection. Early diagnosis of HIV infection and HAART has led to a reduction in the frequency of opportunistic diseases in children with subsequent reduced number of hospitalizations ,8-10. HoBrazil stands out among the developing countries due to its sustained policy of HIV control, with a history of 25 years of a national control program . Since 1Few studies have evaluated changes of clinical patterns with the introduction of HAART in children . The aimThis study is based on analysis of two representative multicenter retrospective cohort studies on survival in Brazilian children with AIDS, infected by mother-to-child transmission (MTCT). Both studies followed similar methodological procedures, as described in detail previously -17. ChilThe first study included 914 Brazilian children with AIDS diagnosed between January 1, 1983 and December 31, 1998. The status of children  was based on the follow-up until death or the end of 2002 ,17. The We considered the first clinical event (primary episode) of each opportunistic illness associated with AIDS in any time of the children follow-up. Based on the Centers for Disease Control and Prevention (CDC) definition  and on tClinical events were diagnosed by pediatricians with experience in management of HIV-1 infection, and data were registered in medical records. We reviewed retrospectively these medical records regarding the clinical events. To establish the diagnosis, we followed the Brazilian criteria for definition of AIDS cases in children, based on presumptive and/or definitive diagnosis . We analWe verified the occurrence of these opportunistic diseases in the pre-HAART (< 1995) and HAART eras (1996-2007), using 1996 as a cut point. Odds ratios (OR) with their respective 95% confidence intervals (95% CI) were calculated for quantitative comparison of relative frequencies. Additionally, we analyzed variables possibly associated with the occurrence of AIDS-defining diseases. Brazilian regions (child' residence), gender, birth cohort , age group , ART use (in any time), year of ART initiation , vital status , prenatal care, breast-feeding, and MTCT prophylaxis. Chi-squared and Fisher's exact tests were used where applicable. Statistical analysis was done with the STATA 11.0 software package .Both studies were approved by the Ethical Review Board of the Center for Reference and Training in STD/AIDS of São Paulo State, following the guidelines of the National Health Council.Epidemiological and demographic characteristics of children included in the analysis are detailed in Table About two thirds of children presented opportunistic infections during the observation period with a significantly lower occurrence of at least one of these events in the second cohort . The bivariate analysis of factors associated with the occurrence of opportunistic infections is depicted in Table P. jirovecii pneumonia (21.9% vs. 13.2%) and bacterial meningitis/sepsis (16.8% vs. 7.4%). We observed a decreased proportion of cases in the second cohort, as compared to the period < 1988. Considering the pre-HAART and HAART eras, a significant decrease was also observed   in the first cohort, and 383 (79.8%) in the second . The occurrence of specific opportunistic illnesses is presented in Table P. jirovecii pneumonia, bacterial meningitis or sepsis, cryptosporidiosis, and cryptococcosis , as observed in other studies [In contrast to these previous studies, we observed that about 1/7 of children still presented  studies ,29. For Children with AIDS diagnosed between 1996-2002 had a three times lower odds of having opportunistic infections, as compared to those born before the release of any ARV. Thus, they had the chance to be treated with ARV, even in advanced stages of HIV infection ,14.Operational issues related to health services examined in this study, as the realization of prenatal care and adoption of breastfeeding were not significantly associated with the occurrence of opportunistic events, the first guidelines for management of HIV infection and opportunistic diseases were published in 1994, and the first therapeutic consensus was established in 1996. Expanded further actions for the prevention of MTCT have occurred since 1999 ,30, therWe identified a positive association between the occurrences of opportunistic illnesses in all regions of the country compared with the North region, mainly in the Southeast where the epidemic is consolidated since the very beginning . It is nChildren aged < 1 year of age had a higher frequency of opportunistic illness compared with children aged 1-5 and 6-12 years. This population of children is known to progress more rapidly to AIDS, with strong evidence of efficacy of early treatment ,8,34, whThis study is based on the two unique national cohorts of children with AIDS for survival analysis with a representative number of children with AIDS in the country and its regions. Considering the sheer magnitude of the analyzed period (1983-2007), measures adopted for data collection were standardized, with a systematic review of all data collected, and minimizing the effects related to changes in criteria for AIDS cases definition, management/diagnosis of opportunistic infections and ART.The present study has limitations beyond those already identified and described extensively in our previous publications on the topic -17. ChilConsidering the study period (1983-2007) and the advance of the Brazilian policy for the control and management of HIV infection/AIDS even after the introduction of HAART, the period after 2002 may have possibly a different pattern of occurrence of opportunistic conditions, indicating the need for further studies.The present study provides evidence for the reduction of morbidity related to AIDS-defining opportunistic illnesses in Brazilian children exposed to HIV through MTCT. This result reflects a period of further consolidation of HAART in a developing country with extensive commitment of the public sector to providing treatment. Bacterial diseases remain the most important opportunistic disease. Our study emphasizes the need to continually expand efforts to prevent MTCT of HIV, early diagnosis of infection, and improved care of pediatric AIDS patients.The authors declare that they have no competing interests.ANRJ participated in the study concept and design, had full access to all of the data, carried out acquisition, analysis, and interpretation of the data, drafted the manuscript. LHM participated in the study conception and design, and acquisition of data; had full access to all of the data, carried interpretation of the data, revising critically the manuscript. NH carried out interpretation of the data, revising critically the manuscript. JH participated in the study concept and design, had full access to all of the data, carried out analysis, and interpretation of the data, drafted the manuscript. All authors read and approved the final manuscript.


Although the effectiveness of methadone maintenance treatment (MMT) is well-established in many countries, it is a relatively new therapy for heroin users in China. Jiangsu Province, a relatively wealthy province, set up 4 MMT clinics in February 2006. No previous studies have evaluated the impact of MMT in a wealthy Chinese province.The aim of this study is to evaluate the impact of a 1-year MMT among heroin users in Jiangsu Province. We investigated the impact of the treatment by examining the following outcomes: 1) reduction of heroin use, 2) increase of appropriate sexual intercourse, 3) reduction of antisocial behavior, 4) increase of better social and family relationships, and 5) HIV prevalence among heroin users in MMT clinics.Repeated cross-sectional surveys were conducted before and after heroin users in Jiangsu Province received at least 1-year of treatment in the MMT clinics. A questionnaire survey was implemented for those who agreed to participate from March to April 2006, before the initiation of MMT (N = 554). The second survey was from August to September 2007 and was administered to those who received MMT for more than 1 year (N = 804). One hundred and ninety-six patients who were investigated in both surveys were included in a longitudinal study to evaluate the factors attributable to behavior change.MMT helped in reducing the percentage of heroin injection and also improved social and familial relationships. Antisocial behavior, including theft, prostitution, and dealing in heroin, decreased after 1-year treatment in the MMT clinics. However, the percentage of patients using condoms was not statistically significant. No case was found to be HIV-positive among those who received more than 1 year MMT. In the longitudinal study of 196 patients who participated in both surveys, no specific demographic variables were found to be associated with heroin use, anti-social behaviors after 1-year MMT.MMT was thought to reduce heroin use, antisocial behaviors and HIV prevalence, and increased appropriate sexual intercourse behaviors and better social and family relationships among heroin users in a wealthy province in China, which was true regardless of gender, age, marital status, or working status. Fifty thousand newly discovered HIV-positive cases were reported in China in 2007. HIV transmission through shared syringes accounted for 42% of all these new cases; this was followed by homosexual transmission and mother-to-child transmission.Methadone maintenance treatment (MMT) is a replacement treatment for heroin addiction. It is used worldwide and this treatment is legal, convenient, safe, and effective.6In China, MMT is a relatively new therapy that was launched in 2004 and is being implemented on a large scale in order to prevent HIV transmission among heroin users. By the end of 2006, a total of 37,345 patients had been treated in 320 clinics across the entire nation.Jiangsu Province is located in south-east China and its economy is relatively well-developed. Since urbanization and drug abuse are known to be associated,In addition, it can be hypothesized that MMT is effective regardless of patient’s demographic characteristics, although few studies investigated how demographic characteristics might change the impact of MMT. Previous studies in the US reported that demographic variables did not affect the effectiveness of MMT.9The objective of this study was to evaluate the impact of 1 year of MMT in the MMT clinics in Jiangsu Province, which is an economically well developed area, in terms of: 1) reduction of heroin use , 2) increase of appropriate sexual behavior, that is, reduction of having multiple partner and increase of condom use in heterosexual intercourse, 3) reduction of antisocial behavior, 4) increase in number of people who are better off related to social and familial relationships, and 5) reduction of HIV prevalence among heroin users in MMT clinics. Among those who could follow-up, the impact of demographic variables on MMT was investigated.To help insure security, participants are forbidden to take methadone outside of the clinic. Patients must come to the clinic daily once they have enrolled in the program. The mean dosage of the therapy in the 4 clinics was 55 mg per patient. The treatment cost was 10 yuan (US$ 1.5) per day regardless of the individual dosage.Once the patient was accepted and enrolled in the program, took part in a monthly urine test for morphine, which enabled supervision of the methadone treatment. The staff did not inform the patient informed in advance which day he/she would be tested. The test was performed using a urine test kit. Since morphine is a metabolite of heroin, the test result will be positive if the patient has taken heroin recently. This allows the patient to be supervised. Termination of the treatment did not occur if the patient provided a positive test result. Instead, a nurse or doctor would counsel the patient about the reason why he/she had used heroin while taking methadone so that related problems might be solved. The counseling provided to the patient was free of charge.By the end of September 2006, a total of 1402 patients had visited the 4 MMT clinics in Jiangsu Province, China. From March to April 2006, patients were recruited and 554 patients agreed to participate in the 1st survey (i.e. these 554 patients don’t receive MMT), and from August to September 2007, 804 patients who received more than 1 year MMT participated in the 2nd survey (i.e. follow-up after 1-year MMT). Among them, 196 patients participated in both the 1st and 2nd survey. Thus, 240 patients didn’t participate in both 1st and 2nd survey. A repeated cross-sectional survey study was conducted and a questionnaire investigation was implemented. The study was conducted by researchers in Jiangsu Provincial Center for Disease Prevention and Control. All the doctors in the MMT clinics were trained to collect information from the patients. Doctors conducted face-to-face interviews with the patients in a private room. The doctors promised the patient that he/she would not be rewarded or punished regardless of whether or not he/she agreed to participate in the investigation. The doctor explained the objective of the survey and the process of participating to each patient. He then read out the information pertaining to informed consent, which was on the front page of the questionnaire. The patient ticked “Yes” if he/she agreed to participate in the investigation. The survey was anonymous, and no personal information appeared on the questionnaire. Responses were identified by unique ID numbers. The database thus created will not be shared without justifiable reason.The outcome measurements were heroin use behavior, sexual intercourse behavior, antisocial behavior, social or family relationships, and HIV prevalence.Heroin use behavior was assessed by the following 5 questions. (1) Have you ever used heroin in the last month? (2) Have you ever injected heroin in the last month? (3) How many times did you inject heroin in the last month? (4) How many times did you share syringes in the last month? (5) In the last month, how often did you contact your friends who also use heroin? The response to the first 2 questions, i.e. (1) and (2), was either yes or no. The last question, i.e. (5), was answered on a 4-point Likert scale—every day, often, occasionally, or never.Sexual intercourse behavior was assessed by 2 questions. (1) Did you use a condom during the last sexual intercourse? (2) In the past 3 months, how many sex partners did you have? The response to the first question was either yes or no. The last question was answered using an exact number.Antisocial behavior was assessed by 4 questions. (1) Have you ever been caught in an illegal act by the police in the last 3 months? (2) Did you steal, rob, or cheat others in the last 3 months in order to support your heroin habit? (3) In the past 3 months, did you have sex with others only to obtain money to buy drugs? (4) Have you ever sold heroin to others in the last 3 months? The response to these questions was either yes or no.Social and family relationships were assessed by 2 questions. (1) Have you got a job at present ? (2) How do you evaluate the recent relationship between you and your family? The first question was answered as either yes or no, while the second question was answered on a 3-point Likert scale—fairly good, average, or worse.We used different time frames for different study outcomes for heroin use. For example, we asked participants about their sexual/illegal behavior in the last 3 months rather than in only the last month because heroin use is a daily-occurring behavior while the latter is a behavior that happens less frequently. Our social and family relationships measure asks participants to evaluate their ‘recent’ relationship with family because we were interested in how the patient felt about their family in the present.To determine the impact of MMT in preventing HIV infection, all patients were requested to undergo blood tests for the HIV antibody every year from the time of entry into the program. The only exception was patients who already had a valid HIV-positive report. Five milliliters of blood was taken from the patient by a nurse and tested by enzyme-linked immunosorbent assay in a local HIV screening laboratory. Positive blood samples were confirmed by western blot analysis in the provincial confirmative laboratory.The following explanatory variables, including demographic characteristics and socioeconomic status, were assessed: gender , age, ethnicity , education , marital status , working status , living status , main source of income in the last 6 months .Data were entered in Epidata 3.0  and analyzed using the SPSS version 13.0 statistical software package. Continuous variables were represented as mean ± standard deviation, while categorical variables were represented as percentages. The Chi-square and Fisher’s exact tests were used to examine the differences in social and behavioral characteristics between the 2 surveys. The p value was reported for a two-tailed statistical test, while α < 0.05 was considered to be statistically significant. Multivariable logistic regression analysis was used to identify factors that affected changes in behavior related to heroin use, sexual intercourse, and social interactions. Explanatory variables were categorized on the basis of their distribution as follows: gender, 2 categories ; education, 2 categories (junior middle school and below or senior middle school and above); marital status, 3 categories , or divorced); working status, 2 categories (unemployed or employed); living status, 2 categories ; and source of income, 2 categories .By the end of September 2006, a total of 1402 patients entered the 4 clinics. There were 404 patients that dropped out during the course of the first year of treatment: among them, 143 patients were 1st survey participants. The dropout rate was 28.8% during this period. The average length of treatment among those who dropped out of this program was 22 weeks. Among those who had dropped out, 54.5% (220/404) were caught by the police for an illegal offence or crime such as continued use of heroin, robbery, or theft. Of the total number of dropouts, 27.7% (112/404) did not come to the clinic any longer for inexplicable reasons or because they broke the clinic rules. Of the total dropouts, 6.7% (27/404) left the city where they were undergoing treatment to work in another city where MMT clinics were not available.The average age of patients in the 1st survey was 34.9 ± 6.2 years, while in the 2nd survey, it was 36.1 ± 6.5 years. The results of the 1st and 2nd surveys did not show any statistically significant difference in terms of gender, education, ethnicity, and living status .There were 495 patients who had injected in the last month before entering the clinics and completing the 1st survey. Others used heroin by sniffing. In the 2nd survey, the percentage of heroin-use in the last month, heroin injected in the last month, and syringes shared with other heroin users in the last month were significantly lower than those in the 1st survey .The percentage of patients with multiple sexual partners during the last 3 months decreased for both male and female patients in the 2nd survey in comparison to the 1st survey . However, the percentage of patients using condoms during the last sexual intercourse was not statistically significant (p = 0.91).The percentage caught in illegal acts by the police in the last 3 months decreased from 19.1% in the 1st survey to 3.1% in the 2nd survey (p <0.01). Illegal behavior and crimes, such as theft or robbery, or prostitution, to obtain money to buy the drug, decreased significantly in the last 3 months .With respect to their recent relationships with their family, working status, marital status, and source of income resource were significantly improved in comparison with 1st and 2nd survey . In addiThere were 11 HIV-positive patients among the 1402 patients who entered the MMT clinics from March 2006 to September 2006. Two patients were confirmed after enrolment, while the other 9 were confirmed prior to enrolment. The HIV-positive rate was 0.8%. After 1 year, with the exception of 20 patients who had transferred to other newly opened clinics where they could obtain treatment conveniently, 978 patients still underwent treatment. None of the HIV-negative patients had seroconverted to the HIV-positive state.In the 1st survey, all 554 patients had positive results because they had just used heroin, while in the last month of the 2nd survey, only 92 of 804 patients (11.4%) had positive results.The findings from the study showed that MMT contributed to a reduction of heroin use, especially in the form of injections, anti-social behaviors, and in improving social and familial relationships. Both male and female patients tended to have fewer sex partners after MMT. A longitudinal study of 196 patients showed that there was no specific demographic variable that could be attributed to promoting or deteriorating the impact of MMT. Thus, MMT treatment appeared to be effective regardless of demographic variables such as age, gender, or socioeconomic status, which is consistent with previous studies across cultures.Consistent with the findings of an earlier study on 8 pilot MMT clinics in China,13Although it is well-known that MMT is effective in reducing heroin use among addicts, a few studies have shown that demographic variables modify the effectiveness of MMT. A retrospective study conducted among female patients in methadone clinics showed that ethnicity played a role in changes in sexual behavior over the last 6 months.The positive rate for morphine in the urine test conducted in the last month after more than 1 year of MMT treatment (11.4%) in our study was much lower than that reported in the study by Liu et al in Guizhou, China (30.0%).Our study showed that the percentage of patients with multiple sex partners was lower after 1-year MMT treatment, while condom use was not improved. An intervention survey conducted among MMT patients in the U.S. demonstrated that safe sex counseling and behavior intervention decreased the incidence rate of unsafe sexual behavior.After 1-year MMT, the percentage of antisocial behavior decreased substantially. A systematic review conducted by Holloway and his colleagues showed that clients in treatment program had less criminal behavior than the comparison groups.Several studies conducted in different countries have proved that MMT is effective in treating heroin addiction.It was shown that the effectiveness of MMT depended on the quality of the treatment in terms of factors such as the methadone medication dose, support from society, and financial stability to maintain access to the MMT clinic.31One limitation of our study is that not all of the samples in the second survey were investigated in the first survey. In other words, our longitudinal study had a selection bias. However, the distribution of demographic variables between those that could be followed and those that could not be followed did not differ significantly in our sensitivity analysis (data not shown). In addition, some of the patients who were investigated in the first survey dropped out over time. It may be speculated that the percentage reduction in negative behavior observed in this study might be an overestimation.Another limitation of our study is that there is no parallel control group when the efficacy of MMT is evaluated. Ethical considerations restrict the recruitment of community heroin users if MMT is not offered to them. The mass media in each city publicized the benefits of MMT when the local MMT clinics began operations, and the MMT clinics sent brochures to patients and urged them to bring their friends who also used heroin to the clinic. It was difficult to contact heroin users in the community if they were reluctant to come to the clinic. The findings of our study showed that the percentage of behavior change was significant and substantial and was considered most likely due to MMT. However, it would be desirable to compare the behavioral changes among heroin users who received MMT with those who did not receive MMT. One possible method would be to compare the HIV-related behavior of heroin users in Jiangsu Province with that of heroin users in other cities that do not have MMT clinics. Further studies with a control group are required to show the effectiveness of MMT in reducing risky behavior related to HIV transmission.


While the overall HIV prevalence in Tanzania has declined recently to 5.6%, in 2009, the HIV prevalence among PWID remains alarmingly high at 35%. In this paper, we describe how the Tanzania AIDS Prevention Program (TAPP), Médecins du Monde France (MdM-F), and other organisations have been at the forefront of addressing this public health issue in Africa, implementing a wide array of harm reduction interventions including medication-assisted treatment (MAT), needle and syringe programs (NSP), and “sober houses” for residential treatment in the capital, Dar es Salaam, and in Zanzibar. Looking toward the future, we discuss the need to (1)  Until recently, heroin use and associated health risks were not perceived as major issues in sub-Saharan Africa. However, in the mid-1980s and early 1990s, East Africa became an important stop along international drug trafficking routes thereby introducing heroin in the region , 3. The During the 2000s, the rapid escalation of injection drug use in Tanzania accompanied a synergistic rise in HIV prevalence among people who inject drugs (PWID) due to unsafe injection practices and risky sexual behavior. Since 2003, the majority of PWID in Dar es Salaam reported injecting three times per day , 6, withOn World AIDS Day 2006, researchers from Muhimbili University of Health and Allied Sciences (MUHAS) and the University of Texas School of Public Health (UT-Houston) conducted a day-long media workshop in Dar es Salaam to present findings they had published in peer-reviewed journals to the press, community-based organisations (CBOs), nongovernmental organisations (NGOs), and donors. The national press coverage of the event and of other antidrug trafficking efforts presaged the Tanzanian government's 2007 request to direct some funds from the President's Emergency Funds for AIDS Relief (PEPFAR) toward HIV prevention outreach projects specifically targeting PWID. Saba Saba Trade Fair. In Dar es Salaam, PEPFAR funded the Tanzania AIDS Prevention Program (TAPP) in 2007 to implement prevention and outreach activities among PWID. TAPP is a consortium that MUHAS manages in partnership with UT-Houston, Pangaea Global AIDS Foundation (Pangaea), the Tanzanian Ministry of Health and Social Welfare (MoHSW), and the Tanzanian Drug Control Commission (DCC). TAPP partners coordinate a multiarm approach to HIV prevention and outreach, covering a broad population of clients. For the general population in Dar es Salaam, TAPP offers HIV testing and counseling (HTC) for individuals and couples through mobile van outreach, provider-initiated testing and counseling (PITC) and onsite testing at Muhimbili National Hospital, as well as training for health care personnel in prevention and outreach procedures. TAPP staff have also provided HTC services at annual events, including World AIDS Day, Africa Day, Rotary Club Day at Chanika, International Day Against Drug Abuse and Illicit Trafficking, and the For PWID, the community-based outreach project helps to coordinate many intervention programs through the cooperation and input from local partner CBOs: Kimara Peer Educators and Health Promoters Trust Fund (KPE); Youth Volunteers Against Risky Behaviours (YOVARIBE); Centre for Human Rights Promotion (CHRP); and Blue Cross Society of Tanzania (BCST). These CBOs and two mobile clinics provide HTC outreach services for IDUs in the Kinondoni District of Dar es Salaam. These services include distribution of health kits  materials along with kits for wound care, condoms, and bleach kits for cleaning of works), psychosocial support services, individual counseling, self-support groups, Narcotics Anonymous (NA) and Methadone Anonymous (MA) meetings, and family group therapy meetings. As part of this project, UT-Houston, together with community outreach workers from MUHAS and CBO partners, maps communities to identify suitable locations for mobile units, and monitors current heroin use patterns in Dar es Salaam to modify program strategies. Additionally, TAPP provides continuing education training for community outreach workers. Through August 2012, TAPP partner CBOs have engaged over 11,800 heroin users through outreach activities, of which 2530 were PWIDs and referred 571 to the medication-assisted treatment (MAT) clinic (see below) . During February 2011, a dedicated public methadone-based MAT clinic, the second in sub-Saharan Africa after Mauritius, opened at the Muhimbili National Hospital. The MAT clinic is staffed year-round to accommodate the project participants who are all required to travel to the clinic on a daily basis to receive their dose of liquid methadone where consumption is directly observed by healthcare providers. CBO outreach efforts also include identifying, screening, and preparing possible candidates for medically assisted treatment. Through the development of service provision guides and clinical mentoring, Pangaea assisted in building local capacity to launch the MAT clinic and continues to support the services with ongoing clinical mentoring and the use of implementation science methodologies. From its opening to August 2012, TAPP has enrolled over 431 PWID in methadone treatment at its MAT clinic .During late 2010, Médecins du Monde France (MdM-F) began a harm reduction program in the Temeke District of Dar es Salaam with a drop-in center (DIC) and outreach activities. This program is funded by the French Agency for Development (AFD), the Municipality of Paris, and private donors. In November 2010, MdM-F signed a Memorandum of Cooperation with the MoHSW and the district council in Temeke to strengthen local capacities of stakeholders in harm reduction. Between August 2011 and March 2012, MdM-F had engaged 2932 PWID and 1265 PWUD  through outreach activities and the DIC. Approximately 45 PWID attend the DIC daily, and an additional 120 PWUD attend during the two days per week when the DIC is open to those who do not inject heroin. In March 2011, MdM-F began a needle and syringe program (NSP). This program distributes approximately 25,000 syringes and condoms per month, and tests clients for HIV, hepatitis B, and hepatitis C.MdM-F also has special services for women due to their increased vulnerability as PWID/PWUD. There is a separate room for women at the DIC, and, once a week, the DIC is open only to women. Many bring their children as the DIC provides food assistance, and MdM-F provides a staff member to accompany pregnant clients to HIV and antenatal care at other clinics. MdM-F supports several self-support groups: one for women who use drugs, one for PWUD who are HIV-positive, and one for PWID enrolled in the MAT program. MdM-F has also been working with government and private clinics in Temeke to provide services that are more welcoming to PWID/PWUD and others who often experience discrimination in these settings . Finally, because PWID/PWUD are often blamed for social problems and criminal activities, MdM-F advocates for fair treatment of PWID/PWUD in accordance with local laws.To build local capacity and sustainability of harm reduction activities, MdM-F has initiated a “Temeke committee” to help design and expand interventions for PWUD. The committee coordinates government agencies and nongovernment organisations to strengthen referral systems, to exchange experiences and to advocate jointly at national level for increased attention and funding for HIV-prevention services for PWUD. MdM-F offers training and coaching to stakeholders who have a role in HIV prevention among PWUD in Temeke, including medical staff, police officers, community, and religious leaders. They also provide intensive training and mentoring through internships, exchange of staff and continuous consultation to several national nongovernment organisations: Poverty Fighters, Tayohag, and Mukikute. MdM-F has also been working with the Alliance of Mayors and Municipal Leaders on HIV/AIDS in Tanzania (AMICALL) to support the development of a strategic plan for HIV prevention efforts, improving access to care and treatment. For their PWID clients, MdM-F provides training and support for income-generating activities. Some have been trained as peer educators; others have received training and legal assistance to develop small businesses.Milati.” A key PWID leader emerged from within this Zanzibari recovery group movement, Sulieman Mauly, and in 2009 through his CBO and with support from Bi Fatma and others he created the first Zanzibari “sober house” based on the 12-step recovery model. The program integrates group counseling with art therapy, yoga, and acupuncture. The men also play soccer and engage in meditation, and they can receive training in carpentry. By May 2012, there were nine sober houses in Zanzibar, including one for women that opened in 2010 [In Zanzibar, PEPFAR funded two projects to address the needs of PWID: The American International Health Alliance (AIHA) partnered with the DCC, MOHSW, and the Department of Substance Abuse Prevention and Rehabilitation (DSAPR) in Zanzibar, and the Great Lakes Addiction Technologies Transfer Center, based in Detroit, Michigan, to introduce the recovery oriented systems of care (ROSC) model in Zanzibar. These initial efforts focused on establishing recovery groups like Narcotics Anonymous, using the “12 Steps Recovery Model” and the “Islamic  in 2010 . The other PEPFAR-funded project on Zanzibar is United for Risk Reduction and HIV/AIDS Prevention (URRAP) initiated through Columbia University's International for AIDS Care and Treatment Programs (ICAP). URRAP involves a partnership between national government agencies and three nongovernmental organisations: Zanzibar Youth Education, Environment and Development Support Association; Zanzibar Association of Information against Drug Abuse and Alcohol; and the Zanzibar Youth Forum. Outreach workers provide PWUD with information regarding HIV prevention, linkage to HIV testing and, for those found to be HIV-infected, access to care and treatment. URRAP provides static and mobile HTC outreach services in conjunction with sexually transmitted infection (STI) and tuberculosis (TB) screening, and peer escort referrals for services and for those needing HIV care and treatment. Between January 2009 and March 2011, 698 PWID received HTC services in Zanzibar. Eighty-seven were HIV positive and 64 enrolled in care and treatment .extend existing services and programs to reach more PWID and others at risk for HIV; (2) develop additional programs to strengthen existing programs; and (3) expand activities to include structural interventions to address vulnerabilities that increase HIV risk for all Tanzanians.TAPP, MdM-F, and other organisations have made great strides in providing behavioral interventions to prevent the spread of HIV among PWID in Tanzania. Now that these organisations have created the basic structures and established the viability of medication-assisted treatment (MAT), needle and syringe programs (NSP), and other forms of drug treatment and rehabilitation, there is a need to improve the implementation of HIV prevention interventions along three dimensions: (1) Extending existing services can occur along several distinct avenues. First, harm reduction organisations are extending services geographically to reach a greater number of PWID. To date, interventions to reduce HIV risk behaviors among PWID in Tanzania are limited to Zanzibar and parts of the capital, Dar es Salaam. TAPP, with funding from the Open Society Foundation, is preparing to launch a needle and syringe program (NSP) in Kinondoni District of Dar es Salaam during 2012 to complement MDM-F's existing NSP activities in the neighboring Temeke District. TAPP is also extending HIV testing and counseling (HTC) services and the recruitment of PWID for the MAT program to the other two districts of Dar es Salaam  and is exploring different options for distribution of methadone beyond the clinic at Muhimbili National Hospital. As part of this effort, MdM-F has recently begun referring PWID clients to MAT clinic at Muhimbili Hospital. The American International Health Alliance (AIHA) team from Zanzibar, with assistance from the Detroit Recovery Program, is expanding the 12-step program and sober houses to Dar es Salaam and other areas of mainland Tanzania. Efforts are also underway to extend existing programs and services to PWID across the country. TAPP is collecting behavioral data and estimating PWID population sizes in the cities of Arusha and Tanga for possible extension of intervention programs, and other organisations are conducting similar surveys in Mbeya, Mwanza, Iringa, and other towns with an eye toward implementing similar programs for PWID in those areas.kokteli) of tobacco and marijuana. For those who transition from smoking to injecting, the median transition time from smoking to injection is five years, and those PWUD under 25 years of age transition in two years [Second, there is a strong argument for extending drug treatment services to noninjecting heroin users. Most heroin users in Tanzania consume the drug by smoking it in a “cocktail” —including PWID, men who have sex with men, and sex workers—as their risky behaviors often overlap . For exaIn terms of developing additional programs, MdM-F has been advocating a comprehensive approach to harm reduction as defined by various UN agencies (WHO/UNAIDS/UNODC). In Temeke, MdM-F strives to offer a holistic package of interventions, including psychosocial support, economic (re)integration, overdose prevention and management, and defense of human rights for PWID/PWUD. TAPP is also planning a broad array of intervention activities and services to enhance the efficacy of existing programs. First, because HIV is spread through intimate activities such as sexual intercourse and needle/syringe sharing, TAPP is developing programs that move beyond individual behaviors to address these intimate interactions, including (a) targeting couples for testing, counseling, and other intervention activities and (b) integrating gender-based and interpersonal violence reduction strategies into counseling and outreach activities. In addition to adapting and developing the content for these activities, TAPP will train partner CBOs and service providers from government ministries  to implement these interventions.Second, because of the synergistic intersections between polysubstance abuse, violence, and risky sexual behavior, TAPP is developing a brief, motivational intervention to reduce alcohol consumption among PWID and others who use TAPP services. TAPP will also integrate alcohol moderation messages into community outreach activities. Third, TAPP is also exploring the possibilities for more women-friendly services, such as extending MAT clinic hours and locations for those PWID who are sex workers and unable to travel to the MAT clinic during daytime hours.Finally, TAPP is developing additional clinical services to address comorbidities among PWID and members of other key groups. These clinical services include (a) integrated HIV and TB testing and treatment, and testing for hepatitis B and C; (b) training of “treatment navigators” to assist clients in their use of health and social services; and (c) training of local clinic and organisation personnel in issues of stigma, human rights, and values clarification concerning sexual orientation, drug use, and sex work, as well as awareness of specific health needs of people who engage in these activities .While behavioral interventions  have proven effective in reducing HIV/AIDS prevalence among PWID in high-income countries, many countries in sub-Saharan Africa face structural challenges that need to be addressed before long-term, sustainable changes can occur. Many of the drug users in Dar es Salaam use heroin to escape the harsh realities of life associated with past traumas and continuing limitations on political and economic opportunities . While tFor example, sixty-eight percent of young PWID in a 2009-2010 survey were orphaned . So even These social structures exist across different levels of society  and interact with biological organisms and individual behaviors to form a complex, dynamic system. Because these systems are composed of numerous elements and change in unpredictable (nonlinear) ways, a comprehensive approach using a variety of methodologies is required. “Combination prevention” includes biomedical, behavioral, and structural interventions for HIV prevention tailored to local conditions , 23. TAPInawezakana, calling for an end to the HIV epidemic in the country through harm reduction services. In August 2012, group screened its first short film Mdudu Mbaya . These productions are widely distributed to raise awareness throughout Tanzanian society and to foster a sense that everyone in Tanzania is addressing HIV together. The group is also planning to produce an educational video on HIV prevention. Along the same line the initiatives mentioned earlier  are strongly supported by MdM-F.MdM-F is also developing programs to help vulnerable communities speak for themselves. In collaboration with Openair Communication, MdM-F has trained a group of PWUD to use film and music as advocacy tools. For World Aids Day 2011, clients produced the music video While these organisations have made great strides in promoting individual harm reduction, more work on these structural barriers remains, and every harm reduction organisation is looking at new ways to integrate different interventions at various levels to ensure that behavioral interventions produce better outcomes and are sustainable beyond the life of the programs. Unless organisations can coordinate with governments, other social institutions, and communities to address structural disparities, help recovered users reintegrate into communities and pursue functional positions in society, harm reduction may only offer short-term, temporary benefits. TAPP, MdM-F, and the other organisations are committed to responding to the large numbers of PWID and their families and communities, but coordination with government and nongovernment organisations is needed to address the many contentious and complex issues associated with heroin use in Tanzania. TAPP, MdM-F, and the other organisations working in Dar es Salaam and Zanzibar are pioneers of harm reduction in sub-Saharan Africa because we have overcome considerable ideological and structural barriers to offer services such as medication-assisted treatment and needle and syringe programs. These are monumental achievements given a political atmosphere that favors drug trafficking control and the criminalization of drug use. Furthermore, the Tanzanian government has promised to continue supporting clients in the MAT program if external funding ends, signifying a long-term commitment to recognizing and addressing PWID needs. Tanzania is one of only two countries in sub-Saharan Africa to offer public methadone services, and one of the few countries to have recognized the severity of HIV in the PWID population. Government agencies, community-based organisations, and international collaborators have come together to respond to the problem via specific public health programming. Looking toward the future, organisations working with PWID/PWUD should strive to integrate input from the community during program planning stages to develop well-targeted, streamlined programs that address the specific experiences and needs of that community. Harm reduction organisations working in Tanzania continue to develop collaborative efforts to serve PWID/PWUD, but we need strong support from national governments and regional intergovernmental organisations such as the East African Community (EAC). While there are many challenges in the road ahead, these harm reduction programs serve as positive examples for the possibility of coordinated public health responses to PWID epidemics in sub-Saharan Africa.