Myanmar is experiencing an HIV epidemic documented since the late 1980s. The National AIDS Programme national surveillance ante-natal clinics had already estimated in 1993 that 1.4% of pregnant women were HIV positive, and UNAIDS estimates that at end 2005 1.3% (range 0.7–2.0%) of the adult population was living with HIV. While a HIV surveillance system has been in place since 1992, the programmatic response to the epidemic has been slower to emerge although short- and medium-terms plans have been formulated since 1990. These early plans focused on the health sector, omitted key population groups at risk of HIV transmission and have not been adequately funded. The public health system more generally is severely under-funded.By the beginning of the new decade, a number of organisations had begun working on HIV and AIDS, though not yet in a formally coordinated manner. The Joint Programme on AIDS in Myanmar 2003–2005 was an attempt to deliver HIV services through a planned and agreed strategic framework. Donors established the Fund for HIV/AIDS in Myanmar (FHAM), providing a pooled mechanism for funding and significantly increasing the resources available in Myanmar. By 2006 substantial advances had been made in terms of scope and diversity of service delivery, including outreach to most at risk populations to HIV. More organisations provided more services to an increased number of people. Services ranged from the provision of HIV prevention messages via mass media and through peers from high-risk groups, to the provision of care, treatment and support for people living with HIV. However, the data also show that this scaling up has not been sufficient to reach the vast majority of people in need of HIV and AIDS services.The operating environment constrains activities, but does not, in general, prohibit them. The slow rate of service expansion can be attributed to the burdens imposed by administrative measures, broader constraints on research, debate and organizing, and insufficient resources. Nevertheless, evidence of recent years illustrates that increased investment leads to more services provided to people in need, helping them to obtain their right to health care. But service expansion, policy improvement and capacity building cannot occur without more resources. Myanmar is one of South-East Asia's countries hardest hit by the HIV epidemic. At the end of 2005, UNAIDS and WHO estimate that 1.3% (range 0.7–2.0%) of the adult population were infected by HIV [An HIV sentinel surveillance system has been in place since 1992. It found that 1.4% of sampled pregnant women attending ante-natal care services were infected with HIV in 1993 [Concerning knowledge, the latest published behavioural surveillance report of the National AIDS Programme  containsWith respect to condom use, in the behavioural survey of the National AIDS Programme, 60% of young men (15–24 years) reported consistent condom use with sex workers . This fiThe national response to HIV and AIDS was slow to take off during the 1990s, despite increasing evidence that HIV prevalence was rising. A number of factors constrained the range of services available for HIV activities during the first ten years of the epidemic. Myanmar has an under-funded public health system and limited political support was expressed in support of HIV services. There were few national civil society organisations with HIV programmes, and the formation of civil society in general, outside of those linked to the government, remains problematic. Among the limited number of international non-governmental organizations present in Myanmar, a few started HIV prevention programmes on a limited scale after 1995 and initiated critical advocacy work. UNICEF began supporting services for HIV as early as 1994. As one of the few donors present in Myanmar during that period, UNICEF supported a range of interventions in HIV prevention. The World Health Organisation (WHO) provided training and technical assistance for HIV surveillance, the management of sexually transmitted diseases and the prevention of mother to child transmission of HIV. The United Nations Development Programme (UNDP) provided support to the National AIDS Programme as well as local civil society organisations. Activities supported included condom promotion and supply, provision of test kits to the national blood safety programme as well as the production of information, education and communication materials.By the turn of the millennium, interest in expanding work in the area of AIDS had grown, but there was no formal mechanism coordinating such efforts. More international NGOs had been able to establish operations in Myanmar and a few parastatal national organizations had begun discussing HIV and AIDS. The National AIDS Programme, though continuing to be based largely around health sector activities, added some non-health sector HIV prevention and awareness-raising work , albeit Early into the new decade, the United Nations agencies present in Myanmar increased their level of investment and began advocating collectively, both within and outside of the country, for increased, concerted action on HIV. A United Nations Joint Action Plan (2001–2002) was developed, and the Joint United Nations Programme on AIDS opened an office. In 2002, a United Nations Expanded Theme Group on AIDS with membership including organisations outside the United Nations system was established and it developed the Joint Programme on AIDS in Myanmar 2003–2005, negotiated with the Government, the National League for Democracy (the leading opposition party) and donors.The Joint Programme articulated a multi-sectoral framework into which all constituencies  could position themselves and which increased the focus on specific vulnerabilities around the purchase of sex by men and drug use . TechnicThe Fund for HIV/AIDS in Myanmar (FHAM) was created by three donors – expanded to six by 2006 – to finance the Joint Programme. In the end, the FHAM programmed approximately $26 million over four years starting from 2003, financing the work of 35 implementing partners. UNAIDS Myanmar estimates that the FHAM contributed to roughly 30% of the total funding on AIDS in 2005. The FHAM was itself a product of United Nations collaboration, relying on UNDP to manage the finances and administration of contracts, while the UNAIDS Secretariat mounted a programme support team and chaired a management committee to oversee the use of FHAM funds. The FHAM programme support team monitored all partners' activities on the basis of quarterly progress and financial reports as well as annual reports. During its four years, the Fund undertook a total of 35 field monitoring missions in 62 locations across Myanmar.As a result of the increased investments in AIDS programming, advocacy efforts in favour of a stronger and more coordinated response, and Government steps to improve the enabling environment, prevention and care service provision for HIV grew. By 2005, these investments had started to pay off and significant increases in service provision were reported by implementing partners ,12,13.In 2005, the National AIDS Programme and 15 non-governmental organisations reported reaching a total of 25,500 female sex workers by targeted HIV prevention services. The services were spread over a substantial part of Myanmar with a more concentrated effort in the large urban centres  programme was launched in 2000 by the National AIDS Programme with the assistance of United Nations agencies, and was functioning in 89 out of the 324 townships and 37 state, divisional and other hospitals by the end of 2006. In 2005, a total of 629 mother-baby pairs received Nevirapine  prophylaxis through the National AIDS Programme as well as three non-governmental organisations.The Ministry of Education has introduced life skills training that includes HIV education in the national curriculum for the primary school and in selected secondary schools. The programme has been ongoing since 1998 and the Ministry reports that 46% of the secondary schools are covered by the programme reportedly reaching 900,000 children aged 10 to 16 years in 2005. However, a recent review noted that the quality, coverage and impact of the school-based life skills programme require continued attention .Prevention efforts for specific, targeted groups have been accompanied by advocacy and HIV prevention campaigns for the general population. The mass media have increasingly carried HIV-related message from the government, United Nations agencies and international non-governmental organisations. Population Services International, a non-governmental organisation, reported that 250 HIV-related television spots were shown in 2005. In 2006 this increased to 438. UNAIDS Myanmar tracks HIV media coverage in 10 popular newspapers and journals and found an increasing frequency of HIV and AIDS related reporting since the beginning of 2004 [The availability of condoms either through social marketing or free distribution has increased greatly. With 11.1 million condoms distributed in 1999 compared to 39.9 million by the end of 2005, the figures have risen nearly fourfold over a period of six years . Over haConcerning treatment, care and support, the beginning of anti-retroviral treatment (ART) in Myanmar dates from 2003, when Médecins Sans Frontières Holland first introduced treatment. Since, they have expanded progressively and additional organisations have begun providing treatment, including through the public health sector launched in 2005, resulting in a substantial scale-up , townships with any kind of sex worker outreach or peer education programme (273 townships in 2005), or townships with HIV programmes for drug users (24 townships) . HoweverAs a result actions by the Ministry of Health and the National AIDS Programme and advocacy by international actors, the environment has allowed actors to expand their work on AIDS. At the same time, the overall operational setting remains unpredictable and constrained, without being broadly prohibitive.Carrying out health and humanitarian programmes in Myanmar is characterized by a high level of administrative control. Obtaining approvals to establish an organization and a programme – whether national or international – can take a year or more. Memorandums of Understanding with detailed workplans must be negotiated annually down to the township level. Approval by a cabinet-level body is required for every international staff member to be posted in Myanmar. All domestic travel by foreigners requires approval, usually with at least three weeks notice, from both the technical counterpart ministry as well as the Ministry of Defence; foreigners cannot visit projects sites, and not even those under their own direct management, without being accompanied by a government official. Approval for importing commodities is slow to be obtained, and international and national NGOs do not benefit from exemptions provided in other countries for the tax-free importation of vehicles and other project supplies. Much of the procurement funded by international sources has been undertaken by various members of the United Nations system. Difficulties related to coordination of roles and timeliness of procurement have in some instances further delayed programme implementation.Activities are also constrained by limits of the capacity of the implementers and limits that the national health services can influence other government bodies. The external review of the National AIDS Programme undertaken in April 2006 highlights many of these issues . CapacitCharacteristics of the broader operating environment also hamper, rather than facilitate, HIV prevention and care. Discussion of cultural values and roles, much of which must explore traditional norms about sexual behaviour, often for the first time in the public domain, is essential for sustainable HIV prevention. The meaningful participation of people living with HIV and other civil society actors is essential for such discussions and requires an ability to form self-help groups and formal networks across the country. More research from a variety of viewpoints, including from outside the government, is needed to inform debate which best takes place in an atmosphere of a free exchange of ideas. While such cultural discussion is occurring in the growing (but censored) press, as well as through small informal networks of people living with HIV, its expansion is slow and requires a more conducive environment.Access to populations in need of services remains difficult and in some cases impossible. Some sensitive border regions, other areas containing large numbers of mobile populations, such as mining camps, and conflict areas are off-limits to international NGOs and United Nations agencies. Some progress has been made, but the HIV epidemic in these areas can only be reliably reversed with full access to all parts of the country.The operational environment remains difficult to predict. In February 2006, the Ministry of Foreign Affairs, the Ministry of Home Affairs and the Ministry of National Planning and Economic Development, issued new draft guidelines to the international community – United Nations agencies and NGOs alike – for the coordination of organisations undertaking humanitarian work . PartnerSufficient and predictable resource flows are critical for planning and service delivery. Government health expenditures in 2005 were reported to be $0.37 per person  (using tFrom the international community, Myanmar receives a very low level of financial support considering its development profile. Total official overseas development assistance in the country was estimated as $2.4 per capita in 2004, as compared to $47 for Laos, $35 for Cambodia and $22 for Viet Nam . For HIVThe highly politicized context of operating in Myanmar requires any potential donor to be very committed to its investment. All grants are closely scrutinized by a variety of political actors both inside and outside the country, who in other circumstances might not pay detailed attention to HIV funding. Donors can expect public commentary on the appropriateness of their investments from the government, the National League for Democracy, Myanmar political groups based outside of Myanmar, and international organizations with a principle focus on political affairs in Myanmar. Large grants can become political issues in and of themselves, testified to by the extensive commentary preceding and following the termination of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Round 3 AIDS grant , which oWhile partners were slowly expanding services, several motivating – and complicating – factors led to a further evolution of HIV strategic planning and coordination efforts. In line with the "Three Ones" principles being advocated for AIDS programmes worldwide, the government argued for its own leadership role in the national response to AIDS while acknowledging that international standards militated in favour of more participatory practices in strategy design and coordination . An indeReflecting these reviews, events, and evolving views, extensive discussions among all stakeholders led to a new configuration. Continuing the provision of key HIV prevention and care services for the people of Myanmar remained the unifying motivator. The United Nations supported the government in developing a National Strategic Plan 2006–2010 and a targeted, prioritized and budgeted Operational Plan 2006 – 2008 ,16. This, responding both to the termination of the Global Fund grants and the imperative to continue the service provision that the FHAM had begun. The Three Diseases Fund's structure more formally divides national strategy making from financial allocation decisions. It provides an incentive for participatory planning and coordination while keeping final decision-making on resource allocation – and the ultimate responsibility for performance – clearly with the donors. It incorporated the United Nations Country Team's statement on principles for the provision of humanitarian assistance into its programme document [Beginning 2006, six donor countries have worked to establish the Three Diseases Fund document . It has Since the start of the decade, the provision of HIV prevention and care services has expanded significantly as a direct result of advocacy by internal and external actors concerned about HIV in Myanmar, increased investment of international resources and increased recognition by the Ministry of Health of the issue. Although programme implementation is characterized by high transaction costs and long delays, the environment has not prevented partners from delivering HIV services to people in need but the restrictions have limited geographic coverage and hampered timely implementation. These findings support arguments made as early as 2004 that additional resources can lead to more pragmatic approaches by government .Despite the turbulence created by the Global Fund termination and the generally politicized atmosphere, actors both inside and outside the country have demonstrated that carefully negotiated agreements on HIV and AIDS programming are still possible. The new National Strategic Plan on AIDS 2006 – 2010 currently reflects international best practice in many areas, highlights most at risk populations for HIV, and was developed in a much more participatory manner than any preceding plan. Six donors have crafted an accountable, independent and transparent structure to fund service delivery, using the National Plan as an important reference.Early indications suggest these new structures offer a way forward in the Myanmar context, yielding benefits for people living with HIV and the population as a whole. Programme output data demonstrates that increased resources and policy engagement can result in increased services for people in need and facilitate the evolution of HIV policies. However, more capacity building of the public health system and NGOs, more operational and behavioural research, more policy discussion, and more partners are all needed to build on this foothold of successful programming. Without more investment, from the Government as well as international sources, the road towards universal access to HIV prevention and care will be much longer than it needs to be.AIDS Acquired Immunodeficiency SyndromeART Antiretroviral TreatmentFHAM Fund for HIV/AIDS in MyanmarHIV Human Immunodeficiency VirusNAP National AIDS ProgrammeNGO Non-governmental OrganizationPLHIV People living with HIVSTD Sexually Transmitted DiseaseUN United NationsUNAIDS United Nations Joint Programme on AIDSUNFPA United Nations Population FundUNICEF United Nations Children FundUNDP United Nations Population FundUNGASS United Nations General Assembly Special Session on HIVWHO World Health OrganisationThe authors have no competing financial interest. BW, DB, MB and CP are based in Myanmar and work for United Nations agencies. This article was written in a personal capacity and does not necessarily reflect the view of UNAIDS or any other United Nations organisations.BW and MB led in writing the manuscript. MB also researched background data, prepared tables and charts. DB and CP participated in manuscript preparation.


The emergence of alternative medicines for AIDS in Asia and Africa was discussed at a satellite symposium and the parallel session on alternative and traditional treatments of the AIDSImpact meeting, held in Marseille, in July 2007. These medicines are heterogeneous, both in their presentation and in their geographic and cultural origin. The sessions focused on the role of these medications in selected resource poor settings in Africa and Asia now that access to anti-retroviral therapy is increasing. The aims of the sessions were to (1) identify the actors involved in the diffusion of these alternative medicines for HIV/AIDS, (2) explore uses and forms, and the way these medicines are given legitimacy, (3) reflect on underlying processes of globalisation and cultural differentiation, and (4) define priority questions for future research in this area. This article presents the insights generated at the meeting, illustrated with some findings from the case studies  that were presented. These case studies reveal the wide range of actors who are involved in the marketing and supply of alternative medicines. Regulatory mechanisms are weak. The efficacy claims of alternative medicines often reinforce a biomedical paradigm for HIV/AIDS, and fit with a healthy living ideology promoted by AIDS care programs and support groups. The AIDSImpact session concluded that more interdisciplinary research is needed on the experience of people living with HIV/AIDS with these alternative medicines, and on the ways in which these products interact (or not) with anti-retroviral therapy at pharmacological as well as psychosocial levels. A large number of new treatments offered to people living with HIV/AIDS (PLWA) have appeared over the last fifteen years in the therapeutic domain of AIDS. These medicines are particularly heterogeneous, both in their presentation and in their geographic and cultural origin. They constitute a group of products with a therapeutic aim that occupies a space between the customary traditional, popular and biomedical sectors of health care . These pThe emergence of alternative medicines for AIDS in Asia and Africa was discussed at a satellite symposium and the parallel session on alternative and traditional treatments of the AIDSImpact meeting, held in Marseille, in July 2007. We were especially interested in the role of these medications since the introduction and rapid scale-up of highly active anti-retroviral therapy (HAART) in resource poor settings.Twenty anthropologists and health researchers attended the satellite session and presented exploratory findings from Asia and Africa . The aims of the satellite, the results of which were presented at the parallel session , were tojamu in Indonesia. Jamu is the traditional term for Indonesian indigenous medicines usually prepared from herbal medicines such as leaves, bark, roots and flowers. Nowadays a multimillion dollar industry is involved in the production of Ayurvedic and Unani medicines in India, and of jamu in Indonesia. A rapidly expanding assortment of powders, creams, pills, capsules and cosmetics has been manufactured both in small cottage industries as in large factories with increasingly sophisticated technologies [There has been an increased professionalisation and commercialisation of traditional medicine in response to the development of biomedicine. This trend is not specific to AIDS and not necessarily a recent development. Social scientists first noted this trend in the late 1980s: Charles Leslie  for examnologies ,4. The mnologies . Under gAt the seminars in Marseille, we discussed the ways in which such alternative remedies operate in the therapeutic domain of AIDS care. In the first decade of the AIDS epidemic there was no effective treatment for HIV/AIDS and patients were faced with nearly certain premature death. At that time, there were regular hypes offering hope for life. But with the introduction of ART, alternative treatments are now marketed for many additional purposes too: to prevent AIDS, to kill viruses, to delay the need for ART, to restore and enhance health while on ART, to treat opportunistic infections, and to alleviate adverse side effects of other treatments. Biomedical practitioners generally discourage the use of alternative medicines, fearing interactions with ART and also through the concern that patients may stop using ART.At the AIDSImpact sessions Egrot and colleagues  presenteA case study from Uganda showed how health workers operating an anti-retroviral treatment program adopted a locally available traditional ointment as an alternative medication for skins problems of people living with HIV and AIDS. The skin problems result from adverse effects of ART or symptoms of opportunistic infections. The health workers obtained the recipe from local traditional healers (patients had told them that the cream works well), and the patients help collect the ingredients. They 'repackage' this traditional remedy into what is now called 'mobile cream' . One of the nurses reports:The mobile cream, which we ourselves prepare either at our chief nurse's home or here at the office depending on how busy we are at the office, is very efficacious for many kinds of skin related conditions. We are quick to prescribe it to the patients because we know it works and it is popular among patients too because it works for them[" for them."Content analysis of drug information leaflets, advertisements, product catalogues, and brochures distributed by medical representatives in the West Africa case studies ,8 casts However, such efficacy claims are not static. The producer of Virusinest (Nesto-Pharma) recently withdrew the antiviral claim, stating in its information leaflet: "the analyses carried out among patients do not allow the anti-HIV assertion to be upheld". There may be also inconsistencies between various information sources. The brochure for Viralgic (Pharma Concept) says that this is a product which renders the virus undetectable, but the website of the manufacturer presents the drug as immunostimulant , and present the product as treatment for opportunistic infections: "anti-herpes...for healthy persons".jamu. Jamu are sold for a wide range of indications: common colds, influenza, headaches, aches and pains, high blood pressure, beauty, improvements in sexual performance, and recently to treat and prevent HIV-related health problems. AIDS prevalence is below 1% , but the disease is stigmatised, because of its association with intravenous drug use and prostitution. Hardon and her colleagues conducted interviews with women and men who live with HIV and use anti-retroviral therapy, mainly intravenous drug users and their partners. All of them had better health since taking these modern drugs. Nonetheless, all of them see the need to take jamu as well. They do so in part out of their intention to live positively , as promoted by many of the support groups in which PLWA participate. The respondents do not make distinctions between modern medicines and jamu in these health maintenance and restoring practices. Rather they distinguish the drugs by their effects. They use popular jamu to treat side effects of HAART, such as itchiness. These jamus are not specifically promoted for HIV and AIDS in Indonesia, perhaps partly because the disease is so stigmatised.A case study on Indonesia  dealt wiHowever one neo-traditional preparation stood out in the narratives of our respondents as a product which can treat HIV/AIDS: virgin coconut oil. Ceri, for example, started using coconut oil shortly after she found out she was HIV-positive. She says:Actually, the effect is not only for your immune system. So, I feel better, don't feel tired, and have more energy. I think what influences most is self-suggestion. It's self-suggestion that matters...She stopped taking the oil because it is very expensive.Mia (a 28 year old woman from Jakarta) was given virgin coconut oil by a friend from Yogjakarta:I got 70 boxes. A box contains 60 capsules. It took it every day until I felt sick, but there was no effect. My CD4 level did not increase. Three months, three months made me look like a coconut you just needed to squeeze (laughing). I became very oily. The good effect when you take VCO is that your skin is silk smooth, your face is fairer and if you take a shower, you don't need any lotion, because your skin is naturally oily. That is the positive effect. Your hair is also stronger.But Buli, a 29-year-old ex-drug user from Karawang, one of the most active members of the support group in Karawang says:The coconut oil, I was also suggested it, but I don't dare to try it, because I thought I'm taking ARV now, so it's better if I just continue.In Indonesia, the drug sellers were not very willing to discuss the effects of VCO. They would acknowledge that indeed these drugs are used by PLWA, or they would deny knowing anything about the drugs. But their pharmacies are full of advertisements for the products and they have prominent positions on their shelves  states that the drug has "a high content of lauric acid which has anti-virus, anti-bacterials and anti-protozoa properties." And that it is "believed to help improve the health condition of those with cholesterol, diabetes, coronary heart disease, hepatitis C, HIV positive, cancer, prostate, uric acid, osteoporosis, influenza and weight problems". The package for Virjint  states that the medicine is safe for daily use and without side effects. It lists two dosages: one for prevention (2 × 2 capsules per day) and another for treatment (2 × 3 capsules per day). The leaflet stipulates that the indications are:- "to increase energy and body stamina- to increase body resistance (Meningkatkan daya tahan tubuh) against bacterial, viral and fungal pathogens- to reduce weight- anti-oxidant, anticancer, and anti-HIV- to overcome uric acid, hypertension, stroke, heart disease, atherosclerosis, osteoporosis, influenza, hepatitis, chickenpox, herpes, TB, diabetes, epilepsy, eczema, liver, haemorrhoids, kidney, peradangan (burning sensation), infection, degenerative disease."The packages cite clinical research conducted elsewhere  to give legitimacy to the products. For example the leaflet of Holistic Virgin Coconut Oil states: "Based on research conducted in the Philippines, Holistic Virgin Coconut Oil is very effective to fight against SARS and AIDS".One of the key characteristics of alternative medicines in Asia and Africa is that they move from one cultural and geographic space to another, apparently without being constrained by trade-barriers, or regulatory mechanisms. Some governments promote the production and diffusion of neo-traditional medicines. They do so for economic reasons: alternative medicines are big business, but they also do so for ideological reasons: neo-traditional medicines reflect an attractive hybrid of modernity and national heritage, providing a sense of national identity in the globalized health economy . The govMass-produced alternative medicines meet an increasing demand for health products, a trend which has been labelled the "commodification of health" ,14: fromThe case studies make clear that the market of alternative medicines for HIV/AIDS is dynamic. It adapts to progress in biomedicine, which has produced potent anti-retroviral medications. In some cases, the efficacy claims for alternative medicines reinforce a biomedical paradigm for HIV/AIDS, and fit with a healthy living ideology promoted by AIDS care programs and support groups. More interdisciplinary research is needed on the experience of people living with HIV/AIDS with these alternative medicines, the ways in which the products and their representations move from one cultural setting to another, and on the ways in which these products interact (or not) with anti-retroviral therapy at pharmacological as well as psychosocial levels. More research is also needed to assess the economic impact of these therapies, since people seem to be spending much on these 'other' medicines while ART is provided for free. A blanket denial of the relevance of these products for the quality of life of PLWA does not make sense for patients, who need precise information that make clear which products are likely to have negative interactions with ART, and which ones could be beneficial. Unfortunately research on the interactions between alternative medicine and antiretroviral drugs is sparse . To be aThe authors prepared papers for a joint seminar held in Aix-en-Provence, see reference list for the titles of the contributing papers. A summary of the insights from the papers was subsequently presented at the Marseille Impact Meeting, based on which a draft of this manuscript was written by AH and AD. All authors have contributed to the final manuscript.


The qualitative study in this article portrays the couple relationship among AIDS carriers, based on Sternberg's triangular love theory . The central study hypothesis is that certain components of the Sternberg model will be more significant than others among the AIDS carrier population. The study was conducted on ten AIDS carriers aged 21-37 who had experienced a couple relationship. Six men and four women participated; most of them were in a romantic couple relationship of homosexual orientation.The interviewees answered a questionnaire that included the three domains-- intimacy, passion and commitment--in the personal interview technique. The interview focused on interviewee's attitude towards his/her relationship with a partner, as he/she understood it. The findings of the study focus on relevant content that was gathered from the interviews and these portray a limited view of couple patterns in the world of AIDS carriers. The study reveals two major findings regarding the carrier's desires: On the one hand, the carrier describes a powerful need for a stable, permanent relationship--from the diagnosis of AIDS and throughout the subsequent years. On the other hand, the carrier also expresses powerful sexual desires that are not necessarily limited to a permanent partner. Thus passion is the dominant among the three domains.The intimacy domain is mainly affected by disclosure of the disease and the joint coping that follows.The findings are discussed in the context of the romantic internalized model theory and Sternberg's triangular love theory. We chose to enlarge the research field on this subject.Much has been written about the effects of AIDS on various spheres of life. However, one aspect that has been relatively neglected is the impact of AIDS on couple relationships. AIDS is an inherently anti-couple disease as it is transmitted The literature review below relates to AIDS and its effect on couplehood.Much attention was focused in the past on the functioning of a family unit in which one member suffers from chronic illness or disability, but the functioning of the spouses as a couple has not merited sufficient attention.The starting point for examining the effect of illness on a couple is the knowledge that the situation mandates a process of adjustment on the individual, couple and family levels. This adjustment takes place in the short-term as well as in the long-term--in an ongoing, broad sphere of coping mechanisms. The physical, psychological, social and economic impacts of the disease can make it difficult for a couple to maintain a stable relationship and keep the lines of communication open. The need for nursing services in the home can add even more severe, unique challenges. These sources of stress can have an adverse effect on the cohesion of the couple's relationship, on its stability and on the measure of satisfaction of the partners. Physical limitations can also disrupt the smooth running of the family and cause tension in a marriage. The effects of chronic illness can include ongoing deterioration in mobility, employment and earning a livelihood; escalating treatment costs; continuous weakening in the physical, emotional and social realms and difficulties in sexual functioning.The partner or spouse of a person with a disability or disease must acquire crisis-managing and coping skills without any advance preparation and then practice them under cumulative conditions and over an extensive period of time. These kinds of situations lead to changes regarding role division of partners, quantity of tasks, expectations of functioning, and emotional participation. Sometimes these changes are accompanied by a buildup of care-giving tasks that may tax the healthy partner to the maximum vis-à-vis his or her physical, emotional or economic abilities. Furthermore, these changes create gaps between the partners regarding their evaluation of the condition, their expectations of coping with the situation and the assessment of the other spouse's method of coping. These changes take place in both the inter- and intra-personal realms .The challenges described above are even more salient when one of the spouses suffers from AIDS, a contagious disease transmitted by sexual relations which has great impact on the relationship of the couple. Yet despite the greater public awareness of AIDS and dissemination of the ways to prevent its transmission, there has not been a decrease in the number of newly infected AIDS victims every year. In fact, many countries report a yearly rise in the number of new incidents. One of the possible explanations for this phenomenon may be attributed to the unwillingness of AIDS carriers to use condoms as they perceive this as a form of social coercion that impinges on their enjoyment of sexual relations , 3. Anotet al  and is not appropriate to the homosexual population." As a result, only three full questionnaires were returned and the unexpected need arose to change the structure and wording of the questionnaires and to recruit a target population. Thus it was decided to adopt the qualitative research method. From that point on, recruitment of examinees was carried out via the "snowball method."The researchers disseminated questionnaires at a yearly AIDS convention The interviews were carried out in the offices of the IATF (except for one interview held in the house of an interviewee). The interviews were about two hours in length each and were recorded and transcribed by the interviewers. Participants who were not involved in a relationship during the time of the interview were asked to talk about a former relationship. The head researchers conceptualized the following five main headings for the interview: the behavior and feelings that accompanied the disclosure/diagnosis of the disease; the disease as a secret; intimacy, passion and commitment.The researchers analyzed the interviews separately to uncover major themes, using constant comparative method, then held a discussion to synthesize the themes while using grounded theory principles .Content analysis was carried out in four major stages:Reading all the interviews to become closely familiar with the words, outlooks, thoughts and emotions of the interviewees .Identifying, dividing, sorting and organizing of repeating sections connected to study issues, and/or those sections that have broad qualitative influence and ramifications for the interviewees . ParalleCreating core categories by reducing the number of categories to the following five:A. Behaviors and feelings when the disease first made its appearance.B. The disease as a secret: variables of the disease as a secret.C. Intimacy: Emotional communication and the degree of trust in the relationship.D. Passion: Attraction, sexual behavior and fantasies regarding the partner.E. Commitment: stability of the relationship and sexual commitment.The findings are presented below according to these categories and are illustrated by representative quotes from interviews .An attempt was made to comprehensively cite the participants' perspectives regarding the impact of the AIDS virus on the three variables: intimacy, passion, commitment..The research findings are distilled into five major themes that emerged from analysis of the data.The diagnosis of the AIDS virus brings on painful/difficult feelings of loss, terminality, severe emotional shakeup and attempts at repression. All the interviewees viewed the disease as something that would change their lives in a negative, extreme manner:Ami: "In January I received the results and my life was turned upside down, I had very difficult moments…what we knew then was that people [with AIDS] died from the disease. My 35th birthday was like a funeral, family and friends came to say their goodbyes."Talya: "At the beginning of the relationship I felt 100% perfect, but ever since the disease I don't feel that way…Sometimes I cry, why did it have to happen to us, why me? Sometimes I cry and think that I'll never be free [of this ill ness] my entire life."Yet after the initial emotional storm that accompanies the disclosure of the virus, we see that most of the interviewees then describe feelings of desire to re-build their lives, to continue to function and even actualize themselves:Eran: "Three days after my diagnosis I was released from the army and started to work as a waiter…I viewed it as a personal achievement that [I developed aspirations] for the remainder of my short life: I decided that I wanted to be part of a long, stable, productive relationship; after that, I could die [in peace]".AIDS victims are often the objects of widespread, negative social stigma; therefore many of the interviewees were initially reluctant to disclose it to partners or family members.Talya: "I didn't tell anyone, they think I have low iron and that's why I'm weak. Even my older sister doesn't know…I don't even buy the medications myself, I can't bring myself to get near the place. I send my boyfriend andhe makes the purchases. I don't want to see that place and don't want them to see me".Yet when the person made the decision to confide in certain people about the AIDS diagnosis, all the interviewees received support and recognition:Oren: "I was very afraid of what would happen if they'd know, but all my friends know and no one turned their backs on me. Anyone who won't accept me, won't accept anyone."The IATF and the community of AIDS carriers are sources of significant support in the lives of the interviewees. The support is expressed in the transmission of knowledge, in physical and emotional backing, and help in the couplehood sphere:Shiri: "The first thing he did was take me to the IATF. At first I put my foot down, but he dragged me there. I sat here with a few representatives and talked to some people and also with the social worker. I emerged like a reborn person. Suddenly, things opened up for me, I felt different."An important issue raised by most of the interviewees is connected to the process of revealing the AIDS secret in the couple relationship. The main difficulty stemmed from fear of rejection and the dilemma was: at what stage to tell the partner about the AIDS virus--if at all?Eran: "Some people don't tell anyone. For a year they take their meds in private. One of the central questions is, how and when to tell? Before sex? After sex? How to bring it up after a month? Coping with repression. It's a matter of trial and error, to size up your partner as quickly as possible, how he'll cope with it. Will he run away, reject you, become violent, betray your secret to others, etc."Concern for the well-being of the partner was expressed in all the interviews. Evidently AIDS is a significant variable in relation to emotional communication, due to the health-related aspects of the disease:Eran: "I worry a lot about his well-being. On his side, there's room for improvement. He does take care of my medications, he brings me the pills when I ask. As far as coping with actual illness, till now we haven't had to deal with that. He's happy when I get good results [from the blood tests] and we even drink a toast to that. So [he] is concerned about my welfare, but in a different way.Oren: "I'll always feel great responsibility for him. If he doesn't work then I take care of him, when he's sick I make sure he takes his meds, or things connected to his family."Most of the interviewees mentioned that the mutual coping of a couple (when one of them has AIDS) bestows a measure of security on the relationship and alleviates the daily difficulties associated with the disease:Eran: "Joint coping makes it easier to deal with the meds. There was an experimental treatment involving eggs that was smelly and disgusting. Since we were together, I coped a lot better than if I had been alone. He used to prepare the medicine for me and we would take it together. It was a very unpleasant treatment and being a couple helped."Oren: "Ro'i helped me know more [about the disease]; we'd go to the doctor together, I'd nod my head and afterwards Ro'i would explain to me [what the doctor said]. That's his commitment--he makes sure I take my pills and meds."In addition to solicitude, welfare and emotional support, 5 out of 6 interviewees testify to difficulties in communication and a perception of lack of understanding on the side of the partner:Oren: "Ukrainians are emotionally blocked. You're not supposed to talk [with them] about problems or difficult things. Every time I try to raise issues about things that are difficult for me, he treats me like a weakling, someone who goes to emotional extremes. It's hard to tell what he thinks or feels. They know nothing about talking about problems in order to understand the person they live with. There is an emotional block at the foundation of the relationship. I don't know everything about him."Oren: "During the recent time period I feel that I'm not receiving enough emotional support. I don't [the reason], but something is missing. Our communication could be better. Often we don't understand each other, for example when he answers me in a certain tone of voice it creates misunderstanding, also the reverse is true. Our communication is not working well, we came from different family backgrounds--in my house it was acceptable to shout, but not in Ro'i's family.The degree of trust is described by the interviewees as comprised of variables such as: security and honesty in the relationship, sharing experiences and problems, friendship and esteem. Most of the interviewees interpret 'trust' on twoEran: "He gives me security that he is with me and will remain with me. He stays with me because he wants to be with me; not because of convenience or because it's a great honor."Oren: "I can rely on him that he will remain in the relationship even in difficult periods, let's say if I'll be in the hospital then I know he'll be there for me."Some interviewees said that the disease interfered and inhibited the formation of trust in the relationship. Shiri describes her desire to keep the illness to herself versus the need to involve her partner fully in her life as two contradictory needs that create conflict on the subject of trust:"I put up a wall in front of him [It came to the point where] either I'd talk about what's happening, or it's over. I felt that our relationship was starting to deteriorate. One day, after a year, I got up the courage and told him. I didn't know how he would react…It was to terribly stressful…But the first thing he said was, 'Darling, I'm so sorry.' See, he thought about me first! Then I cried a little and the penny started to fall in his mind: 'Why didn't you tell me? How could you assume responsibility for me? You know that we are not in a committed relationship, how could you take responsibility for another girl that maybe I was with."An important and essential variable that figured prominently in the interviews is mental and physical preoccupation with sex. All the interviewees described great sexual attraction and passion in the couple relationship:Oren: "I very much enjoy physical contact. There's something magical when he touches me, the palm of his hand [touches himself], one like that and you're in the clouds…"Ro'i: "I'm always horny over him. We always want to be together but that feeling can disappear for a day or two when we're irritable at each other. I get excited when I see him, I think about him during most of the day. I fantasize about him a lot."Ami: "There's a lot of passion between us. I get very excited over him. Sometimes I feel like a teenager. Our ability to encourage one another surprises me. Like two children."In most of the cases, this passion is also expressed in sexual openness, unique sexual experiences and externalized sexual behavior.Eran: "He compliments me that I'm the best lover he ever had, and we enjoy sexual experiences beyond just the two of us (with a third person). I enjoy participating in novel [sexual] experiences for him."Ami: "Sometimes we get carried away. Yesterday when we came home we found ourselves running wild in bed; usually we close the door but this time we didn't notice that our daughter had come home…it was very funny…we didn't stop laughing."Still, half of the interviewees talk about sexual problems arising from the existence of the HIV virus. Note two major points in this context: the danger of infection of the virus via sexual relations, and the danger posed to the HIV carrier from the introduction of additional germs in the body (resulting from damage to the carrier's immune system):Eran: "There's lack of sexual satisfaction with people . Couples in a relationship expect to be able to stop using a condom at a certain point, and entering a relationship with a carrier carries with it the commitment to using a condom 100% of the time."Talya: "Regarding sex, at the beginning everything was great, we couldn't do without it. We'd do it several times a day. Ever since the disease, it's not all the time. He says that he doesn't feel like a man completely because he can't enjoy it."Ami: "One more infection isn't enough to affect our lives, we can be together completely freely. That's the choice of two adult men. I can understand people who are not willing to make such a decision and decide they don't want to be infected by the virus and so they use condoms all their lives. Everything is possible. People make their own, personal choices. I don't think there's a consensus on this issue."All the interviewees said that they fantasized about their partners. They also talked about feelings of great admiration and appreciation:Ro'i: "I feel that our relationship is enchanted, magical. I admire him for many things--stubbornness (like me), for things he does despite the difficulties involved… personal responsibility. I am capable of imagining life without Oren but such a life would be boring and routine."Ami: "Sometimes I admire him. He has tons of strength and abilities in things that I can't do. More than that, though--I appreciate him… I admire his ability to contain things in life, but I am also very critical about a lot of things. There are things I wish would change about him but I knew that there are things that won't change, just like it's hard for me to change."Talya: "I think he's perfect."The stability of the couple relationship encompasses two intertwined aspects. Half of the interviewees described the stability of their relationships on the day-to-day, here- and-now level, and how it affects commitment in the future:Ro'i: "I am thankful for his existence and feel that I can truly trust him. I know that if I run into a problem I have someone I can lean on, for example in the recent period regarding financial matters, or when I was hospitalized and he was with me."When facing the future, 4 out of 6 interviewees felt difficulty in being secure about the stability of the relationship:Ami: "I felt that since I don't have much time to live while my partner has his whole life ahead of him, I should break up with him. Afterwards I realized that's a silly way to think-- neither of us really knows how much longer he will live."Eran: "Commitment both stabilizes our relationship and also undermines it at the same time. It's hard to explain. On the one hand we try to be stable and cope with very difficult situations, but sometimes we feel that we're on a roller coaster. We have a lot of ups and downs."Ro'i: "I really care about Oren, I have confidence in the stability of our relationship but I don't want to think what will be, I just let things happen. I hope that things will remain as they are now and that my love for him will remain…I view my commitment for mutual understanding and a stable, unshakable relationship, that is what will ensure the stability of our relationship. I can imagine a scenario in which the relationship will end, but I am sure of my love for him. I don't think ahead 10 or 15 years, that's too far, but I do see our relationship as a permanent thing."Most of the interviewees express the desire and willingness to struggle and sacrifice for the stability of the couple relationship. The sacrifice is expressed by forfeiting contact with the family of origin in favor of the partner, by relinquishing a livelihood, giving up old habits and even risking damage to one's self-respect:Eran: "I'll fight to maintain the relationship, I am willing to swallow my pride, I'll do everything I can. There was a time when he wanted to leave, I begged him and even went down on my knees. I'll do anything, I believe that's the right thing--up until murder (laughs)."Oren: "In principle I'm willing to give of myself. That means to give up certain things like family, to risk things in other areas for the relationship and for Ro'i…Work, for example? So I'll find other work. Work is important… but it's more important to me that it should be good for me with Ro'i."Ro'i: "I feel that the relationship with him is the most important thing in my life, it expresses sacrifices I am willing to make. Sacrifices for the man I care about, even crucial things like not going alone to parties… this is an example of a sacrifice I make for him."One interviewee describes his commitment for his partner in the fact that he encourages his partner to assume responsibility to persist in taking his medication, in order to lengthen the time he will have with his partner in the relationship:Eran: "This love is so great that it causes me to assume greater responsibility for my health and my meds in order to prolong this love. Before I met Sasha I had big problems in following my treatment plan, I put down the whole pill scene and played games with them. Now I'm a lot more careful; it's part of commitment, he also says so--to remain healthy for as long as possible."Most of the interviewees do not feel sexual commitment (fidelity) towards their partners. This lack of commitment is expressed in two ways: by sexual experiences with other partners, as well as by introducing other partners to the sexual act between the couple:Oren: "I am not committed to him when it comes to sex. As a rule it doesn’t bother Ro'i because he knows that I distinguish between sex and true love, and it also doesn’t bother me, but I'm not willing that Ro'i won't be committed to the relationship."Ami: "We have an open relationship, which means that if one of us meets someone else, it's OK to go with him. We can also be three, or with another couple. It's not a way of life but if it happens, we don't make a big deal about it. It doesn't threaten our relationship. That's the understanding we have and we really want to be together. It's not instead of, but in addition to."Eran: "We like enjoying sexual experiences beyond the two of us, with a third person."One interviewee described the fact of her being an AIDS carrier as the factor that harmed her willingness and emotional ability to assume a committed, revealing couple relationship:Shiri: "Here and there it continued as an uncommitted relationship. It was convenient for him too, he was afraid of commitment, but that was his business and his fears. As far as I was concerned, it was very convenient. I didn't have to tell him what was happening with my body. It was convenient for me to tell him that I don't take [birth control] pills and I prefer a condom."This study deals with significant issues regarding the relationships of AIDS carrier couples in Israel. The findings point to a picture of couple relationships involving elements affected by AIDS as well as elements reflecting normative couples, in accordance with Sternberg's love indexes: intimacy, passion and commitment.Below are some conclusions drawn from an analysis of the findings based on Sternberg's triangular theory of love:The study hypothesis was that the variable of 'intimacy' would be more dominant among couple relationships with AIDS sufferers or carriers whose medical situation was known, in comparison with couples in which the disease was kept secret. This hypothesis was strengthened. According to Clark & Reiss , intimacIt seems that the research hypothesis whereby passion would have less importance among AIDS carriers, has been refuted by the study. On the contrary: the passion variable emerges as important and fundamental amongst all the interviewees who described strong sexual attraction and passion in their couple relationship. In most cases this passion is expressed by a readiness for unique sexual experiences and externalized sexual behavior. A possible explanation for this interesting finding may lie in the fact that most of the interviewees belong to the homosexual community which has different sexual patterns than the heterosexual world, as mentioned at the beginning of the chapter.Foucault  claims tAnother explanation for the centrality of sex in the lives of the interviewees is the initial development stage of their relationships. According to Sternberg , there aThe research hypothesis regarding commitment among AIDS carrier couple relationships was that the commitment component would receive less importance than the other two elements in the model.The research presents two central findings related to security, stability of the relationship and trust on the one hand, and sexual connection on the other: While the interviewees describe a strong need for a stable, permanent relationship--from the diagnosis of AIDS and throughout the years--the need for sexual contact is not necessarily limited to the permanent partner but is very powerful and externalized.A possible explanation of this duality may be found in psychoanalytic object-relation theories. The concept behind these theories is that the mother-infant relationship is internalized by the child and becomes a model to the child for other relationships during his life . HendricThe findings demonstrate that AIDS carriers often develop the desire to create deep, stable and significant relationships for the rest of their lives. While all couple relationships have a component of searching for a parent figure, the need for medical attention amongst this specific population increases and intensifies the search for a stable, caretaking figure. In effect, there is a hidden conflict between knowing that one's life expectancy is likely to be shorter than usual, and the need to devote oneself to a couple relationship. A shorter life expectancy leads the carrier to the desire to make the most of life. Most of the interviewees reported that they do not feel sexually committed to their partners. Perhaps the AIDS carriers' desires to 'make the most of life' is expressed by their experiences of multiple sexual partners and experiences.The findings demonstrate a clear distinction in sexual commitment between homosexual and heterosexual interviewees. Therefore, we must avoid assigning false labels on sexual behavior as being normative among AIDS couples. It is likely that this behavior is part of accepted sexual patterns in the male homosexual community as a whole, and not necessarily the homosexual AIDS couples in specific.There are some who claim that social isolation of AIDS carriers leads to lack of support of the victims in their communities . The stuThere are several reasons for the world-wide negative stigma attached to AIDS. First, the illness is identified with sexual relations, homosexuality, drug use and death. Secondly, incorrect notions regarding the transmission of the illness are still rife in the general population. As a result, many women with AIDS report outright social isolation , which iAdditional significant differences are embodied in the health status of partners of AIDS carriers. The findings point to asymmetrical power division in relationships where one of the partners is not an HIV carrier. This situation seems to arouse feelings of inferiority among carriers and intense fears of abandonment. The carriers see themselves as undesirable, defiled and with low chances for creating a new couple relationship. Other studies conducted in the United States strengthen the results of this study and claim that the very existence of AIDS, causes many afflicted women to remain within conflictual relationships due to their belief that their illness limits their abilities for creating new spousal relationships. Furthermore, conflicts in the couple relationship can have significant negative impact on the mental health of women with AIDS since the illness itself affects physical, economic and social needs of women . This faIt is important to address the major limitation of this study that affects the results and conclusions drawn from it: the study integrates both homo- and heterosexual interviewees, thus making it impossible to isolate the AIDS variable. The homo- and heterosexual couple populations have different lifestyles in certain domains, thus it is hard to attribute research findings to the presence of the HIV virus in a single-sex couple when the results are typical of the behavioral norms in the homosexual community; for example, multiple sex partners. Furthermore, the homosexual experience carries with it a unique gamut of psychological issues, and coping with HIV only adds to these already present issues. We feel that homosexual partners living with AIDS should be studied separately in their own unique sociological context, which is replete with negative stigmas.Another limitation of the research is the small number of participants who agreed to take part in it. One possible cause is that the questionnaire was not appropriate to the target population (as described above). However, the lack of participation may also be partly attributed to the unwillingness or uncapability of desired participants to expose their couple relationship to foreign researchers.The study hypotheses and their results have great importance as they portray preliminary outlines of AIDS couple relationships--a population that has so far received very little attention both in research and in theory. This situation created great difficulty in finding theoretical material for the body of the work and as a basis for findings. We can even say that this study is pioneering in its sphere, and contributes to a body of knowledge in the subject of AIDS disease's influence over couplehood.The research results may contribute to couple therapy of AIDS couples, by making us aware of the typical emotional reactions and stresses facing these couples. This study and additional ones in the sphere will form a basis for establishing both treatment techniques and preventive therapeutic programs towards creating open, aware, healthy and productive couple relationships.This study opens a number of possible directions for future research. First of all, it is important to conduct comparative research between couples coping with AIDS and healthy couples in different couple configurations . This comparison could bring to light the unique coping domains of AIDS couples and contribute to the development of intervention and assistance methods. An important emphasis should be placed on isolating the sexual preference variable that crudely affects the results of the study. Second, the components of the commitment variable need to be studied more in-depth as it seems to be influenced by many independent factors  and it would be interesting to examine which additional factors influence the evaluation of this variable in the couple relationship. Third, a longitudinal study could be conducted to examine the three variables of love according to Sternberg-- intimacy, passion and commitment--within couple relationships of AIDS carriers and then at a later stage, to examine these same domains in more advanced stages of full-blown AIDS. This kind of study would facilitate credible comparison of these domains at different points in the development of the couple relationship, and also enable close examination of the effects of the disease during active, decisive coping. In light of the findings of the present research, such a study would be extremely important.The present study examined the relatively chaste field of AIDS carriers' couple relationship, based on Sternberg's triangular love typology . After cIn summary, we feel that there is great ignorance and lack of awareness regarding this disease and its results in the sphere of the couple relationship, making it evident that the subject of the couplehood of the individual coping with AIDS requires additional empirical research.


Diabetic foot infections are common, serious, and diverse. There is uncertainty about optimal antibiotic treatment, and probably substantial variation in practice. Our aim was to document whether this is the case: A finding that would raise questions about the comparative cost-effectiveness of different regimens and also open the possibility of examining costs and outcomes to determine which should be preferred.We used the Veterans Health Administration (VA) Diabetes Epidemiology Cohorts (DEpiC) database to conduct a retrospective observational study of hospitalized patients with diabetic foot infections. DEpiC contains computerized VA and Medicare patient-level data for VA patients with diabetes since 1998, including demographics, ICD-9-CM diagnostic codes, antibiotics prescribed, and VA facility. We identified all patients with ICD-9-CM codes for cellulitis/abscess of the foot and then sub-grouped them according to whether they had cellulitis/abscess plus codes for gangrene, osteomyelitis, skin ulcer, or none of these. For each facility, we determined: 1) The proportion of patients treated with an antibiotic and the initial route of administration; 2) The first antibiotic regimen prescribed for each patient, defined as treatment with the same antibiotic, or combination of antibiotics, for at least 5 continuous days; and 3) The antibacterial spectrum of the first regimen.We identified 3,792 patients with cellulitis/abscess of the foot either alone (16.4%), or with ulcer (32.6%), osteomyelitis (19.0%) or gangrene (32.0%). Antibiotics were prescribed for 98.9%. At least 5 continuous days of treatment with an unchanged regimen of one or more antibiotics was prescribed for 59.3%. The means and (ranges) across facilities of the three most common regimens were: 16.4%, (22.8%); 15.7%, (36.1%); and 10.8%, (50.5%). The range of variation across facilities proved substantially greater than that across the different categories of foot infection. We found similar variation in the spectrum of the antibiotic regimen.The large variations in regimen appear to reflect differences in facility practice styles rather than case mix. It is unlikely that all regimens are equally cost-effective. Our methods make possible evaluation of many regimens across many facilities, and can be applied in further studies to determine which antibiotic regimens should be preferred. Foot infections in diabetic patients are among the most frequent precipitating causes of hospitalization and amputation-3. They The Veterans Health Administration is the largest integrated health care system in the country and includes 147 hospitals. It has an excellent computerized patient record system, which contains patient demographics, diagnoses, diagnostic studies, treatments received and patient outcomes. With this information it is possible to examine the antibiotic regimens of large numbers of diabetic patients with foot infections and the degree to which practice patterns vary across facilities.In previous work, we reported the construction of a classification system for diabetic foot infections that is expressly designed for use with computerized medical data. We applied it to a database that contains all diabetic patients in the Veterans Health Administration (VA), and found support for our classification in its correlation with patient characteristics, treatments received, and outcomes, including rehospitalization, amputation, transition to long-term care, and death .In the present study, we have used our classification system to identify diabetic patients with serious active foot infections, as defined by hospitalization with isolated cellulitis or cellulitis accompanied by gangrene, osteomyelitis, or ulcer. We have also developed and applied methods for assessing variation in complex multi-drug antibiotic regimens to examine how the treatment of these patients varies across hospitals in the VA healthcare system. We have found that there is large variation in treatment across facilities and that there is more variation across facilities than across different types of infection. This suggests that practice styles play a larger role in the choice of regimen than does case mix.This study was approved by the Institutional Review Board (IRB) of the Edith Nourse Rogers VA Medical Center in Bedford, Massachusetts. It was conducted in the population of hospitalized veteran diabetic patients receiving care from the Veterans Health Administration (VA) in fiscal year (FY) 2006. We used the national VA Diabetes Epidemiology Cohorts (DEpiC), a linked, computerized research database that serves as a registry of virtually all VA patients with diabetes. Patients are included in DepiC on the basis of having two of the following ICD-9CM codes within a 24-month period: 250.xx, 357.2, 362.0, or 366.41. It contains patient-level data on medical visits, pharmacy and laboratory data, with diagnoses and procedures for VA and non-VA care (from Medicare claims data),11. For Our methods for the identification and classification of diabetic foot infections have been described elsewhere. In brieWe assumed that patients were under treatment for diabetic foot infection while in the hospital if, during that hospitalization, they were assigned an ICD-9-CM code for cellulitis of the foot.First, we eliminated from consideration antibiotics that would not be used in the treatment of diabetic foot infections. These included antivirals, antifungals, and antiparasitics, as well as select antibacterial agents, including antituberculosis agents other than rifampin, agents used only for urinary tract infections , and antibacterial agents with a very narrow spectrum of activity, such as penicillin G and spectinomycin. We then evaluated antibiotic prescribing in the following ways:1. The proportion of patients treated with an antibiotic and the initial route of administration on the first day that any antibiotic was given.regimen prescribed for each patient, defined as treatment with the same antibiotic, or combination of antibiotics, for at least 5 continuous days. This may not be the same as the antibiotics that were given on the first day. We chose this duration of time to allow for consultation about the choice of antibiotics, integration of microbiological information, and observation of clinical response. Also, duration sufficient to observe clinical response is a necessary requirement for future studies to determine which regimens should be preferred.2. The first antibiotic spectrum of the first antibiotic regimen prescribed for each patient. We used the Medical Letter on Drugs and Therapeutics Handbook of Antimicrobial Therapy to determine whether an antibiotic was a recommended agent for: gram-positive organisms other than S. aureus; methicillin sensitive S. aureus; methicillin resistant S. aureus; Ps. aeruginosa; and B. fragilis[3. The antibacterial  fragilis.  in that large values mean that the range of true rates is large relative to the typical value of the true rates. A large value could indicate one or more extreme outliers or true rates with large variation but without extreme outliers.There were nearly 1.2 million veteran VA patients with diabetes in DEpiC in FY 2006. We identified 3,792 who had a VA hospitalization in that year with ICD-9-CM codes classifiable into one of our four categories of cellulitis. Of these, 3751 (98.9%) were treated with one or more antibiotics and 2248 (59.3%) received at least 5 continuous days with the same antibiotic(s). Table In this analysis we included all the antibiotics that were prescribed on the first day that any antibiotic was given. Of 3,792 patients overall who had cellulitis, 3,751 (98.9%) were treated, 79.8% parenterally, 11.5% orally, 7.6% both parenterally and orally, and 1.1% neither (i.e. no antibiotic). The greatest difference in initial route of administration was in the Cellulitis-Only group, in which purely parenteral antibiotics were used least often (74.6%), and purely oral antibiotics most often (15.4%), compared to the other groups  never received a course of antibiotics that met our definition of an antibiotic regimen. This reflects the fact that either a single day's missed dose or 1-4 days of an additional antibiotic would disqualify an antibiotic regimen from consideration.The percentage of patients with no first regimen varied across our four categories of cellulitis. Seventy-four percent of patients with Cellulitis-Gangrene received a first regimen, compared to 70% for Cellulitis-Osteomyelitis, 52% for Cellulitis-Ulcer, and 33% for Cellulitis-Only. Since we know that at least 98% of patients in each group were given antibiotics, these declining percentages reveal a corresponding decrease in the proportion of patients who received an unmodified course of treatment for 5 days or more. A total of 199 different antibiotic regimens were used. This large number reflects the many possible combinations of the 52 different antibiotics that were prescribed.Table The rows of the table reveal that there are not large differences in the choice of each regimen across the categories of cellulitis. The greatest difference is 11.4% for Piperacillin-tazobactam . In general, the largest differences in frequency of use across the different categories of cellulitis occur with Cellulitis-Only, in which a substantially smaller proportion of patients received piperacillin-tazobactam and piperacillin-tazobactam plus vancomycin.within each category of cellulitis is at least equal to, and usually substantially greater than, the range of observed proportions across the different types of cellulitis .The range of use for each regimen across facilities Figure In this analysis we collapsed the extensive array of antibiotic regimens into smaller groups on the basis of their antibacterial spectra. If more than one regimen was used, we assigned the spectrum based on the first. Only 10 different spectra were used in more than 1.6% of patients. Table There have been numerous studies of variation in antibiotic use in different types of infection -22. The Evaluation of variation in complex multi-drug regimens presents methodological challenges. Perhaps for this reason, most studies of differences in antibiotic treatment have used strategies that simplify the assessment of variation, such as examining any treatment versus no treatment, deviatioWe decided to carry out such a study, first, because diabetic foot infections are such an important cause of hospitalization, amputation, and disability and, second, because there is no generally accepted standard antibiotic regimen, so we expected to find large variations in antibiotic management. We used data derived from the computerized medical records of the largest integrated medical care organization in the country, the Veterans Health Administration. This gave us the power to evaluate variation in a large variety of antibiotic regimens, across a large number of hospitals, in a large number of patients. We have focused on patients where antibiotic choices are most important, namely those with serious foot infections as defined by hospital treatment for cellulitis accompanied by gangrene, osteomyelitis, cutaneous ulcer, or occurring in isolation.The complex antibiotic regimens often used to treat diabetic foot infections present methodological issues that we needed to address before we could begin. First, we had to take into account that the initial antibiotic prescribed might not necessarily represent a final decision about the preferred antibiotic regimen. To address this we examined what we considered to be a stable "course" of antibiotics, given singly or in combination, without change, over a period of at least 5 days. Such a time frame is a requirement for future studies, which will not be able to evaluate the outcomes of different regimens unless they have been given for long enough to assess clinical response. Second, we recognized that variation in the choice of antibiotics would be governed, in part, by the breadth of the anti-bacterial spectrum desired. Hence, we also examined variation in the antibacterial spectrum of treatment well as variation in the antibiotics themselves.We have found very large differences in antibiotic use across VA facilities. It is evident in the antibiotics that make up the initial regimen, as well as in the antibacterial spectra of the chosen regimens. The variation may be partly driven by differences in case mix, but this is unlikely, because we did not find substantial differences in case mix across facilities as judged by the comparative prevalence of our different categories of cellulitis. It is probably truly related to foot infections, because the percentage of patients treated with any antibiotic is close to 100%, the great majority of treatments are parenteral, and the spectrum of antibacterial activity is broad, all of which are to be expected in the treatment of these infections,25-28. IThere is evidence in this study that antibiotic choice is driven by the existence of differing practice styles across VA facilities. The variation in antibacterial spectrum across facilities within each category of infection almost certainly reflects different views about how broadly to treat. , Ps. aeruginosa, or neither. Each of these organisms is recognized as a cause of serious foot infections, but they are not so common as to mandate routine coverage.) There Even though there is no general agreement about antibiotic choice in the infections we have studied, our findings raise concern about the cost-effectiveness of the care that is being given. It is unlikely that all regimens are equally advantageous. For example, there is some evidence that ampicillin-sulbactam may be more cost-effective than imipenem,31. TherClearly, further studies are needed to identify which antibiotic regimens are most cost-effective. This study has established a number of methodological approaches that can facilitate the conduct of such investigations using computerized medical data. These include, 1) a classification system for diabetic foot infections that can be applied to computerized medical data; 2) an operational definition of the initial antibiotic regimen, including the requirement to exclude drugs unlikely to be used for foot infection; 3) a taxonomy for classifying the spectra of antibacterial agents that has proven to be useful in evaluating variation in complex antibiotic regimens, and 4) the benefit of using of shrunken means to make possible the analysis of antibiotic variation across large numbers of facilities, each of which may see only a few patients treated with a given antibiotic regimen. These methods set stage for observational studies of the relationship between different antibiotic regimens, treatment outcomes, and costs. They are also applicable to other conditions, such as intra-abdominal infections, that require empiric treatment with broad-spectrum regimens that may be achieved using many different antibiotic combinations.There are a number of limitations to this study. First, 41% of the patients never met our definition of a stable antibiotic regimen. This occurred more commonly among patients with milder infections, which indicates that our findings regarding the chosen antibiotic regimens are biased toward patients with greater severity. This might result in the use of broader spectrum regimens and therefore reduce observed differences in treatment across our categories of infection. Second, the antibiotic regimens that we studied may have been customized in response to microbiologic data. To explain our results, however, would require very large differences across facilities in the prevalence of organisms such as MRSA and Ps. aeruginosa. In a recent study, each of these was isolated from less than 5% of cultures, which makes this possibility very unlikely. Third, We have found large variations in the antibiotic regimens used to treat patients with diabetic foot infections. They appear to reflect facility differences in practice styles rather than case mix. It is unlikely that these regimens are equally cost-effective. The methods we have developed can be applied in further studies to examine both costs and outcomes in order to determine which regimens should be preferred. They also can be extended to the evaluation of any condition, infective or not, that is often treated with a multidrug regimen.The authors declare that they have no competing interests.All authors contributed to the conception, design, interpretation of data and drafting of the manuscript. DMR acquired the data. CLC designed and oversaw the statistical analyses. All authors have read and approved the manuscript040.0 Gas Gangrene440.24 Atherosclerosis of the extremities with gangrene785.4 Gangrene but only if any one of the following is also present:250.7 Diabetes with peripheral circulatory disorders440.2 Atherosclerosis of native arteries of the extremitiesAny condition classifiable to 440.21, 440.22, and 440.23730.07 Acute osteomyelitis of ankle and foot730.17 Chronic osteomyelitis of ankle and foot730.27 Unspecified osteomyelitis of ankle and foot730.97 Unspecified infection of bone of ankle and foot440.23 Atherosclerosis of the extremities with ulceration707.14 Ulcer of heel and mid foot707.15 Ulcer of other part of foot707.1 Ulcer of lower limbs680.7 Carbuncle and furuncle of foot, heel, toe682.7 Cellulitis and abscess of foot, except toes681.1 Cellulitis and abscess of toe681.10 Cellulitis, toe nos681.11 Onychia and paronychia of toeThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/193/prepub